Malpractice in Dermatopathology-Principles, Risk Mitigation, and Opportunities for Improved Care for the Histologic Diagnosis of Melanoma and Pigmented Lesions

Clinics in Laboratory Medicine

Volumn 28, Issue 2, 2008, Pages 261-284

  High, Whitney A ^a  

^a UNIVERSITY OF COLORADO   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

DIAGNOSTIC ERROR; JUVENILE MELANOMA; LICHENOID ERUPTION; MALPRACTICE; MEDICOLEGAL ASPECT; MELANOMA; PRIORITY JOURNAL; REVIEW; SKIN CANCER; SKIN DISEASE; SKIN PIGMENTATION;

DERMATOLOGY; DIAGNOSTIC ERRORS; HUMANS; MALPRACTICE; MELANOMA; PATHOLOGY, CLINICAL; QUALITY OF HEALTH CARE; RISK MANAGEMENT; SKIN DISEASES; SKIN NEOPLASMS;

EID: 43049162436     PISSN: 02722712     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.cll.2007.12.006     Document Type: Review

References (96)

1. Troxel D.B. Pitfalls in the diagnosis of malignant melanoma. Am J Surg Pathol 27 (2003) 1278-1283
2. Troxel D.B. An insurer's perspective on error and loss in pathology. Arch Pathol Lab Med 129 (2005) 1234-1236
3. Troxel D.B. Medicolegal aspects of error in pathology. Arch Pathol Lab Med 130 (2006) 617-619
4. Read S., and Hill H.F. Dermatology's malpractice experience: clinical settings for risk management. J Am Acad Dermatol 53 (2005) 134-137
5. Lydiatt D.D. Medical malpractice and cancer of the skin. Am J Surg 187 (2004) 688-694
6. Glusac E.J. Under the microscope: doctors, lawyers, and melanocytic neoplasms. J Cutan Pathol 30 (2003) 287-293
7. Albert V.A., Koh H.K., Geller A.C., et al. Years of potential life lost: another indicator of the impact of cutaneous malignant melanoma on society. J Am Acad Dermatol 23 (1990) 308-310
8. Bevona C., and Sober A.J. Melanoma incidence trends. Dermatol Clin 20 (2002) 589-595
9. Erie Railroad v. Tompkins, 304 U.S. 64. 1938.
10. Fox B.C., Siegel M.L., and Weinstein R.A. "Curbside" consultation and informal communication in medical practice: a medicolegal perspective. Clin Infect Dis 23 (1996) 616-622
11. Kelley v. Middle Tennessee Emergency Physicians, P.C., 133 S.W.3d 587 (Tenn. 2004).
12. Scafide v. Bazzone, NO. 2004-CA-01658-COA (Miss.Ct. App. 2004).
13. Epstein J.I. Pathologists and the judicial process: how to avoid it. Am J Surg Pathol 25 (2001) 527-537
14. Troxel D.B., and Sabella J.D. Problem areas in pathology practice uncovered by a review of malpractice claims. Am J Surg Pathol 18 (1994) 821-831
15. Tomaszewski J.E., and LiVolsi V.A. Mandatory second opinion of pathologic slides: is it necessary?. Cancer 86 (1999) 2198-2200
16. Dahl J. Quality, assurance, diagnosis, treatment, and patient care. Pathology review-patient safety and quality healthcare (2006). http://www.psqh.com/marapr06/pathologist.html Accessed August 18, 2007
17. Martello J. Basic medical legal principles. Clin Plast Surg 6 (1999) 9-14
18. Furrow B., Greaney T., Johnson S., et al. Health law. 3rd edition (1997), West Publishing, St. Paul (MN)
19. Vergara v Doan, 593 N.E.2d 185 (Ind. 1992).
20. Kinney E., and Wilder M. Medical standard setting in the current malpractice environment: problems and possibilities (1989), University of California at Davis Law Review, Davis (CA) 22:421-40
21. Trotter M.J., and Bruecks A.K. Interpretation of skin biopsies by general pathologists: diagnostic discrepancy rate measured by blinded review. Arch Pathol Lab Med 127 (2007) 1489-1492
22. Goldberg D.J. Legal issues in laser operation. Clin Dermatol 24 (2006) 56-59
23. Gittler G.J., and Goldstein E.J.C. Medicolegal case reviews. Clin Infect Dis 23 (1996) 1152-1155
24. Melville v. Southward, 791 P.2d 383 (Colo. 1990).
25. Marshall J.C. Credibility: the key to the successful physician witness. Surv Ophthalmol 40 (1995) 69-72
26. Palsgraf v Long Island Railway Co., 248 N.Y. 339 (N.Y. 1928).
27. Callahan v. Cardinal Glennon Hosp., 863 S.W.2d 852 (Mo. 1993).
28. St. George v. Pariser, 484 S.E.2d 888 (Va. 1997).
29. American Academy of Pediatrics. Committee on Medical Liability. Professional liability coverage for residents and fellows. Pediatrics 106 (2000) 605-609
30. Pace N.M., Zakaras L., and Golinelli D. Capping non-economic awards in medical malpractice trials: Califronia jury vedicts Ander MICRA (2004), Rand Corporation, Santa Monica (CA)
31. Ellington D.P., and Rosenthal R.S. The defense perspective. Med Malpractice 94 (1997) 323-327
32. Moran T. So you've been sued: tips for enduring and avoiding the malpractice roller coaster ride. Tex Med 9 (1995) 24-31
33. Summerton N., and Graham J.R. Effects of the medical liability system in Australia, the UK, and the USA. Lancet 368 (2006) 240-246
34. Colorado Governmental Immunity Act. Colorado Revised Statutes, Section 24-10-101, 2006.
35. National Institutes of Health. Consensus statement. Diagnosis and treatment of early melanoma. NIH Consensus Development Conference. Bethesda, MD, January 27-29, 1992.
36. Balch C.M., Soong S.J., Atkins M.B., et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 54 (2004) 131-149
37. Balch C.M., Soong S.J., Gershenwald J.E., et al. Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol 19 (2001) 3622-3634
38. Hancox J.G., Neville J.A., Chen J., et al. Interpretation of dermatopathology specimens is within the standard of care of dermatology practice. Dermatol Surg 31 (2005) 306-309
39. Kirsner R.S., and Federman D.G. Interpretation of cutaneous biopsy specimens: choice of pathologist by primary care practitioners. South Med J 94 (2001) 461-463
40. American Board of Medical Specialites. Recognized physician specialty and subspecialty certificates. Available at: http://www.abms.org/Who_We_Help/Physicians/specialties.aspx. Accessed August 19, 2007.
41. Grant-Kels J.M. The whys and wherefores of who reads dermatopathology slides. J Am Acad Dermatol 53 (2005) 703-704
42. Ackerman A.B. Dermatologist not equal to dermatopathologist: no place in a profession for pretenders. J Am Acad Dermatol 53 (2005) 698-699
43. Leboit P.E. Fire your dermatopathologist!. Arch Dermatol 135 (1999) 137-138
44. Barnhill R.L., Argenyi Z.B., From L., et al. Atypical Spitz nevi/tumors: lack of consensus for diagnosis, discrimination from melanoma, and prediction of outcome. Hum Pathol 30 (1999) 513-520
45. Crowson A.N. Medicolegal aspects of neoplastic dermatology. Mod Pathol 19 (2006) S148-S154
46. Brennan T.A., Leape L.L., Laird N.M., et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324 (1991) 370-376
47. Localio A.R., Lawthers A.G., Brennan T.A., et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med 325 (1991) 245-251
48. Studdert D.M., Mello M.M., Gawande A.A., et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 354 (2006) 2024-2033
49. Schmoeckel C., Castro C.E., and Braun-Falco O. Nevoid malignant melanoma. Arch Dermatol Res 277 (1985) 362-369
50. Magro C.M., Crowson A.N., and Mihm M.C. Unusual variants of malignant melanoma. Mod Pathol 19 (2006) S41-S70
51. McNutt N.S., Urmacher C., Hakimian J., et al. Nevoid malignant melanoma: morphologic patterns and immunohistochemical reactivity. J Cutan Pathol 22 (1995) 502-517
52. Fernandez E.M., Helm T., Ioffreda M., et al. The vanishing biopsy: the trend toward smaller specimens. Cutis 76 (2005) 335-339
53. Clark W.J., and Mihm M.J. Lentigo maligna and lentigo-maligna melanoma. Am J Pathol 55 (1969) 39-67
54. Pardasani A.G., Leshin B., Hallman J.R., et al. Fusiform incisional biopsy for pigmented skin lesions. Dermatol Surg 26 (2000) 622-624
55. Dalton S.R., Gardner T.L., Libow L.F., et al. Contiguous lesions in lentigo maligna. J Am Acad Dermatol 52 (2005) 859-862
56. Rigel DS. Melanoma symposium. Presented at the Program of the 60th Annual Meeting. American Academy of Dermatology. New Orleans, LA, February 22-27th, 2002.
57. Pariser R.J., Divers A., and Nasser A. The relationship between biopsy technique and uncertainty in the histopathologic diagnosis of melanoma. Dermatol Online J 5 (1999) 4
58. Dalton S.R., Baptista M.A., Libow L.F., et al. Lichenoid tissue reaction in malignant melanoma: a potential diagnostic pitfall. Am J Clin Pathol 117 (2002) 766-770
59. Weedon D. Skin pathology (2002), Churchhill Livingstone, New York p. 38
60. Spitz S. Cutaneous tumors of childhood. Disparity between clinical behavior and histologic appearance. J Am Med Womens Assoc 6 (1951) 209-219
61. Urso C., Borgognoni L., Saieva C., et al. Sentinel lymph node biopsy in patients with "atypical Spitz tumors." A report on 12 cases. Hum Pathol 37 (2006) 816-823
62. Roaten J.B., Partrick D.A., Bensard D., et al. Survival in sentinel lymph node-positive pediatric melanoma. J Pediatr Surg 40 (2005) 988-992
63. Gelbard S.N., Tripp J.M., Marghoob A.A., et al. Management of Spitz nevi: a survey of dermatologists in the United States. J Am Acad Dermatol 47 (2002) 224-230
64. Blessing K., and McLaren K.M. Histological regression in primary cutaneous melanoma: recognition, prevalence and significance. Histopathology 20 (1992) 315-322
65. High W.A., Stewart D., Wilbers C.R., et al. Completely regressed primary cutaneous malignant melanoma with nodal and/or visceral metastases: a report of 5 cases and assessment of the literature and diagnostic criteria. J Am Acad Dermatol 53 (2005) 89-100
66. Flax S.H., Skelton H.G., Smith K.J., et al. Nodular melanosis due to epithelial neoplasms: a finding not restricted to regressed melanomas. Am J Dermatopathol 20 (1998) 118-122
67. Clark Jr. W.H., Elder D.E., Guerry D., et al. Model predicting survival in stage I melanoma based on tumor progression. J Natl Cancer Inst 81 (1989) 1893-1904
68. Slingluff Jr. C.L., Vollmer R.T., Reintgen D.S., et al. Lethal "thin" malignant melanoma. Identifying patients at risk. Ann Surg 208 (1988) 150-161
69. Ronan S.G., Eng A.M., Briele H.A., et al. Thin malignant melanomas with regression and metastases. Arch Dermatol 123 (1987) 1326-1330
70. Naruns P.L., Nizze J.A., Cochran C.A., et al. Recurrence of potential thin primary melanomas. Cancer 57 (1986) 545-548
71. Sondergaard K., and Hou-Jensen K. Partial regression in thin primary cutaneous malignant melanomas clinical stage I. Virchows Arch A Pathol Anat Histopathol 408 (1985) 241-247
72. Paladugu R.R., and Yonemoto R.H. Biologic behavior of thin malignant melanomas with regressive changes. Arch Surg 118 (1983) 41-44
73. Gromet M.A., Epstein W.L., and Blois M.S. The regressing thin malignant melanoma: a distinctive lesion with metastatic potential. Cancer 42 (1978) 2282-2292
74. Fontaine D., Parkhill W., Greer W., et al. Partial regression of primary cutaneous melanoma. Am J Dermatopathol 25 (2003) 371-373
75. Shaw H.M., McCarthy W.H., McCarthy S.W., et al. Thin malignant melanomas and recurrence potential. Arch Surg 122 (1987) 1147-1150
76. Cooper P.H., Wanebo H.J., and Hagar R.W. Regression in thin malignant melanoma. Microscopic diagnosis and prognostic importance. Arch Dermatol 121 (1985) 1127-1131
77. Kelly J.W., Sagebiel R.W., and Blois M.S. Regression in malignant melanoma. A histologic feature without independent prognostic significance. Cancer 56 (1985) 2287-2291
78. Briggs J.C., Ibrahim N.B., Hastings A.G., et al. Experience of thin cutaneous melanomas (less than 0.76 mm and less than 0.85 mm thick) in a large plastic surgery unit: a 5 to 17 year follow-up. Br J Plast Surg 37 (1984) 501-506
79. Trau H., Rigel D.S., Harris M.N., et al. Metastases of thin melanomas. Cancer 51 (1983) 553-556
80. McGovern V.J., Shaw H.M., and Milton G.W. Prognosis in patients with thin malignant melanoma: influence of regression. Histopathology 7 (1983) 673-680
81. McGovern V.J., Shaw H.M., Milton G.W., et al. Prognostic significance of the histological features of malignant melanoma. Histopathology 1 (1979) 385-393
82. Slingluff C.L., and Seigler H.F. Thin malignant melanoma: risk factors and clinical management. Ann Plast Surg 28 (1992) 89-94
83. Nahabedian M.Y., Tufaro A.P., and Manson P.N. Sentinel lymph node biopsy for the T1 (thin) melanoma: is it necessary?. Ann Plast Surg 50 (2003) 601-606
84. Wong S.L., Brady M.S., Busam K.J., et al. Results of sentinel lymph node biopsy in patients with thin melanoma. Ann Surg Oncol 13 (2006) 302-309
85. Liszkay G., Orosz Z., Peley G., et al. Relationship between sentinel lymph node status and regression of primary malignant melanoma. Melanoma Res 15 (2005) 509-513
86. Carlson J.A., Dickersin G.R., Sober A.J., et al. Desmoplastic neurotropic melanoma. A clinicopathologic analysis of 28 cases. Cancer 75 (1995) 478-494
87. Reed RJ. Spindle-cell neoplasia. Presented at the annual meeting of the American Academy of Dermatology. New Orleans, LA, March 19-24, 1999.
88. Jensen K., Wilkinson B., Wines N., et al. Procollagen 1 expression in atypical fibroxanthoma and other tumors. J Cutan Pathol 31 (2004) 57-61
89. Tripp J.M., Kopf A.W., Marghoob A.A., et al. Management of dysplastic nevi: a survey of fellows of the American Academy of Dermatology. J Am Acad Dermatol 46 (2002) 674-682
90. Smoller B.R., and Egbert B.M. Dysplastic nevi can be diagnosed and graded reproducibly: a longitudinal study. J Am Acad Dermatol 27 (1992) 399-402
91. Kossard S. Atypical lentiginous junctional naevi of the elderly and melanoma. Australas J Dermatol 43 (2002) 93-101
92. King R., Page R.N., Googe P.B., et al. Lentiginous melanoma: a histologic pattern of melanoma to be distinguished from lentiginous nevus. Mod Pathol 18 (2005) 1397-1401
93. Davis T., and Zembowicz A. Histological evolution of lentiginous melanoma: a report of five new cases. J Cutan Pathol 34 (2007) 296-300
94. High W.A., Alanen K.W., and Golitz L.E. Is melanocytic nevus with focal atypical epithelioid components (clonal nevus) a superficial variant of deep penetrating nevus?. J Am Acad Dermatol 55 (2006) 460-466
95. Maize Jr. J.C., Resneck Jr. J.S., Shapiro P.E., et al. Ducking stray "magic bullets": a Melan-A alert. Am J Dermatopathol 25 (2003) 162-165
96. Demartini C.S., Dalton M.S., Ferringer T., et al. Melan-A/MART-1 positive "pseudonests" in lichenoid inflammatory lesions: an uncommon phenomenon. Am J Dermatopathol 27 (2005) 370-371