Reviewer's report
Title:Development of a diagnostic test set to assess agreement in breast
pathology: Practical application of the Guidelines for Reporting Reliability and
Agreement Studies (GRRAS)
Version: 2Date:27 November 2012
Reviewer: antonio rizzo
Reviewer's report:
1) Major Compulsory revisions
Oversampled… (page 5 last paragraph). At this point, please could you explain
me better if the selection of cases in the set have been selected a greater
number of cases of ADH and DCIS than the US average? If so, I think that is
misguided concept because it could alterate the reality : also you know, the
reproducibility in that sector of the disease is low. In addition, please note on
page 8, second paragraph, made by the same authors : " We aimed to create a
test set of slides that, as closely as possible, mirrored the quality and variety of
cases observed in everyday clinical practice... "
You could try to extrapolate a set with a greater number of cases with ADH and
DCIS for educational and training but no for reproducibility. The use of category
B1-B5 (Rahka et al, Int J Cancer 2010, 129.1417 -1424) such as is important, for
dubious categories (B3), not to make a precise diagnosis, but to suggest the next
step of diagnostic procedure. For example, the diagnosis of ADH is not desirable
to maintain it on core biopsy because diagnosis criteria are also quantities over
DCIS: it is preferable to use an atypical intraductal proliferative lesion diction also
because WHO 2012 hasn't established unique criteria to differentiate ADH from
DCIS (involvement of at least two membrane-bound spaces ducts or > 2 mm): “
….the WHO Working Group did not consider that it was possible to recommend
one approach rather then another and many expert use combination of both in
their clinical practice. It should be noted that quantitative thresholds are meant to
be pragmatic guidelines that are useful in preveting the categorization of very
small low grade lesions as DCIS and in turn in avoiding overtreatment of patients
with these minimal or equivocal lesions. A conservative approach should
particularly be used in needle-core biopsy specimens in which the differential
diagnosis includes ADH and low grade DCIS of limited extent. Categorization of
such lesion as either ADH or as atypical intraductal proliferative lesion should be
sufficient to prompt a surgical excision and definitive categorization of such
lesions should be based on evaluation of the subsequent surgical excision
specimen…" from WHO Classification of Tumours of the breast, 2012, page 88).
2)Major Compulsory Revisions
Except as stated in item 1, I totally agree with the authors on the need to
carefully define the selection of cases and establish the gold standard. In the
discussion I would add that there are, beyond those reported, several readers
agreement mode: the last proposed by Ian Ellis (2011, available at
http://www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp02.pdf) is
also a good way of detecting the reproducibility, and perhaps more "realistic":
realistic not - as rightly pointed out by the authors- since the majority diagnosis is
the diagnosis "right"; but why is the best diagnosis possible and reachable by
80% of readers. It won't be perfect, proper diagnosis, true, but the best in current
conditions, because it is unthinkable that all the core biopsies are read by a panel
of international experts.
I think that we can't said at the moment which is the better gold standard , but we
also can't minimized the document that I quoted,and please note, 600 breast
pathologists of the UK worked on.
3) Major Compulsory Revisions
I don't understand the reason of entering lobular carcinoma in situ between non
proliferative lesions. Even flat epithelial atypia to escape me the motivation for
which was sandwiched between non-proliferating atypical lesions. I think it
should be explained why.
4) Minor Essential Revisions
The bibliographic entry 24 missing reporting year of publication
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that i have no competing interests