Should Patients Being Considered for Surgical Management in Melanoma Centers Have Their Histology Reviewed by Specialized Pathologists

The outlook for patients with cutaneous melanoma has substantially improved. This is attributable to a variety of factors, including enhanced patient and professional awareness of the clinical events and changes in appearance that mark the early evolution of cutaneous melanoma. This facilitates early clinical diagnosis at a time when local surgery can be curative. Increasingly, logical approaches to the extent of surgical clearance of primary tumors and new approaches to the management of the regional lymph nodes have also been contributory. Primary care physicians and general dermatologists, while willing to undertake excision of nonmelanocytic and clinically benign melanocytic lesions, are less often willing to undertake definitive excision of diagnostically established primary melanomas, and are seldom prepared to perform lymphatic mapping and sentinel node biopsy. This has led to the evolution of highly specialized ‘‘melanoma surgeons’’ who work in complex multidisciplinary units that focus on surgical management of all clinical stages of cutaneous melanoma. I have been associated with such a unit (i.e., the Division of Surgical Oncology at UCLA) for many years, and from my day-to-day experience, I strongly recommend that the histology of alleged primary melanomas is reviewed prior to any extensive surgery by a surgical pathologist or dermatopathologist who has extensive experience in the interpretation of melanocytic lesions. We usually agree with the diagnosis rendered by our colleagues in the community, but not always. Most problems relate to overdiagnosis of atypical, but benign, melanocytic lesions that represent dysplastic nevi, variants of Spitz ‘‘nevi,’’ deep penetrating nevi, and cellular blue nevi. Most surgeons are comfortable with this extra layer of review, despite the inconvenience of procuring the original slides, the possibility of modest delay to operative plans, and a cost increase to the patient. Conversion of those who are less in favor of additional review rapidly follows their experience with cases in which a second opinion significantly changes the diagnosis, the T stage, and the predicted outcome for the patient or the evidence used to determine the need for lymphatic mapping and sentinel node biopsy. Although cumulated experience has made me (and many of my colleagues) committed supporters of specialist pathology review prior to major local or regional surgery for cutaneous melanoma (and other neoplasms), this position is derived from clinical workday experience rather than deliberately winnowed scientific evidence. Formal evidence that emphatically supports specialist pathology review prior to surgery is provided by the excellent paper by Niebling et al. in the current edition of the Annals of Surgical Oncology. The authors from the Melanoma Institute of Australia (MIA) evaluated 5,011 pairs of pathology reports from melanoma patients referred to their institute for further treatment between 2002 and 2011. They compared the pathology reports prepared at the referring institutes (Non-Melanoma Institute of Australia (NMIA) reports) with the findings at MIA (MIA reports): diagnosis, information needed to determine American Joint Committee on Cancer (AJCC) T staging, the extent of wide excision required, and the need for lymphatic mapping and sentinel lymph node biopsy (SLNB). They found clinically significant diagnostic differences in 5.1 % of patients: 108 of 529 regarded as melanoma in situ (MIS) in the NMIA reports were upgraded to Society of Surgical Oncology 2014