Improving Diagnostic Accuracy of Dermoscopically Equivocal Pink Cutaneous Lesions with Reflectance Confocal Microscopy in Telemedicine Settings: Double Reader Concordance Evaluation of 316 Cases

Abstract

BackgroundSolitary pink lesions in differential diagnosis with hypopigmented/amelanotic melanoma present a diagnostic challenge in daily practice and are regularly referred for second expert opinion. Reflectance confocal microscopy (RCM) has been shown to improve diagnostic accuracy of dermoscopically equivocal pink lesions. No studies have been performed to evaluate the effect of adding a second expert reader and automatic removal of lesions with discordant management recommendations and its potential effect on diagnostic sensitivity and final management of these lesions in retrospective or telemedicine settings.ObjectiveTo improve diagnostic accuracy and reduce potential mismanagement of dermoscopically equivocal pink cutaneous lesions by implementing double reader concordance evaluation of RCM images.Methods316 dermoscopically equivocal pink lesions with dermoscopy-RCM image sets were evaluated retrospectively. Accuracy of three readers was evaluated by single reader evaluation of dermoscopy only and dermoscopy-RCM image sets and finally by double reader evaluation of dermoscopy-RCM image sets. Lesions with discordant diagnosis between two readers were automatically recommended for excision.ResultsDermoscopy only evaluation resulted in an overall sensitivity of 95.9% and specificity of 33.6%, with 1 of 12 amelanotic melanomas mismanaged. Dermoscopy-RCM image set single reader evaluation resulted in an overall sensitivity of 93.9% and overall specificity of 54.2%, with 1 of 12 melanomas mismanaged. Dermoscopy-RCM image set double reader concordance evaluation resulted in an overall sensitivity of 98.3% and specificity of 42.7%, with no amelanotic melanoma mismanagement.ConclusionEvaluation of dermoscopy-RCM image sets of equivocal pink lesions by a single reader in telemedicine settings is limited by the potential for misdiagnosis of dangerous malignant lesions. Double reader concordance evaluation with automatic referral of lesions for removal in the case of discordant diagnosis improves the diagnostic sensitivity in this subset of lesions and reduce potential misdiagnosis in settings where a second expert opinion may be employed.

Improving diagnostic sensitivity of combined dermoscopy and reflectance confocal microscopy imaging through double reader concordance evaluation in telemedicine settings: A retrospective study of 1000 equivocal cases

“…Previous RCM studies tested performance of single evaluators and reported variable sensitivities and specificities, mainly related to different study settings, study populations and evaluator expertise, but all studies demonstrated a good diagnostic performance in settings of difficult to diagnose lesions [ 5 – 22 ]. Previous studies include two main types: non-interventional and interventional studies.…”

“…These studies mostly evaluated diagnostic performance of RCM alone and differential diagnosis was predominantly based on dermoscopically equivocal lesions [ 5 , 7 – 10 , 13 – 22 ]. Reported diagnostic sensitivity was high in all cases (ranging between 84 to 100%) and specificity variable, lower in more difficult study populations such as those containing pink lesions [ 5 , 7 ] and equivocal lesions that presented with architectural changes during sequential digital dermoscopic follow-up [ 8 , 9 ], demonstrating the usefulness and reliability of this methodology for achieving a precise MM diagnosis. The always superior specificity and comparable sensitivity, when compared with dermoscopy alone, suggests the benefit of combined use of these technologies in clinical settings [ 18 , 20 ].…”

“…In the past decade reflectance confocal microscopy (RCM) use in clinical practice has been shown to further improve early MM diagnosis and help to reduce the number of unnecessary excisions in different settings, as summarized in Table 1 [ 5 – 22 ] and confirmed by recent reviews and meta-analysis [ 23 , 24 ].…”

“…Recently, the reliability of teleconsultation with dermoscopy images only [ 25 , 26 ] or combined dermoscopy-RCM images [ 5 , 10 , 14 ] has been tested which showed the capability of an accurate diagnosis but risk of mismanagement of potentially dangerous lesions, with diagnostic accuracy depending greatly on the level of expertise. Since RCM is a newly adopted technology its limitation to proper and safe diffusion may be due to the limited number of expert users in the field and lack of dedicated training programs to properly support the necessary knowledge acquisition and experience needed for safe and effective implementation in clinical practice.…”

Seborrheic keratoses mimicking melanoma unveiled by in vivo reflectance confocal microscopy

“…For the selected lesions, different criteria were investigated according to RCM features previously outlined in literature . Table shows a brief description of the RCM criteria for non‐melanocytic lesions evaluated in the study.…”