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Br J Dermatol:我们需要重新考虑对原位黑色素瘤和严重发育异常痣的诊断吗?

2022-03-17 医路坦克 MedSci原创

原位黑色素瘤和细小侵袭性黑色素瘤的发病率逐年增加,本文对已发表的证据进行了搜索和调查,以支持或拒绝改变诊断阈值和用于这些低风险黑素细胞病变的术语,并就我们的发现提供详细的报告。

     近几十年来,许多国家的皮肤黑色素瘤报告发病率急剧上升,这主要是由于原位黑色素瘤和细小侵袭性黑色素瘤的诊断增加所致。浸润黑色素瘤和转移性黑色素瘤的发生率以及黑色素瘤死亡率保持相对稳定。虽然老龄化人口可能会导致黑色素瘤发病率的一些真正增加,但这种增加很大程度上可能是过度诊断:如果不发现和不治疗,对永远不会造成伤害的病变的诊断。如果发生这种情况,黑色素瘤过度诊断可能会对个人造成潜在的心理和身体伤害,并因程序和长期监测而给保健系统带来巨大成本。使用新的诊断标签(例如“黑素细胞肿瘤”)和/或重新校准原位诊断黑色素瘤的诊断阈值可以减少这些危害。

    这些策略还可以应用于严重发育不良痣的诊断,因此MPATH-Dx报告方案中的诊断标签和与原位黑色素瘤的明显等效性(以及相关的治疗建议)也可能导致患者和临床医生的严重焦虑。

    我们对已发表的证据进行了搜索和审查,以支持或拒绝改变诊断阈值和/或用于这些低风险黑素细胞病变的术语,并就我们的发现提供详细的报告。对三条证据进行了评估。首先是关于这些病变的自然病史的证据,我们发现这些证据很少,因为原位黑色素瘤和严重的发育不良痣通常都要切除。我们发现了四项关于自然历史的研究,都存在很高的偏见风险。一项统计建模研究估计,每年最多有3.5%的恶性雀斑(一种原位黑色素瘤)可能进展为恶性雀斑黑色素瘤(一种侵袭性黑色素瘤)。三项回顾性研究报告了严重发育不良痣患者不完全切除后的情况。经过6个月至29.9年的随访,127例切缘呈阳性或接近边缘的患者中,无一例在与严重发育不良痣或转移瘤相同的部位发生侵袭性黑色素瘤。

    第二是关于这两类病变诊断标准可靠性的证据。我们发现了14项重复性研究,其中3项具有较低的偏倚风险。Elmore和他的同事们发现其中最大的一项对原位黑色素瘤和严重发育异常痣(MPATH-Dx III级)的诊断重复性较差,研究病理学家与专家小组共识之间的一致性为40%,观察者间的一致性为45%,观察者内的一致性为59.5%。其他研究也表明,原位黑色素瘤和严重发育不良痣的诊断重复性较差。

   第三,有证据表明,随着时间的推移,诊断阈值会发生漂移,因此,即使之前同样的黑素细胞病变被判定为良性病变,现在也会使用更“恶性”的诊断标签。我们发现有两项研究提供了诊断的证据,这两项研究都有很高的偏倚风险。这为原位黑色素瘤和严重发育不良痣的诊断阈值下降和疾病定义的扩展提供了证据。第一项回顾研究比较了1988-1990年40个黑素细胞病变的原始诊断与2008-2009年皮肤病理学家的诊断,后者对原始诊断视而不见。在1998-1990年的40个病灶中,29个被诊断为严重发育不良痣,11个被诊断为浅表性播散性黑色素瘤。2008-2009年升级为黑色素瘤的平均比例为7/40(17.5%),没有皮损降级。在另一项研究中,2011-2012年对1179个最初在1980-1989年诊断为交界性或复合性痣的皮损进行了重新审查。根据现代组织病理学标准,117/1179(10%)被重新分类为发育不良痣(7例重度发育不良,42例中度发育不良,66例轻度发育不良,2例除外)。这两项研究都表明,随着时间的推移,黑色素瘤和严重发育不良痣的诊断门槛会降低,导致疾病定义的扩大。

    总之,稀少的自然病史证据表明,从原位黑色素瘤进展到侵袭性黑色素瘤的风险不确定,但可能很低,而从严重发育不良痣进展到侵袭性黑色素瘤的风险可以忽略不计。这些类型的病变可能更好地被概念化为侵袭性黑色素瘤的危险因素,而不是前驱症状。有强有力的证据表明,这两种类型的病变诊断的重复性都很低,一些证据表明,随着时间的推移,疾病定义已经扩大。

文献来源:Semsarian CR,  Ma T,  Nickel B, Do we need to rethink the diagnoses melanoma in situ and severely dysplastic naevus?Br J Dermatol 2022 Jan 10; 

 

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    2022-09-12 sunylz
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    2022-03-17 仁术2021

    不错,学习了。

    0

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    2022-03-16 neurowu
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    2022-03-16 yese
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