Double reporting and second opinion in head and neck pathology

Abstract

This editorial aims to discuss the practice of “double reporting” and “second opinion” diagnosis in routine diagnostic pathology interpretation. It does not encompass reviews performed as part of audit and quality assurance functions, but is from the perspective of experienced head and neck and oral and maxillofacial specialists. “Double reporting” generally refers to showing a case to one or more colleagues working in the same histopathology unit before issuing a malignant diagnosis [1]. When there is concurrence, the fact that the case has been seen by two pathologists may or may not be mentioned in the report, often determined by individual practice, medical-legal environments and relative value units of workload. The final report may be signed by all pathologists who reviewed the case or might simply include a statement that the “case has been reviewed by {name of reviewer(s)}, who concur(s) with the diagnosis”. In case of a major disagreement between experienced pathologists in the same unit (e.g., benign vs. malignant), additional evaluation should be solicited and the issued diagnosis may be a majority decision. This difference of opinion should be mentioned in the report, with typical examples including cases of melanoma or hematopoietic and lymphoid neoplasia. The practice of “double reporting” varies between diagnostic histopathology units worldwide, from non-existent to voluntary to mandatory. Nevertheless, increasing risk from medical litigation may eventually tip the scales towards mandatory double reporting as a standard protocol for subsets of pathology diagnosis, such as malignant lesions. “Double reporting” may also be applied to unusual, rare, and difficult diagnoses, including benign lesions. The variations in practices have made comparisons between institutions difficult, with very little reported literature. Nevertheless, a study involving 45 laboratories in the USA reported a median rate of review of about 1 in 12 cases, with malignancy and difficult diagnosis being the primary reported reasons for review [2]. The study documented that head and neck lesions accounted for 4.1 % of cases with “double reporting”, while three-fifths were focused on gastrointestinal tract, breast, skin and female genital tract lesions [2]. Referring a case for a “second opinion” implies the traditional, formal approach of sending a case to an external, recognized specialist department or individual pathologist with experience and expertise in a particular field. It often involves rare or difficult cases where the referring pathologists are uncertain of the diagnosis, recognize the inherent challenges of the case and regard “second opinion” part of their required/expected diligence in working up and finalizing a diagnosis. Other reasons include the lack of access to required laboratory investigations, tests, or molecular testing to confirm a diagnosis. “Second opinion” may be retrospective when there is an institutional review of outside pathology slides as a standard protocol for referral patients before definitive treatment. A retrospective request for “second opinion” can also be made directly by the patient, relatives or legal representatives. This may occur after investigation into the diagnosis by the patient and is becoming more common with the universal availability of the internet, lay access to medical literature and litigation. Finally, “second opinion” can be retrospectively requested when departmental audit or quality assurance reveals a disagreement between pathologists that cannot be resolved internally. “Second opinion” can account for a significant component of a specialist head and neck/oral and maxillofacial pathologist’s workload. The number of “second opinion” evaluations should be audited when assessing target workloads for individual pathologists.