Background: Diagnosing facial melanoma, specifically lentigo maligna (LM) and lentigo maligna melanoma (LMM), is a daily clinical challenge, particularly for small or traumatized lesions. LM and LMM are part of the broader group of atypical pigmented facial lesions (aPFLs), which also includes benign look-alikes such as solar lentigo (SL), atypical nevi (AN), seborrheic keratosis (SK), and seborrheic-lichenoid keratosis (SLK), as well as pigmented actinic keratosis (PAK), a potentially premalignant keratinocytic lesion. Standard dermoscopy with handheld devices is the most widely used diagnostic tool in dermatology, but its accuracy heavily depends on the clinician’s experience and the perceived difficulty of the case. As a result, many benign aPFLs are excised for histological analysis, often leading to aesthetic concerns. Reflectance confocal microscopy (RCM) can reduce the need for biopsies, but it is limited to specialized centers and requires skilled operators. Aims: This study aimed to assess the impact of personal skill, diagnostic confidence, and perceived difficulty on the diagnostic accuracy and management in the differential dermoscopic diagnosis of aPFLs. Methods: A total of 1197 aPFLs dermoscopic images were examined on a teledermoscopic web platform by 155 dermatologists and residents with 4 skill levels (<1, 1–4, 5–8, >8 years). They were asked to give a diagnosis, to estimate their confidence and rate the case, and choose a management strategy: “follow-up”, “RCM” or “biopsy”. Diagnostic accuracy was examined according to the personal skill level, confidence level, and rating in three settings: (I) all seven diagnoses, (II) LM vs. PAK vs. fully benign aPFLs, (III) malignant vs benign aPFLs. The same analyses were performed for management decisions. Results: The diagnostic confidence has a certain impact on the diagnostic accuracy, both in terms of multi-class diagnosis of six aPFLs in diagnostic (setting 1) and in benign vs malignant (setting 3) or benign vs. malignant/premalignant discrimination (setting 2). The perceived difficulty influences the management of benign lesions, with easy ratings predominantly matching with “follow-up” decision in benign cases, but not that of malignant lesions assigned to “biopsy”. The experience level had an impact on the perception of the number of real easy cases and had no to minimal impact on the average diagnostic accuracy of aPFLs. It, however, has an impact on the management strategy and specifically in terms of error reduction, namely the lowest rates of missed malignant cases after 8 years of experience and the lowest rates of inappropriate biopsies of benign lesions after 1 year of experience. Conclusions: The noninvasive diagnosis and management of aPFLs rest on a daily challenge. Highlighting which specific subgroups of lesions need attention and second-level examination (RCM) or biopsy can help detect early malignant cases, and, in parallel, reduce the rate of unnecessary removal of benign lesions.
背景：面部黑色素瘤，尤其是恶性雀斑样痣（LM）和恶性雀斑样痣黑色素瘤（LMM）的诊断，是日常临床工作中的一大挑战，对于小型或创伤性病变尤为如此。LM和LMM属于非典型色素性面部皮损（aPFLs）这一更广泛的类别，该类别还包括良性相似病变，如日光性雀斑样痣（SL）、非典型痣（AN）、脂溢性角化病（SK）和脂溢性苔藓样角化病（SLK），以及色素性光化性角化病（PAK）——一种潜在癌前性角质形成细胞病变。手持设备的标准皮肤镜检查是皮肤病学中最广泛使用的诊断工具，但其准确性在很大程度上依赖于临床医生的经验和对病例难度的主观判断。因此，许多良性aPFLs被切除进行组织学分析，这常常引发美观方面的担忧。反射式共聚焦显微镜（RCM）可以减少活检需求，但其应用仅限于专业中心且需要熟练的操作人员。 目的：本研究旨在评估个人技能、诊断信心和主观难度感知对aPFLs皮肤镜鉴别诊断的准确性及临床处理决策的影响。 方法：在远程皮肤镜网络平台上，由155名具有4种技能水平（<1年、1-4年、5-8年、>8年经验）的皮肤科医生和住院医师，对总计1197张aPFLs皮肤镜图像进行了评估。评估者被要求给出诊断、评估自身信心水平、对病例难度进行评级，并选择处理策略：“随访”、“RCM检查”或“活检”。在三种设定下，根据个人技能水平、信心水平和难度评级对诊断准确性进行了分析：（I）所有七种诊断，（II）LM vs. PAK vs. 完全良性aPFLs，（III）恶性 vs 良性aPFLs。对处理决策也进行了同样的分析。 结果：诊断信心对诊断准确性有一定影响，无论是在六种aPFLs的多类别诊断（设定1），还是在良性 vs 恶性（设定3）或良性 vs 恶性/癌前病变的鉴别（设定2）中都是如此。主观难度感知影响良性皮损的处理决策，在良性病例中，低难度评级主要与“随访”决策相匹配，但恶性皮损被分配为“活检”决策则不受此影响。经验水平影响对真正简单病例数量的感知，但对aPFLs的平均诊断准确性没有或仅有极小影响。然而，经验水平对处理策略有影响，特别是在减少错误方面，即拥有8年以上经验者漏诊恶性病例的比率最低，拥有1年以上经验者对良性皮损进行不适当活检的比率最低。 结论：aPFLs的无创诊断和处理是日常面临的挑战。明确哪些特定亚组的皮损需要关注并进行二级检查（RCM）或活检，有助于早期发现恶性病例，同时降低良性皮损不必要切除率。
肿瘤(癌症)患者之家