PROSPECTIVE-STUDY OF THE ACCURACY OF THE SURGEONS DIAGNOSIS IN 2000 EXCISED SKIN TUMORS

Expeditious yet efficacious removal of skin tumors is a common respons ibility for the plastic surgeon. The need to minimize potential risks for mortality or morbidity from undue or excessive surgical resections and to control costs by avoiding unnecessary procedures behooves us t o make a precise clinical diagnosis preceding any decision even for su ch ''minor'' surgery. Just how accurate these decisions can be expecte d to be for a typical surgical practice was scrutinized by means of th is prospective 4-year study involving the resection of 2058 skin lesio ns. Each lesion was initially assigned a clinical diagnosis after a br ief gross examination and then compared with the pathology report, whi ch was always considered to be the correct answer. Within these parame ters, only 65 percent of all tumors were identified correctly preopera tively. Two-thirds of all lesions were benign. Three-quarters of benig n lesions were as assumed, and 92 percent of all presumed benign lesio ns were benign even if incorrectly identified initially, whereas fortu nately only 3 percent proved to he malignant. On the other hand, only three-fifths of malignant lesions were identified correctly clinically , yet only 11 percent were benign, implying that most such lesions pro perly deserved excision anyway. Therefore, approximately 90 percent of all lesions whether benign or malignant were removed appropriately wi thout compromising the patient, but to expect a clinical acumen of 100 percent in this setting may not be realistic. The accuracy of the sur geon in identifying lesions as probably benign was certainly high enou gh that cost-containment mechanisms designed to deny authorization for their removal probably would be justifiable and difficult to appeal. Any suspicious or equivocal lesions still will require mandatory inter vention despite such constraints, because often only histologic examin ation will allow a definitive diagnosis.