Hallock G G, Lutz D A
Division of Plastic Surgery, the Lehigh Valley Hospital, Allentown, PA, USA.
Plast Reconstr Surg. 1998 Apr;101(5):1255-61. doi: 10.1097/00006534-199804050-00014.
Expeditious yet efficacious removal of skin tumors is a common responsibility 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 to make a precise clinical diagnosis preceding any decision even for such "minor" surgery. Just how accurate these decisions can be expected to be for a typical surgical practice was scrutinized by means of this prospective 4-year study involving the resection of 2058 skin lesions. Each lesion was initially assigned a clinical diagnosis after a brief gross examination and then compared with the pathology report, which was always considered to be the correct answer. Within these parameters, only 65 percent of all tumors were identified correctly preoperatively. Two-thirds of all lesions were benign. Three-quarters of benign lesions were as assumed, and 92 percent of all presumed benign lesions were benign even if incorrectly identified initially, whereas fortunately only 3 percent proved to be 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 properly deserved excision anyway. Therefore, approximately 90 percent of all lesions whether benign or malignant were removed appropriately without compromising the patient, but to expect a clinical acumen of 100 percent in this setting may not be realistic. The accuracy of the surgeon in identifying lesions as probably benign was certainly high enough 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 intervention despite such constraints, because often only histologic examination will allow a definitive diagnosis.
对整形外科医生来说，迅速且有效地切除皮肤肿瘤是一项常见的职责。通过避免不必要的手术来尽量减少因过度或不当手术切除导致的死亡或发病的潜在风险，并控制成本，这就要求我们在做出任何决定之前，即使是对于这样的“小手术”，也要进行精确的临床诊断。通过这项为期4年的前瞻性研究，对2058例皮肤病变的切除情况进行了审查，以探究在典型的外科手术实践中这些诊断的准确程度。在进行简短的大体检查后，每个病变最初都被给出一个临床诊断，然后与病理报告进行比较，病理报告始终被视为正确答案。在这些参数范围内，术前正确识别的肿瘤仅占所有肿瘤的65%。所有病变中有三分之二是良性的。四分之三的良性病变与预期相符，所有推测为良性的病变中有92%即使最初识别错误也是良性的，而幸运的是只有3%被证明是恶性的。另一方面，临床上仅五分之三的恶性病变被正确识别，但只有11%是良性的，这意味着大多数此类病变无论如何都值得切除。因此，所有病变中约90%，无论良性还是恶性，都在不影响患者的情况下被适当切除，但期望在这种情况下临床敏锐度达到100%可能并不现实。外科医生将病变识别为可能良性的准确性肯定足够高，以至于旨在拒绝批准切除这些病变的成本控制机制可能是合理的且难以申诉。尽管有这些限制，任何可疑或模棱两可的病变仍将需要进行强制性干预，因为通常只有组织学检查才能做出明确诊断。
