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Interobserver Agreement for Assessing Invasion in Stage 1A Vulvar Squamous Cell Carcinoma

Abdel-Mesih, Amal MD*; Daya, Dean MD; Onuma, Kazu MD*; Sur, Monalisa MD; Tang, Shangguo MD; Akhtar-Danesh, Noori PhD‡,§; Boutross-Tadross, Odette MD; Ceballos, Kathy M. MD; Chapman, William MD#; Colgan, Terence MD**; Deb, Pratima MD*; Nucci, Marisa R. MD††; Oliva, Esther MD‡‡; Lytwyn, Alice MD†,§

The American Journal of Surgical Pathology: September 2013 - Volume 37 - Issue 9 - p 1336–1341
doi: 10.1097/PAS.0b013e31829f306a
Original Articles

Invasive squamous cell carcinoma of the vulva with ≤1 mm stromal invasion is classified as stage 1A. Cancer staging systems state that the depth of invasion should be measured from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of the invasive tumor. Measurement of the depth of invasion guides patient management. Even though this measurement is critical, no studies have reported the reliability among pathologists for determining the cutoff point of ≤1 mm stromal invasion in vulvar cancer. We assessed agreement among pathologists for determining whether a vulvar tumor is invasive, for the depth of invasion, and for tumor thickness. Forty-five cases of vulvar squamous cell carcinoma with a depth of invasion of ≤5 mm were chosen. Eleven gynecologic pathologists independently reviewed the slides and, for a subset of cases, pictorially recorded measurements on photographs. The number of cases that were reported as invasive by the 11 pathologists ranged from 21 to 44. The number of cases that were reported as showing a depth of invasion of ≤1 mm ranged from 7 to 27. Eight pathologists provided measurements for all lesions reported as invasive, the remaining 3 pathologists stated that they were unable to measure 2, 7, and 16 lesions, respectively. Mean κ for diagnosing vulvar carcinoma as invasive was 0.24 and for measuring the depth of invasion and thickness was 0.51 and 0.49, respectively. There was only fair agreement in determining whether the lesion was invasive. In cases in which pathologists agreed upon the diagnosis of invasion, agreement on depth was moderate. When using the recommended cancer staging method, interpretation of the location of the most superficial dermal papilla varied among pathologists. Measuring thickness did not improve agreement. This is the first study that has assessed the reliability of the diagnosis of invasion in vulvar cancer among gynecologic pathologists, the interobserver agreement for reporting the critical 1 mm threshold of depth of stromal invasion, and the way in which the International Federation of Gynecology and Obstetrics method is used by pathologists.

*Department of Pathology and Molecular Medicine

Department of Pathology and Molecular Medicine, Juravinski Hospital

School of Nursing

§Department of Clinical Epidemiology and Biostatistics

Department of Pathology and Molecular Medicine, McMaster University Medical Centre, McMaster University, Hamilton

#Department of Pathology, St Joseph’s Hospital

**Department of Pathology, Mt Sinai Hospital, University of Toronto, Toronto, ON

British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada

††Department of Pathology, Brigham and Women’s Hospital

‡‡Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Amal Abdel-Mesih, MD, Department of Pathology and Molecular Medicine, St. Joseph's Hospital 50 Charlton Ave. East, Hamilton, Ontario, ON, Canada L8N-4A6 (e-mail:

© 2013 by Lippincott Williams & Wilkins.