Change in Diagnosis and Level of Errors Pak Armed Forces Med J 2021; 71 (3): 729-33 729 LEVEL OF ERRORS, CHANGE IN DIAGNOSIS AND THEIR IMPACT ON MANAGEMENT IN CASES REFERRED FOR SECOND OPINION Madeeha Anwar, Muhammad Asif, Rabia Ahmed, Muhammad Tahir Khadim, Shahid Jamal*, Hamza Mansur Armed Forces Institute of Pathology/National University of Medical Sciences (NUMS) Rawalpindi Pakistan, *Watim Medical College Rawalpindi Pakistan ABSTRACT Objective: To determine the frequency of change in diagnosis and level of errors in cases referred to Armed Forces Institute of Pathology for second opinion and their impact on modifications of treatment and prognosis. Study Design: Cross sectional study. Place and Duration of Study: Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, form Mar to Oct 2017 Methodology: All the cases referred for review diagnosis were tested by applying panel of immunohistochemical markers and special stains on formalin fixed paraffin embedded tissue sections as decided on morphology. Level of errors were defined as level I error: minor discrepancy with no impact on management, level II: minor discrepancy with impact on management, level III: main category remains same but there was change/confirmation of specific diagnostic entity with an impact on management and level IV: gross changes in diagnosis with significant impact on management. Level IV was further subdivided into IV a: benign misdiagnosed as malignant, IV b: malignant misdiagnosed as benign and IV c: changes in tumor subtype. Results: A total of 100 cases, where review diagnosis was changed were included. Minor discrepancies (level I and level II) were observed in only 7% cases with little or no impact on the management. Most frequent discrepancy observed as Level III in 75% cases. Major discrepancy (Level IV errors) was noted in 18% cases. Conclusion: There were high discrepancy rates between previous diagnosis and review diagnosis. The higher use of extended panels of immunohistochemistry markers were the most likely explanations. Keywords: Discrepancy in diagnosis, Immunohistochemistry, Review diagnosis, Second opinion. INTRODUCTION Several studies reported the advantages of obtai- ning second opinion for more accurate diagnosis 1,2 . Second opinion after initial histopathological diagnosis is required in different situations 3-6 . The criteria when to get the second opinion vary considerably 3 . It may be needed for the patient/relatives satisfaction and if clinical impression of treating clinician does not tally with histological diagnosis. Sometimes second opinion is required when the patient is not responding to the treatment being given after initial diagnosis 4 . Such second opinions help to expose diagnostic errors and helps in proper management of patient 5 . Jamal et al, reported in their study that in 50.7% of the total cases, diagnosis was changed on review, out of which majo- rity were malignant 3 . Hamdani et al, reported 72% dis- crepancy between initial and review diagnosis 6 . In the same study, different categories of discrepancies have also been discussed. In Pakistan, surgical pathology is still evolving as a science and clinicians are becoming increasingly aware of the importance of an accurate surgical pathology diagnosis for the treatment of their patients. While the basic aim of the practice of surgical pathology is to provide accurate diagnosis, it is equally essential to prevent an erroneous diagnosis, which can result in serious errors in the treatment and prognosis of the patient 7 . In a developing country like Pakistan most of the centers lack the facility of immunohistoche- mistry and special stains, which is thought to be essen- tial for the diagnosis in many cases, and this further necessitates the importance of second opinion from more specialized referral centers. The section of His- topathology at Armed Forces Institute of Pathology (AFIP) Rawalpindi is serving as the major referral center for diagnostic surgical pathology. With the aid of extended immunohistochemical panel and special stains, accurate diagnosis has been made possible and subsequent change in the diagnosis of referred cases for review has a huge impact on the modification of management of patients. The purpose of this study was to review the cases sent to AFIP for second opinion and to determine the changes in the diagnosis and to ascertain level of errors in the diagnosis. The results would help to establish the significance of acquiring second opinion and use of extended panel of immunohistochemistry for accurate diagnosis and subsequent benefit for the patient and This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Correspondence: Dr Madeeha Anwar, Department of Histopathology, Armed Forces institute of Pathology, Rawalpindi Pakistan Received: 15 Jan 2019; revised received: 26 Sep 2019; accepted: 31 Oct 2019 madihaxulfiqar@gmail.com Original Article Open Access