Assessment of a Diagnostic Classification System for Management of Lesions to Exclude Melanoma

Key Points

Question  What is the reliability of a more clinically focused, modified diagnostic classification system for diagnosing all lesions (ie, melanocytic and nonmelanocytic) excised to exclude melanoma and how is it associated with pathologists’ diagnostic confidence?

Findings  In this cohort study that included 197 patients with suspected melanoma, the interrater agreement overall of Management of Lesion to Exclude Melanoma (MOLEM) diagnosis vs majority diagnosis and by mean confidence level of pathologists was excellent. The overall accuracy of pathologist compared with the majority diagnosis based on concordance rates per MOLEM class was 88.6% (class I), 50.8% (class II), 76.2% (class III), 77.2% (class IV), and 74.5% (class V).

Meaning  These results suggest that combining melanocytic and nonmelanocytic lesions excised to exclude melanoma with similar prognostic outcomes into standardized classification categories may be more clinically relevant than the previous schema.

Importance  The proposed MOLEM (Management of Lesion to Exclude Melanoma) schema is more clinically relevant than Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MATH-Dx) for the management classification of melanocytic and nonmelanocytic lesions excised to exclude melanoma. A more standardized way of establishing diagnostic criteria will be crucial in the training of artificial intelligence (AI) algorithms.

Objective  To examine pathologists’ variability, reliability, and confidence in reporting melanocytic and nonmelanocytic lesions excised to exclude melanoma using the MOLEM schema in a population of higher-risk patients.

Design, Setting, and Participants  This cohort study enrolled higher-risk patients referred to a primary care skin clinic in New South Wales, Australia, between April 2019 and December 2019. Baseline demographic characteristics including age, sex, and related clinical details (eg, history of melanoma) were collected. Patients with lesions suspicious for melanoma assessed by a primary care physician underwent clinical evaluation, dermoscopy imaging, and subsequent excision biopsy of the suspected lesion(s). A total of 217 lesions removed and prepared by conventional histologic method and stained with hematoxylin-eosin were reviewed by up to 9 independent pathologists for diagnosis using the MOLEM reporting schema. Pathologists evaluating for MOLEM schema were masked to the original histopathologic diagnosis.

Main Outcomes and Measures  Characteristics of the lesions were described and the concordance of cases per MOLEM class was assessed. Interrater agreement and the agreement between pathologists’ ratings and the majority MOLEM diagnosis were calculated by Gwet AC1 with quadratic weighting applied. The diagnostic confidence of pathologists was then assessed.

Results  A total of 197 patients were included in the study (102 [51.8%] male; 95 [48.2%] female); mean (SD) age was 64.2 (15.8) years (range, 24-93 years). Overall, 217 index lesions were assessed with a total of 1516 histological diagnoses. Of 1516 diagnoses, 677 (44.7%) were classified as MOLEM class I; 120 (7.9%) as MOLEM class II; 564 (37.2%) as MOLEM class III; 114 (7.5%) as MOLEM class IV; and 55 (3.6%) as MOLEM class V. Concordance rates per MOLEM class were 88.6% (class I), 50.8% (class II), 76.2% (class III), 77.2% (class IV), and 74.2% (class V). The quadratic weighted interrater agreement was 91.3%, with a Gwet AC1 coefficient of 0.76 (95% CI, 0.72-0.81). The quadratic weighted agreement between pathologists’ ratings and majority MOLEM was 94.7%, with a Gwet AC1 coefficient of 0.86 (95% CI, 0.84-0.88). The confidence in diagnosis data showed a relatively high level of confidence (between 1.0 and 1.5) when diagnosing classes I (mean [SD], 1.3 [0.3]), IV (1.3 [0.3]) and V (1.1 [0.1]); while classes II (1.8 [0.2]) and III (1.5 [0.4]) were diagnosed with a lower level of pathologist confidence (≥1.5). The quadratic weighted interrater confidence rating agreement was 95.2%, with a Gwet AC1 coefficient of 0.92 (95% CI, 0.90-0.94) for the 1314 confidence ratings collected. The confidence agreement for each MOLEM class was 95.0% (class I), 93.5% (class II), 95.3% (class III), 96.5% (class IV), and 97.5% (class V).

Conclusions and Relevance  The proposed MOLEM schema better reflects clinical practice than the MPATH-Dx schema in lesions excised to exclude melanoma by combining diagnoses with similar prognostic outcomes for melanocytic and nonmelanocytic lesions into standardized classification categories. Pathologists’ level of confidence appeared to follow the MOLEM schema diagnostic concordance trend, ie, atypical naevi and melanoma in situ diagnoses were the least agreed upon and the most challenging for pathologists to confidently diagnose.

The criterion standard diagnosis for melanoma is morphological assessment of hematoxylin-eosin–stained sections of biopsied material. However, there may be discordance between pathologists in the histologic distinction of melanoma from benign lesions in a significant number of so-called borderline lesions.^1-3 For example, accuracy versus an expert panel has been reported to be as low as 45% for lesions including moderately dysplastic naevi and melanoma in situ.³ This level of discordance is likely to be because of the complexity of morphology within these melanocytic lesions combined with subjective diagnostic criteria,⁴ with difficult lesions showing overlapping histopathological features of benign naevus and melanoma. The misdiagnosis of melanoma has consequences for both patients and pathologists. In the US, the most common malpractice claim in dermatopathology practice is for the misdiagnosis of melanoma.⁵ In contrast, overdiagnosis of melanoma in ultimately benign lesions may lead to unnecessary surgeries. Titus et al⁵ reported that 1 in 4 US pathologists upgrade melanocytic skin lesions due to malpractice concerns, which could contribute to discordant diagnoses and lead to unnecessary care.

The American College of Radiology established a standard (BI-RADS [Breast Imaging-Reporting and Data System]) to address a similar lack of international standardization in radiology, which has since been adapted to melanocytic skin lesion pathology via the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) reporting schema for melanocytic proliferations.⁶ Moving from a natural language diagnostic reporting scheme to a numerical system could have substantial benefits for quality of care and economy of service. Further, a numerical system could be a more robust bridge to computer-aided diagnosis and patient management.

Artificial intelligence (AI), including machine learning, has the potential to be useful in the interpretation of medical images. The algorithms used to train machines use a process called supervised learning. Having an accurate standard truth is vital in this process. It is evident that without a definite standard, the training may not be accurate.⁷ It is postulated that a diagnosis made by machine learning algorithms, especially of early-stage melanoma, may be more consistent and more replicable than human interpretation, but not necessarily close to the truth.⁷ A numerical classification scheme is attractive as a way of training an AI algorithm. However, the weakness of such method is that an algorithm cannot weight any data and will learn equally from any 2 cases in the same diagnostic class, irrespective of how challenging it was for human pathologists to classify the lesion.

When physicians become overconfident, there may be a miscalibration or misalignment between diagnostic accuracy and confidence. As a result, higher confidence may contribute to diagnostic errors.⁸ Although the original MPATH-Dx study suggested that an estimate of diagnostic confidence be added to a report of a melanocytic lesion,⁵ there are no subsequent publications to support this finding.

In practice, when pathologists are diagnosing melanoma, there are many types of confounding lesions that are nonmelanocytic in origin. Some of these include pigmented actinic keratosis, large cell acanthoma, seborrheic keratosis, and lichen planus such as keratosis, cysts, dermatofibroma, basal cell carcinoma, and squamous cell carcinoma.⁹ To our knowledge, there were no publications that examine the diagnostic variability in this entire spectrum of lesions excised to exclude melanoma at the time of writing. In this current study, the previously reported MPATH-Dx schema⁶ was extended into a 5-class scheme, which we have termed Management of Lesions to Exclude Melanoma (MOLEM), to include melanocytic and nonmelanocytic lesions in the categories.¹⁰

In this study, pathologists have used the MOLEM reporting scheme and included a measure of diagnostic confidence. It is hypothesized that, in the study population, compared with the MPATH-Dx, there would be similar variability in diagnosing so-called borderline lesions (ie, class II in the proposed MOLEM schema) and that this would be associated with confidence in diagnosis.

This was a reliability cohort study conducted in a primary care skin cancer clinic in New South Wales, Australia. Data were collected between April 2019 and December 2019. This study assessed the reliability of a diagnostic classification system MOLEM for melanoma diagnosis. Nine certified pathologists comprised a panel whose goal was to give a histopathology report of histology slides based on the proposed MOLEM schema. (A diagram of flow of participants is found in Figure 1; pathologists’ characteristics and level of expertise are supplied in eTable 1 in the Supplement.) Images and data set are available for public access.¹¹ Ethical approval was granted by the Bellberry Human Research Ethics Committee, and participants gave written informed consent.

Post hoc power calculation and sample size calculation were not performed. Instead, we selected a pool of high-risk participants with lesions suspicious for melanoma that clinicians decided to excise to rule out melanoma. Suspicion of having melanoma was defined as an indication to perform testing, including signs and symptoms, and the presence of risk factors or results of previous medical tests. Baseline demographic information (Table 1) was collected from the participants such as age, sex, and previous medical and family history of melanoma. All participants underwent clinical evaluation, dermoscopy imaging, and subsequent excision biopsy of the suspicious lesion(s). Slides were prepared by conventional histologic method and stained with hematoxylin-eosin with immunohistochemical stains added if clinically indicated. A total of 198 patients were enrolled but the histopathology slides from 1 patient were not available; hence, 197 patients were included for histological analysis.

All lesions underwent conventional clinical diagnosis by the attending or referring physician prior to excision and histopathology assessment. The same slides were reviewed by up to 9 independent pathologists from Australia and/or the US for histopathologic diagnosis using the MOLEM schema. For logistical reasons, not all pathologists examined each lesion—a minimum of 5 pathologists made a diagnosis on the lesions. The 9 pathologists were presented with either digital histology slides or glass histology slides. Digital slide scanning was carried out with a pathology scanner (Leica Biosystems) at ×40 magnification, and then uploaded to a digital slide presentation platform (Pathpresenter). Glass histology slides and digital histology slides were considered equivalent for the purposes of this study. Pathologists were given access to standard patient data of each case, including patients’ age, sex, and basic clinical details present on the pathology request form. A total of 217 lesions were presented as glass or scanned slides. The principal investigator (I.K.) reviewed each case and chose 1 or more representative sections that included relevant immunohistochemistry stains.

Diagnoses were requested from each pathologist in a form of descriptive text and MOLEM assessment (Table 2). MOLEM schema consists of 5 classes. Class I lesions, which include benign naevus, naevus with mild atypia, seborrheic keratosis, lichenoid keratosis, and cyst, pose very low risk, and generally no further treatment is recommended. Class II lesions include moderately atypical naevus, Spitz, and deep penetrating naevus, which have low risk of progression and may merit narrow but complete excision (<5 mm margins). Class III lesions, such as melanoma in situ and severely atypical naevus, have higher risk of progression and may require complete excision (>5 mm but <10 mm margins). Class IV encompasses invasive melanoma and poses the highest risk of progression, and potentially warrants complete excision, with margins larger than 10 mm. Class V includes nonmelanoma skin cancer such as basal cell carcinoma and in situ squamous cell carcinoma, which requires definitive malignant-nonmelanoma management (eg, excision or other topical therapy). The suggested management for MOLEM classes I through IV was based on its diagnostic reference, MPATH-Dx. Pathologists were asked to assume the slides presented for each case were representative of the lesion and that the lesion went to the margins of the excision. Pathologists were also asked to score their diagnostic confidence from most (1) to least (5). The reference standard was defined by the most frequent MOLEM class level (ie, mode by majority diagnosis) of each case by all participating pathologists. In the case of a bimodal tie, the more severe diagnosis was chosen.

Descriptive statistics were used to describe the characteristics of the sample and lesions. Interrater agreement (overall and by majority MOLEM class) and confidence ratings were assessed using Gwet AC1 coefficients¹² with quadratic weighting applied because of the ordinal nature of the ratings for melanocytic and, separately, nonmelanocytic lesions.¹² It must be noted that the MOLEM classes include both melanocytic and nonmelanocytic lesions, which presents a statistical challenge wherein the difference between nonmelanocytic classes I and V are a single step from each other. Therefore, lesions in class I were set as a value of “1” in the calculations and class V were given a value of “2”, whereas the other classes (II, III, and IV) were given their corresponding values vs class I. Class V lesions share suggested management courses with class II lesions, and so both had a set value of 2 for statistical analysis. The strength of agreement was classified as follows: agreement of less than 0.2 was poor, 0.21 to 0.40 was slight, 0.41 to 0.60 was fair, 0.61 to 0.80 was substantial, and 0.81 to 1.00 was almost perfect.¹³ Overdiagnosis was calculated by dividing the number of the number of diagnoses with MOLEM scores above the majority diagnosis by the total number of diagnoses. Underdiagnosis was calculated by dividing the number of diagnoses below the majority MOLEM score by the total number of diagnoses. Concordance analysis was also performed by calculating the number of cases that are concordant over the number of cases assessed. Excel (Microsoft) and Stata version 16.1 (StataCorp) were used for the analyses. A 2-sided P < .05 was considered significant.

One hundred ninety-seven patients were included in the study; the mean (SD) age of patients was 63.5 (15.8) years (range, 23-92 years), 102 (51.8%) were men, and 95 (48.2%) were women (Table 1). Overall, 217 index lesions were assessed with a total of 1516 histological diagnoses. Of 1516 diagnoses, 677 (44.7%) were classified as MOLEM class I; 120 (7.9%) as class II; 564 (37.2%) as class III; 114 (7.5%) as class IV; and 55 (3.6%) as class V. Class II interpretations showed 29 of 120 lesions being overcalled (ie, classed above the majority) and 30 of 120 lesions being undercalled (classed below the majority). Overall, compared with majority diagnosis, there was an overdiagnosis of melanoma of 5.3% (44 of 797 diagnoses), and 18.1% (123 of 678) of melanoma diagnoses were called benign.

The mean (SD) number of raters (ie, pathologists) was 6.9 (1.1) for class I, 7.5 (1.2) for class II, 6.8 (1.1) for class III, 6.9 (1.4) for class IV, and 6.8 (0.9) for class V, respectively (Table 3). The concordance rate of MOLEM classes I through V were 88.6% (600 of 677 diagnoses), 50.8% (61 of 120 diagnoses), 76.2% (430 of 564 diagnoses), 77.2% (88 of 114 diagnoses), and 74.5% (41 of 55 diagnoses), respectively (eTable 3 in the Supplement). Figure 2 shows examples of lesions with high and low rates of concordance for MOLEM class II (examples for all classes are shown in eFigure 2 in the Supplement). The strength of interrater agreement by majority MOLEM class ranged from fair to almost perfect. Class II had the lowest interrater agreement (fair, 50.8%) with a quadratic weighted Gwet AC1 coefficient of 0.55 (95% CI, 0.44-0.66), while class V had the highest interrater agreement (almost perfect, 96.6%) with an AC1 coefficient of 0.94 (95% CI, 0.88-1.00) in both unweighted and weighted agreement analyses (Table 3). Classes III and IV had substantial interrater agreement (76.2% and 77.2%) with quadratic weighted Gwet AC1 coefficients of 0.82 (95% CI, 0.76-0.88) and 0.83 (95% CI, 0.67-0.89), respectively.

The overall confidence level of each pathologist was rated as almost perfect, with an interrater agreement with Gwet AC1 coefficient of 0.92 (95% CI, 0.90-0.94). Overall, the reliability of MOLEM diagnosis confidence ratings was 95.2%, with a Gwet AC1 coefficient of 0.92 (95% CI, 0.90-0.94). Class II diagnosis confidence ratings showed the least mean (SD) values (1.8 [0.7]) of all classes with 93.5% agreement and a quadratic weighted Gwet AC1 coefficient of 0.85 (95% CI, 0.79-0.91) (eTable 2 in the Supplement). The highest diagnostic confidence ratings and agreement were found in class V diagnoses, which had mean confidence values of 1.1 (0.1) with a quadratic weighted Gwet AC1 coefficient of 0.97 (95% CI, 0.93-1.00).

While some lesions were uniformly interpreted with similar diagnostic terms, other lesions showed substantial variability in diagnostic labeling (see eFigure 1 in the Supplement for histology images with different descriptions grouped in the same MOLEM class). This study involved pathologists from different parts of Australia and from other countries. It is quite likely that there are variations in terminologies and diagnoses. Moreover, there were variations in terms of diagnostic confidence and interrater agreement (see eFigure 2 and eFigure 3 in the Supplement for histology images with high diagnostic confidence but with low interrater agreement, or with low diagnostic confidence but with high interrater agreement).

The major finding of this study was that in a population of lesions excised to exclude melanoma and uniquely including melanocytic and nonmelanocytic lesions, the MOLEM schema was clinically useful. This finding is supported by the MOLEM interrater agreement alignment with previous studies and a high level of agreement was found within the pathologist confidence rating data. This study has shown effective lesion classification without prior knowledge or selection of lesion diagnosis. The data showed that dermatopathologists do not always agree upon a diagnosis, but statistical analysis reveals that dermatopathologists are aware of these difficult cases when diagnosing, which could be a point of entry for automated analysis in the future.

Additionally, the data from this study shows that, in an Australian population, there is an over- and underdiagnosis of melanoma (5.3% and 18.1%, respectively) compared with the estimated population-based statistics reported by Elmore et al³ using prevalence data from the US (8% overdiagnosed and 9% underdiagnosed). In this study and an associated report discussing only the nonmelanocytic lesions,¹⁰ we have proposed MOLEM as a modification to the MPATH-Dx diagnostic and management schema for classification of melanocytic lesions. Although the MPATH-Dx has been shown to be more concordant for the diagnosis of melanocytic lesions, the current study also reveals that there is variation in the terminology and over- and underdiagnosis of malignancy for nonmelanocytic lesions, similar to melanocytic lesions. Similar to Elmore et al,³ we have shown that most of the variability is in class II and class III lesions. A unique aspect of the current study was that the primary data set, including each benchmark diagnosis, was complete and made freely available, which adds value to this study by enabling future research.

Discordance in diagnosis is not unique to melanocytic lesions. Diagnoses made by physicians are not correct all the time. In fact, second reviews of images or specimens in radiology, pathology, and dermatology show potential for diagnostic error ranging from 10% to 50%.¹⁴ Disagreement between pathologists has also been reported for prostate, thyroid, and breast lesions.^3,4,7

Another novel aspect of this study is the inclusion of confidence scores. There have been no studies, to our knowledge, that examine the association of confidence of pathological diagnosis with accuracy of diagnosis of lesions biopsied to exclude melanoma, or even difficult melanocytic lesions alone. Confidence in making diagnosis may sometimes influence accuracy of diagnosis. Ferrara et al¹⁵ suggested that more information available for melanocytic lesion improves pathologists’ confidence in diagnosis and leads to more accurate diagnosis. Clinically, for instance, in Benvenuto-Andrade et al¹⁶ the level of diagnostic confidence in clinical and dermoscopy examination of skin lesions that would be within MOLEM classes II and III (eg, dysplastic naevus and melanoma in situ) had lower confidence scores than lesions which would be classified as class I (eg, blue naevus, congenital naevus) and class IV (eg, malignant melanoma).¹⁶ In Meyer et al⁸ the physicians’ level of clinical diagnostic confidence was relatively insensitive to diagnostic accuracy and case difficulty. This contrasts with our outcome. We hypothesize that these similarities and differences are due to the unique nature of the morphological diagnosis of melanoma, which mainly relies primarily on pattern recognition. If confirmed, this hypothesis supports the combined use of automated image analysis with expert morphological assessment to achieve a higher level of diagnostic accuracy for melanoma. In the current study, pathologists showed the least confidence in the cases with the lowest levels of agreement.

In the nascent stages of AI in skin pathology, creating a data set that contains minimal bias in terms of disease classification and diagnosis remains a challenge as there are difficulties in deriving criterion standard diagnosis in pathology to be used in machine learning.⁷ Some inherent bias in the data used to train AI algorithm has been observed in the health care sphere.¹⁷ Interestingly, none of the recent papers looking at the AI diagnosis of images of skin lesions clinically and dermoscopically has mentioned the difficulty of developing a criterion standard to allow accurate histological diagnoses.¹⁸ As AI becomes more prevalent in assisting both clinical and histopathological diagnosis, developing a criterion standard for accurate histological diagnosis is vital. Using a diagnostic classification schema such as MOLEM can accommodate all lesions encountered when excluding melanoma. This makes the MOLEM schema viable for translation from the academic setting, where MPATH-Dx is commonly used, to the clinic. Translating MOLEM or a similarly scoped schema into practice will help address the issue of variation in diagnostic terminology; developing a viable clinical criterion standard will be beneficial for machine learning and, ultimately, patient outcomes.

There are a few potential methods to create this criterion standard. Such a standard could be defined in consensus meetings, similar to what was used in the development of the MPATH-Dx system.⁴ In addition, correlation with clinical and dermoscopic images has been shown to improve diagnostic certainty because in many cases, the clinical and dermoscopic impression can be more typical than the histological impression.^19-21 Other methods to improve diagnostic certainty could include requesting second opinions including expert opinions, consensus discussions and diagnosis, additional sampling and slides, and ordering specialized tests.⁵ For example, Lohman et al²² described how newer immunohistochemical stains such as PRAME and p16 may be useful in helping to distinguish benign from malignant melanocytic lesions. Molecular diagnostics may also be an important source of objective diagnostic data.²³

It is unclear which approach would be most beneficial when defining entities for training AI algorithms. However, oversimplifying classification systems might hinder the potential for machine-based learning algorithms to offer new, and previously unrecognized insights into disease biology. Adamson and Welch⁷ suggest that it may be useful to use information from a panel of pathologists and divide lesions into 3 categories: total agreement lesion is benign, total agreement the lesion is malignant, and disagreement whether the lesion is malignant. We believe using a classification schema such as MPATH-Dx or MOLEM that groups lesions with similar management strategies will help address the issue of variation in the diagnostic terminology, which will be beneficial for machine learning and developing a criterion standard.

This study had several limitations. First, the selection of the participant cohort was subject to selection bias. Second, the histologic classification of lesions was subject to observation bias, which was addressed by involving 9 independent pathologists masked to the histopathologic diagnosis.

Although the sample population of 217 lesions is comparable with previously published work in this area, the sample size is somewhat limiting.^24-29 Additionally, the cases included in this study were a more clinically relevant spectrum of disease (eg, nonmelanocytic lesions) compared with previous studies^24-29 that used curated data sets, which enabled large-scale diagnostic surveys and showed similar population-based results. One of the most interesting facts about this cohort was the higher number of previous melanomas in situ and invasive melanoma, which informed this cohort being considered as higher risk. Hence, a majority diagnosis was used as the comparator instead of the expert consensus diagnosis, and the diagnostic confidence score of each pathologist was included. This study was not limited by pathologists only having access to the clinically representative lesion because they also had access to multiple sections on 1 or more slides that included immunohistochemical stains, which was closer to the clinical pathological workflow used to diagnose a lesion. Moreover, pathologists involved had several years (ie, 3 to 29 years) of reporting melanocytic lesions in private pathology practices with referral populations from around Australia and in the US.

In this study, the proposed schema for classifying lesions had good interrater agreement. A more clinically relevant concise diagnostic nomenclature and management hierarchy for lesions excised to exclude melanoma (MOLEM) including nonmelanocytic lesions has the potential to improve diagnostic agreement and reduce confusion over diagnosis compared with the previously reported MPATH-Dx schema. Moreover, numerical diagnostic schemes like MOLEM may be used as a natural bridge for AI-based diagnostic tool development.

Accepted for Publication: September 7, 2021.

Published: December 10, 2021. doi:10.1001/jamanetworkopen.2021.34614

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Katz I et al. JAMA Network Open.

Corresponding Author: Tarl W. Prow, Future Industries Institute, University of South Australia, Adelaide Mawson Lake Campus, Mawson Lakes, Adelaide, South Australia, Australia (tarl.prow@unisa.edu.au).

Author Contributions: Prof Prow had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Katz, Prow.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Katz, Clark, Schapiro, Azzi, Boyle, Prow.

Critical revision of the manuscript for important intellectual content: Katz, O'Brien, Thompson, Schapiro, Azzi, Lilleyman, Boyle, Espartero, Yamada, Prow.

Statistical analysis: Katz, Boyle, Prow.

Obtained funding: Katz.

Administrative, technical, or material support: Katz, Clark, Azzi, Yamada, Prow.

Supervision: Katz, Prow.

Conflict of Interest Disclosures: Dr Lilleyman reported receiving payment from Southern Sun Pathology for work on clinical images during the conduct of the study. No other disclosures were reported.

Funding/Support: Dr Katz and Prof Prow acknowledge the Skin Cancer College of Australasia. Prof Prow and Dr Yamada acknowledge the Rattigan Family Foundation for their melanoma research support.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.