Rethinking certainty: a retrospective study on diagnostic revisions in gynecologic pathology

Objective: Expert pathology review plays a crucial role in gynecologic oncology, where diagnostic complexity can substantially affect patient management and medico-legal accountability. This study aimed to assess the frequency, nature, and impact of diagnostic revisions arising from second opinion evaluations of gynecologic lesions. Methods: We retrospectively analyzed 319 consecutive cases of gynecologic lesions submitted for second opinion review by a senior gynecologic pathologist at a tertiary referral center between 2018 and 2024. Each case was categorized as concordant, minorly discrepant, or majorly discrepant compared with the referring diagnosis. Clinical impact and medico-legal relevance were systematically evaluated. Results: Of the 319 reviewed cases, 47.0% were fully concordant with the original diagnosis, whereas 34.5% exhibited major discrepancies and 18.5% minor discrepancies. The most frequent sources of diagnostic disagreement involved tumor histotype, grade, and determination of the primary site. Ovarian and endometrial specimens accounted for most revisions. Diagnostic reinterpretation led to changes in clinical management in 54.9% of cases, and potential medico-legal implications were identified in 11.3%. Conclusions: Expert second opinion pathology in gynecologic oncology revealed a high rate of diagnostically and clinically significant revisions. Routine implementation of specialist review for complex or high-risk gynecologic lesions is strongly recommended to improve diagnostic accuracy, guide appropriate patient care, and reduce medico-legal risk.