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Dermatopathology: Practical & Conceptual July - September 2001
Evolution in Thinking: Criteria for Clinical Diagnosis of Melanoma, 1947–2000: A Critique in Historical Perspective
Mary Aldrene L. Tan, M.D.
A. Bernard Ackerman, M.D.
Becker and Obermayer
Ormsby and Montgomery
Sulzberger and Wolf
Pillsbury, Shelley, and Kligman
Fitzpatrick and Clark
Lewis and Wheeler
Callen, Stawiski, and Voorhees
Roses, Harris, and Ackerman
Dobson and Abele
Friedman, Rigel, and Kopf
Fitzpatrick, Rhodes, Sober, and Mihm
Koh and Rogers
McCarthy et al.
Mooi WJ and Krausy
Fitzpatrick, Milton, Balch, Shaw, McCarthy, and Sober
National Institutes of Health Consensus Conference
Holzle, Kind, Plewig, and Burgdorf
Marghoob, Slade, Kopf, Rigel, and Friedman
Arndt, Wintroub, Robinson, and LeBoit
Elder and Elenitsas
Maize et al.
Langley, Fitzpatrick, and Sober
Farmer and Hood
Fleischer, Feldman, Katz, and Clayton
Ackerman, Kerl, Sánchez, et al.
Ormsby and Montgomery
"Melano-epithelioma usually begins as a blue-black or steel-blue nodule from 3 mm. to several centimeters in diameter. Occasionally, it may be light brown in color. The early lesion may be flat and level with the skin, or may be raised, later becoming fungoid or ulcerated. The color does not disappear on diascopic pressure. Fine, radiating lines of pigment may extend along the lymphatics, indicative of dissemination, which may be followed by the development of satellite lesions or other evidences of metastasis." (
Ormsby OS, Montgomery H.
Diseases of the Skin.
7th Edition. Philadelphia: Lea & Febiger, 1948:840.
Fig. 2 Our diagnosis and comment: Three melanomas that gave rise to metastases. The plaque made up of papules in the pre-auricular region in (a) cannot be an "early melanoma" because it is not small and flat. The legends above are testimony to the thinking in 1954 of physicians, including dermatologists, about the cause of melanoma, namely, trauma, such as use on "an electric needle" of a "single blood blister" in the (b) lesion and "injury from a tack in a shoe" for the (c) lesion.
Melanoma is not an epithelioma (carcinoma), but a sarcoma, the abnormal melanocytes that cvonstitute it being non-epithelial cells. Moreover, melanoma never begins "blue-black" or "steel-blue;" at the beginning, it usually is a shade of brown, often being fawn colored or tan. Never is it a nodule from the outset, despite the claim of Clark that "nodular melanoma" bypasses completely the "radial growth phase." Almost always, by the time a melanoma is "fungoid or ulcerated" it already has metastasized. As Ormsby and Montgomery note correctly, extension of pigment along lymphatics is a sign of metastasis, which, in the case of melanoma, signifies a grim prognosis, just as a so-called satellite metastasis conveys the same message for prognosis as does a so-called distant metastasis, namely, nearly inevitable death if a patient lives long enough and does not die of another cause. Parenthetically, a 3 mm elevated lesion is a papule, not a nodule.
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