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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.
Pillsbury, Shelley, and Kligman
"Certain general criteria are useful in determining whether or not a mole may be undergoing untoward changes. These include:
A change in the distribution and degree of pigment. Increased pigmentation occurs normally after exposure to sunlight and during puberty and pregnancy. The absence of pigment does not mean that the lesion is necessarily completely benign. Any marked sudden change in the character, including change from even color to speckled, in degree of color or in the amount of pigment at the border is justification for excision.
The presence of hair has been mentioned as a reassuring sign of the benign nature of a mole. If it is lost and the surface of the lesion becomes smoother, this is an untoward change.
A significant change in size of a pigmented mole, unless temporary due to inflammation of the hair follicles, is justification for excision.
Ulceration and/or bleeding of moles is obviously an untoward change, though this may be evidence of the development of frank melanocarcinoma and too late for cure. This will almost always be preceded by more subtle changes." (
Pillsbury DM, Shelley WB, Kligman AM.
A Manual of Cutaneous Medicine.
Philadelphia: W.B. Saunders Company, 1961:315.
Fig. 3 Our diagnosis and comment: Two melanomas. What was called "active, premalignant junction nevus" in the A lesion fulfills criteria clinically for melanoma and not for a nevus of any kind. The lesion is a melanoma because it is asymmetrical, has a slightly notched border, and is marked by an uneven surface. In the late 1940s, throughout the 1950s, and well into the 1960s, the term "active (activated) junction (junctional) nevus" was employed commonly by dermatologists and pathologists for what they thought was a peculiar nevus but, in actuality, was a melanoma sui generis.
In 1961, it was thought, generally, as Pillsbury, Shelley, and Kligman averred, that melanoma began as a "changing mole." In fact, in Asians and Africans, virtually all melanomas begin
and not in company with a melanocytic nevus. In Caucasians, less than 20% of all melanomas begin in association with pre-existing nevus; all the others begin
. What all patients and many physicians regard as a "changing mole" is actually a slowly evolving melanoma that arose
At an early, that is, macular, stage in the development of melanoma, changes occur extraordinarily slowly, never suddenly. That pertains particularly to alterations in color. The presence or absence of hair is not a criterion for diagnosis of melanoma clinically . Although obliteration of the normal dermatoglyphic pattern of the surface of a pigmented lesion is an indication of melanoma, smoothness, per se, is not. Last, melanoma is a sarcoma, not a carcinoma.
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