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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.
Lewis and Wheeler
"Malignant melanoma, or melanocarcinoma, known colloquially as "the black death," is a highly malignant tumor. It is much less common than basal or squamous cell carcinoma, occurring in approximately 1 to 2 persons per 100,000 . . ."
"Signs of transition of a junctional or other nevus to malignant melanoma are increase in size, increase in depth of color which may be diffuse or spotty, crusting, bleeding, formation of nodules within the mole or as satellite lesions, and lymphadenopathy. The first sign of melanoma may be the appearance of a pigmented spot. If untreated, it may progress to become a papulo-nodular tumor which crusts, bleeds, erodes, ulcerates, or resembles a mass of friable granulation tissue. Some melanomas are non-pigmented (amelanotic melanoma) and resemble pyogenic granulomas. In most instances, however, at least a small amount of melanin can be seen." (
Lewis GM, Wheeler CE Jr.
3rd Edition. Philadelphia: W.B. Saunders Company, 1967:5637.
Fig. 4 Our diagnosis and comment: Melanoma. A history of "increased growth " does not enable a clinician to determine whether a lesion is a nevus, such as that of Spitz and Clark, or of a melanoma. The neoplasm pictured here is a melanoma because it is asymmetrical, has a notched border, and sports a surface that is markedly uneven.
Melanoma is a sarcoma, not a carcinoma, and, in 1967, it still was known as the "black death," not because it always is "a highly malignant tumor," but because it so often went unrecognized clinically for decades, by which time it had metastasized. When it is macular and without signs of regression, melanoma is benign biologically. As long as neoplastic melanocytes of melanoma are confined to epidermis and to epithelial structures of adnexa, there is no possibility of metastasis from it having already occurred.
The contention of Lewis and Wheeler that melanoma develops as a consequence "of transition of a junction or other nevus" was accepted universally by physicians in 1967. In fact, the vast majority of melanomas in the world develop
and not in conjunction with a pre-existing nevus. It is true that melanoma, being the malignant neoplasm that it is, increases, albeit slowly, in size and often in depth of color, but those changes cannot be discerned by a clinician who sees a patient for the first time; such changes can be learned about from a history given accurately or by photographs of a lesion taken serially, not from assessment clinically on a single occasion. By the time that there is "crusting, bleeding, formation of nodules within the mole or its satellite lesions, and lymphadenopathy, the melanoma has already metastasized," and, for that reason, clinicians must be keenly aware that the first sign of melanoma, at a stage when it is curable easily by simple excision is "the appearance of a pigmented spot." Those melanomas that "resemble pyogenic granulomas" are exophytic and often ulcerated, by which time they nearly always have long since given rise to metastases.
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