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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.
"Not enough attention has been paid toward educating physicians, medical students, nurses, and patients to recognize clinical features of early evolving, flat lesions of malignant melanoma. It is when the lesions are flat and when the atypical melanocytes are wholly confined to the epidermis, that the disease is curable in all cases. Pathologists have been reluctant to certify a stage of malignant melanoma that is
and instead have evaded the issue by using a number of ambiguous euphemisms like "active" or "atypical junctional nevus," "atypical melanocytic hyperplasia," "melanocytic dysplasia," "incipient melanoma," and "borderline melanoma . . . ."
"The diagnostic clinical features of an early, evolving, macular malignant melanoma wholly confined to the epidermis are fundamentally the same, irrespective of the anatomic site . . . These features are: 1) irregular, scalloped margins . . . 2) asymmetry . . . 3) various hues of tan, brown, and black, and even of red and blue . . . 4) relatively larger size in that flat lesions of malignant melanoma
when first noted by patients or physicians usually have diameters more than 6 mm . . ." (
Ackerman AB. Clinical diagnosis of malignant melanoma in situ. In: Ackerman AB, ed.
Pathology of Malignant Melanoma.
New York: Masson Publishing USA, Inc., 1981:57.
Fig. 7 Our diagnosis and comment: Melanomas. Each of the lesions on different anatomic sites pictured here is a small flat lesion of melanoma (melanoma
) for the reasons given in the legend. The diagnosis of melanoma clinically, just as is the case histopathologically, is made by using the very same morphologic criteria irrespecive of anatomic site, an indication that the so-called histogenetic classification of lentigo maligna melanoma, superficial spreading melanoma, and acrolentiginous melanoma really is based entirely on anatomic site, that is, sun-damaged skin, usually of the face, for lentigo maligna melanoma, the trunk and proximal extremities for superficial spreading melanoma, and palms, soles, and nail units for acrolentiginous melanoma.
The four clinical features enumerated here in 1981 became the ABCDs promulgated by Friedman, Regal, and Kopf in 1985. For those three collaborators, the asymmetry became the A, irregular scalloped margins became the B of border irregularity, various hues of tan, brown, black, and even of red and white became the C for color variegation, and diameter more than 6 mm became the D of diameter generally greater than 6 mm. In 1981, the year that this was published, Friedman was a trainee in dermatopathology of Ackerman at New York University.
The statement that macules of melanoma are "fundamentally the same, irrespective of the anatomic site" is correct and refutes the notion that there are clinical differences among macules of so-called lentigo maligna melanoma, superficial spreading melanoma, and acrolentiginous melanoma. That classification of Clark is actually predicated entirely on anatomic site and not at all on histogenesis.
The statement just quoted from 1981 was the first to emphasize recognition of melanoma when it was still macular. An atlas that accompanied the chapter showed, exclusively, small flat lesions of melanoma on different anatomic sites. It was the first time that only flat lesions of melanoma, rather than elevated lesions, had been pictured, the effort being to call attention to features that enabled identification of melanoma at a stage when the malignant neoplasm was curable with surety.
Ackerman would have been better advised not to have employed the word "irregular" to describe the margin of the lesion; by 1985, he not only avoided it, but criticized the use of it.
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