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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.
Dobson and Abele
"The clinical features that suggest a malignant melanoma are as follows:
A size greater than 1 cm in diameter. Most benign, acquired, pigmented nevi are smaller.
Variegated color. Benign lesions usually have uniform coloration. Melanomas often contain shades of red, white, gray, blue, brown, and black within a single lesion. Variation in the degree of pigmentation is also suggestive: one area may show reticulated pigmentation, another may be deeply pigmented, and still another may lack pigmentation.
Irregular border with angular indentation and notching
Increase in size
Change in color
Ulceration and inflammation. These are late changes and are usually associated with a vertical growth phase.
These diagnostic guidelines are probably applicable to the majority of melanomas but, if relied on exclusively, will result in misdiagnosis in a significant percentage of patients. Therefore, it is better to err in the direction of overdiagnosis. If there is any doubt of suspicion, biopsy!"
Dobson RL, Abele DC.
The Practice of Dermatology.
Philadelphia: Harper & Row Publishers, 1985:289.
The authors acknowledge that application of "their diagnostic guidelines . . . will result in misdiagnosis in a significant percentage of patients," an admission that leads them to suggest "it is better to err in the direction of over-diagnosis." But morphologic diagnosis should be predicated on criteria that are repeatable and reliable, that is, there should be neither "under-diagnosis," nor "over-diagnosis," but accurate diagnosis.
Dobson and Abele state correctly that the criteria they set forth for "clinical features that suggest a malignant melanoma" do not work and some reasons why are as follows : 1) All melanomas begin much smaller than 1 cm in diameter and the optimal time to diagnose melanoma is when it is small, flat, and curable; 2) Most melanomas do not "contain shades of red, white, gray, blue, brown, and black." 3) "Irregular" as a description of a border is inadequate not only because "regular" in this sense has never been defined, but some Clark's nevi also show "angular indentation and notching." 4) The criticism just made of "irregular" for attributes of a border applies equally to "irregular"characteristics of a surface, and, moreover, many small congenital nevi have an uneven surface. 5) "Increase in size," cannot be determined by morphological observation. 6) "Change in color," like "increase in size" usually is learned from history. 7) Ulceration never is seen in flat and slightly elevated lesions. By the time ulceration has occurred, a melanoma usually is thick and has metastasized, and, for that reason, the authors are right to state that ulceration (and inflammation) are "late changes."
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