< Current issue
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.
Mooi WJ and Krausy
"Clinically, melanoma exhibits a large variety of appearances. In its most classical form, it appears as an asymmetrical, irregularly pigmented macule, papule or nodule, with irregular, notched and sometimes indistinct borders, varying in size from a few millimetres to, rarely, several centimetres. In individual tumours, colours may vary from white, pink, slate-grey or bluish, to different shades of brown, and black. The overlying epidermis is intact or ulcerated. Irregular pink or white, sometimes depressed areas point to foci of tumour regression. The tumour may arise
on previously normal skin, or may originate in a pre-existent naevus, the malignant transformation of which has as its hallmark a sudden change in size, shape and colour, together with the features mentioned above. 'Satellites' consist of small usually pigmented macules or papules in the surrounding skin within a distance of a few centimetres (different authors suggesting a distance of 2, 3 and 5 cm), or in-transit metastases, situated at a greater distance, in the skin region drained by the same lymph node basin.
Many of these clinical features of melanoma do not develop until relatively late in its natural course; early detection of melanoma is based on the accurate recognition of suspicious pigmented lesions, arising in previously unblemished skin, showing some degree of irregularity and asymmetry, together with variations in pigmentation, and sometimes itching or, alternatively, suspicious changes in hitherto quiescent moles."
Mooi WJ, Krausy T.
Biopsy Pathology of Melanocytic Disorders.
London: Chapman & Hall Medical, 1992:2178.
As Mooi and Krausy rightly acknowledge, "many of these clinical features of melanoma do not develop until relatively late in its natural course," which eliminates them from consideration in regard to their having much practical value for either a patient or a physician. The authors state that "early detection of melanoma is based on the accurate recognition of suspicious pigmented lesions," but for them "suspicious" is "showing some degree of irregularity in asymmetry, together with variations in pigmentation, and sometimes itching . . ." Pruritus is of no assist in leading to a diagnosis of melanoma, "irregularity" is imprecise, and, therefore, uninstructive, and "asymmetry, together with variegations in pigmentation" can be seen in a host of benign proliferations of melanocytes ranging from Clark's nevi to garment nevi. In short, much of what Mooi and Krausy have written about the "classical" expression of melanoma clinically, namely, sudden change in size, shape, and color, is plain wrong. By the time that "satellites" are noted, the patient is doomed. Last, detection of melanoma at a time when it is flat and still curable cannot be based on the wooly notion of "suspicious." It must be rooted in morphologic findings that are repeatable and reliable.
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