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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.
" . . . The
rule has been promulgated as a pneumonic [sic] device to assist in detection:
symmetry of lesional contour is an important early sign of malignant change. Nevi are almost always uniform to the point of mirror symmetry. One should become concerned if a pigmented lesion becomes even minimally lopsided. An example of this would be a small papule appearing at the margin of a completely flat lesion.
order irregularity in melanoma may manifest itself as a notching or feathering.
olor variation is often the most obvious early change in melanoma. The "flag sign" has been described, in which variations of red, white, and blue colors are randomly dispersed through an otherwise brown or black lesion.
iameters of acquired benign nevi are usually less than 0.6 cm. Congenital nevi, dysplastic moles, and seborrheic keratoses may be considerable larger than this, however. Thus a pigmented mole which is 0.6 cm or greater in size should raise one's [sic] suspicions, but other differential diagnostic possibilities must be considered using this criterion alone."
Pigmentation and Pigmentary Disorders.
Boca Raton: CRC Press, Inc., 1993:262.
Levine concentrates on "early" signs and on changes in melanoma. Macular lesions, however, may not be markedly asymmetrical, show "feathering" (whatever that may be), be associated ever with "red, white, and blue colors," or present themselves as "0.6 cm or greater in size."Although Levine directs his attention to recognition of melanoma at an early stage, he, nonetheless, advises that "if a pigmented lesion becomes even minimally lopsided," such as "a small papule appearing at the margin of a completely flat lesion," a clinician should become concerned. By the time that a papule has developed, a melanoma no longer is very early in the sense that it is
but "invasive," thereby putting a person who bears it at risk for metastasis.
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