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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.
"Survival of patients with melanoma depends on early diagnosis. If the criteria of a bleeding, nodular black mole are used to diagnose melanoma, it is usually too late to save the patient. The clinical diagnosis of early melanoma is the subject of an excellent review. Melanomas may be suspected early from two findings that are rare in benign nevi.
1.Variegated coloration. Be suspicious when you see red, white, or blue areas in a brown or black nevus.
2.An irregular border, often with angular induration or notches.
Two other objective findings are helpful in differentiating nevi from melanomas. A melanoma tends to be asymmetrical, whereas a nevus tends to be symmetrical. Melanomas are usually larger than nevi; the Skin Cancer Foundation has used a diameter of 6 mm as the cutoff point for diagnosing a benign nevus. In my experience, the size criterion is the least useful in detecting early melanomas. A significant number of persons have nevi larger than 6 mm in diameter, and melanomas smaller than 6 mm in diameter are not rare.
The Skin Cancer Foundation has promoted the widely accepted mnemonic
for the four criteria of asymmetry, border irregularity, color variegation, and diameter enlargement. These criteria should be used together to decide whether there is enough suspicion of melanoma to warrant a biopsy.
The following are subjective signs said to be significant in suspecting a melanoma:
Change in color, shape, or size of a mole.
Bleeding from a pigmented lesion.
Itching in a mole.
By far the most significant of these signs is a change in the appearance of a mole. If an adult reports a significant change in color, shape, thickness, or diameter of a nevus, it warrants a biopsy. Although these lesions are usually benign, I have vivid memories of reassuring patients that a mole appeared perfectly harmless, adding, "let's remove it to be sure," and then getting a pathology report of melanoma . . ." (
Common Skin Disorders.
Philadelphia: W B Saunders Company, 1994:130.
Fig. 11 Our diagnosis and comment: Melanoma. The large lesion situated just above the paranasal fold is a melanoma because it is asymmetrical, uneven in regard to its surface, and variegate in color. Note the difference between it and the smaller solar lentigines positioned above the malar eminence.
By the mid-1990s the clichés manufactured by the "melanoma mavens" at New York University, the University of Pennsylvania, and Harvard University were very much a part of common parlence, chief among those being "red, white and blue" and "the ABCDs" for clinical diagnosis of melanoma. What was intended to be simple turned out to be simple-minded; the overwhelming majority of melanomas have nary a hint of red, white, and blue, and, as Dr. Epstein rightly commented, a diameter of 6.0 mm actually is unhelpful in diagnosis of melanoma clinically and in differential diagnosis of it from various kinds of congenital and acquired melanocytic nevi, not the least reason being because that number is both arbitrary and wrong. At least by 1994 it was appreciated fully by clinicians that "If the criteria of a bleeding, nodular black mole are used to diagnose melanoma, it is usually too late to save the patient." But a melanoma is not a mole, and, in most instances, the oft-referred to "changing mole" is actually a changing melanoma.
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