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Dermatopathology: Practical & Conceptual October - December 2006
3. New Heights: An unabridged history of the ABCDs
Michael Wile, M.D.
In July 2002, Mones and Ackerman presented a poster at the 20th World Congress of Dermatology in Paris, they giving it the title,
"The ABCDs for diagnosis of melanoma are an abject failure."
] The basis for their conclusion was that practically never does a clinician diagnose accurately, prior to biopsy, a papule or nodule of melanoma in a prepubescent, thereby giving the lie to efficacy of the ABCDs for diagnosis of melanoma.
In August 2002, in a "Lesson" to be learned from Interactive Quiz 34 on the website,
] Ackerman restated his criticism of the ABCDs in these lines:
"Kopf and coworkers have advocated the use of the ABCDs for both melanoma and dysplastic nevi. It is obvious that the same criteria cannot be employed successfully for distinguishing morphologically between a benign neoplasm, in this case a nevus, and a malignant one, namely, a melanoma."
In October 2002, in a video given to the subject of
"Exploding myths about melanoma (II),"
] Ackerman illustrated graphically the many problems inherent in the ABCDs at the same time he expressed astonishment that this mnemonic was actually accepted, unquestioningly and universally, by dermatologists in academe and in practice. His presentation compelled to the conclusion that the ABCDs are fatally flawed.
In 2004, in an article in
about early diagnosis of cutaneous melanoma, Rigel, et al., proposed that an "E" be added to the ABCDs, this time the "E" being for "
volving" rather than for "
] Rigel, et al., stressed that
"The ABCDs were thus intended to help describe a subset of melanomas, namely early, thin tumors that might otherwise be confused with benign pigmented lesions . . . "
In the same piece, the coworkers made this statement:
"'E' for 'Evolving' recognizes the dynamic nature of this skin malignancy. This is especially important for the diagnosis of
[emphasis mine], which frequently present at more advanced stages (i.e., thicker tumors), thus contributing greatly to melanoma mortality rates."
That contradiction not withstanding, "Evolving," according to Ackerman, is not a criterion identifiable by inspection of a particular pigmented lesion. Moreover, he has written for nearly 20 years that every kind of acquired nevus also evolves; in fact, a "changing mole" usually is not a melanoma, but
"a nevus in the expected course sequential of it"
"What are deemed to be changing moles, in most instances and in this context, are really changing melanomas."
In 2005, Rigel, Friedman, Kopf, and Polsky repeated the mantra in support of adding "E" for "Evolving" to the ABCDs.[
] They referred to the work of Healsmith, et al., Lucas, et al., Thomas, et al., and Cassileth, et al., [
]on behalf of that modification considered by them to be an advance. Bränström, et al., [
] and Buettnerm, et al., [
] called attention to inadequacies inherent in the methodology of the aforementioned "supporting studies," thereby eroding further legitimacy of 'E.' Later in 2005, on the website Derm101.com, in a video lecture in three parts captioned, "Do you know your ABCDs?," [
] Ackerman said this about the merit of "E" for "
"Evolving is a judgment made biologically by assessments morphologic over the course of time. Criteria for the diagnosis morphologic of melanoma must be applicable to a lesion on the patient on the very first visit of that patient to a physician."
In short, Ackerman rejected the notion that "E" for "
volving" could have any benefit for diagnosis of a particular melanoma, it representing a kind of "moving picture," when what a clinician sees on a single visit is the equivalent of a snapshot.
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