I have a number of patients with a quite persuasive clinical picture of malignant melanoma and the histopathology not confirming the clinical diagnosis. I require a revision and additional sections from the pathologist, but the answer is almost the same. In all these cases I can not blame the pathologists for not doing their job properly. Could some clinical features of malignant melanoma anticipate histopathological changes? How often do you have similar experiences?
Thanks a lot for your answer. I agree with everything you wrote. I am aware of the rhetoricity of my question. Histopathology is the golden standard in the diagnosis of melanoma, but it still remains a subjective identification and interpretation of multiple, and sometimes disparate architectural and cytological features, so…
Best regards!
I can tell you that early diagnosis of cutaneous melanoma on acral skin should rely on clinical pathological correlation. Early lentiginous melanoma on acral sites can be clinically very obvious but histopathologically very subtle. There are a some articles published regarding this issue. At least on volar skin, yes, melanoma can be diagnosed earlier on clinical grounds.
Arch Pathol Lab Med. 2011 Jul;135(7):847-52. Acral junctional nevus versus acral lentiginous melanoma in situ: a differential diagnosis that should be based on clinicopathologic correlation. Bravo Puccio F1, Chian C.
Am J Dermatopathol. 2014 Feb;36(2):142-7. Acral lentiginous melanoma: indolent subtype with long radial growth phase. Kim JY1, Choi M, Jo SJ, Min HS, Cho KH.
Ann Dermatol. 2011 Aug;23(3):400-4. Acral Lentiginous Melanoma Developing during Long-standing Atypical Melanosis: Usefulness of Dermoscopy for Detection of Early Acral Melanoma. Oh TS1, Bae EJ, Ro KW, Seo SH, Son SW, Kim IH.
Thank you for your answer. I don't have so many experiences with acral melanomas because there are relatively rare in my practice. I have had only a few very advanced cases. I suppose you have much more practical knowledge about this topic since in your country the frequency of acral melanomas is up to 40% of all melanomas. Do you tend to excise every heavily pigmented acral nevus larger than 7 mm in diameter?
Hello Marko. This is really a complex problem because of the very many different types of melanomas (the acral type being one of them, with peculiar dermoscopic and histopathological characteristics) and the existence of borderline lesions. Certainly, dermoscopy is a great help to call attention to atypical pigmented lesions, including very early melanomas and precursor lesions (De novo intraepidermal epithelioid melanocytic dysplasia: an emerging entity. J Cutan Pathol 2010; 37:866-869 Magro CM et al.). However, one also should keep in mind the existence of melanoma mimickers (benign lesions with bizarre dermoscopic patterns). So, in my opinion the best solution is the one pointed out by Seniz Duygulu "clinico-pathological correlation meetings to discuss problem cases on clinical and histopathological grounds with clinical and histopathological images". One single view, be it dermoscopic or histopathological, cannot be taken as "absolut truth"!
As for acral pigmented lesions. In our area the dermoscopic pattern mostly associated with melanoma is the diffuse heterogeneous pattern. However, this pattern is also seen in benign lesions which are much more frequent than melanomas. So, at present, if we see this pattern we must excise the lesion to confirm the diagnosis with the help of histopathology.
Hi Juan! Thank you for your opinion. I agree, this is really a complex topic since in some cases neither the clinical appearance, nor the histological picture reflect the true biological nature of the neoplasm. And I am of the same opinion regarding clinicopathological correlation meetings. Of course, it is much easier when the patient is assisted under the same roof, and the meetings are regularly scheduled. It is more complicated when different profiles operating in different institutions (GP, dermatologist, surgeon, pathologist, oncologist) communicate sporadically or don't communicate at all.
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