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. 2018 Apr 30;8(2):89-103.
doi: 10.5826/dpc.0802a06. eCollection 2018 Apr.

Screening for malignant melanoma-a critical assessment in historical perspective

Wolfgang Weyers  1
Affiliations

Screening for malignant melanoma-a critical assessment in historical perspective

Wolfgang Weyers. Dermatol Pract Concept. .

Abstract

Screening for melanoma has been advocated for many years because early detection and excision have been regarded as the most important measure to lower mortality from that neoplasm. In the past decade, concern has been raised by epidemiologists that screening might result in excision chiefly of "inconsequential cancer," i.e., melanomas that would never have progressed into life-threatening tumors, a phenomenon referred to by the misleading term "overdiagnosis." Without any firm evidence, that speculation has been embraced worldwide, and incipient melanomas have been trivialized. At the same time, efforts at early detection of melanoma have continued and have resulted in biopsy of pigmented lesions at a progressively earlier stage, such as lesions with a diameter of only 2, 3, or 4 mm. Those tiny lesions often lack sufficient criteria for clinical and histopathologic diagnosis, the result being true overdiagnoses, i.e., misdiagnoses of melanocytic nevi as melanoma. This is especially true if available criteria for histopathologic diagnosis are diminuished even further by incomplete excision of lesions. The reliability of histopathologic diagnosis is far higher in excisional biopsies of lesions that were given some more time to develop changes that make them recognizable. Biopsy of pigmented lesions with a diameter of 6 mm has been found to result in a far higher yield of melanomas. In addition to better clinical judgment, slight postponement of biopsies bears the promise of substantial improvement of the reliability of histopathologic diagnosis, and of alleviating true overdiagnoses.

Keywords: melanoma; overdiagnosis; screening.

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Conflict of interest statement

Competing interests: The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Poster of the Sydney Melanoma Unit in the 1990s.
Figure 2
Figure 2
“Sid Seagull” as a teacher of cautious sun exposure in the Australian “SunSmart” campaign.
Figure 3
Figure 3
“Getting to know your moles”. First American publication for melanoma education by the New Mexico Melanoma Project in the late 1970s.
Figure 4
Figure 4
“The ABCDs of Moles & Melanomas”. Leaflet of the American Skin Cancer Foundation in 1985.
Figure 5
Figure 5
“Fight Against Black Cancer”. Leaflet of the Giessen Melanoma Group in the mid 1980s.
Figure 6A–C
Figure 6A–C
Clinical, dermatoscopic, and confocal microscopic presentation of lentigo maligna demonstrating the potential of adjunctive techniques in the clinical diagnosis of melanoma (courtesy of Harald Kittler, Vienna).
Figure 7
Figure 7
Figure 7A. Exophytic melanoma in nearly complete regression. Neoplastic cells have given way to granulation tissue in the exophytic nodule and to superficial fibrosis adjacent to it. In the nodule, small aggregations of neoplastic cells have remained. [Copyright: ©2018 Weyers.] Figure 7B. A dense lichenoid infiltrate of lymphocytes is present beneath remnants of epithelioid melanoma cells with pronounced nuclear atypia. Beneath the infiltrate, neoplastic cells have been substituted by granulation tissue. [Copyright: ©2018 Weyers.] Figure 7C. In the periphery, only moderate fibrosis of the papillary dermis with dilated, thick-walled blood vessels, some colloid bodies, and a few melanophages signify that the melanoma was once far larger. [Copyright: ©2018 Weyers.]
Figure 8
Figure 8
Melanoma in situ fulfilling all criteria for malignancy, namely, high cellularity, irregular size and form of nests, irregular distribution of nests and of solitary melanocytes, focal predominance of solitary melanocytes over nests, and many melanocytes in the upper reaches of the epidermis. This is melanoma and not a “precursor,” irrespective of whether or not additional step sections reveal some melanocytes in the papillary dermis. [Copyright: ©2018 Weyers.]
Figure 9
Figure 9
Figure 9A. Small melanocytic neoplasm measuring 2 mm in diameter. At this early stage, a definite clinical distinction between Clark’s nevus and melanoma in situ is not yet possible because, in the latter instance, the lesion did not have enough time to develop features indicating malignancy, such as an irregular border or irregular distribution of pigment. [Copyright: ©2018 Weyers.] Figure 9B. The lesion was removed. Histopathologically, it is composed of solitary melanocytes only. Predominance of solitary melanocytes over nests is a criterion for malignancy that cannot be applied to such early lesions. [Copyright: ©2018 Weyers.] Figure 9C. The regular distribution for solitary melanocytes is in favor of benignancy. However, presence of numerous melanocytes above the basal layer in the absence of signs of irritation is unusual for a melanocytic nevus. A melanoma in situ cannot be excluded with confidence. [Copyright: ©2018 Weyers.] Figure 9D. The lesion was probably excised completely, but it comes close to one lateral margin. Incomplete excision cannot be excluded. If this is a nevus, excision of it qualifies as “overtreatment” in the first place. Because a melanoma in situ cannot be ruled out, and the lesion may have been excised incompletely, a re-excision was performed, probably “double overtreatment.” [Copyright: ©2018 Weyers.]
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