Criteria for diagnosis clinically: An ill-defined plaque with a pink-orange-slightly brown
cast covered in part by scale and on one side of it by scale-crust
represents an unusual presentation of melanoma.
clinically: This could be misconstrued as Bowen's
disease and biopsy is requisite to resolving the issue.
Criteria for diagnosis
histopathologically: An asymmetrical neoplasm of
strikingly abnormal melanocytes characterized (1) in the epidermis
by nests that are not equidistant from one another, vary
considerably in size and shape, have resumed peculiar outlines
geometric, and have become confluent in loci, as well as by
melanocytes disposed mostly as solitary units at all levels of it,
including the cornified layer, and (2) in the dermis by confluence
of aggregations of character similar to that in the epidermis,
they, in loci, forming a sheet, is a melanoma.
histopathologically: There is none.
correlation: The plaque came into being
mostly by virtue of the neoplastic melanocytes in a patchy front
across the upper part of the dermis; the reddish hue is a
consequence of venules dilated widely in the upper part of the
dermis, they, in vivo, having been stuffed with
erythrocytes; the paucity of brown derives from melanin being so
scant; and the scale is a result of orthokeratosis.
Options for therapy predicated on knowledge of
histopathologic findings: A melanoma must be excised
in toto with just enough normal skin around it to ensure
that that desideratum has been accomplished.
1) It is impossible, on grounds clinical alone, to make a
diagnosis in this patient of melanoma. In fact, the lesion is much
more consonant clinically with Bowen's disease than it is with
melanoma, it being reddish and scaly and devoid largely of
pigmentation. Biopsy, however, produced a specimen from which
sections show melanoma indubitable.
2) The vaunted ABCDEs, much trumpeted as the surest route to
clinical diagnosis of melanoma, fail miserably here-the C
(Color variability) is missing.
3) As impossible as it is to make a diagnosis with specificity
of melanoma clinically here, so easy it is to come to a diagnosis
of melanoma histopathologically. The neoplasm shown in the
photomicrographs fulfills all criteria for melanoma, both ones
architectural and cytopathologic. The neoplasm is strikingly
asymmetrical in all respects, including the surface and the base of
it, as well as in terms of distribution of melanocytes and of
lymphocytes. Moreover, nuclei of melanocytes are large,
pleomorphic, and heterochromatic, and some are in mitosis.
4) The scale-crust so prominent clinically is not present in the
5-micron section of tissue pictured here.
5) The brown lesions on this patient's arm and forearm are