scopic features, relevant clinical differential di- agnosis, histopathology, as well as practical as- pects of management. Core messages recapitulate the most pertinent facets of each entity.
This introductory chapter, therefore, can be considered a plea for recognition of the signifi- cance, and the unchanging importance, of the human eye and the human neural network for achieving diagnosis in the protean field of mela- nocytic skin lesions. We currently are on the edge of the development of new technologies, such as imaging technologies and molecular- biologic tests, for identifying individuals at risk and for refining the benign/malignant thresh- old. These new technologies are challenging the currently well-accepted morphologic methods including histopathology. However, the present reality, even in high-tech countries, is that der- matologists are, and most probably will remain, at the forefront of diagnosing and treating skin cancers as well as managing melanocytic skin lesions.
I.1.2 The Benign/Malignant Threshold in Morphology
The boundary between benignity and malig- nancy is not as sharp as our established catego- ries would like them to be. Dermoscopic – but also histopathologic – diagnoses, not to men- tion clinical diagnosis, are subjective as well as objective. in 1962 these facts were well depicted for the histopathologic diagnosis by rambo who stated that “pathologists are physicians and hu- man beings. They […] traditionally have been regarded to be more scientific than many of their colleagues. a mystic perversion of this as- sumption prevails among those clinicians who Chapter I.1
The Morphologic Dimension in the Diagnosis of Melanocytic Skin Lesions
H. Peter Soyer and Elisabeth M.T. Wurm
I.1
Contents
I.1.1 a Color atlas of Melanocytic lesions of the Skin . . . .1 I.1.2 The Benign/Malignant Threshold
in Morphology . . . .1 I.1.3 a New Era of “Clinicoimaging”
Diagnosis in Dermatology . . . .2 references . . . .2
I.1.1 A Color Atlas of Melanocytic Lesions of the Skin
The book in your hands has been designed basi- cally as an atlas entitled Color Atlas of Melano- cytic Lesions of the Skin and focuses on the mor- phologic dimension of melanocytic skin lesions.
it encompasses all the classical methods of mor- phology such as the clinical and dermoscopic examination and dermatopathology, as well as the most up-to-date diagnostic approaches such as laser scanning in-vivo microscopy, multi- spectral image analysis, automatic diagnosis, and teledermatology. With the exception of the chapters on automatic diagnosis and on multi- spectral analysis, all chapters focus on the mor- phologic dimension, albeit in its various facets, thus justifying the title of this book.
The core of this book represents an atlas with clinical, dermoscopic, and histopathologic im- ages of the many faces of melanocytic nevi, the various types of melanomas, as well as the vari- able features of non-melanocytic pigmented skin tumors. Each of these well-illustrated enti- ties are presented following the same ductus characterized by definition, clinical and dermo-
H. P. Soyer, E. M.T. Wurm
I.1 believe that the pathologist, given only a piece of the patient’s tissue, has all the other ingredients necessary to produce a statement of absolute truth at the end of his report. More dangerous to the mankind is a pathologist with the same con- cept…” [1]. Even today it is not easy at all to find references which indicate that expert patholo- gists sometimes have great difficulties in recog- nizing, for example, the threshold separating carcinoma in situ or melanoma in situ from atypia or dysplasia. interestingly, many dermos- copists reveal more insight with regard to their diagnostic limitations. in a recent issue of the
“archives of Dermatology” an article by Skvara et al. entitled “limitations of dermoscopy in the recognition of melanoma” focuses on the limi- tations of dermoscopy in the diagnosis of very early, and mainly featureless, melanomas [2].
The authors report that baseline dermoscopic patterns of 262 melanocytic nevi and 63 mela- nomas, which were followed by digital dermos- copy and finally excised because of changes over time, did not differ substantially from each oth- er. Suffice it to say that histopathology repre- sented the gold standard in this study.
I.1.3 A New Era of “Clinicoimaging”
Diagnosis in Dermatology
in 2005 June robinson, the editor of the “ar- chives of Dermatology,” wrote in an editorial titled “Biotechnology succeeds in revolutioniz- ing medical sciences” the following statement:
“Given the unique visual learning patterns of our discipline, it is not surprising that we eager- ly adapt emerging bioimaging techniques. [...]
We are beginning to move away from clinico- pathologic diagnosis into an era of ‘clinicoimag- ing’ diagnosis” [3]. The introduction of these new ‘clinicoimaging’ techniques in the near fu- ture certainly will have a major impact on the current dermatologic practice, although there will be a need to define new quality standards in order to integrate these techniques into the dai- ly workflow. We should not forget, however, that all of these new “clinicoimaging” techniques have, like every other purely morphologic meth-
od, limitations due to methodologic drawbacks, and sometimes even due to personal restraints.
in addition, we are presently also on the edge of a period of radical change in histopathology, as DNa and rNa can be analyzed by advanced technologies even from archival paraffin-em- bedded material, allowing us to make diagnos- tic leaps and bounds [4]. This “new biology” will certainly also affect the benign/malignant threshold in pathology, and a more functional approach to establish the risk associated with sharply defined categories will substitute the fanciful separation of benign from malignant [4, 5]; thus, one can easily foresee that in the fu- ture the conventional morphologic methods will probably be substituted by these new “clini- coimaging” techniques and by novel microbio- logic methods. Until then, a combined approach linking the most legitimate and effective mor- phologic methods, namely, clinical examina- tion, dermoscopy, and histopathology, will strengthen the validity of classical morphology [6, 7]. in this spirit this introductory chapter, and this atlas, has been written.
References
1. rambo oN. The limitations of histologic diagnosis.
Progr radiat Ther 1962; 2: 215–224
2. Skvara H, Teban l, Fiebiger M, Binder M, Kittler H. limitations of dermoscopy in the recognition of melanoma. arch Dermatol 2005; 141: 155–160 3. robinson JK, Callen JP. Biotechnology succeeds rev-
olutionizing medical sciences. arch Dermatol 2005;
141: 133–134
4. Quirke P, Mapstone N. The new biology: histopathol- ogy. lancet 1999; 354: Si26–Si31
5. Foucar E. Carcinoma-in-situ of the breast: Have pa- thologists run amok? lancet 1996; 347: 707–708 6. Soyer HP, Massone C, Ferrara G, argenziano G.
limitations of histopathologic analysis in the recog- nition of melanoma: a plea for a combined diagnostic approach of histopathologic and dermoscopic evalu- ation. arch Dermatol 2005; 141: 209–211
7. Bauer J, leinweber B, Metzler G, Blum a, Hofmann- Wellenhof r, leitz N, Dietz K, Soyer HP, Garbe C.
Correlation with digital dermoscopic images can help dermatopathologists to diagnose equivocal skin tumours. Br J Dermatol 2006;155: 546–551
