ideally, the patient should lie in a horizontal position on the examining table. The entire an- terior and posterior cutaneous surface of the patient is examined with the patient assuming a supine, then a prone, position. intertriginous areas, including the axillae, groin, and interdig- ital webs of the hands and feet, plus the nail ap- paratus, are included in the complete cutaneous examination.
Finally, examination of the scalp is best ac- complished by the use of a hair blower that parts the hair down to the skin of the scalp for view- ing.
I.2.2 ABCDE Criteria and Other Diagnostic Methods
The acronym aBCDE was created as a simple mnemonic to alert both the general community and health care workers of some of the key fea- tures of melanoma. The acronym stands for:
a = asymmetry. No matter where the lesion is bisected, the one half will not match the other in silhouette and/or lesion content.
B = Border irregularity. The perimeter of the lesion is uneven, undulating, ragged, notched, or blurred.
C = Color. Multiple shades of tan, brown, black, red, white, and blue are admixed, produc- ing a mottled appearance.
D = Diameter >6 mm. The largest diameters of most melanomas will exceed 6 mm at a point in their evolution that can be identified. This is not an inviolate rule, and currently a significant portion of melanomas are diagnosed by experts when these cancers are 6 mm or less in diame- ter.
Chapter I.2
Clinical Examination of Melanocytic Neoplasms Including ABCDE Criteria
alfred W. Kopf
I.2
Contents
I.2.1 Clinical recognition of Melanoma . . . .3 I.2.2 aBCDE Criteria and other
Diagnostic Methods . . . .3
I.2.1 Clinical Recognition of Melanoma The clinical recognition of melanoma in its ear- ly phases of progression is exceedingly impor- tant since the total surgical removal of such lesions is almost invariably curative. When the clinical recognition is delayed, the opportunity for distant metastases increases and the progno- sis is guarded since treatment of such metasta- ses is problematic.
Since dysplastic nevi and melanomas can occur on any area of the cutaneous surface, it is mandatory that a complete cutaneous examina- tion be performed on every patient regardless of age. all new patients should have a complete cu- taneous examination either at the initial visit or in the near future. The frequency for an estab- lished patient depends on their history. Those patients with a history of actinic keratosis, dys- plastic nevi, non-melanoma skin cancer or mel- anoma should be seen every 6 months for a complete cutaneous examination.
The examining room should have proper illumination and the temperature should be comfortable for the patient, who should be completely undressed except – maybe – for the examination gown, which should be provided.
The examiner should have available a simple
magnifying lens, an instrument for dermosco-
py, and an ultraviolet lamp (“Woods light”) for
special examinations such as looking for areas
of hyper- or hypopigmentation on the skin.
A.W. Kopf
I.2
E = Evolving. While common melanocytic nevi evolve slowly and reach a final stage of growth usually within the first few decades of life, melanomas usually undergo constant change in size, shape, shades of color, symme- try, symptoms (especially pruritus, scaliness, oozing, bleeding), or surface alterations [ero- sion, ulceration, papule, and/or nodule forma- tion and the development of areas of hypopig- mentation and depigmentation (a clinical correlate of spontaneous regression)].
Another easy mnemonic are the three Cs of melanoma standing for: color, contour, and change.
The diagnostic method of the Glasgow 7- point checklist for diagnosis of melanoma in- cludes: (a) change in size; (b) irregular shape; (c) irregular color (major criterion); (d) diameter at least 7 mm; (e) inflammation; (f) oozing/bleed- ing; and (g) change in sensation (minor criteri- on).
The features described above are suggestive of melanoma (especially superficial spreading melanoma), but they also appear in benign le- sions (such as atypical nevi), thus causing diag- nostic difficulties. Nodular melanomas, on the other hand, often appear as small and symmet- ric round nodules, smaller than 6 mm in diam- eter, the only hint of malignancy being a clinical history of evolution and change. These limita- tions to specificity and sensitivity of naked-eye examination can be reduced by dermoscopy as a useful aid in the in-vivo differentiation of such lesions (see Chap. I.3).
Furthermore, total cutaneous photography can be performed for patients who have many melanocytic nevi (especially when atypical).
Baseline total-cutaneous photographs (Fig. I.2.1) are very helpful in identifying significant chang- es in pre-existing lesions and identifying new melanocytic neoplasms on subsequent follow- up clinical examinations.
Last but not least, patients should be instruct- ed and encouraged to regularly perform self-ex- amination of their skin (Fig. I.2.2).
Fig. I.2.1. Illustrations for different views taken of to-
tal-body photographs. Sites photographed are bound by
dashed lines or solid-line rectangles. Top: On anterior and
posterior surfaces of body, all demarcated areas (shaded
and unshaded) are photographed. On lateral aspects of
body, only shaded areas are photographed
Clinical Examination of Melanocytic Neoplasms Chapter I.2
Fig. I.2.2. Self-examination of the skin (continuation see next page)
C
