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2 comments on “[5 min watch] Second opinion & clinico-pathologic correlation Part 2: Prof Giuseppe Argenziano”

1. I am intrigued by the discussion here. The first lesion has dermoscopic features suggestive of melanoma. (Giuseppe Argenziano has said so!) But the pathologist is emphatic this is benign. The second lesion has similar dermoscopic features, again the pathologist considered it histologically benign, until the significant increase in size, with greater structural dermoscopic irregularity was brought to his attention. Because of the ‘macroscopic’ growth shown to him, the pathologist considers it malignant. (That growth is not a criterion in specific visual histologic characteristics, but in the general concept of malignancy it is significant.) The third lesion has evident dermoscopic and histologic criteria of malignancy (we see the dermoscopy) but it is sitting at the end of a two year old excision line. The origina lesion would have had a wider excision had it then been specified histologically as malignant. (I suspect with this history, a pathologist reviewing the initial – two year old – slides of the lesion would now find convincing features of malignancy!)

   From the Australian perspective, a major problem is the iron-clad control the pathologist has on pigmented skin lesion diagnosis – and the consequent major difference between the financial billing for a ‘benign lesion’ (even if specified as ‘dysplastic’ – with advice to excise as if a melanoma) and the billing for a histologic melanoma. The dermoscopic images presented of the first two lesions (we have no dermoscopic image of the initial state of the third) I consider are sub-optimal with insufficient fine definition. Is the problem that high quality dermoscopic images are not routinely sought by dermatopathologists, nor provided routinely to them? In the second case, I cannot see the two different aspects of the lesion (one quite brown, the other much less so) presented in the histologic slide presented. Certainly not commented on. If there is malignancy in this lesion, perhaps it was it not histologically sampled and viewed? In the second lesion, are the peripheral reticular structures subtly expanding outward, their inner aspects being ‘swallowed up’ by the encroachment of the increasing central area of regression? But regression has recently been suggested as ‘a protective value’ for survival. [PMID: 28386963 DOI: 10.1111/BJD.15552]
   The outer reticular rim has a greater chaotic variety of extent and colour than in the initial image.
   So is the malignancy in the darker, more anomalous reticular parts of the rim? We would not know unless they are specifically sampled in a histologic transection.

   An essential Australian problem is that Medicare financially discounts the excision of ‘benign’ lesions, the implication being they should be left intact. The diagnosis being histologic, not dermoscopic. Excise too many ‘benign’ lesions, and you may be investigated for overservicing. For each dermoscopic criterion, there is a continuum from frankly benign to frankly malignant. (The same is true for histopathology.) Certainly, the second (two year later) excision of the third example was billed for malignancy, as was the necessary wider excision to complete the treatment. It is just as well this lesion was picked up when it was. (Very possibly, it could have been dermoscopically identified at an earlier stage of re-growth. But would that regrowth of itself be a sufficient evidence for malignancy, or would the lesion still need to satisfy histologic criteria?)

   Present dermoscopy of itself does not always efficiently, nor sufficiently discriminate. And demoscopic criteria are not usually viewed nor considered by the pathologist. In Australia, one is not adequately paid for being careful.

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