Dermatology: Practical and Conceptual


Editorial  |  Dermatol Pract Concept 2018;8(2):1 73

DERMATOLOGY PRACTICAL & CONCEPTUAL
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In his opinion piece, Wolfgang Weyers (2018) suggests that 

the practice of biopsying small lesions (<6 mm in diameter) 

without conspicuous clinical and/or dermoscopic features 

of melanoma is a key contributing factor to the so-called 

epidemic of melanoma overdiagnosis. He contends that these 

clinically non-diagnostic lesions often lack histopathologic 

criteria that allow precise classification, which leads to false-

positive diagnoses. He proposes delaying biopsy of lesions 

that are suspicious, but not diagnostic, for melanoma until 

features consistent with malignancy arise, the aim being to 

decrease diagnostic and biologic uncertainty and thereby 

minimize the potential for melanoma overdiagnosis together 

with its associated cost and morbidity. The view expressed by 

Dr. Weyers is intriguing, and the overarching concept raises 

important questions relevant to the diagnosis of melanoma.

1. What is the optimal sensitivity and specificity threshold 

for melanoma diagnosis? While taking a watch-and-wait 

approach until melanoma unequivocally declares itself will 

increase specificity and possibly decrease the likelihood 

of overdiagnosis, this approach implies a concomitant 

decrease in sensitivity for melanoma detection. This, in 

turn, may result in some individuals developing advanced 

stage melanomas due to the missed opportunity of early 

detection. This is not an uncommon scenario occurring in 

patients with difficult to detect melanoma subtypes, such 

as nodular, desmoplastic, nevoid, amelanotic, or spitzoid 

melanoma. Further research is needed to determine if the 

benefits of a reduction in overdiagnosis and unnecessary 

biopsies outweigh the harm that may result from missed 

early melanoma detection.

2. Which patient population is most amenable to watchful 

waiting of suspicious but not overtly malignant lesions? 

The concept of waiting until melanoma declares itself 

before performing a biopsy is contingent upon (a) patient 

and physician acceptance of monitoring as a reasonable 

choice, and (b) patient vigilance and periodic physician 

based follow-up. Regarding the former, the idea of observ-

ing a suspicious lesion that may be an early melanoma may 

not be acceptable to certain patients, such as those with 

significant anxiety, a personal history of melanoma, or a 

family history of lethal melanoma. In some countries, the 

practice may also be associated with increased legal liabil-

ity to the physician. Regarding the latter, although there 

are some patients who are meticulous about regularly 

examining their skin, others lack the needed confidence 

or are unwilling or unable to consistently perform self-

examinations. Even if patients are monitoring their own 

skin, the ability to detect subtle (and occasionally seem-

ingly obvious) changes indicative of melanoma progres-

sion is not always possible. Finally, a significant number 

of patients fail to keep their follow-up appointments, and 

some of these patients may go on to develop aggressive 

melanomas.

3. How are small equivocal lesions best monitored? To some 

extent, the concepts alluded to by Dr. Weyers are already 

implemented in clinical practice. Total body photography 

Comment on: Screening for malignant melanoma— 
a critical assessment in historical perspective

Ashfaq A. Marghoob1, Michael Marchetti1, Allan C. Halpern1, Klaus J. Busam1

1 Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA

Citation: Marghoob AA, Marchetti M, Halpern AC, Busam KJ. Comment on: Screening for malignant melanoma--a critical assessment in 
historical perspective. [Editorial]. Dermatol Pract Concept. 2018;8(2):73-74. DOI: https://doi.org/10.5826/dpc.0802a01

Published: April 30, 2018

Copyright: ©2018 Marghoob et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Corresponding author: Ashfaq A. Marghoob, MD. Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer 
Center, 16 E 60th St, New York, NY 10065. Email: marghooa@MSKCC.org.



74 Editorial  |  Dermatol Pract Concept 2018;8(2):1

of melanoma only if there is compelling evidence from 

microscopic review (e.g., marked asymmetry, florid and 

chaotic pagetoid spread, and severe atypia) or ancillary 

studies. The same is true for small and partial biopsies. It 

is not our experience that pathologists issue a diagnosis of 

melanoma as a default option when the diagnosis is dif-

ficult; instead, they usually admit diagnostic uncertainty. 

While the biopsy of small lesions and small partial biopsies 

of lesions have undoubtedly contributed to an inflation of 

descriptive pathology reports (e.g., “atypical melanocytic 

proliferation”), such evasive diagnoses should not enter 

melanoma statistics and therefore cannot be responsible 

for the increase in the reported incidence of melanoma.

We agree with Dr. Weyers that wholesale biopsy (espe-

cially partial biopsies) of small, non-palpable, equivocal 

lesions should be discouraged. We also agree that if a lesion 

has compelling clinical or dermoscopic features for mela-

noma, then a biopsy should be performed, irrespective of 

the lesion’s diameter. However, while there are benefits to 

the watch-and-wait approach for small equivocal lesions as 

outlined by Dr. Weyers, there are also potential pitfalls and 

unanswered questions that require further study. We posit 

that a combined approach using morphologic (clinical exami-

nation, dermoscopy, confocal microscopy, etc.), comparative 

(e.g., ugly duckling sign), temporal (monitoring using TBP, 

dermoscopy, confocal microscopy), and genomic data (e.g., 

non-invasive molecular assays obtained via microbiopsies, 

tape-stripping, etc.), augmented someday by machine learn-

ing approaches, will likely address some of the core issues 

described in the opinion piece by Dr. Weyers. Furthermore, as 

our understanding of the biology of melanocytic neoplasms 

continues to expand, the prevalence of lesions with diagnostic 

and biologic uncertainty will decrease, but complete knowl-

edge of the potential nature of every lesion over the course of 

each individual’s life will, of course, remain elusive.

(TBP) and digital dermoscopic monitoring is one standard 

of care used in many clinics that screen patients at high 

risk for melanoma. The aim of digital monitoring is to 

actively follow banal and equivocal flat lesions with the 

aim of biopsying only those lesions that are changing in 

a concerning manner. However, while this time- and cost-

intensive approach can improve the yield for diagnosis of 

melanoma, in our experience it does not always eliminate 

the biopsy of lesions that prove to be histopathologi-

cally equivocal. In fact, borderline lesions and nevi with 

unusual features appear to be enriched. Among biologi-

cally dynamic, small, equivocal lesions, how certain do we 

need to be before performing a biopsy? If our threshold 

is too high, some patients may die from advanced disease 

because lesions were not biopsied at an earlier point in 

time. In practical terms, however, TBP and digital dermo-

scopic monitoring are not always available to patients, and 

the best approach to monitoring lesions without access to 

these technologies remains unclear.

4. What is the most appropriate interval for follow-up, and 

until what time point should small equivocal lesions be 

monitored? Based on currently available data, there are 

no clear answers to these questions.

5. Finally, does the removal of small equivocal lesions truly 

result in the overdiagnosis of melanoma? It is worth 

highlighting that there is no solid evidence and no study 

referenced to support Dr. Weyers’ claim that dermatopa-

thologists’ interpretation of smaller lesions contributes to 

overdiagnosis. In fact, the opposite may be true. Since most 

small lesions are captured in their entirety by a biopsy, all 

available diagnostic criteria can be applied, and if needed, 

modern ancillary methods are available to support the 

correct diagnosis. Furthermore, most pathologists hesi-

tate to establish a diagnosis of melanoma because of the 

small diameter of a lesion and usually render a diagnosis