QUICK TIPS
- Look, look, and look again, especially at sun-exposed areas (faces, ears, scalps [as hair thins], and dorsal forearms).
- Make sure patients are appropriately gowned no matter what the reason for their visit. Listening to heart and lung sounds and palpating abdomens through overcoats may work for some physicians, but not those interested in finding asymptomatic basal cell carcinomas, actinic keratoses, dysplastic nevi, and melanomas. Melanoma in men is most common on the back; in women, it’s most common on the legs. Seeing these areas requires that they be accessible.
- Biopsy when you’re in doubt. If you see a lesion and it is not recognizable as benign (eg, cherry angioma, seborrheic keratosis, nevus), biopsy it. Let the pathologist determine if it’s benign or malignant. If the lesion is questionable and is in an area that you are uncomfortable biopsying, refer the patient for evaluation and potential biopsy.
Mistake #2: Using insufficient light
As a former family practice academic, I used to preach to residents that they needed to use “light, light, and more light” for evaluation of skin lesions. Despite this, I was often asked to evaluate a patient with a resident who hadn’t even bothered to turn on a goose-neck lamp for illumination.
Even with my current “double bank” daylight fluorescent examination room lighting, it often takes additional (surgical-type) lighting to see the diagnostic features of skin lesions. Without such intense light, it is often impossible to see whether there is pearliness, rolled edges, or fine telangiectasia.
QUICK TIP
- Use whatever intense source of light you have, whether it’s a goose-neck lamp, a halogen, or a surgical light. If you don’t have at least a portable source of bright light, you are under-equipped for a good skin exam.
Mistake #3: Using insufficient (or no) magnification
I was once examining a patient in a hospital room that had inadequate light, despite my best efforts. So I took out my digital camera with flash and autofocus feature and photographed the lesion. I then looked at the lesion on the camera’s LCD monitor and determined that it was a BCC.
The benefit of the camera was 2-fold: Not only did the flash serve as an instant source of light, but the macro feature also provided magnification. Viewing a magnified digital image on a computer screen also allows unhurried, self “second opinions,” where details can often be ascertained that were not immediately apparent in “real time,” such as rolled edges, telangiectasia, dots, streaks, and subtleties of color.
QUICK TIPS
- Use a hand-held magnifying lens (5X to 10X) routinely during skin exams. They’re not expensive and should be part of every primary care physician’s armamentarium—just like stethoscopes, ophthalmoscopes, and reflex hammers.
- Use a digital camera to provide the magnification needed to see details that can be missed clinically. I’m convinced that using a digital camera has made me a better observer—and clinician. Additionally, digital photographs can be stored and compared with histologic results as “self-education.” When purchasing a camera for this purpose, make sure it has a good close-up (macro) feature.
Mistake #4: Assuming that pathology is a perfect science
Most physicians assume that dermatopathologists have a high rate of interrater concordance with diagnoses such as melanoma. Unfortunately, that is not always the case. Consider the following:
- As part of a National Institutes of Health consensus conference on melanoma, 8 dermatopathologists considered experts in melanoma were asked to provide 5 slides each. The slides were relabeled and sent to the same 8 dermatopathologists. (Three slides were eliminated.) Their findings: At the extremes, 1 pathologist called 21 cases melanoma and 16 benign, whereas another called 10 melanoma, 26 benign, and one indeterminate.2 (Remember: These were all experts in melanoma.)
- In a study of 30 melanocytic lesion specimens (including Spitzoid lesions), 10 Harvard dermatopathologists evaluated each sample independently of each other. Given 5 diagnostic categories to choose from, in only one case did as many as 6 of the 10 agree on a diagnosis. In all of these cases, there was long-term clinical follow-up, so the biologic behavior of these lesions was known. Some lesions that proved fatal were categorized by most observers as benign (eg, Spitz nevi or atypical Spitz tumors). The converse, reporting benign lesions as melanoma, also occurred.3
So consider this: If this degree of discordance occurs among dermatopathologists, what results could we expect from non-dermatopathologists?
I have personally seen instances where reports of melanoma from non-dermatopathologists did not even report Clark and Breslow staging information (although one could determine Clark staging from reading the body of the report), and reports of dysplastic nevi that were accompanied by recommendations for re-excision with 1 cm margins.