10.5826/dpc.1203a100
text/xml
2160-9381
1991
en
Andrea Michelerio
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
malpractice claims
Dermoscopy for Cutaneous Melanoma: under the eye of both the dermatologist and the legal doctor 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2022-07-28
2021-08-25
2022-07-28
2022-09-13
e2022100
Dermatol Pract Concept
Andrea Michelerio
2022/07/28
10.5826/dpc.1203a100
e2022100
Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
2160-9381
malpractice claims
en
e2022100
Dermoscopy for Cutaneous Melanoma: under the eye of both the dermatologist and the legal doctor 
https://dpcj.org/index.php/dpc/article/download/1991/1700
                    Dermatology Practical & Conceptual


 Dermoscopy for Cutaneous Melanoma: Under the
Eye of Both the Dermatologist and the Legal Doctor
                                         Vittorio Bolcato1, Andrea Michelerio2,3


1 Department of Public Health, Experimental and Forensic Medicine, Forensic Medicine Unit, University of Pavia, Pavia, Italy
2 Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, Pavia, Italy
3 Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy



Citation: Bolcato V, Michelerio A. Dermoscopy for Cutaneous Melanoma: under the eye of both the dermatologist and the legal doctor.
Dermatol Pract Concept. 2022;12(03):e2022100. DOI: https://doi.org/10.5826/dpc.1203a100
Accepted: October 31, 2021; Published: July 2022
Copyright: ©2022 Bolcato et al. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and
reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Andrea Michelerio, MD, Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, 19, and
Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100, Pavia, Italy. E-mail: andrea.michelerio01@
universitadipavia.it




Worldwide, melanoma is the 20th most common cancer,                      can appreciate the deeper primary morphology of cutane-
with 287,723 estimated new cases (1.6% of all cancers) and               ous lesions beyond the gross morphologic features, such as
60,712 related deaths (0.6% of all cancer deaths) in 2018,               size, shape, colors, contours, and topography. This approach
and a five-year prevalence of 965,623 cases [1]. Cutaneous               improves the diagnostic accuracy for melanoma [6] and the
melanoma (CM) is by far the most common melanoma sub-                    observers confidence in their clinical diagnosis [7].
type and a potentially fatal disease. Early recognition is of                 Unfortunately, even with dermoscopy, some melanomas
utmost importance to improve the prognosis, since if mel-                remain clinically and dermoscopically indistinguishable from
anoma is diagnosed at noninvasive stage, the patient will                other lesions, such as seborrheic keratoses, whose suggestive
be treated by excision of the primary tumor, but if mela-                features might be displayed in up to 18% of melanomas,
noma becomes invasive, the chance of recovery decreases as               vascular lesions and pyogenic granulomas, lichen planus-like
invasion thickness increases [2]. Given its dramatic rise in             keratoses, warts, dermatofibromas, ulcers and, finally, from
incidence, its predilection for middle-aged patients, and its            melanocytic nevi, hence difficult to diagnose [8-16]. This is
ability to masquerade as a benign lesion, melanoma is easily             particularly true in patients with atypical mole syndrome,
misdiagnosed, providing a basis for malpractice claims [3,4].            whose nevi share clinically some, or all, the features of CM
    Dermatoscopy, commonly referred as dermoscopy, is a                  (the ABCDs: asymmetry, border, irregularity, color variabil-
noninvasive technique allowing microscopic visualization of              ity, and diameter > 6 mm).
subsurface skin structure not visible to the naked eye [5].                   A strategy involves the dermoscopic follow‐up of atypi-
A trained user, through a hand-held microscope, equipped with            cal lesions, through sequential digital dermatoscopy imaging,
a magnification lens and a light source (the dermatoscope),              and excision only of those lesions that change over time [17].




Review | Dermatol Pract Concept. 2022;12(03):e2022100                                                                                        1
The introduction of digital dermatoscopes or so-called vid-         for recovery has been lost. It has been widely proven that
eodermatoscopes (VDS), the sequential digital dermatoscopy          sequential dermoscopy imaging detects mostly thin incipi-
imaging (SSDI) and total body photography (TBP) are fur-            ent melanomas [15,27,28] and patients with these lesions
ther options in the general digital progress within medicine        are generally considered to be at low risk for metastasis and
and dermatology. These systems are equipped with high-res-          melanoma-related death, but it is well known that a portion
olution color video cameras that reveal monitor images ob-          of this group will eventually experience disease recurrence
tained using non-polarized or polarized light. They achieve         and risk death from melanoma [29–32]. One can wonder if,
higher magnifications than most common hand-held derma-             comprehensively informed, a patient would rather opt for
toscopes and simplify image acquisition, storage, organiza-         immediate surgical removal, sacrificing specificity over sen-
tion, analysis, and retrieval. These techniques are appreciated     sitivity. On the other hand, removal of all unusual-appearing
and requested by the patients who, however, might do not            nevi, especially in patients with multiple atypical nevi, is usu-
fully understand the rational of the methods , often believing      ally impractical.
their nevi are being monitored because at risk of malignant            The use of TBP might further facilitate the detection of
evolution, especially the atypical ones [18]. Indeed, the ac-       new lesions, as well as visual changes in pre-existing lesions,
tual risk of any given nevus of transforming into a melanoma        by providing a comparative reference point of areas of skin
has been estimated to be low, whereas the majority of mela-         for subsequent examinations [33].
nomas appear to arise de novo [19], and “atypical” nevi are            During a dermoscopic and clinical visit, we might be
at no higher risk of developing into a melanoma; rather, the        tempted to feel that our conversation with a patient suffi-
“atypical” nevus is more likely to actually be a melanoma           ciently ensures that the patient has freely and knowingly
whose dermoscopic features may not differ significantly at          accepted the procedure. However, while dialogue is neces-
baseline from nevi [15].                                            sary, it is not sufficient for legally documenting informed
    A discrepancy between patients and physician’ expecta-          consent, given that in some countries, Italy and Spain for
tions towards VDS and TBP might be even at the base of the          example, the law stipulates that consent must be given by
doctor-patient relationship, and this is not without danger.        traceable means, such as in writing [34,35]. The informed
The availability of monitoring during follow-up changes the         consent doctrine has, in fact, three goals: (1) to include
clinician threshold for biopsy suspicious pigmented lesions,        patients in the decision-making process; (2) to involve the
resulting in a fall in the sensitivity for melanoma at the first    patient in the choices that affect the psycho-physical aspect;
examination, to increase the specificity and the accuracy           and (3) to ensure the patient is aware of the potential bene-
for melanoma detection at the next evaluation. There are            fits and hazards of the treatment [36].
2 main approaches: short-term follow-up (3 months) is used             In dermoscopy context, compared with the issue of
to make a clinical decision about single, flat or slightly raised   patient’s follow-up in medicine as a whole, for the several
suspicious melanocytic lesion, lacking dermoscopic features         aforementioned issues and regarding especially the third
of melanoma; while medium or long-term monitoring, gen-             point, proper documentation of the care planning, with in-
erally restricted to patients with multiple nevi, mainly aims       formation about prognosis, follow-up, and therapeutic ap-
at comparison of multiple inconspicuous lesions over stan-          proaches, to which the patient consents, is fundamental in
dard surveillance periods (usually 6 or 12 months) [20].            the reduction of litigation related to melanoma misdiagnosis,
    To work properly, this method of follow-up needs                usually seen as diagnostic delay and illicit reduction of sur-
­patients’ compliance with follow-up timing. Unfortunately, it      vival and/or quality of life. In medicolegal cases, a physician
has been proven that patients compliance strongly decreases         note may provide additional evidence that the physician met
with long-term control visits, with the risk of melanoma            the applicable standard of care, while inadequate documen-
un-treatment [21–23], and we cannot exclude this is due to          tation may reduce the likelihood of a successful defense [3].
a misunderstanding and miscommunication between patient                Of great interest, a recent pronunciation of the II Civil
and physician about how the method works.                           Section of the Genua Tribunal (n. 939/2017) discusses two
    Moreover, the depth of invasion is the most critical            of the main issue on diagnostic delay for melanoma: at first,
prognostic factor of malignant melanoma, but dermoscopic            the importance of written health records, to identify the
findings do not allow a reliable evaluation of the tumor            followed diagnostic procedure and the proper information;
thickness, nor a sure distinction between an in situ and an         secondly, the need of standard formation of dermatologist
early invasive phase [24-26] and, consequently, diagnosis re-       about dermoscopy, to avoid, in cases of doubtful lesions,
mains only histopathological. The question is of more than          “that there was not even observation with a dermatoscope”
academic interest because melanoma is a completely curable          [37]. In addition to documentation, photography becomes
disease if diagnosed early, while still in situ. Once it becomes    more widespread in both general dermatological setting,
invasive, the diagnosis becomes easier but the best chance          and in dermoscopy, because specific part of the method;



2                                                                             Review | Dermatol Pract Concept. 2022;12(03):e2022100
photography, in fact, may directly impact patient care by al-               sources and methods. Int J Cancer. 2019;144(8):1941-1953.
lowing the clinician to detect changes in pigmented lesions.                DOI: 10.1002/ijc.31937. PMID: 30350310.
                                                                       2.   Naik PP. Cutaneous Malignant Melanoma: A Review of Early
A proper patient’s disclosure over picture management must
                                                                            Diagnosis and Management. World J Oncol. 2021;12(1):
also be added in the medical records [38,39].
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imaging, with their particular characteristics, might need             3.   Marghoob AA, Changchien L, DeFazio J, et al. The most com-
a deep information and appropriate signed written con-                      mon challenges in melanoma diagnosis and how to avoid them.
sent [36].                                                                  Australas J Dermatol. 2009;50(1):1-13; quiz 14-15. DOI:
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tologists and hospitals might face medicolegal concerns for
                                                                       6.   Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic ac-
some months delay, even in case of small and likely in situ                 curacy of dermoscopy. Lancet Oncol. 2002;3(3):159-165. DOI:
melanomas, if not properly diagnosed and followed [41].                     10.1016/s1470-2045(02)00679-4. PMID: 11902502.
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mandatory to guarantee optimal follow-up and to meet the                    AA. Differences in dermoscopic images from nonpolarized der-
                                                                            moscope and polarized dermoscope influence the diagnostic
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                                                                            accuracy and confidence level: a pilot study. D   ­ ermatol Surg.
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several key elements, clinical and medicolegal. Melanoma              10.   Braun RP, Gaide O, Oliviero M, et al. The significance of mul-
diagnosis remains difficult, with frequent misdiagnosis, so                 tiple blue-grey dots (granularity) for the dermoscopic diagno-
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