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Prevalence of Melanoma Clinically Resembling Seborrheic Keratosis Analysis of 9204 Cases

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Prevalence of Melanoma Clinically Resembling Seborrheic Keratosis Analysis of 9204 Cases STUDY Prevalence of Melanoma Clinically Resembling Seborrheic Keratosis Analysis of 9204 Cases Leonid Izikson, BS; Arthur J. Sober, MD; Martin C. Mihm, Jr, MD, FRCP; Artur Zembowicz, MD, PhD Objective: To estimate the prevalence of melanoma clini- Main Outcome Measure: Histological diagnosis, which cally mimicking seborrheic keratosis. was correlated with the preoperative clinical diagnosis. Design: Retrospective review of cases submitted for his- Results: Melanoma was identified in 61 cases (0.66%) tological examination with a clinical diagnosis of sebor- submitted for histological examination with a clinical rheic keratosis or with a differential diagnosis that in- diagnosis that included seborrheic keratosis. Melanoma cluded seborrheic keratosis. was in the clinical differential diagnosis of 31 cases (51%). The remaining lesions had a differential diagno- Setting: A tertiary medical care center–based der- sis of seborrheic keratosis vs melanocytic nevus (17 matopathology laboratory serving academic der- cases, 28%), basal cell carcinoma (7 cases, 12%), or a squa- matology clinics that have a busy pigmented lesion mous proliferation (3 cases, 5%). In 3 cases (5%), seb- clinic. orrheic keratosis was the only clinical diagnosis. All histological types of melanoma were represented. Materials and Methods: A total of 9204 consecutive pathology reports containing a diagnosis of seborrheic Conclusions: Our results confirm that melanoma can keratosis in the clinical information field were identi- mimic seborrheic keratosis. These data strongly support fied between the years 1992 and 2001 through a com- the current policy of submitting for histological examina- puter database search. Reports with a final histological tion all specimens that have been removed from patients. diagnosis of melanoma were selected for further review and clinicopathological analysis. Arch Dermatol. 2002;138:1562-1566 EBORRHEIC KERATOSIS is one of dures and treatments may be subopti- the most common benign neo- mal. For these reasons, clinicians must bal- plasms in adults. Seborrheic ance a high index of suspicion for keratoses begin to appear af- malignancy in clinically diagnosed sebor- ter the age of 30 years in ge- rheic keratoses against the impracticality Snetically susceptible individuals and con- and costs of histological evaluation of all tinue to develop throughout their life span. lesions. Thus, appropriate clinical man- These lesions account for a large number agement of seborrheic keratosis requires of physician visits and have an associated an understanding of the frequency with significant health care cost. Most clinically which melanoma clinically mimics this be- diagnosed seborrheic keratoses are un- nign lesion. treated or removed by cryotherapy with- We have encountered several cases of out histological confirmation of the diag- melanoma clinically resembling sebor- nosis despite limited accuracy of the clinical rheic keratosis in our dermatopathology diagnosis of seborrheic keratosis.1-5 practice at the Massachusetts General Hos- From the Dermatopathology Seborrheic keratoses are most often pital Dermatopathology Unit and in our Unit, Departments of confused clinically with actinic keratoses clinical practice at the Massachusetts Gen- Dermatology (Drs Sober and or benign conditions such as solar len- eral Hospital Pigmented Lesions Clinic, Mihm) and Pathology tigo or viral warts, with relatively little Boston. Two small retrospective series ad- (Drs Mihm and Zembowicz), consequence for prognosis or therapy. In dressing this issue identified 2 cases of Massachusetts General Hospital 6 and Harvard Medical School, contrast, misdiagnosis of skin cancer, es- melanoma among 577 specimens and 1 4 Boston, Mass. Mr Izikson is a pecially melanoma, as seborrheic kerato- case among 328 specimens submitted for third-year medical study at sis might have untoward implications for histological examination with a clinical di- Harvard Medical School. the patient, as both diagnostic proce- agnosis that included seborrheic kerato- (REPRINTED) ARCH DERMATOL / VOL 138, DEC 2002 WWW.ARCHDERMATOL.COM 1562 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 sis. Seborrheic keratosis was one of the most common nonmelanoma diagnoses in retrospective studies that ex- Table 1. Demographic and Clinical Characteristics amined the accuracy of clinical diagnosis of histologi- of Patients With Melanoma Clinically Resembling Seborrheic Keratosis cally confirmed melanomas.7-16 In the present article, we assess the prevalence of Mean melanoma resembling seborrheic keratosis in our ter- Clinical Diagnostic Group (n) Age, y M/F Ratio Distribution* tiary medical care center–based dermatopathology prac- All cases (61) 60.5 37/24 (1.54) 20 H/N, 23 T, 18 E tice serving a large academic dermatology practice and a Seborrheic keratosis (3) 61.3 0/3 1 H/N, 2 E busy pigmented lesions clinic and provide a clinicopatho- Seborrheic keratosis vs 75.3 1/2 (0.5) 1 H/N, 2 E logical analysis of identified cases. squamous proliferation (3) Seborrheic keratosis vs 61.8 3/4 (0.75) 1 H/N, 4 T, 2 E basal cell carcinoma (7) METHODS Seborrheic keratosis vs 55.8 9/8 (1.12) 4 H/N, 7 T, 6 E melanocytic nevus (17) Pathology reports generated at the Massachusetts General Hos- Seborrheic keratosis vs 61.3 24/7 (3.4) 13 H/N, 12 T, 6 E pital Dermatopathology Unit from 1992 to 2001 were searched melanoma (31) to identify those cases in which the clinical diagnosis of seb- orrheic keratosis was entered as the primary diagnosis or was *H/N indicates head/neck; T, trunk; and E, extremities. included in the differential diagnosis for the submitted speci- men. This search yielded 9204 reports, from which 61 cases with the histopathological diagnosis of melanoma were iden- ential diagnosis was between seborrheic keratosis and a tified for further analysis. The vast majority of our laboratory’s melanocytic nevus. material is submitted by dermatologists from Massachusetts Gen- Demographic and clinical information about the iden- eral Hospital dermatology clinics, including the Massachu- tified cases is summarized in Table 1. We found a slight setts General Hospital Pigmented Lesion Clinic, which are staffed male predominance among the patients, and 54 patients by full- and part-time clinical staff supervising residents and (80%) were 50 years of age or older. The lesions were dis- fellows. Community dermatologists and Massachusetts Gen- tributed almost equally on the head and neck region, ex- eral Hospital surgical and medical services submit a small per- tremities, and trunk. As expected, the trunk was the most centage of cases. In our practice, residents and fellows do not common site in men (16 of the 37 cases); the extremities make decisions regarding biopsy specimens without the input of staff members. were the most common site in women (11 of the 24 cases). Clinical analysis involved a review of patients’ charts for Of note, but without obvious explanation, all 3 cases in any clinical and historical information relevant to the diagno- which seborrheic keratosis was the only clinical consid- sis of melanoma, including site, clinical appearance, clinical dif- eration occurred in women. The choice of diagnostic pro- ferential diagnosis, and personal or family history of mela- cedure depended on the clinical differential diagnosis. Eight noma. Data were collected in accordance with the institutional lesions (85%) with the clinical differential diagnosis of squa- and National Institutes of Health guidelines for clinical stud- mous proliferation or basal cell carcinoma were sampled ies, and the experimental protocols were approved by the in- as shave biopsy specimens. Shave biopsy specimens were stitutional review board. obtained in 18 cases (37%) in which a melanocytic lesion Pathological analysis included a review of available diag- was included in the clinical differential diagnosis. The rest nostic material from biopsy or excision specimens, which con- sisted of formalin-fixed, paraffin-embedded sections stained with of the cases were submitted as punch biopsy (n=19 [39%]) hematoxylin-eosin. Histological information included maxi- or excision (n=9 [19%]) specimens. One case clinically mal tumor thickness, Clark anatomical level of invasion, pres- diagnosed as seborrheic keratosis was submitted as a cu- ence of intralesional inflammatory response (absent or pres- rettage specimen. The remaining 2 cases were shave bi- ent, brisk or nonbrisk), number of mitoses, evidence of opsy specimens. ulceration, evidence of regression, presence of microsatellites, A clinicopathological analysis of the cases is sum- evidence of precursor lesion, and lymphovascular invasion. marized in Table 2. The diagnosis of melanoma was con- sidered in the clinical differential diagnosis of 31 speci- mens (51%). Seborrheic keratosis was the only clinical RESULTS diagnosis in 3 cases (5%). One lesion was described as an inflamed stucco keratosis. All 3 lesions were invasive In our series, of the 9204 consecutive lesions clinically melanomas, with a mean thickness of invasion of 0.84 diagnosed as seborrheic keratosis or with seborrheic kera- mm. One case was a superficial spreading melanoma, one tosis in the differential diagnosis, 61 (0.66%) revealed was lentigo maligna melanoma, and the third was an in- melanoma on histological examination. Of note, mela- vasive melanoma not further classified. noma was included in the clinical differential diagnosis In 3 cases (5%), a differential
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