临床误诊的皮肤黑素瘤118例分析

Analysis of 118 cases of clinically misdiagnosed cutaneous melanoma

目的探讨误诊皮肤黑素瘤的临床特点、误诊原因及防范措施。方法收集第四军医大学西京皮肤医院2005年1月至2019年12月临床初诊为其他疾病后经病理确诊为皮肤黑素瘤的患者资料,分析其临床表现、误诊原因。结果临床误诊的皮肤黑素瘤118例,男38例,女80例,误诊时中位年龄48岁,发病中位年龄40.5岁,病程中位数为54个月。皮损表现以黑色斑疹、丘疹为主。临床初诊为色素痣(53例,44.92%)、甲母痣(12例,10.17%)、脂溢性角化病(14例,11.86%)、血管肿瘤(10例,8.47%)、鳞状细胞癌(5例,4.24%)、基底细胞癌(4例,3.39%)、其他疾病(20例,16.95%)。按黑素瘤ABCDE法则(A:病灶不对称;B:边缘不规则,界限不清;C:颜色不均匀;D:直径>6 mm;E:进展迅速),符合A 78例(66.10%)、B 64例(54.24%)、C 57例(48.31%)、D 66例(55.93%)、E 39例(33.05%),符合ABCDE 14例、ABCD 13例,13例均不符合。53例原位黑素瘤中,28例(52.83%)误诊为色素痣,11例(20.75%)误诊为甲母痣;65例浸润性黑素瘤中,25例(37.88%)误诊为色素痣,9例(13.64%)误诊为血管肿瘤,5例(7.58%)误诊为鳞状细胞癌。67例误诊患者有送检医师信息,42例的医师出诊年资≤5年;27例至少符合ABCD的患者中,9例有送检医师信息,其中7例的医师出诊年资≤5年。结论皮肤黑素瘤皮损形态多样,易误诊,临床医生经验和是否遵从“ABCDE”标准甄别非常重要。

Objective To investigate clinical features and preventive measures of misdiagnosed cutaneous melanoma,as well as causes of its misdiagnosis.Methods Clinical data were collected from patients with pathologically confirmed cutaneous melanoma which was initially clinically misdiagnosed as other diseases in Department of Dermatology,Xijing Hospital,the Fourth Military Medical University from January 2005 to December 2019,and clinical manifestations and causes of its misdiagnosis were analyzed.Results A total of 118 patients with clinically misdiagnosed cutaneous melanoma were collected,including 38 males and 80 females.The median age at misdiagnosis was 48 years,the median age at onset was 40.5 years,and the median disease duration was 54 months.The main skin lesions were black maculae and papules.The initial clinical diagnoses were pigmented nevi(53 cases,44.92%),nail matrix nevi(12 cases,10.17%),seborrheic keratosis(14 cases,11.86%),vascular tumors(10 cases,8.47%),squamous cell carcinoma(5 cases,4.24%),basal cell carcinoma(4 cases,3.39%)and other diseases(20 cases,16.95%).As far as the ABCDE(asymmetry,border irregularity,color variegation,diameter>6 mm,evolving)rule for melanoma was concerned,78(66.10%),64(54.24%),57(48.31%),66(55.93%)and 39(33.05%)cases conformed to hte A,B,C,D and E rules respectively,14 conformed to the ABCDE rule,13 conformed to the ABCD rule,and 13 did not conform to any of them.Among the 53 cases of melanoma in situ,28(52.83%)were misdiagnosed as pigmented nevi,11(20.75%)as nail matrix nevi;among the 66 cases of invasive melanoma,25(37.88%)were misdiagnosed as pigmented nevi,9(13.64%)as vascular tumors,and 5(7.58%)as squamous cell carcinoma.The information of physicians of 67 misdiagnosed patients was available,and those of 42 out of the 67 patients had clincial experience of≤5 years;among 27 misdiagnosed patients conforming to the ABCD or ABCDE rule,the information of physicians of 9 patients was available,and those of 7 out of the 9 patients had clinical experience of≤5 years.Conclusion Cutaneous melanoma has a variety of lesion patterns and is easily misdiagnosed,and physicians′clinical experience and the ABCDE rule-based evaluation are important for diagnosis.