title: Heel melanoma: the final result of wrong diagnostic and therapeutic approach in another bulgarian patient. First documented case from the board of the adcrstr-association for dermatohistopathologic control, reevaluation and subsequent therapeutic recomme.
abstract: Difficulties with frequent misdiagnoses and incorrectly defined tumor thicknesses applied to the same histopathological preparation occurring among Bulgarian patients, has led to the creation of national and/or international associations or boards for control in problematic circumstances, particularly for patients with melanocytic and non melanocytic cutaneous tumors. Once again we report a problematic case of a patient with acral lentiginous melanom&#1072;, localized in the heel area of the right foot, in an otherwise healthy 69-year old woman. A pigmented lesion gradually developed in her heel area, where the patient had been previously treated several times with invasive therapeutic methods (cryosurgery, shave curettage) due to misdiagnosis as a verrucous lesion or as a viral wart in the absence of any prior histopathology report. Years later, the lesion progressed and changed in color, leading to surgical removal, followed by several histopathological evaluations that produced very different results on three separate occasions. The first result described the lesion as melanocytic nevus, and removed with tumor-free margins. The second report from the Department of Dermatology and Venereology, Military Academy in Sofia , Bulgaria, stated no data for Verrucous carcinoma. Only on the third assessment the correct diagnosis of malignant melanoma was given. A relapse of the melanoma occurred as only at the time of the last histopathologic evaluation, (following surgical resection of the lesion with adequate margins, performed in the Onkoderma- Policlinic for Dermatology, Venereology and Dermatologic Surgery, Sofia, Bulgaria) were criteria followed for appropriate pathological evaluation consistent with the recommendations of the AJCC for reporting of melanomas. Tumor thickness at that time was 1.31 mm. Removal of the draining lymph node, followed by inguinal lymphadenectomy was performed in the National Oncological Hospital in accordance with the recommendations of the AJCC. Unfortunately disease progression was observed with loco-regional lymph node involvement. Systemic therapy with interferon was planned. The incorrect therapeutic approach in this patient, as well as the several subsequent misdiagnoses that were made in the leading pathology departments of the capital, undoubtedly helped lead to the creation of a national board with international participation in order to minimize errors in the diagnostic and therapeutic approach in dermatology, surgery and histopathology. The already-created Association for Dermatohistopathologic Control, Reevaluation and Subsequent Therapeutic Recommendations-ADCRSTR, aims to take control of histopathological preparations with wrong diagnoses and subsequent therapy in patients with cutaneous tumors, as well as their documentation. Another task of the Institution is to focus on the preservation and protection of the rights and interests of affected patients.
authors.affiliation: Onkoderma-Policlinic for Dermatology, Venereology and Dermatologic Surgery, Sofia, Bulgaria.
authors.forename: A A
authors.initials: AA
authors.lastname: Chokoeva
authors.affiliation: Onkoderma-Policlinic for Dermatology, Venereology and Dermatologic Surgery, Sofia, Bulgaria.
authors.forename: G
authors.initials: G
authors.lastname: Tchernev
authors.affiliation: Dermatological Department University of Pisa, Pisa, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Gianfaldoni
authors.affiliation: University of Virginia Health System, Department of Pathology, Charlottesville, VA USA.
authors.forename: J W
authors.initials: JW
authors.lastname: Patterson
authors.affiliation: Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt.
authors.forename: U
authors.initials: U
authors.lastname: Wollina
authors.affiliation: Professor and Chair of Dermatology, University of Rome "G. Marconi", Rome, Italy.
authors.forename: T
authors.initials: T
authors.lastname: Lotti