CONTROVERSIES
Actinic keratoses—malignant or not?
found the article by Heaphy and Ackerman,1 enti-
tled “The Nature of Solar Keratosis,” to be very
provocative (as I am sure they intended it to be).
very subtle stages of the mysterious process we call
cancer? How then do we even define cancer? I don’t
know and I suspect that even the experts can’t agree.
In its extreme form leading to death, it seems easy to
say what a cancer is. However, for any level of behav-
ior less than that, we continually fall into the quandary
of lack of criteria that allow us to identify and prog-
nosticate from the dead tissue that we are studying.
Even the biochemical studies cited by the authors in
their article provide only some general trends in dis-
tinguishing differences between normal and abnor-
mal cells, and these so-called chemical morphologic
markers certainly have their limitations in helping to
identify what is cancerous and what is not. In the end,
trying to define cancer at the present time by any type
of morphologic criteria that do not adequately allow
us to predict the eventual behavior of the individual
lesion is an exercise of dubious value.
My main criticism of this article, however, has to
do with more practical considerations. The degree of
certainty with which Heaphy and Ackerman state
their opinion leaves those of us who actually deal
with the clinical problem presented by the solar ker-
atosis in somewhat of a dilemma. The concept of the
solar keratosis as cancer rather than precancer has
the potential to change a widespread, but at present
manageable, problem into a public health night-
mare. Ackerman2 states, “Recognition of the fact that
a solar keratosis is a squamous cell carcinoma does
not necessarily mandate surgical extirpation of every
one of them. Several different methods of therapy
are available for solar keratoses….” (page 103) This
is the voice of the pathologist making an unproven
assertion that is ostensibly intended to help both the
patient and the clinician. I think that just the oppo-
site result is obtained. With the concept of precan-
cer, correct or incorrect, the clinical dermatologist is
able to reassure patients that, at least for now, most
of the lesions are not yet dangerous and the idea of
watching them carefully and treating suspect lesions
seems reasonable, especially in the case of the
numerous patients who have enormous numbers of
solar keratoses. We can also say exactly these same
words substituting the word “cancer” for solar ker-
atoses. But can patients really be effectively reas-
sured if told that all the lesions are, indeed, already
cancer but that they need not worry too much
because most aren’t aggressive and won’t bother
them? The word “cancer,” especially when referring
I
They totally dismiss the concept of the precancerous
nature of the solar keratosis, and, using primarily mor-
phologic criteria along with a smattering of inconclu-
sive and certainly inconsistent biochemical data, they
forcefully proclaim the truly cancerous nature of
this very same keratosis. But forceful proclamation
doesn’t necessarily make it so, no matter which side
of the argument you come down on. They state that
“…no histopathologist, no matter how prescient, can
predict when scrutinizing a solar keratosis through a
conventional microscope whether it will move for-
ward steadily into lethal cancer….” (page 150) They
then add, somewhat disingenuously, “The role of a
histopathologist is not to predict behavior of diseases,
but to make the diagnoses accurately and to couch
those diagnoses in language that clinicians really
understand in order that those physicians can manage
patients properly.” (page 150) I may be missing some-
thing here, but I was unaware that the morphologic
diagnosis of disease was so totally detached from the
predictive implications of such diagnosis. It would
seem that if I perform a biopsy on a changing pig-
mented lesion and the pathologist’s interpretation of
said biopsy specimen is that of malignant melanoma,
there is an important predictive quality to this diag-
nosis that tells me I had better set in motion a certain
set of events vis-à-vis the patient’s future welfare. It
seems to me that, historically, the pathologist’s inter-
pretation of the dead, fixed, sectioned, and stained
material examined under the microscope derives its
validity from the subsequent clinical course of so
many patients who have these changing pigmented
lesions. There may be other ancillary aspects in deter-
mining the final label used to designate the diagnosis,
such as studies to determine the cell of origin, but
melanoma—the diagnosis—always purports to have
predictive value, and any physician who chooses to
ignore it runs a great personal and professional risk.
So, despite their denial, Heaphy and Ackerman, in
their role as histopathologists, are indeed involved in
the business of predictions. But since when has the
pathologist been able to rely on morphologic criteria
to predict biologic behavior, especially in the early,
J Am Acad Dermatol 2001;45:466-9.
Copyright © 2001 by the American Academy of Dermatology, Inc.
466
Ratschinskii
