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Hypopigmented atypical Spitzoid neoplasms (atypical Spitz nevi, atypical Spitz tumors, Spitzoid melanoma): a clinicopathological update.

Ferrara G, Cavicchini S, Corradin MT - Dermatol Pract Concept (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Oncology, Anatomic Pathology Unit, Gaetano Rummo Hospital, Benevento, Italy.

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During the following forty years, however, the entity described by Sophie Spitz was thought to be completely benign, with metastasizing cases being intuitively considered as cases of melanomas simulating Spitz nevus (Spitzoid melanoma)... According to this view, the adjective “atypical” is redundant and useless, because any Spitz nevus is “atypical” by definition; nevertheless, it can be differentiated from its malignant simulator (i.e., Spitzoid melanoma) according to a well defined set of histologic criteria; every Spitzoid (and non-Spitzoid) melanocytic proliferation behaves as either a benign or a malignant neoplasm which we can be unable to correctly categorize simply because our brain can fail to correctly apply the diagnostic criteria... The first problem is purely morphologic: by assuming that Spitz nevus is a simulator of melanoma (Spitz nevus as a pseudomalignancy) and that melanoma resembling Spitz nevus is a simulator of its simulator (Spitzoid melanoma as a pseudo-pseudomalignancy), it is not surprising that the diagnosis of such lesions is a quandary even among experts who may be indeed unable to place an “I don’t know” lesion into a either “nevus” or “melanoma” category... Ackerman’s approach is biological... A tutorial held in Graz, Austria, in 2008 evaluated 57 melanocytic tumors of uncertain malignant potential, 35 of which being thick Spitzoid neoplasms: a panel of expert was unable to differentiate cases with favourable and unfavourable behaviour on morphologic grounds; therefore, it was concluded that the cases were all malignant, albeit clearly different from “conventional” melanoma because of a great thickness associated with a relatively low metastatic rate... A hypopigmented Spitzoid melanocytic neoplasm can be typified by at least one of the following: Homogeneous pink color: sometimes associated with a brownish hue or remnant(s) of brown pigmentation... In 2005, Urso performed a review of 19 papers reporting 62 Spitzoid neoplasms showing an aggressive biological behavior in spite of histopathologic features not enough for a diagnosis of clear-cut malignancy... Nine criteria were thus found to be predictive of metastatic potential: notably, such criteria were not the very same as for “conventional” melanoma and, most important, they had to be used in a completely different manner, because even the presence of one criterion could be virtually incompatible with benignity... In our experience, a diagnosis of Spitz nevus in the presence of a polymorphous vascular pattern must be made only under a compelling histopathological evidence of benignity; we have also suggested that when a given Spitzoid lesion is histopathologically atypical but its “grading” is uncertain, the presence of a highly atypical vascular pattern could point toward its management as a “tumor” instead of an “atypical nevus”... On the excision specimen, the “shoulder” of the neoplasm disclosed a bland morphology, featuring monomorphic spindle cells, probably representing a benign background (Spitz nevus) in which Spitzoid melanoma had been developing... The suggested management for both pediatric-type and adult-type Spitzoid melanoma is obviously the same as for “conventional” melanoma... The introduction of dermoscopy has significantly changed the clinical diorama of Spitzoid lesions... Since there are still many controversial points in the histopathologic categorization of these lesions, clinicopathologic correlation must be the mainstay for their diagnosis and proper management.

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Related in: MedlinePlus

An atypical neoplasm of the face in an 11-year-old girl. Dermoscopically (A) the lesion is biphasic: a flat portion shows reticular depigmentation along with structureless and globular brown areas; a nodular area discloses a non-descript vascular pattern, featuring a diffuse reddish area. The lesion was clinically diagnosed as a pyogenic granuloma associated with a Spitz nevus. For aesthetic reasons, the nodular portion was thus curetted. Histopathologically, the nodule showed a widespread derma atrophy (B) with large sheets of epithelioid cells at the junction (C); cytomorphologically, dermal melanocytes were epithelioid but devoid of true ‘Spitzoid’ features (D). The excision specimen showed a bland junctional proliferation of spindle cells (E), which were clearly different from epithelioid melanocytes of the previously curetted nodule (F). Histopathological diagnosis: melanoma according to Ackerman’s classification [8]; Spitzoid melanoma according to Barnhill’s classification, 2006 [19]. Our histopathological diagnosis was pediatric Spitzoid melanoma (melanoma over a Spitz nevus). The dermoscopic differential diagnosis between pyogenic granuloma and nodular melanoma is virtually impossible; nevertheless, histopathologically we have never seen a pyogenic granuloma associated with a melanocytic nevus. (Copyright: ©2015 Ferrara et al.)
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f6-dp0501a06: An atypical neoplasm of the face in an 11-year-old girl. Dermoscopically (A) the lesion is biphasic: a flat portion shows reticular depigmentation along with structureless and globular brown areas; a nodular area discloses a non-descript vascular pattern, featuring a diffuse reddish area. The lesion was clinically diagnosed as a pyogenic granuloma associated with a Spitz nevus. For aesthetic reasons, the nodular portion was thus curetted. Histopathologically, the nodule showed a widespread derma atrophy (B) with large sheets of epithelioid cells at the junction (C); cytomorphologically, dermal melanocytes were epithelioid but devoid of true ‘Spitzoid’ features (D). The excision specimen showed a bland junctional proliferation of spindle cells (E), which were clearly different from epithelioid melanocytes of the previously curetted nodule (F). Histopathological diagnosis: melanoma according to Ackerman’s classification [8]; Spitzoid melanoma according to Barnhill’s classification, 2006 [19]. Our histopathological diagnosis was pediatric Spitzoid melanoma (melanoma over a Spitz nevus). The dermoscopic differential diagnosis between pyogenic granuloma and nodular melanoma is virtually impossible; nevertheless, histopathologically we have never seen a pyogenic granuloma associated with a melanocytic nevus. (Copyright: ©2015 Ferrara et al.)

Mentions: While adult Spitzoid melanoma is often clinically and dermoscopically indistingiuishable from “conventional” melanoma, pediatric Spitzoid melanoma shows very peculiar clinicopathologic features. Histopathologically, it differs from atypical Spitz nevus or Spitz tumor by showing a non-Spitzoid cytomorphologic clone arising in the context of a Spitzoid lesion. Such a highly unusual occurrence can be detected even clinically and dermoscopically. In Figure 6 the “clone” is the red nodule with a nondescript vascular pattern; the nodule was initially treated as per pyogenic granuloma, but histopathologically disclosed a highly atypical proliferation of pleomorphic epithelioid cells. On the excision specimen, the “shoulder” of the neoplasm disclosed a bland morphology, featuring monomorphic spindle cells, probably representing a benign background (Spitz nevus) in which Spitzoid melanoma had been developing. Based on the very few exceptional cases we have seen, pediatric Spitzoid melanoma is a malignancy arising in the background of a Spitz nevus [17], just like already suggested for melanoma arising in Spitz tumor [29].


Hypopigmented atypical Spitzoid neoplasms (atypical Spitz nevi, atypical Spitz tumors, Spitzoid melanoma): a clinicopathological update.

Ferrara G, Cavicchini S, Corradin MT - Dermatol Pract Concept (2015)

An atypical neoplasm of the face in an 11-year-old girl. Dermoscopically (A) the lesion is biphasic: a flat portion shows reticular depigmentation along with structureless and globular brown areas; a nodular area discloses a non-descript vascular pattern, featuring a diffuse reddish area. The lesion was clinically diagnosed as a pyogenic granuloma associated with a Spitz nevus. For aesthetic reasons, the nodular portion was thus curetted. Histopathologically, the nodule showed a widespread derma atrophy (B) with large sheets of epithelioid cells at the junction (C); cytomorphologically, dermal melanocytes were epithelioid but devoid of true ‘Spitzoid’ features (D). The excision specimen showed a bland junctional proliferation of spindle cells (E), which were clearly different from epithelioid melanocytes of the previously curetted nodule (F). Histopathological diagnosis: melanoma according to Ackerman’s classification [8]; Spitzoid melanoma according to Barnhill’s classification, 2006 [19]. Our histopathological diagnosis was pediatric Spitzoid melanoma (melanoma over a Spitz nevus). The dermoscopic differential diagnosis between pyogenic granuloma and nodular melanoma is virtually impossible; nevertheless, histopathologically we have never seen a pyogenic granuloma associated with a melanocytic nevus. (Copyright: ©2015 Ferrara et al.)
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4325689&req=5

f6-dp0501a06: An atypical neoplasm of the face in an 11-year-old girl. Dermoscopically (A) the lesion is biphasic: a flat portion shows reticular depigmentation along with structureless and globular brown areas; a nodular area discloses a non-descript vascular pattern, featuring a diffuse reddish area. The lesion was clinically diagnosed as a pyogenic granuloma associated with a Spitz nevus. For aesthetic reasons, the nodular portion was thus curetted. Histopathologically, the nodule showed a widespread derma atrophy (B) with large sheets of epithelioid cells at the junction (C); cytomorphologically, dermal melanocytes were epithelioid but devoid of true ‘Spitzoid’ features (D). The excision specimen showed a bland junctional proliferation of spindle cells (E), which were clearly different from epithelioid melanocytes of the previously curetted nodule (F). Histopathological diagnosis: melanoma according to Ackerman’s classification [8]; Spitzoid melanoma according to Barnhill’s classification, 2006 [19]. Our histopathological diagnosis was pediatric Spitzoid melanoma (melanoma over a Spitz nevus). The dermoscopic differential diagnosis between pyogenic granuloma and nodular melanoma is virtually impossible; nevertheless, histopathologically we have never seen a pyogenic granuloma associated with a melanocytic nevus. (Copyright: ©2015 Ferrara et al.)
Mentions: While adult Spitzoid melanoma is often clinically and dermoscopically indistingiuishable from “conventional” melanoma, pediatric Spitzoid melanoma shows very peculiar clinicopathologic features. Histopathologically, it differs from atypical Spitz nevus or Spitz tumor by showing a non-Spitzoid cytomorphologic clone arising in the context of a Spitzoid lesion. Such a highly unusual occurrence can be detected even clinically and dermoscopically. In Figure 6 the “clone” is the red nodule with a nondescript vascular pattern; the nodule was initially treated as per pyogenic granuloma, but histopathologically disclosed a highly atypical proliferation of pleomorphic epithelioid cells. On the excision specimen, the “shoulder” of the neoplasm disclosed a bland morphology, featuring monomorphic spindle cells, probably representing a benign background (Spitz nevus) in which Spitzoid melanoma had been developing. Based on the very few exceptional cases we have seen, pediatric Spitzoid melanoma is a malignancy arising in the background of a Spitz nevus [17], just like already suggested for melanoma arising in Spitz tumor [29].

View Article: PubMed Central - PubMed

Affiliation: Department of Oncology, Anatomic Pathology Unit, Gaetano Rummo Hospital, Benevento, Italy.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

During the following forty years, however, the entity described by Sophie Spitz was thought to be completely benign, with metastasizing cases being intuitively considered as cases of melanomas simulating Spitz nevus (Spitzoid melanoma)... According to this view, the adjective “atypical” is redundant and useless, because any Spitz nevus is “atypical” by definition; nevertheless, it can be differentiated from its malignant simulator (i.e., Spitzoid melanoma) according to a well defined set of histologic criteria; every Spitzoid (and non-Spitzoid) melanocytic proliferation behaves as either a benign or a malignant neoplasm which we can be unable to correctly categorize simply because our brain can fail to correctly apply the diagnostic criteria... The first problem is purely morphologic: by assuming that Spitz nevus is a simulator of melanoma (Spitz nevus as a pseudomalignancy) and that melanoma resembling Spitz nevus is a simulator of its simulator (Spitzoid melanoma as a pseudo-pseudomalignancy), it is not surprising that the diagnosis of such lesions is a quandary even among experts who may be indeed unable to place an “I don’t know” lesion into a either “nevus” or “melanoma” category... Ackerman’s approach is biological... A tutorial held in Graz, Austria, in 2008 evaluated 57 melanocytic tumors of uncertain malignant potential, 35 of which being thick Spitzoid neoplasms: a panel of expert was unable to differentiate cases with favourable and unfavourable behaviour on morphologic grounds; therefore, it was concluded that the cases were all malignant, albeit clearly different from “conventional” melanoma because of a great thickness associated with a relatively low metastatic rate... A hypopigmented Spitzoid melanocytic neoplasm can be typified by at least one of the following: Homogeneous pink color: sometimes associated with a brownish hue or remnant(s) of brown pigmentation... In 2005, Urso performed a review of 19 papers reporting 62 Spitzoid neoplasms showing an aggressive biological behavior in spite of histopathologic features not enough for a diagnosis of clear-cut malignancy... Nine criteria were thus found to be predictive of metastatic potential: notably, such criteria were not the very same as for “conventional” melanoma and, most important, they had to be used in a completely different manner, because even the presence of one criterion could be virtually incompatible with benignity... In our experience, a diagnosis of Spitz nevus in the presence of a polymorphous vascular pattern must be made only under a compelling histopathological evidence of benignity; we have also suggested that when a given Spitzoid lesion is histopathologically atypical but its “grading” is uncertain, the presence of a highly atypical vascular pattern could point toward its management as a “tumor” instead of an “atypical nevus”... On the excision specimen, the “shoulder” of the neoplasm disclosed a bland morphology, featuring monomorphic spindle cells, probably representing a benign background (Spitz nevus) in which Spitzoid melanoma had been developing... The suggested management for both pediatric-type and adult-type Spitzoid melanoma is obviously the same as for “conventional” melanoma... The introduction of dermoscopy has significantly changed the clinical diorama of Spitzoid lesions... Since there are still many controversial points in the histopathologic categorization of these lesions, clinicopathologic correlation must be the mainstay for their diagnosis and proper management.

No MeSH data available.


Related in: MedlinePlus