Historical Perspective: Coe, 1925; Pack and Anglem, 1939

 
In 1925, in a report devoted to "Malignant pigmented mole in an infant," Coe1 detailed findings in a 3-month-old child who was noted at birth to have "two small wart-like growths slightly larger than the head of a black pin in the hair of the left frontal region." The growths apparently grew rapidly and metastasized widely, resulting in the death of the infant two months later. Of the gross and microscopic findings, Coe had this to say:
 
"The tissue removed was examined by Dr. R E. Mosimon and his report is as follows: Gross specimen shows two masses of tissue each about 6x3x5 cm. The larger piece shows a markedly pigmented area. Cross section shows a markedly circular and pigmented area suggesting a very rapidly growing type of tumor. Microscopic sections show a tumor covered with a thick layer of epithelial cells. In some areas the papillae extend rather deeply into the underlying tissues. In one area underneath the tumor tissue there is a very vascular area suggesting a hemangioma type of reaction. The tumor nuclei are about twice the size of an ordinary pus cell. These nuclei are irregular in shape and size and show irregular staining qualities. There are many mitotic figures everywhere among the tumor cells from the subcutaneous tissue to the very depths of the tumor. Though I do not find any pigmented cells among the tumor cells, from the size and shape and staining properties of the tumor cells and their tremendous number of mitotic figures, I feel that this specimen is a malignant pigmented mole."
 
It was Pack and Anglem, surgeons both, who, 14 years later in 1939, called attention, forcefully, in a publication captioned, Tumors of Soft Tissues in Infancy and Childhood, to what they thought were melanomas in young persons.2 In it they told of their experience with 100 children less than 16 years of age who had a variety of soft tissue tumors that had been diagnosed at the Memorial Hospital in New York City between January 1, 1917 and October 1, 1938. Seven of those children were diagnosed as having melanoma. One of the youngsters was said to be less than one year of age, one between 5 and 6 years of age, one between 9 and 10 years of age, two 10 to 11 years of age, and one 15 to 16 years old. Only one of the six children died of metastases of melanoma. This is what the surgeons concluded:
 
"Although pigmented naevi occur in infancy and childhood, the malignant melanoma is seldom found in individuals before puberty . . . Although malignant melanomas are found in infancy and childhood, they are of low-grade malignancy and seldom metastasize. Under the microscope these tumors may be indistinguishable from other melanomas occurring in adult life which exhibit a high degree of malignancy by diffuse metastasis, so that the pathologist, on microscopic examination, may term them melanomas, yet their behavior is not in keeping with their morphologic structure . . . One patient was referred for diagnosis and received no treatment. The low-grade malignancy of melanomas in childhood, in contrast to adult life, is shown in the end results of the other six patients. Only one of these six patients has died. One patient has lived five years without recurrence and another ten years."
 
Pack and Anglem neither described histopathologic findings nor showed photomicrographs, and they gave no indication of having understood that all but one of the children with reputed melanoma probably had what today is called Spitz's nevus, that child having died as a result of metastases of melanoma. Nonetheless, the coworkers were prescient enough to advise that surgical treatment for melanomas in children should be different from that in adults. This is what they proposed:
 
"The malignant melanoma is removed by very wide surgical dissection, carrying the dissection below the deep fascia. In adults this procedure is routinely followed in six weeks' time by meticulous dissection of the regional lymph nodes draining the skin which is the site of the melanoma. . . . In infants and children, however, the routine dissection of regional lymph nodes is not done, because the tendency of melanomas in infancy and childhood to metastasize is latent."