In an editorial given to the subject of "Pre-pubertal Melanoma of Skin,"⁵ Pack, in 1948, shared his thoughts about a conundrum that continued to vex his colleague in pathology at Memorial Hospital, Sophie Spitz (and her husband, Arthur Allen), who wrote about the same subject that same year.⁷ Pack averred what he called pre-pubertal melanoma (and Spitz was to designate "melanoma of childhood") was not a malignant melanoma at all, but a nevus* that often had features in common histopathologically with melanoma. Pack and Spitz doubtlessly knew of the existence of one another at Memorial Hospital and of the interest of each other in melanomas in young persons, but neither of them gave any indication that they ever looked together at sections of tissue that housed those proliferations of melanocytes or that they ever even discussed the subject. It is questionable whether sections of tissue from any of the neoplasms removed surgically by Pack were seen by Spitz; the person at Memorial who acted as Pack's personal pathologist was the head of the Department of Pathology there, namely, Fred Stewart (personal communication, Leo Koss, M.D.). Although nowhere in Pack's writings did he state, without equivocation, that "pre-pubertal melanomas" were benign, he surely referred to them as nevi in the editorial in 1948. This is some of what Pack wrote in that editorial about "pre-pubertal melanoma":

Even though "practically identical" was an overstatement, Pack, in the editorial, modified further his recommendations for surgical treatment of what he continued to refer to as melanomas in prepubescent children from "very wide surgical dissection, carrying the dissection below the deep fascia," a procedure he advocated in 1939 for persons 16 years of age or younger, to a much more limited procedure. This is what he advised:

"A microscopic diagnosis of melanoma in a skin tumor removed during infancy and childhood does not call for an extension of radical surgery such as wide excision and skin grafting and dissection of regional lymph nodes provided the child has not entered the postpubertal stage."

Pack seemed to believe that a "prepubescent melanoma" had the potential to become malignant melanoma by virtue of the affects of hormones generated at puberty. The evidence for that inference comes from these remarks by him:

Also in 1948, MacDonald told of her experience with 349 patients whose melanoma was recorded in the registry of the State of Connecticut during the period of 1936 through 1946.⁶ Six patients were younger than 15 years of age and three of them were younger than 10. One male child, 6 years of age, had a melanoma on a knee that metastasized. A 2-year-old and an 8-year-old, both girls, had melanomas on the left leg and right shoulder, respectively, and neither of those neoplasms showed evidence of having metastasized after follow-up periods of 8 and 4 years, respectively. The other three children, all older than 10 years, namely, 13, 14 and 13, all had metastases to regional lymph nodes, one of those children having succumbed to the disease. No description of histopathologic findings was provided and no photomicrographs were shown; in all instances in which metastases occurred, however, the diagnosis histopathologically was melanoma. In the two youngsters in whom there were no metastases, the possibility exists that the neoplasms really were a "juvenile melanoma."