Historical Perspective: Truax and Allen, 1953; Allen and Spitz, 1953

 
In 1953, Truax and Page11 told of their experience with a 2-1/2 -year-old child whose melanoma developed in a pre-existing congenital nevus on the scalp and metastasized with deadly consequences. They also provided additional information about the 9-year-old child, the patient of Dr. Bjarne Pearson whom Spitz had commented on in her article in 19487 in this account: "A further follow-up is presented on a previously reported case of malignant melanoma in a nine-year-old girl with lymph node metastasis who is now alive and apparently free from disease five and a half years after the original treatment." Despite the disclaimer, the result of that follow-up in no way minimized the gravity for prognosis of metastatic melanoma.
 
It was not until 1953 that Allen and Spitz proposed criteria designed to enable "juvenile melanomas" to be distinguished clinically and histopathologically from authentic melanomas in children. In an article given to the subject of "Malignant melanoma: A clinicopathological analysis of the criteria for diagnosis and prognosis,"12 they recounted their experience with 934 patients with what they regarded to be melanoma divisible into three groups as follows: "Series I" consisted of 337 patients with primary melanoma in whom sections of tissue from the primary neoplasm were available for study and follow-up data for a period of 5 years or longer was adequate; "Series II" was made up of the patients in Series I and of 286 additional patients whose diagnosis of melanoma was established on the basis of histopathologic findings in a metastasis (but not on findings in the primary neoplasm because sections of tissue from it were not available) and about whom follow-up data for five years or longer was adequate; and "Series III" was constituted of 311 patients who had been diagnosed too recently for follow-up to be adequate, who were lost to follow-up, or who had died of causes other than metastases of melanoma. Allen and Spitz placed "juvenile melanomas" in the group of lesions they classified as "benign," putting it in fourth place, second to last and immediately ahead of "blue (Jadassohn-Tieche) nevus." As Allen had done in 1949, Allen and Spitz made it clear in 1953 that for them, "juvenile melanoma" was benign. This is some of what they averred:
 
"Juvenile melanoma" is the term applied to those lesions occurring for the most part, BUT BY NO MEANS EXCLUSIVELY, prior to puberty. They are benign in behavior, but, as indicated, have the histological appearance, either indistinguishable, [sic] or distinguishable only with the keenest evaluation, from those of adults. The percentage of juvenile melanomas that can be segregated by any individual pathologist from the adult melanocarcinomas on histological grounds alone manifestly increases with increments of experience. This point is made because it is accurate to state that there are combinations of histological details that by themselves suggest the nature of the lesion in most instances. These cytological details which were originally described in 1948 include: (1) the relative superficiality of the essential landmarks of the lesion; (2) the two elements of a compound nevus, junctional and intradermal; (3) edema and telangectasia of the cutis just below the epidermis; (4) the tendency for single cells to be segregated sharply from adjacent ones; (5) the occurrence of large cells with abundant, usually uniformly basophilic, myogenous-appearing cytoplasm; (6) the superficially located, characteristic giant cells, those with the single large nucleus, as well as the multinucleated ones resembling the pattern either of the giant cells of measles or of Touton giant cells, with a complete or incomplete peripheral rim of small nuclei; (7) the generally abrupt transition between the acantholytic, loose junctional cells and the still intact adjacent epidermis; and (8) the relative sparsity of pigmentation, so that, in association with the superficial dermal edema and telangectases, most of the juvenile melanomas clinically appear purplish red rather than dark brown."
 
In fact, and contrary to the assertion by Allen and Spitz in 1953, none of "these cytological details" were provided by Spitz in her article of 1948. In addition it must be noted that all of the eight criteria set forth by Allen and Spitz as being definitive for juvenile melanoma may be encountered in authentic malignant melanoma in prepubescent children.
 
In addition to their comments about "juvenile melanomas," Allen and Spitz related their experience with five children whom they considered to have authentic melanomas, referred to by them incorrectly as "melanocarcinomas," melanoma really being a sarcoma because melanocytes are non-epithelial cells. The opinion of Allen and Spitz about true melanomas in children were set forth in these lines in a section in the same article subtitled, "Melanocarcinomas of children":
 
"The extraordinarily few remaining lesions of children that were truly malignant in behavior—and we have seen five such instances—revealed their potentialities microscopically in each case, principally by the excessive virulence of their histological appearance. These seldom-encountered malignant tumors [melanocarcinomas] of children are likely to have a degree of cellular anaplasia, and a cordlike pattern of invasiveness, combined with a lack, or a minimum, of the features of the juvenile melanoma just described, which place them in a histological category quite apart from that of the juvenile melanomas. Rather, they are likely to resemble histologically the more active appearing of the adult melanocarcinomas and give little or no hint of microscopic similarity to those of the pre-pubertal group . . . In short, it is our belief that the few primary neoplasms of children that actually behave as adult melanocarcinomas are histologically recognizable as such."
 
Although Allen and Spitz sought at this time to establish histopathologic criteria for distinguishing juvenile melanoma from authentic melanoma, they acknowledged that distinction between them was not always possible. They asserted, again and again, that in the ultimate analysis, diagnosis of juvenile melanoma and of true melanoma turned on the age of the patient rather than on histopathologic findings (Fig. 2A–C). This is one example of how they put it:
 
"On the basis of the histological criteria [for diagnosis of juvenile melanoma] just outlined, it is possible, in about two thirds of the cases, to learn to differentiate the benign juvenile melanomas from the adult melanocarcinomas; in the remainder, this histological differentiation is not possible without knowledge of the age of the patient. However, if the pre-pubertal age of the child is made available to the pathologist, there then can be very little doubt that the lesion is benign if the exceptional patterns outlined in the following section are borne in mind. . . . In short, it is our belief that the few primary neoplasms in children that actually behave as adult melanocarcinomas are histologically recognizable as such."

View Figure  
View Figure  
View Figure  		Fig. 2A–C  Comment: Allen and Spitz pictured these three melanomas in children (their figs. 34, 37, and 38) at high magnification only, thereby limiting severely the capability of a viewer to come to a diagnosis with surety. That the three neoplasms truly were malignant is evidenced by the fact that each of them metastasized.
 
In brief, Allen and Spitz waffled; they stated that juvenile melanoma and malignant melanoma in children could not always be distinguished from one another on histopathologic grounds alone (history was essential for differentiation of them), but at the same time they affirmed that that distinction could be made on histopathologic grounds alone.
 
Allen and Spitz went on to proclaim that in approximately 6% of patients, juvenile melanoma has capability to "transform" into malignant melanoma, a proposition they advanced thus:
 
"In a small percentage of melanocarcinomas (5.9 per cent, or twenty-one of 362), there is noted residual evidence of a preexisting juvenile melanoma. Therefore, the second assumption that appears warranted is that some of the juvenile melanomas—apparently only a small portion—become converted later in life into melanocarcinomas."