Historical Perspective: McWhorter et al., 1954; Hendrix, 1954; Dobson, 1955

 
McWhorter and other associates of his wrote an article in 1954 that concentrated on the "Treatment of juvenile melanomas and malignant melanomas in children."15 The same five children as reported on by McWhorter and Woolner again were the basis of the communication, but this time no photomicrographs were accompanying. McWhorter and his colleagues revealed clearly their understanding that authentic melanomas in children truly were malignant and that juvenile melanomas were not malignant. They articulated that succinctly as follows:
 
"The juvenile melanoma is a newly identified lesion that appears to be benign and that can be differentiated histologically from malignant melanoma, with which it has been confused in the past. . . . Malignant melanoma occurs in children and may result in metastatic spread and death."
 
A 2-year-old boy who died as a result of a melanoma that arose in a giant hairy nevus was the subject of a report in 1954 by Hendrix titled, "Juvenile melanomas, benign and malignant: Fatal melanoblastoma in a two year old boy."16 He culled from the literature 35 examples of melanocytic lesions in prepubertal children and arranged them in what he called a semi-quantitative continuum from obvious melanocytic nevus to indubitable melanoma. Hendrix compared and contrasted histopathologic findings in what he considered to be obvious nevi with those of obvious melanomas. Eight of the 35 lesions were deemed by him to be the same or similar to that of the melanoma in the 2-year-old. Based on these findings, Hendrix came to these positions:
 
"It is possible to arrange nevi, malignant juvenile melanomas, and both juvenile and adult malignant melanoblastomes in series varying in respect to increasing degrees of cellularity, lack of cellular cohesion, size of cells, lateral extent of the junctional change, and depth of dermal invasion. The variants grade almost impercetively into one another, and in prepubertal children there is a group which appears to be malignant by all present histologic criteria but which, in the great majority of cases, is clinically benign. . . . The melanomas which are histologically malignant can be differentiated from juvenile melanomas in general by the spreading of the junctional reaction so that the nevus cells no longer appear as discrete nests, but cover a wide area in which the lower layers of the epidermis are replaced."
 
Although Hendrix recognized that authentic melanomas do occur in prepubertal children, he continued to support the contention of Pack, Spitz, and Spitz and Allen that "juvenile melanomas" could not be distinguished readily by conventional microscopy from adult malignant melanoblastomas, as he called them, and he believed that the differences between them were "quantitative rather than qualitative," the major difference being loss of readily identifiable nests and prominent replacement of the epidermis by neoplastic melanocytes of melanomas in adults.
 
In 1955, two children with melanoma were reported on by Dobson,17 one of them a 2-year-old girl whose melanoma began in a giant congenital nevus and the other a 4-year-old boy whose melanoma arose de novo on an elbow (Fig. 4). According to Dobson, the de novo melanoma had the following histopathologic attributes:
 
"The tumor is cellular and is composed largely of large polyhedral cells, but there are also many spindle-shaped cells. These cells have a vesicular nucleus with a prominent nucleolus. Mitotic figures are present, but not very common. The cytoplasm is indistinct, pale and basophilic. The cells form acinar clusters with little intervening stroma. No pigment intra- or extracellular is found. Two clusters of tumor cells are seen within endothelial lined channels. There is moderate polymorphonuclear leukocytic and lymphocytic infiltration of the stroma. . . . The surface epithelium [was] raised and the papillae of the corium widened by a tumor which extends into the subcutaneous tissue and down to the basal line of resection. . . . Two axillary lymph nodes contained metastases. Eighteen months later a local recurrence was excised. There is no evidence of recurrence or metastases nine years after the first operation and seven and a half years after excision of a local recurrence."

View Figure  		Fig. 4  Comment: Because the photomicrographs of this malignant melanoma in a child were shown only at intermediate and high magnifications, the findings easily could be misconstrued as those of "juvenile melanoma."
 
In brief, the primary neoplasm in this 4-year-old surely fulfilled criteria for melanoma because some neoplastic melanocytes were present in cutaneous intravascular spaces. Moreover, some of the cells metastasized to lymph nodes.