Historical Perspective: Hoagland and Hughes, 1960

 
Hoagland and Hughes, in 1960,19 imparted the story of a 12-year-old boy who at age 10 had on a shoulder a pigmented lesion thought initially to be a "juvenile melanoma," but that two years later metastasized to axillary lymph nodes. On review of sections of tissue from the original biopsy specimen, those coworkers determined, in retrospect, the neoplasm was a melanoma and not a "juvenile melanoma" as they at first had believed. Based on reassessment of the histopathologic findings in the primary melanoma and in metastases from it, Hoagland and Hughes made these observations:
 
"The malignant change appeared to be arising in a lesion that was previously benign, as in one area of the specimen there were nevus cells which were fairly uniform and nonpleomorphic. Much of the lesion, however, was composed of relatively large pigmented cells present at the junction of the epidermis and dermis and also extending into the dermis. In many areas, these cells showed no particular arrangement with the supporting stroma, and sometimes showed loss of cohesion. Scattered mitotic figures were present, and it was felt that the lesion did not fit into the category of juvenile melanoma."
 
Although the decision that the neoplasm was malignant doubtlessly was correct, the criteria employed by Hoagland and Hughes for coming to the diagnosis do not work, and, moreover, they, like Pack and Anglem and others after them, claimed that the effects of puberty were responsible for metastasis of melanoma in this 2-year-old. These are some of their thoughts about that matter:
 
"This patient illustrates a case of pre-pubertal melanocarcinoma arising in a pigmented lesion which had been present for up to 2 years without change. At the time of the axillary dissection, there was no evidence of residual tumor in the site of his previous wide excision on either gross or microscopic examination. It would seem logical to assume that metastasis had occurred at the time of, or prior to, his initial operative procedure and then had lain dormant until stimulated by early pubertal changes."
 
Hoagland and Hughes recommended, as Pack had done as early as 1948, that treatment for "juvenile melanomas" be simple excision and for adult melanomas wide excision. This is what they suggested for management surgically:
 
"As a clinical distinction from juvenile melanoma and other benign gravities is impossible, initially an excisional biopsy is performed, followed by a second wide excision of the lesion if it proves to be malignant. This is in contradiction to the treatment of malignant melanoma occurring in adults in which a suspected lesion is removed as widely as possible without awaiting histologic confirmation."
 
In actuality, an indubitable juvenile melanoma need not be excised at all because it is benign, and an authentic melanoma, no matter its thickness, need only be removed completely because once it has been extirpated, no matter how narrow the margin, nothing more of benefit can be done locally. In the case of melanoma that has metastasized, nothing that is done systemically has been shown to be of any worth whatsoever.