Historical Perspective: Lerman et al., 1970

 
In an article published in 1970 under the heading "Malignant melanoma of childhood: A clinicopathologic study and report of 12 cases,"27 Lerman and collaborators reported on 12 children under 14 years of age, all of whom had evidence of metastasis of melanoma. The cases were pulled from the files of the Memorial and James Ewing Hospitals between 1928 and 1968. In their study were two children in whom melanoma developed in a giant hairy nevus, one child in whom neoplastic melanocytes of melanoma were transferred across the placenta, one child whose primary melanoma arose on the buccal mucosa, and one who was said to have a retrobulbar melanoma in association with a "blue nevus." Lerman et al. identified seven children with primary cutaneous melanomas (their cases #1, 2, 3, 7, 9, 11 and 12) that seemed to have arisen "de novo", including one whose melanoma was said to be associated with a blue nevus. Of particular interest was a photomicrograph of a metastasis to a lymph node (their Case 11) in a 12-year-old girl who Spitz in 1948 had included in her series of 13 cases as the only patient who had died of metastatic disease. Lerman and coworkers, in the legend to that photomicrograph, stated that the "focal pigmentation is histochemically melanin," thereby confirming the opinion of Spitz that this child had a melanoma and not another type of malignant neoplasm. These were the reasoned judgments, in general, of Lerman and co-workers:
 
"All 12 cases [of malignant melanomas of childhood] are structurally similar to malignant melanoma of adulthood. . . . Although prognosis could not be entirely correlated with the histology of our group of patients, the deeper lesions did more poorly than the 'superficial' ones. The metastatic lesions in 3 of the surviving patients were histologically of a lower grade than the other cases. . . . We generally agree with the concept that the greatest accuracy in interpretation is attained by the recognition and separation of the traits of malignant melanoma of adulthood and juvenile melanoma."
 
Ten of the 12 melanomas were photographed, including Cases 1, 2 and 7, but almost all are shown at high magnification, which excludes the possibility of assessing the silhouette of them (Fig. 6). Patients 1, 2 and 7 were said to be alive and, for that reason, Lerman et al. attributed those melanomas to be of "lower grade"; nowhere, however, do Lerman and colleagues define what they mean by "lower grade" of melanoma. No comments were made in legends to the photomicrographs about histopathologic findings in the "lower grade" melanomas. That the concept of "lower grade" melanoma as an explanation for apparently longer time of survival in these patients is illogical can be learned from the course of Case 7, the period of follow-up and time of "survival" being a bare six months.

View Figure  		Fig. 6  Comment: The two photomicrographs of Lehrman et al. shown on top are of a melanoma that metastasized in a 4-year-old and the two photomicrographs on the bottom are of a melanoma that metastasized in a 7-year-old. The photomicrographs do not convey, compellingly, findings that fulfill criteria for malignant melanoma, and that is especially true of the photomicrographs at the bottom in which the changes could be misconstrued as those of a "juvenile melanoma." It is essential to picture neoplasms such as these at scanning magnification, at which silhouette, which is so crucial for diagnosis histopathologically, can be assessed.