Historical Perspective: Peters and Goellner, 1986

 
Peters and Goellner, in 1986,36 recorded their findings in patients 20 years or younger with Spitz's nevi and melanoma in an article titled, "Spitz naevi and malignant melanomas of childhood and adolescence." There were 33 patients with Spitz's nevi and 19 with melanoma. They emphasized the fact that none of the children with melanoma in their series were younger than 9 years of age. Three of the children with melanoma were 9 and/or 10 years old, metastases occurring in two of them, a 9 year-old girl and a 10 year-old whose sex was not given. The histopatholgic findings in the melanomas of both children are shown in their Figures 2 (Fig. 8) and 3 (Fig. 9), but no photomicrograph was published at scanning magnification. Peters and Goellner also attempted to establish histopathologic criteria for diagnosis of Spitz's nevi and for melanoma, and they did that by devising a scoring system to assess attributes such as "nuclear hyperchromasia", "mitotic activity," "pleomorphism," "pagetoid spread," "pigmentation," "epithelioid cells," "ulceration," "necrosis," "intranuclear inclusions," "macronuclei," "atypical mitotic figures," "naevus cells," "spindle cells," "lateral margins sharp," "Kamino bodies," "clefting'" "junctional activity," "inflammation," "epithelial hyperplasia," "vascularity," "giant or multinucleated cells," "maturation of cells with depth'" and "symmetry." Based on this calculus of importance, Peters and Goellner offered these assessments:
 
"A high mitotic rate was seen only in malignant melanomas, and 18 of the 19 malignant lesions showed some degree of mitotic activity. Hence, the absence of mitotic activity would be against the diagnosis of malignant melanoma. The one malignant melanoma that lacked mitotic activity had been classified histologically on our review as a Spitz naevus; it had a predominantly spindle cell population, slight hyperchromasia, cellular maturation with depth, no ulceration and no pagetoid spread. The lesion was removed from the neck of a 17-year-old girl who had widespread metastasis with multiple subcutaneous nodules involving the back, breasts, upper and low extremities and lymph nodes. Some mitotic activity was present in 19 of the 33 Spitz naevi but it was low in 13 of these cases; six of these lesions also showed bizarre or atypical mitotic figures. These bizarre forms were more common in the malignant melanoma group but were not helpful in distinguishing between the two groups. Malignant melanomas, on average, were deeper (mean thickness:3.49 mm, range 0.60–8.10 mm) than Spitz naevi (mean thickness: 1.38 mm, range 0.65–5.50 mm) as well as broader (diameter: melanomas, mean 8.06 mm, range 3.9–13.3 mm; naevi, mean 4.45 mm, range 1.3–9.8mm). Although most lesions in both groups lacked ulceration, marked ulceration was seen only in malignant melanomas (four). Intranuclear inclusions and macronuclei were present in 48% of the Spitz naevi and in 79% of the malignant melanomas. Some degree of cellular necrosis was seen in 79% of the malignant lesions and was also seen in 48% of the Spitz naevi. The lateral tumor margins were sharply defined in 78% of Spitz naevi but were also well defined in 47% of malignant melanomas. Similarly, clefting between nests of cells and surrounding epidermis was present in 76% of Spitz naevi but was also noted in 42% of malignant melanomas. Kamino bodies (eosinophilic globules) were present in 52% of the Spitz naevi and in 26% of the malignant melanomas; the Kamino bodies were coalescent or present in clumps as well as singly in 21% of the Spitz naevi and 16% of the malignant melanomas. Seven features were seen with equal frequency in the Spitz naevus and malignant melanoma groups, including junctional activity, inflammation, epithelial hyperplasia, prominent vascularity, giant or multinucleated cells, maturation of cells with depth, and symmetry."

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View Figure  		Fig. 8  Comment: Peters and Goellner pictured a thick melanoma that metastasized in a 9-year-old girl. The changes in the epidermis, seen best in their figure 2B, surely are those of melanoma; atypical pagetoid melanocytes are present in pagetoid pattern. The distribution of melanocytes in the dermis (their figure 2A) and the cytologic features of those melanocytes (their figure 2C) are characteristic of melanoma.

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View Figure  		Fig. 9  Comment: These photomicrographs of Peters and Goellner depict a melanoma in a 10-year-old that metastasized. Although the architectural pattern and the cytologic features of neoplastic melanocytes in the dermis are typical of melanoma, no signs of melanoma in situ are apparent in these photomicrographs.
 
Peters and Goellner were alert to the pitfalls inherent in distinguishing histopathologically between Spitz's nevus and melanoma, and this is how they phrased it:
 
"Analysis of our 52 cases of Spitz naevi and malignant melanomas emphasizes that the problem lies not in the lack of differences between groups of benign and malignant lesions but in the diagnosis of any one lesion because of overlap in histological features between the two groups . . . No single criterion is reliable in distinguishing Spitz naevi from malignat melanomas, and we agree with the statement of Roses et al. (1983) that 'a Spitz's naevus may have more features in common with a malignant melanoma than it has differences.'"