Historical Perspective: Barnhill, 1998; Spatz and Barnhill, 1999

 
Barnhill, in 1998, wrote anew about the subject of "Childhood melanoma."72 He studied 23 children up to 15 years of age with melanomas that he classified in the same manner as he had in 1995, to wit, as "small cell," "adult type," and "Spitz like." Among them he also included "metastasizing Spitz tumors" and "atypical Spitz tumors." Of the "metastasizing Spitz tumors" and "atypical Spitz tumors," Barnhill offered this opinion:
 
"Examination of the two metastasizing Spitz tumors and nine atypical Spitz lesions in this series revealed morphological features similar to those reported by Smith et al. In general, these tumors had features of Spitz's nevus in addition to atypical features, including large size; significant depth; cellularity; cellular atypia; and dermal, deep, and occasionally atypical mitoses. Many of the last-mentioned features have specifically been cited as indicative of melanoma . . . Nonetheless, the probability of an atypical Spitz tumor being malignant in children younger than 10 to 12 years of age is extraordinarily low. Thus, caution is urged in making a diagnosis of melanoma in this age group without compelling evidence. Almost all such lesions prove to be benign. Rarely, some of these lesions may metastasize to regional lymph nodes without apparent further disease."
 
The criticisms voiced already about the concepts of "atypical Spitz tumor" and of "malignant (metastasizing) Spitz tumor" apply equally to them in the more recent statements of Barnhill. It must be stressed, too, that melanoma does not metastasize just to regional lymph nodes and stop there; once melanoma metastasizes it is gone—paying no heed to artificial boundaries, such as "satellite" and "regional," created by oncologists. Once a patient has metastases of melanoma, the prognosis is grim, even though no one can determine, precisely when, if a person lives long enough and does not die of another malady, death as a consequence of metastases will occur.
 
In "The Spitz tumor 50 years later: Revisiting a landmark contribution and unresolved controversy," Spatz and Barnhill, in 1999,73 took on the matter of criteria for distinguishing histopathologically between Spitz's nevus and melanoma. This is some of what they said about it:
 
"The typical Spitz tumor almost never metastasizes. However, as the histologic features of Spitz nevi become more accurate and reproducible, the more exceptional and challenging for the pathologist are the lesions for which no definitive diagnosis of benignity or melanoma can be made. These lesions have been successively designated as borderline or minimal-deviation melanomas, atypical Spitz nevi, Spitz tumors with uncertain prognosis, and atypical Spitz tumors . . . Nonetheless, because we lack specific criteria to distinguish atypical Spitz tumors from melanoma, it seems reasonable to categorize such atypical Spitz tumors into low- or high-risk categories based on the accumulation of abnormal features . . . whether these lesions represent a broad histologic continuum extending from benign to malignant tumors which is likely, or can be definitely categorized as nevus or malignant melanoma, is still unknown."
 
The statement that "The typical Spitz tumor almost never metastasizes" does not go anywhere near far enough; Spitz's nevus never metastasizes because it is a nevus and a nevus, being benign, never metastasizes. Every so-called metastasizing Spitz's nevus is a melanoma that was misdiagnosed histopathologically. Other lines in the preceding quotation contain evasions that impede diagnosis of Spitz's nevus and melanoma with specificity.