Historical Perspective: Kogut et al., 2000; Patterson et al., 2000; Zuckerman et al., 2001

 
Also in 2000, Kogut and colleagues78 told of two children with cutaneous melanoma, both of whom had metastases in sentinel lymph nodes. One of the children was a 30-month-old boy with a melanoma, 6.0 mm in thickness, situated between the eyebrows and that had metastasized to sentinel lymph nodes anterior to the left ear and below the left mandible. The child was receiving interferon-alpha-2 therapy and was alive at the time of publication. The other child was a 7-year-old boy with a 3.5 mm thick melanoma on the left ear that metastasized to the left anterior cervical, to posterior auricular sentinel lymph nodes, and to a node on the side of the neck. He was said to be alive and receiving therapy with interferon. Kogut and associates concentrated their work on lymphoscintintigraphy and sentinel node biopsy for diagnosis of metastatic disease. They did not show any photomicrographs.
 
In 2000, in an article about "Melanoma in children,"79 Patterson and coworkers failed to present any histopathologic findings in their muddled discussion of atypical Spitz's nevus and Spitz's nevus with "malignant" histopathologic features. This is part of what they had to say:
 
"However, the atypical Spitz's nevus often poses a significant problem when attempting to distinguish it from a malignant melanoma. Misdiagnosis of a melanoma as a Spitz's nevus, or vice versa, commonly occurs due to the numerous histologic features shared by the two lesions. Distinction between the two is further complicated by the notion that Spitz's nevi exhibit histologic features that range from completely benign to malignant. A grading system has recently been proposed to assist in the classification of malignant potential. Parameters include patient age, diameter, fat involvement, ulceration, and mitotic activity."
 
The histopathologic findings in every authentic Spitz's nevus are those of a benign neoplasm, no matter the degree of cytologic atypia of constituent melanocytes or the character of a mitotic figure in one of them. Striking nuclear pleomorphism and an abnormal mitotic figure do not make a Spitz's nevus a melanoma, any more than do "monster cells" in a dermatofibroma translate into malignant fibrous histiocytoma. A Spitz's nevus remains the benign neoplasm that it is and a dermatofibroma stays the inflammatory process that it is. There is no direct relationship between conspicuous cytologic atypia and malignancy, just as there is no direct relationship between lack of cytologic atypia and benignancy, as is witnessed compellingly in neoplastic cells of dermatofibrosarcoma protuberans whose nuclei are thin and monomorphous, and in neoplastic cells in macules/patches of mycosis fungoides whose lymphocytes display a nucleus that is small and monomorphous.
 
In 2001, Zuckerman and associates 81 reported on two pediatric patients with melanoma confirmed by metastases to sentinel lymph nodes. One was a 8-year-old girl with a melanoma on the left elbow diagnosed initially as "atypical Spitz nevus" (Fig. 17). The melanoma was 7.0 mm in thickness and the sentinel lymph node showed "micrometastasis within the subcapsular sinus." The neoplasm was pictured at scanning magnification and was seen to be thick and asymmetrical, the abnormal melanocytes being distributed in confluence throughout the dermis. The child was alive 30 months post-operatively.

View Figure  		Fig. 17  Comment: The silhouette of the neoplasm illustrated by Zuckerman et al. in their figure 1a is typical of melanoma in a child, in this instance, an 8-year-old. The neoplasm is oriented vertically, made up in foci of a sheet of neoplastic cells, and extends deep (to the bottom of the photomicrograph). It was first diagnosed histopathologically as an "atypical Spitz's nevus," but the authors conclude rightly that because it metastasized, it really is a melanoma. On histopathologic grounds alone it is a melanoma.
 
The other patient detailed by Zuckerman et al. was a 14-year-old boy with a "blue cutaneous lesion of the left ear." It first was interpreted histopathologically as a 1.9 mm thick melanoma but was re-interpreted by "outside consultation" as a "cellular neurothekeoma with focal mucinous alteration and focal marked cytologic atypia." A sentinel lymph node showed metastases. Zuckerman et al. pictured the lesion at scanning magnification and that depiction conveyed an appearance of marked asymmetry. Higher magnification showed confluence of abnormal melanocytes within the dermis. Metastases were present in regional lymph nodes. The patient was said to be without evidence of disease two years later.
 
Reflection on their observations of the neoplasms in the two patients compelled Zuckerman and colleagues to these contentions:
 
"These two patients highlight the fact that there is often confusion in rendering a diagnosis of melanoma in the pediatric population. Clinically, Spitz nevi, traumatized acquired nevi, pyogenic granuloma, dysplastic nevi, traumatized verrucae, blue nevi and hemangiomas are only a few of the entities that may mimic melanoma. Histologically, it may be difficult if not impossible to distinguish a Spitz nevus from melanoma."