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Dermatopathology: Practical & Conceptual October - December 2003
New Heights: “Atypical” Spitz’s Nevus, “Malignant” Spitz’s Nevus, and “Metastasizing” Spitz’s Nevus: A Critique in Historical Perspective of Three Concepts Flawed Fatally
Joan M. Mones, D.O.
A. Bernard Ackerman, M.D.
Confusion from the outset
How the concept and the term “Spitz’s nevus” came to be
How the concepts and the terms “atypical,”“malignant,” and “metastasizing” Spitz’s nevus/tumor came to be
Because "atypical Spitz's nevus" as a diagnosis issued by histopathologists never has been defined in a comprehensible, repeatable way, it serves only to bewilder clinicians and, therefore, is not beneficial to patients. On the contrary; it is harmful to them. Most examples of the many "atypical Spitz nevi/tumors" reported on are not nevi at all, but melanomas; they metastasized, many some of them resulting in death (
). The modifier "atypical" for "Spitz's nevus" is as confusing as the modifier "recurrent" for melanoma. In the case of the latter, the term does not distinguish between "persistence locally" or "metastasis," two very different circumstances with very different implications for a patient; in the case of the former, the term does not distinguish between "Spitz's nevus" and "melanoma", implications of magnitude for a patient. The diagnoses "atypical Spitz nevus," "malignant Spitz nevus," and "metastasizing Spitz nevus" denote, no matter how bizarrely, benignancy, the last word of each triplet being "nevus." And no nevus, including Spitz's nevus, can be malignant and none can metastasize. A nevus that metastasizes is a melanoma that was misdiagnosed originally. Moreover, the idea that "these lesions have the ability to metastasize to local lymph nodes but are not capable of widespread metastases" is poppycock, an affront to logic; a metastasis, by definition, disseminates.
If there is an "atypical Spitz's nevus," then there must be a "typical Spitz's nevus." But what is that? Is it not the neoplasm described by Spitz in 1948 and now known eponymically for her? But for Spitz, herself, that neoplasm was so "atypical" (by virtue of attributes cytopathologically) that in her seminal publication about it, she stated, unequivocally, that she considered it to be malignant melanoma, and why she titled her article, "Melanomas of childhood." Is it the "pigmented spindle cell tumor of Reed?" Is it a combined nevus, one component of which is cells of the epithelioid type of so-called Spitz's nevus?
From the very beginning, starting with Darier and Civatte, proceeding to Pack, Spitz, Allen, Reed, Helwig, Barnhill, Lupton, and others to this very day, the issue of the nevus known for Spitz has been muddied chiefly by (1) priority given to cytopathologic changes rather than to architectural pattern as assessed at scanning magnification, i.e., silhouette, and to clinical features, (2) revisionist theories with the consistency of meringue that have come to triumph over solid principles that infuse classic pathology, and (3) garble that reflects muddled thinking instead of lucid language that expresses logical thought. In the ultimate analysis, if a histopathologist is uncertain about a diagnosis of a particular melanocytic neoplasm, that disquiet should be reflected not as "melanocytic tumor of uncertain biologic potential," but stated directly as uncertainty on the part of the histopathologist, e.g., as "I don't know." And the same principle obtains for all the other circumlocutions and evasions that are disguises for uncertainty, among them, "minimal deviation melanoma," "borderline melanoma," "nevoid melanoma," "potentially low-grade malignant neoplasm," "atypical melanocytic neoplasm," and "atypical Spitz's nevus;" none of those "diagnoses" conveys specificity. In the matter of the neoplasms under discussion here, the only two diagnoses possible are Spitz's nevus and melanoma (melanoma developing in a Spitz's nevus so exceedingly rarely that it is not of moment in this discussion). If melanoma, a histopathologist is obligated to request another opinion from a respected colleague and/or advise complete excision with a narrow margin. In the ultimate analysis, the "diagnosis" of "atypical Spitz's nevus" is a non-diagnosis destined to the same inglorious fate as "activated junctional nevus" and "dysplastic nevus;" now is the time to jettison it, rather than later when every pathologist, at long last, has abandoned it.
From the Ackerman Academy of Dermatopathology in New York City where Dr. Mones is an associate dermatopathologist and Dr. Ackerman is the Director.
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