< Current issue
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
Confusion from the outset
The distinction histopathologically between Spitz's nevus and primary cutaneous melanoma is one of the most vexing in all of pathology, and it has been so since 1910 when Darier and Civatte first struggled with the matter of the precise nature of the melanocytic neoplasm now known eponymically for Spitz (
) and known universally (except in certain parochia) to be benign.
The conundrum for those two French dermatologists/dermatopathologists was expressed directly in the title of their article, to wit, "Is it nevus or nevo-carcinoma?" That the same quandary continues to dog histopathologists to this day is apparent from the popularity of terms such as "atypical Spitz's nevus," "malignant Spitz's nevus," and "metastasizing Spitz's nevus," all three of which are the subject of this essay.
Fig. 1 Sophie Spitz
At the outset, we want to state clearly our intention here, namely, to show, by virtue of a critique in historical perspective,* that an overwhelming majority of neoplasms claimed to be "atypical Spitz's nevus," in fact, are melanomas and every example of "malignant Spitz's nevus," and "metastasizing Spitz's nevus," is a melanoma. Moreover, that those designations, and variants of them, like "atypical Spitz's lesion," "atypical dermal melanocytic lesion with features of Spitz's nevus," "atypical Spitzoid melanocytic neoplasm," and "problematic Spitzoid melanocytic lesion," are mere evasions from a diagnosis, straightforwardly, of either Spitz's nevus** or melanoma.*** Rather than admit uncertainty forthrightly, those who employ circumlocutions that we deplore like those just mentioned, resort to linguistic maneuvers that, at first blush, seem to be "academic" (the jargon being in keeping with a slew of other well-accepted, but equally bogus diagnoses in pathology, among those being "minimal deviation melanoma," "borderline melanoma," "nevoid melanoma," "potentially low-grade melanocytic neoplasm," and "melanocytic lesion of uncertain biologic potential." All those terms and phrases are constructed in such a way as to appear to convey confidence, rather than tentativeness, on the part of a histopathologist. On further scrutiny, however, each is revealed to be devoid of content. For example, "malignant Spitz's nevus" and "metastasizing Spitz's nevus" not only are contradictions in terms, but they are outrageous violations of fundamental principles of classic Virchowian pathology. "Atypical Spitz's nevus" not only is a redundancy because the neoplasm was so atypical to Spitz, herself, she insisted (from the time she spawned the idea in 1948
) it was a "malignant melanoma," but is abject intellectually, those who invoke it never setting forth in clear-cut fashion criteria for what constitutes a "typical" Spitz's nevus in contradistinction to an "atypical" one.
*The history told in these pages is abbreviated because it is recounted in more elaborate form in an article by us that appeared in the first issue of
Dermatopathology: Practical & Conceptual
for 2002 under the heading, "Melanomas in pre-pubescent children: Review comprehensively, critique historically, criteria diagnostically, and course biologically."
** The word "nevus" is used throughout this work is a synonym for melanocytic nevus.
*** The word "melanoma," unmodified, refers throughout this article specifically to malignant melanoma.
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