Case Number : Case 1869 - 27 July - Dr Arti Bakshi Posted By: Guest

Sarcoidosis

Difficult case. A bit asimmetrical silhouette and expansive nodular growth with pushing margins in deep dermis, as expected in melanoma. But my first spot is Spitz nevus (atypical type), because there aren't important atypical nuclear features and it seems to see some ordered sloping pattern.

I would be cautious with this one. The overall architecture is polypoid and mostly symmetric, with deep confluent nests touching the hipodermis and evident cupping effect. Moderate cellular pleomorphism is seen along with isolated apoptotic bodies, no mitoses on these pictures. I would suggest follow-up, IHC, FISH, etc. I think this is a polypoid Spitzoid lesion of uncertain malignant potential, favour malignant 

Good to be back after a hiatus! My department's scanner has broken down so could not put in cases last 2 weeks. Thanks to Iskander for bailing out and also for taking images for me for this case!

The history is of a 4 year old male child  with a 1cm lesion on forearm.

don't know if there are any recent/new guidelines for classifiying Spitz tumours. would ahve called this atypical favouring benign.

1 hour ago, urmilapandey said:

don't know if there are any recent/new guidelines for classifiying Spitz tumours. would ahve called this atypical favouring benign.

To the best of my knowledge Spatz classification of Spitz tumors in children is still valid. Considering the age,  clinical impression and histology this case would give us a score of 2 so I will downgrade my initial dx to low risk and of course suggest follow-up

STUMP for further work up. A very difficult area in Dermatopathology. 

3 hours ago, Raul Perret said:

To the best of my knowledge Spatz classification of Spitz tumors in children is still valid. Considering the age,  clinical impression and histology this case would give us a score of 2 so I will downgrade my initial dx to low risk and of course suggest follow-up

thanks for the info Raul

An intradermal, with only focal interface involvement, proliferation of spitzoid melanocytes with a somewhat fascicular/plexiform growth pattern that tracks deeply down and around a hair follicle throughout the dermis and extending into the superficial subcutaneous fat in a dumbbell-shape configuration. There is only a single mitotic figure and no nuclear pleomorphism can be discerned. Maybe something like Spitz nevus with deep penetrating features would be proper for academic interest. Nevertheless, in practical terms, I would call it simply as Spitz nevus once I think complete excision with free margins is enough for definitive treatment.

Interesting discussion...as always Spitz tumours are difficult!

Agree with most of the observations, but what is not possible to assess in these images is the mitotic count. It was actually quite high including deep and atypical forms. I counted 7-8 mitoses/hpf in the most active areas. To my eye, there is lack of maturation with expansile lower margin, diffuse cytological atypia and epidermal thinning. All of this with high mitoses puts the lesion in the ATYPICAL SPITZ/STUMP category.. For all its drawbacks, the SPATZ criteria is the only histological tool available to guide management. This lesion scores as : intermediate risk (age- 0,  diameter-0, fat involvement-2, ulceration-0, mitoses- 2: total score 4)

I took a second opinion from a national expert who agreed with an Atypical Spitz with an intermediate SPATZ score . I  summarise his comments:

"I think the lesion poses significant concern regarding potential biological  behaviour. The lesion is too close to the margins and I would certainly advocate a significant re-excision.  As you indicate in your
letter, the role of sentinel lymph node biopsy in spitzoid tumours is even more contentious than in        
conventional melanoma.  I have discussed some similar cases previously with Professor Mooi (Amsterdam) and we have sometimes advocated detailed PET scanning of the regional   
node basin which may be advantageous in the event of any suspicion of node involvement in the future. There now seems to be increasing evidence that sentinel node biopsy offers additional staging advice but no long term therapeutic advantage."

The patient is due for a further excision.

Thanks for all your comments.

Nice to see this difficult cases with a range of opinions Arti. Hopefully in the future we will find a way for accurately categorizing these lesions, for the sake of the patients!