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A 10-year-old girl is referred to dermatology for evaluation of an asymptomatic “wart” that manifested on her thigh several years ago. At first, the lesion grew rapidly, but it has since stabilized. It remains unaffected despite multiple treatments with liquid nitrogen.
According to her parents (with confirmation from her medical record), the patient is otherwise quite healthy.
EXAMINATION
A spindle-shaped, pinkish red, 1.2 x 0.7-cm nodule with a smooth surface and rounded borders is located on the patient’s distal left anterior thigh. The lesion itself is quite firm but nontender to the touch, and its long axis is parallel to transverse local skin tension lines. The patient’s type II skin is otherwise unremarkable.
After consultation with the patient and her family, the lesion is excised under local anesthesia with 5-mm margins in an elliptical pattern to yield favorable lines of closure. The sample is sent to pathology.
What is the diagnosis?
The pathology report showed both epithelioid and spindle cells with scattered apoptotic cells seen at the dermoepidermal junction, with no atypia. The margins were clear. Such findings are consistent with a diagnosis of Spitz nevus.
Prior to the 1950s, lesions with these clinical and histologic features were believed to be melanoma and therefore termed juvenile melanoma. But their unique morphologic and histologic architecture—and a lack of signs of progressive or metastatic disease in affected patients—prompted suspicion that they were not really malignant. A pathologist named Sophie Spitz conducted a retrospective study that revealed no cancerous activity in any of the patients. Her findings, on a superficial level, eventually led to the elimination of the term “juvenile melanoma”—but more importantly, they eradicated a great deal of unnecessary, and often mutilating, surgery.
The features of the case patient’s lesion—color, texture, shape, and initial rapid growth —are typical of Spitz nevi, as are the location and the age of the patient. However, the range of morphologic presentations includes darker lesions (some almost black) and those of varying vertical depth and appearance (ie, intradermal, compound, junctional).
A note of caution, however: Although Spitz nevi are benign, true melanomas can present with “Spitzoid” morphologic and histologic features (they’re even called “Spitzoid melanomas”). Key distinguishing features can only be identified via microscopic examination of the lesion’s full vertical structure. So, for safety’s sake, the standard of care for Spitz nevi is to excise them totally, with clear, deep, wide margins, whenever possible.
The case patient had her sutures removed 10 days after surgery. Her ongoing care will include a biannual check for signs of recurrence.
TAKE-HOME LEARNING POINTS
• Until the mid-1950s, what we now refer to as Spitz nevi were called “juvenile melanoma” and were treated as such, with radical and often disfiguring surgeries.
• Spitz nevi are usually seen in children. They can be red, pink, or even black, and often have a history of recent growth and an elliptiform shape.
• Excision with totally clear margins is the correct approach, along with pathologic examination.
• Spitz nevi have histologic features suggestive of melanoma, and some melanomas have “Spitzoid” features. Therefore, all cases must be handled with great care.
A 10-year-old girl is referred to dermatology for evaluation of an asymptomatic “wart” that manifested on her thigh several years ago. At first, the lesion grew rapidly, but it has since stabilized. It remains unaffected despite multiple treatments with liquid nitrogen.
According to her parents (with confirmation from her medical record), the patient is otherwise quite healthy.
EXAMINATION
A spindle-shaped, pinkish red, 1.2 x 0.7-cm nodule with a smooth surface and rounded borders is located on the patient’s distal left anterior thigh. The lesion itself is quite firm but nontender to the touch, and its long axis is parallel to transverse local skin tension lines. The patient’s type II skin is otherwise unremarkable.
After consultation with the patient and her family, the lesion is excised under local anesthesia with 5-mm margins in an elliptical pattern to yield favorable lines of closure. The sample is sent to pathology.
What is the diagnosis?
The pathology report showed both epithelioid and spindle cells with scattered apoptotic cells seen at the dermoepidermal junction, with no atypia. The margins were clear. Such findings are consistent with a diagnosis of Spitz nevus.
Prior to the 1950s, lesions with these clinical and histologic features were believed to be melanoma and therefore termed juvenile melanoma. But their unique morphologic and histologic architecture—and a lack of signs of progressive or metastatic disease in affected patients—prompted suspicion that they were not really malignant. A pathologist named Sophie Spitz conducted a retrospective study that revealed no cancerous activity in any of the patients. Her findings, on a superficial level, eventually led to the elimination of the term “juvenile melanoma”—but more importantly, they eradicated a great deal of unnecessary, and often mutilating, surgery.
The features of the case patient’s lesion—color, texture, shape, and initial rapid growth —are typical of Spitz nevi, as are the location and the age of the patient. However, the range of morphologic presentations includes darker lesions (some almost black) and those of varying vertical depth and appearance (ie, intradermal, compound, junctional).
A note of caution, however: Although Spitz nevi are benign, true melanomas can present with “Spitzoid” morphologic and histologic features (they’re even called “Spitzoid melanomas”). Key distinguishing features can only be identified via microscopic examination of the lesion’s full vertical structure. So, for safety’s sake, the standard of care for Spitz nevi is to excise them totally, with clear, deep, wide margins, whenever possible.
The case patient had her sutures removed 10 days after surgery. Her ongoing care will include a biannual check for signs of recurrence.
TAKE-HOME LEARNING POINTS
• Until the mid-1950s, what we now refer to as Spitz nevi were called “juvenile melanoma” and were treated as such, with radical and often disfiguring surgeries.
• Spitz nevi are usually seen in children. They can be red, pink, or even black, and often have a history of recent growth and an elliptiform shape.
• Excision with totally clear margins is the correct approach, along with pathologic examination.
• Spitz nevi have histologic features suggestive of melanoma, and some melanomas have “Spitzoid” features. Therefore, all cases must be handled with great care.
A 10-year-old girl is referred to dermatology for evaluation of an asymptomatic “wart” that manifested on her thigh several years ago. At first, the lesion grew rapidly, but it has since stabilized. It remains unaffected despite multiple treatments with liquid nitrogen.
According to her parents (with confirmation from her medical record), the patient is otherwise quite healthy.
EXAMINATION
A spindle-shaped, pinkish red, 1.2 x 0.7-cm nodule with a smooth surface and rounded borders is located on the patient’s distal left anterior thigh. The lesion itself is quite firm but nontender to the touch, and its long axis is parallel to transverse local skin tension lines. The patient’s type II skin is otherwise unremarkable.
After consultation with the patient and her family, the lesion is excised under local anesthesia with 5-mm margins in an elliptical pattern to yield favorable lines of closure. The sample is sent to pathology.
What is the diagnosis?
The pathology report showed both epithelioid and spindle cells with scattered apoptotic cells seen at the dermoepidermal junction, with no atypia. The margins were clear. Such findings are consistent with a diagnosis of Spitz nevus.
Prior to the 1950s, lesions with these clinical and histologic features were believed to be melanoma and therefore termed juvenile melanoma. But their unique morphologic and histologic architecture—and a lack of signs of progressive or metastatic disease in affected patients—prompted suspicion that they were not really malignant. A pathologist named Sophie Spitz conducted a retrospective study that revealed no cancerous activity in any of the patients. Her findings, on a superficial level, eventually led to the elimination of the term “juvenile melanoma”—but more importantly, they eradicated a great deal of unnecessary, and often mutilating, surgery.
The features of the case patient’s lesion—color, texture, shape, and initial rapid growth —are typical of Spitz nevi, as are the location and the age of the patient. However, the range of morphologic presentations includes darker lesions (some almost black) and those of varying vertical depth and appearance (ie, intradermal, compound, junctional).
A note of caution, however: Although Spitz nevi are benign, true melanomas can present with “Spitzoid” morphologic and histologic features (they’re even called “Spitzoid melanomas”). Key distinguishing features can only be identified via microscopic examination of the lesion’s full vertical structure. So, for safety’s sake, the standard of care for Spitz nevi is to excise them totally, with clear, deep, wide margins, whenever possible.
The case patient had her sutures removed 10 days after surgery. Her ongoing care will include a biannual check for signs of recurrence.
TAKE-HOME LEARNING POINTS
• Until the mid-1950s, what we now refer to as Spitz nevi were called “juvenile melanoma” and were treated as such, with radical and often disfiguring surgeries.
• Spitz nevi are usually seen in children. They can be red, pink, or even black, and often have a history of recent growth and an elliptiform shape.
• Excision with totally clear margins is the correct approach, along with pathologic examination.
• Spitz nevi have histologic features suggestive of melanoma, and some melanomas have “Spitzoid” features. Therefore, all cases must be handled with great care.
