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Church AJ, Moustafa D, Pinches RS, Hawryluk EB, Schmidt BAR. Genomic comparison of malignant melanoma and atypical Spitz tumor in the pediatric population. Pediatr Dermatol 2022; 39:409-419. [PMID: 35194848 DOI: 10.1111/pde.14935] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES The diagnostic distinction between atypical Spitz tumor (AST) and malignant melanoma (MM) in pediatric tumors is challenging. Molecular tests are increasingly used to characterize these neoplasms; however, limited studies are available in pediatric patients. This study aimed to provide a genomic comparison of pediatric MM and AST in the context of comprehensive clinical annotation. METHODS Pediatric patients diagnosed with MM (n=11) and AST (n=12) were compared to a cohort of 693 adult melanoma patients. DNA next-generation sequencing assessed kinase gene fusions, tumor mutational burden, sequence variants, copy number alterations, structural variants, microsatellite instability, and mutational signatures. RESULTS Seven AST cases and eight MM cases were successfully sequenced. Kinase gene fusions were identified in both the MM and AST cohorts (NTRK1, ROS1, and MET). MM cases had TERT, BRAF, and CDKN2A alterations, which were not identified in the AST cohort. Tumor mutational burden (TMB) analysis showed pediatric ASTs had an average of 2.82 mutations/Mb, pediatric MM had an average of 5.7 mutations/Mb, and adult MM cases averaged 18.8 mut/Mb. One pediatric MM case had an elevated TMB of 15 mutations/Mb and a UV mutational signature. CONCLUSIONS These data expand our understanding of pediatric malignant melanoma. The differences between the molecular signatures for AST and MM are not statistically significant, and histopathology remains the gold standard for the diagnosis of pediatric AST and MM at this time. With more data, molecular studies may provide additional support for diagnosis and targeted therapeutics.
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Affiliation(s)
- Alanna J Church
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Danna Moustafa
- Harvard Medical School, Boston, Massachusetts, USA
- Dermatology Section, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert Seth Pinches
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elena B Hawryluk
- Harvard Medical School, Boston, Massachusetts, USA
- Dermatology Section, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Birgitta A R Schmidt
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
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2
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Davies OMT, Majerowski J, Segura A, Kelley SW, Sokumbi O, Humphrey SR. A sixteen-year single-center retrospective chart review of Spitz nevi and spitzoid neoplasms in pediatric patients. Pediatr Dermatol 2020; 37:1073-1082. [PMID: 32857447 DOI: 10.1111/pde.14320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/22/2020] [Accepted: 07/14/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Spitzoid neoplasms in pediatric patients pose an interesting challenge for clinicians. More data on the clinical, histologic, and molecular characteristics of these lesions are necessary to distinguish features that may portend recurrence or malignant behavior to help determine future treatment guidelines in pediatric patients. METHODS Institutional Review Board approval was obtained from Children's Hospital of Wisconsin to conduct a retrospective analysis of spitzoid neoplasms. Patients with biopsied or excised spitzoid neoplasms between 01/01/2000 and 08/01/2016 were included. Pertinent clinical and histologic data were collected. Atypical, unusual, or diagnostically uncertain lesions were selected for re-review. RESULTS 266 lesions from 264 patients were included. 243 were classified as benign (91.35%), 22 as atypical (8.27%), and 1 as spitzoid melanoma (0.38%). No clinical or histologic variables were found to be statistically significant between the benign Spitz, atypical Spitz, and spitzoid melanoma cohorts. No known deaths occurred. CONCLUSION Our findings highlight the extreme variability of spitzoid neoplasms clinically and histologically. Importantly, this study demonstrates that the vast majority of spitzoid neoplasms in pediatric populations are benign and supports conservative management of spitzoid lesions in children.
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Affiliation(s)
| | | | - Annette Segura
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Olayemi Sokumbi
- Departments of Dermatology and Laboratory Medicine & Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Stephen R Humphrey
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI, USA
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3
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Papageorgiou C, Apalla Z, Bobos M, Gkentsidi T, Kyrgidis A, Lallas K, Manoli SM, Moutsoudis A, Nikolaidou C, Spyridis I, Lallas A. Dermoscopy of Spitz/Reed naevi and management. GIORN ITAL DERMAT V 2019; 154:457-465. [DOI: 10.23736/s0392-0488.19.06294-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pfau D, Tamaki A, Hoppe KR, Honda K, Rezaee R, Zender CA. Sentinel Node Biopsy in Young Patients with Atypical Melanocytic Tumors of the Head and Neck. OTO Open 2019; 3:2473974X19850752. [PMID: 31428727 PMCID: PMC6684149 DOI: 10.1177/2473974x19850752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/19/2019] [Accepted: 04/25/2019] [Indexed: 11/17/2022] Open
Abstract
Objective To examine the diagnostic value of the sentinel lymph node biopsy in pediatric through young adult head and neck melanocytic tumors of unknown malignant potential. Study Design Retrospective case series. Setting Single academic institution. Subjects and Methods Demographics, histology, and outcomes were examined in 14 patients aged 4 to 24 years with head and neck melanocytic tumors of unknown malignant potential. Information on age at diagnosis, primary lesion characteristics, and sentinel lymph node biopsy were compared. Results Of 14 patients meeting criteria for head and neck melanocytic tumors of unknown malignant potential, 8 patients underwent sentinel lymph node biopsy (57%). Of those, 4 biopsies (50%) had positive sentinel nodes. All patients undergoing sentinel lymph node biopsy had primary lesions greater than 1 mm depth or mitotic rate of at least 1 mitosis per mm2. No patients had recurrence of their primary lesion at time of follow-up. Conclusion Our data show a high rate of node-positive sentinel lymph node biopsy for pediatric and young adult head and neck patients with melanocytic tumors of unknown malignant potential, supporting the value of sentinel lymph node biopsy in this population.
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Affiliation(s)
- David Pfau
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Akina Tamaki
- Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Kathryn R Hoppe
- Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Kord Honda
- Department of Dermatology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Rod Rezaee
- Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Chad A Zender
- Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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5
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Dika E, Ravaioli GM, Fanti PA, Neri I, Patrizi A. Spitz Nevi and Other Spitzoid Neoplasms in Children: Overview of Incidence Data and Diagnostic Criteria. Pediatr Dermatol 2017; 34:25-32. [PMID: 27874206 DOI: 10.1111/pde.13025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Spitz nevi are benign melanocytic neoplasms characterized by epithelioid or spindle melanocytes or both. In some rare cases their presentation overlaps with the clinical and histopathologic features of malignant melanoma, so a differential diagnosis can be difficult to make. Intermediate forms between Spitz nevi and malignant melanoma, with unpredictable behavior, have been called atypical Spitz tumors. A literature search was performed to review the clinical, dermoscopic, genetic, and histopathologic aspects of spitzoid tumors. Spitz nevi mainly occur in children, with no predilection for sex, and in young women. Common sites are the head and lower arms, where Spitz nevi present as pink nodules or hyperpigmented plaques. Spitzoid lesions may have diverse dermoscopic patterns: vascular, starburst, globular, atypical, reticular, negative homogeneous, or targetoid. The management of spitzoid lesions can be invasive or conservative; surgical excision is usually reserved for those with doubtful features, whereas clinical and dermoscopic follow-up is preferred for typical pediatric Spitz nevi. The role of sentinel lymph node biopsy in atypical Spitz tumors is debated. Immunohistochemistry and new molecular techniques such as comparative genomic hybridization, polymerase chain reaction, and fluorescence in situ hybridization offer new diagnostic perspectives, investigating genetic alterations that are specific for malignant melanoma or for Spitz nevi.
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Affiliation(s)
- Emi Dika
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Giulia Maria Ravaioli
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Pier Alessandro Fanti
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Iria Neri
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Annalisa Patrizi
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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Abstract
Childhood melanoma is a rare pediatric malignancy, with fewer than 500 new diagnoses annually. The incidence is increasing, particularly in the adolescent population. This review highlights the epidemiology, clinical presentation, and histopathologic challenges of pediatric melanoma. Surgical resection remains the cornerstone for localized and regionally advanced disease. Adjuvant therapies, including current options and potential novel therapeutics for this unique population will be discussed.
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Affiliation(s)
- Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children׳s Hospital, The Ohio State University College of Medicine, Nationwide Children׳s Dr, FB Suite 6B.1, Columbus, Ohio 43205.
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Abstract
Malignant melanoma can affect patients of any age. It has been well documented that the overall incidence of melanoma has increased in the past several decades, and this increase extends to the pediatric population (both preadolescent and, to a greater extent, adolescent children). Melanoma in adolescents, commonly defined as patients 11 to 19 years of age, behaves similarly to melanoma in adults; however, there are a number of distinct differences in the presentation and prognosis of melanoma in the preadolescent population. Though our treatment options for melanoma are increasing with the advent of novel drugs and clinical trials, the rarity of pediatric melanomas often excludes this population from clinical studies. The treatment options for the pediatric patient are predominantly based on adult clinical trials. Awareness of the differences in clinical presentation, as well as management of melanoma in younger patients compared with their adult counterparts, is crucial to guarantee prompt and appropriate care.
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8
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Latchana N, Regan K, Howard JH, Aldrink JH, Ranalli MA, Peters SB, Zhang X, Gru A, Payne PRO, Suarez-Kelly LP, Carson WE. Global microRNA profiling for diagnostic appraisal of melanocytic Spitz tumors. J Surg Res 2016; 205:350-358. [PMID: 27664883 DOI: 10.1016/j.jss.2016.06.085] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/27/2016] [Accepted: 06/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Melanoma skin cancer remains the leading cause of skin cancer-related deaths. Spitz lesions represent a subset of melanocytic skin lesions characterized by epithelioid or spindled melanocytes organized in nests. These lesions occupy a spectrum ranging from benign Spitz and atypical Spitz lesions all the way to malignant Spitz tumors. Appropriate management is reliant on accurate diagnostic classification, yet this effort remains challenging using current light microscopic techniques. The discovery of novel biomarkers such as microRNAs (miR) may ultimately be a useful diagnostic adjunct for the evaluation of Spitz lesions. miR expression profiles have been suggested for non-Spitz melanomas but have yet to be ascribed to Spitz lesions. We hypothesized that distinct miR expression profiles would be associated with different lesions along the Spitz spectrum. MATERIALS AND METHODS RNAs extracted from paraffin-embedded, formalin-fixed tissues of 11 resected skin lesions including benign nevi (n = 2), benign Spitz lesions (n = 3), atypical Spitz lesions (n = 3), and malignant Spitz tumors (n = 3) were analyzed by the NanoString platform for simultaneous evaluation of over 800 miRs in each patient sample. RESULTS Benign Spitz lesions had increased expression of miR-21-5p and miR-363-3p compared with those of benign nevi. Malignant Spitz lesions exhibited overexpression of miR-21-5p, miR-155-5p, and miR-1283 relative to both benign nevi and benign Spitz tumors. Notably, atypical Spitz tumors had increased expression of miR-451a and decreased expression of miR-155-5p expression relative to malignant Spitz lesions. Conversely, atypical Spitz lesions had increased expression of miR-21-5p, miR-34a-5p, miR-451a, miR-1283, and miR-1260a relative to benign Spitz tumors. CONCLUSIONS Overall, distinct miR profiles are suggested among Spitz lesions of varying malignant potential with some similarities to non-Spitz melanoma tumors. This work demonstrates the feasibility of this analytic method and forms the basis for further validation studies.
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Affiliation(s)
- Nicholas Latchana
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Kelly Regan
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - J Harrison Howard
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Jennifer H Aldrink
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Mark A Ranalli
- Department of Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH
| | - Sara B Peters
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Xiaoli Zhang
- Center for Biostatistics, The Ohio State University, Columbus, OH
| | - Alejandro Gru
- Department of Pathology, University of Virgina, Charlottesville, VA
| | - Philip R O Payne
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Lorena P Suarez-Kelly
- Department of Molecular Virology, Immunology and Medical Genetics, The Arthur G. James Comprehensive Cancer Center and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH
| | - William E Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH.,Department of Molecular Virology, Immunology and Medical Genetics, The Arthur G. James Comprehensive Cancer Center and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH
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9
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Lorimer PD, White RL, Walsh K, Han Y, Kirks RC, Symanowski J, Forster MR, Sarantou T, Salo JC, Hill JS. Pediatric and Adolescent Melanoma: A National Cancer Data Base Update. Ann Surg Oncol 2016; 23:4058-4066. [PMID: 27364504 DOI: 10.1245/s10434-016-5349-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Studies suggest that the biology of pediatric and adolescent melanoma differs from that of adult disease. We report the largest series to date examining the natural history of pediatric and adolescent melanoma. We aim to elucidate the natural history of pediatric and adolescent melanoma and to examine the appropriateness of diagnostic and therapeutic modalities developed for adults and that are currently being used in children. METHODS A retrospective cohort study was conducted of patients with an index diagnosis of cutaneous non-metastatic melanoma from 1998 to 2011 using the National Cancer Data Base (NCDB; n = 420,416). Three age-based cohorts were analyzed: 1-10 years (pediatric), 11-20 years (adolescent), and ≥21 years (adult). Multivariate analyses were used to identify factors associated with overall survival (OS). RESULTS Pediatric melanoma patients have longer OS than their adolescent (hazard ratio [HR] 0.50, 95 % CI 0.25-0.98) and adult counterparts (HR 0.11, 95 % CI 0.06-0.21). Adolescents have longer OS than adults. No difference was found in OS in pediatric patients who are node-positive versus node-negative. In pediatric patients, sentinel lymph node biopsy and completion lymph node dissection are not associated with increased OS. In adolescents, nodal positivity is a significant negative prognostic indicator (HR 4.82, 95 % CI 3.38-6.87). CONCLUSIONS Age-based differences in melanoma outcomes warrant different considerations for diagnostic and therapeutic approaches in each group in order to maximize quality of life while minimizing complications and costs. Prospective, multicenter studies should evaluate the role of diagnostic procedures for pediatric patients.
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Affiliation(s)
- Patrick D Lorimer
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Richard L White
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Kendall Walsh
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Yimei Han
- Department of Biostatistics, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Russell C Kirks
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - James Symanowski
- Department of Biostatistics, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Meghan R Forster
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Terry Sarantou
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Jonathan C Salo
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Joshua S Hill
- Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA.
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10
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Kim J, Sun Z, Gulack BC, Adam MA, Mosca PJ, Rice HE, Tracy ET. Sentinel lymph node biopsy is a prognostic measure in pediatric melanoma. J Pediatr Surg 2016; 51:986-90. [PMID: 27041229 PMCID: PMC5140081 DOI: 10.1016/j.jpedsurg.2016.02.067] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 02/26/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE Sentinel lymph node biopsy (SLNB)-based management has been shown to improve disease-free survival in adult melanoma, but there is scant evidence regarding the utility of SLNB in pediatric melanoma. METHODS The 2004-2011 Surveillance, Epidemiology, and End Results database was queried for patients with primary cutaneous melanoma of Breslow depth>0.75mm and clinically negative nodes. Pediatric patients, defined as less than 20years of age, were grouped by whether they underwent SLNB or not. Kaplan-Meier analysis was performed to compare melanoma-specific survival (MSS) in propensity-matched groups. RESULTS 310 pediatric patients met study criteria: 261 (84%) underwent SLNB, while 49 (16%) did not. There was no difference in MSS between matched children who received SLNB and those who did not (p=0.36). Among children who received SLNB, a positive SLNB was associated with worse MSS compared to a negative SLNB (89% vs. 100% at 84months, p=0.04). However, children with a positive SLNB had more favorable survival compared to patients >20years of age (88% vs. 66% at 84months, p=0.02). CONCLUSIONS SLNB does not confer a survival benefit to children with melanoma, but it provides valuable prognostic information regarding MSS.
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Affiliation(s)
- Jina Kim
- Duke University, Department of Surgery, USA.
| | - Zhifei Sun
- Duke University, Department of Surgery, USA
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Massi D, De Giorgi V, Mandalà M. The complex management of atypical Spitz tumours. Pathology 2016; 48:132-41. [PMID: 27020385 DOI: 10.1016/j.pathol.2015.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022]
Abstract
In recent years, advances in molecular genetic characterisation have revealed that atypical Spitz tumours (ASTs) are basically heterogeneous diseases, although the clinical relevance of these findings is yet to be determined. Evidence of molecularly-defined diverse groups of lesions continues to accumulate; however, conflicting, confusing, and overlapping terminology has fostered ambiguity and lack of clarity in the field in general. The lack of fundamental diagnostic (morphological) unambiguous classification framework results in a number of challenges in the interpretation of the molecular genetic data. In this review, we discuss the main difficulties for pathologists and clinicians in the complex management of ASTs, with particular emphasis on the different genetic and biological features of recently-described entities, and offer our view of what could be medically reasonable to guide a rational approach in light of current data.
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Affiliation(s)
- Daniela Massi
- Division of Pathological Anatomy, Department of Surgery and Translational Medicine, University of Florence, Italy.
| | | | - Mario Mandalà
- Unit of Medical Oncology, Department of Oncology and Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
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12
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Sreeraman Kumar R, Messina JL, Reed D, Navid F, Sondak VK. Pediatric Melanoma and Atypical Melanocytic Neoplasms. Cancer Treat Res 2016; 167:331-369. [PMID: 26601871 DOI: 10.1007/978-3-319-22539-5_15] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Melanoma is uncommon in the pediatric age range, but is increasing in frequency and often presents with atypical features compared to the classic ABCDE criteria common to adult melanoma cases. Moreover, many melanocytic neoplasms in childhood pose diagnostic challenges to the pathologist, and sometimes cannot be unequivocally classified as benign nevi or melanoma. This chapter addresses the evaluation and management of pediatric patients with melanoma and atypical melanocytic neoplasms, including the roles of and unresolved questions surrounding sentinel lymph node biopsy, completion lymphadenectomy, adjuvant therapy, and treatment of advanced disease.
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Affiliation(s)
| | - Jane L Messina
- Department of Anatomic Pathology, Moffitt Cancer Center, Tampa, FL, USA
- Department of Cutaneous Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
- Department of Pathology and Cell Biology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Dermatology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Damon Reed
- Department of Cutaneous Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Adolescent and Young Adult (AYA) Program, Sarcoma Department, Moffitt Cancer Center, Tampa, FL, USA
- Department of Hematology/Oncology , All Children's Hospital Johns Hopkins Medicine , St. Petersburg, FL, USA
| | - Fariba Navid
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Vernon K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
- Department of Oncologic Sciences and Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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13
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EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma. Eur J Nucl Med Mol Imaging 2015. [PMID: 26205952 DOI: 10.1007/s00259-015-3135-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Sentinel lymph node biopsy is an essential staging tool in patients with clinically localized melanoma. The harvesting of a sentinel lymph node entails a sequence of procedures with participation of specialists in nuclear medicine, radiology, surgery and pathology. The aim of this document is to provide guidelines for nuclear medicine physicians performing lymphoscintigraphy for sentinel lymph node detection in patients with melanoma. METHODS These practice guidelines were written and have been approved by the European Association of Nuclear Medicine (EANM) to promote high-quality lymphoscintigraphy. The final result has been discussed by distinguished experts from the EANM Oncology Committee, national nuclear medicine societies, the European Society of Surgical Oncology (ESSO) and the European Association for Research and Treatment of Cancer (EORTC) melanoma group. The document has been endorsed by the Society of Nuclear Medicine and Molecular Imaging (SNMMI). CONCLUSION The present practice guidelines will help nuclear medicine practitioners play their essential role in providing high-quality lymphatic mapping for the care of melanoma patients.
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14
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A Case of Pediatric Melanoma: Treatment Considerations in Advanced Disease. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e402. [PMID: 26090292 PMCID: PMC4457265 DOI: 10.1097/gox.0000000000000370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/27/2015] [Indexed: 11/29/2022]
Abstract
We document a 3-year-old healthy African American girl who developed malignant melanoma on her lower extremity. The clinical appearance offered little indication of the lesion’s severity (T4), and only the history of de novo presentation and disproportionate growth raised clinical suspicion. This case report highlights the subtle clinical findings of this condition and presents controversies related to surgical management of pediatric melanoma.
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15
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Kottschade LA, Grotz TE, Dronca RS, Salomao DR, Pulido JS, Wasif N, Jakub JW, Bagaria SP, Kumar R, Kaur JS, Morita SY, Moran SL, Nguyen JT, Nguyen EC, Hand JL, Erickson LA, Brewer JD, Baum CL, Miller RC, Swanson DL, Lowe V, Markovic SN. Rare presentations of primary melanoma and special populations: a systematic review. Am J Clin Oncol 2014; 37:635-41. [PMID: 23563206 PMCID: PMC4349521 DOI: 10.1097/coc.0b013e3182868e82] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A subset of patients with melanoma present in rare and unique clinical circumstances requiring specific considerations with respect to diagnostic and therapeutic interventions. Herein, we present our review of patients with: (1) primary mucosal melanoma of the head and neck, gastrointestinal, and genitourinary tracts; (2) primary melanoma of the eye; (3) desmoplastic melanoma; (4) subungual melanoma; (5) melanoma in special populations: children, nonwhites, as well as a discussion of familial melanoma.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Riten Kumar
- Department of Pediatric Hematology/Oncology-Hospital for Sick Children, Toronto
| | | | - Shane Y. Morita
- The Queen’s Medical Center/Queen’s Cancer Center-University of Hawaii/John A Burns School of Medicine
| | | | | | | | - Jennifer L. Hand
- Department of Dermatology-Mayo Clinic
- Department of Pediatrics-Mayo Clinic
- Department of Medical Genetics-Mayo Clinic
| | | | | | | | | | | | - Val Lowe
- Department of Radiology-Mayo Clinic
| | - Svetomir N. Markovic
- Department of Oncology- Mayo Clinic
- Department of Hematology-Mayo Clinic
- Department of Immunology-Mayo Clinic
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16
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Malkan AD, Sandoval JA. Controversial tumors in pediatric surgical oncology. Curr Probl Surg 2014; 51:478-520. [PMID: 25524425 DOI: 10.1067/j.cpsurg.2014.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 11/17/2014] [Indexed: 12/13/2022]
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McCormack CJ, Conyers RK, Scolyer RA, Kirkwood J, Speakman D, Wong N, Kelly JW, Henderson MA. Atypical Spitzoid neoplasms: a review of potential markers of biological behavior including sentinel node biopsy. Melanoma Res 2014; 24:437-47. [PMID: 24892957 DOI: 10.1097/cmr.0000000000000084] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atypical cutaneous melanocytic lesions, including those with Spitzoid features, can be difficult to categorize as benign or malignant. This can lead to suboptimal management, with potential adverse patient outcomes. Recent studies have enhanced knowledge of the molecular and genetic biology of these lesions and, combined with clinicopathological findings, is further defining their biological spectrum, classification, and behavior. Sentinel node biopsy provides important prognostic information in patients with cutaneous melanoma, but its role in the management of melanocytic lesions of uncertain malignant potential (MELTUMP) is controversial. This paper examines the role of molecular testing and sentinel node biopsy in MELTUMPs, particularly atypical Spitzoid tumors.
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Affiliation(s)
- Christopher J McCormack
- aPeter Macallum Cancer Institute, East Melbourne bVictorian Melanoma Service, Alfred Hospital, Prahran cDepartment of Paediatrics, Murdoch Children's Research Institute, Royal Children's Hospital, The University of Melbourne, Parkville dThe Royal Children's Hospital, Flemington Road, Parkville, Victoria eMelanoma Institute Australia , Royal Prince Alfred Hospital, The University of Sydney, Sydney, New South Wales, Australia fDepartment of Medicine, Melanoma and Skin Cancer Program, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, USA
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Lallas A, Kyrgidis A, Ferrara G, Kittler H, Apalla Z, Castagnetti F, Longo C, Moscarella E, Piana S, Zalaudek I, Argenziano G. Atypical Spitz tumours and sentinel lymph node biopsy: a systematic review. Lancet Oncol 2014; 15:e178-83. [PMID: 24694641 DOI: 10.1016/s1470-2045(13)70608-9] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Sentinel lymph node biopsy has been proposed as a diagnostic method for estimation of the malignant potential of atypical Spitz tumours. However, although cell deposits are commonly detected in the sentinel lymph nodes of patients with atypical Spitz tumours, their prognosis is substantially better than that of patients with melanoma and positive sentinel lymph node biopsies. We did a systematic review of published reports to assess the role of sentinel lymph node biopsy as a prognostic method in the management of atypical Spitz tumours. The results of our analysis did not show any prognostic benefit of sentinel lymph node biopsy; having a positive sentinel lymph node does not seem to predict a poorer outcome for patients with atypical Spitz tumours. These findings indicate that, especially in the paediatric population, it might be prudent initially to use complete excision with clear margins and careful clinical follow-up in patients with atypical Spitz tumours.
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Affiliation(s)
- Aimilios Lallas
- Skin Cancer Unit, Arcispedale Santa Maria Nuova Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Reggio Emilia, Italy
| | - Athanassios Kyrgidis
- Department of Otolaryngology Head and Neck Surgery, Medical School, Aristotle University, Thessaloniki, Greece
| | - Gerardo Ferrara
- Anatomic Pathology Unit, Department of Oncology, Gaetano Rummo General Hospital, Benevento, Italy
| | - Harald Kittler
- Department of Dermatology, Division of General Dermatology, Medical University of Vienna, Austria
| | - Zoe Apalla
- State Clinic of Dermatology, Hospital of Venereal and Skin Diseases, Thessaloniki, Greece
| | - Fabio Castagnetti
- Surgery Unit, Arcispedale Santa Maria Nuova Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Reggio Emilia, Italy
| | - Caterina Longo
- Skin Cancer Unit, Arcispedale Santa Maria Nuova Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Reggio Emilia, Italy
| | - Elvira Moscarella
- Skin Cancer Unit, Arcispedale Santa Maria Nuova Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Reggio Emilia, Italy
| | - Simonetta Piana
- Pathology Unit, Arcispedale Santa Maria Nuova Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Reggio Emilia, Italy
| | - Iris Zalaudek
- Skin Cancer Unit, Arcispedale Santa Maria Nuova Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Reggio Emilia, Italy; Department of Dermatology, Medical University, Graz, Austria
| | - Giuseppe Argenziano
- Skin Cancer Unit, Arcispedale Santa Maria Nuova Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Reggio Emilia, Italy.
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Reed D, Kudchadkar R, Zager JS, Sondak VK, Messina JL. Controversies in the evaluation and management of atypical melanocytic proliferations in children, adolescents, and young adults. J Natl Compr Canc Netw 2014; 11:679-86. [PMID: 23744867 DOI: 10.6004/jnccn.2013.0087] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The rising incidence of melanoma in children has brought increased attention to the clinical and pathologic diagnosis of pigmented lesions in the pediatric age group. Although melanoma in infancy and early childhood is often associated with large congenital nevi, in older children and teenagers it is most often sporadic, occurring in patients with a low skin phototype and substantial sun exposure. The rarity of this potentially fatal disorder demands astute clinical attention and a high index of suspicion for atypical lesions in pediatric patients. The challenges include the difficult decision of whether to biopsy and an often equivocal pathologic diagnosis. These diagnostically challenging and equivocal lesions lead to a degree of uncertainty regarding additional workup, prognosis, potential therapy, and follow-up plans. Consultation with a specialty dermatopathologist can be very helpful, and advanced molecular diagnostic techniques may be used in selected circumstances. Although still controversial, good evidence exists to justify a role for sentinel lymph node biopsy. Patients with atypical melanocytic proliferations have a high rate of positive sentinel lymph nodes; however, their outcomes are clearly better than in similarly staged adults with conventional melanoma. With the multiple variables involved and the relative lack of prospectively derived evidence, clinical decision-making is challenging and patients and families may experience considerable stress. This article provides data and weighs the pros and cons of a rationale for decision-making in pediatric and young adult patients with diagnostically challenging melanocytic lesions.
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Affiliation(s)
- Damon Reed
- Department of a Sarcoma Oncology, Moffitt Cancer Center, Tampa, Florida 33612, USA.
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Hinkle NM, Malkan AD, Sandoval JA. The Application and Indications for Sentinel Lymph Node Biopsy in Pediatric Solid Tumors: Current Status and Future Directions. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ijcm.2014.518145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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The surgical management of Spitz naevi and atypical spitzoid neoplasms: A review of the literature. Surgeon 2013; 11:205-9. [DOI: 10.1016/j.surge.2013.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Revised: 12/17/2012] [Accepted: 01/01/2013] [Indexed: 11/21/2022]
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Caracò C, Mozzillo N, Di Monta G, Botti G, Anniciello A, Marone U, Di Cecilia M, Staibano S, De Rosa G. Sentinel lymph node biopsy in atypical Spitz nevi: Is it useful? Eur J Surg Oncol 2012; 38:932-5. [DOI: 10.1016/j.ejso.2012.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 05/21/2012] [Accepted: 05/24/2012] [Indexed: 11/28/2022] Open
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Han D, Zager JS, Han G, Marzban SS, Puleo CA, Sarnaik AA, Reed D, Messina JL, Sondak VK. The unique clinical characteristics of melanoma diagnosed in children. Ann Surg Oncol 2012; 19:3888-95. [PMID: 22864798 DOI: 10.1245/s10434-012-2554-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Studies have demonstrated a higher rate of nodal metastases in melanoma of childhood, but there is controversy about the overall prognosis relative to adults. We describe a large single-institution experience with pediatric melanoma and assess prognostic characteristics. METHODS Retrospective review identified 126 patients diagnosed with melanoma at <21 years of age and referred for treatment from 1986 to 2011. Atypical lesions were excluded. Clinicopathologic characteristics were correlated with sentinel lymph node (SLN) status and outcomes. RESULTS SLN biopsy was positive in 18 of 62 cases (29 %). Increasing Breslow thickness correlated with a positive SLN (p < 0.05). After a median follow-up of 5 years, there were 27 recurrences and 20 deaths. Positive SLN patients had significantly worse recurrence-free survival (RFS, p < 0.05) and significantly worse melanoma-specific survival (MSS, p = 0.05) compared with negative SLN patients. The 5-year RFS and MSS for positive SLN patients were 59.5 and 77.8 %, compared with 93.7 and 96.8 % for negative SLN patients. Recurrences and melanoma-related deaths were often seen beyond 5 years. No deaths have occurred in patients <12 years, but 9.1 % of patients 12-17 years and 17.2 % of patients 18-20 years died from melanoma (p = 0.291). CONCLUSIONS Children with melanoma have higher rates of SLN metastases (29 %) than adults with comparable melanomas. Despite the higher incidence of nodal metastases, survival is equal to or better than what is reported for adults. However, long-term follow-up is necessary in this population since recurrences and deaths are often seen beyond 5 years.
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Affiliation(s)
- Dale Han
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
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Cerrato F, Wallins JS, Webb ML, McCarty ER, Schmidt BA, Labow BI. Outcomes in pediatric atypical spitz tumors treated without sentinel lymph node biopsy. Pediatr Dermatol 2012; 29:448-53. [PMID: 22211716 DOI: 10.1111/j.1525-1470.2011.01699.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The diagnosis of atypical Spitz tumor (AST) in a pediatric patient conveys an uncertain potential for malignancy. Although pediatric melanoma is rare, AST may be treated aggressively with sentinel lymph node biopsy (SLNB) and subsequent completion lymphadenectomy. These procedures have unclear therapeutic benefit and potential morbidity. We aimed to collect outcomes on children with AST treated with excision alone to assist in the management of these lesions. We queried our institution's pathology database for AST specimens submitted between 1994 and 2009. A dermatopathologist reviewed pathology slides to confirm AST diagnosis. Clinical information was obtained from medical records, and outcomes surveys were administered to children with AST. Twenty-nine patients met AST diagnostic criteria and were included in this study. Mean age at first excision was 9.0 ± 4.2 (range 2.3-17.5), and 19 patients underwent more than one excision procedure to achieve clear margins. No patient had SLNB. Fourteen patients (48%) with mean follow-up time of 8.4 years (range 3.5-15.8) completed clinical outcomes surveys. Outcomes with mean follow-up time of 2.8 years (range 0.02-8.1 years) were obtained for 10 additional patients from medical records. There were no reports of recurrence, additional lesions, or metastases in these 24 patients. We report one of the largest series of children with AST treated using excision alone and who remain disease free after a significant follow-up period. Our data suggest that SLNB is not warranted in the routine management of pediatric AST. We recommend complete excision with clear margins and careful clinical follow-up.
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Affiliation(s)
- Felecia Cerrato
- Department of Plastic and Oral Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115, USA
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Mills OL, Marzban S, Zager JS, Sondak VK, Messina JL. Sentinel node biopsy in atypical melanocytic neoplasms in childhood: a single institution experience in 24 patients. J Cutan Pathol 2012; 39:331-6. [PMID: 22335592 DOI: 10.1111/j.1600-0560.2011.01853.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Sentinel lymph node biopsy (SLNB) is a controversial but frequently used adjunct to wide excision of difficult-to-diagnose melanocytic proliferations of childhood. We herein report our institutional experience with SLNB in pediatric patients with these lesions, hereafter referred to as 'atypical melanocytic proliferations'. METHODS Our prospectively collected melanoma database was queried for patients ≤21 years of age status post-SLNB for a diagnosis of atypical melanocytic proliferation in which the diagnosis of melanoma ≥1 mm in depth was considered in the differential diagnosis by one or more expert dermatopathologists and for which no diagnostic consensus could be reached. RESULTS Of 24 patients identified over 17 years, 7 patients (29%) had a positive sentinel lymph node (SLN). Six SLN-positive patients underwent complete lymph node dissection, with one (14%) having additional nodal involvement identified. With a median follow-up of 4.1 years (range < 0.1 to 14.8 years), all patients showed no evidence of disease. CONCLUSIONS Despite a significant rate of identification of melanocytes in SLNs of children with atypical melanocytic proliferations, survival appears favorable and controversy surrounding the significance of nodal involvement remains. Further studies with larger numbers of patients and long-term follow-up are needed before the true prognostic value of SLNB in this setting can be determined.
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Affiliation(s)
- Omie L Mills
- Department of Pathology and Cell Biology, College of Medicine, University of South Florida, Tampa, FL 33612, USA
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26
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Hill SJ, Delman KA. Pediatric melanomas and the atypical spitzoid melanocytic neoplasms. Am J Surg 2012; 203:761-7. [DOI: 10.1016/j.amjsurg.2011.04.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 04/11/2011] [Accepted: 04/11/2011] [Indexed: 02/06/2023]
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Parida L, Morrisson GT, Shammas A, Hossain AKMM, McCarville MB, Gerstle JT, Charron M, Rao BN, Shulkin BL. Role of lymphoscintigraphy and sentinel lymph node biopsy in the management of pediatric melanoma and sarcoma. Pediatr Surg Int 2012; 28:571-8. [PMID: 22526545 PMCID: PMC3608674 DOI: 10.1007/s00383-012-3066-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2012] [Indexed: 02/05/2023]
Abstract
PURPOSE The purpose of this study was to describe the use of lymphoscintigraphy and sentinel lymph-node biopsy (SLNB) for the management of children with melanoma and sarcomas. We report the experience of two children's hospitals that utilize this technique to identify sentinel lymph nodes for lymph-node biopsy and dissection. METHODS We identified 56 patients (median age 10.8 years) who underwent 58 lymphoscintigraphy procedures. There were 33 patients with melanoma and melanocytic lesions, and 23 with sarcomas. RESULTS Of 58 lymphoscintigraphy procedures, sentinel lymph nodes were identified in 52 (90% success rate). Using the combination of intraoperative blue dye injection and lymphoscintigraphy, the success rate was 95% (55/58). Metastatic disease was found in 14 sentinel lymph nodes (13 patients with melanoma and melanocytic lesions, and 1 patient with rhabdomyosarcoma). CONCLUSION We have found that lymphoscintigraphy with SLNB is an effective method to identify patients who may benefit from more extensive lymph-node dissection and to identify those patients who are unlikely to benefit from further lymph-node exploration.
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Affiliation(s)
- Lalit Parida
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
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Abstract
Melanoma is rare in children and young adults. The incidence is rising yearly in this population. The clinical features of the disease in the pediatric population have been well documented through single-institution experiences and population-based analyses. Still, our understanding of the etiologic factors in the majority of children remains unclear, and diagnosis of melanoma remains challenging in certain cases. Because of its rarity, the staging, management and treatment of melanoma in this population is adopted from adult guidelines. In this review, we provide information on the epidemiology, clinical presentation, staging, prognosis and management of melanoma in children and young adults.
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Luo S, Sepehr A, Tsao H. Spitz nevi and other Spitzoid lesions part II. Natural history and management. J Am Acad Dermatol 2011; 65:1087-92. [PMID: 22082839 DOI: 10.1016/j.jaad.2011.06.045] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 06/23/2011] [Accepted: 06/26/2011] [Indexed: 02/04/2023]
Abstract
For dermatologists, evidence-based management guidelines for Spitz tumors have not been established. Despite the lack of a standardized approach, most dermatologists recommend the excision of Spitz tumors occurring in adults and adopt more conservative measures towards pediatric cases. The histopathologic attributes and the clinical scenario are factored into management in each case. While the metastatic behavior of certain Spitz tumors is well known, the malignant potential of these lesions remains unclear because they only rarely result in negative outcomes. The risks and benefits of adjunctive measures, such as sentinel lymph node biopsy and interferon use, remain untested and are subjects of ongoing controversy. (In part II of this continuing medical education article, we will continue to use the terminology defined in part I for purposes of continuity. "Spitz tumor" is used as the umbrella term for the entire category of lesions, "common Spitz nevi" refers to only the most typical lesions seen in pediatric cases, and "atypical Spitz tumors" encompass the "all other" category, which continues to cause debate.).
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Affiliation(s)
- Su Luo
- Wellman Center for Photomedicine and Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Mu E, Lange JR, Strouse JJ. Comparison of the use and results of sentinel lymph node biopsy in children and young adults with melanoma. Cancer 2011; 118:2700-7. [DOI: 10.1002/cncr.26578] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 08/19/2011] [Accepted: 09/02/2011] [Indexed: 12/27/2022]
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Atypical Spitzoid melanocytic tumors: a morphological, mutational, and FISH analysis. J Am Acad Dermatol 2011; 64:919-35. [PMID: 21496703 DOI: 10.1016/j.jaad.2010.05.043] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 04/26/2010] [Accepted: 05/13/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identification of the clinical behavior of atypical Spitzoid tumors with conflicting histopathologic features remains controversial. OBJECTIVE We sought to assess whether molecular findings may be helpful in the diagnostic and prognostic assessment of atypical Spitzoid tumors. METHODS A total of 38 controversial, atypical Spitzoid lesions (≥ 1 mm in thickness) were analyzed for clinicopathological features, chromosomal alterations by fluorescence in situ hybridization (FISH) analysis (RREB1/MYB/CCND1/CEP6), BRAF(V600E) mutation by allele-specific real-time polymerase chain reaction confirmed by sequencing, and H-RAS gene mutation by direct sequencing. RESULTS Atypical Spitzoid lesions developed in 21 female and 17 male patients (mean age 22 years). Nine patients underwent sentinel lymph node biopsy and a sentinel lymph node micrometastasis was detected in 4 of these 9 cases. Four additional patients, who did not receive a sentinel lymph node biopsy, experienced bulky lymph node metastases and one experienced visceral metastases and death. Lesions from patients with lymph node involvement showed more deep mitoses (P < .01), less inflammation (P = .05), and more plasma cells (P = .04). FISH analysis demonstrated the presence of chromosomal alterations in 6 of 25 cases. Correlation with follow-up data showed that the only case with fatal outcome showed multiple chromosomal alterations by FISH analysis. BRAF(V600E) mutation was detected in 12 of 16 cases (75%) and H-RAS mutation on exon 3 was found in 3 of 11 cases (27%). LIMITATIONS Our results require validation in a larger series with longer follow-up information. CONCLUSIONS FISH assay may be of help in the prognostic evaluation of atypical Spitzoid tumors. Diagnostic significance of BRAF(V600E) and H-RAS mutations in this setting remains unclear.
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Zedek DC, McCalmont TH. Spitz Nevi, Atypical Spitzoid Neoplasms, and Spitzoid Melanoma. Clin Lab Med 2011; 31:311-20. [DOI: 10.1016/j.cll.2011.03.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tom WL, Hsu JW, Eichenfield LF, Friedlander SF. Pediatric “STUMP” lesions: Evaluation and management of difficult atypical Spitzoid lesions in children. J Am Acad Dermatol 2011; 64:559-72. [DOI: 10.1016/j.jaad.2009.12.063] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 11/25/2009] [Accepted: 12/31/2009] [Indexed: 02/01/2023]
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Raval MV, Bilimoria KY, Bentrem DJ, Stewart AK, Ko CY, Reynolds M, Wayne JD. Use of sentinel lymph node biopsy for melanoma in children and adolescents. J Surg Oncol 2010; 102:634-9. [DOI: 10.1002/jso.21683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Increased detection of metastatic melanoma in pediatric sentinel lymph node biopsies using RT-PCR on paraffin-embedded tissue. Appl Immunohistochem Mol Morphol 2010; 18:365-70. [PMID: 20571343 DOI: 10.1097/pai.0b013e3181ce1e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sentinel lymph node (SLN) biopsy has become integral in the staging of patients with melanoma, and entails detailed histologic examination with immunohistochemistry. Reverse transcriptase-polymerase chain reaction (RT-PCR) for tyrosinase transcripts has been used to increase sensitivity but requires a dedicated piece of tissue that does not undergo histologic examination. We developed a nested RT-PCR assay for tyrosinase applicable on paraffin-embedded tissue and applied this to a series of SLNs from pediatric patients with melanoma. Thirty-six SLNs from 4 females and 4 males were included in the study. Eight lymph nodes with reactive changes were included as controls. SLNs were examined histologically and immunohistochemically for S100, tyrosinase, and MART1. Seven patients had between 1 and 4 morphologically-positive SLNs and one patient had negative SLNs (HISTO+; 12/36, 33%). Three lymph nodes were excluded from molecular analysis owing to inadequate RNA, and 29 of the remaining 33 nodes were positive (MOL+; 88%). All patients had at least 1 SLN positive by RT-PCR. Twelve were HISTO+/MOL+; 17 were HISTO-/MOL+; and 4 were HISTO-/MOL-. All control lymph nodes were negative for tyrosinase transcripts. The application of RT-PCR for tyrosinase to paraffin-embedded tissue significantly increased the number of positive SLNs and upstaged one patient from negative to positive. The prognostic implications of such findings require further investigation, especially in the pediatric age group. Nonetheless, this technique provides a useful tool to determine the clinical significance of RT-PCR positivity in melanoma SLNs.
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Berk DR, LaBuz E, Dadras SS, Johnson DL, Swetter SM. Melanoma and melanocytic tumors of uncertain malignant potential in children, adolescents and young adults--the Stanford experience 1995-2008. Pediatr Dermatol 2010; 27:244-54. [PMID: 20403119 DOI: 10.1111/j.1525-1470.2009.01078.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pediatric melanoma is difficult to study because of its rarity, possible biological differences in preadolescents compared with adolescents, and challenges of differentiating true melanoma from atypical spitzoid neoplasms. Indeterminant lesions are sometimes designated as melanocytic tumors of uncertain malignant potential (MelTUMPs). We performed a retrospective, single-institution review of melanomas, MelTUMPs and Spitz nevi with atypical features (SNAFs) in patients at 21 years of age and younger from 1995 to 2008. We identified 13 patients with melanoma, seven with MelTUMPs, and five with SNAFs. The median age for melanoma patients was 17 years, 10 for MelTUMPs, and six for SNAFs. Of the 13 melanoma patients, only four were younger than 15 years, while six were adolescents, and three were young adults. Nine melanoma patients (69%) were female. The most common histologic subtype was superficial spreading. The median depth for melanomas was 1.2 mm, and 3.4 mm for MelTUMPs. Microscopic regional nodal involvement detected on elective or sentinel lymph node (SLN) dissection was present in 2/10 (20%) of primary melanomas and 2/6 (33%) of Mel-TUMPs. Complete lymphadenectomy was performed on four melanoma patients, with three positive cases. Patient outcome through March 31, 2009 revealed no in-transit or visceral metastasis in patients with MelTUMPs or SNAFs. One SLN-positive patient (8%) with melanoma developed recurrent lymph node and liver metastasis and died 15 months after primary diagnosis. Our data highlight the rarity, female predominance, and significant rate of SLN positivity of pediatric melanoma. The high rate of MelTUMPs with regional nodal disease reinforces the need for close follow-up.
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Affiliation(s)
- David R Berk
- Department of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center, Stanford, California 94063, USA
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39
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Ghazi B, Carlson GW, Murray DR, Gow KW, Page A, Durham M, Kooby DA, Parker D, Rapkin L, Lawson DH, Delman KA. Utility of lymph node assessment for atypical spitzoid melanocytic neoplasms. Ann Surg Oncol 2010; 17:2471-5. [PMID: 20224858 DOI: 10.1245/s10434-010-1022-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Atypical spitzoid melanocytic neoplasms (ASMN) are cutaneous lesions of uncertain malignant potential, which can be difficult to distinguish from cutaneous melanoma. Sentinel lymph node (SLN) biopsy is a safe and useful prognostic tool for staging melanoma, but its role in staging ASMNs is not established nor is the significance of positive SLNs in these patients known. This study attempts to characterize the significance of nodal disease in ASMN. METHODS Patients with ASMNs who presented to the melanoma service from 1992 to 2007 were identified from a prospective database. Histological review was performed by two dermatopathologists. Demographic, treatment, and outcome data were reviewed. RESULTS A total of 58 patients with ASMNs were treated during the time analyzed; 31 (53%) underwent wide local excision and observation (WLE); 27 underwent wide excision and SLN biopsy. Median age was 24 (range, 6-60) years. Mean Breslow thickness was 2.9 (range, 0.5-10) mm. Median follow-up was 56 (range, 1-160) months. Ten of 58 (17%) patients had nodal metastasis. Four (13%) of 31 patients who underwent WLE developed nodal recurrences, and 6 of 27 (22%) patients had a positive SLN biopsy. Of patients with positive SLNs, none have recurred after undergoing completion lymphadenectomy. One patient presented with synchronous brain metastasis and inguinal lymphadenopathy and died of disease. CONCLUSIONS Nodal status does not seem to convey the same prognosis that it does in standard melanoma. There may be a limited ability for progression within the nodal basin in patients with these lesions. This subset of patients would benefit from genetic data complementing histologic analysis.
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Affiliation(s)
- Bahair Ghazi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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Magro CM, Crowson AN, Mihm MC, Gupta K, Walker MJ, Solomon G. The dermal-based borderline melanocytic tumor: A categorical approach. J Am Acad Dermatol 2010; 62:469-79. [DOI: 10.1016/j.jaad.2009.06.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 06/03/2009] [Accepted: 06/04/2009] [Indexed: 02/04/2023]
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Fleming MG. Pigmented lesion pathology: what you should expect from your pathologist, and what your pathologist should expect from you. Clin Plast Surg 2010; 37:1-20. [PMID: 19914454 DOI: 10.1016/j.cps.2009.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The first part of this review examines the reliability of histologic diagnosis in pigmented lesions, as measured by concordance studies and medicolegal analysis. It emphasizes the role of clinicians in maximizing that reliability, by providing adequate clinical descriptions, using appropriate biopsy technique, and critically interpreting pathology reports. It identifies those entities that are especially problematic, either because they cannot be reliably recognized by the histopathologist or because their histology is a poor guide to their biologic behavior. The second part of the review is a guide to some of the more difficult and controversial pigmented lesions, including dysplastic nevus, spitzoid nevi and melanomas, cellular blue nevus, animal-type melanoma, and deep penetrating nevus.
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Affiliation(s)
- Matthew G Fleming
- Department of Dermatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Abstract
The family practitioner, pediatrician, and dermatologist all have potential roles in the primary prevention, diagnosis, and treatment of localized thin melanomas. Surgical and medical oncologists are often involved when controversy arises over the nature of the skin lesion or whether sentinel lymph node (SLN) biopsies and adjuvant therapy are to be contemplated. This overview of melanoma will deal with the primary and nodal pathology, surgery, and medical therapy of melanoma in pediatric, adolescent, and young adult patients--and will raise areas of controversy that are only recently being addressed in databases of cases from this age group.
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Affiliation(s)
- John M Kirkwood
- Department of Medicine, University of Pittsburgh School of Medicine, and Melanoma and Skin Cancer Program, University of Pittsburgh Cancer Institute, Pittsburgh, PA 15213, USA.
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Abstract
Spitz nevi and melanoma represent benign and malignant counterparts commonly coupled in the same differential diagnosis. The precise distinction between the two entities remains an ongoing challenge in dermatopathology and surgical pathology. In past years, considerable work has been devoted to the assembly of criteria to permit exact diagnosis. Although diagnostic accuracy has improved, many lesions remain challenging to classify based solely upon conventional microscopic criteria. In this article, the clinical and histopathological attributes of Spitz nevi and spitzoid melanoma are reviewed. Lesions that cannot be definitively classified based solely upon conventional microscopic criteria are referred to as atypical spitzoid neoplasms, which the authors view as a provisional diagnostic category rather than as a formal disease entity. Molecular assessment by way of comparative genomic hybridization or fluorescence in situ hybridization is increasingly used to facilitate assessment of this challenging differential and is especially germane to the evaluation of ambiguous lesions.
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Affiliation(s)
- Daniel C Zedek
- University of California, San Francisco, Dermatopathology, 1701 Divisadero Street, Suite 350, San Francisco, CA 94115, USA
| | - Timothy H McCalmont
- University of California, San Francisco, Dermatopathology, 1701 Divisadero Street, Suite 350, San Francisco, CA 94115, USA.
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Howman-Giles R, Shaw HM, Scolyer RA, Murali R, Wilmott J, McCarthy SW, Uren RF, Thompson JF. Sentinel lymph node biopsy in pediatric and adolescent cutaneous melanoma patients. Ann Surg Oncol 2009; 17:138-43. [PMID: 19672660 DOI: 10.1245/s10434-009-0657-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 07/14/2009] [Accepted: 07/14/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rarity of melanoma in young patients, particularly pediatric ones, has to date precluded any valid comparisons being made between young patients and adults undergoing sentinel lymph node biopsy (SLNB) for intermediate thickness localized melanoma. The present study takes advantage of the large Sydney Melanoma Unit (SMU) database to clarify this issue. MATERIALS AND METHODS Clinical and pathologic data on pediatric and adolescent AJCC Stage I and II cutaneous melanoma patients aged <20 years undergoing SLNB at the SMU between January 1993 and February 2008 were reviewed. SLNB positivity rates and outcomes in these patients were compared with adult SMU patients. RESULTS In 55 young patients, overall median tumor thickness was 1.7 mm (range, 0.6-5.2 mm) and overall SLNB positivity rate was 14 of 55 (25%), tumors tending to be thicker (median, 2.6 mm), and SLNB positivity rate higher (2 of 6; 33%) in patients aged <10 years. Of the 14 patients, 13 underwent immediate completion lymph node dissection (CLND); 2 patients had non-SLN metastases (15.4%). Only 0.7% of a total of 295 lymph nodes removed at CLND were involved with melanoma. In 14 SLNB-positive patients with follow-up data, 3 (21%) have died from melanoma after a median follow-up of 60 months, compared with 42% of 356 SLNB positive adults. CONCLUSIONS Although the SLNB positivity rate was higher in pediatric and adolescent melanoma patients than in adults (25% vs. 17%, respectively), non-SLN positivity and melanoma-specific death rates were low.
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Affiliation(s)
- Robert Howman-Giles
- Sydney Melanoma Unit and Melanoma Institute Australia, Royal Prince Alfred and Mater Hospitals, Sydney, NSW, Australia.
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Abstract
Background Malignant mela-noma is a rare neoplasm in the pediatric population, but its incidence has risen in recent years. Methods The literature was reviewed to define the current clinical and pathologic features of pediatric melanoma, highlighting the similarities and differences between adult and pediatric melanoma. Results Distinctive features of this disease, including frequency and type of genetic abnormalities, predisposing conditions, clinical presentation, stage at diagnosis, prognostic features, and frequency of sentinel lymph node positivity are emphasized. Treatment strategies, extrapolated from adult mela-noma trials, are also discussed. Conclusions Despite the differences between pediatric and adult melanoma, survival rates are similar and are improving in both populations. Further studies will help delineate the pathogenesis of both adult and pediatric melanoma, with the goal of contributing to early detection and improved survival.
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Affiliation(s)
- Omie Mills
- University of South Florida College of Medicine, Department of Pathology and Cell Biology, and the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Jane L. Messina
- University of South Florida College of Medicine, Department of Pathology and Cell Biology, and the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Urso C, Borgognoni L, Doria M, Tinacci G, Zini E. Non-sentinel lymph node involvement in a patient with an atypical Spitz tumor and a positive sentinel node. Report of a case and review of the literature. J Cutan Pathol 2009; 36:586-90. [DOI: 10.1111/j.1600-0560.2008.01080.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Ludgate MW, Fullen DR, Lee J, Lowe L, Bradford C, Geiger J, Schwartz J, Johnson TM. The atypical Spitz tumor of uncertain biologic potential: a series of 67 patients from a single institution. Cancer 2009; 115:631-41. [PMID: 19123453 DOI: 10.1002/cncr.24047] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Atypical Spitz tumors (AST) are rare spitzoid melanocytic proliferations with an uncertain malignant potential. ASTs have overlapping features of both Spitz nevi and spitzoid melanoma, and consequently generate controversy with diagnosis and management. Sentinel lymph node biopsy (SLNB) has been proposed as a possible means to gain additional insight into the true biologic potential of these tumors; however, previous reports on the use of SLNB in ASTs have been limited by small numbers of patients and short durations of follow-up. METHODS The authors extracted data from their institution's prospective melanoma database, collected between 1994 and 2007, for all patients with ASTs of uncertain biologic potential. They reviewed the clinical features of these patients, including the sentinel lymph node status, and the histological features of the tumors. RESULTS A total of 67 patients with ASTs were identified, with a median age of 23.7 years. The mean depth was 2.4 mm. Of these, 57 had a SLNB performed, with 27 (47%) having a positive sentinel lymph node. SLNB-positive cases had a significantly lower mean age than SLNB-negative cases (17.9 vs 28.7 years; P = .013); however, no other significant differences were observed. All 27 patients with a positive SLNB were alive and disease free with median follow-up of 43.8 months. One patient who did not receive a SLNB developed recurrent disease with regional and distant metastases. CONCLUSIONS ASTs do not appear to behave like conventional melanoma. There is a high incidence of microscopic lymph node deposits in SLNBs, but despite this finding, patients have a favorable prognosis. Our findings raise several questions regarding the malignant potential of ASTs, and the role of SLNB in their management.
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Affiliation(s)
- Mathew W Ludgate
- Department of Dermatology, University of Michigan Medical School and Comprehensive Cancer Center, Ann Arbor, Michigan 48109, USA.
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Gow KW, Rapkin LB, Olson TA, Durham MM, Wyly B, Shehata BM. Sentinel lymph node biopsy in the pediatric population. J Pediatr Surg 2008; 43:2193-8. [PMID: 19040933 DOI: 10.1016/j.jpedsurg.2008.08.063] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 08/29/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) has only been recently used for childhood neoplasms. METHODS We reviewed all patients younger than 19 years who underwent SLNB for 5 years. RESULTS Twenty patients were identified (11 male, 9 female). Sentinel lymph node biopsy was performed for 10 sarcomas (5 synovial, 3 rhabdomyosarcoma, 1 epitheliod, 1 other); 9 skin neoplasms (4 melanomas, 3 Spitz nevi, 2 melanocytomas); and 1 acinic cell carcinoma. All patients underwent Technetium 99m sulfur microcolloid injection and 4-quadrant subdermal injection with Lymphazurin 1% (Autosuture, Norwalk, Conn). Six patients required either sedation for lymphoscintigraphy. Intraoperative gamma probe was used. Primary lesions were found in lower extremity (n = 8), upper extremity (n = 6), trunk (n = 3), and head and neck (n = 3). The lymphatic basins were inguinal (n = 8), axilla (n = 8), neck (n = 3), and both inguinal and axilla (n = 1). At least one lymph node was identified in each procedure. Of 20 patients, 5 (25%) had metastatic disease (4 skin neoplasms and 1 sarcoma). There were no complications in our series, and all patients are alive with no recurrence at an average follow-up of 2.2 years. CONCLUSIONS Sentinel lymph node biopsy allows for an accurate biopsy in children. However, some younger patients may require sedation, and it may be more challenging to isolate the sentinel node.
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Affiliation(s)
- Kenneth W Gow
- Division of Pediatric Surgery, Department of Surgery, Emory School of Medicine, Atlanta, GA, USA.
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