Current issues

On the nature of histologic observations: The case of the Spitz nevus

The extent of variability in treatment suggestions for melanocytic lesions made by pathologists is unknown.

We investigated how often pathologists rendered suggestions, reasons for providing suggestions, and concordance with national guidelines.

We conducted a cross-sectional survey of pathologists. Data included physician characteristics, experience, and treatment recommendation practices.

Of 301 pathologists, 207 (69%) from 10 states (California, Connecticut, Hawaii, Iowa, Kentucky, Louisiana, New Jersey, New Mexico, Utah, and Washington) enrolled. In all, 15% and 7% reported never and always including suggestions, respectively. Reasons for offering suggestions included improved care (79%), clarification (68%), and legal liability (39%). Reasons for not offering suggestions included referring physician preference (48%), lack of clinical information (44%), and expertise (29%). Training and caseload were associated with offering suggestions (P < .05). Physician suggestions were most consistent for mild/moderate dysplastic nevi and melanoma. For melanoma in situ, 18 (9%) and 32 (15%) pathologists made suggestions that undertreated or overtreated lesions based on National Comprehensive Cancer Network (NCCN) guidelines, respectively. For invasive melanoma, 14 (7%) pathologists made treatment suggestions that undertreated lesions based on NCCN guidelines.

Treatment suggestions were self-reported.

Pathologists made recommendations ranging in consistency. These findings may inform efforts to reduce treatment variability and optimize patterns of care delivery for patients.

In the last 10 years, few efforts have been carried out to apply vibrational spectroscopy in the study of dermal pathologies in order to characterize the most relevant spectral markers for distinguishing benign from cancerous lesions.

Spitz nevi are a special group of benign melanocytic lesions, characterized by spindled and/or epithelioid nevomelanocytes, with peculiar clinical, dermoscopic and histopathological features. The “atypical forms” of Spitz nevi are among the commonest problems of differential diagnosis with the so-called “spitzoid melanomas”. The clinical and histological criteria for discriminating these two entities are very subtle and often still quite subjective, and, in a significant percentage of cases, can lead to diagnostic pitfalls and inadequate therapies. Therefore, it is noteworthy to outline that the diagnosis of melanocytic lesions still represents a challenging problem and a continue matter of discussion.

We exploited FTIR microspectroscopy to study the different kinds of spitzoid melanocytes, in order to define the most relevant spectral markers of each specimen and to achieve objective information on “borderline” histologically atypical lesions. In particular, the spectroscopic investigation was carried out on melanocytes deriving from normal skin (as a normal control), malignant melanoma and Spitz nevi. The presence of the characteristic bands of melanin was investigated, too.

Dermoscopy improves the recognition of melanoma and Spitz nevus but occasionally melanoma may exhibit a symmetric pattern mimicking Spitz nevus.

We sought to investigate the likelihood of finding melanoma when excising a symmetric Spitzoid-looking lesion in patients aged 12 years or older.

This study included patients aged 12 years or older with symmetric, Spitzoid-looking lesions that were diagnosed histopathologically as Spitz nevus or melanoma. Demographic, clinical, and dermoscopic variables were included in the analysis. We used χ² for nonparametric comparisons. Crude odds ratios and 95% confidence intervals were calculated by univariate logistic regression.

Of 384 included lesions, 333 (86.7%) were histopathologically diagnosed as Spitz nevus and 51 (13.3%) as melanoma. The risk of melanoma significantly increased with increasing age, being 50% or higher after the age of 50 years.

Limitations are retrospective design, exclusion of patients younger than 12 years, lack of detailed histopathologic data, and limited sample size.

Our results confirm the observation that melanoma may be dermoscopically indistinguishable from Spitz nevi, strongly suggesting that the only safe strategy not to miss melanoma is to excise all Spitzoid-looking lesions in patients aged 12 years or older.

The histologic diagnosis of melanoma and nevi can be subject to discordance and errors, potentially leading to inappropriate treatment and harm. Diagnostic terminology is not standardized, creating confusion for providers and patients and challenges for investigators.

We sought to describe the development of a pathology reporting form for more precise research on melanoma and a diagnostic-treatment mapping tool for improved patient care and consistency in treatment.

Three dermatopathologists independently reviewed melanocytic lesions randomly selected from a dermatopathology database. Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) reporting schema evolved from iterative case review and form revision.

Differences in diagnostic thresholds, interpretation, and nomenclature contributed to development of the MPATH-Dx histology reporting form, which groups lesions by similarities in histogenesis and degrees of atypia. Because preliminary results indicate greater agreement regarding suggested treatments than for specific diagnoses, the diverse terminologies of the MPATH-Dx histology reporting form were stratified by commonalities of treatments in the MPATH-Dx diagnostic-treatment mapping scheme.

Without transformative advances in diagnostic paradigms, the interpretation of melanocytic lesions frequently remains subjective.

The MPATH-Dx diagnostic-treatment mapping scheme could diminish confusion for those receiving reports by categorizing diverse nomenclature into a hierarchy stratified by suggested management interventions.

Spitz nevi are melanocytic proliferations that are characterized by spindled and/or epithelioid nevomelanocytes. First interpreted as juvenile melanoma, these lesions were later characterized as benign and were observed to affect all age groups. Today, contrasting opinions persist regarding the fundamental benignancy versus malignancy within the spectrum of Spitz tumors. Beyond clinical outcome, this controversy has also been fueled by complex and sometimes convoluted classification schemes based on pathologic characteristics. More recently, immunophenotypic and molecular analyses have begun to clarify the etiologic nature of these tumors. Recent evidence suggests that histopathologic features that suggest more aggressiveness in Spitz tumors relate to mitoses and inflammation.