Difference between revisions of "Melanocytic lesions"

Jump to navigation Jump to search

Melanocytic lesions (view source)

Revision as of 18:47, 11 February 2021

11,615 bytes removed ,  18:47, 11 February 2021
→‎Desmoplastic melanocytic nevus: +nodal nevus
 
(77 intermediate revisions by the same user not shown)
Line 1: Line 1:
[[Image:Blue nevus - intermed mag.jpg|thumb|right|A melanocytic lesion ([[blue nevus]]). [[H&E stain]]. (WC/Nephron)]]
'''Melanocytic lesions''' are commonly encountered in [[dermatopathology]] and an area which causes some difficulty, i.e. it is hard to decide in some cases whether a lesion is benign (e.g. [[Spitz nevus]]) or malignant ([[malignant melanoma]]).
'''Melanocytic lesions''' are commonly encountered in [[dermatopathology]] and an area which causes some difficulty, i.e. it is hard to decide in some cases whether a lesion is benign (e.g. [[Spitz nevus]]) or malignant ([[malignant melanoma]]).


==Overview==
=Overview=
===Identifying melanocytes===
===Identifying melanocytes===
*Clear ''or'' pigmented cytoplasm.
*Clear ''or'' pigmented cytoplasm.
Line 108: Line 109:
*"Maturation" in the context of melanocytic lesions ''means'' (1) the cells get smaller with depth, (2) cells are less mitotic with depth.
*"Maturation" in the context of melanocytic lesions ''means'' (1) the cells get smaller with depth, (2) cells are less mitotic with depth.


=Lentiginous melanocytic lesions=
==Lentigo simplex==
==Lentigo simplex==
*[[AKA]] ''simple lentigo''.<ref>URL: [http://www.dermnetnz.org/lesions/lentigo-simplex.html http://www.dermnetnz.org/lesions/lentigo-simplex.html]. Accessed on: 27 March 2013.</ref>
{{Main|Lentigo simplex}}
 
==Solar lentigo==
*Plural ''solar lentigines''.
===General===
===General===
*Benign.
*Benign.
*Usually <40 years old.


Fits into the larger category of ''lentiginous melanocytic proliferations'' - these include:<ref name=Ref_Derm438>{{Ref Derm|438}}</ref>
Fits into the larger category of ''lentiginous melanocytic proliferations'' - these include:<ref name=Ref_Derm438>{{Ref Derm|438}}</ref>
*[[Solar lentigo]].
*Solar lentigo.
*Lentigo simplex.
*[[Lentigo simplex]].
*[[Lentiginous nevus]].
*Lentiginous nevus.
*Lentiginous [[melanoma in situ]].
*Lentiginous [[melanoma in situ]].


Associated syndromes:<ref name=dermamin_ls>URL: [http://dermaamin.com/site/histopathology-of-the-skin/64-l/1852-lentigo-simplex-.html http://dermaamin.com/site/histopathology-of-the-skin/64-l/1852-lentigo-simplex-.html]. Accessed on: 17 December 2012.</ref>
===Gross===
*[[Peutz-Jeghers syndrome]].
Features:<ref name=Ref_Derm438>{{Ref Derm|438}}</ref>
*[[LEOPARD syndrome]].
*Small (< 4 mm), irregular brown [[macule]].
*[[LAMB syndrome]].
*Usu. sun-exposed area.


===Gross===
DDx (clinical):
*Small flat pigmented lesion.<ref name=Ref_WMSP498>{{Ref WMSP|498}}</ref>
*[[Lentigo maligna]] - melanoma in situ on sun damaged skin.
*[[Seborrheic keratosis]], flat.<ref name=dermammin_sl>URL: [http://www.dermaamin.com/site/histopathology-of-the-skin/53-a/1555-actinic-lentigo-.html http://www.dermaamin.com/site/histopathology-of-the-skin/53-a/1555-actinic-lentigo-.html]. Accessed on: 6 May 2013.</ref>


===Microscopic===
===Microscopic===
Features:<ref name=Ref_WMSP498>{{Ref WMSP|498}}</ref>
Features:<ref name=Ref_Derm437>{{Ref Derm|437}}</ref>
*Melanocytes in epidermis only.
*Hyperpigmented melanocytes - may be present in increased quantities - '''key feature'''.
*No melanocytic nests.
**Classically at the tips of the rete ridges.
*No (melanocyte) nuclear atypia.
*Solar damage ([[solar elastosis]]).<ref name=pmid19536147>{{Cite journal  | last1 = Hafner | first1 = C. | last2 = Stoehr | first2 = R. | last3 = van Oers | first3 = JM. | last4 = Zwarthoff | first4 = EC. | last5 = Hofstaedter | first5 = F. | last6 = Klein | first6 = C. | last7 = Landthaler | first7 = M. | last8 = Hartmann | first8 = A. | last9 = Vogt | first9 = T. | title = The absence of BRAF, FGFR3, and PIK3CA mutations differentiates lentigo simplex from melanocytic nevus and solar lentigo. | journal = J Invest Dermatol | volume = 129 | issue = 11 | pages = 2730-5 | month = Nov | year = 2009 | doi = 10.1038/jid.2009.146 | PMID = 19536147 }}</ref>
 
Notes:
*Should ''not'' be present:<ref name=Ref_Derm438>{{Ref Derm|438}}</ref>
**Nests of melanocytes.
**Pagetoid spread of melanocytes.
 
DDx:<ref name=Ref_Derm437>{{Ref Derm|437}}</ref>
*Pigmented [[actinic keratosis]].
*[[Lichen planus-like keratosis]].
*Pigmented [[seborrheic keratosis]].
*[[Ephelis]] (freckle).
 
====Images====
<gallery>
Image:Skin_tumors_181.jpg | Solar lentigo. (WC)
</gallery>
*[http://www.dermaamin.com/site/images/histo-pic/a/actinic-lentigo/actinic-lentigo1.jpg Solar lentigo (dermammin.com)].<ref name=dermammin_sl>URL: [http://www.dermaamin.com/site/histopathology-of-the-skin/53-a/1555-actinic-lentigo-.html http://www.dermaamin.com/site/histopathology-of-the-skin/53-a/1555-actinic-lentigo-.html]. Accessed on: 6 May 2013.</ref>


DDx:<ref name=humpath_ls/>
===Sign out===
*[[Solar lentigo]] - in sun exposed areas.
<pre>
*Ephelis (freckle) - change with UV light exposure.
FOREARM LESION, RIGHT, PUNCH BIOPSY:
*Melanotic macule.
- SOLAR LENTIGO.
*Lentiginous nevus.
</pre>


Images:
====Micro====
*[http://dermaamin.com/site/histopathology-of-the-skin/64-l/1852-lentigo-simplex-.html Lentigo simplex - several images (dermamin.com)].<ref name=dermamin_ls/>
The sections show hair-bearing skin with basilar pigmentation at the tips of the rete ridges and solar elastosis. No melanocytic nests are identified. The epidermal cells mature to the surface. No significant inflammation is present.
*[http://www.humpath.com/IMG/jpg/lentigo_simplex_20x.jpg Lentigo simplex (humpath.com)].<ref name=humpath_ls>URL: [http://www.humpath.com/?lentigo-simplex http://www.humpath.com/?lentigo-simplex]. Accessed on: 17 December 2012.</ref>


==Lentiginous melanocytic nevus==
==Lentiginous melanocytic nevus==
Line 164: Line 187:


DDx:
DDx:
*[[Dysplastic nevus]] - specifically ''lentiginous dysplastic naevus of the elderly''.<ref name=pmid10911797>{{Cite journal  | last1 = Edwards | first1 = SL. | last2 = Blessing | first2 = K. | title = Problematic pigmented lesions: approach to diagnosis. | journal = J Clin Pathol | volume = 53 | issue = 6 | pages = 409-18 | month = Jun | year = 2000 | doi =  | PMID = 10911797 }}</ref>
*[[Atypical lentiginous nevus]].
*[[Dysplastic nevus]].
*[[Melanoma in situ]] - especially if [[solar elastosis]] is present.
*[[Melanoma in situ]] - especially if [[solar elastosis]] is present.


Images:
====Images====
www:
*[http://www.derm101.com/Popups/FigurePopup.aspx?id=dp0101a06f005&aid=740564&filename=dp0101a06g005b Lentiginous nevus (derm101.com)].
*[http://www.derm101.com/Popups/FigurePopup.aspx?id=dp0101a06f005&aid=740564&filename=dp0101a06g005b Lentiginous nevus (derm101.com)].
*[http://commons.wikimedia.org/wiki/File:Skin_Tumors-171.jpg Lentiginous nevus (WC)].


===Sign out===
<pre>
SKIN LESION, BACK, SHAVE EXCISION:
- JUNCTIONAL LENTIGINOUS NEVUS.
-- COMPLETELY EXCISED (LATERAL CLEARANCE 1 MM).
</pre>
====Micro====
The sections show skin with non-nested melanocytes in the epidermis. The melanocytes have no significant cytologic atypia. There is no upward scatter of melanocytes. The lesion is completely excised the in plane of section.
=Nested melanocytic lesions=
==Common melanocytic nevus==
==Common melanocytic nevus==
*[[AKA]] ''common nevus''.
*[[AKA]] ''common nevus''.
*In common language: ''mole''.
===General===
===General===
*Benign.
*Benign.
*Common.
*Common.
*In common language: ''mole''.
*Think ''[[melanoma]]''.
*Think ''melanoma''.
 
Clinical:  
Clinical:  
*''ABCD'' = asymmetric, borders (irregular), colour (black), diameter (large).
*''ABCD'' = asymmetric, borders (irregular), colour (black), diameter (large).
Line 197: Line 231:
====Subtypes====
====Subtypes====
=====Compound melanocytic nevus=====
=====Compound melanocytic nevus=====
*Abbreviated ''CMN''.
*Abbreviated ''CMN'' and ''CN''.


*In the dermis '''and''' epidermis - '''key feature'''.
*In the dermis '''and''' epidermis - '''key feature'''.


=====Junctional melanocytic nevus=====
=====Junctional melanocytic nevus=====
*Abbreviated ''JN''.
*In the epidermis - '''key feature'''.
*In the epidermis - '''key feature'''.


Line 208: Line 244:
*[[AKA]] ''intradermal melanocytic nevus''.
*[[AKA]] ''intradermal melanocytic nevus''.
*[[AKA]] ''intradermal nevus'', abbreviated ''IDN''.<ref name=pmid11493376>{{Cite journal  | last1 = Fullen | first1 = DR. | last2 = Reed | first2 = JA. | last3 = Finnerty | first3 = B. | last4 = McNutt | first4 = NS. | title = S100A6 preferentially labels type C nevus cells and nevic corpuscles: additional support for Schwannian differentiation of intradermal nevi. | journal = J Cutan Pathol | volume = 28 | issue = 8 | pages = 393-9 | month = Sep | year = 2001 | doi =  | PMID = 11493376 }}</ref>
*[[AKA]] ''intradermal nevus'', abbreviated ''IDN''.<ref name=pmid11493376>{{Cite journal  | last1 = Fullen | first1 = DR. | last2 = Reed | first2 = JA. | last3 = Finnerty | first3 = B. | last4 = McNutt | first4 = NS. | title = S100A6 preferentially labels type C nevus cells and nevic corpuscles: additional support for Schwannian differentiation of intradermal nevi. | journal = J Cutan Pathol | volume = 28 | issue = 8 | pages = 393-9 | month = Sep | year = 2001 | doi =  | PMID = 11493376 }}</ref>
{{Main|Intradermal nevus}}


*Only in the dermis - '''key feature'''.
===Sign out===


Note:
====Junctional melanocytic nevus====
*In the oral cavity these are known as ''[[intramucosal melanocytic nevus|intramucosal nevi]]''.
 
===Sign out===
====Compound melanocytic nevus====
<pre>
<pre>
SKIN LESION, RIGHT NECK, SHAVE BIOPSY:
SKIN LESION, RIGHT LATERAL UPPER ARM, BIOPSY:
- BENIGN COMPOUND MELANOCYTIC NEVUS.
- BENIGN JUNCTIONAL NEVUS.
</pre>
</pre>


=====Micro=====
=====Micro=====
The sections show melanocytes in the dermis and epidermis. The lesion is symmetrical in its architecture and pigment distribution. There is no pagetoid spread of melanocytes in the epidermis.
The sections show melanocytes in nest confined to the epidermis. The lesion is symmetrical in its architecture and pigment distribution. There is no pagetoid spread of melanocytes in the epidermis. No significant nuclear atypia is identified. No mitotic activity is appreciated.  
Superficially, melanocytes are in nests. Melanocytes mature with depth. No mitotic activity is appreciated.  


The lesion is completely excised in the plane of section.
The lesion is completely excised in the plane of section.


======Barely compound======
====Compound melanocytic nevus====
The sections show melanocytes predominantly in the dermis. Rare melanocytic nests are seen at the dermal-epidermal junction. There is no pagetoid spread of melanocytes in the epidermis. The lesion is symmetrical in its architecture. Superficially, melanocytes are in nests and pigment is present.  The melanocytes mature with depth. No mitotic activity is appreciated.
{{Main|Compound nevus}}
 
The lesion is present at the margin.


====Intradermal melanocytic nevus====
====Intradermal melanocytic nevus====
<pre>
{{Main|Intradermal nevus}}
SKIN LESION, BACK, PUNCH BIOPSY:
- BENIGN INTRADERMAL MELANOCYTIC NEVUS.
</pre>
 
=====Micro=====
The sections show melanocytes in the dermis separated from the epidermis by a Grenz zone.  The lesion is symmetrical in its architecture and pigment distribution.  Superficially, melanocytes are in nests.  Melanocytes mature with depth. No mitotic activity is appreciated.
 
The lesion is completely excised in the plane of section.


==Congenital-pattern nevus==
==Congenital-pattern nevus==
Line 293: Line 315:
DDx:<ref name=Ref_Derm465>{{Ref Derm|465}}</ref>
DDx:<ref name=Ref_Derm465>{{Ref Derm|465}}</ref>
*[[Melanoma in situ]] - classically spread beyond the scar, unlike pseudomelanoma - growth confined to epidermis.
*[[Melanoma in situ]] - classically spread beyond the scar, unlike pseudomelanoma - growth confined to epidermis.
*[[Sclerosing nevus]].


===IHC===
===IHC===
Line 321: Line 344:
==Pigmented spindle cell nevus==
==Pigmented spindle cell nevus==
*[[AKA]] ''pigmented spindle cell nevus of Reed''.
*[[AKA]] ''pigmented spindle cell nevus of Reed''.
{{Main|Pigmented spindle cell nevus}}


===General===
==Spitz nevus==
*Uncommon.
*[[AKA]] ''epithelioid and spindle cell nevus''.
*Women in teens & 20s.
{{Main|Spitz nevus}}
*Location: shoulder, pelvic girdle region.


===Microscopic===
==Acral nevus==
Features:<ref name=Ref_WMSP500>{{Ref WMSP|500}}</ref>
*[[AKA]] ''melanocytic nevus with intraepidermal ascent of cells'' ([[MANIAC]]).
*Nests of heavily pigmented spindle cells at dermal-epidermal junction - '''key feature'''.
*[[AKA]] ''volar nevus''.
**Nevoid cells in epidermis & dermis - form "basket weave" pattern
{{Main|Acral nevus}}
*Well-circumscribed lesion.


Notes:
==Dysplastic melanocytic nevus==
*No epithelioid nevus cells.
*[[AKA]] ''dysplastic nevus''.
*[[AKA]] ''Clark nevus''.
*[[AKA]] ''nevus with architectural disorder''.
**This term is recommended by the American NIH; however, it is not widely adopted.<ref name=pmid22703907>{{Cite journal  | last1 = Elston | first1 = D. | title = Practical advice regarding problematic pigmented lesions. | journal = J Am Acad Dermatol | volume = 67 | issue = 1 | pages = 148-55 | month = Jul | year = 2012 | doi = 10.1016/j.jaad.2012.04.006 | PMID = 22703907 }}</ref>
{{Main|Dysplastic nevus}}


DDx:
==Desmoplastic melanocytic nevus==
*[[Spitz nevus]].
*[[AKA]] ''sclerosing melanocytic nevus''.
*[[Malignant melanoma]].
 
Images:
*WC:
**[http://commons.wikimedia.org/wiki/File:Pigmented_spindle_cell_nevus_-_low_mag.jpg PSCN - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Pigmented_spindle_cell_nevus_-_2_-_intermed_mag.jpg PSCN - intermed. mag. (WC)].
*www:
**[http://www.histopathology-india.net/Reed.htm Reed nevus - collection (histopathology-india.net)].
 
==Spitz nevus==
*AKA ''epithelioid and spindle-cell nevus''.


===General===
===General===
*May be very difficult to differentiate from [[melanoma]].
*Benign.


Epidemiology:
===Gross===
*Children & adolescents.
*Usu. "small" and symmetric.


Treatment:
Clinical DDx:
*Complete excision.<ref name=pmid12140468>{{Cite journal  | last1 = Gelbard | first1 = SN. | last2 = Tripp | first2 = JM. | last3 = Marghoob | first3 = AA. | last4 = Kopf | first4 = AW. | last5 = Koenig | first5 = KL. | last6 = Kim | first6 = JY. | last7 = Bart | first7 = RS. | title = Management of Spitz nevi: a survey of dermatologists in the United States. | journal = J Am Acad Dermatol | volume = 47 | issue = 2 | pages = 224-30 | month = Aug | year = 2002 | doi =  | PMID = 12140468 }}</ref>
*[[Dermatofibroma]].
 
*[[Dermal scar]].
===Gross===
*Usually face ''or'' extremity.<ref name=Ref_Derm449>{{Ref Derm|449}}</ref>


===Microscopic===
===Microscopic===
Features:<ref name=Ref_WMSP499>{{Ref WMSP|499}}</ref>
Features:<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
*Architecture:
*[[Compound nevus]] ''or'' [[intradermal nevus]] with prominent dermal fibrosis.
**Nests of cells (spindle, epithelioid or spindle/epithelioid) - in both dermis and epidermis.
**Fibrosis: extra pink - versus surrounding.
***Nests are vertically arranged, i.e. the long axis of the nests are perpendicular to the skin surface.
****Nest arrangement/orientation described as "cluster of bananas".
*+/-Hyperkeratosis (more keratin, i.e. thick stratum corneum).
*+/-Hypergranulosis (thick stratum granulosum).
*+/-Acanthosis (thick stratum spinosum).
*Kamino bodies (also written ''Camino bodies'') - dense eosinophilic bodies.<ref name=PMC2797485>{{Cite journal  | last1 = Kirkwood | first1 = John M. | last2 = Jukic | first2 = Drazen | last3 = Averbook | first3 = Bruce J. | last4 = Sender | first4 = Leonard S. | title = Melanoma in Pediatric, Adolescent, and Young Adult Patients | journal = Semin Oncol. | volume = 36 | issue = 5 | pages = 419-31 | month = October | year = 2009 | doi =  | PMID =  | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797485/?tool=pmcentrez |PMC = 2797485 }}</ref>
**Apoptotic cells.
**Kamino bodies are rare in melanoma.


Notes:
DDx:
*'''Never''' in the setting of [[solar elastosis]].<ref>Jakubovic, H. 16 July 2010.</ref>
*[[Desmoplastic neurotropic malignant melanoma]] - usually mitotic figures, nuclear atypia (enlarged, hyperchromatic).
**If there is solar elastosis -- it's melanoma.
*[[Dermatofibroma]].
*[[Dermal scar]] - no adnexal structures.


DDx:
===IHC===
*[[Malignant melanoma]].
Features:<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
*[[Pigmented spindle cell nevus of Reed]].
*Melan A (MART-1) +ve.
**Usually -ve in desmoplastic melanoma.<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
*S-100 +ve.
**Should stain approximally the same number of cells as Melan A.
*Ki-67 -- only rare cells.


Images:
==Nodal nevus==
*www:
*AKA ''nevus in lymph node'' and ''benign nevus cells in lymph node''.
**[http://www.drmihm.com/cases/case.cfm?CaseID=51 Spitz nevus - collection of images (drmihm.com)].
{{Main|Nodal nevus}}
**[http://alf3.urz.unibas.ch/pathopic/e/getpic-fra.cfm?id=006734 Spitz nevus with arrow to camino body (unibas.ch)].
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Spitz_nevus_-_intermed_mag.jpg Spitz nevus - intermed. mag. (WC)].


=Miscellaneous=
==Blue nevus==
==Blue nevus==
:'''''Common blue nevus''' redirects here''.
:'''''Common blue nevus''' redirects here''.
Line 414: Line 422:


DDx:
DDx:
*[[Malignant melanoma]] - often lacks a Grenz zone (lesion in papillary dermis),<ref name=pmid16446716/> mitotic figures, [[necrosis]], cytologic atypia, asymmetry (architecture, pigment).
*Atypical blue nevus - have some of the features of melanoma.
*[[Clear cell sarcoma]].
*[[Dermatofibroma]] - esp. amelanotic BN.
*[[Dermatofibroma]] - esp. amelanotic BN.
*[[Malignant melanoma]].
*[[Clear cell sarcoma]].
*[[Combined melanocytic nevus]] - blue nevus found together with another nevus (classically [[common melanocytic nevus]]), superficial.
*[[Combined melanocytic nevus]] - blue nevus found together with another nevus (classically [[common melanocytic nevus]]), superficial.
*[[Pigmented epithelioid melanocytoma]] - superificial dermis, has nuclear atypia.  
*[[Pigmented epithelioid melanocytoma]] - superificial dermis, has nuclear atypia.  
*[[Vascular lesions]] ([[venous lake]], [[hemangioma]]).


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Blue_nevus_%281_of_4%29.jpg Blue nevus (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Blue_nevus_-_very_low_mag.jpg Blue nevus - very low mag. (WC)].  
Image:Blue_nevus_%281_of_4%29.jpg | Blue nevus (WC)
*[http://commons.wikimedia.org/wiki/File:Blue_nevus_-_intermed_mag.jpg Blue nevus - intermed. mag. (WC)].
Image:Blue_nevus_-_very_low_mag.jpg | Blue nevus - very low mag. (WC)
Image:Blue_nevus_-_intermed_mag.jpg | Blue nevus - intermed. mag. (WC)
</gallery>
www:
*[http://www.dermatopathonline.com/blue%20nevus2.html Several types of blue nevi (dermatopathonline.com)].
*[http://www.nature.com/modpathol/journal/v19/n2s/fig_tab/3800516f25.html#figure-title Melanoma that looks a bit like a blue nevus (nature.com)].<ref name=pmid16446716>{{Cite journal  | last1 = Magro | first1 = CM. | last2 = Crowson | first2 = AN. | last3 = Mihm | first3 = MC. | title = Unusual variants of malignant melanoma. | journal = Mod Pathol | volume = 19 Suppl 2 | issue =  | pages = S41-70 | month = Feb | year = 2006 | doi = 10.1038/modpathol.3800516 | PMID = 16446716 }}</ref>


====Variants of blue nevus====
====Variants of blue nevus====
Line 435: Line 450:
Memory device:  
Memory device:  
*''C CASE'' = '''C'''ommon, '''C'''ellular, '''A'''melanotic, '''S'''clerosing, '''E'''pithelioid.
*''C CASE'' = '''C'''ommon, '''C'''ellular, '''A'''melanotic, '''S'''clerosing, '''E'''pithelioid.
===IHC===
*HMB-45 diffusely +ve.{{fact}}
**Melanoma patchy +ve.
*MART-1 diffusely +ve.
*Ki-67 low.


===Sign out===
===Sign out===
Line 450: Line 471:
The sections show pigmented spindle cells in the dermis between collagen bundles. The spindle cells show no nuclear atypia and no mitotic activity is appreciated.  
The sections show pigmented spindle cells in the dermis between collagen bundles. The spindle cells show no nuclear atypia and no mitotic activity is appreciated.  


The lesion does not extend into the epidermis. There are no melanocyte nests. There is no significant inflammation. The lesion is completely excised.
The lesion does not extend into the epidermis and is separated from it by a Grenz zone. There are no melanocyte nests. There is no significant inflammation. The lesion is completely excised.


The pigmented cells are negative on the Prussian blue stain.
The pigmented cells are negative on the Prussian blue stain.
=====Sclerosing blue nevus=====
The sections show pigmented spindle cells in the dermis between densely packed collagen fibres. The spindle cells show no significant nuclear atypia, and no mitotic activity is appreciated.  The lesion extends up to the epidermis; however, it does not appear to involve the epidermis. The overlying epidermis has hyperkeratosis; otherwise, it is unremarkable. There are no nests of melanocytes. There is no significant inflammation. The lesion is completely excised in the plane of section.


==Cellular blue nevus==
==Cellular blue nevus==
Line 470: Line 494:
Images:
Images:
*[http://www.dermpedia.org/case/cellular-blue-nevus-0 Cellular blue nevus (dermpedia.org)].
*[http://www.dermpedia.org/case/cellular-blue-nevus-0 Cellular blue nevus (dermpedia.org)].
==Acral nevus==
*[[AKA]] ''melanocytic nevus with intraepidermal ascent of cells'' (MANIAC).
*[[AKA]] ''volar nevus''.
===General===
*Palms ''or'' soles.
Note:
*''Volar'' refers to the palmar aspect ''or'' plantar aspect.<ref>URL: [http://www.medterms.com/script/main/art.asp?articlekey=9907 http://www.medterms.com/script/main/art.asp?articlekey=9907]. Accessed on: 14 January 2013.</ref>
===Gross===
*Pigmented lesion.
Note:
*Should be bisected perpendicular to the dermatoglyphs (ridges).<ref name=pmid22703907/>
**Lesions sectioned parallel to the ridges (on microscopy) may appear to have confluent junctional nests (leading to the diagnosis of melanoma).
===Microscopic===
Features:
*Acral skin:
**Thick stratum corneum (hyperkeratotic).
**Thick stratum spinosum (acanthotic).
*Nevus with intraepidermal ascent of cells.
**May be referred to as ''Pagetoid scatter''.
**Should '''not''' be present at the edge of the lesion - '''key feature'''.<ref name=pmid22703907/>
Notes:
*Intraepidermal ascent of cells is usually suggestive of melanoma.
**In acral sites (esp. at the centre of a lesion) the criteria are relaxed, i.e. this is considered benign for this site.
*Nests in the ridges raise the suspicion of melanoma.
**Memory device "ridges are risky, furrows are fine".<ref name=pmid22703907>{{Cite journal  | last1 = Elston | first1 = D. | title = Practical advice regarding problematic pigmented lesions. | journal = J Am Acad Dermatol | volume = 67 | issue = 1 | pages = 148-55 | month = Jul | year = 2012 | doi = 10.1016/j.jaad.2012.04.006 | PMID = 22703907 }}</ref>
DDx:
*Acral lentiginous [[melanoma]].
==Dysplastic melanocytic nevus==
*[[AKA]] ''dysplastic nevus''.
*[[AKA]] ''Clark nevus''.
*[[AKA]] ''nevus with architectural disorder''.
**This term is recommended by the American NIH; however, it is not widely adopted.<ref name=pmid22703907>{{Cite journal  | last1 = Elston | first1 = D. | title = Practical advice regarding problematic pigmented lesions. | journal = J Am Acad Dermatol | volume = 67 | issue = 1 | pages = 148-55 | month = Jul | year = 2012 | doi = 10.1016/j.jaad.2012.04.006 | PMID = 22703907 }}</ref>
===General===
*Benign.
*Dysplastic nevi are considered a risk factor for [[malignant melanoma|melanoma]] and may be a precursor of melanoma, as the name ''dysplastic nevus'' suggests.<ref name=pmid21308311>{{Cite journal  | last1 = Rezze | first1 = GG. | last2 = Leon | first2 = A. | last3 = Duprat | first3 = J. | title = Dysplastic nevus (atypical nevus). | journal = An Bras Dermatol | volume = 85 | issue = 6 | pages = 863-71 | month = Dec | year = 2010 | doi =  | PMID = 21308311 }}</ref>
**Most melanoma cases do not have evidence of a pre-existing (dysplastic) nevus.<ref name=pmid21715047>{{Cite journal  | last1 = Longo | first1 = C. | last2 = Rito | first2 = C. | last3 = Beretti | first3 = F. | last4 = Cesinaro | first4 = AM. | last5 = Piñeiro-Maceira | first5 = J. | last6 = Seidenari | first6 = S. | last7 = Pellacani | first7 = G. | title = De novo melanoma and melanoma arising from pre-existing nevus: in vivo morphologic differences as evaluated by confocal microscopy. | journal = J Am Acad Dermatol | volume = 65 | issue = 3 | pages = 604-14 | month = Sep | year = 2011 | doi = 10.1016/j.jaad.2010.10.035 | PMID = 21715047 }}</ref>
*Large numbers of these nevi (10-100) are seen in ''dysplastic nevus syndrome''.<ref name=omim155600>{{OMIM|155600}}</ref>
**Individuals with this syndrome have an increased risk of melanoma and approximately one third of their melanomas arise from a ''Clark nevus''. The other two thirds arise ''de novo''.
Clinical:<ref name=pmid22220461>{{Cite journal  | last1 = Dediol | first1 = I. | last2 = Bulat | first2 = V. | last3 = Zivković | first3 = MV. | last4 = Marković | first4 = BM. | last5 = Situm | first5 = M. | title = Dysplastic nevus--risk factor or disguise for melanoma. | journal = Coll Antropol | volume = 35 Suppl 2 | issue =  | pages = 311-3 | month = Sep | year = 2011 | doi =  | PMID = 22220461 }}</ref>
*Associated with sun exposure.
Treatment:
*Dysplastic nevi with severe nuclear atypia are treated like melanoma - excision with a 5 mm margin.
*Dysplastic nevi with moderate nuclear atypia with margin involvement are re-excised.<ref name=pmid15509670>{{Cite journal  | last1 = Culpepper | first1 = KS. | last2 = Granter | first2 = SR. | last3 = McKee | first3 = PH. | title = My approach to atypical melanocytic lesions. | journal = J Clin Pathol | volume = 57 | issue = 11 | pages = 1121-31 | month = Nov | year = 2004 | doi = 10.1136/jcp.2003.008516 | PMID = 15509670 }}</ref>
===Gross===
Features:<ref name=pmid22220461/>
*"Ugly duckling sign" - lesion looks different than the rest.
*[[Malignant_melanoma#Gross|ABCDE criteria of in melanoma]].
*Tend to be greater than 5 mm - '''important'''.† <ref name=pmid3275948>{{Cite journal  | last1 = Barnhill | first1 = RL. | last2 = Hurwitz | first2 = S. | last3 = Duray | first3 = PH. | last4 = Arons | first4 = MS. | title = The dysplastic nevus: recognition and management. | journal = Plast Reconstr Surg | volume = 81 | issue = 2 | pages = 280-9 | month = Feb | year = 1988 | doi =  | PMID = 3275948 }}</ref>
Note:
* † Size matters - things smaller than 4 mm are usually ''not'' a dysplastic nevus.
===Microscopic===
Features:<ref name=Ref_WMSP502>{{Ref WMSP|502}}</ref>
*Melanocytes "bridges" between sides of rete ridges.
**Joining of three or more adjacent rete ridges = suspicious for melanoma.<ref name=pmid15509670/>
*Drapping fibrous tissue - "lamellar fibrosis" - collagen deep to epidermis.
*Usually moderate nuclear atypia (small nucleoli present) - see ''grading'' section.
*+/-Junctional component (cells in the epidermis at the DE junction) larger than the intradermal component - ''shoulder phenomenon''.
DDx:
*[[Melanoma in situ]] - especially on [[solar elastosis|sun damaged skin]] ([[lentigo maligna]]).<ref name=pmid15953373>{{Cite journal  | last1 = Farrahi | first1 = F. | last2 = Egbert | first2 = BM. | last3 = Swetter | first3 = SM. | title = Histologic similarities between lentigo maligna and dysplastic nevus: importance of clinicopathologic distinction. | journal = J Cutan Pathol | volume = 32 | issue = 6 | pages = 405-12 | month = Jul | year = 2005 | doi = 10.1111/j.0303-6987.2005.00355.x | PMID = 15953373 }}</ref><ref name=pmid10911797>{{Cite journal  | last1 = Edwards | first1 = SL. | last2 = Blessing | first2 = K. | title = Problematic pigmented lesions: approach to diagnosis. | journal = J Clin Pathol | volume = 53 | issue = 6 | pages = 409-18 | month = Jun | year = 2000 | doi =  | PMID = 10911797 }}</ref>
*[[Malignant melanoma]] - especially on sun damaged skin ([[lentigo maligna melanoma]]).
*[[Compound melanocytic nevus]].
Images:
*[http://commons.wikimedia.org/wiki/File:Dysplastic_nevus_-_low_mag.jpg Dysplastic nevus - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Dysplastic_nevus_-_intermed_mag.jpg Dysplastic nevus - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Dysplastic_nevus_-_add_-_high_mag.jpg Dysplastic nevus - high mag. (WC)] - shows bridging and lamellar fibrosis.
*[http://commons.wikimedia.org/wiki/File:Dysplastic_nevus_-_add_-_very_high_mag.jpg Dysplastic nevus - very high mag. (WC)] - shows bridging and lamellar fibrosis.
====Grading====
These lesions are often graded § :<ref name=Ref_Derm447-8>{{Ref Derm|447-8}}</ref>
{| class="wikitable sortable"
! Grade
! Size of nucleus
! Other features
|-
| Mild
| 1x keratinocyte nucleus
| no [[nucleoli]]/very small nucleoli †,<ref name=pmid12920220>{{Cite journal  | last1 = Arumi-Uria | first1 = M. | last2 = McNutt | first2 = NS. | last3 = Finnerty | first3 = B. | title = Grading of atypia in nevi: correlation with melanoma risk. | journal = Mod Pathol | volume = 16 | issue = 8 | pages = 764-71 | month = Aug | year = 2003 | doi = 10.1097/01.MP.0000082394.91761.E5 | PMID = 12920220 | URL = http://www.nature.com/modpathol/journal/v16/n8/full/3880837a.html }}</ref> slight hyperchromasia
|-
| Moderate
| 1-2x keratinocyte nucleus
| small nucleoli †, irregular nuclear contours
|-
| Severe
| >2x keratinocyte nucleus
| prominent nucleoli †‡
|}
† The sizes "very small", "small" and "prominent" are not defined; it is suggested that "very small" is visible with the 40x objective, "small" with the 20x objective and "prominent" with the 10x objective.  Focal, rare small nucleoli are not significant; they can be seen in benign melanocytic nevi.<br>
‡ Prominent nucleoli (alone) is considered enough to call "severe".<ref name=Ref_Derm447-8>{{Ref Derm|447-8}}</ref>
Notes:
*§ There is no consensus on this and practise (embarrassingly) is all over the map.<ref name=pmid22703907>{{Cite journal  | last1 = Elston | first1 = D. | title = Practical advice regarding problematic pigmented lesions. | journal = J Am Acad Dermatol | volume = 67 | issue = 1 | pages = 148-55 | month = Jul | year = 2012 | doi = 10.1016/j.jaad.2012.04.006 | PMID = 22703907 }}</ref>
**A two-tier grading system also exists (''low-grade'' (leave it alone) / ''high-grade'' (cut it out)).
**Some pathologists do not grade dysplastic nevi.
===Sign out===
====Compound====
<pre>
SKIN LESION, CENTRAL BACK, EXCISION:
- DYSPLASTIC COMPOUND NEVUS WITH MILD NUCLEAR ATYPIA.
- NEAREST MARGIN (LATERAL MARGIN) 6 MM.
</pre>
=====Micro=====
The sections show hair-bearing skin with a compound melanocytic lesion.  The epidermal component extends at least three rete ridges further than the dermal component (shoulder phenomenon). There is bridging between the sides of the rete ridges and lamellar fibrosis.  The melanocyte nuclei are approximately the size of the keratinocyte nuclei, and do not have a prominent nucleolus (mild nuclear atypia).
There is no upward scatter of melanocytes and melanocytes in the dermis are mature.  No mitotic activity is appreciated.
====Junctional====
<pre>
SKIN LESION, LOWER BACK, EXCISION:
- DYSPLASTIC JUNCTIONAL MELANOCYTIC NEVUS WITH MILD NUCLEAR ATYPIA.
- NEAREST MARGIN (LATERAL MARGIN) 1 MM.
</pre>
=====Micro=====
The sections show hair-bearing skin with a junctional melanocytic lesion.  There is bridging between the sides of the rete ridges and lamellar fibrosis.  The melanocyte nuclei are approximately the size of the keratinocyte nuclei, and do not have a prominent
nucleolus (mild nuclear atypia).
There is no upward scatter of melanocytes.  No mitotic activity is appreciated.
==Neurocristic hamartoma==
{{Main|Neurocristic hamartoma}}
==Desmoplastic melanocytic nevus==
*[[AKA]] ''sclerosing melanocytic nevus''.
===General===
*Benign.
===Gross===
*Usu. "small" and symmetric.
Clinical DDx:
*[[Dermatofibroma]].
*[[Dermal scar]].
===Microscopic===
Features:<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
*[[Compound nevus]] ''or'' [[intradermal nevus]] with prominent dermal fibrosis.
**Fibrosis: extra pink - versus surrounding.
DDx:
*[[Desmoplastic neurotropic malignant melanoma]].
*[[Dermatofibroma]].
===IHC===
Features:<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
*Melan A (MART-1) +ve (not usu. +ve in desmoplastic melanoma).<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
*S-100 +ve.
*Ki-67 -- only rare cells.
==Solar lentigo==
*Plural ''solar lentigines''.
===General===
*Benign.
Fits into the larger category of ''lentiginous melanocytic proliferations'' - these include:<ref name=Ref_Derm438>{{Ref Derm|438}}</ref>
*Solar lentigo.
*[[Lentigo simplex]].
*Lentiginous nevus.
*Lentiginous [[melanoma in situ]].
===Gross===
Features:<ref name=Ref_Derm438>{{Ref Derm|438}}</ref>
*Small (< 4 mm), irregular brown [[macule]].
*Usu. sun-exposed area.
DDx (clinical):
*[[Lentigo maligna]] - melanoma in situ on sun damaged skin.
===Microscopic===
Features:<ref name=Ref_Derm437>{{Ref Derm|437}}</ref>
*Hyperpigmented melanocytes - may be present in increased quantities - '''key feature'''.
**Classically at the tips of the rete ridges.
*No (melanocyte) nuclear atypia.
Notes:
*Should ''not'' be present:<ref name=Ref_Derm438>{{Ref Derm|438}}</ref>
**Nests of melanocytes.
**Pagetoid spread of melanocytes.
DDx:<ref name=Ref_Derm437>{{Ref Derm|437}}</ref>
*Pigmented [[actinic keratosis]].
*[[Lichen planus-like keratosis]].
*Pigmented [[seborrheic keratosis]].
Image:
*[http://commons.wikimedia.org/wiki/File:Skin_tumors_181.jpg Solar lentigo (WC)].


==Combined melanocytic nevus==
==Combined melanocytic nevus==
Line 696: Line 516:
</pre>
</pre>


==See also==
==Neurocristic hamartoma==
{{Main|Neurocristic hamartoma}}
 
=See also=
*[[Dermatopathology]].
*[[Dermatopathology]].
*[[Cytopathology]].
*[[Cytopathology]].
*[[Non-malignant skin disease]].
*[[Non-malignant skin disease]].
*[[Pigmented lesions of the oral cavity]].
*[[Melanosis coli]].
*[[Small bowel pseudomelanosis]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


==External links==
=External links=
*[http://www.youtube.com/watch?v=_4jgUcxMezM Dear 16 year-old me (youtube.com)] - with Dr. G.
*[http://www.youtube.com/watch?v=_4jgUcxMezM Dear 16 year-old me (youtube.com)] - with Dr. G.


[[Category:Dermatopathology]]
[[Category:Dermatopathology]]
[[Category:Melanocytic lesions]]
Michael
48,466

edits

Retrieved from "https://librepathology.org/wiki/Special:MobileDiff/20880...51106"

Navigation menu