Difference between revisions of "Melanocytic lesions"

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[[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]]).


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=Lentiginous melanocytic lesions=
=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}}
===General===
*Benign.
*Usually <40 years old.
 
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]].
 
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>
*[[Peutz-Jeghers syndrome]].
*[[LEOPARD syndrome]].
*[[LAMB syndrome]].
 
===Gross===
*Small flat pigmented lesion.<ref name=Ref_WMSP498>{{Ref WMSP|498}}</ref>
 
DDx - clinical:
*[[Melanocytic nevus]].<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>
 
===Microscopic===
Features:<ref name=Ref_WMSP498>{{Ref WMSP|498}}</ref>
*Melanocytes in epidermis only.
**Melanocytes basally located (normal location) with hyperpigmentation.
*No melanocytic nests.
*+/-Mild/moderate elongation of the rete ridges.<ref name=pmid19536147/>
 
DDx:<ref name=humpath_ls/>
*[[Solar lentigo]] - in sun exposed areas.
*[[Ephelis]] (freckle) - change with UV light exposure.
*Melanotic macule.
*Lentiginous nevus.
 
Images:
*[http://dermaamin.com/site/histopathology-of-the-skin/64-l/1852-lentigo-simplex-.html Lentigo simplex - several images (dermamin.com)].<ref name=dermamin_ls/>
*[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>
 
===Sign out===
<pre>
SKIN LESION, LEFT ABDOMEN, BIOPSY:
- SIMPLE LENTIGO, COMPLETELY EXCISED IN THE PLANE OF SECTION.
</pre>
 
<pre>
SKIN LESION, LEFT ABDOMEN, BIOPSY:
- BENIGN SIMPLE LENTIGO.
</pre>


==Solar lentigo==
==Solar lentigo==
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**Classically at the tips of the rete ridges.
**Classically at the tips of the rete ridges.
*No (melanocyte) nuclear atypia.
*No (melanocyte) nuclear atypia.
*Solar damage ([[solar elastosis]]).<ref name=pmid19536147/>
*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:
Notes:
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*[[Lichen planus-like keratosis]].
*[[Lichen planus-like keratosis]].
*Pigmented [[seborrheic keratosis]].
*Pigmented [[seborrheic keratosis]].
*[[Ephelis]] (freckle).


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Skin_tumors_181.jpg Solar lentigo (WC)].
<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>
*[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>


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www:
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)].
<gallery>
Image:Skin_Tumors-171.jpg | Lentiginous nevus. (WC)
</gallery>


===Sign out===
===Sign out===
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====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'''.


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*[[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'''.
*+/-Adipocytes - uncommon.<ref name=pmid9810886>{{Cite journal  | last1 = Eng | first1 = W. | last2 = Cohen | first2 = PR. | title = Nevus with fat: clinical characteristics of 100 nevi containing mature adipose cells. | journal = J Am Acad Dermatol | volume = 39 | issue = 5 Pt 1 | pages = 704-11 | month = Nov | year = 1998 | doi =  | PMID = 9810886 }}</ref>
 
Note:
*In the oral cavity these are known as ''[[intramucosal melanocytic nevus|intramucosal nevi]]''.


===Sign out===
===Sign out===
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====Compound melanocytic nevus====
====Compound melanocytic nevus====
<pre>
{{Main|Compound nevus}}
SKIN LESION, RIGHT NECK, SHAVE BIOPSY:
- BENIGN COMPOUND NEVUS.
</pre>
 
=====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.
Superficially, melanocytes are in nests. Melanocytes mature with depth. No mitotic activity is appreciated.
 
The lesion is completely excised in the plane of section.
 
======Barely compound======
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.
 
The lesion is present at the margin.


====Intradermal melanocytic nevus====
====Intradermal melanocytic nevus====
<pre>
{{Main|Intradermal nevus}}
SKIN LESION, BACK, PUNCH BIOPSY:
- BENIGN INTRADERMAL NEVUS.
</pre>
 
=====Adipocytes present=====
<pre>
SKIN LESION, BACK, PUNCH BIOPSY:
- BENIGN INTRADERMAL NEVUS WITH MATURE ADIPOCYTES.
</pre>
 
=====Clinically suspicious=====
<pre>
SKIN LESION, LEFT UPPER ARM, PUNCH BIOPSY:
- BENIGN INTRADERMAL NEVUS, INCOMPLETELY EXCISED.
 
COMMENT:
HMB-45 marks very rare superficial cells. Ki-67 staining does not show apparent melanocyte
staining. MITF marks the melanocytes and demonstrates maturation of the melanocytes with depth.
</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==
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==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===
*Uncommon.
*Women in teens & 20s.
*Location: shoulder, pelvic girdle region.
 
===Microscopic===
Features:<ref name=Ref_WMSP500>{{Ref WMSP|500}}</ref>
*Nests of heavily pigmented spindle cells at dermal-epidermal junction - '''key feature'''.
**Nevoid cells in epidermis & dermis - form "basket weave" pattern
*Well-circumscribed lesion.
 
Notes:
*No epithelioid nevus cells.
 
DDx:
*[[Spitz 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==
==Spitz nevus==
*AKA ''epithelioid and spindle-cell nevus''.
*[[AKA]] ''epithelioid and spindle cell nevus''.
 
{{Main|Spitz nevus}}
===General===
*May be very difficult to differentiate from [[melanoma]].
 
Epidemiology:
*Children & adolescents.
 
Treatment:
*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>
 
===Gross===
*Usually face ''or'' extremity.<ref name=Ref_Derm449>{{Ref Derm|449}}</ref>
 
===Microscopic===
Features:<ref name=Ref_WMSP499>{{Ref WMSP|499}}</ref>
*Architecture:
**Nests of cells (spindle, epithelioid or spindle/epithelioid) - in both dermis and epidermis.
***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:
*'''Never''' in the setting of [[solar elastosis]].<ref>Jakubovic, H. 16 July 2010.</ref>
**If there is solar elastosis -- it's melanoma.
 
DDx:
*[[Malignant melanoma]].
*[[Pigmented spindle cell nevus of Reed]].
 
Images:
*www:
**[http://www.drmihm.com/cases/case.cfm?CaseID=51 Spitz nevus - collection of images (drmihm.com)].
**[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)].


==Acral nevus==
==Acral nevus==
*[[AKA]] ''melanocytic nevus with intraepidermal ascent of cells'' (MANIAC).
*[[AKA]] ''melanocytic nevus with intraepidermal ascent of cells'' ([[MANIAC]]).
*[[AKA]] ''volar nevus''.
*[[AKA]] ''volar nevus''.
===General===
{{Main|Acral nevus}}
*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==
==Dysplastic melanocytic nevus==
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*[[AKA]] ''nevus with architectural disorder''.
*[[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>
**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}}
===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]].
*[[Atypical lentiginous nevus]].
 
====Images====
<gallery>
Image:Dysplastic_nevus_-_low_mag.jpg | Dysplastic nevus - low mag. (WC/Nephron)
Image:Dysplastic_nevus_-_intermed_mag.jpg | Dysplastic nevus - intermed. mag. (WC/Nephron)
Image:Dysplastic_nevus_-_add_-_high_mag.jpg | Dysplastic nevus - high mag. - shows bridging and lamellar fibrosis. (WC/Nephron)
Image:Dysplastic_nevus_-_add_-_very_high_mag.jpg | Dysplastic nevus - very high mag. - shows bridging and lamellar fibrosis. (WC/Nephron)
</gallery>
 
====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, BACK, EXCISION:
- DYSPLASTIC COMPOUND NEVUS WITH MILD CYTOLOGIC ATYPIA AND MILD ARCHITECTURAL ATYPIA,
  COMPLETELY EXCISED IN THE PLANE OF SECTION (2 MM CLEARANCE).
</pre>
 
<pre>
SKIN LESION, CENTRAL BACK, EXCISION:
- DYSPLASTIC COMPOUND NEVUS WITH MILD CYTOLOGIC 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 cytologic 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.


==Desmoplastic melanocytic nevus==
==Desmoplastic melanocytic nevus==
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DDx:
DDx:
*[[Desmoplastic neurotropic malignant melanoma]].
*[[Desmoplastic neurotropic malignant melanoma]] - usually mitotic figures, nuclear atypia (enlarged, hyperchromatic).
*[[Dermatofibroma]].
*[[Dermatofibroma]].
*[[Dermal scar]] - no adnexal structures.


===IHC===
===IHC===
Features:<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
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>
*Melan A (MART-1) +ve.
**Usually -ve in desmoplastic melanoma.<ref name=Ref_Derm_464>{{Ref Derm|464}}</ref>
*S-100 +ve.
*S-100 +ve.
**Should stain approximally the same number of cells as Melan A.
*Ki-67 -- only rare cells.
*Ki-67 -- only rare cells.
==Nodal nevus==
*AKA ''nevus in lymph node'' and ''benign nevus cells in lymph node''.
{{Main|Nodal nevus}}


=Miscellaneous=
=Miscellaneous=
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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]]).
*[[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====
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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===
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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==
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*[[Cytopathology]].
*[[Cytopathology]].
*[[Non-malignant skin disease]].
*[[Non-malignant skin disease]].
*[[Pigmented lesions of the oral cavity]].
*[[Melanosis coli]].
*[[Small bowel pseudomelanosis]].


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

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