Melanocytic tumors of the skin:Melanocytic tumors of the skin:IntroductionIntroduction

Deba P Sarma, MDDeba P Sarma, MD

OmahaOmaha

MelanocyteMelanocyte

MelanocyteMelanocyte

MITF immunostain

Melanocytic lesionsMelanocytic lesions

Benign- 95%Benign- 95% Malignant- 4%Malignant- 4% Undetermined- 1%Undetermined- 1%

Dr. Sarma’s classification of Dr. Sarma’s classification of pigmented lesionspigmented lesions

Benign: Benign: Lentigo simplexLentigo simplex Solar lentigoSolar lentigo Nevus (Junctional, Dermal, Nevus (Junctional, Dermal,

Compound,Compound, Blue, Spitz, Dysplastic)Blue, Spitz, Dysplastic)

Potentially malignant: Potentially malignant: Atypical melanocytic hyperplasiaAtypical melanocytic hyperplasiaMalignant:Malignant: Melanoma in-situMelanoma in-situ Invasive melanomaInvasive melanoma

Lentigo, Freckle, Mole, NevusLentigo, Freckle, Mole, Nevus

Lentigo: From Latin word for lentil. A dark spot on Lentigo: From Latin word for lentil. A dark spot on skin that looks like a lentil bean and does not fade in skin that looks like a lentil bean and does not fade in the winter.the winter.

Freckle:Freckle: Small brownish spot turning darker or Small brownish spot turning darker or increasing in number upon exposure to the sun and increasing in number upon exposure to the sun and fading in winter. (Freckle=Speckle)fading in winter. (Freckle=Speckle)

Mole : Spot, common name for nevus.Mole : Spot, common name for nevus. MOLE = NEVUSMOLE = NEVUS

Nevus: Latin word meaning birthmark.Nevus: Latin word meaning birthmark.

Lentigo simplex

Elongated rete ridgesBasal melanosisNo junctional nestNo solar elastosis

Solar lentigo

Elongated rete ridgesBasal melanosisNo junctional nestDermal solar elastosis

Nevus = MoleNevus = Mole

Life of a nevusLife of a nevus

Congenital nevusCongenital nevus

Common neviCommon nevi

JunctionalJunctional CompoundCompound DermalDermal

Nevus: Junctional

Flat epidermal lesionJunctional nests with clefts

Nevus: Compound

Raised or flat (older person) lesionJunctional clefted nests and dermal nests

F 25, left abdomenF 25, left abdomen

Dysplastic nevusDysplastic nevus

Nevus: Blue

Flat lesionNo junctional nestDermal pigmented spindled melanocytes

Nevus: Epithelioid (Spitz nevus)

70% occurs in pts < 20 yrsRaised, junctional or compound nevusEpithelioid clefted nests oriented vertically Cytologic and nuclear pleomorphism

MelanomaMelanoma

TypesTypes

Melanoma in-situMelanoma in-situ

Melanoma (Invasive melanoma)Melanoma (Invasive melanoma)

Melanoma Melanoma

Lentigo maligna & lentigo maligna melanomaLentigo maligna & lentigo maligna melanoma

Superficial spreading ( Pagetoid): In-situ & Superficial spreading ( Pagetoid): In-situ & invasiveinvasive

Acral-lentiginous: In-situ & invasiveAcral-lentiginous: In-situ & invasive

Nodular: InvasiveNodular: Invasive

Desmoplastic: InvasiveDesmoplastic: Invasive

Melanoma in-situ: Lentigo maligna typeMelanoma in-situ: Lentigo maligna type

Neoplastic melanocytes spread from the junction upwardsand along the adnexa.No dermal invasion.

Melanoma in-situ: Lentigo maligna typeMelanoma in-situ: Lentigo maligna type

Epidermal atrophy, solar elastosisConfluent and nested proliferation of pleomorphic melanocytes

Superficial spreading in-situ & invasive Superficial spreading in-situ & invasive melanomamelanoma

Nodular melanomaNodular melanoma

Raised, ulcerated, no radial spread, deep dermal invasion

Acral lentiginous melanomaAcral lentiginous melanoma

Epidermal atrophy, dermal actinic change, mononuclear celland spindle cell infiltration

Desmoplastic melanoma

Pleomorphic spindle cells within desmoplastic stroma.Note the mitotic figure.

S-100: Positive

Risk factorsRisk factors

Uncontrollable: Uncontrollable: Skin typeSkin type (race) (race) History of melanomaHistory of melanoma MolesMoles and atypical molesand atypical moles Age: 70 + Age: 70 + Gender: M > FGender: M > F

Controllable: Controllable: UV radiationUV radiation ( sunlight, tanning booths and ( sunlight, tanning booths and

lamps).lamps).

Skin typesSkin types

VVI

IV

I II III

History of melanomaHistory of melanoma

First-degree relatives: Father, mother, First-degree relatives: Father, mother, brother, sister, childbrother, sister, child

Personal history of melanomaPersonal history of melanoma

Melanoma pt.: Family history in 10% Melanoma pt.: Family history in 10%

Estd new cancer cases, USA, 2008Estd new cancer cases, USA, 2008 American Cancer SocietyAmerican Cancer Society

Male:Male: Female:Female: 1. Prostate (25%) 1. Breast (31%)1. Prostate (25%) 1. Breast (31%) 2. Lung (15%) 2. Lung (14%)2. Lung (15%) 2. Lung (14%) 3. Colorectum (10%) 3. Colorectum (10%)3. Colorectum (10%) 3. Colorectum (10%) 4. Bladder (7%) 4. Uterus (5%)4. Bladder (7%) 4. Uterus (5%) 5. NH Lymphoma (5%) 5. NH Lymphoma (4%)5. NH Lymphoma (5%) 5. NH Lymphoma (4%) 66. . Melanoma (5%)Melanoma (5%) 6. Thyroid (4%) 6. Thyroid (4%)

7. Kidney (4%)7. Kidney (4%) 7. Melanoma (4%) 7. Melanoma (4%)

Melanoma sitesMelanoma sites

Five-year survival rateFive-year survival rate

Overall 90%Overall 90% Localized 99%Localized 99% With regional spread 45%With regional spread 45%

Good news: 80% localized at diagnosisGood news: 80% localized at diagnosis

Editorials 1985-2008Editorials 1985-2008

April;144: 533-534. Ackerman AB. No April;144: 533-534. Ackerman AB. No one should die of malignant melanoma. one should die of malignant melanoma. J Am Acad Dermatol. 1985 Jan; 12: 115-J Am Acad Dermatol. 1985 Jan; 12: 115-6.6.

Kittler H. Early recognition at last. Arch Kittler H. Early recognition at last. Arch Dermatol. 2008Dermatol. 2008