A case posted to the IDS forum by Iris Zalaudek

Age: 6 years

Sex: f location lower arm, left

Clinical history: Recently growing lesion, image 1 baseline, image 2: after 3 months; image 3: after 5 months.

Diagnosis: I guess we have some quite good idea

Question: How would you manage this lesion based on the age and dermoscopic patterns?

This is a summary of 3 discussions. Every image was submitted separately by dr Zalaudek, that saw the patient 3 times and discussed the management with the forum members.

Answers (comments)

Pyne John: Iris, you must be trying to give us nightmares about Spitz and anxious parents. Sophie Spitz would have never realized how famous she would become after she published her original article in 1948...."Childhood Melanoma".

Baker Ron: I think I would be brave enough to simply observe this at this age, though I'm not very brave: I'd surely be sharing it on this site for advice and support for observing.

Bartalini Paolo: Hi Iris, nice picture. In my opinion, is a Spitz nevus, hyperchromic type. Given the age, I'd recommend only a periodic follow-up. I would think to removal only in case of occurrence of severe architectural disorder.

Landi Christian: Quite big, but perfecly symmetrical and really young patient. I would follow-up every 4 months and consider a threeshold: if it becames ulcerated or more than 10 mm, that wil be the time to excise it.

Fox Gary: In the US, even Dr. Johr would say, I believe, from his books (with prominent coauthors), this cannot stay. Spitzoid, but the peripheral globules are not symmetric. Mgt: I'd photograph, post on IDS and, no peds derm consultation being available, discussion 2 options with parents: excise or 2nd opinion at U. Med Center. I don't have the stripes to call this keeper by my lonesome.

Baker Ron: I'd run right out of what little bravery I had when you showed the first images; I couldn't recommend continued observation and still sleep. Be interested to read the debate that will undoubtedly follow...

Zalaudek Iris: ron, why you are concerned - the lesion grew basically quite symmetrically as one may expect...

Muir James: Sometimes you have to forget everything about a lesion except what it looks like on the day. History, symptoms and age do not determine biology. Rare things happen and if this was attached to a 26 year old it would go in a heartbeat as it shows irregular growth, blue grey, possibly even an attempt at a negative net and regression. All things we would expect in a melanoma as well. I would not want it on me or mine.

This illustrates one of my bugbears of stm. This lesion looked suspect in the first instance and more suspect after three months. So a Spitz could do this as could a melanoma, right? Unless we see definite melanoma features at review we have not resolved the issue i.e. the base line snap does not help us much as it merely confirms that a lesion known to change has changed. As melanoma and Spitz share clinical, dermosocpic and indeed histological features reference to previous images is not of much use I think. Willing to be convinced otherwise.

Zalaudek Iris: I agree with you all but - but if we have to make a diagnosis: How much do you think this is melanoma and how much do you think this is a Spitz nevus?

Burns John: Obviously you have seen way more of these than I and are possibly aware of the evolution of globular spitz. However, due to my limited experience with these and the difficulty noted with differentiating these lesions clinically from melanoma, though age speaks for Spitz, I would go ahead and have plastics remove it. My clinical diagnosis would be Spitz. Thanks for the case and look forward to your treatment plan.

Landi Christian: Again: quite big, but perfectly symmetrical and really young patient. I would follow-up in 4 months and consider a threshold: if it becomes ulcerated or more than 10 mm, that will be the time to excise it.

Zalaudek Iris: we followed Christian's approach and continued with FU in 2 months...

At this time we also were not brave enough to continue with the FU. Histopathology was not easy (as expected) but at then end two dermato-pathologists agreed on atypical Spitz nevus.

Question: I think its fascinating that even after decades of research we still cannot say whether Sophie Spitz was right or not. Maybe Spitz tumors are indeed similar to keratoacanthomas within the keratinocyte spectrum- they have all morphologic features of malignancy but a rather benign biology...

Muir James: I'd be getting antsy once the pathologists started getting second opinions. Especially with a thick lesion as dynamic as this one with very significant change over a short period. Anyway I am glad it is off and it is a good illustration of the need for informed, thorough and documented consent when entering individual suspect naevi into surveillance programs. The bottom line with STM is that the reason a lesion is selected for this is because melanoma is a possibility after all. One of the few lesions that I entered into STM this year disappeared from sight for 9 instead of three months. At review it still looked harmless and unchanged. Luckily for me.

Baker Ron: So, you can and did run out of bravery here too.... Interesting path report...brings back memories of some comments in a previous case (by a doc who shall remain nameless but whose initials are IZ) that the words "atypical" or "dysplastic" in path reports really mean that the pathologist is unsure whether he or she is looking at a melanoma, whereas the lesion itself knows perfectly well what it is. So is the patient well rid of this lesion, or would it have been safe to observe it indefinitely? Or can we ever know the answer to that kind of question? Thanks for a most interesting case.

Pyne John: The only certainty is ongoing uncertainty. The features to drive immediate excision could include:

(1) Rapid increase in size out of proportion of the growth rate of the patient - this may depend on the patient's parents(child) or patient's(older) own recall.

(2) Recent ulceration unrelated to trauma - this may not be clear cut.

(3) Obvious overt features of melanoma.

Fox Gary: Thanks for the case. Even a 12-hr clock with the battery removed is precisely correct twice daily. So, I figure if I say "excise" on every case on the IDS, I might be right, say, twice a year. ;)

Zalaudek Iris: well, to your answers - we won't know the course of the individual lesion but most likely it will have grown still until at a certain moment it would have entered into the apoptosis program and disappear. However, since morphology and biology are two pairs of shoes and since we cannot predict biology from morphology, I decided that the morphology was enough to remove the tumor. I am convinced this is the end of the story and we can just speculate about all the rest. The fact that the pathologists agreed on a nevus and not tumor reinforces this concept. As John says the only certainty is ongoing uncertainty. Thanks for the many comments!

Affleck Andrew: I am sorry but I have to make a comment here. Atypical Spitz naevus is also known as atypical Spitz tumour to highlight its uncertain malignant potential. Was a wide local excision peformed, was any molecular genetic testing offered or was a Sentinel lymph node biopsy considered? This tumour BY HISTOLOGICAL DEFINITION may have metastatic potential albeit of unknown biological significance. As several contributors have said, we need to accept our limitations with the dermoscope with Spitzoid lesions, in my opinion excising them all is best and safest practice, and let the dermatopathologists decide (if they can) and then decide on any further management based on the path and clinical features (mostly age and diameter of lesions). In STUMP which this case is an example of, I would hope that molecular genetic studies will come in the future to allow differentiation from Spitzoid melanoma. If I did choose to follow a Spitzoid lesion it would have to be small (<10mm), macular, Reed-Spitz sub-type, child < 10 years and stable / not enlarging.