800-gotlieb g topics in melanocytic neoplasia€¦ · folklore in melanocytic neoplasia the...
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Topics in Melanocytic
Neoplasia
Geoff Gottlieb MD
Ackerman Academy of
Dermatopathology
Folklore in Melanocytic Neoplasia
Folklore in Melanocytic NeoplasiaThe Religion of
THE DYSPLASTIC NEVUS
• What is it?
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THE DYSPLASTIC NEVUS
• What is it?
• The presence and grading of atypia.
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THE DYSPLASTIC NEVUS
• What is it?
• The presence and grading of atypia.
THE DYSPLASTIC NEVUS
• What is it?
• The presence and grading of atypia.
• Is it a precursor of melanoma?
Clark and Elder’s opinion
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Clark and Elder’s opinion..NOIs the DN the most common
precursor melanoma?
Is the DN the most common precursor melanoma?
• NO!
Is the DN the most common precursor melanoma?
• NO!
• Superficial congenital nevi are!
It is just one type of nevus! It is just one type of nevus!
• Clark’s nevus
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It is just one type of nevus!
• Clark’s nevus
– No grading of atypia
– No margins on shave biopsies
– No recommendation for re-excision ordinarily
NONDIAGNOSES
NONDIAGNOSES
• Borderline
• Minimal Deviation
• MELTUMP
• SAMPUS
The diagnoses of a melanocytic neoplasm:
The diagnoses of a melanocytic neoplasm:
• NEVUS
The diagnoses of a melanocytic neoplasm:
• NEVUS
• MELANOMA
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The diagnoses of a melanocytic neoplasm:
• NEVUS
• MELANOMA
• NEVUS AND MELANOMA
The diagnoses of a melanocytic neoplasm:
• NEVUS
• MELANOMA
• NEVUS AND MELANOMA
• “I DON’T KNOW”
The diagnoses of a melanocytic neoplasm:
• NEVUS
• MELANOMA
• NEVUS AND MELANOMA
• “I DON’T KNOW” “I’M NOT SURE”
Melanoma Excision: Wider for Deeper
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Wider for deeper have always
been arbitrary recommendations without hard data to support them!
It makes no sense biologically!
The Sentinel Node Biopsy The Sentinel Node Biopsy
• Does it have therapeutic benefit?
– An indication for elective lymph node dissection?
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The Sentinel Node Biopsy
• Does it have therapeutic benefit?
– An indication for elective lymph node dissection?
The Sentinel Node Biopsy
• Does it have therapeutic benefit?
– An indication for elective lymph node dissection?...NO
GAME OVER
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Site Of First Recurrence at ANY SITENEJM 2006;355:1311
Observation (500) Sentinel Node (769)
Nodal 65 (13%) 32 (4.2%)
Distant 39 (7.8%) 85 (11%)
Local 30 (6%) 42 (5.5%)
NO 366(73.2) 610 (79.3)
Recurrence
The Sentinel Node Biopsy
• Does it have prognostic significance?
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1. 5 Year survival is 72% for SN+ and 90%
for SN-
1. 5 Year survival is 72% for SN+ and 90%
for SN-
2. Percent survival for an individual patient
at any time is 0 or 100%.
1. 5 Year survival is 72% for SN+ and 90%
for SN-
2. Percent survival for an individual patient
at any time is 0 or 100%.
3. A negative SNB does not mean that
metastasis of melanoma has not occurred.
1. 5 Year survival is 72% for SN+ and 90%
for SN-
2. Percent survival for an individual patient
at any time is 0 or 100%.
3. A negative SNB does not mean that
metastasis of melanoma has not occurred.
50% of patients who died of melanoma never had +LNs
1. 5 Year survival is 72% for SN+ and 90%
for SN-
2. Percent survival for an individual patient
at any time is 0 or 100%.
3. A negative SNB does not mean that
metastasis of melanoma has not occurred.
50% of patients who died of melanoma never had +LNs
4. The data is suspect.
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The Sentinel Node Biopsy
• Does it have prognostic significance?
The Sentinel Node Biopsy
• Does it have prognostic significance?
– NOT MUCH!
If SNB has little or no therapeutic or prognostic value, can it be of
potential harm to the patient?
• YES!
Lymph Node InvolvementNEJM 2006;355:1312
Observation (500) Sentinel Node (764)
78 (15.5%) 122 (16.0%)
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Lymph Node InvolvementNEJM 2006;355:1312
Observation (500) Sentinel Node (764)
78 (15.5%) 122 (16.0%)
Conclusion: A positive SN would
eventuate into clinically evident LN
metastases if not for the immediate lymphadenectomy
Site Of First Recurrence at ANY SITENEJM 2006;355:1311
Observation (500) Sentinel Node (769)
Nodal 65 (13%) 32 (4.2%)
Distant 39 (7.8%) 85 (11%)
Local 30 (6%) 42 (5.5%)
NO 366(73.2) 610 (79.3)
Recurrence
Site Of First Recurrence at ANY SITENEJM 2006;355:1311
Observation (500) Sentinel Node (769)
Nodal 65 (13%) 32 (4.2%)
Distant 39 (7.8%) 85 (11%)
Local 30 (6%) 42 (5.5%)
NO 366(73.2) 610 (79.3)
Recurrence
False Negative Sentinel Lymph Nodes
• Table 1 32/769 4.2%
• Text (page 1312) 26/764 3.4%
Lymph Node InvolvementNEJM 2006;355:1312
Observation (500) Sentinel Node (764)
78 (15.5%) 122 (16.0%)
Lymph Node InvolvementNEJM 2006;355:1312
Observation (500) Sentinel Node (764)
78 (15.5%) 122 (16.0%)
False Neg. 0 26 (3.4%)(Developed grossly + nodes)
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Lymph Node InvolvementNEJM 2006;355:1312
Observation (500) Sentinel Node (764)
78 (15.5%) 122 (16.0%)
False Neg. 0 26 (3.4%)(Developed grossly + nodes)
TOTAL 78 (15.5%) 148 (19.4%)
Lymph Node InvolvementNEJM 2006;355:1312
Observation (500) Sentinel Node (764)
78 (15.5%) 148 (19.4%)
Lymph Node InvolvementNEJM 2006;355:1312
Observation (500) Sentinel Node (764)
78 (15.5%) 148 (19.4%)
Conclusion: NOT all patients with a positive SN will develop clinically evident metastases
ConclusionsSentinel node biopsy
1. affords NO real benefit for patients.
ConclusionsSentinel node biopsy
1. affords NO real benefit for patients.
2. may potentially harm patients
ConclusionsSentinel node biopsy
1. affords NO real benefit for patients.
2. may potentially harm patients
3. Should NOT be the standard of Care
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ConclusionsSentinel node biopsy
1. affords NO real benefit for patients.
2. may potentially harm patients
3. should NOT be the standard of care.
4. raises ethical Issues:
ConclusionsSentinel node biopsy
1. affords no real benefit for patients.
2. may potentially harm patients
3. should NOT be the standard of care.
4. raises ethical Issues:
-Medicolegal
ConclusionsSentinel node biopsy
1. affords no real benefit for patients.
2. may potentially harm patients
3. should not be the standard of care.
4. raises ethical Issues:
-Medical-Legal
-Economic – Who Pays?
An Algorithmic Approach to the Diagnosis of Melanocytic Lesions
The Problems
• Imposing orderly criteria on a
natural/pathologic process
The Problems
• Imposing orderly criteria on a
natural/pathologic process
• Application of criteria is variable and
idiosyncratic
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The Problems
• Imposing orderly criteria on a
natural/pathologic process
• Application of criteria is variable and
idiosyncratic
• Biopsy type and size
• Variability in classification of melanocytic
lesions
My “Solution”: Keep it Simple
• Nevus vs. Melanoma
My “Solution”: Keep it Simple
• Nevus vs. Melanoma
• Few major criteria to evaluate the
likelihood of melanoma or not
My “Solution”: Keep it Simple
• Nevus vs. Melanoma
• Few major criteria to evaluate the
likelihood of melanoma or not
• Use a list of criteria to identify the
exceptions.
Melanoma, Nevus, Melanoma
and Nevus or….
“I’m Not Sure
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MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
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MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
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MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
MELANOCYTIC NEOPLASM
Small (<4mm) Large (>4mm)
ALMOST ALWAYS BENIGN Symmetrical Asymmetrical
* Exceptions Usually benign
* Exceptions Well circumscribed Poorly circumscribed
Often benign
Maturation No maturation
* Exceptions
* Melanoma or ALMOST ALWAYS
nevus MELANOMA
* Exceptions
Criteria for Exceptions
• Major Criteria Not Already Addressed
• “Too Many Melanocytes”
• Anatomic Site
• Type of Nevus
• Evidence of Prior Trauma
• Melanocytes Above the DE Junction
• Variation in Sizes, Shapes and Confluence of Nests
• Atypia
• Mitoses
• Necrosis
Criteria for Exceptions
• Major Criteria Not Already Addressed
• “Too Many Melanocytes”
• Stroma/Elastosis
• Anatomic Site
• Type of Nevus
• Evidence of Prior Trauma
• Melanocytes Above the DE Junction
• Variation in Sizes, Shapes and Confluence of Nests
• Atypia
• Mitoses
• Necrosis
Stroma/Elastosis
• RED/PURPLE Elastosis - Benign
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Stroma/Elastosis
• RED/PURPLE Elastosis - Benign
Stroma/Elastosis
• RED/PURPLE Solar Elastosis – Benign
• Location of Normal Solar Elastosis
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