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Presented by Jonathan Epstein, M.D. and prepared by Orin Buetens, M.D.
Case 2: 14 year old female with skin lesion on the arm
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1. Question
Week 5: Case 2
14 year old female with skin lesion on the arm
Correct
Answer: Spitz nevus
Histolgy: At low magnification, the lesion is small (<5 mm) and has a symmetrical dome shaped appearance. Epidermal hyperplasia is noted overlying the dermal infiltrate. At higher magnification, the surface of the lesion in areas is ulcerated. Where the overlying squamous epithelium is intact there is no spread of the lesion into the epidermis. The dermal lesion consists of a spindle cell proliferation arranged in nests. In areas the nests are arranged perpendicular to the overlying epidermis. Some of the nests are seen at the dermal-epidermal junction. The cells within the nests have a spindle morphology yet are uniform in size and shape. Occasional mitotic figures are seen in the superficial dermal component. However, within the deeper dermal infiltrate, mitotic figures are not identified. A lymphocytic infiltrate is seen scattered throughout the lesion. There is only a scant amount of pigment present within the lesion. At the dermal-epidermal junction occasional hyaline pink bodies are identified. These are termed Kamino bodies.
Discussion: The major differential diagnosis in this lesion is between Spitz nevus and malignant melanoma. Spitz nevi may have both epithelioid and spindled appearance. The current case consists of a totally spindled Spitz nevus. Features that favor the diagnosis of Spitz nevus over melanoma include: 1) small size (most melanomas are >6 mm); 2) symmetry; 3) lack of prominent epidermal component; 4) presence of epidermal hyperplasia overlying the lesion; 5) the lesion is circumscribed where the epidermal component does not extend beyond the dermal component; 6) mitoses are few and only present in the superficial portion of the dermis; 7) eosinophilic Kamino bodies are found at the dermal-epidermal junction; and 8) the young age of the patient. A schwannoma potentially could have a similar spindled appearance although a schwannoma would occur as a circumscribed dermal nodule lacking epidermal involvement. Dysplastic nevus is a term which is controversial and has been used differently by different investigators. In general, it refers to typical common nevi which have either architectural and/or cytologic atypia and not specific subtypes of nevi such as Spitz nevus.
Incorrect
Answer: Spitz nevus
Histolgy: At low magnification, the lesion is small (<5 mm) and has a symmetrical dome shaped appearance. Epidermal hyperplasia is noted overlying the dermal infiltrate. At higher magnification, the surface of the lesion in areas is ulcerated. Where the overlying squamous epithelium is intact there is no spread of the lesion into the epidermis. The dermal lesion consists of a spindle cell proliferation arranged in nests. In areas the nests are arranged perpendicular to the overlying epidermis. Some of the nests are seen at the dermal-epidermal junction. The cells within the nests have a spindle morphology yet are uniform in size and shape. Occasional mitotic figures are seen in the superficial dermal component. However, within the deeper dermal infiltrate, mitotic figures are not identified. A lymphocytic infiltrate is seen scattered throughout the lesion. There is only a scant amount of pigment present within the lesion. At the dermal-epidermal junction occasional hyaline pink bodies are identified. These are termed Kamino bodies.
Discussion: The major differential diagnosis in this lesion is between Spitz nevus and malignant melanoma. Spitz nevi may have both epithelioid and spindled appearance. The current case consists of a totally spindled Spitz nevus. Features that favor the diagnosis of Spitz nevus over melanoma include: 1) small size (most melanomas are >6 mm); 2) symmetry; 3) lack of prominent epidermal component; 4) presence of epidermal hyperplasia overlying the lesion; 5) the lesion is circumscribed where the epidermal component does not extend beyond the dermal component; 6) mitoses are few and only present in the superficial portion of the dermis; 7) eosinophilic Kamino bodies are found at the dermal-epidermal junction; and 8) the young age of the patient. A schwannoma potentially could have a similar spindled appearance although a schwannoma would occur as a circumscribed dermal nodule lacking epidermal involvement. Dysplastic nevus is a term which is controversial and has been used differently by different investigators. In general, it refers to typical common nevi which have either architectural and/or cytologic atypia and not specific subtypes of nevi such as Spitz nevus.
