The Enigmatic Spitz Lesion

Transcription

1 The Enigmatic Spitz Lesion

2 The Dawn of Spitz

3 S Spitz Sophie Spitz Melanomas of Childhood ; Am J Pathol children (18 mo - 12 yrs) 12/13 had a benign clinical course

4 Sophie Spitz Born 1910 in Nashville AFIP 1944/45: Atlas of Pathology of Tropical Diseases MSK

5 Sophie Spitz

6 Spitz & Allen

7 Am J Pathol 1948

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9 S Spitz Sophie Spitz Melanomas of Childhood ; Am J Pathol children (18 mo - 12 yrs) 12/13 had a benign clinical course JUVENILE MELANOMA - different from adult tumors

10 Sophie Spitz s Melanomas - Heterogeneous Group of Tumors Am J Pathol 1948 S Spitz 13 children (18 mo -12 yrs) All benign except for one: 12 yo girl Tumor on foot Deeply locate: plantar fascia Probable correct diagnosis: Clear cell sarcoma

11 Juvenile Melanoma A sheep in wolf s clothes

12 Spitz Nevus Kernan JA, Ackerman LV. Spindle cell nevi and epithelioid cell nevi (socalled juvenile melanomas) in children and adults: a clinicopathological study of 27 cases. Cancer. 1960;13: Weedon D, Little J. Spindle and epithelioid cell nevi in children and adults. A review of 211 cases of Spitz nevi. Cancer 1977; 40: Paniago-Pereira C, Maize JC, Ackerman AB. Nevus of large spindle and/or epithelioid cells (Spitz's nevus). Arch Dermatol. 1978; 114:

13 Spitz Nevus Melanoma J Derm Surg 1975

14 Distinction by Microscopy Spitz Nevus Architecture Symmetric Sharply circumscribed Cytology Maturation Spindle and/or epitheloid Other Features Kamino bodies Clefts Melanoma Architecture Asymmetric Ill-defined Cytology No maturation Pagetoid, Pleomorphism Other Features No Kamino bodies Consumption of epidermis

15 Picasso vs DaVinci

16 Real Picasso vs Fake Picasso

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18 28 F, left arm Spitz Nevus

19 Spitz Nevus Kamino Bodies

20 Pigmented Spitz Nevus

21 The Spitz Family Grows Spitz nevus, nos Pigmented spindle cell nevus of Reed Desmoplastic Spitz nevus Angiomatoid Spitz nevus Halo Spitz nevus Pagetoid Spitz nevus Others

22 Darth Spitz

23 Reported as Spitz Nevus 28 yo man with dark mole on chest Spitz s nevus

24 Junctional nests of pigmented spindle cells with cleft Maturation Mitotic figures

25 Spitzoid Melanoma 6 yrs later 6 yrs later: LN Metastasis

26 The Fog of Spitz

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31 Atypical Spitz Tumor or Spitz Nevus?

32 Spitz Nevus, AST or Melanoma? Nevoid Borderline Tumor

33 BAP1 Diagnosis: BAP1-Deficient Nevus (aka Wiesner s Nevus)

34 Surgery to the Rescue

35 J Am Acad Dermatol 2000;42:527-30

36 SLN Findings for Diagnosis If any neoplasm made up of melanocytes metastasizes, it is a melanoma A Spitz-like lesion that metastasizes is a melanoma, pure and simple Mones & Ackerman Am J Dermatopathol 2004;26: AB Ackerman

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39 Dermal Solar Elastotic Material in SLN Am J Surg Pathol 2010; 34:1492-7

40 Mesothelial Cells in LN

41 Subcapsular Melanocytes What do they mean? Mart1 Mart1 Axillary SLN from 44F with mammary adenocarcinoma

42 The Brave New Spitz The Molecularization of Spitz

43 Molecular Classification of Spitz Tumors

44 Desmoplastic Spitz Nevus 33 F SNP-array: 11p

45 Spitz Nevus with ALK Fusions 25 M ALK

46 Alk-Fusion Partners in Spitz lesions TPM3 DCTN1 GTF3C2 NPM1 CLIP1 TPR MLPH (1q21.3) (2p13.1) (2p23.3) (5q35.1) (12q24.31) (1q31.1) (2q37.3)

47 28F NTRK1 Spitz Nevus with NTRK1 expression

48 NTRK-Fusions LMNA-NTRK1 TP53 NTRK1 ETV6 - NTRK3 MYO5A NTRK3 MYH9 NTRK3

49 Atypical Spitz Tumor with ALK-Fusion ALK

50 Atypical Spitz with NTRK1-Fusion

51 Value of Molecular Findings Clarity of Terminology Adjunct Evidence for Diagnosis Possibly Useful for Prognosis and/or Treatment

52 Clarity of Terminology Spitzoid Resembles a Spitz Nevus Spitz/Spitzian Pathway of Spitz Nevus

53 Spitzoid Melanomas

54 Melanomas with BRAF and NRAS Mutations Conventional melanomas with minor spitzoid features

55 Spitzoid Melanoma vs Malignant Spitz Tumor BRAF- or NRAS- mutated conventional melanomas with spitzoid features Melanomas with genomic aberrations typical of Spitz = malignant Spitz tumors

56 Spitz Nevus vs Melanoma Role of Molecular Studies for Diagnostic Accuracy

57 19 F, rt wrist

58 Diagnosis in 2001 Spitz Nevus, Compound Type

59 LN, rt axilla, 2013 S100P

60 FISH for EWSR1 break apart TRANSLOCATION NORMAL

61 Diagnosis Compound Clear Cell Sarcoma J Cutan Pathol 2013; 40: 950-4

62 14 F; rt cheek Diagnosis?

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64 Path Report: Spitzoid Neoplasm with Severe Atypia

65 Cytogenetics: Gain of 11p 11p

66 14 F, rt cheek Diagnosis: Spitz Nevus

67 Spitzoid Melanoma 6 yrs later FISH Results: Gains in CCDN1 (11q13) and RREB1 (6p25) in > 70% of cells Metastatic melanoma

68 Potential Prognostic or Therapeutic Significance Kinase fusions

69 Spitzoid Neoplasms Spitz Nevi Atypical Spitz Tumors (AST) Spitzoid/Spitzian Melanoma

70 Spitzoid Neoplasms Tools for Dx Conventional H&E IHC Molecular Studies Clinical Correlation

71 Spitz Nevus or Melanoma?

72 Spitzoid Neoplasm

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75 Clinical Findings 68 yo woman New lesion within past year Has doubled in diameter in 3 months

76 Diagnosis: Melanoma

77 Mutation Status: NRASQ61R

78 Cytogenetic Analysis: Melanoma

79 Spitzoid Melanoma of Adults A Diagnostic Problem Wolf in Sheep s Clothing - Modern ancillary methods can reduce diagnostic errors - Better clinical correlation can reduce errors

80 Use of Atypical Spitz Tumor Diagnostic Problem Short Term Work-up incomplete Diagnostic Uncertainty Long Term Work-up did not yield definitive evidence Low Grade Malignant Neoplasm

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82 Pediatric Melanomas Melanoma death rates (2007, USA): 13.5% ( MSKCC: Death rate of patients with melanoma diagnosed before age 18: 12%

83 Is Spitzoid Melanoma of Childhood a Malignant Melanoma? Cancer 2013; 119: 3911

84 Spitz Rebirth From Juvenile Melanoma to Spitzoid Melanoma of Childhood

85 Summary Spitz nevus vs tumor vs melanoma Spitzoid vs Spitz/Spitzian Molecular Pathology (Diagnosis/Classification)

86 The Spectrum of Spitz Benign Spitz Atypical Spitz Malignant Spitz

87 MSKCC Dept of Pathology 1948

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89 New Textbook

90 Thank You!