Deba P Sarma, MD

CUMC, Omaha
Common sense classification of pigmented lesions

Benign: Lentigo simplex

Solar lentigo
Nevus (Junctional, Dermal, Compound, Blue,
Spitz, Dysplastic)

Potentially malignant:
Atypical melanocytic hyperplasia
Malignant:
Melanoma in-situ
Invasive melanoma
 Melanoma
In-situ Invasive
Lentigo maligna Lentigo maligna melanoma
Superficial spreading Superficial spreading(Pagetoid melanoma)
Acral-lentiginous Acral-lentiginous melanoma
None Nodular
None Desmoplastic
 Lentigo simplex

Elongated rete ridges

Basal melanosis
No junctional nest
No solar elastosis
 Solar lentigo

Elongated rete ridges

Basal melanosis
No junctional nest
Dermal solar elastosis
 Nevus: Junctional

Flat epidermal lesion

Junctional nests with clefts
 Nevus: Dermal

Raised lesion
Dermal nests
No junctional nests
 Nevus: Compound

Raised or flat (older person) lesion

Junctional clefted nests and dermal nests
 Nevus: Epithelioid (Spitz nevus)

70% occurs in pts < 20 yrs

Raised, junctional or compound nevus
Epithelioid clefted nests oriented vertically
Cytologic and nuclear pleomorphism
 Nevus: Dysplastic

All ages
Compound nevus
Junctional clefted nests with transverse growth pattern (bridging)
Cytologic and nuclear pleomorphism
 Nevus: Blue

Flat lesion
No junctional nest
Dermal pigmented spindled melanocytes
Lentiginous nevus

Flat lesion.
Common nevus + lentigo simplex
 Atypical melanocytic hyperplasia

Flat, lentiginous lesion in older people

Junctional melanocytic hyperplasia with small nests
Mild to moderate pleomorphism
Not like any common nevus
Not enough for in-situ melanoma
Melanoma

 Lentigo maligna & lentigo maligna melanoma

 Superficial spreading ( Pagetoid): In-situ &

invasive

 Acral-lentiginous: In-situ & invasive

 Nodular: Invasive

 Desmoplastic: Invasive
Melanoma in-situ: Lentigo maligna type

Epidermal atrophy, solar elastosis

Confluent and nested proliferation of pleomorphic melanocytes
Melanoma in-situ: Lentigo maligna type

Neoplastic melanocytes spread from the junction upwards

and along the adnexa.
No dermal invasion.
Malignant melanoma: Lentigo maligna type
(Lentigo maligna melanoma)

Tumor has invaded into the dermis

Superficial spreading in-situ & invasive melanoma
Acral-lentiginous in-situ & invasive melanoma

Location: foot,toes, hand,fingers

Race: Dark-skinned people
Microscopic appearance: same as lentigo maligna melanoma
Nodular and Desmoplastic melanoma

No in-situ phase
Invasive at diagnosis
Nodular melanoma

Raised, ulcerated, no radial spread, deep dermal invasion

 Desmoplastic melanoma

Sun-exposed skin
Older people
Indurated plaque
Spindle cell proliferation in dermis
Solar elastosis
Lymphocyte-plasma cell aggregates

NEED HIGH DEGREE OF SUSPICION

GET S-100 STAIN
 REMEMBER

1. Most (95%) of the pigmented lesions are benign, 4% malignant, 1% borderline.

2. Most (70%) of the melanoma are superficial spreading type.

3. Most of the melanoma occurs in the sun-protected skin.

4. Most of the melanomas occur on the trunk (specially back) of man and
lower extremities (specially thigh) of woman.

5. Melanoma is very rare in person below 20 years of age. Exclude Spitz nevus first.

6. If you are not sure of melanoma, do not call MELANOMA. Raise the possibility in
comment, ask for complete resection for further evaluation.

7. Ask for another expert opinion.

8. Do not make ‘wishy-washy’ and confusing comment in melanoma diagnosis.