Interactive Microscopy Session:

Second Edition: Modern Surgical

Pathology Through the Expert Eyes of
APSS-USCAP: Practical Issues in
Melanocytic Tumors
Handout

Steven D. Billings, MD
Professor of Pathology at the Cleveland Clinic Lerner College of Medicine of
Case Western Reserve University School of Medicine
Co-Director of the Dermatopathology Section
Cleveland, Ohio

Course Dates: October 27-30, 2019

Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

Melanocytic Tumors

It is important to develop a systematic approach to examination of melanocytic tumors.

With all melanocytic tumors, one should approach them in a systematic uniform way
before coming to terms with the specific diagnosis.

Low Power Magnification

Symmetry

The most important first step is to examine the entire lesion at low magnification. During
this process the number one quality to judge is the symmetry of the lesion. When judging
the symmetry of the lesion all aspects of the tumor should be included. Therefore
evaluation of the symmetry includes the junctional and dermal components of the
neoplasm as well as other factors including pigmentation and any associated
inflammatory response. Mentally divide the lesion into two equal halves and assessing
whether or not one half of the lesion appears similar to the other.

Medium-Powered Examination.

Growth Pattern

• Single cell vs. nested growth pattern: Assess whether the melanocytes along the
dermoepidermal junction are arranged predominantly as single cell (lentiginous pattern)
or nested

• Symmetry of growth pattern: Benign nevi typically have large nests at the center
of the lesion and smaller nests at the periphery. Melanoma has more varied nests.

• Location of nests: Benign nevi tend to have nests at the tip of the rete pegs.
Dysplastic nevi and melanoma have nests at varied location of the epidermis.

• Pagetoid spread: Is there upward migration of melanocytes?

• Circumscription: Are the lateral ends of the lesion nested or arranged as single
cells? A circumscribed pattern is more common in benign nevi.

• Dermal component: Are the dermal nests orderly? They should be larger at the
top and smaller deeper in the dermis for benign nevi. They are irregular in melanoma. A
confluent sheet-like growth pattern is worrisome for melanoma, though congenital nevi
may also appear confluent.

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

• Maturation: In benign nevi the nevus cells get smaller with increasing depth into
the dermis. This is called maturation. Melanomas typically do not mature.

High-Power Examination:

• Cytologic features: Assess cytologic atypia in the junctional and dermal

components.

• Pagetoid spread: Distinguish melanocytes from haloed keratinocytes

• Mitotic activity: Look for dermal mitotic figures

• Necrosis: single cell necrosis is sometimes seen in melanoma.

Additional General Rule for Melanocytic Tumors:

• Additional levels often helpful. If you are uncertain on the classification of

melanocytic tumors on initial routine sections, it is often helpful to additional deeper levels
through the block. This may reveal important features that are not seen in the initial
sections.

• Friday Afternoon Rule. In general at the end of the day or at the end of the week,
you are often tired and prone to make mistakes on difficult lesions. Therefore as a general
rule I almost never signout a difficult melanocytic lesion at the end of the day on Friday.
Waiting until Monday morning can be very helpful.

• Don’t be a Hero. It is often a good idea to share difficult cases with your partners
or get outside consultation if you are at all uncertain. Diagnosing melanocytic lesions is
difficult and a very lentiginous area in the practice of pathology. Therefore do not be
afraid to look for outside help.

Histology Issues:

Tangentially oriented skin: This often results in a pseudo-melanomatous pattern that is

not evident in well-oriented sections of epidermis. Tangentially oriented skin often shows
a single cell predominant pattern and may show pseudo-pagetoid spread of melanocytes.

During fixation, some keratinocytes show a retraction of the cytoplasm from the nucleus.
This can result in the keratinocytes of the spinous zone of the epidermis mimicking
pagetoid spread of melanocytes. A helpful clue to differentiate this phenomenon from
true pagetoid spread of melanocytes is the nature of the cytoplasm. In haloed
keratinocytes there is typically no cytoplasm clinging to the nucleus whereas any
retraction artifact around the melanocytes shows cytoplasm clinging to the nucleus and
the peripheral halo surrounding the cytoplasm.

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

Case 1: Melanocytic Hyperplasia

A common problem in evaluating melanomas is determining negative margins.

Frequently adjacent to melanomas (and other cutaneous neoplasms) there is reactive
melanocytic hyperplasia characterized by an increased number of melanocytes along the
dermoepidermal junction. It is important not to overcall this melanocytic proliferation as
residual melanoma in-situ. Unless there is marked atypia, contiguous proliferation of
melanocytes or melanocytic nests, it should not be interpreted as melanoma in-situ.

Reference: Trotter MJ. Melanoma margin assessment. Clin Lab Med. 2011
Jun;31(2):289-300.

Case 2: Recurrent/Traumatized Nevus

Previously biopsied or incompletely excised nevi can sometimes recur. The recurrent
lesion can show architectural abnormalities that can raise the differential diagnostic
consideration of melanoma. Specifically, overlying the scar the junctional component can
take on a single cell predominant pattern and can show upward migration of both nests
as well as individual melanocytes. Key to recognizing recurrent nevi is the fact that these
architectural abnormalities only occur overlying the area of scarred dermis.

References:

1. Kornberg R, Ackerman AB. Pseudomelanoma: recurrent melanocytic nevus

following partial surgical removal. Arch Dermatol. 1975 Dec;111(12):1588-90.
2. Arrese Estrada J. Pierard-Franchimont C. Pierard GE. Histogenesis of recurrent
nevus. American Journal of Dermatopathology. 12:370-2, 1990.

Case 3: Special Site Nevi and Special Situation Nevi

Nevi occurring in specific anatomic locations result in unusual histologic features that can
cause diagnostic difficulty. These special sites include acral skin, genital skin, breast
skin, hairline, and ear skin to name the most common special site locations. Nevi in these
locations have more architectural disarray than conventional nevi and may show some
increased atypia. As a general rule they still show some features of more conventional
nevi, including maturation, and absence of dermal mitotic activity. There are also special
situation nevi. Nevi in young children, teen-agers and pregnant patients often have some
epithelioid change and may show rare superficial dermal mitotic figures.

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

References:

1. Brenn T. Atypical genital nevus. Arch Pathol Lab Med. 2011 Mar;135(3):317-20.
2. Ahn CS, Guerra A, Sangüeza OP. Melanocytic Nevi of Special Sites. Am J
Dermatopathol. 2016 Dec;38(12):867-881.

Case 4: Atypical/Dysplastic Nevus

Dysplastic nevus is somewhat of a controversial topic. If one has numerous dysplastic

nevus, then there is a risk of dysplastic nevus syndrome which predisposes one to
develop melanoma. Clinically, they are irregular, but lack overt clinical features of
malignancy.

The junctional component has a lentiginous to nested growth pattern with bridging of
nests across rete pegs and odd placement of nests with associated lamellar fibroplasia.
There may be focal, limited upward migration. When present, the dermal component is
usually restricted to the papillary or upper reticular dermis. The dermal component
exhibits maturation and dermal mitotic figures should be absent. There is typically a
lymphocytic infiltrate and some associated melanoderma.

Grading of dysplastic nevi is based on nuclear features of the melanocytes. Traditionally,

if the melanocyte nuclei are about the same size or smaller than the basal keratinocyte
nuclei, it is considered to have mild atypia. If the melanocyte nuclei are up to twice the
size of the keratinocyte nuclei, the lesion has moderate atypia. If the nuclei are greater
than twice the size of keratinocyte nuclei, the lesion has severe atypia. With increasing
atypia, the megalocytes tend to have more abundant cytoplasm and more prominent
nucleoli. In the current WHO classification, what has been considered mildly dysplastic
nevi are no longer classified as dysplastic nevi. Dysplastic nevi with nuclei 1-1.5X nuclear
size of basal keratinocyte nuclei are now classified as low-grade dysplasia. Nevi with
>1.5X nuclear size are considered high-grade dysplasia.

References:

1. Elder DE. Dysplastic naevi: an update. Histopathology. 2010 Jan;56(1):112-20.

2. WHO Classification of Skin Tumours. DE Elder, D Massi, RA Scolyer, R Willemze,
eds. IARC, 2018.

Case 5: Classic Spitz Nevus

Spitz nevi tend to present in young patients. As a general rule of thumb, a spitzoid lesion
presenting in a patient < 20 years of age is much more likely to be a Spitz nevus. A
spitzoid lesion in someone > 40 years of age is much more likely to be a melanoma.
Clinically, Spitz nevi are often re to red brown in color and may clinically be confused with

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

vascular lesions. They are most common on the head and neck area and the proximal
extremities. Microscopically, Spitz nevi are usually symmetric with a predominantly
nested growth pattern. Frequently there are clefts overlying the junctional nests. The
nests are composed of epithelioid and/or spindled melanocytes. The melanocytes may
show significant cytologic atypia with enlarged, hyperchromatic nuclei and prominent
nucleoli. The lesion matures with descent into the dermis, and dermal mitotic figures are
absent or rare located only in the most superficial aspect of the dermal component. One
helpful clue to the diagnosis of Spitz is the presence of Kamino bodies, eosinophilic
globules of basement membrane material in the epidermis. Not all Spitz nevi have
Kamino bodies.

Case 6: Desmoplastic Spitz Nevus

Desmoplastic Spitz nevi have prominent stromal fibrosis. Microscopically desmoplastic

Spitz nevi have variable amounts of a junctional component. Superficially they have
epithelioid morphology than tends to transition to spindled cells deeper in the dermis.
They are associated HRAS mutations.

Case 7: Spitz Nevus with ALK Fusion

It is now recognized that a number of Spitz tumors have gene fusions involving, ROS1,
ALK, NTRK1, NTRK3, BRAF, and RET. Some fusions result in distinct phenotypes. ALK
fusions result in a tumor with intersecting fascicles, as in this case.

Case 8: Pagetoid Spitz Nevus

This rare variant typically presents on the legs of young women as a small, 0.5 cm or
smaller lesion. Microscopically, it can bear a striking resemblance to melanoma in situ
with a proliferation of intraepidermal atypical epithelioid melanocytes with pagetoid
scatter. Features that help distinguish this lesion from melanoma is the lack of
pleomorphism, the absence of mitotic activity and the absence of fine, dusty melanocytic
pigment.

References:

1. Menezes FD, Mooi WJ. Spitz Tumors of the Skin. Surg Pathol Clin. 2017
Jun;10(2):281-298.
2. Tetzlaff MT, Reuben A, Billings SD, Prieto VG, Curry JL. Toward a Molecular-
Genetic Classification of Spitzoid Neoplasms. Clin Lab Med. 2017 Sep;37(3):431-
448.
3. WHO Classification of Skin Tumours. DE Elder, D Massi, RA Scolyer, R Willemze,
eds. IARC, 2018.

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

Case 9: BAP1 Inactivated Nevus

BAP1 inactivated nevus is usually a biphasic, mostly or entirely intradermal tumor

composed of large epithelioid cells with abundant dense cytoplasm, crisp cytoplasmic
membranes and large nuclei with prominent nucleoli admixed with conventional
appearing melanocytes. A brisk lymphocytic infiltrate is often present. The diagnosis can
be confirmed with BAP-1 IHC demonstrating loss of nuclear staining in the epithelioid
melanocytes. If a patient has multiple such tumors, they may have germline BAP1
mutations (BAP1 tumor predisposition syndrome) and increased risk of uveal melanoma,
mesothelioma, renal cell carcino0ma and basal cell carcinoma.

References:

1. Garfield EM, Walton KE, Quan VL, VandenBoom T, Zhang B, Kong BY, Isales MC,
Panah E, Kim G, Gerami P. Histomorphologic spectrum of germline-related and
sporadic BAP1-inactivated melanocytic tumors. J Am Acad Dermatol. 2018
Sep;79(3):525-534.
2. Zhang AJ, Rush PS, Tsao H, Duncan LM. BRCA1-associated protein (BAP1)-
inactivated melanocytic tumors. J Cutan Pathol. 2019 Jun 24. [Epub ahead of print]
Review.

Case 10: Spitzoid Melanoma

Spitzoid melanoma tends to occur in adults but may rarely occur in children. They are
not clinically distinctive. Microscopically they resemble Spitz nevi in that they tend to be
symmetric, circumscribed and are composed of epithelioid melanocytes. Clefts overlying
junctional nests may be seen. Kamino bodies are typically absent and not clustered. The
growth pattern of the dermal component is often where distinction from a Spitz nevus is
possible. The dermal component is often quite deep in the reticular dermis and even
subcutis. A confluent, sheet-like growth pattern is common as well as large nodules.
There is an absence of maturation and cells with prominent nucleoli are frequently seen
deep in the dermis. There is increased pleomorphism at the same latitude within the
tumor. Mitotic figures are often present. They often have loss of p16 expression.

Reference:

Gerami P, Busam K, Cochran A, Cook MG, Duncan LM, Elder DE, Fullen DR, Guitart J,
LeBoit PE, Mihm MC Jr, Prieto VG, Rabkin MS, Scolyer RA, Xu X, Yun SJ, Obregon R,
Yazdan P, Cooper C, Weitner BB, Rademaker A, Barnhill RL. Histomorphologic
assessment and interobserver diagnostic reproducibility of atypical spitzoid melanocytic
neoplasms with long-term follow-up. Am J Surg Pathol. 2014 Jul;38(7):934-40.

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

Case 11: Hypopigmented Blue Nevus

Blue nevus is a commonly biopsied melanocytic lesion that can present in any location
and at any age. The most typical histologic appearance is that of pigmented spindled
melanocytes within a collagenous stroma. It is important to remember that some blue
nevi may lack pigment altogether. The hypopigmented variant is often difficult to
recognize. However they have the same bland nuclear features and sclerotic stroma of
conventional blue nevi.

Reference:

Bolognia JL, Glusac EJ. Hypopigmented common blue nevi. Arch Dermatol. 1998
Jun;134(6):754-6.

Case 12: Cellular Blue Nevus

Cellular blue nevi tend to arise in children and young adults. They present as blue-black
lesions and are most commonly seen in the buttocks, sacral area and scalp, though
almost any location can be affected. Microscopically, they have a lobular growth pattern,
often with a “dumbbell” shape and pushing border. They are intradermal tumors that lack
a junctional component. Cellular blue nevi have a biphasic appearance with oval to
spindled melanocytes with clear to eosinophilic cytoplasm and a population of pigmented
dendritic melanocytes, like those seen in conventional blue nevi, and melanophages.
Melanomas may arise in cellular blue nevi, and typically show abrupt transition to cells
with significant atypia and mitotic activity.

Reference:

WHO Classification of Skin Tumours. DE Elder, D Massi, RA Scolyer, R Willemze, eds.

IARC, 2018.

Case 13: Deep Penetrating Nevus (DPN)

DPN are clinically often darkly pigmented. Microscopically, they often have a wedge
shape and are composed of fascicles of epithelioid and spindled melanocytes with
admixed melanophages. A limited junctional component is often present. The intradermal
melanocytes often have intranuclear cytoplasmic inclusions. By IHC, they will show
nuclear positivity for beta-catenin, unlike blue nevi.

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

Reference:

de la Fouchardière A, Caillot C, Jacquemus J, Durieux E, Houlier A, Haddad V, Pissaloux

D. β-Catenin nuclear expression discriminates deep penetrating nevi from other
cutaneous melanocytic tumors. Virchows Arch. 2019 May;474(5):539-550.

Case 14: Superficial Spreading Melanoma (Low-Chronic Sun Damage Melanoma)

Classic superficial spreading melanoma typically occurs on the trunk or other sites with
low-cumulative sun damage. Microscopically, they are asymmetric and composed of
atypical epithelioid melanocytes and usually have pagetoid spread. The dermal
component lacks maturation and often exhibits mitotic activity. They are associated with
BRAF V600E mutations.

Reference:

WHO Classification of Skin Tumours. DE Elder, D Massi, RA Scolyer, R Willemze, eds.

IARC, 2018.

Case 15: Melanoma In-Situ on Heavily Sun-Damaged Skin of the Head and Neck
(lentigo maligna and lentigo maligna melanoma)

Lentigo maligna refers to a melanoma in-situ in chronically sun-damaged skin that

clinically has resemblance to a solar lentigo. If there is invasive tumor, the designation of
lentigo maligna melanoma is used. Histologically melanoma in-situ in this clinical setting
may be diagnostically problematic, as the degree of nuclear atypia or pagetoid spread is
less than that seen in superficial spreading melanoma. The tumor is characterized by a
contiguous proliferation of single melanocytes with focal nests. The atypia is typically
mild in nature. Extension down adnexal structures is also a helpful clue. It is very
important to have a high index with suspicion of melanoma in-situ in this setting. I
consider almost any contiguous proliferation of melanocytes in combination with
melanocytic nests melanoma in-situ in this clinical context.

Reference:

WHO Classification of Skin Tumours. DE Elder, D Massi, RA Scolyer, R Willemze, eds.

IARC, 2018.

Case 16: Desmoplastic Melanoma

Desmoplastic melanomas (DM) comprise up to 4% of all melanomas. DM usually

presents in older patients, most commonly on the head and neck followed by the lower
extremities. They are often clinically amelanotic. Pure DM is composed of

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

hyperchromatic spindled cells with a distinctly ‘packeted’ growth pattern embedded within
a collagenous stroma. The lesion should have low cellularity, with ~90% of the tumor
volume composed of the collagenous stroma. More cellular tumors should be classified
as spindle cell melanoma or mixed type DM. An overlying component of lentigo maligna
is often present. Essentially all DM show strong, diffuse immunoreactivity for S-100
protein and SOX10 but are negative for melanocyte specific markers.

Reference:

Busam KJ. Desmoplastic melanoma. Clin Lab Med. 2011 Jun;31(2):321-30.

Case 17: Nevoid Melanoma

Nevoid Melanoma clinically is often innocuous in appearance. It may have a verrucous

dome-shape and clinically mimics a benign nevus. Microscopically, nevoid melanoma
also bears a resemblance to benign nevi on scanning power and low magnification. They
are typically composed of a relatively symmetric proliferation of small epithelioid
melanocytes. There is only subtle atypia recognized at low magnification. A clue to the
diagnosis is a tendency for the melanoma to grow in solid sheets rather than nests. The
higher power the subtle atypia is more obvious with relatively prominent nucleoli and
irregular nuclear membranes. Nevoid melanoma typically shows significant mitotic
activity within the dermal component.

Reference:

Zembowicz A, McCusker M, Chiarelli C, Dei Tos AP, Granter SR, Calonje E, McKee PH.
Morphological analysis of nevoid melanoma: a study of 20 cases with a review of the
literature. Am J Dermatopathol. 2001 Jun;23(3):167-75.

Case 18: Acral Melanoma

Acral melanoma occur in any race but it the most common subtype in darkly pigmented
people, presenting as pigmented lesion on the volar aspect of feet, hands or on the nail
apparatus. It usually has a lentiginous growth pattern but may also be nodular or
superficial spreading melanoma. Classic ALM has a single cell growth pattern along the
epidermis as well as irregular nests. Skip areas are common. There is variable upward
migration of melanocytes, becoming more prominent in older and larger lesions. When
present it tends to be more prominent and irregular than that seen in acral nevi. Nuclear
atypia is frequently mild in nature, usually consisting of melanocytes with slightly enlarged
hyperchromatic nuclei. There is frequently a halo around the junctional tumor cells
resulting in an angulated appearance. KIT mutations or amplifications are the most
common genetic abnormality.

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Interactive Microscopy Session | Second Edition: Modern Surgical Pathology Through the Expert Eyes
of APSS-USCAP: Practical Issues in Melanocytic Tumors | Steven D. Billings, MD (Oct. 27-30, 2019)

References:

1. Brenn T. Melanocytic lesions - Staying out of trouble. Ann Diagn Pathol. 2018
Dec;37:91-102.
2. WHO Classification of Skin Tumours. DE Elder, D Massi, RA Scolyer, R Willemze,
eds. IARC, 2018.

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