Melanocytic Nevi and
Neoplasms
Andrew’s chapter 30
JoAnne M. LaRow, D.O.
Epidermal Melanocytic Lesions
 Normal melanocte occurring at the epidermal-Normal melanocte occurring at the epidermal-
d...
Nevus Spilus
Pigmented, light brown orPigmented, light brown or
tan macule, variedtan macule, varied
diameter, speckled wi...
Nevus SpilusWhen these nevi follow aWhen these nevi follow a
dermatomal distribution theydermatomal distribution they
may ...
Nevus Spilus
-The darker speckles usually contain nevus-The darker speckles usually contain nevus
cellscells
-Due to this ...
Lentigo Simplex
 Usually arise in childhood but can arise anytimeUsually arise in childhood but can arise anytime
 Sharp...
Solar Lentigines
Commonly called “liverCommonly called “liver
spots”spots”
Hyperpigmented maculesHyperpigmented macules
Ma...
Penile and Vulvar Melanosis
 Localized pigmentaryLocalized pigmentary
alterationsalterations
 Most often show basilarMos...
Bannayan-Riley-Ruvalcaba
Syndrome
 Rare, AD disorder that manifests inRare, AD disorder that manifests in
childhoodchildh...
Multiple Lentigenes Syndrome
 Lentigines are darkLentigines are dark
brown macules 1-5brown macules 1-5
mm.mm.
 Preponde...
LEOPARD Syndrome
 Leopard syndrome =Leopard syndrome =
acronym for lentigines,acronym for lentigines,
electrocardiographi...
Moynahan Syndrome
 Multiple lentiginesMultiple lentigines
 Congenital mitral stenosisCongenital mitral stenosis
 Dwarfi...
Centrofacial Lentiginosis
 Characterized by lentigines on the nose, andCharacterized by lentigines on the nose, and
adjac...
Inherited Patterned Lentiginosis
in Blacks
 AD- reportedly, 10 light-AD- reportedly, 10 light-
complexioned blackcomplexi...
Carney’s Syndrome
 AKA NAME syndrome or LAMBAKA NAME syndrome or LAMB
syndromesyndrome
 Characterized by cardiocutaneous...
Peutz-Jeghers Syndrome
 ADAD
 Pigmented macules onPigmented macules on
the lips, oral mucosa,the lips, oral mucosa,
peri...
Melanoacanthoma
 uncommon lesion, a benign epidermaluncommon lesion, a benign epidermal
melanocytic neoplasm, occurring o...
Cellular Nevi
 Begins to appear in first yrs of life, increase inBegins to appear in first yrs of life, increase in
preva...
Junctional Nevi
 Nevi begin as small, flat,Nevi begin as small, flat,
pigmented macules =pigmented macules =
junctional n...
Compound Nevus
 The compound nevus is one that is stillThe compound nevus is one that is still
manifesting so-called junc...
Junctional Nevi
 Nevi begin as small, flat,Nevi begin as small, flat,
pigmented macules =pigmented macules =
junctional n...
Compound Nevus
 The compound nevus is one that is stillThe compound nevus is one that is still
manifesting so-called junc...
Compound Nevus
 An 8-mm, well-An 8-mm, well-
circumscribed,circumscribed,
symmetric, uniformlysymmetric, uniformly
colore...
Compound Nevus
 Nests ofNests of
nevusnevus
cells incells in
thethe
epidermiepidermi
ss
overlyingoverlying
a dermala derm...
Compound Nevus
 Acral type-thickened basketAcral type-thickened basket
weave stratum corneumweave stratum corneum
shows t...
Intradermal Nevus
 a compound nevus in which junctionala compound nevus in which junctional
activity- that is, theques of...
Intradermal Nevus
 Low power-as inLow power-as in
junctional nevi , dermaljunctional nevi , dermal
nevi contain nevus cel...
Balloon Cell Nevus A pigmented nevus, varyingA pigmented nevus, varying
in size from 1 –5 mm, usuallyin size from 1 –5 mm...
Halo Nevus
 AKA Sutton’s nevus,AKA Sutton’s nevus,
perinevoid vitilgo, &perinevoid vitilgo, &
leukoderma acquisitumleukod...
Halo Nevus
 The nevus architectureThe nevus architecture
is obscured by a denseis obscured by a dense
lymphocytic infiltr...
Congenital Nevocytic Nevus
 Giant Pigmented NevusGiant Pigmented Nevus
(Giant hairy nevus,(Giant hairy nevus,
bathing tru...
Congenital Nevocytic Nevus
 Giant hairy nevi areGiant hairy nevi are
present at birth and growpresent at birth and grow
p...
CNN
 About 40% of the malignantAbout 40% of the malignant
melanomas seen in childrenmelanomas seen in children
occur in l...
Small and Medium-sized
Congenital Nevocytic Nevus
 Small - < 1.5 cm in greatest diameterSmall - < 1.5 cm in greatest diam...
Epitheliod and Spindle-Cell
Nevus(benign Juvenile
Melanoma, Spitz Nevus)
Spitz Nevus
 A smooth-surfaced, raised, round, slightlyA smooth-surfaced, raised, round, slightly
scaly, firm papule with...
Spitz Nevus
A variant of the compoundA variant of the compound
nevusnevus
 Epidermal irregularEpidermal irregular
acantho...
Spitz Nevus
Giant cells with eosiophilicGiant cells with eosiophilic
cytoplasm and a largecytoplasm and a large
nucleus ma...
Spitz Nevus
* Immunohistochemical staining for MIB-1* Immunohistochemical staining for MIB-1
and bcl-2 will distinguish mo...
Dysplastic Nevus
 Variegated tan, brown,Variegated tan, brown,
pink colorationpink coloration
 Pink hues seen in macular...
Dysplastic Nevus Syndrome
 Around 1978 Lynch et al recognized an autosomalAround 1978 Lynch et al recognized an autosomal...
Dysplastic Nevus Syndrome-
Genetics
 25% -33% of pts have germline mutations on25% -33% of pts have germline mutations on...
Dysplastic Nevus Syndrome
 Dysplasic nevi occur commonly in pts without aDysplasic nevi occur commonly in pts without a
p...
Dysplastic Nevus Syndrome
 Histologic features as per an NIH consensus-Histologic features as per an NIH consensus-
basil...
Dysplastic Nevi
 Patients with dysplastic nevi and a positivePatients with dysplastic nevi and a positive
family or perso...
Melanoma
 Originate fromOriginate from
melanocytes at epidermal-melanocytes at epidermal-
dermal junctiondermal junction
...
Melanoma
 One in 80 Americans willOne in 80 Americans will
develop melanomadevelop melanoma
 Incidence is low until afte...
Diagnosis of Melanoma
- surgical excision is the best method- surgical excision is the best method
-for larger lesions an ...
Histologic diagnosis:
-presence of mitoses-presence of mitoses
-inflammatory reaction-inflammatory reaction
composed ofcom...
Histologic diagnosis:
-a moderately brisk tumor--a moderately brisk tumor-
infiltrating lymphocyteinfiltrating lymphocyte
...
Melanoma
Metastasis-usuallyMetastasis-usually
manifested bymanifested by
pigmented nodulespigmented nodules
appearing arou...
Melanoma
 > 50 benign nevi> 50 benign nevi
 Presence of large congenital nevusPresence of large congenital nevus
 Prese...
Melanoma
There are four recognized clinicohistologicThere are four recognized clinicohistologic
types:types:
1.) Lentigo m...
Melanoma
*Pedunculated, polypoidal melanomas,*Pedunculated, polypoidal melanomas,
inflammatory melanomas, amelanoticinflam...
Lentigo maligna(melanoma in
situ, noninvasive melanoma)
 Begins as a tan macule that extends peripherally,Begins as a tan...
Lentigo maligna(melanoma in
situ, noninvasive melanoma)
Superficially spreading
melanoma
 In a study by Bolognia etIn a study by Bolognia et
al 5% of lesions with anal 5% of les...
Acral-lentiginous melanoma
 Acral-lentiginous melanoma lies midway betweenAcral-lentiginous melanoma lies midway between
...
Melanoma- workup and follow-
up
-establish a family history-establish a family history
-thorough review of systems-thoroug...
Melanoma-treatment
-early diagnosis and excision-early diagnosis and excision
-margin of 0.5 to 1.0 cm for melanoma in sit...
Melanoma-treatment
-high-dose interferon alfa-2b therapy has been used,-high-dose interferon alfa-2b therapy has been used...
Dermal Melanocytic Lesions
 At birth, melanocytes may be present in theAt birth, melanocytes may be present in the
dermal...
Mongolian Spot
 Bluish gray macule ofBluish gray macule of
varying size from 2-8 cmvarying size from 2-8 cm
 Occurs typi...
Mongolian Spot
Multiple spots occurring in a widespreadMultiple spots occurring in a widespread
distribution have been ter...
Nevus of Ota
 Aka nevus fuscocerulleusAka nevus fuscocerulleus
opthalmaomaxillarisopthalmaomaxillaris
 Usually present a...
Nevus of Ito
 Aka nevus fuscoceruleus acromiodeltoideusAka nevus fuscoceruleus acromiodeltoideus
 Has the same features ...
Blue Nevus
 Two types:Two types:
 1.) Blue nevus of Jadassohn-Tiche1.) Blue nevus of Jadassohn-Tiche
(common blue nevus)...
Blue Nevus Within the dermis there isWithin the dermis there is
a poorly defined buta poorly defined but
symmetric spindl...
Blue Nevus of Jadassohn-Tiche
 The typical common blueThe typical common blue
nevus or nevus ceruleusnevus or nevus cerul...
Cellular Blue Nevus
 Large, firm, blue or blue-Large, firm, blue or blue-
black noduleblack nodule
 Frequently seen on t...
Cellular Blue Nevus
 Frequently large andFrequently large and
involve a good part of theinvolve a good part of the
dermis...
Cellular Blue Nevus
 The cellular areas areThe cellular areas are
composed of uniformcomposed of uniform
spindled melanoc...
Epithelioid Blue Nevus
 Newly described lesionNewly described lesion
 Strong association with Carney’s complexStrong ass...
Malignant Blue Nevus
 -Cellular blue nevus may rarely undergo-Cellular blue nevus may rarely undergo
malignant transforma...
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
Melanocytic Nevi and Neoplasms Andrew's chapter 30
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Melanocytic Nevi and Neoplasms Andrew's chapter 30

  1. 1. Melanocytic Nevi and Neoplasms Andrew’s chapter 30 JoAnne M. LaRow, D.O.
  2. 2. Epidermal Melanocytic Lesions  Normal melanocte occurring at the epidermal-Normal melanocte occurring at the epidermal- dermal junction is a dendritic secretory celldermal junction is a dendritic secretory cell supplying all normal melanin to skinsupplying all normal melanin to skin  These cells contain pigment granulesThese cells contain pigment granules (melanosomes)(melanosomes)  Stain with dopa reaction and silver stainsStain with dopa reaction and silver stains  Melanocytes of the epidermis transfer theMelanocytes of the epidermis transfer the melanosomes through their thin dendriticmelanosomes through their thin dendritic processes into surrounding keratinocytesprocesses into surrounding keratinocytes  Size and number in keratinocytes determineSize and number in keratinocytes determine pigmentation of skin and hairpigmentation of skin and hair
  3. 3. Nevus Spilus Pigmented, light brown orPigmented, light brown or tan macule, variedtan macule, varied diameter, speckled withdiameter, speckled with smaller, darker-coloredsmaller, darker-colored macules or papulesmacules or papules Lower extremity & trunkLower extremity & trunk frequentlyfrequently May be <1cm or largeMay be <1cm or large May follow a dermatomalMay follow a dermatomal distribution when largedistribution when large Usually they do not cross theUsually they do not cross the midlinemidline
  4. 4. Nevus SpilusWhen these nevi follow aWhen these nevi follow a dermatomal distribution theydermatomal distribution they may be referred to as amay be referred to as a zosteriform, or sometimes azosteriform, or sometimes a speckled lentiginous nevusspeckled lentiginous nevus When nevus spilus is present withWhen nevus spilus is present with a nevus flammeus =a nevus flammeus = phakomatosisphakomatosis pigmentovascularispigmentovascularis phakomatosisphakomatosis pigmentokeratotica= apigmentokeratotica= a syndrome of organoid nevussyndrome of organoid nevus with sebaceous differentiation,with sebaceous differentiation, hemiatrophy with muscularhemiatrophy with muscular weakness & other neurologicweakness & other neurologic findings & speckledfindings & speckled lentiginous nevuslentiginous nevus
  5. 5. Nevus Spilus -The darker speckles usually contain nevus-The darker speckles usually contain nevus cellscells -Due to this melanoma may arise in the with-Due to this melanoma may arise in the with greater frequency than in normal skingreater frequency than in normal skin -However, removal is not necessary-However, removal is not necessary -Removal by Q-switched ruby laser has been-Removal by Q-switched ruby laser has been reported effectivereported effective
  6. 6. Lentigo Simplex  Usually arise in childhood but can arise anytimeUsually arise in childhood but can arise anytime  Sharply defined, rounded, brown or black maculesSharply defined, rounded, brown or black macules found anywhere on body or mucosafound anywhere on body or mucosa  Histologically shows elongation of rete ridges,Histologically shows elongation of rete ridges, increase in number of melanocytes in basal layer,increase in number of melanocytes in basal layer, increase of melanin in both melanocytes, and basalincrease of melanin in both melanocytes, and basal keratinocytes, and melanophages in the upperkeratinocytes, and melanophages in the upper dermisdermis  No therapy is needed/ there is no predisposition toNo therapy is needed/ there is no predisposition to neoplastic changeneoplastic change
  7. 7. Solar Lentigines Commonly called “liverCommonly called “liver spots”spots” Hyperpigmented maculesHyperpigmented macules May evolve into sk’s orMay evolve into sk’s or lichenoid keratoseslichenoid keratoses Tx=liquid nitrogen, laserTx=liquid nitrogen, laser May recur, as a lentigoMay recur, as a lentigo maligna or lentigomaligna or lentigo maligna melanomamaligna melanoma Be aware-oral methoxsalenBe aware-oral methoxsalen photochemotherapy orphotochemotherapy or frequent tanning salonsfrequent tanning salons may develop lentiginesmay develop lentigines on non-sun-exposed areason non-sun-exposed areas and these may showand these may show cellular atypiacellular atypia
  8. 8. Penile and Vulvar Melanosis  Localized pigmentaryLocalized pigmentary alterationsalterations  Most often show basilarMost often show basilar hyperpigmentationhyperpigmentation  May appear in largeMay appear in large patches or in smaller,patches or in smaller, well-demarcated lesionswell-demarcated lesions  Present on the penis or inPresent on the penis or in women on the labiawomen on the labia majoramajora
  9. 9. Bannayan-Riley-Ruvalcaba Syndrome  Rare, AD disorder that manifests inRare, AD disorder that manifests in childhoodchildhood  80% of the pts are male80% of the pts are male  Characterized by genital lentiginosis,Characterized by genital lentiginosis, macrocephaly, motor and speech delay,macrocephaly, motor and speech delay, mental retardation, lipomas, hemangiomas,mental retardation, lipomas, hemangiomas, verruca vulgaris, and many types of facialverruca vulgaris, and many types of facial papulespapules
  10. 10. Multiple Lentigenes Syndrome  Lentigines are darkLentigines are dark brown macules 1-5brown macules 1-5 mm.mm.  Preponderance on thePreponderance on the trunktrunk  Multiple generalizedMultiple generalized lentigines may occurlentigines may occur with a number ofwith a number of associated signs as anassociated signs as an dominantly inheriteddominantly inherited syndromesyndrome  ll
  11. 11. LEOPARD Syndrome  Leopard syndrome =Leopard syndrome = acronym for lentigines,acronym for lentigines, electrocardiographicelectrocardiographic abnormalities, ocularabnormalities, ocular hypertelorism, pulmonaryhypertelorism, pulmonary stenosis, abnormalities ofstenosis, abnormalities of genitalia, retardation ofgenitalia, retardation of growth, and deafnessgrowth, and deafness
  12. 12. Moynahan Syndrome  Multiple lentiginesMultiple lentigines  Congenital mitral stenosisCongenital mitral stenosis  DwarfismDwarfism  Genital hypoplasiaGenital hypoplasia  Mental deficiencyMental deficiency
  13. 13. Centrofacial Lentiginosis  Characterized by lentigines on the nose, andCharacterized by lentigines on the nose, and adjacent cheeksadjacent cheeks  Sometimes associated with statusSometimes associated with status dysraphicus, multiple skeletal anomalies,dysraphicus, multiple skeletal anomalies, and CNS disordersand CNS disorders  Spares the mucous membranesSpares the mucous membranes  Onset is first years of lifeOnset is first years of life
  14. 14. Inherited Patterned Lentiginosis in Blacks  AD- reportedly, 10 light-AD- reportedly, 10 light- complexioned blackcomplexioned black patients who developedpatients who developed numerous lentigines innumerous lentigines in infancy or early childhoodinfancy or early childhood  Distribution is centralDistribution is central face, lips, with variableface, lips, with variable involvement of dorsalinvolvement of dorsal hands and feet, elbows,hands and feet, elbows, and buttocksand buttocks  Sparing of mucousSparing of mucous membranes and nomembranes and no internal abnormalitiesinternal abnormalities
  15. 15. Carney’s Syndrome  AKA NAME syndrome or LAMBAKA NAME syndrome or LAMB syndromesyndrome  Characterized by cardiocutaneousCharacterized by cardiocutaneous myxomas, lentigines, blue nevi, andmyxomas, lentigines, blue nevi, and endocrine anomaliesendocrine anomalies
  16. 16. Peutz-Jeghers Syndrome  ADAD  Pigmented macules onPigmented macules on the lips, oral mucosa,the lips, oral mucosa, perioral acral areasperioral acral areas  GastrointestinalGastrointestinal polyps, especiallypolyps, especially prominent in theprominent in the jejunum are seenjejunum are seen
  17. 17. Melanoacanthoma  uncommon lesion, a benign epidermaluncommon lesion, a benign epidermal melanocytic neoplasm, occurring on themelanocytic neoplasm, occurring on the headhead  Resembles a pigmented sk or a pigmentedResembles a pigmented sk or a pigmented BCCBCC  Predominantly seen in white men > 60 yrsPredominantly seen in white men > 60 yrs
  18. 18. Cellular Nevi  Begins to appear in first yrs of life, increase inBegins to appear in first yrs of life, increase in prevalence and number over the next two decades,prevalence and number over the next two decades, after which there is a steady declineafter which there is a steady decline  Females tent to have more than malesFemales tent to have more than males  Less common in sun-protected areasLess common in sun-protected areas  Maximum number is at age 20- 25 yrs, the averageMaximum number is at age 20- 25 yrs, the average number is 40number is 40  Sun exposure increases the number of nevi in theSun exposure increases the number of nevi in the exposed skinexposed skin  Eruptive nevi are rare, but may occur after severeEruptive nevi are rare, but may occur after severe bullous disease such as TEN, EM, or severebullous disease such as TEN, EM, or severe sunburn, Addison’s disease or immunosuppresionsunburn, Addison’s disease or immunosuppresion
  19. 19. Junctional Nevi  Nevi begin as small, flat,Nevi begin as small, flat, pigmented macules =pigmented macules = junctional nevijunctional nevi  A smooth, hairless, lightA smooth, hairless, light to dark brown macule,to dark brown macule, varying in size from 1 –6varying in size from 1 –6 mmmm  Occurs on any site,Occurs on any site, especially on palms,especially on palms, soles, scrotumsoles, scrotum  During adolescence someDuring adolescence some will become compound orwill become compound or intradermalintradermal  It is characterized byIt is characterized by single melanocytes, orsingle melanocytes, or theques of them in thetheques of them in the
  20. 20. Compound Nevus  The compound nevus is one that is stillThe compound nevus is one that is still manifesting so-called junctionalmanifesting so-called junctional activity( accumulation of melanocytes inactivity( accumulation of melanocytes in theques in the epidermis) but has formedtheques in the epidermis) but has formed structure of a cellular nevus in the dermis asstructure of a cellular nevus in the dermis as wellwell
  21. 21. Junctional Nevi  Nevi begin as small, flat,Nevi begin as small, flat, pigmented macules =pigmented macules = junctional nevijunctional nevi  A smooth, hairless, lightA smooth, hairless, light to dark brown macule,to dark brown macule, varying in size from 1 –6varying in size from 1 –6 mmmm  Occurs on any site,Occurs on any site, especially on palms,especially on palms, soles, scrotumsoles, scrotum  During adolescence someDuring adolescence some will become compound orwill become compound or intradermalintradermal  It is characterized byIt is characterized by single melanocytes, orsingle melanocytes, or theques of them in thetheques of them in the
  22. 22. Compound Nevus  The compound nevus is one that is stillThe compound nevus is one that is still manifesting so-called junctionalmanifesting so-called junctional activity( accumulation of melanocytes inactivity( accumulation of melanocytes in theques in the epidermis) but has formedtheques in the epidermis) but has formed structure of a cellular nevus in the dermis asstructure of a cellular nevus in the dermis as wellwell
  23. 23. Compound Nevus  An 8-mm, well-An 8-mm, well- circumscribed,circumscribed, symmetric, uniformlysymmetric, uniformly colored papulecolored papule  A lesion of this sizeA lesion of this size could be an acquiredcould be an acquired nevus or a smallnevus or a small congenital patterncongenital pattern nevusnevus
  24. 24. Compound Nevus  Nests ofNests of nevusnevus cells incells in thethe epidermiepidermi ss overlyingoverlying a dermala dermal componecompone nt ofnt of orderlyorderly nevusnevus cellscells
  25. 25. Compound Nevus  Acral type-thickened basketAcral type-thickened basket weave stratum corneumweave stratum corneum shows that it is an acral siteshows that it is an acral site  Nevus is small andNevus is small and symmetric, and shows bothsymmetric, and shows both a junctional and superficiala junctional and superficial dermal componentdermal component  The nests in the papillaryThe nests in the papillary dermis are small, orderly,dermis are small, orderly, and lack atypia. Theand lack atypia. The epidermal component mayepidermal component may show a few pagetoid cellsshow a few pagetoid cells
  26. 26. Intradermal Nevus  a compound nevus in which junctionala compound nevus in which junctional activity- that is, theques of melanoctyes inactivity- that is, theques of melanoctyes in the epidermis or at the dermal epidermalthe epidermis or at the dermal epidermal junction- has ceased, and all the nevus cellsjunction- has ceased, and all the nevus cells are in the dermisare in the dermis
  27. 27. Intradermal Nevus  Low power-as inLow power-as in junctional nevi , dermaljunctional nevi , dermal nevi contain nevus cellsnevi contain nevus cells that are recognized at thisthat are recognized at this power by tendency to bepower by tendency to be arranged in nestsarranged in nests  High power- at the base ofHigh power- at the base of this dermal nevus thethis dermal nevus the melanocytic cellsmelanocytic cells resemble neuralresemble neural structures( neurotization)structures( neurotization)
  28. 28. Balloon Cell Nevus A pigmented nevus, varyingA pigmented nevus, varying in size from 1 –5 mm, usuallyin size from 1 –5 mm, usually occurring on the head, neck,occurring on the head, neck, and trunk.and trunk.  They are clinicallyThey are clinically indistinguishable fromindistinguishable from ordinary pigmented orordinary pigmented or nonpigmented nevusnonpigmented nevus  Histologically, the lesions areHistologically, the lesions are composed of peculiarcomposed of peculiar vesicular cells that appear tovesicular cells that appear to be foamy and form large palebe foamy and form large pale polyhedral balloon cells thatpolyhedral balloon cells that may be multinucleated giantmay be multinucleated giant cells in addition to nevuscells in addition to nevus cells.cells.  Not considered potentiallyNot considered potentially malignant, and treatment ismalignant, and treatment is same as other nevi
  29. 29. Halo Nevus  AKA Sutton’s nevus,AKA Sutton’s nevus, perinevoid vitilgo, &perinevoid vitilgo, & leukoderma acquisitumleukoderma acquisitum centrifugumcentrifugum  A pigmented nevus withA pigmented nevus with surrounding depigmentedsurrounding depigmented zonezone  Nevus is usually compoundNevus is usually compound or intradermalor intradermal  May be single or multipleMay be single or multiple  Usually on the trunkUsually on the trunk  Mostly develop in teenagersMostly develop in teenagers  No tx indicated- centralNo tx indicated- central nevus disappears with timenevus disappears with time leukodermic area willleukodermic area will usually repigment with timeusually repigment with time
  30. 30. Halo Nevus  The nevus architectureThe nevus architecture is obscured by a denseis obscured by a dense lymphocytic infiltratelymphocytic infiltrate  Lymphocytes infiltrateLymphocytes infiltrate among the dermalamong the dermal nevus cells, whichnevus cells, which eventually degenerateeventually degenerate and disappearand disappear
  31. 31. Congenital Nevocytic Nevus  Giant Pigmented NevusGiant Pigmented Nevus (Giant hairy nevus,(Giant hairy nevus, bathing trunk nevus)bathing trunk nevus)  Characterized by a large,Characterized by a large, darkly pigmented hairydarkly pigmented hairy patch in which smaller,patch in which smaller, darker patches aredarker patches are interspersed or present asinterspersed or present as small satellite lesionssmall satellite lesions  Skin may be thickened orSkin may be thickened or verrucousverrucous  Has a tendency to followHas a tendency to follow a dermatome distributiona dermatome distribution  Trunk favored siteTrunk favored site
  32. 32. Congenital Nevocytic Nevus  Giant hairy nevi areGiant hairy nevi are present at birth and growpresent at birth and grow proportionally to the siteproportionally to the site of the body where they areof the body where they are locatedlocated  By definition they areBy definition they are >20cm>20cm  When a large congenitalWhen a large congenital nevus involves the axialnevus involves the axial skin, there may be anskin, there may be an associated neurocutaneousassociated neurocutaneous melanocytosismelanocytosis  Incidence of melanomaIncidence of melanoma developing is 3% to 7%developing is 3% to 7%
  33. 33. CNN  About 40% of the malignantAbout 40% of the malignant melanomas seen in childrenmelanomas seen in children occur in large congenital nevioccur in large congenital nevi -risk is greatest for axial-risk is greatest for axial lesionslesions  If neurocutaneous melanosisIf neurocutaneous melanosis is present (which can beis present (which can be detected by MRI), the risk ofdetected by MRI), the risk of dying at a young age is highdying at a young age is high secondary to hydrocephalus orsecondary to hydrocephalus or leptomeningeal melanomaleptomeningeal melanoma  Most recommend totalMost recommend total surgical excision andsurgical excision and resurfacing autograftsresurfacing autografts  Alternative treatments-Alternative treatments- dermabrasion, curettage, anddermabrasion, curettage, and laser ablation- are designed tolaser ablation- are designed to eliminate some of the nevuseliminate some of the nevus cells, with theoretic loweringcells, with theoretic lowering
  34. 34. Small and Medium-sized Congenital Nevocytic Nevus  Small - < 1.5 cm in greatest diameterSmall - < 1.5 cm in greatest diameter  Medium- > 1.5 cm but < 20 cmMedium- > 1.5 cm but < 20 cm  Found in 1% of newbornsFound in 1% of newborns  Half eventually become hairyHalf eventually become hairy  Data to determine the incidence of melanoma areData to determine the incidence of melanoma are still being gatheredstill being gathered  Excision is recommended for lesions of the hairyExcision is recommended for lesions of the hairy scalp, or those of great cosmetic concern or neviscalp, or those of great cosmetic concern or nevi with unusual clinical featureswith unusual clinical features
  35. 35. Epitheliod and Spindle-Cell Nevus(benign Juvenile Melanoma, Spitz Nevus)
  36. 36. Spitz Nevus  A smooth-surfaced, raised, round, slightlyA smooth-surfaced, raised, round, slightly scaly, firm papule with distinctive pink,scaly, firm papule with distinctive pink, brownish red, or purplish red colorbrownish red, or purplish red color  Typically, firm,rosy papule on the face,Typically, firm,rosy papule on the face, especially on the cheekespecially on the cheek  3 – 10 mm in diameter3 – 10 mm in diameter  Female predominanceFemale predominance  Should be completely excisedShould be completely excised
  37. 37. Spitz Nevus A variant of the compoundA variant of the compound nevusnevus  Epidermal irregularEpidermal irregular acanthosis,acanthosis, pseudoepitheliomatouspseudoepitheliomatous hyperplasia, and thinninghyperplasia, and thinning of the epidermisof the epidermis  Nevus cells areNevus cells are pleomorphic, but mostlypleomorphic, but mostly spindle-shaped (fusiform),spindle-shaped (fusiform), or polygonal (epithelioid)or polygonal (epithelioid) cellscells
  38. 38. Spitz Nevus Giant cells with eosiophilicGiant cells with eosiophilic cytoplasm and a largecytoplasm and a large nucleus may be seennucleus may be seen  Multinucleated giant cellsMultinucleated giant cells are seen less frequentlyare seen less frequently  No difference betweenNo difference between childhood and adultchildhood and adult lesionslesions  Eosinophilic globules withEosinophilic globules with fibrillar microstructurefibrillar microstructure (Kamino bodies) are(Kamino bodies) are found in 60% - 85% of SNfound in 60% - 85% of SN  May also be present inMay also be present in melanomas (12&) andmelanomas (12&) and compound nevi(8%), butcompound nevi(8%), but are fewer and smaller inare fewer and smaller in SNSN
  39. 39. Spitz Nevus * Immunohistochemical staining for MIB-1* Immunohistochemical staining for MIB-1 and bcl-2 will distinguish most Spitz neviand bcl-2 will distinguish most Spitz nevi from melanoma;melanomas arefrom melanoma;melanomas are immunoreactive, whereas Spitz nevi are notimmunoreactive, whereas Spitz nevi are not * Differential diagnosis-pyogenic granuloma,* Differential diagnosis-pyogenic granuloma, mastocytoma, juvenile xanthogranuloma, ormastocytoma, juvenile xanthogranuloma, or melanomamelanoma
  40. 40. Dysplastic Nevus  Variegated tan, brown,Variegated tan, brown, pink colorationpink coloration  Pink hues seen in macularPink hues seen in macular portionportion  Macular portion alwaysMacular portion always present, may comprisepresent, may comprise entire lesion, butentire lesion, but frequently surrounds afrequently surrounds a papular centerpapular center  Generally larger than areGenerally larger than are common nevi, usually 5 –common nevi, usually 5 – 12mm, with irregular12mm, with irregular bordersborders
  41. 41. Dysplastic Nevus Syndrome  Around 1978 Lynch et al recognized an autosomalAround 1978 Lynch et al recognized an autosomal dominant inheritance pattern in families withdominant inheritance pattern in families with unusual nevi and multiple melanomas-initiallyunusual nevi and multiple melanomas-initially described by Clark et al as B-K mole syndrome-described by Clark et al as B-K mole syndrome- then named familial atypical multiple mole-then named familial atypical multiple mole- melanoma syndromemelanoma syndrome  Now termed dysplastic nevus syndrome (DNS)Now termed dysplastic nevus syndrome (DNS)  Pts with dysplastic nevi send at least two bloodPts with dysplastic nevi send at least two blood relatives with dysplastic nevi and melanoma haverelatives with dysplastic nevi and melanoma have the worst prognosis with possibly 100% lifetimethe worst prognosis with possibly 100% lifetime risk of melanomarisk of melanoma
  42. 42. Dysplastic Nevus Syndrome- Genetics  25% -33% of pts have germline mutations on25% -33% of pts have germline mutations on chromosome 9p in the CDKN2A tumor-chromosome 9p in the CDKN2A tumor- suppressor gene-which encodes for an inhibitor ofsuppressor gene-which encodes for an inhibitor of a cyclindependent kinase 4 (CDK4) that functionsa cyclindependent kinase 4 (CDK4) that functions to suppress proliferationto suppress proliferation  In these pts with mutations that impair theIn these pts with mutations that impair the function of the p16 suppressor protein, referred tofunction of the p16 suppressor protein, referred to as the p16M alleles, there is a concomitantas the p16M alleles, there is a concomitant predisposition to pancreatic cancerpredisposition to pancreatic cancer
  43. 43. Dysplastic Nevus Syndrome  Dysplasic nevi occur commonly in pts without aDysplasic nevi occur commonly in pts without a personal or family history of melanoma-5% -20%personal or family history of melanoma-5% -20% of pts having at least one clinically dysplasticof pts having at least one clinically dysplastic nevusnevus  This is important for (1) histologic evaluation isThis is important for (1) histologic evaluation is neede (2) a careful history and evaluation ofneede (2) a careful history and evaluation of family members (3) they provide another riskfamily members (3) they provide another risk factor for melanoma predispositionfactor for melanoma predisposition
  44. 44. Dysplastic Nevus Syndrome  Histologic features as per an NIH consensus-Histologic features as per an NIH consensus- basilar melanocytic hyperplasia with elongation ofbasilar melanocytic hyperplasia with elongation of rete ridges; spindle-shaped or occasionally,rete ridges; spindle-shaped or occasionally, epithelioid melanocytes arranged horizontally andepithelioid melanocytes arranged horizontally and aggregating in nests that fuse with adjacent reteaggregating in nests that fuse with adjacent rete ridges; lamellar and concentric superficial dermalridges; lamellar and concentric superficial dermal infiltrate; cytologic atypia, usually present but notinfiltrate; cytologic atypia, usually present but not essential for diagnosisessential for diagnosis
  45. 45. Dysplastic Nevi  Patients with dysplastic nevi and a positivePatients with dysplastic nevi and a positive family or personal history of melanoma,family or personal history of melanoma, physician examination every 3 – 6 monthsphysician examination every 3 – 6 months  Excision of those nevi that change clinicallyExcision of those nevi that change clinically  Photographs with measured scale is usefulPhotographs with measured scale is useful
  46. 46. Melanoma  Originate fromOriginate from melanocytes at epidermal-melanocytes at epidermal- dermal junctiondermal junction  Half will develop inHalf will develop in preexisting nevipreexisting nevi  Prolonged, non invasive,Prolonged, non invasive, horizontally orientedhorizontally oriented growth phasegrowth phase  When tumor noduleWhen tumor nodule develops the verticaldevelops the vertical growth phase is occurringgrowth phase is occurring and the risk of metastaticand the risk of metastatic disease increasesdisease increases dramaticallydramatically
  47. 47. Melanoma  One in 80 Americans willOne in 80 Americans will develop melanomadevelop melanoma  Incidence is low until afterIncidence is low until after pubertypuberty  Children may present withChildren may present with congenital melanoma orcongenital melanoma or acquired melanomaacquired melanoma  Congenital melanoma mayCongenital melanoma may occur because ofoccur because of transplacentaltransplacental transmission, as a primarytransmission, as a primary intrauterine lesion, as aintrauterine lesion, as a melanoma from amelanoma from a congenital nevus in utero,congenital nevus in utero, or as prenatal metastaticor as prenatal metastatic lesions fromlesions from neurocutaneous melanosisneurocutaneous melanosis all of these have a poorall of these have a poor prognosisprognosis
  48. 48. Diagnosis of Melanoma - surgical excision is the best method- surgical excision is the best method -for larger lesions an incisional or punch biopsy,-for larger lesions an incisional or punch biopsy, deep enough is considered good practicedeep enough is considered good practice -when melanoma is suspected in a melanotic freckle-when melanoma is suspected in a melanotic freckle or a giant pigmented nevus, biopsy should be doneor a giant pigmented nevus, biopsy should be done through the thickest and most atypical area andthrough the thickest and most atypical area and multiply sectioned to find thickest area ofmultiply sectioned to find thickest area of involvementinvolvement
  49. 49. Histologic diagnosis: -presence of mitoses-presence of mitoses -inflammatory reaction-inflammatory reaction composed ofcomposed of lymphocytes andlymphocytes and possibly plasma cellspossibly plasma cells -dermoepidermal-dermoepidermal junctional activityjunctional activity -absence of dermal-absence of dermal stromastroma
  50. 50. Histologic diagnosis: -a moderately brisk tumor--a moderately brisk tumor- infiltrating lymphocyteinfiltrating lymphocyte response is present aroundresponse is present around the nodulethe nodule - the cells in the nodule are- the cells in the nodule are large epithelioidlarge epithelioid melanoma cells that havemelanoma cells that have abundant cytoplasm andabundant cytoplasm and large irregular nuclei withlarge irregular nuclei with prominent nucleoli withprominent nucleoli with numerous mitosesnumerous mitoses
  51. 51. Melanoma Metastasis-usuallyMetastasis-usually manifested bymanifested by pigmented nodulespigmented nodules appearing around theappearing around the site of the excisionsite of the excision Early remote metastasesEarly remote metastases occur via lymphaticsoccur via lymphatics and regionaland regional lynphadenopathy maylynphadenopathy may be the first signbe the first sign
  52. 52. Melanoma  > 50 benign nevi> 50 benign nevi  Presence of large congenital nevusPresence of large congenital nevus  Presence of clinically dysplasic nevusPresence of clinically dysplasic nevus  Mutations in the p16-CDK4Mutations in the p16-CDK4  Immunodefiency syndromes-acquired or geneticImmunodefiency syndromes-acquired or genetic  PUVA treatmentsPUVA treatments  Xeroderma pigmentosumXeroderma pigmentosum  Use of tanning lampsUse of tanning lamps  Levodopa therapy for Parkinson’s disease hasLevodopa therapy for Parkinson’s disease has been implicated in 19 case reports by Rampenbeen implicated in 19 case reports by Rampen
  53. 53. Melanoma There are four recognized clinicohistologicThere are four recognized clinicohistologic types:types: 1.) Lentigo maligna (melanoma in situ,1.) Lentigo maligna (melanoma in situ, noninvasive melanoma)noninvasive melanoma) 2.) Superficially spreading melanoma2.) Superficially spreading melanoma 3.) Acral-lentiginous melanoma3.) Acral-lentiginous melanoma 4.) Nodular melanoma4.) Nodular melanoma
  54. 54. Melanoma *Pedunculated, polypoidal melanomas,*Pedunculated, polypoidal melanomas, inflammatory melanomas, amelanoticinflammatory melanomas, amelanotic melanomas, and hyperkeratotic andmelanomas, and hyperkeratotic and verrucous melanomas are clinical findingsverrucous melanomas are clinical findings *At a microscopic level-desmoplastic,*At a microscopic level-desmoplastic, neurotropic, myxoid, balloon cell, andneurotropic, myxoid, balloon cell, and signet cell patterns are seensignet cell patterns are seen
  55. 55. Lentigo maligna(melanoma in situ, noninvasive melanoma)  Begins as a tan macule that extends peripherally,Begins as a tan macule that extends peripherally, with gradual uneven darkening, over several yearswith gradual uneven darkening, over several years  After a radial growth of 5 to 20 years, verticallyAfter a radial growth of 5 to 20 years, vertically growing melanoma usually develops within itgrowing melanoma usually develops within it  A palpable nodule within the original macule is theA palpable nodule within the original macule is the best evidence that a lentigo maligna melanoma hasbest evidence that a lentigo maligna melanoma has occurredoccurred  Equal incidence in men and womenEqual incidence in men and women  Usually 60-70 yrsUsually 60-70 yrs  Usually on chronically sun-damaged skin, mostUsually on chronically sun-damaged skin, most often on the faceoften on the face  Accounts for 5% of all melanomasAccounts for 5% of all melanomas
  56. 56. Lentigo maligna(melanoma in situ, noninvasive melanoma)
  57. 57. Superficially spreading melanoma  In a study by Bolognia etIn a study by Bolognia et al 5% of lesions with anal 5% of lesions with an eccentric foci ofeccentric foci of hyperpigmentation(ahyperpigmentation(a roundish area of brown orroundish area of brown or black 3mm or< andblack 3mm or< and located peripherally) arelocated peripherally) are melanomas arising frommelanomas arising from within a nevuswithin a nevus  It is necessary to ensureIt is necessary to ensure that the pathologistthat the pathologist sections through the blacksections through the black dot to make this earlydot to make this early diagnosisdiagnosis
  58. 58. Acral-lentiginous melanoma  Acral-lentiginous melanoma lies midway betweenAcral-lentiginous melanoma lies midway between the lentigo maligna and the superficially spreadingthe lentigo maligna and the superficially spreading melanoma in respect to speed of horizontal growthmelanoma in respect to speed of horizontal growth into adjacent epidermisinto adjacent epidermis  Subungual and mucosal lesions are in thisSubungual and mucosal lesions are in this categorycategory  Account for 10% of all melanomasAccount for 10% of all melanomas  The most common type among Japanese, AfricanThe most common type among Japanese, African American, Hispanics, and Native AmericansAmerican, Hispanics, and Native Americans  Median age is 50 yrs with equal sex distributionMedian age is 50 yrs with equal sex distribution
  59. 59. Melanoma- workup and follow- up -establish a family history-establish a family history -thorough review of systems-thorough review of systems - physical examphysical exam - A consensus conference in 1992 concluded that aA consensus conference in 1992 concluded that a staging workup was not indicated for melanomasstaging workup was not indicated for melanomas below 1.0 mm thicknessbelow 1.0 mm thickness - Many physicians obtain a CXR and an LDHMany physicians obtain a CXR and an LDH - As in the initial workup, more information and aAs in the initial workup, more information and a consensus statement would help to establishconsensus statement would help to establish indications for testingindications for testing - Consultation with an oncologist is worthwhileConsultation with an oncologist is worthwhile
  60. 60. Melanoma-treatment -early diagnosis and excision-early diagnosis and excision -margin of 0.5 to 1.0 cm for melanoma in situ-margin of 0.5 to 1.0 cm for melanoma in situ -1.0 cm margin for melanomas < 2.0 cm thick-1.0 cm margin for melanomas < 2.0 cm thick -3.0 cm margin for those thicker than 2.0 mm-3.0 cm margin for those thicker than 2.0 mm -Zitelli et al recommended wider margins for-Zitelli et al recommended wider margins for melanomas of the head, neck, hands, and feet-melanomas of the head, neck, hands, and feet- they recommend a minimum surgical margin ofthey recommend a minimum surgical margin of 1.5 cm, unless Mohs’ micrographic surgery is use1.5 cm, unless Mohs’ micrographic surgery is use - ELND is controversial and therefore intraoperative- ELND is controversial and therefore intraoperative lymphatic mapping is usedlymphatic mapping is used
  61. 61. Melanoma-treatment -high-dose interferon alfa-2b therapy has been used,-high-dose interferon alfa-2b therapy has been used, however efficacy is equivocal and toxicity highhowever efficacy is equivocal and toxicity high -adjuvant interferon alfa-2a treatment has been-adjuvant interferon alfa-2a treatment has been reported to diminish the occurrence of mets andreported to diminish the occurrence of mets and prolong disease free survival in pts withprolong disease free survival in pts with melanoma > 1.5 mm thickmelanoma > 1.5 mm thick -chemotherapy is not effective-chemotherapy is not effective -Adoptive immunotherapy with lymphokine--Adoptive immunotherapy with lymphokine- activated killer cells + interleukin-2, or high –doseactivated killer cells + interleukin-2, or high –dose into leukin-2 alone is also toxic, some patients areinto leukin-2 alone is also toxic, some patients are responsiveresponsive -perfusion chemotherapy has been used for extremity-perfusion chemotherapy has been used for extremity melanoma and has almost eliminated the need formelanoma and has almost eliminated the need for amputationamputation
  62. 62. Dermal Melanocytic Lesions  At birth, melanocytes may be present in theAt birth, melanocytes may be present in the dermal portion of the skin of the scalp, thedermal portion of the skin of the scalp, the backs of the hands, and the sacrumbacks of the hands, and the sacrum  These are large ameboid cells that normallyThese are large ameboid cells that normally disappear shortly after birthdisappear shortly after birth
  63. 63. Mongolian Spot  Bluish gray macule ofBluish gray macule of varying size from 2-8 cmvarying size from 2-8 cm  Occurs typically in theOccurs typically in the sacral area of the newbornsacral area of the newborn  80-90% of Asians,80-90% of Asians, Southern Europeans,Southern Europeans, American blacks, andAmerican blacks, and Native AmericansNative Americans  Multiple spots may beMultiple spots may be situated in other locationssituated in other locations
  64. 64. Mongolian Spot Multiple spots occurring in a widespreadMultiple spots occurring in a widespread distribution have been termed generalizeddistribution have been termed generalized dermal melanocytosis or dermaldermal melanocytosis or dermal melanocytic hamartomasmelanocytic hamartomas If associated with a nevus flammeus-If associated with a nevus flammeus- phakomatosis pigmentovascularisphakomatosis pigmentovascularis
  65. 65. Nevus of Ota  Aka nevus fuscocerulleusAka nevus fuscocerulleus opthalmaomaxillarisopthalmaomaxillaris  Usually present at birth ,Usually present at birth , especially if the patient is goingespecially if the patient is going to have ocular involvementto have ocular involvement  May have involvement of theMay have involvement of the conjunctiva and the skin aboutconjunctiva and the skin about the eyethe eye  On the skin brown, slate gray,On the skin brown, slate gray, or blue-black macules growor blue-black macules grow slowly larger and deeper inslowly larger and deeper in colorcolor  80% occur in women; 5% are80% occur in women; 5% are bilateralbilateral  Usually a benign lesionUsually a benign lesion malignant melanoma may occurmalignant melanoma may occur  Most common location is theMost common location is the choroidchoroid  Glaucoma may occurGlaucoma may occur
  66. 66. Nevus of Ito  Aka nevus fuscoceruleus acromiodeltoideusAka nevus fuscoceruleus acromiodeltoideus  Has the same features as nevus of OtaHas the same features as nevus of Ota except that it occurs in the distribution ofexcept that it occurs in the distribution of the posterior supraclavicular and lateralthe posterior supraclavicular and lateral cutaneous brachial nervescutaneous brachial nerves  It involves the shoulder, side of the neck,It involves the shoulder, side of the neck, and supraclavicular areasand supraclavicular areas  Tx –Q-switched ruby laser are dramaticTx –Q-switched ruby laser are dramatic
  67. 67. Blue Nevus  Two types:Two types:  1.) Blue nevus of Jadassohn-Tiche1.) Blue nevus of Jadassohn-Tiche (common blue nevus)(common blue nevus)  2.) Cellular blue nevus2.) Cellular blue nevus
  68. 68. Blue Nevus Within the dermis there isWithin the dermis there is a poorly defined buta poorly defined but symmetric spindle cellsymmetric spindle cell proliferation that is darkproliferation that is dark brown in colorbrown in color  No significant change inNo significant change in the overlying dermisthe overlying dermis  The spindled heavilyThe spindled heavily pigmented cells encirclepigmented cells encircle collagen bundles in thecollagen bundles in the reticular dermis, a patternreticular dermis, a pattern also seen inalso seen in dermatofibromasdermatofibromas  The lesion is composed ofThe lesion is composed of elongate cells that areelongate cells that are heavily pigmented andheavily pigmented and show prominentshow prominent pigmented dendritespigmented dendrites
  69. 69. Blue Nevus of Jadassohn-Tiche  The typical common blueThe typical common blue nevus or nevus ceruleusnevus or nevus ceruleus  Steel-blue nodule thatSteel-blue nodule that begins early in lifebegins early in life  Slow growingSlow growing  Rarely reaches 2-10mmRarely reaches 2-10mm  Occurs most frequently onOccurs most frequently on the dorsal hands, feet,the dorsal hands, feet, forearms, shins, face, andforearms, shins, face, and the buttocksthe buttocks
  70. 70. Cellular Blue Nevus  Large, firm, blue or blue-Large, firm, blue or blue- black noduleblack nodule  Frequently seen on theFrequently seen on the buttock and sacrococcygealbuttock and sacrococcygeal regionregion  Occasionally present at birthOccasionally present at birth  Seen in women 2.5 times asSeen in women 2.5 times as frequently as menfrequently as men  Average age is 40Average age is 40  Uncommonly these invadeUncommonly these invade underlying structure such asunderlying structure such as the skull in scalp lesionsthe skull in scalp lesions
  71. 71. Cellular Blue Nevus  Frequently large andFrequently large and involve a good part of theinvolve a good part of the dermis and extendingdermis and extending deeply as tonguelikedeeply as tonguelike aggregates of tumor cellsaggregates of tumor cells at the base of the lesionat the base of the lesion  Involvement of theInvolvement of the subcutaneous fat issubcutaneous fat is common and does notcommon and does not imply a malignantimply a malignant diagnosisdiagnosis
  72. 72. Cellular Blue Nevus  The cellular areas areThe cellular areas are composed of uniformcomposed of uniform spindled melanocytic cellsspindled melanocytic cells with mor cytoplasm andwith mor cytoplasm and larger nuclei than what islarger nuclei than what is seen in common blueseen in common blue nevus.nevus.  There are irregularlyThere are irregularly distributed collections ofdistributed collections of course melanin pigmentcourse melanin pigment within the cellswithin the cells
  73. 73. Epithelioid Blue Nevus  Newly described lesionNewly described lesion  Strong association with Carney’s complexStrong association with Carney’s complex (myxomas, spotty skin pigmentation, endocrine(myxomas, spotty skin pigmentation, endocrine over activity, and schwannomas)over activity, and schwannomas)  Occur frequently on the head and neck, and are atOccur frequently on the head and neck, and are at times multipletimes multiple  They are darkly pigmented, domed, and less thanThey are darkly pigmented, domed, and less than 1 cm1 cm
  74. 74. Malignant Blue Nevus  -Cellular blue nevus may rarely undergo-Cellular blue nevus may rarely undergo malignant transformation into malignantmalignant transformation into malignant melanomamelanoma  -clinically increase in size, suddenly and-clinically increase in size, suddenly and ulcerationulceration  -histologically, pleomorphism of nuclei, mitotic-histologically, pleomorphism of nuclei, mitotic figures, and invasion of clusters of malignant cellsfigures, and invasion of clusters of malignant cells into the deep dermis and fatty tissueinto the deep dermis and fatty tissue  -excision has been mainstay of treatment-excision has been mainstay of treatment  -Q-switched ruby laser has been reported to be-Q-switched ruby laser has been reported to be successfulsuccessful  - treatment of the malignant variety is the same as- treatment of the malignant variety is the same as MMMM
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