Well-defined nests of amelanotic cells surrounded by collagen and variable numbers of dendritic melanocytes and melanophages comprise the alveolar pattern of CBN (Fig. 4B). The merging of the alveolar pattern into nevoid cell sheets or areas of a fascicular pattern is common. Occasionally, the nests may be separated by areas of loose, edematous tissue, which may represent precursors to cystic change.74 In the fascicular or neuronevoid pattern, the tumor is composed of fascicles of amelanotic spindle cells with clear cytoplasm, surrounded by fibrous tissue containing dendritic melanocytes and melanophages. Neuroid structures are frequently interspersed with the tumor.74 Occasional tumors may contain balloon cells with vacuolated/foamy cytoplasm.89 Rare cases may exhibit myxoid stroma.90 Mitotic activity is usually absent and should be low (<1/mm2).74 Focal areas of necrosis have been reported as being present in rare cases of otherwise benign CBN,74 although in our view, the presence of any necrosis is an atypical finding and concerning for malignancy. If isolated mitotic activity or necrosis is present but no other atypical findings (including cell crowding, nuclear atypia, hyperchromasia, or expansile growth) are seen, we report such tumors as atypical CBN and state that it is not possible to predict the biologic behavior/malignant potential of the tumor with certainty from its morphologic features but consider the risk of aggressive behavior to be low. The cells are usually positive for S-100 and HMB-45,91,92 although we have seen some cases which are negative for S-100 and exhibit only weak or focal positivity for HMB-45. In view of the often prominent melanin pigmentation of these lesions, the use of a red chromogen for immunohistochemistry usually allows easier interpretation than a brown chromogen. A rare angiomatoid variant of CBN containing numerous dilated blood vessels has been described.93
Kazakov and Michal noted the presence of “ball in mitts” structures in CBNs, composed of a single centrally placed rounded or oval melanocyte (ball) encircled by a single dendritic cell (mitt) with an oval or spindle-shaped nucleus and slender bipolar processes containing melanin and surrounding at least a quarter of the diameter of the rounded melanocyte. They also found “microalveolar structures,” composed of 2 to 10 central rounded cells surrounded by one or more dendritic cells similar to those seen in the “ball in mitts” structures. The authors noted that similar structures may occur in combined nevi, deep penetrating nevi, acquired melanocytic nevi and in common blue nevi, and in light of this, they proposed that there may be a spectrum of evolution from common acquired nevus to combined nevus to CBN and deep penetrating nevus (DPN) through a progressive expansion and prominence of the “ball in mitts” and “microalveolar structures.”94 However, differences in the clinicopathologic characteristics of blue nevi (and their variants) and common nevi are against this hypothesis.
Histologically, PTBN shows a combination of features seen in DBN and CBN. In addition to pigmented spindle and dendritic cells, aggregates of variably pigmented epithelioid and often clear melanocytic cells are present, as are foci extending deeply into subcutaneous tissues. The dermal melanocytes are often found in a periappendageal and perivascular location (Figs. 5A, B). No significant cytologic atypia is seen and mitotic activity is rare (Fig. 5C).85,86,95 The lesional cells are positive for S-100, HMB-45 (Gp100), and Melan-A/Mart-1 (A103).84 Busam et al84 suggested that onset in childhood and the presence of heterogenous (DBN-like and CBN-like) areas are features that distinguish PTBN from CBN. However, as PTBN are composed of areas resembling CBN, histologic distinction between these entities is not possible without correlation with the clinical features. For this reason, we regard PTBN as a clinicopathologic variant of CBN characterized by large size and extension along fascial planes.
CBNs show a range of histologic features, which may cause them to be misdiagnosed as melanoma. Rare cases of melanoma arising within preexisting CBN have also been reported.75,96 Also, congenital giant CBNs may show intracranial involvement and such tumors are associated with a high rate of malignant transformation, often occurring before puberty.78,79,97 Like melanoma, CBN is usually composed of large epithelioid and/or spindle cells, lacks maturation with depth, may extend deeply, may be pigmented, and may contain an occasional mitotic figure.6,74,98 Perineural extension and intralymphatic tumor may be seen in CBNs and does not indicate malignancy. Various histologic features have been proposed as being helpful for the discrimination of CBN and CBN-like melanoma. However, these criteria are not infallible and in those cases with some atypical but not overtly malignant features, confident prediction of likely biological behavior may not always be possible on the basis of the morphologic assessment of the primary tumor. Pathologic features reported as favoring malignancy include tumoral necrosis, cytologic atypia and pleomorphism, and frequent mitoses (>2/mm2).6 Other findings that favor melanoma over CBN include the presence of large pleomorphic epithelioid cells, cell crowding (usually associated with increased cell nuclear to cytoplasmic ratios), an “infiltrating” growth pattern (where the margins of the tumor are irregular, as opposed to the generally rounded or “pushing” margins of CBN), expansile growth, the presence of junctional activity (especially if it is atypical or shows pagetoid epidermal invasion), or the presence of a “sarcomatoid” growth component, in which sheets of spindle cells replace small fascicular aggregates and nests of melanocytes.6,74
A recent study documented poor interobserver reproducibility among expert pathologists in the diagnosis of atypical CBN and so-called malignant blue nevus, highlighting the lack of uniformly accepted and applied criteria for the pathologic diagnosis of these lesions.99 Further studies preferably correlated with molecular data and long patient follow-up periods are required to determine the morphologic criteria that best predict biologic behavior in these lesions.
In general, the blue nevi described above behave in a benign fashion. Involvement of regional lymph nodes is rare, as has been discussed above. Very rare cases of persistence or recurrence of blue nevi [DBN, CBN, and combined nevi with blue nevus component(s)] have been reported, often, but not always, after incomplete excision.6,111,112 The recurrent lesions usually resemble the original tumor, although occasionally, they may exhibit degenerative (“ancient”) changes or atypical features (pleomorphism and mitotic activity), the latter raising concern for subtle malignancy.111 Persistent or recurrent blue nevi seem to follow a benign course, and the atypical and degenerative morphologic changes seen in some recurrent tumors were not associated with aggressive behavior in most cases. It has been suggested that these changes are likely related to the inflammatory response to the previous surgical procedure.111 However, as clinical recurrence of blue nevi may herald malignant transformation, careful clinical follow-up and histologic examination of the recurrent lesion is warranted.74,113,114
So-called malignant blue nevi comprise a rare group of melanocytic tumors, which in some cases are not easy to classify precisely as benign or malignant purely on the basis of the morphologic features of the primary tumor. Mones and Ackerman127 have published a comprehensive review of cases reported in the literature bearing these diagnoses, and are strongly critical of the use of such terms. These authors are firmly of the opinion that all such lesions should be categorized into “blue nevus,” “melanoma,” and “melanoma in association with a blue nevus.” Although their interpretation is largely based on a logical analysis of the literature, precise categorization of such lesions is not always possible, nor is it possible to reliably predict from histologic features of the primary tumor the biologic behavior of atypical melanocytic lesions showing some morphologic similarities to blue nevus or CBN. Nevertheless, we agree that the term malignant blue nevus is inadvisable, given the juxtaposition of the adjective “malignant” with the noun “nevus,” which connotes a benign lesion. It is far better, we believe, to term such lesions as “blue nevus-like melanoma (BNLM) or atypical blue nevus-like lesion of uncertain malignant potential,” depending on the degree of atypia and the degree of histologic certainty of the malignant potential of the lesion. If the latter term is used, the evidence in favor of a diagnosis of nevus and melanoma respectively should be discussed in the report and, whenever possible, a favored diagnosis proffered. Furthermore, in this situation, or whenever genuine doubt exists about the biologic potential of the lesion, it is probably appropriate to seek an opinion from one or more experienced colleagues. Rather than adding new diagnostic entities to the dermatopathologic lexicon, these terms indicate the difficulty in histologically classifying such lesions as benign or malignant, and reflect the uncertainty in prediction of their behavior. This allows communication of the level of concern about a given lesion to the clinician, facilitating the formulation of an appropriate management plan.128,129 In this difficult area, we believe that such an approach is of more value than to attempt to precisely categorize all such lesions as either benign (nevi) or melanoma when there is a significant possibility that such categorization may be inaccurate. Further study of these cases, correlated with prolonged clinical follow-up and preferably also with molecular data, may be helpful in refining diagnostic criteria for this uncommon but difficult and problematic group of tumors.
Most of the cases of BNLM are associated with CBN (either pure CBN or CBN in combination with other nevus types). Melanoma apparently arising in association with a pure DBN is very rare.122,130,131 Connelly and Smith113 proposed 2 criteria to enable distinction of BNLM from metastatic or nodular melanoma, namely the lack of a junctional component and the presence of a background benign blue nevus. Clearly, correlation with clinical details is also important if a diagnosis of metastatic melanoma is being considered, particularly to establish whether the patient has a known history of melanoma and whether there is evidence of metastatic disease elsewhere.
Genetic studies of small numbers of cases have suggested that aberrations commonly seen in melanomas (such as mutations in CDKN2A and alterations in chromosomes 10q, 1p, and 17) are not identified in BNLM, suggesting that the molecular pathogenesis of BNLMs is distinct from that of conventional melanoma.125 Further genetic studies are required to confirm these findings. A recent study reported the presence of frequent somatic mutations in the heterotrimeric G protein alpha-subunit, Guanine nucleotide binding protein (G protein), q polypeptide, in blue nevi (83%) and ocular melanoma of the uvea (46%).132 The mutations occurred exclusively in codon 209 in the Ras-like domain and resulted in constitutive activation, turning Guanine nucleotide binding protein (G protein), q polypeptide into a dominant acting oncogene. These findings provide molecular evidence of a histogenetic link between these tumors which, as we recognized many years ago, show morphologic similarities in a subset of cases.
BNLM is rare. They often occur in older individuals (often >45 y), are usually large (3-13 cm), and may show clinical evidence of a residual CBN. Many of the reported cases exhibit local invasion or widespread metastasis.116–118,121,123,124,133–136 The scalp is the commonest site of involvement, followed by the face, buttocks, and chest. Rarely BNLMs in other locations, such as the vulva,118 have also been reported.
Cases of BNLM reported in the literature have behaved very aggressively, with a majority exhibiting metastases leading to patient death.113,121,123,125,131,135,137–142 There are probably a number of factors contributing to this poor outcome, including delayed diagnosis and treatment of the malignant component, an overestimate due to difficulties in separating nonmetastasizing BNLM from atypical CBN, and reporting bias. However, metastasis or death may be delayed up to 19 years after the diagnosis.118,133 Reliable prediction of the behavior of BNLM based on histopathologic features has not always been successful, although some studies have suggested that Breslow thickness may be predictive of outcome.122 A recent comprehensive analysis of 23 patients with BNLM treated at the Melanoma Institute Australia (incorporating the Sydney Melanoma Unit), the largest series reported to date, found that clinical outcome was similar to that of conventional melanoma patients when matched for tumor thickness and other important prognostic factors.143
BNLM can generally be distinguished from CBN by the presence of a frankly malignant component (Figs. 8A, B).118 Histologically, BNLM is characterized by widespread necrosis in many cases (Figs. 8C, D),6,116,133,134,144 and palisading of cells around the areas of necrosis may be seen.133,134 However, necrosis is not a common finding in all series.122 Focal necrosis has been reported to occur rarely in otherwise typical CBN,74 although it is our opinion that, in the absence of prior biopsy or trauma, the presence of necrosis is very concerning for malignancy. Other criteria supportive of a diagnosis of BNLM include high mitotic rate (>2/mm2), abnormal mitotic figures, vascular invasion, excessive cell crowding, expansile growth and marked cytologic pleomorphism and atypia (Figs. 8D, E). Occasional cases of BNLM may, however, be associated with a low mitotic rate.113,118,121,122,135,136,138–142,145–147
Some authors found that ACBNs tend to recur, and may acquire a more aggressive phenotype if incompletely excised,153 whereas other studies found no evidence of recurrence or metastasis in their cases.149 Until further data emerges, it therefore seems an appropriate course of action to regard such lesions as being of uncertain/indeterminate malignant potential and to treat them with complete resection, followed by close clinical follow-up for local recurrence or regional/distant spread.
Histologically, DPNs are relatively symmetric and well-demarcated lesions extending to the deep reticular dermis and sometimes into subcutis, and often exhibit an inverted wedge-shaped silhouette (Fig. 9A). They are usually composed of nests and fascicles of predominantly ovoid epithelioid cells, which often contain cytoplasmic melanin pigment, the latter being more prominent in associated melanophages. Extension around and in association with skin adnexal structures or nerves is common (Fig. 9B). They usually exhibit some nuclear pleomorphism, but mitotic activity is low or absent. Cells with “smudged” nuclear hyperchromatism and intranuclear cytoplasmic invaginations (pseudoinclusions) are often present (Figs. 9C, D). DPNs are almost invariably positive for S-100 and HMB-45.91,155
Seab et al asserted that, although there is some overlap between the clinical and morphologic features of DPN with those of DBN, CBN, and Spitz nevus, DPN constitutes a relatively homogenous group with sufficiently distinctive architectural and cytologic features to permit distinction from these other lesions.155 We concur with this point of view. In contrast to DPN, DBN lacks junctional nests, exhibits a diffuse rather than a nested dermal component, is predominantly composed of more fusiform or dendritic cells and lacks nuclear pleomorphism. CBN lacks junctional nests and is composed of prominent nests of nonpigmented or scantily pigmented uniform ovoid to spindled cells, unlike DPN. Spitz nevi generally occur in younger patients and are often clinically nonpigmented.158,159 They show prominent junctional nests and epidermal hyperplasia, and are composed of epithelioid and spindle cells with vesicular nuclei.160 Superficial mitotic figures are not uncommon. Melanomas generally lack the circumscription, symmetry and wedge-shaped architecture seen in DPN. Additional features that favor melanoma include mitoses (>2/mm2), atypical mitotic figures, diffusely atypical melanocytes with coarsely granular chromatin and fine, dusty melanin pigment, solid growth pattern, stromal reaction, and an in situ melanoma component.155
EBN is composed of combinations of large epithelioid melanocytes with abundant cytoplasm, variable amounts of coarsely granular cytoplasmic melanin pigment and prominent nucleoli, sometimes associated with heavily pigmented spindle cell and dendritic cell components. In some epithelioid cells, the pigment is distributed evenly throughout the cytoplasm, but in others, the pigment is concentrated at the periphery of the cell, leading to a pigment-free perinuclear zone. The cells are interspersed between dermal collagen bundles. The large and pleomorphic nuclei in the epithelioid cells may contain occasional very prominent nucleoli (Fig. 10). Maturation of the lesional cells with depth is lacking and occasional mitotic figures (typically <1/50 high power fields) may be seen. Melanophages are readily identified.64,161,163–165 The tumor cells stain with S-100, HMB-45, Melan-A, and MiTF, as well as CD68.161,167 Additional (junctional or intradermal) melanocytic nevi are commonly associated with EBN, such lesions therefore representing combined melanocytic nevi.<!/HEADING><!/HEADING>161,165
DPN may display some features seen in EBN, such as pigmentation, wedge shape, presence of epithelioid and some spindled cells and common extension to subcutaneous fat. However, DPN is more common in the head and neck region than in the trunk and extremities. Nests and fascicles of cells seen in DPN are unusual in EBN. Nuclei in DPN tend to be irregular, nucleoli are not usually prominent, the nuclear chromatin is often smudged, and intranuclear pseudoinclusions are common; in contrast, the nuclei in EBN contain prominent nucleoli and the nuclear chromatin is clear.161 Like EBN, Spitz nevus occurs at a young age and may exhibit a dome shape. However unlike EBN, Spitz nevi are typically sparsely pigmented, are situated in the reticular dermis, contain cells arranged in nests, show cell “maturation” with dermal depth, exhibit epidermal hyperplasia, and nucleoli are only occasionally prominent; they are frequently negative for HMB-45.161,167
PEM occurs in patients over a wide age range, with a median age of 27 years. It is most often located on the extremities. Histologically, PEM is a heavily pigmented dermal melanocytic proliferation with infiltrative margins. The tumor may abut the epidermis or be separated from it by a grenz zone, and there may be associated epidermal hyperplasia (Figs. 10A, B). A junctional component is sometimes present and PEM is associated with a nevus in a minority of cases. The tumor is composed of a mixture of epithelioid and spindled melanocytes with heavy cytoplasmic pigmentation. The epithelioid cells range in size from medium-sized to large, and contain moderate to abundant cytoplasm. Nuclear atypia and nucleolar prominence is generally more pronounced in the large cells (Fig. 10C). The spindle cells are more prevalent at the periphery of the lesion and exhibit similar nuclear features to those seen in the epithelioid cells. Their cytoplasm, which is focally dendritic, is also heavily pigmented (Fig. 10D). Mitotic activity is low (0 to 3 mitotic figures/mm2) and tumor necrosis is uncommon. Numerous melanophages are often also present and lymphocytes are seen in occasional cases, usually at the periphery of the tumor.168,177–180
Some authors have questioned the need for the term “PEM” given that it subsumes other well-documented entities such as animal-type melanoma and at least some examples of EBN (as mentioned previously, we believe there remain examples of EBN that do not fulfill criteria for a diagnosis of PEM).181 However, the originators of the term suggest that it is justified, as animal-type melanoma and EBN cannot be distinguished histologically, nor can metastasizing and nonmetastasizing cases. Furthermore, PEM seems to exhibit distinct clinicopathologic features and clinical behavior, when contrasted with conventional melanoma. Moreover, a recent study analyzed mutations of the protein kinase A regulatory subunit type 1α (coded by the PRKAR1A gene), loss of heterozygosity at the gene locus (17q22 to 24) and immunohistochemistry for the protein product (R1alpha) in PEMs, a variety of nevi and melanomas.182 Mutations of the PRKAR1A gene are found in more than half of Carney complex patients. No mutations were found in PEMs, in nevi or in melanomas, but 17q22 to 24 loss of heterozygosity was much more common and extensive in PEMs than in nevi or melanomas. In contrast, immunohistochemical expression of R1α was absent in 82% of PEMs and in all Carney complex-associated EBNs, but was present in virtually all melanomas and melanocytic nevi. These findings provide molecular evidence in support of the proposal that PEM is a distinct melanocytic tumor. Until the nature of these tumors is resolved beyond doubt, we recommend complete local excision and careful clinical follow-up. In view of the apparently favorable prognosis of patients with PEM, the unknown clinical significance of sentinel lymph node metastases in PEM and the absence of conclusive evidence that sentinel lymph node biopsy followed by complete lymphadenectomy in those patients with metastases improves overall survival, the role of sentinel lymph node biopsy in patients with PEM is probably limited. Nevertheless, lymphoscintigraphy to identify the sites of sentinel lymph nodes (which can then be regularly carefully monitored by regular high resolution ultrasound) offers an alternative noninvasive strategy that enables growing metastases to be detected at an early stage and appropriate management to be instigated.
As highlighted by Groben et al, there is probably a spectrum of pigmented melanocyic tumors and occasional cases may show overlapping features and may be difficult to classify. In view of this, and the presence of occasional melanocytic nevi which show cellular heterogeneity but not clear cut evidence of 2 or more distinct nevus cell types, the proposal of Barnhill and colleagues to refer to some lesions as nevi with phenotypic heterogeneity has merit and is probably a more accurate description of the pathogenesis of the morphologic features. However, in our view, the proposal of Groben et al to classify some lesions as “epithelioid combined nevi” with various subtypes (Carney complex-like, “BLITZ”, DPN-like and mixed types) seems complex and does not reflect the documented cellular heterogeneity that occurs in the previously described subtypes of blue nevi.
In the final analysis, genetic studies of large numbers of cases may aid in refining the classification of these entities (some of which may not turn out to be entities in their own right) and relationships (if any) between them.
Cutaneous neurocristic hamartoma (CNH) refers to very rare cutaneous tumors exhibiting divergent differentiation along nevomelanocytic, neural and pigmented dendritic cell lines. They may be congenital or acquired, and present as slow-growing multinodular plaques. Histologically, they are infiltrating multinodular tumors involving the dermis and subcutis and lacking a junctional component. The tumors comprise areas resembling DBN, CBN, EBN, neurofibroma, and schwannoma, and may infiltrate along nerves. Typically, these tumors exhibit low grade (but progressive) behavior and the clinical course is characterized by slow growth punctuated by numerous recurrences.183–185 Rare tumors may develop expansile nodular areas composed of epithelioid cells exhibiting cytologic atypia, mitotic activity and necrosis. Such tumors have led to metastasis and death and have been termed “malignant metastasizing neurocristic tumors.”186 Whether or not these represent unusual forms of melanoma arising in association with a blue nevus is open to debate.
We remain doubtful that these lesions represent distinct entities and challenge the appropriateness of referring to them as hamartomas. We concur with the suggestion that both PNHs and CNHs may represent variants of blue nevus with peripheral nerve sheath differentiation,1 and a case of a dermal melanocytic proliferation exhibiting features of both PTBN and neurocristic hamartoma has been described.190 There seems to be some clinical and morphologic overlap between CNH, PNH, and PEM, although the precise relationship between these entities is unclear at present. The recently described paraganglioma-like dermal melanocytic tumor has some similar features to CBN and may represent another blue nevus variant or “melanocytoma.”191,192
Blue nevi exhibit a spectrum of appearances, with variation in parameters such as cellularity, cellular composition, degree of sclerosis, and pigmentation. Although such lesions are usually classified into one of the well-defined subtypes, in some cases displaying overlapping features, subclassification may not be precise. However, awareness of the clinical and histologic spectrum of blue nevi is important for their recognition and for their distinction from melanoma, particularly in the case of large blue nevi, CBN, and blue nevus variants exhibiting unusual or atypical morphologic features. In blue nevus-like tumors with some atypical features but without clear cut evidence of malignancy, it may not be possible in all cases to definitively predict the biological behavior by morphologic assessment of the primary tumor. In such cases, we recommend documenting in the pathology report the evidence in favor of (and against) a diagnosis of nevus or melanoma and providing a favored diagnosis whenever possible. It is probably appropriate in such difficult/problematic/borderline cases to seek further opinion from one or more experienced colleagues. Complete excision is probably mandatory (if clinically appropriate), however, the role of sentinel lymph node biopsy in the management of these patients remains uncertain. In the future, it is hoped that the use of molecular testing may allow more precise classification of melanocytic tumors and more accurate prediction of their biologic potential and clinical behavior.193
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