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An. Bras. Dermatol. vol.85 no.4 Rio de Janeiro July/Aug. 2010
IMAGING IN DERMATOLOGY
Ana Maria Costa PinheiroI; Gustavo Alonso PereiraII; Alessandro Guedes AmorinIII; Tatiana Cristina Nogueira VarellaIV; Horacio FriedmanV
IProfessor of Dermatology, University of Brasilia. Coordinator of the Tumor Outpatient Clinic, Teaching Hospital, University of Brasília, Brasília, DF, Brazil
IIDermatologist, São Paulo State Cancer Institute (ICESP), São Paulo, SP, Brazil
IIIDermatologist, Dermatology Outpatient Clinic of Surgery and Tumors, Teaching Hospital, University of Brasilia, Brasília, DF, Brazil
IVDermatologist, Outpatient Clinic of Phototherapy and Tumors, Teaching Hospital, University of Brasilia, Brasília, DF, Brazil
VProfessor, Head of the Pathology Department, Teaching Hospital, University of Brasilia, Brasília, DF, Brazil
The Spitz nevus is a benign melanocytic lesion with clinical and histopathological features similar to those of melanoma. It was first described in 1948 but great controversy still remains today with respect to its diagnosis and management. The use of dermoscopy may increase diagnostic accuracy. In Spitz nevus, the most common dermoscopic finding is a starburst-like pattern, followed by globular and atypical patterns. Diagnosis must be confirmed by histopathology, particularly in atypical cases.
Keywords: Dermatoscopy; Melanoma; Nevus, epithelioid and spindle cell
The Spitz nevus is a benign melanocytic proliferation that was first described in 1948 by Sophie Spitz as a melanoma of childhood. 1 It was initially described as an erythematous papule or nodule of rapid growth, most commonly located on the extremities or on the face of children and adolescents. More recently, the Spitz nevus was found to present as a pigmented lesion in 71-92% of cases. 2,3 This pigmentation, often intense and associated with the sudden appearance of the lesion, makes differential diagnosis with melanoma important. A diagnosis of Spitz nevus may be confirmed by dermoscopy, which shows three distinct patterns: a starburst pattern, a globular pattern and an atypical pattern. 4 There is no consensus on the management of the Spitz nevus and removal of the lesion is often recommended in view of its clinical and dermoscopic similarity with melanoma. Histopathologically, the Spitz nevus may be classified as junctional, intradermal and, in the majority of cases, compound. It is formed of large melanocytes, sometimes with nuclear atypia and abundant, rounded, oval, fusiform and polygonal cytoplasm with a fusiform and epithelioid appearance, arranged in nests. 5,6
BISG, a two-year old girl with skin phototype 2, living in the Federal District of Brazil. According to her mother, the child had a "mark" that grew in size and bled spontaneously. Dermatological examination showed a brownish hyperchromic papule with blackened areas on the front of her right ankle (Figure 1). Dermoscopy showed a nonspecific global pattern with the presence of atypical striations associated with a negative pigment network at the center of the lesion and areas resembling a bluish-white veil (Figures 2 and 3). Histopathology showed nests of fusiform cells at the epidermal base and in the dermis (Figure 4).
The Spitz nevus is a rare, benign indolent lesion that is generally acquired and is brownish in color, flat or slightly raised and symmetrical. 3 It is more commonly found in children or adolescents, rarely being found in elderly patients, a fact that suggests regression of the lesions with age. 4 It often presents as a melanocytic lesion and the accuracy of its diagnosis may increase from 46% with the naked eye to 93% with the use of dermoscopy. 7 Dermoscopy may reveal different patterns, the most common pattern specific to the Spitz nevus being a starburstlike pattern, which occurs in 53% of cases. Its characteristics include the presence of multiple pigmented striations and/or large brown or black globules distributed symmetrically along the margins of the lesion, with a radiated appearance. 4 The second most common pattern is the globular pattern, which occurs in 22% of cases and features the presence of regular, brownish or greyish central pigmentation and brownish globules along the margins. The third pattern described by Argenziano et al., which occurs in 25% of cases, is the atypical pattern, characterized by the irregular distribution of structures and colors, areas of diffuse, irregular pigmentation and a whitish-blue veil. It may also present radiated striations at the margins and a punctuated, vascular pattern. 7,8
Dermoscopy aids in the diagnosis of cases of Spitz nevus with a starburst or globular pattern; however, in cases with the atypical pattern, diagnosis may be confused with melanoma. 7 The dermoscopic patterns represent different morphological expressions that correspond to the phases of progression of the pigmented Spitz nevus. Follow-up studies of patients with Spitz nevus reveal different patterns at different times in the progression of the condition, evolving from a starburst pattern to a reticular pattern. 9,10
Dermoscopy may result in a more precise diagnosis; however, a consensus on the management of the Spitz nevus can only be reached following more prolonged clinical and dermoscopic follow-up.
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3. Lyon V. The Spitz Nevus: review and update. Clin Plast Surg. 2010;37:21-33. [ Links ]
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8. Rezze G, Sá B, Neves R. Atlas de dermatoscopia aplicada. São Paulo: Lemar; 2008. [ Links ]
9. Nino M, Brunetti B, Delfino S, Brunetti B, Panariello L, Russo D. Spitz Nevus: follow-Up Study of 8 cases of childhood Starbust type and proposal for Management. Dermatology. 2009;218;48-51. [ Links ]
10. Pizzicheta M, Argenziano G, Grandi G, Giacomi C, Trevisan G, Soyer H. Morphologic changes of a pigmented Spitz nevus assessed by dermoscopy. J Am Acad Dermatol. 2002;47:137-9. [ Links ]
Received on 16.02.2010. * Study conducted at the Brasília Phototherapy and Dermoscopy Center, Brasilia, DF, Brazil.
Approved by the Advisory Board and accepted for publication on 22.02.10
Conflict of interest: None
Financial funding: None
Received on 16.02.2010.
* Study conducted at the Brasília Phototherapy and Dermoscopy Center, Brasilia, DF, Brazil.