Junctional nevus: Difference between revisions

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Suspected dysplastic nevus (also called dysplastic melanocytic nevus).
[[File:Histopathology of melanocytic nevus 2.jpg|thumb|350px|'''Junctional nevus''' (here seen in H&E stain and Melan A stain), where all nests are continuous with the epidermis.]]
{{Comprehensiveness}}
A suspected dysplastic nevus (also called dysplastic melanocytic nevus) generally presents as a [[Dark skin focalities|dark skin focality]].
{{Fixation - standard}}
{{Gross processing of skin excisions}}
==Microscopic evaluation==
A junctional nevus is characterized by:<ref>{{cite web|url=https://www.pathologyoutlines.com/topic/skintumormelanocyticJunctnevus.html|title=Skin melanocytic tumor - Nevi - Junctional nevus|author=Christopher S. Hale, M.D.|website=Pathology Outlines}} Topic Completed: 1 February 2017. Revised: 4 April 2019</ref>
*Rounded melanocyte nests on the epidermal side of dermoepidermal junction
*Variable lentiginous melanocytic hyperplasia


==Evaluation==
===Differential diagnosis===
<gallery mode=packed heights=200>
File:Histopathology of lentigo maligna.jpg|'''[[Melanoma in situ]]''', by higher atypia and dysplasia (see table in [[#Grading|the grading section]]).
File:Histopathology of dermal nevus, high magnification.jpg|'''[[Dermal nevus]]''', with nevus cells enclosed within the dermis.
File:Histopathology of compound nevus.jpg|thumb|'''Compound nevus''', with nevus cells in both dermis and epidermis.
</gallery>
*'''[[Epidermal nevus]]''', nests of nevus cells enclosed within the epidermis.


===Swedish approach===
===Grading===
Review of '''clinical information''', mainly:<ref name=KVAST>{{cite web|author=Katarzyna Lundmark, Britta Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel|title=Histopatologisk bedömning och gradering av dysplastiskt nevus samt gränsdragning mot melanom in situ/melanom (Histopathological assessment and grading of dysplastic nevus and distinction from melanoma in situ/melanoma)|url=https://medlem.foreningssupport.se/foreningar/uploads/L15178/kvast/hud/Histopatologisk%20bedomning%20och%20gradering%20av%20dysplastiskt%20nevus%20samt%20gransdragning%20mot%20melanom%20in%20situ-melanom%2020150330.pdf|website=KVAST (Swedish Society of Pathology)|accessdate=2019-09-18}}</ref>
{{Epidermal and junctional nevus grading}}
*Growth
[[File:SOX10 immunohistochemistry of normal skin (edited).jpg|thumb|center|300px|In contrast, normal skin (pictured) has a melanocyte about every 4 cells along the basement membrane.]]
*Abnormal visual appearance
*Size >10mm


'''Microscopy''':
===Report===
''Mandatory findings'':<ref name=KVAST/>
*Presence or absence of atypia.
*Shoulder phenomenon, meaning that the extent of the dermal component is larger than the epidermal component.
:{{Moderate-begin}}If atypical, low-or high grade, or degree of atypia.{{Moderate-end}}
*Lentiginous proliferation, meaning an increased amount of melanocytes in the basal area, along rete pegs and sometimes between them.
*{{Comprehensive-begin}}Size
*Irregularly distributed nests of melanocytes.
*Findings included in table above if applicable.
*Atypia
*Most likely grade if possible.{{Comprehensive-end}}
 
{|class=wikitable
Classify into either of the following:
| Skin, upper back, excision:<br>- Junctional {{Moderate-begin}}melanocytic{{Moderate-end}} nevus with {{Moderate-begin}}moderate{{Moderate-end}} atypia.
 
{|class="wikitable"
!rowspan=2 colspan=2| Parameter !!colspan=2| Low-grade dysplasia !! High-grade dysplasia !!rowspan=2| Suspected melanoma in situ
|-
| Mild || Moderate || Severe
|-
|rowspan=7| Structural<br>''(Low<br>mag.)'' || Delimitation<ref name=KVAST/> || Rarely diffuse || Sometimes diffuse ||colspan=2| Often diffuse
|-
| Lentiginous proliferation<ref group="notes">Lentiginous proliferation is proliferation along the basal layer of the epidermis</ref><ref name=KVAST/> || Yes, along with rete pegs || Yes, along with and focally between rete pegs || Yes, along with and focally between rete pegs || Yes partially continuous, multilayered [[File:Histopathology of lentigo maligna.jpg|center|140px]]
|-
| Bridging<ref name=KVAST/> || Rarely ||colspan=3| Often
|-
| Confluent nests<ref name=KVAST/> || Rarely || Sometimes || Often || Often widespread
|-
| Pigment distribution<ref name=KVAST/> || Regular ||colspan=3| Irregular
|-
| Suprabasal presence<ref name=KVAST/> (less than most superficial third of epidermis) || No ||colspan=2| Yes || Yes, multifocal
|-
| Pagetoid migration including superficial third of epidermis<ref name=KVAST/> || No || No || Yes, in a maximum of 2 HPF centrally, but not peripherally ||
Yes, multifocal and/or in periphery
|-
|rowspan=4| Cellular<br>''(high<br>mag.)'' || Nuclear pleomorphism<ref name="HusainMein2011">{{cite journal|last1=Husain|first1=Ehab A|last2=Mein|first2=Charles|last3=Pozo|first3=Lucia|last4=Blanes|first4=Alfredo|last5=Diaz-Cano|first5=Salvador J|title=Heterogeneous topographic profiles of kinetic and cell cycle regulator microsatellites in atypical (dysplastic) melanocytic nevi|journal=Modern Pathology|volume=24|issue=4|year=2011|pages=471–486|issn=0893-3952|doi=10.1038/modpathol.2010.143}}</ref> || Slight ||colspan=2| Prominent
|-
| Chromatin pattern<ref name="HusainMein2011"/> ||colspan=2| Usually thin || Usually granular
|-
| Nucleolus<ref name="HusainMein2011"/> ||colspan=2| Usually inconspicuous || Usually prominent
|-
| Histological regression<ref name="HusainMein2011"/><ref group="notes">Histological regression is one or more areas within a tumor in which neoplastic cells have disappeared or decreased in number. In this case, this means complete or partial disappearance from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.<br>- {{cite journal|last1=Ribero|first1=Simone|last2=Gualano|first2=Maria Rosaria|last3=Osella-Abate|first3=Simona|last4=Scaioli|first4=Giacomo|last5=Bert|first5=Fabrizio|last6=Sanlorenzo|first6=Martina|last7=Balagna|first7=Elena|last8=Fierro|first8=Maria Teresa|last9=Macripò|first9=Giuseppe|last10=Sapino|first10=Anna|last11=Siliquini|first11=Roberta|last12=Quaglino|first12=Pietro|title=Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status|journal=JAMA Dermatology|volume=151|issue=12|year=2015|pages=1301|issn=2168-6068|doi=10.1001/jamadermatol.2015.2235}}</ref> ||colspan=2| Usually || Usually not
<!--
Most prevalent
Dominant
atypigrad
Easy
Easy-moderate
Moderate-severe
Moderate-severe
cellular
atypia *
Percentage of atypical
melanocytes
<10%
about 10 - 50%
about 50-90%
Usually> 90%
Extended retelists
Yes,
regular
Yes, varying
Yes, often
irregular
Varying,
planarized
Concentric fibrosis Yes Yes Yes Varies
Lamellar fibrosis Rarely Often Often Pronounced Varying
lymphocytic *
Sparingly,
perivascular
Easy-moderate
perivascular
Varying
Varying
reactive
changes
regressive
changes
No
No
Rarely
Varying
Melanocytic atypia
No
Rarely, in superficial
part
Can be detected in
superficial part
Can be detected in
superficial part.
intradermal
component
maturation
Yes
Yes, can be
partial
Yes, can be
partial
Yes, can be
partial; if
No
ripening
recital
invasive
melanoma!
! Further workup !!  !!  !!  Immunohistochemistry
|}
 
 
-->
|}
|}
{{Reporting}}
{{Bottom}}
{{Bottom}}

Latest revision as of 12:43, 24 October 2023

Author: Mikael Häggström [note 1]

Junctional nevus (here seen in H&E stain and Melan A stain), where all nests are continuous with the epidermis.

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

A suspected dysplastic nevus (also called dysplastic melanocytic nevus) generally presents as a dark skin focality.

Fixation

Generally 10% neutral buffered formalin.

Gross processing of skin excisions

Gross pathologic processing of skin excisions[1][note 2]
Lesion size
<4 mm 4 - 8 mm 9 - 15 mm
Benign appearance

Suspected malignancy

In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used. Further information: Gross processing of skin excisions

Microscopic evaluation

A junctional nevus is characterized by:[2]

  • Rounded melanocyte nests on the epidermal side of dermoepidermal junction
  • Variable lentiginous melanocytic hyperplasia

Differential diagnosis

Grading

edit
((Grade a nevus into either low or high grade by the following algorithm:))[3]

In uncertain cases, more specific grading, and/or differentiation from a non-atypical congenital nevus and suspected melanoma, the following table can be used to determine the most fitting diagnosis:

Comparison of congenital pattern nevus, dysplastic nevus and suspected melanoma   edit
Parameter Non-atypical congenital pattern Low-grade dysplastic nevus High-grade dysplastic nevus Suspected melanoma in situ
Mild dysplasia Moderate dysplasia Severe dysplasia
Macroscopic Lateral circumscription[4] Sharp Slightly diminished Moderate Poor
Symmetry[4] Good Often broken Rare
Structural
(Low
mag.) 		Delimitation[5] Rarely diffuse Sometimes diffuse Often diffuse
Lentiginous proliferation[note 3][5] Yes, along with rete pegs Yes, along with and focally between rete pegs Yes, along with and focally between rete pegs Yes partially continuous, multilayered
Bridging[5] Rarely Often
Confluent nests[5] Rarely Sometimes Often Often widespread
Pigment distribution[5] Regular Irregular
Suprabasal presence (less than most superficial third of subcorneal epidermis) Occasionally centrally[4] No[5] or rarely[4] Occasionally centrally[4] Yes, multifocal[5]
Pagetoid migration including superficial third of subcorneal epidermis[5] No No Yes, in a maximum of 2 HPF centrally, but not peripherally Yes, multifocal and/or in periphery
Peripheral.
Extended rete pegs Ocassional[4] Yes, regular[5] Yes, varying[5] Yes, often irregular[5] Varying, flattened[5]
Concentric fibrosis Regressive[4] Yes[5] Occasional[4]
Lamellar fibrosis Rarely[5] Often[5] Often pronounced[5] Occasional[4]
Lymphocytic infiltrate[5] Mild, perivascular Mild or moderate, perivascular Varying Varying
Suprapapillary plate involvement No[4] Usually no[4] Often[4] Yes[4]
Cellular
(high
mag.) 		Image
Junctional extension[4] Unusual Usual Extensive
Nuclear size[4] Age-related Small Medium Large Medium or large. Pleomorphic[6]
Nuclear pleomorphism[7] Slight Prominent
Chromatin pattern Uniform[4] Condensed[4] Partically expanded[4] Expanded, coarse in some cells[4] Expanded, hyperchromatic, coarse.[4] Usually granular.[7]
Nucleoli[4] Age-related Small Medium Large Usually[7] large
Mitoses[4] Few superficial Superficial and deep
Histological regression[7][note 4] Usually Usually not
Percentage of atypical melanocytes[5] <10% About 10 - 50% about 50-90% Usually> 90%
Intradermal melanocytic atypia[5] No Rarely, in superficial part Can be detected in superficial part
Intradermal melanocyte maturation[5] Yes Yes, can be partial Yes, can be partial Variable

In suspected but not certain nevus or melanoma in situ, generally perform immunohistochemistry with SOX10, whereby melanocyte proliferation and nuclear pleomorphism is easier to see.[note 5]

  • SOX10 immunohistochemistry of a junctional nevus, with atypical melanocytic proliferation, seen mainly in hair follicles.
    SOX10 immunohistochemistry of a junctional nevus, with atypical melanocytic proliferation, seen mainly in hair follicles.
  • SOX10 immunohistochemistry of lentigo maligna, showing an increased number of melanocytes along stratum basale, and nuclear pleumorphism.
    SOX10 immunohistochemistry of lentigo maligna, showing an increased number of melanocytes along stratum basale, and nuclear pleumorphism.
In contrast, normal skin (pictured) has a melanocyte about every 4 cells along the basement membrane.

Report

  • Presence or absence of atypia.
(If atypical, low-or high grade, or degree of atypia.)
  • ((Size
  • Findings included in table above if applicable.
  • Most likely grade if possible.))
Skin, upper back, excision:
- Junctional (melanocytic) nevus with (moderate) atypia.

  See also: General notes on reporting


Notes

  1. ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. ↑ The excision examples show a normal mole (upper row, benign appearance) and a superficial basal cell carcinoma (lower row, suspected malignancy).
  3. ↑ Lentiginous proliferation is proliferation along the basal layer of the epidermis
  4. ↑ Histological regression is one or more areas within a tumor in which neoplastic cells have disappeared or decreased in number. In this case, this means complete or partial disappearance from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.
    - Ribero, Simone; Gualano, Maria Rosaria; Osella-Abate, Simona; Scaioli, Giacomo; Bert, Fabrizio; Sanlorenzo, Martina; Balagna, Elena; Fierro, Maria Teresa; et al. (2015). "Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status ". JAMA Dermatology 151 (12): 1301. doi:10.1001/jamadermatol.2015.2235. ISSN 2168-6068. 
  5. ↑ SOX10 stains cell nuclei of melanocytes.
    - Miettinen, Markku; McCue, Peter A.; Sarlomo-Rikala, Maarit; Biernat, Wojciech; Czapiewski, Piotr; Kopczynski, Janusz; Thompson, Lester D.; Lasota, Jerzy; et al. (2015). "Sox10—A Marker for Not Only Schwannian and Melanocytic Neoplasms But Also Myoepithelial Cell Tumors of Soft Tissue ". The American Journal of Surgical Pathology 39 (6): 826–835. doi:10.1097/PAS.0000000000000398. ISSN 0147-5185. 

Main page

References

  1. ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources: ". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. . 
    - With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen.
    - It also shows an example of circular coverage, with equal coverage distance in all four directions.
    - The entire specimen may be submitted if the risk of malignancy is high.
  2. ↑ Christopher S. Hale, M.D.. Skin melanocytic tumor - Nevi - Junctional nevus. Pathology Outlines. Topic Completed: 1 February 2017. Revised: 4 April 2019
  3. ↑ Pozo, Lucia; Naase, Mahmoud; Cerio, Rino; Blanes, Alfredo; Diaz-Cano, Salvador J. (2001). "Critical Analysis of Histologic Criteria for Grading Atypical (Dysplastic) Melanocytic Nevi ". American Journal of Clinical Pathology 115 (2): 194–204. doi:10.1309/KXJW-1UJE-BPG6-AXBV. ISSN 0002-9173. 
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 Arumi-Uria, Montserrat; McNutt, N Scott; Finnerty, Bridget (2003). "Grading of Atypia in Nevi: Correlation with Melanoma Risk ". Modern Pathology 16 (8): 764–771. doi:10.1097/01.MP.0000082394.91761.E5. ISSN 0893-3952. 
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 Katarzyna Lundmark, Britta Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel. Histopatologisk bedömning och gradering av dysplastiskt nevus samt gränsdragning mot melanom in situ/melanom (Histopathological assessment and grading of dysplastic nevus and distinction from melanoma in situ/melanoma). KVAST (Swedish Society of Pathology). Retrieved on 2019-09-18.
  6. ↑ Christopher S. Hale. Skin melanocytic tumor - Melanoma - Invasive melanoma. Topic Completed: 1 May 2013. Revised: 17 September 2019
  7. ↑ 7.0 7.1 7.2 7.3 Husain, Ehab A; Mein, Charles; Pozo, Lucia; Blanes, Alfredo; Diaz-Cano, Salvador J (2011). "Heterogeneous topographic profiles of kinetic and cell cycle regulator microsatellites in atypical (dysplastic) melanocytic nevi ". Modern Pathology 24 (4): 471–486. doi:10.1038/modpathol.2010.143. ISSN 0893-3952. 

Image sources


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