Case Letter
Plantar Spitz nevus mimicking melanoma
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While melanocytic nevi are relatively common on the palmoplantar region, Spitz nevus rarely affects this site, with few reports in the literature.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This case report describes a 20-year-old female patient, phototype III, with a complaint of a "spot" on the plantar surface for years, with recent growth. On the left plantar region, she had a blackened macula measuring 0.5 cm, with precise limits and irregular edges (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Dermoscopy showed a melanocytic lesion with a whitish blue veil in the center and peripheral brownish homogeneous areas, with a fibrillar pattern at one o'clock position (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). An excisional biopsy was performed, with hypotheses of blue nevus and acrolentiginous melanoma. The anatomopathological examination revealed a compound fusocellular-epithelioid melanocytic nevus compatible with a Spitz nevus (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">According to a publication by Wiedemeyer et al. in 2018, acral Spitz nevus has a predilection for the plantar region of young female adults, a finding consistent with the present case. Moreover, it was observed that the acral variant is predominantly pigmented, with irregular borders and a larger size than conventional acral nevi. Such characteristics raise suspicion for malignancy, including atypical nevus and melanoma in the differential diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Dermoscopy is a valuable tool in the clinical diagnosis of pigmented lesions. Basically, in the case of acral melanocytic lesions, the parallel ridge pattern or diffuse, irregular pigmentation is highly suggestive of melanoma; the parallel furrow pattern prevails in benign melanocytic nevi.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Regarding acral Spitz nevus, however, it is possible to find varied patterns with more than one component, and the lack of specific findings makes it difficult to exclude malignancy.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In parallel, the confocal reflectance microscopy (CRM) is a non-invasive imaging test that has helped to differentiate between benign nevi and melanomas. However, its use is limited in the investigation of acral lesions due to the palmoplantar stratum corneum thickness, which makes observation of deeper structures difficult.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Histopathologically, the classic Spitz nevus presents large, spindle-shaped, and/or epithelioid melanocytes, with abundant eosinophilic cytoplasm, vesicular nucleus and small nucleolus. In acral Spitz nevus, which can be junctional or compound, a combination of spitzoid cytomorphology with the atypical junctional growth pattern of acral nevi is observed. It is also possible to find junctional nests with irregular distribution and shapes, pagetoid spread, and transepidermal elimination of melanocytic nests, findings that mimic the histopathological pattern of acrolentiginous melanoma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In dubious cases, the correct diagnosis can be aided by immunohistochemistry: Spitz nevi, with rare exceptions, express large amounts of P16 and P21 markers; conversely, acrolentiginous melanomas show significant loss of these markers.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore, while there are no studies that clarify the role of dermoscopy and CRM in differentiating between acral Spitz nevus and acrolentiginous melanoma, the excisional biopsy and histopathological study remain the diagnostic pillars for atypical acral pigmented lesions.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Guilherme Camargo Julio Valinoto: Drafting and editing of the manuscript; collection, analysis, and interpretation of data.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Felipe Henrique Yazawa Santos: Drafting and editing of the manuscript; collection, analysis, and interpretation of data.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Rute Facchini Lellis: Design and planning of the study; collection, analysis, and interpretation of data; effective participation in research orientation; critical review of the literature; critical review of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Marcus Maia: Approval of the final version of the manuscript; effective participation in research orientation; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-23" "fechaAceptado" => "2020-10-16" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Dermatology Clinic, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2142 "Ancho" => 1675 "Tamanyo" => 207485 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Blackened macule measuring 0.5 cm on the left plantar region.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1257 "Ancho" => 1675 "Tamanyo" => 167972 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy showing a whitish-blue veil in the center and brownish pigment at the periphery, with a fibrillar pattern at one o'clock position.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1205 "Ancho" => 1675 "Tamanyo" => 403040 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathological examination evidencing a compound fusocellular-epithelioid melanocytic nevus with Spitz nevus characteristics (Hematoxylin & eosin, ×200).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acral Spitz Nevi: A Clinicopathologic Study of 50 Cases With Immunohistochemical Analysis of P16 and P21 Expression" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 31 | 11 | 42 |
| 2024 October | 185 | 68 | 253 |
| 2024 September | 278 | 80 | 358 |
| 2024 August | 274 | 120 | 394 |
| 2024 July | 272 | 114 | 386 |
| 2024 June | 196 | 83 | 279 |
| 2024 May | 120 | 65 | 185 |
| 2024 April | 187 | 83 | 270 |
| 2024 March | 137 | 62 | 199 |
| 2024 February | 149 | 85 | 234 |
| 2024 January | 96 | 51 | 147 |
| 2023 December | 98 | 78 | 176 |
| 2023 November | 116 | 87 | 203 |
| 2023 October | 97 | 84 | 181 |
| 2023 September | 125 | 68 | 193 |
| 2023 August | 96 | 39 | 135 |
| 2023 July | 113 | 38 | 151 |
| 2023 June | 104 | 59 | 163 |
| 2023 May | 93 | 31 | 124 |
| 2023 April | 59 | 24 | 83 |
| 2023 March | 65 | 49 | 114 |
| 2023 February | 44 | 33 | 77 |
| 2023 January | 60 | 28 | 88 |
| 2022 December | 77 | 35 | 112 |
| 2022 November | 84 | 61 | 145 |
| 2022 October | 176 | 72 | 248 |
| 2022 September | 63 | 69 | 132 |
| 2022 August | 75 | 47 | 122 |
| 2022 July | 96 | 86 | 182 |
| 2022 June | 43 | 40 | 83 |
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