A PRACTICAL APPROACH TO THE

DIAGNOSIS OF MELANOCYTIC
LESIONS

KURSUS DERMATOPATHOLOGY PPDS

NOVEMBER 2021
Sitologi
 Epithelioid
• Cells were round to oval or polygonal with a variable amount of cytoplasm.
• Cell size and amount of cytoplasm varied from minimal to moderate.
• Nuclei usually were eccentric (plasmacytoid) and adjacent to the cell membrane.
• Cytoplasmic processes were a frequent feature of some specimens.

Spindle
• Long, slender bipolar cytoplasmic extensions with a centrally placed oval nucleus
that was nearly equal to the maximal width of the cell characterized the spindle
shape.
Small Round
• Small round cells were twice the size of a small lymphocyte with a round, smooth
nucleus;
• had inconspicuous nucleoli;
• and had scant cytoplasm. Differentiation from surrounding lymphocytes was
difficult in some cases
Giant or Bizarre
• Giant or bizarre cells were those with multiple nuclei and prominent nucleoli
Kriteria Umum • usually were more than twice the diameter of a histiocyte.
• The cytoplasm generally was abundant in this cell type.
Pseudoinclusions
• Pseudoinclusions were defined as intranuclear invaginations of the cytoplasm
imparting a distinct membrane-bound area within the nucleus with tinctorial
properties similar to those of the surrounding cytoplasm
Pelaporan Diagnosis
Khusus Untuk Melanoma Maligna Kulit
 Pelaporan berdasarkan CAP

Histopathologic Parameters of
*Clark Level
Melanoma in Biopsy Specimen
Epidermis I Intra-epidermal
MELANOMA, INVASIVE, SUPERFICIAL SPREADING TYPE
* CLARK LEVEL, IV II Extend into
BRESLOW THICKNESS, 0.97MM papillary dermis
Papillary dermis
* RADIAL (NON-TUMORIGENIC) GROWTH PHASE, PRESENT Fills and expands
III
* VERTICAL (TUMORIGENIC) GROWTH PHASE, PRESENT papillary dermis
MITOTIC FIGURES/MM2, 1
Reticular dermis IV Reticular dermis
ULCERATION, PRESENT
REGRESSION, PRESENT, FOCAL (< 50%) Subcutaneous fat V Subcutaneous fat
VASCULAR INVASION, NOT IDENTIFIED Clark level
PERINEURAL INVASION, NOT IDENTIFIED
MICROSCOPIC SATELLITOSIS, NOT IDENTIFIED
(not required; we still report it)
* TUMOR-INFILTRATING LYMPHOCYTES, PRESENT, NON-BRISK
* ASSOCIATED MELANOCYTIC NEVUS, NOT IDENTIFIED
* PREDOMINANT CYTOLOGY, EPITHELIOID
SURGICAL MARGINS: MELANOMA IN SITU PRESENT AT PERIPHERAL
TISSUE EDGES
 AJCC-TNM Edisi 8th ___
Primary Tumor (pT)

pTX Primary tumor thickness cannot be assessed (eg, diagnosis by curettage)

No evidence of primary tumor (eg, unknown primary or completely regressed melanoma) Melanoma in situ (ie, not an
invasive tumor: anatomic level I)
pT0 Melanoma 1.0 mm or less in thickness, ulceration status unknown or unspecified (see Note D) Melanoma <0.8 mm in
thickness, no ulceration
pTis Melanoma <0.8 mm in thickness with ulceration OR melanoma 0.8 to 1.0 mm in thickness with or without ulceration
pT1 Melanoma >1.0 to 2.0 mm in thickness, ulceration status unknown or unspecified
pT1a Melanoma >1.0 to 2.0 mm in thickness, no ulceration
pT1b Melanoma >1.0 to 2.0 mm in thickness, with ulceration
pT2 Melanoma >2.0 to 4.0 mm in thickness, ulceration status unknown or unspecified
pT2a Melanoma >2.0 to 4.0 mm in thickness, no ulceration
pT2b Melanoma >2.0 to 4.0 mm in thickness, with ulceration
pT3 Melanoma >4.0 mm in thickness, ulceration status unknown or unspecified
pT3a Melanoma >4.0 mm in thickness, no ulceration
pT3b Melanoma >4.0 mm in thickness, with ulceration
 Question
Mengukur Kedalaman Breslow
Pitfall-1-Periadnexal Melanoma Cells
Which
meas
The correct
A
answer 1) A
is 2) B
1) A
2) B
3) C B

Periadneksal X
Do not include melanoma cells located in association with
adnexal structures in measurement of Breslow thickness
Satelit dan LVI X
 Pitfall-4-Nevus Cells in Deeper Dermis

A
B
Pitfall-3-Tangential Sectioning
Potongan tangensial X

The correct answer is

The correct answer Sel nevus di bagian dalam dermisX
1) A
2) B
is? Breslow thickness = A
1) A Breslow thickness ≠ B
2) Cannot be
A Do not include nevus cells present at deeper dermis in the
measured
measurement of Breslow thickness
accurately
 Pitfall-5-Breslow Thickness Pitfall-6-Artifactual Cleft
is Not Additive
The best
The correct answer is A answer is
BT2 1) A
1) BT1
B
2) BT2 2) B
3) BT1+BT2
3) B-A
4) At least BT1
5) At least BT2 4) B+A
BT1

BT1 BT2 BT3

Breslow thickness=
BT1
(at least in ---- mm)
Artefact space X
Ukur yang paling dalam, bukan penjumlahan Breslow thickness = B-A
 • Absence of previous trauma (surgery)
Potential Pitfalls
in Assessment of Ulceration
Ulserasi
• Trans-epidermal elimination /consumption of epidermis
•Trans-epidermal elimina.on /consump.on of epidermis
• •Scale
Scalecrust
crust over intact epidermis
over intact epidermis
• •Detached
Detached epidermis
epidermis
sec.ons
• •Incomplete
Incomplete sections
• Prior trauma or biopsy site
• Prior trauma or biopsy site
Mitosis Ulceration
Regional Lymph Nodes (pN) (applicable to invasive tumor only)
pNx Regional lymph nodes not assessed (e.g., SLN biopsy not performed, regional nodes previously
removed for another reason
pN0 No regional lymph node metastasis detected
pN1 One tumor-involved node or in-transit, satellite, and/or microsatellite metastases with no tumor-involved nodes
pN1a One clinically occult tumor-involved node (ie, detected by sentinel node biopsy) with no in-transit, satellite and/or microsatellite
metastases
pN1b One clinically detected tumor-involved node with no in-transit, satellite and/or microsatellite metastases
pN1c Presence of in-transit, satellite and/or microsatellite metastases with no regional lymph node disease
pN2 Metastasis in two to three regional nodes or in-transit, satellite, and/or microsatellite with one tumor- involved node
pN2a Two to three clinically occult tumor-involved node (ie, detected by sentinel node biopsy) with no in- transit, satellite and/or
microsatellite metastases
pN2b Two to three tumor-involved nodes at least one of which was clinically detected with no in-transit, satellite and/or microsatellite
metastases
pN2c One clinically occult or clinically apparent tumor-involved node with presence of in-transit, satellite and/or microsatellite
metastases
pN3 Metastasis in four or more regional lymph nodes, or in-transit, satellite or microsatellite metastases with two or more tumor-
involved nodes or any number of matted nodes without or with in-transit, satellite or microsatellite metastases
pN3a Four or more clinically occult tumor-involved nodes (ie, detected by sentinel node biopsy) with no in-transit, satellite and/or
microsatellite metastases
pN3b Four or more tumor-involved nodes, at least one of which was clinically detected, with no in-transit, satellite and/or
microsatellite metastases
pN3c Two or more clinically occult or clinically detected tumor-involved nodes with in-transit, satellite and/or microsatellite
metastases and/or any number of matted nodes with in-transit, satellite and/or microsatellite metastases
Distant Metastasis (pM) (required only if confirmed pathologically in this case)

pM1 Distant metastasis (documented in this specimen)

pM1a Distant metastasis in skin, subcutaneous tissues, soft tissues including
muscle and/or nonregional lymph nodes
pM1b Distant metastasis to lung with or without M1a sites of disease
pM1c Distant metastasis to non-CNS visceral sites with or without M1a or M1b
sites of disease
pM1d Distant metastasis to CNS with or without M1a, M1b or M1c