SKIN 
 

November 2018     Volume 2 Issue 6 
Copyright 2018 The National Society for Cutaneous Medicine 347 

CLINICAL MANAGEMENT RECOMMENDATIONS 
 

 
How to Discuss Equivocal Melanocytic Neoplasms with Patients 
 
Clay Cockerell MD, MBAa 
 

aCockerell Dermatopathology, Dallas, TX 
 

 
 
While fortunately relatively rare, occasionally 
a dermatologist will biopsy a pigmented 
lesion, submit it to the dermatopathologist 
and a diagnosis is rendered that is equivocal 
for one reason or another.  One of the more 
perplexing cases is when it comes back as 
“atypical Spitzoid melanocytic neoplasm,” 
especially when the patient is not a young 
child.  As a clinical dermatologist and 
dermatopathologist, I have had experience in 
rendering these diagnoses as well as 
counseling patients who have received such 
diagnoses.   

 
While this has the potential to create 
confusion for many stakeholders, there is a 
reasonable way to deal with this.  First, there 
are techniques that can increase accuracy of 
diagnosis such as fluorescence in situ 
hybridization (FISH) and gene expression 
profiling (GEP) that can add information that 
that leads the dermatopathologist to change 
the diagnosis from “atypical Spitzoid 
neoplasm” to either melanoma or Spitz’s 
nevus. This would resolve the problem right 
away.   
 
Another option is to submit the specimen to 
an expert in the evaluation of melanocytic 
neoplasia for a second opinion.  However in 
a number of cases, this information is also  
 

 
equivocal and does not allow a more 
definitive diagnosis to be made.   

Just as in every other field of medicine, there 
are cases in which the diagnosis and/or 
prognosis is simply unclear.  Diseases “do 
not always read the textbook,” and medicine 
is simply not an exact science. I tell my 
patients that I recommend excising the lesion 
as widely as possible causing the least 
amount of deformity and follow them carefully 
as if the lesion could ultimately behave as a 
melanoma.   
 
While the GEP performed by Castle 
Biosciences provides prognostic information, 
it is not recommended for equivocal lesions 
unless the diagnosis of melanoma has been 
rendered. Some individuals have 
recommended sentinel lymphadenectomy 
when the lesion is 1mm or greater in 
thickness. If positive, the patient should be 
followed more intensely.   
 
There is data to indicate that even if an 
atypical Spitzoid neoplasm or true “Spitzoid” 
melanoma spreads to a lymph node, it may 
never spread further or cause significant 
harm to the patient.1 This should be stressed 
to patients who have a positive sentinel node 
result.  

HOW TO STRENGTHEN THE 
DIAGNOSIS 

WHAT TO TELL PATIENTS AND THEIR 
FAMILIES? 



SKIN 
 

November 2018     Volume 2 Issue 6 
Copyright 2018 The National Society for Cutaneous Medicine 348 

Patients can be left with a myriad of high level 
concerns after a diagnosis of atypical 
Spitzoid neoplasm. I spend significant 
personal time with the patient and do my best 
to explain the situation and outline an 
approach that offers the best possible 
outcome while conveying some degree of 
remaining uncertainty.  
 
The fact that many patients with these lesions 
do well even if there is evidence of lymph 
node involvement provides encouragement 
that things may not be as bad as they might 
seem.  Hopefully by following a similar 
approach, you can create cautious optimism 
and allay the understandable fear patients 
and their families will experience.  

 
After receiving an ambiguous diagnosis with 
uncertain prognosis, patients will have many 
questions for their dermatologists. Given this, 
we suggest the following approaching when 
discussing these issues with patients: 
 

1. Convey to the patient the difficulty in 
making a definitive diagnosis. Atypical 
Spitzoid Neoplasms represent a 
diagnostic challenge even to 
experienced pathologists as they are 
difficult to distinguish between a 
benign Spitz nevus and a Spitzoid 
melanoma. 
 

2. Offer new genetic tests, such as FISH 
and GEP, that can improve diagnostic 
accuracy and render a stronger 
diagnosis. 

3. In cases where the diagnosis remains 
uncertain, wide excision with careful 
follow up is recommended. 
 

4. The prognosis for these lesions may 
be quite good. Many cases of true 
Spitzoid melanoma may spread to a 
local lymph node yet never 
metastasize more widely. 
 

5. Spending time with patients and their 
families to discuss the issue is very 
helpful in helping them to understand 
the complexity of their case and 
assuage their fears.  

With the ubiquity of this topic in dermatology, 
questions from patients will invariably arise. 
Using this framework, dermatologists will be 
more prepared to answer patient questions, 
dispel fears, and optimize patient outcomes.   
 
Conflict of Interest Disclosures: Dr. Cockerell is a 
consultant for Castle Biosciences.  
 
Funding: None.  
 
Corresponding Author: 
Clay Cockerell, MD, MBA 
Cockerell Dermatopathology 
Dallas, TX 

References: 
1. Kelly L. Harms, MD, PhD; Lori Lowe, 

MD; Douglas R. Fullen, MD; Paul W. 
Harms, MD, PhD.  Atypical Spitz 
Tumors. A Diagnostic Challenge. Arch 
Pathol Lab Med. 2015;139:1263–1270.  

 

WHAT CAN DERMATOLOGISTS DO TO 
EASE PATIENT CONCERNS? 

 

HOW TO APPROACH THIS ISSUE 
WITH PATIENTS