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A Grading System for Risk Stratification

Alain Spatz, MD; Eduardo Calonje, MD; Susan Handfield-Jones, MD; Raymond L. Barnhill, MD

Arch Dermatol. 1999;135:282-285.

Objective  To describe a grading system for risk stratification of atypical Spitz tumors in children and adolescents. In some circumstances, unequivocal distinction between Spitz nevus and melanoma is practically impossible. It is likely that these lesions for which we lack specific diagnostic criteria represent a broad histological continuum extending from benign to malignant tumors. Therefore, we propose that Spitz tumors be categorized into low-, intermediate-, or high-risk categories based on the accumulation of abnormal features.

Design  Retrospective study.

Settings  Institutional practice.

Patients  We present 30 cases of atypical Spitz tumors in patients younger than 18 years evaluated for at least 3 years or in whom a metastatic event developed during this period.

Intervention  None.

Main Outcome Measure  The grading system was formulated after data collection.

Results  Among the parameters studied, only diagnosis at age greater than 10 years, diameter of the lesion greater than 10 mm, presence of ulceration, involvement of the subcutaneous fat (level V), and mitotic activity of at least 6/mm² carried a likelihood ratio greater than 1.50 and were therefore used for the grading system.

Conclusion  The application of an objective grading system, such as the one described herein for the first time, is the first step in providing useful information for the management of atypical Spitz tumors.

From the Department of Pathology, Institut Gustave-Roussy, Villejuif, France (Dr Spatz); St John's Institute of Dermatology, St Thomas' Hospital, London, England (Drs Calonje and Handfield-Jones); and Division of Dermatopathology and Oral Pathology, the Johns Hopkins Medical Institutions, Baltimore, Md (Dr Barnhill).

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