• Atypical lentiginous and  junctional melanocytic hyperplasia (dysplasia)
• Expansion of the papillary dermis by fibrous tissue to a thickness of greater than 1 millimeter
• The presence of widely scattered, small clusters of slightly atypical nevus cells or melanocytes in the fibrotic papillary dermis
• Lack of a  history of superficial trauma

 
• Compound dysplasia; borderline melanocytic neoplasia of indeterminate malignant potential or, based on size, intermediate melanocytic neoplasia of indeterminate malignant potential; incomplete arrested variant growth pattern present.

Comment: This diagnosis embodies terminology that is included in a Web presentation by R.J. Reed. At first glance, this terminology appears cumbersome, but it actually is an accurate reflection of what is present. It conveys an appropriate degree of concern regarding the biology of the lesion without committing the lesion to a benign or malignant category.
• Atypical compound nevus with moderate to severe melanocytic dysplasia and arrested incomplete development of variant vertical growth

Comment:  This would be a good alternative to the diagnosis given above, particularly if it a statement regarding prognostic uncertainty were appended.
• Atypical or severely dysplastic nevus

Comment: Dysplastic nevi exist, but these have been variously defined to include architectural disorder with or without cytologic atypia. The associated risk factor, particularly for the lesions lacking cytological atypia, was initially overstated for the nonfamilial lesions. This  has led to the abandonment of the term by some dermatopathologists. A more complete designation reflecting the extreme fibrosis and scattered nature of the small nests of slightly atypical cells (arrested variant vertical growth) would be desirable if this lesion is to be studied as an entity. 'Atypical nevus' has been suggested as a replacement for dysplastic nevus, but that term has been defined exclusively by clinical criteria in some centers. If the term 'atypical nevus' reflects cytologic atypia, it should be clarified in the pathology report.
• Lentiginous compound dysplastic nevus with moderate to severe atypia; recommend conservative re-excision.

Comment: A treatment recommendation such as this is appropriate when one is concerned about the biology of any residual lesion.
• Nevoid melanoma

Comment: In the simplest of terms (without getting into a discussion of objective criteria) a diagnosis of nevoid melanoma is often made after an initial impression of nevus is followed by the realization that the lesion is a melanoma. Since many melanomas share some architectural, cytological, or immunohistochemical features with nevi, some fully malignant melanomas, some minimal deviation melanomas, and a variety of worrisome melanocytic lesions get dumped into this category. This would not be my preferred term for this lesion.
• Unusual fibrotic Clark's nevus

Comment: Figure 8-20 on page 191 in Human Malignant Melanoma by Clark et al; Grune and Stratton publishers, 1979 depicts a lesion such as the subject case as  'The melanocytic dysplasia of B-K mole.' Be that as it may, I have seen the term, Clark's nevus, used, probably inappropriately,  for a variety of melanocytic lesions including architectural disorder without atypia.
• Rutten's nevus

Comment: Dr. Heinz Kutzner mentioned that a member of their group, Dr. A. Rutten, has been interested in this type of lesion, and their group has been collecting these since 1989. There have been no metastases or recurrences. Hopefully, they will share their experiences in detail.
• Persistent nevus with atypical features

Comment: Some recurrent or persistent nevi  have atypical lentiginous , junctional, or even pagetoid melanocytic hyperplasia associated with fibrosis, the fibrosis representing traumatic scar. A few clusters of slightly atypical nevus cells or melanocytes will be found in the superficial fibrous tissue in a few cases. Therefore, a superficial biopsy may have features very similar to those presented in this case. Though the pattern of fibrosis in a traumatic scar is usually different than that seen in dysplastic nevus variants, there can be cases where the distinction cannot be made solely on the basis of a small biopsy. A negative history for superficial trauma may be a distinguishing feature as in this case. It was mentioned that the scar from the previous punch biopsy of the subject lesion was not illustrated in the photomicrographs. The hyperplasia in a recurrent nevus is characteristically confined to the area over the scar.
• Ancient fibroblastic or burnt-out Sutton's nevus

Comment: Sutton's nevus (halo nevus or leukoderma acquisitum centrifugum) is, among other things, initially characterized by a lymphocyte attack on nevus cells. Subsequently, this reaction may be followed by disappearance of the lymphocytes and partial or complete replacement of the nevus by fibrous tissue. The type of atypical intraepidermal melanocytic hyperplasia (dysplasia) that is seen in the subject lesion is not a feature of the prototypic halo nevus. The degree of expansion of the papillary dermis by fibrous tissue that is seen in the subject case is not a feature of the histologic halo reaction. In other words, the end result of the histologic halo reaction shares qualitative features with dysplastic nevi having an arrested vertical growth (prominently fibrotic) pattern; however, there are differences in the nature of the initiating lesion.
• Burnt-out dysplastic nevus

Comment: This would take into the account the dysplasia and the fibrosis. This would imply that ongoing proliferation of atypical melanocytes with an accompanying  fibrous host reaction is not currently taking place. In view of the clinical history of expansion, it is not possible to exclude the possibility that this is an ongoing, smouldering process.
• Melanoma, minimal deviation or otherwise

Comment: I have, in the past, put this type of lesion in the minimal deviation melanoma category in spite of the fact that typical vertical growth (a dominant,  expansile nodule of minimally atypical cells) is not present. I did this in an attempt to convey the idea that the biology of the lesion may not be predictable. There obviously is a better way to convey this without using the word 'melanoma'.  A recommendation for a conservative re-excision of the area can be made in good conscience without using the word 'melanoma' in the diagnosis.
 

CONCLUSION

I would like to thank those persons who volunteered opinions on this case. Some gave the opinions directly; others were quoted (I hope accurately) by members of their organization. These include (in alphabetical order):  S. Cowper, H. Kutzner, P. LeBoit, L. Duncan, T. McCalmot, R. Reed, A. Rutter, R. Tuthill, W. Tyler and anonymous department members of some of the groups.

The patient is a 58 year old male, and this came from the hip/buttock area. This lesion measured 1.5 centimeters in greatest dimension three years ago. A 6 mm. punch biopsy was done at that time and read as benign. The lesion has grown to 2.7 mm. in greatest dimension since that time, and the current specimen is the basis of this presentation. The scar from the previous biopsy is not illustrated below.

Scan power view of part of  the lesion. The markedly expanded, fibrotic papillary dermis is demarcated from the reticular dermis by the wavy black line . There are widely scattered nests of  slightly atypical, small, dark melanocytes trapped within the fibrotic papillary dermis. Atypical lentiginous melanocytic hyperplasia with the occasional formation of junctional clusters is seen across the width of the epidermis. Solar elastosis is not seen.This area had not been subjected to superficial therapy.

	Composite low power view of widely scattered clusters of slightly atypical melanocytes in the expanded, fibrotic papillary dermis. The wavy, black line marks the boundary between the papillary dermis and the reticular dermis. No abnormal cells were found in the reticular dermis. The deepest cell clusters were 1.18mm. below the stratum granulosum. There is no maturation.
	Very high power view of  small, dark cells that form clusters in the fibrotic papillary dermis. Some of the small blood vessels have thick walls.
	Composite medium power view of small, dark cells in a wide, lentiginous distribution and also forming clusters in the lower epidermis.
	High power view showing a focus of infiltration of the papillary dermis by slightly atypical, small, dark cells apparently originating in the epidermis. The invasion of the papillary dermis by an abnormal population of intraepidermal melanocytes is a cause for concern but is not unequivocal evidence of malignancy.

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