WHO肿瘤新分类──皮肤肿瘤组织学类型(一)

由世界卫生组织（WHO）编撰和出版的《肿瘤组织学分类》已成为病理组织学诊断共用的国际统一标准分类。《皮肤肿瘤组织学分类》自1974年第一版以来，随着对肿瘤认识的深入，发现了不少新病种。最近刊出第二版（1666）。兹翻译介绍如下。1黑素细胞肿瘤MelanocghcTuntours1．1良性（痣）Benign（naevi）1．1．1寻常后天性黑素细胞痣Lommonacquiredmelanocyticnaevi1．1．1．1单纯性雀斑样痣Lentigosimplex1.1．1．2交界性黑素细胞痣Junctionalmelanocyticnaevus1．1．1．3复合性黑素细胞痣Compoundmelanocyticnaevus1．1．1．4真皮黑素细…     

黑素细胞痣1 011例的特殊组织病理学特征分析

【摘要】 目的 分析黑素细胞痣的特殊组织病理学特征及其与年龄、性别、部位和病理亚型之间的关系。方法 回顾北京医院皮肤科2005年1月至2019年1月就诊的1 011例黑素细胞痣患者的临床及病理资料。计数资料的比较采用χ2检验，计量资料的比较采用t检验。结果 1 011例黑素细胞痣患者就诊年龄为（40.90 ± 19.19）岁，男289例，女722例。皮损发生及取材部位：躯干402例（39.8%），面颈部268例（26.5%），四肢138例（13.6%），手足133例（13.2%），头皮53例（5.2%），外阴17例（1.7%）。病理亚型：皮内痣580例（57.4%），混合痣333例（32.9%），交界痣98例（9.7%）。特殊组织病理学特征：172例（17.0%）有神经化、155例（15.3%）有脂肪增生表现，女性多于男性、年长患者多于年轻患者、头皮部位多于其他部位（均P < 0.05）；313例（31.0%）有血管增生表现，头皮部位多于其他部位（P < 0.05）；502例（49.7%）可见痣细胞沿毛囊/皮脂腺分布，面颈部多于其他部位（P < 0.05）；203例（20.1%）有痣细胞松解、384例（38.0%）有裂隙表现；以上特征皮内痣多于混合痣（均P < 0.05）。20例（2.0%）有痣细胞沿血管分布的表现，四肢多于躯干、手足（P < 0.05），混合痣多于皮内痣（P < 0.05）。结论 黑素细胞痣的多种特殊组织病理学特征如神经化、脂肪增生、血管增生、痣细胞沿毛囊/皮脂腺分布等，与患者的年龄、性别、皮损发生部位和病理亚型有关。     

反射式共聚焦显微镜联合皮肤镜对黑素细胞痣的诊断价值评估

目的 评估皮肤镜与反射式共聚焦显微镜(RCM)单独或联合对黑素细胞痣的诊断价值.方法 收集临床拟诊黑素细胞痣的患者37例,对皮损先进行皮肤镜、RCM检查,再经组织病理学检查确诊.总结黑素细胞痣的影像学特征,计算不同检查诊断黑素细胞痣的敏感度、特异度、阳性预测值、阴性预测值、正确率,分析皮肤影像技术与组织病理学诊断的一致性.结果 皮肤镜和RCM检查结果示真皮内痣细胞的形态结构可分为两种:(a)真皮乳头层不融合、高折光、圆形的痣细胞,皮肤镜下表现为褐色或浅褐色均质模式,见于5处皮损;(b)真皮乳头内不规则、高折光的痣细胞团块,皮肤镜表现为鹅卵石模式或球状模式,见于31处皮损.在诊断黑素细胞痣方面,RCM结合皮肤镜的敏感度、特异度、正确率、阳性预测值、阴性预测值分别为91.7％、87.5％ 、90.9％ 、97.1％ 、70％,RCM为86.1％ 、75％ 、84％ 、93.9％ 、54.5％,皮肤镜为77.8％ 、87.5％ 、75％ 、96.3％ 、41.2％.除特异度与皮肤镜相同外,RCM结合皮肤镜的其他指标均高于二者单独应用;RCM敏感度、正确率、阴性预测值高于皮肤镜,特异度、阳性预测值低于皮肤镜.RCM结合皮肤镜或单用RCM与组织病理诊断结果之间差异无统计学意义(x2值分别为0.25、0.57,P值分别为0.63、0.45),Kappa值分别为0.72、0.53;皮肤镜与病理诊断结果之间差异有统计学意义(x2=5.81,P=0.012).结论 RCM联合皮肤镜较二者单独使用能更准确地诊断黑素细胞痣.     

皮肤镜诊断黑素细胞痣、脂溢性角化和日光性角化与组织病理诊断的一致性

目的：评价皮肤镜诊断黑素细胞痣、脂溢性角化、日光性角化的准确度。方法：收集临床怀疑为黑素细胞痣、脂溢性角化和日光性角化的病例,由两位医生参照目前皮肤镜诊断标准对该三种皮肤肿瘤进行盲法独立诊断,并与组织病理结果相对照。结果：与组织病理诊断比较,(1)A、B两位医生使用皮肤镜诊断黑素细胞痣一致率（89.3%、91.2%）、灵敏度（94%、95.2%）、特异度（84.2%、86.8%）、误诊率（15.8%、13.2%）、漏诊率（6%、4.8%）。(2)A、B两位医生使用皮肤镜诊断脂溢性角化一致率（88%、91.7%）、灵敏度（91.7%、95.8%）、特异度（83.6%、86.9%）、误诊率（16.4%、13.5%）、漏诊率（8.3%、4.2%）;(3)A、B两位医生使用皮肤镜诊断日光性角化一致率（84.1%、86.4%）、灵敏度（87.5%、87.5%）、特异度（17.9%、12.5%）、误诊率（82.1%、85.7%）、漏诊率（17.9%、14.3%）。结论：皮肤镜诊断黑素细胞痣、脂溢性角化和日光性角化的结果与病理诊断结果均有较好的一致性。     

41例皮肤基底细胞癌的临床病理及误诊分析

目的：分析总结41例皮肤基底细胞癌的临床病理特点及误诊情况。方法：对41例皮肤基底细胞癌的临床及病理资料进行回顾性分析。结果：41例皮肤基底细胞癌中,发病年龄中位数为59岁（34～82岁）,多发于头面部,共39例,占95．1％,通过组织病理检查,41例均证实为基底细胞癌。其中9例进行免疫组化标记示CK（＋）,S-100（-）。临床诊断为基底细胞癌24例,占58．5％,误诊为脂溢性角化4例,黑素细胞痣3例,鳞状细胞癌、黑素细胞瘤、寻常狼疮各2例,误诊为其他4例。结论：被误诊的皮肤基底细胞癌患者大多数年龄较大,病程缓慢,临床表现不典型。尽早行组织病理检查,并结合免疫组化标记进行识别,可提高皮肤基底细胞癌的诊断准确率。     

荧光定量聚合酶链反应在一期梅毒诊断中的临床意义探讨

为评价荧光定量聚合酶链反应（FQ－PCR）在一期梅毒诊断中的临床应用价值，以暗视野（D－F）、血清学（RPR／TPHA）检查方法作对照，用FQ－PCR方法检测68例疑诊为一期梅毒病人的生殖器溃疡处分泌物。在68例疑诊为一期梅毒病人中，D－F阳性率27．94％（19／68），RPR阳性率48．53％（33／68），TPHA阳性率61．76％（42／68），FQ－PCR阳性率44．12％（30／68），FQ－PCR与D－F、TPHA比较有显著性差异（P＜0．05），与RPR比较无显著性差异（P＞0．1）。本研究表明FQ－PCR检测生殖器溃疡TP在一期梅毒诊断中有一定的价值。     

发育不良性痣11例临床病理学分析

目的 探讨发育不良性痣的临床病理学特点。方法 对11例临床表现为色素性损害的手术标本行H-E染色，结合临床指标及评分进行研究和分析。结果 临床表现：皮损直径≥5mm者8例，多发性损害者7例，边界模糊者4例，外形不规则者6例，痣表面色素不匀者4例，基底色红者6例。光镜下：交界痣3例，复合痣8例。发育不良性痣较为特异的组织学表现为真表皮交界处雀斑样增生，痣细胞巢增生紊乱倾向于形成“桥型”融合。表皮下方的非典型黑素细胞在基底层呈“Paget”样蔓延，真表皮交界处的黑素细胞向周围延伸，并超过真皮内的痣细胞成分。非典型黑素细胞：细胞核较角质形成细胞核大，多形性，出现核仁，深染。结论 临床和组织病理相结合是诊断发育不良性痣的可行性标准，仅根据组织学的非典型性不能诊断发育不良性痣。     

普通蓝痣伴卫星灶

报告1例普通蓝痣伴卫星灶。患者女，26岁。右臀部蓝黑色结节20年，斑疹2周。皮肤科检查：右臀部见一直径约18 mm蓝黑色结节，边界清楚，边缘见一直径约3 mm蓝黑色斑疹。取结节性皮损组织病理检查：表皮轻度增生；真皮全层及皮下脂肪可见大量树枝样、长梭形黑素细胞弥漫分布，并见致密色素颗粒及噬黑素细胞，局灶胶原纤维增生。斑疹处组织病理：真皮中层可见局灶性树枝样、长梭形黑素细胞，并见致密色素颗粒及噬黑素细胞。诊断：普通蓝痣伴卫星灶。     

手术切除治疗面部黑素细胞痣100例

为探索面部黑素细胞痣理想的治疗方法，对１００例面部黑素细胞痣患者进行了皮肤外科手术切除治疗观察，术后随访１年２个月￣２年。结果无１例复发，治愈率１００％，美容效果：好６２例，较好３５例，一般３例，８８％病人表示非常满意，１２％病人满意。该疗法优于ＣＯ２激光，冷冻等治疗方法。     

跖部黑素细胞性肿瘤:诊断和治疗

在黑人及日本人中,跖部是黑素瘤最好发的部位,而白人此处的黑素细胞肿瘤(良性及恶性)却十分罕见。为了了解白人跖部黑素细胞性肿瘤的临床诊断标准及制定治疗办法,对148例具有跖部色素性损害的白人患者进行回顾性研究。这些患者最初的临床诊断包括:黑素细胞痣,可疑黑素瘤、皮肤黑素瘤(CM)和其它。所有切除的标本均做了病理检查。结果:临床诊断为痣的170例中,仅2例病理检查不能证实为痣,但无一例为 CM。临床疑为 CM 的10例中,6例病理显示为     

The diagnostic yield in submitting nevi for histologic examination

BACKGROUND: Dermatologists have expertise in the clinical diagnosis of benign melanocytic nevi. However, there are no data to confirm the accuracy of diagnosis. Differences in the diagnostic accuracy between dermatologists and nondermatologists with regard to cutaneous tumors has been infrequently studied. OBJECTIVE: We examined the rate of malignant tumors occurring in lesions submitted for routine microscopic examination that were clinically diagnosed as benign melanocytic nevi. METHODS: We conducted a study at a regional, non-hospital-based dermatopathology laboratory using specimens submitted by physicians of various specialties who were practicing in a 5-state Midwest region of the United States. The preoperative and postoperative diagnoses were examined on the basis of information provided by the clinician and of the subsequent histopathologic diagnosis. A total of 7734 cutaneous pathology reports were reviewed. Specimens submitted with a preoperative clinical diagnosis of mole or nevus, with or without a modifier, were examined and compared with postoperative microscopic diagnoses. RESULTS: Of 1946 specimens clinically diagnosed and submitted as benign nevi, 45 (2.3%) were histologically diagnosed as malignant tumors. This included 12 melanomas, 30 basal cell carcinomas, and 3 squamous cell carcinomas. For specimens submitted by dermatologists, the rate of malignant tumors increased when clinical information suggested findings beyond the classic benign clinical presentation with the addition of modifiers such as irritated or atypical, or if a malignancy was considered in the differential diagnosis (trend for increasing clinical suspicion: P = .00002). Fewer dermatologists than nondermatologists mistook a malignant tumor for a benign nevus (1.3% vs 3.8%, P = .003). CONCLUSION: Our data document that 2.3% of clinically diagnosed benign nevi were microscopically diagnosed as malignant tumors. Whether this malignancy rate in clinically diagnosed, benign, melanocytic nevi is above or below the threshold to establish a policy for submission for histopathologic examination remains to be determined as a collective societal and medical professional responsibility.     

Epidermolysis bullosa nevus-like lesions in a pediatric patient with pyoderma gangrenosum

Epidermolysis bullosa-associated nevi are recently described dysplastic nevi found in patients with epidermolysis bullosa. These lesions display clinical features of unusual nevi suggestive of malignancy but thus far cases with malignant transformation have not been reported. We describe a case of epidermolysis bullosa-type nevi developing in a child with pyoderma gangrenosum. The nevi in our patient were found in areas previously affected by pyoderma gangrenosum and were clinically concerning for malignancy. However, they were only moderately atypical on light and confocal microscopy. This case demonstrates that pediatric patients with cutaneous inflammation, bullae formation, or both, are at risk for developing unusual nevi at previous sites of skin involvement. Considering the absence of malignant change in these nevi, we suggest that close observation can be employed in cases where this diagnosis can be confirmed both clinically and microscopically.     

Histologic features and sensitivity of diagnosis of clinically unsuspected cutaneous melanoma.

The purpose of this study was to assess the sensitivity of clinical diagnosis of cutaneous malignant melanoma and to evaluate histologic characteristics of lesions not clinically diagnosed as such. Of 1,784 cases of histologically proven cutaneous malignant melanoma submitted routinely to a university dermatopathology laboratory between 1985 and 1990, 583 (33%) were not clinically suspected. The overall sensitivity in clinical diagnosis was 67%. Histologic features evaluated included presence of melanin, pagetoid spread of melanocytes, degree of inflammation, regression, presence and degree of sun damage as evidenced by solar elastosis, presence of melanin in the cornified layer, and coexisting nevus cells. Melanomas clinically thought to be nevi had less solar elastosis and most frequently had associated nevus cells. Those thought to be basal cell carcinomas had less melanin in lesions and less melanin in the cornified layer, and most often had foci of regression. Lesions thought to be keratoses showed melanin in the cornified layer 70% of the time, more often than any other type of lesion. Melanoma may be unsuspected clinically in a significant number of cases and can be mistaken for less serious cutaneous neoplasms. Histologic features of these lesions correlated well with original clinical diagnoses.     

Large atypical melanocytic nevi in recessive dystrophic epidermolysis bullosa: clinicopathological, ultrastructural, and dermoscopic study

A 3-year-old boy with recessive dystrophic epidermolysis bullosa developed a rapidly growing, large, acquired irregular melanocytic nevus on the lower aspect of the back. The lesion was clinically atypical and fulfilled the criteria for a malignant melanocytic proliferation. A complete surgical excision was performed. Histopathologic examination disclosed a compound melanocytic nevus without melanocytic atypia. Ultrastructural examination showed melanocytic cells located both at the roof and the floor of the blister. Several months later, three pigmentary lesions with a similar clinical appearance developed. Periodic clinical and dermoscopic examinations were recommended. Dermoscopic examination disclosed a globular pattern with brown globules and black dots distributed all over the lesions. The lesions also exhibited blue-greyish dots and multiple rounded white structures corresponding to milia-like cysts. No dermoscopic features suggestive of malignancy were noted. Acquired melanocytic nevi showing atypical clinical features have been reported to occur in areas of blistering in patients with epidermolysis bullosa. These nevi appear as large, asymmetrical pigmentary lesions with irregular borders. Initially, they are very dark in pigmentation, with color variegation and loss of pigment, and even becoming papillomatous over time. Histopathologic examination can show features of compound/junctional nevus as well as persistent/recurrent nevus. The concept of "epidermolysis bullosa nevus" has been proposed to define these peculiar lesions. The clinical, histopathologic and ultrastructural features of these nevi are reviewed. The usefulness of dermoscopic examination in the routine diagnosis and follow-up of these lesions are stressed.     

Melanocytic neoplasia of the sole: diagnosis and therapeutic approach.

We examined retrospectively a series of 184 cases of melanocytic neoplasia of the sole observed and treated as out-patients from January 1977 to December 1987, comparing clinical and histological diagnoses. The original clinical diagnoses were divided into nevi, pigmented lesions of suspected malignancy, cutaneous melanomas and others. Of the 170 cases diagnosed clinically as nevus none was of melanoma. The risk that a pigmented skin lesion diagnosed as clinically benign is melanoma is so low as not to constitute a clinical problem. It is concluded that systematic removal of sole nevi is unjustified. If, however, there is the smallest doubt concerning a sole lesion, it should be removed and examined histologically.     

Histopathologic spectrum of clinically atypical melanocytic nevi. II. Studies of nonfamilial melanoma

We studied the clinically most atypical pigmented lesion removed from each of 142 patients with newly diagnosed sporadic melanoma. The specimens were categorized as to the type of nevus, ie, junctional or compound, presence of congenital features, and degree of nuclear atypicality--presence of nuclear enlargement, nuclear pleomorphism, hyperchromatism, and prominent nucleoli--of intraepidermal nevomelanocytes. The frequency of nuclear abnormality was graded as 1 (rare cells), 2 (10% to 50% of cells), or 3 (greater than 50% of cells) for each nuclear parameter. Among all lesions, 42 (29.6%) were junctional nevi, 74 (52.1%) were compound nevi, and 14 (9.9%) were dermal nevi. Eighteen percent of the total were either dysplastic nevi (23 cases) or malignant melanoma in situ (three cases). Fourteen nevi (9.9%) had congenital features. There were 12 junctional and 39 compound nevi and one dermal nevus that exhibited nuclear abnormality, but only four junctional nevi compared with 19 compound nevi had sufficient atypia for a designation of dysplastic nevus. Only two nevi with congenital features demonstrated any nuclear abnormality, and these were clearly nondysplastic. Thus, among nevi surgically removed as the clinically most atypical lesion in this study, compound nevi were much more likely to demonstrate nuclear atypia (and dysplasia) than were other nevi, ie, junctional or dermal nevi, or nevi with congenital features.     

Multiple skin metastases of malignant melanoma with unusual clinical and histopathologic features in an immunosuppressed patient

Immunosuppressive regimens may have significant impact on the number of pigmented lesions and the clinical appearance of nevi. Whether immunosuppression can also influence the clinical and histopathologic appearance of malignant melanocytic lesions is still a matter of debate. A patient was immunosuppressed because of heart and bone marrow transplantation. A clinically inconspicuous mole was removed from the left flank and was considered to be a papillomatous nevus. After 1 year, the patient developed multiple pigmented lesions over the entire body, which presented clinically as benign papillomatous nevi and histologically as atypical Spitz nevi. Three months later melanoma metastases were removed from the patient's left axilla, which finally resulted in the death of the patient. Thus, in retrospect, the eruptive pigmented lesions have to be considered as cutaneous melanoma metastases. The atypical clinical and histopathologic appearance of the melanocytic lesions as well as the course of disease may have been influenced by the immunosuppression.     

Weight of decision-making impairs clinical assessment of melanocytic lesions

BACKGROUND AND OBJECTIVE: We studied the weight of decision-making on clinical assessment of melanocytic lesions judging benign, atypical, and malignant lesions; common mistakes; and total removal rates, comparing dermatologists with nondermatologists. METHODS: Of 11,246 histopathology specimens, 3,768 had a clinical assessment of melanocytic lesions. Histopathologic diagnosis served as the gold standard. RESULTS: Benign nevi were assessed most accurately (77%). Dermatologists assessed benign nevi better (p < .0001). The accuracy of clinical assessment in atypical nevi and melanoma was lower (23% and 42%, respectively). Seborrheic keratosis was the most common mistaken diagnosis. Complete removal of clinically benign nevi, atypical nevi, and melanoma was 84%, 90%, and 89%. Decision-making impaired clinical assessement of melanocytic lesions by 5% for dermatologists and 9% for nondermatologists. CONCLUSION: The accuracy of clinical assessment of melanocytic lesions is high for benign nevi, with dermatologists outperforming nondermatologists. Clinicians overestimated malignant potential. Complete removal was more frequent in suspicious lesions. Clinical decision-making impaired assessment by 5 to 9%.     

Clinical diagnosis of early malignant melanomas

Criteria for the clinical diagnosis of early malignant melanomas were sought. A total of 213 pigmented tumors, clinically suspected of being early malignant melanomas, were measured, described, photographed, and classified histologically: 40 proved to be definitely malignant, 49 possibly malignant ("dysplastic"), and 124 definitely benign (mostly melano-/nevocytic nevi, spindle-cell nevi, and Spitz nevi). Malignant melanomas had a horizontal diameter of greater than 5 mm, the patients were older than 18 years, and 62.5% were females. A combination of criteria allowed a clinical diagnosis to be made with an accuracy of 76.2%. The criteria of a horizontal diameter of greater than 5 mm, irregular configuration, and uneven pigmentation permitted 80% of all melanomas to be identified. Histologically atypical, dysplastic nevi could not be diagnosed clinically. They probably constitute a heterogeneous group and only some of them appear to be very early, histologically not clearly recognizable, malignant melanomas.     

Diagnostic significance of the blue hue in dermoscopy of melanocytic lesions: a dermoscopic-pathologic study.

In epiluminescence microscopy, the perception of a blue hue is generally considered a clue to malignancy, especially in clinically equivocal melanocytic skin lesions. However, melanocytic nevi can seldom show a blue hue under dermoscopy. The aim of the current study was to evaluate the histopathologic correlates of the blue hue seen in dermoscopy, to clarify its significance and diagnostic value. From a series of 224 consecutive pigmented skin lesions submitted to surgical excision, we selected all the melanocytic skin lesions (n. 36), blue nevi excluded, characterized by the presence of a blue hue dermoscopically. In agreement with recent refinement of dermoscopic semeiology, all cases were further classified in cases showing blue areas and cases showing blue-whitish veil by experts observers blinded to the final diagnosis. Histopathologically, the series included 23 (63.9%) melanocytic nevi and 13 (36.1%) melanomas. For each lesion, several histopathologic parameters related to both epidermal and dermal alterations were assessed. Blue areas were found in 21 melanocytic nevi and 7 melanomas, whereas blue-whitish veil was found in 6 melanomas and 2 nevi. Careful dermoscopic-histopathologic correlation demonstrated that blue areas are related to the presence of large amounts of melanin pigment, either within melanophages (in the context of areas of regression) or within pigmented melanocytes in the superficial dermis. Conversely, the histopathologic correlate of the blue-whitish veil resulted in the presence of an acanthotic epidermis with compact orthokeratosis overlying large amounts of melanin in the dermis. Such melanin was found not only within melanocytes but also in large clusters of melanophages within areas of regression in the dermis. In conclusion, the majority of melanocytic lesions characterized by the presence of blue areas were histopathologically diagnosed as melanocytic nevi whereas the presence of blue-whitish veil was highly indicative of malignant melanoma diagnosis (specificity 91% vs. 9% of blue areas; sensitivity 75% vs. 25% of blue areas). Thus, these two features of blue hue under dermoscopy cannot be longer considered as synonymous in dermoscopy setting, being associated with different histopathologic alterations and different diagnostic information.