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Clinical recognition of the early or atypical malignant melanoma is often difficult. In recent analyses of the problem, Becker1and McMullan and Hubener2have shown the difficulty of such diagnosis, for the percentage accuracy of clinical diagnosis which they reported was in the range of 40%. These authors also listed many of the various types of benign lesions which may be mistaken for malignant melanomas. The problem of accurate clinical diagnosis is familiar to all physicians who manage and treat skin tumors, and the necessity for histopathological examination of all suspicious lesions is well recognized. The commonly accepted danger signals suggesting a malignant melanoma include recent appearance of a new pigmented lesion, change in size or color of a pre-existing pigmented nevus, inflammatory change in a nevus, "migration" of pigment from a pigmented nevus to the surrounding skin, and, possibly most indicative, ulceration, hemorrhage, or serous exudation from

The first case of the metastasis of a giant pigmented nevus to the placenta utero is reported. An explanation for this phenomenon is proposed.

Artifacts of benign pigmented nevi presumed to be shrinkage during tissue-processing are described. These produce separation into clefts or nests leaving spaces that simulate lymphatic or vascular spaces. The artifact was found in 10% of 350 otherwise unremarkable benign pigmented nevi. Actual lymphatic invasion probably also occurs in benign nevi but was observed in only one instance. A second artifact results in nevus cells separating into parallel rows. The latter artifact was reproduced in ten experimental subjects by intralesional injections of local anesthetic, and involved from 10% to 90% of the cross-sectional area of the nevus. Knowledge of these artifacts can prevent misdiagnosis or subclassification of these histologie artifacts.

T HE following case of blue nevusis reported because of the unusual size of the nevus, its rapid growth and clinical characteristics of a melanoma. A blue nevus 1 resembles a melanoma but it is bluish gray or blueblack, round or oval and slightly elevated. It is firm to palpation and is most frequently situated on the face or on the extensor surfaces of the extremities. It is usually benign but occasionally undergoes sarcomatous changes. Clinically, the blue nevus of Jadassohn and Tieche may easily be confused with benign pigmented nevus, pigmented basal cell epithelioma and melanoma.

The concept originally proposed by Pack 1 that malignant melanomas of childhood tend to follow a benign course has been cited repeatedly in medical writing. Theories of Pack 1b and of Spitz 2 that some as yet unknown hormonal influences inhibit malignant melanomas during childhood and stimulate them after puberty to become highly malignant also find frequent mention. Opposing this view have been reports of a small number of childhood lesions that appeared to be malignant melanomas histologically and clinically. 3 Reflecting this background, the treatment of pigmented tumors in childhood is subject to contradictions and confusion. Conservative treatment of childhood malignant melanomas advised by Pack 1b is at variance with suggestions for radical excision and dissection of lymph nodes. 4 Such formidable ideas as the prophylactic removal of all childhood pigmented nevi have been offered. 5 Largely resolving these problems, Allen and Spitz 6 recently presented a new and logical

The incident energy of the powerful beam of the ruby laser has been shown to be absorbed more effectively by colored tissues. 1-3 Nevi and melanomas in an accessible organ, such as the skin, provide adequate masses of such tissues. Superficial changes in pigmented nevi and in melanoma were produced in experiments with low energy lasers (0.5-1.0 joules of exit energy from the laser head) . 1-3 Continued work with high energy lasers (25 to 125 joules of exit energy) has produced more extensive change. Outputs of laser energy were measured by a TRG calorimeter in conjunction with a Keithley microvolt-ammeter. The cellular nevi exposed to the laser included two junctional, seven mixed, and three dermocellular types. The nevi were excised, moistened with saline, and placed on glass slides. In three of the dermocellular nevi, 1% aqueous solution of Evans blue dye was injected into portions of the tissue to determine

Of the numerous problems associated with the pigmented nevi, those concerned with the diagnosis and treatment of the junction nevus and nevocarcinoma (melanoma) are the most important. By the presentation of an orderly concept of junction nevus and nevocarcinoma, it is the purpose of this discussion to provide a working basis for their management. Terminology.— We do not favor the term melanoma, as it is used loosely at times to denote any type of pigmented nevus; and it is ambiguous, as it refers both to a certain type of nevus and to the malignant growth which develops from it. We prefer the terms junction nevus and nevocarcinoma since they are more specific and more descriptive and eliminate the previous objections. Junction nevus is a cellular nevus in which nests of nevus cells can be seen with ease in the basal cell zone. It is called junction because it arises at

This study is a preliminary investigation to determine the effects of electrodesiccation on pigmented nevi. It was felt that a study of the effects of trauma in the form of shave biopsy and light electrodesiccation with a follow-up excisional biopsy and careful histologic comparative studies would do much to advance the knowledge of the behavior of pigmented moles. This is a preliminary study, therefore, of over 100 such treated lesions. There is a point of view that partial removal of nevi, particularly employing electrodesiccation, may lead to the formation of malignant melanoma. There are some reports in the literature recommending wide, complete excision of all nevi and, for that matter, all pigmented lesions, and condemning electrodesiccation of any nevus, because the latter procedure is said to initiate, in certain instances, malignant change in moles. From a review of the literature, no investigation was found

• An attempt is made to state the clinical features by which the physician can decide whether a common pigmented mole, appropriately designated as a melanocytic nevus, should be removed. At the junction or interface between epidermis and dermis lie the melanocytes whose multiplication and extrusion into the dermis is called junctional activity. Junctional activity is considered to be a necessary prerequisite for the development of melanoma when it arises from a preexisting nevus. Polypoid, dome-shaped, sessile, and pedunculated lesions are usually free from this histological feature, but flat lesions, slightly elevated lesions, elevated lesions with pigmented halos, and verruciform lesions are likely to have junctional activity. These latter types should, if treated at all, be totally excised and examined histologically.

Epithelioma of the conjunctiva may vary in malignancy, but in about 80 per cent of the cases it tends to recur, even when superficial. If the diagnosis is made early, it is proper to remove the tumor; but if the eyeball itself is involved, complete enucleation of the globe, together with exenteration of the remainder of the orbital contents, is indicated. Some form of radiation therapy should be employed after following surgical intervention. Malignant growths in the bulbar conjunctiva are often the result of extension from a primary focus in the conjunctiva of the lid. This primary focus may be a nevus, which is a congenital growth usually considered benign. It is a smooth, flat tumor highly pigmented with melanin. The color may vary from light to dark red-brown. These nevi of the conjunctiva have much the same structure histologically as that of the ordinary pigmented nevi found on the

Giant pigmented nevi afflict the patient not only with an unsightly cosmetic defect but also with the hazard of possible conversion to cancer. Such a nevus, extending over the back of an 18-year-old girl, was removed by surgical excision. Several hundred smaller nevi were removed from other parts of her body surface. Three separate operative procedures were required; the first was to remove the nevi from the right side of her body and prepare a skin donor site, the second to remove part of the large nevus and the smaller ones from her left side, and a third for complete excision of the giant nevus. Almost all the skin grafts were successful, and no malignant changes were found in any of the nevi excised.

THE MANAGEMENT of pigmented nevi presents many problems. Methods of treatment and clinical attitudes differ among the surgeons, oncologists, and dermatologists. It has been realized that only by a close liaison between these specialists could the varying concepts be reconciled not only for the management of pigmented nevi but for the therapeutic approach to other tumors of the skin. With this need in mind a Visible Tumor Conference was organized at the Skin and Cancer Unit of the New York University-Bellevue Medical Center, which is attended by dermatologists, a dermatopathologist, a general pathologist, and representatives of the oncological and radiotherapeutic departments. Patients with tumors of the skin that present difficulties of diagnosis or therapy are referred for the opinion of this group, which meets once weekly. Not infrequently at these conferences pigmented nevi, with or without suspected malignancy, and malignant melanomas are seen. HISTOLOGIC CONSIDERATIONS Traub and

To the Editor.— In an article titled "Eccrine-Centered Nevus," which appeared in theArchives(107:59, 1973), Mishima stated that "a peculiar clinical form of pigmented nevus consisting of grouped pigmented papules was illustrated by Scholtz in 1932. 1 This unusual type of nevus has been neglected since that time except for the clinical photographs published in Kawamura's Handbook in 1957. 2 " For historical and scientific accuracy, I want to emphasize that Scholtz illustrated three cases of unilateral nevi consisting of groups of lentigines. Kawamura also illustrated a lentigo nevus. All four illustrations do not show any pigmented papules. In correspondence with Mishima, I pointed out the latter. He answered that his original manuscript did not contain the word papules; it was later inserted in the process of publication. He also write me "I even cannot be sure that the cases of Scholtz and Kawamura are precisely the same as mine."

In 1927 Bloch 1 described benign non-nevoid melanoepithelioma of the skin and subdivided it into two types. Type I consists of a mixture of basal cells, prickle cells, and highly dendritic melanocytes. Type II is composed mainly of deeply pigmented small cells of basal type. Review of Literature Since Bloch's time many authors have referred to these tumors under a bewildering variety of names and offered contradictory interpretations of their nature and classification (Table 1). This confusion can be traced to several factors in Bloch's original publication. Bloch was one of the exponents of the thesis that nevus cells are modified melanocytes, and that epidermal melanocytes are modified basal cells. Therefore, when he found pigmented epidermal tumors without the formation of nevus cells, he called them "non-nevoid" in distinction from pigmented nevus cell tumors. He made no distinction between lesions consisting of pigmented Malpighian cells without dendritic melanocytes (Type II)

Two instances of basal cell epitheliomas and pigmented nevus occurring simultaneously in the same lesion are reported. No explanation other than that of coincidence is offered. However, it is apparent that ulceration or enlargement of a pigmented nevus may be caused by a coexisting basal cell epithelioma. Conversely, the occurrence of pigmentation in basal cell epitheliomas may be due to a coexisting pigmented nevus rather than to symbiotic melanocytes.

Two patients had multiple, somewhat pruritic papulosquamous lesions on the trunk and proximal extremities, almost exclusively involving nevi. Histologically, these lesions showed pigmented nevi with overlying parakeratosis, focal spongiosis, acanthosis, and a lymphocytic perivascular infiltrate in the dermis. The lesions resolved under topical steroid therapy, with the nevi persisting unchanged. A similar disorder has not been noted in the literature.

Metastatic sarcoma of the choroid is an unusual condition. Parsons,1in his book "The Pathology of the Eye," made the statement that there are no well authenticated cases of this condition on record. He expressed the belief that in all cases of sarcoma of the choroid it is impossible to be absolutely certain that the eye contains the primary tumor, but that the balance of evidence is in favor of this view. In an examination of the literature, the following nine case reports have been found. The literature is discussed by Ginsberg2in the "Handbuch der speziellen pathologischen Anatomie und Histologie" by Henke and Lubarsch, but the condition is sufficiently unusual to allow a brief review of the reported cases at this time. In 1870, Bromser3reported a case of melanotic sarcoma of the choroid that occurred a year after a pigmented nevus had been removed from

The purpose of this communication is to call attention to the use of frozen carbon dioxid for the destruction of lesions in the skin or for producing a violent inflammatory reaction in such lesions. Its action, of course, depends on its intense cold and on the effect produced by freezing. Since the idea occurred to me, eighteen months ago, I have used carbon dioxid as a destructive agent in various lesions of the skin. It furnishes a convenient and effective method of removing warts, calluses, senile keratoses and other such lesions. In the case of senile keratoses it is, I believe, an addition of some value to our methods of treatment. I wish, however, especially to call attention to its use in certain intractable conditions, notably nevi. The first case here reported illustrates what can be done in pigmented nevus with carbon dioxid. In this case a black hairy nevus

Masson's1theory that many if not all of the cellular and pigmented nevi have their origin in the peripheral neuroglia or Schwann cells has been receiving increasingly wide acceptance in recent years.2In his original paper on the subject Masson1reaffirmed Soldan's dictum that pigmented nevi were neuromas of the epidermal and dermal portions of the tactile nerves. An illustration accompanying that paper showed a phenomenon common to both Masson's and Unna's theories of the histogenesis of these lesions, that is, the process Unna3had previously designated asAbtropfung, which consisted of the extrusion from the epidermis into the corium of spheroidal nests of large cells with pale-staining cytoplasm. Unna called these altered basal cells; Masson expressed the belief that they were altered cells of the sheath of Schwann. In their earlier stages of differentiation Masson designated themcellules claires, and he and others2have

To the Editor:— The paper by Kurtin (Corrective Surgical Planing of Skin, A. M. A. Arch. Dermat. & Syph. 58 :389-397 [Oct.] 1953) elicits some comments. Credit should be given to Dr. Kurtin for having reintroduced a method that has certain usefulness, but that has been known for over 30 years. It was Kromayer ("Die Behandlung der kosmetischen Hautleiden unter besonderer Berucksichtigung der physikalischen Heilmethoden und der narbenlosen Operationsweisen," Leipzig, Georg Thieme, 1929, p. 15) who described this method that consists of freezing the skin with ethyl chloride and the subsequent use of various sizes of dental burrs mounted on a motordriven flexible cord. This method is known to most Europeans (Volk, R., und Winter, F.: "Lexikon der kosmetischen Proxix," Berlin, Springer-Verlag, 1936, p. 545) and to a good many American dermatologists. Its usefulness was proved in the treatment of keloids, pigmented nevi, freckles, lentigines, tattoos, Berlocque dermatitis, and superficial

To the Editor : Walton et al. (Electrodesiccation of Pigmented Nevi, A. M. A.Arch. Dermat.76:193, 1957) have demonstrated by histologic examination the safety of removal of fleshy pigmented moles by electrodesiccation. This is a method which I have used without histologic study for about 40 years. During this time I have removed thousands of fleshy, pigmented, sometimes hairy, moles from the faces of women solely for cosmetic reasons. I have never observed or heard of any malignancies developing in the scars. These scars are less than those from surgical excision. When such a fleshy, pigmented mole is full of stiff, bristly hairs, a method taught me by the late Prof. Herbert ("Pop") Smith, of the Graduate School of Medicine of the University of Pennsylvania, is sometimes preferable to electrodesiccation, as with it there is less danger of regrowth of the hairs. In this method each hair is thoroughly destroyed