Recent advances and important issues in melanoma pathology: an update for oncologists



1. Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
2. Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
3. Melanoma Institute Australia, North Sydney, New South Wales, Australia.
4. Discipline of Pathology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
5. Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
6. Harvard Medical School, Dana-Farber Cancer Centre and Brigham and Women’s Hospital, Boston, Massachusetts, USA.
7. Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, USA.
8. Department of Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, USA.


The critical role of pathology in the multidisciplinary care of melanoma patients is becoming apparent in the rapidly changing modern era of personalised and precisely targeted medicine. Recent insights into the molecular pathogenesis of melanoma have allowed traditional pathological assessment to be supplemented and enhanced by molecular pathology testing to improve classification, prognostication and selection of patients for targeted therapies. The pathology report remains pivotal as it establishes the definitive diagnosis of melanoma in most instances, while the assessment and documentation of key pathological parameters allow the most accurate determination of prognosis to be made and are utilised to guide the next stages of patient management. Molecular tests (including fluorescent in situ hybridisation) are now routinely utilised to enhance the accuracy of classification and prognostication of selected melanocytic tumours in many institutions. Recent studies have also highlighted important melanoma prognosticators such as mitotic rate, the presence and extent of ulceration, tumour-infiltrating lymphocyte grade and sentinel lymph node biopsy. Pathologists also play a key role in the triage and selection of appropriate tumour tissue and tumour cells to test for various molecular markers which are used to select patients who may benefit from targeted therapies. It is important that clinicians understand important aspects of molecular testing in melanoma, such as when and how to arrange testing, which specimen to test, and the advantages and disadvantages of the various testing methodologies. These issues are addressed in this review.

Pathology is a key component of the multidisciplinary care of melanoma patients. While melanoma may be suspected clinically, the initial definitive diagnosis is usually established by pathological examination of a tissue biopsy. In clinically localised primary cutaneous melanoma, pathological assessment of various tumour parameters enables accurate estimation of prognosis and determines the most appropriate next step(s) in clinical management. Pathological evaluation of any potential or likely metastasis is also critical. Recent discoveries of the molecular pathogenesis of melanoma are now being harnessed clinically to improve patient management. Molecular pathology is now utilised to enhance melanoma diagnosis, classification, prognostication and to predict responsiveness to selective targeted therapies in melanoma, and will undoubtedly play an ever-increasing role in the management of melanoma patients. In this article we review selected important issues in melanocytic tumour pathology. We highlight some recent advances in the molecular pathology of melanocytic tumours and their current and potential clinical applications.

Biopsy of atypical or suspicious melanocytic tumours

Unless clinical circumstances dictate otherwise, excision biopsy with 1-2mm margins is recommended for pathological diagnosis of atypical or suspicious melanocytic tumours.1 This enables accurate pathological assessment and allows planning of definitive treatment if a diagnosis of melanoma is confirmed. Incomplete biopsies may result in misdiagnosis because of non-representative sampling or because they do not include sufficient tumour tissue to allow assessment of the various pathological criteria necessary to establish a diagnosis.2 Furthermore, in biopsies that do not include the thickest portion of the tumour or in superficial shave biopsies that transect the tumour, tumour thickness (an important staging and prognostic factor in melanoma) cannot be accurately determined,2 which may lead to inappropriate management.

A pathological diagnosis of primary cutaneous melanoma usually rests on correlation of a range of histopathological features (including architectural and cytological features and features of the host response), with clinical data including patient age, clinical features and anatomical site of the lesion. The accuracy of the pathology report may depend on the amount of tissue provided and the availability of relevant clinical details. It is particularly important for the clinician to record on the pathology request form the occurrence of factors that may induce atypical pathological features in melanocytic naevi (such as a previous biopsy, trauma, surface irritation, topical treatment, pregnancy or recent prolonged intense sunlight exposure) that may lead to a misdiagnosis of melanoma.3

In most instances, a histopathological diagnosis of melanoma can be made rapidly, accurately, and reproducibly by an appropriately trained, experienced pathologist. Nevertheless, pathological diagnosis can be very challenging, particularly for some subsets of melanocytic tumours. If the clinical and pathological opinions are discordant, or if there is clinical concern about the nature of a lesion or the pathology report, it is often helpful for the clinician to discuss the case with the reporting pathologist. In some cases, it may also be appropriate to seek additional opinion from one or more pathologists experienced in the interpretation of diagnostically challenging melanocytic lesions.4,5

Evolving concept of borderline melanocytic tumours

Most melanocytic tumours can be rapidly and accurately classified as either naevus or melanoma based on routine pathological assessment on haematoxylin/eosin-stained sections. However, there is a small subset of melanocytic tumours, the biological behaviour of which is not accurately predictable based on routine assessment of their pathological features, even by expert pathologists.5 Examples of such tumours and the terminology used to describe them include atypical Spitz tumour,6 atypical Spitz naevus,7 melanocytic tumour of uncertain malignant potential,8 melanocytoma,9 and atypical blue naevus-like or deep penetrating naevus-like tumour of uncertain malignant potential.10 There are also melanomas that display many features of common acquired or dysplastic naevi, the so-called ‘naevoid melanomas’, that often cause diagnostic problems.3,11 There is increasing recognition of the likely existence of a poorly defined intermediate grade of melanocytic neoplasms with low grade malignant potential which show frequent involvement of sentinel lymph nodes, with significantly less frequent extension of disease beyond the regional lymph nodes to distant metastastic sites; some of the aforementioned lesions probably fall into this class of tumours.6, 9,12,13 The assessment of risk and prognostics, (and as a consequence, management decisions) for such tumours remains problematic.5

Molecular pathology for the diagnosis of difficult melanocytic tumours

It has been known for more than a decade that melanomas are characterised by the presence of numerous chromosomal copy number alterations (CNA), including gains and losses, and that such aberrations are not seen in naevi,14-16 an exception being the occurrence of losses of chromosome 11p or 7p in a minority of Spitz naevi.17,18 Assessment for the presence of CNA may assist in the classification of difficult melanocytic tumours in which accurate characterisation of the tumour as benign or malignant is difficult based on routine histopathological assessment.

CNA may be detected in archival formalin-fixed, paraffin-embedded tissue by comparative genomic hybridization (CGH).14 While this technique has the advantage of being able to detect any aberrations occurring in the genome, it is generally not an appropriate adjunct to pathological diagnosis in routine clinical practice for a number of technical and practical reasons. These limitations include the requirement of a large amount of DNA (making it suitable only for thick bulky tumours), inability to visualise/verify that the findings reflect those of the melanocytic tumour cells themselves, the labour-intensive nature of DNA extraction and CGH testing, and the need for expensive, specialised equipment.

Fluorescence in situ hybridisation (FISH) is a technique that can identify specific CNA within individual tumour cells. While it has the limitation of only being able to test for a limited number of changes (compared to CGH which tests for CNA in the entire genome), FISH is more easily applied in routine clinical practice and can be performed on small tumour samples. Recent studies have shown that a combination of FISH probes targeting selected chromosomal loci can accurately classify naevi and melanomas,17-19 and may also assist in the classification of histologically ambiguous melanocytic tumours.20-22 Recent studies also suggest that the results of FISH testing may identify subsets of melanomas with poorer prognosis.23 FISH is already used in many centres as a supplementary diagnostic aid in the assessment of problematic melanocytic tumours. Once the prognostic significance of FISH is validated in larger studies, this technique may also become commonly employed in estimation of prognosis in melanoma patients.

In many melanoma treatment centres with active translational research programs, tissue samples from fresh specimens may be utilised for tissue banking or other research purposes. The decision to provide tissue should only be made if it is certain that the diagnostic process and pathological evaluation will not be compromised. After close examination of the submitted specimen, the pathologist, in consultation with the clinician, is the most appropriate person to make this decision. As a safeguard, research use of the specimen should be deferred until the diagnostic process is complete. If there are any diagnostic problems, (eg. if it is difficult to readily determine whether a lesion is a naevus or a melanoma without examination of the entire lesion), the portion of the specimen that was stored for research can be retrieved and used for diagnostic purposes.

Melanoma prognosis

The provision of a reliable estimate of prognosis in melanoma patients is important to: better inform them and their treating physicians about likely outcomes; to determine the need for further investigations; to guide management (such as the width of further excision margins and the appropriateness of sentinel lymph node biopsy); and for assignment of risk status in patients entering clinical trials. The Melanoma Staging Committee of the American Joint Committee on Cancer (AJCC) has produced a free, web-based prognostic calculator derived from analysis of a large dataset of patients with long-term follow-up. Visit

The histological examination of a primary melanoma provides important prognostic information, as pathological features constitute many of the key prognostic factors in melanoma.24-26 The prognosis for a patient with clinically localised primary cutaneous melanoma is principally correlated with its vertical depth of tumour growth (Breslow thickness). Other important prognostic factors include the presence or absence of ulceration, the anatomical site of the tumour (melanomas on the extremities have a better prognosis), patient age and sex (young females fare better).24, 27 Recent studies have also highlighted a number of other important prognostic factors in primary cutaneous melanomas which are discussed in more detail below. 

Tumour mitotic rate

Several recent studies, including an analysis of a very large number of patients performed by the Melanoma Staging Committee of the AJCC, have demonstrated that mitotic rate (figure 1) is an important prognostic factor for clinically localised primary melanomas.28-37 In view of these findings, the 7th edition of the AJCC staging system recommends that mitotic rate should be assessed in all primary melanomas for prognostic purposes.24 Furthermore, the presence or absence of mitoses in non-ulcerated thin (<1.0mm thick) melanomas is now used for staging (ie. for separating pT1a and pT1b tumours).24


The number of mitotic figures can vary greatly between different regions in a tumour. For consistency and reproducibility, a standardised method must be used to assess mitotic rate. It is recommended that the field diameter of the microscope used to assess mitotic rate be formally calibrated using a stage micrometer to determine the number of high-power fields that equates to a square millimetre. In the 7th edition of the AJCC melanoma staging system,24 the recommended method to determine mitotic rate is to find an area in the dermis with obvious mitotic activity (the ‘hot spot’), to begin counting in this area, and then to count mitoses in immediately adjacent non-overlapping high power fields adding up to a total area of one square millimetre. This method for determining the mitotic rate of melanoma has been shown to have excellent inter-observer reproducibility, even among pathologists with widely differing levels of experience in the assessment of melanocytic tumours.28

Extent of ulceration

Ulceration was first identified as an adverse prognostic factor for melanoma in the 1950s.38,39 Subsequently, it was established that the prognostic value of ulceration was independent of primary tumour thickness,40 and as a result, ulceration was incorporated into the AJCC melanoma staging system.24, 41 A recent study of 4661 patients diagnosed and managed at Melanoma Institute Australia (MIA),26 showed that the extent of ulceration (measured either as diameter or percentage of tumour width) provides even more accurate prognostic information than the mere presence of ulceration. Both the presence and extent of ulceration were independent predictors of survival. The five-year melanoma-specific survival (MSS) for ulcerated and non-ulcerated melanomas was 77.6% and 91.3%, respectively. The five-year MSS was 82.7% in minimally/moderately ulcerated melanomas (ulceration measuring <5mm), compared to 59.3% in extensively ulcerated (>5mm) melanomas. The presence and extent of ulceration were independent predictors of poorer MSS after adjusting for other known prognostic factors.26

Tumour-infiltrating lymphocytes

The presence of tumour-infiltrating lymphocytes (TIL) in melanoma has been shown to be associated with a favourable prognosis in some studies,42-49 and has been interpreted as indicating a more effective host immunological response to the tumour. A recent study of 1865 patients treated at MIA,50 showed that TIL grade (graded 0 to 3, based on increasing extent and density of the TIL infiltrate) was an independent predictor of survival and sentinel lymph node status in melanoma patients. In this study, the majority of patients had either no (TIL grade 0, 35.4%) or few (TIL grade 1, 45.1%) TIL, with a minority showing moderate (TIL grade 2, 16.3%) or marked (TIL grade 3, 3.2%) TIL. Sentinel lymph node positivity rates for each TIL grade were: 0=27.8%, 1=20.1%, 2=18.3%, 3=5.6%; p<0.0001. Patients with a pronounced TIL infiltrate had an excellent prognosis.50

Sentinel lymph node biopsy

The sentinel lymph node biopsy procedure is a highly accurate and minimally invasive staging technique in melanoma patients. The tumour-harboring status of the sentinel lymph node (figure 2) provides the most accurate prognostic information currently available for clinically localised melanoma. As larger numbers of effective targeted therapies for melanoma are developed (see below), accurate identification of patients at high risk of disease progression (i.e. those with a positive sentinel lymph node) will become increasingly important. Careful identification, removal and pathological assessment of sentinel lymph node is critical to the accuracy of the technique,51, 52 and deficiencies in any of these steps may result in a falsely negative biopsy.53  Pathologists should examine multiple sections from each sentinel lymph node, stained routinely with haematoxylin/eosin and immunohistochemically for melanoma-associated antigens.51,52 In the third interim analysis of the results of a large, randomised, multi-centre clinical trial (the first Multicenter Selective Lymphadenectomy Trial, MSLT-I), there appeared to be a substantial survival benefit in sentinel lymph node -positive patients if they had an early complete lymph node dissection.54,55 In MSLT-I, the five-year survival for patients who were sentinel lymph node -negative was 90.2% whereas it was 72.3% for those who were sentinel lymph node-positive.55 The ongoing second Multicenter Selective Lymphadenectomy Trial (MSLT-II) is designed to determine whether immediate complete lymph node dissection results in improved survival in melanoma patients who are sentinel lymph node -positive.56


Structured/synoptic melanoma pathology reporting

It is important that all relevant histological features are described in the pathology report to allow accurate estimation of prognosis and formulation of an appropriate management plan. A structured or synoptic reporting format can facilitate this.57-59 Recently in Australia, there has been widespread recognition of the need to improve the quality and completeness of cancer pathology reports. Efforts have been made to improve the quality of melanoma pathology reports by education of the pathology community. In 2010, as part of this endeavour, the Royal College of Pathologists of Australasia published a recommended structured pathology reporting protocol for melanoma.12 Furthermore, the international pathology community (through the respective pathology colleges of the US, Canada, UK and Australasia) is also working to develop consensus melanoma pathology reporting guidelines for implementation in their respective jurisdictions.

Molecular and somatic mutation testing

Molecular genetic testing of melanocytic tumours has the potential to identify subgroups of tumours with specific genetic signatures that may accurately predict their likely clinical course and/or response to treatment.

An interesting finding of recently reported molecular studies is the confirmation that the well-established, traditional clinico-pathological classification of melanomas into lentigo maligna, superficial spreading and acral-lentiginous subtypes correlates with the genetic findings.60 For example, tumours with prominent solar damage (lentigo maligna) commonly harbour NRAS and sometimes KIT mutations,61 while superficial spreading melanomas from intermittently sun-exposed areas often have BRAF mutations.60 BRAF mutation occur in about 50% of melanomas overall, but are more frequent in the melanomas of younger patients.  Approximately 80% of BRAF mutations are BRAFV600E, while the BRAFV600K mutation occurs in approximately 19%.62,65a While much less common, activating KIT mutations or amplifications in melanomas have also been identified, usually in mucosal or acral lentiginous primary melanomas (about 10-12% of melanomas from such sites).63-65 These findings have important clinical implications for targeted therapy, as the clinical efficacy of inhibitors of mutant BRAF and KIT (in melanomas carrying these respective mutations) has been recently demonstrated.63, 66-70

Important issues for clinicians to consider when ordering melanoma mutation testing:

1. When should melanoma mutation testing be ordered?
At the present time, mutation testing is most appropriate for planning treatment in melanoma patients with advanced stage (unresectable AJCC stage III or AJCC stage IV) disease.

2. Which specimen should be tested (primary or metastasis)?
At the current time, only limited data are available regarding the concordance of BRAF and NRAS mutation status between primary and metastatic melanomas from individual patients. In one recent study, the concordance rates ranged from 75% to 96% in metastases from different locations.71 We therefore recommend testing of the most recent distant metastatic melanoma specimen. If this is not available, locoregional/in-transit metastases are preferred to the primary melanoma. Mutation testing of the primary tumour could potentially result in a falsely positive BRAF test if BRAF-mutant naevus cells are admixed with the melanoma in the analysed tissue (approximately 80% of melanocytic nevi harbour BRAF mutations).72

3. What type of tissue is required for mutation testing?
Mutation testing can be performed on routinely collected archival formalin-fixed, paraffin-embedded tissue. It can also be performed on fresh tissue, but this is not essential. Specimens containing a high percentage of tumour cells are the most suitable (sentinel lymph node containing micrometastases admixed with numerous lymphocytes are often unsatisfactory). Core biopsies and cell blocks made from fine-needle biopsy cytology specimens also often yield diagnostic results.
4. What information does the pathologist require from the clinician?
To enable the most efficient and timely testing, it is helpful if the pathology department is provided with the accession number of the specimen to be tested and the name and location of the laboratory in which the tissue is stored, along with a copy of the histopathology report of the specimen.

5. Which techniques for mutation testing?
There are various methods currently available for mutation testing. The ideal assay should be highly sensitive, simultaneously test all clinically relevant genes, cover all relevant mutations in each gene, be cost effective, allow high throughput, work well on small biopsies and formalin-fixed, paraffin-embedded tissue, and provide fast turnaround times/results. The sensitivity of the mutation test includes both its technical sensitivity (the minimum percentage of mutant tumour cells that can be detected as a positive test) and diagnostic sensitivity/comprehensiveness of the test (some assays will detect common targeted mutations only, while others will detect all mutations, including rare mutations of unknown significance).

Mutation testing assays include traditional Sanger sequencing, allele-specific reverse transcriptase-polymerase chain reaction (RT-PCR), pyrosequencing and mass spectroscopy/multiplex assays (eg. Sequenom) (Figure 3). Each of these techniques has some advantages and disadvantages, and as a consequence no one method is ideal. Sanger sequencing has traditionally been considered the gold standard (usually supplemented by pre-screening with high resolution melting curve analysis to select only abnormal specimens for sequencing). While it detects all known and new mutations (ie. it is comprehensive), it has only moderate technical sensitivity (about 25%) and is labour-intensive and slow. Allele-specific RT-PCR tests (eg. the Roche cobas 4800 BRAFV600 mutation test) offer high sensitivity but will only detect known targeted mutations. For example, the Roche cobas test was designed to detect BRAFV600E mutations and does not detect all other BRAF mutations (including a significant proportion of BRAFV600K mutations). This may have important clinical consequences, particularly in Australia, where BRAFV600K mutations occur in 19-30% of BRAF mutant melanomas.62,73 It is therefore important that oncologists understand the methodology and limitations of various mutation testing methods. Pyrosequencing and mass spectroscopy assays offer high sensivity and the ability to test for the presence of a range of mutations in a single test.


Immunohistochemistry (IHC) may also be used for molecular testing (figure 4). Recent studies showed correlation of IHC expression of the BRAFV600E-specific antibody VE1 with the presence of the BRAFV600E mutation in 97% of cases.74 However, there was some intra-tumoural heterogeneity in VE1 expression,74 implying that the diagnostic accuracy of IHC might be affected by the region(s) and size of the tumour sampled for testing. Variable results have been obtained in studies correlating IHC for KIT with KIT mutation status.61,75 Additional studies are required to determine whether IHC (allied with morphological assessment) can be a useful technique for mutation testing, or for stratifying tumours into high and low likelihood groups (the former undergoing confirmatory mutation testing using other methods) for harbouring specific mutations.


There are a number of limitations to traditional mutation testing techniques. Most provide limited technical sensitivity (which can be a problem for specimens with a low percentage of tumour cells), and many do not cover all mutations of interest. There is also an increasing need for information about multiple genes and it would not be feasible to perform sequential mutation tests on small biopsies with limited DNA, which would also inevitably increase costs and turnaround times. Massively parallel (so-called ‘next-generation’) sequencing is a recently developed technique that combines the advantages of high technical sensitivity and comprehensiveness. It enables full sequencing of many genes in a single test. However, significant challenges remain to be overcome before its implementation into clinical practice, including: infrastructure costs, interpretation of data, bioinfomatic support and overall cost.76-78 Despite these issues, there is already great optimism that these challenges will be overcome and that next-generation sequencing will be routinely used in clinical practice in the very near future.


New genetic alterations in melanoma are being discovered at an increasing rate. Following functional validation some of these genes, their protein products and the cellular pathways in which they are involved could serve as potential targets for the development of novel therapies. The role of pathology in melanoma will continue to evolve as our knowledge of the molecular pathogenesis of melanoma evolves. Pathologists will play key roles not only in the histological assessment of primary and metastatic tumours (pre- and post-treatment), but also in the triage and selection of appropriate tumour tissue and tumour cells for clinical testing for various molecular markers, and in the correlation of clinical, pathological and molecular findings in research studies.


The authors thank staff of the Department of Tissue Pathology and Diagnostic Oncology at the Royal Prince Alfred Hospital and Melanoma Institute Australia for their support and assistance.


1. Cancer Council Australia/Australian Cancer Network/Ministry of Health NZ. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. Canberra: National Health and Medical Research Council, 2008.
2. Ng JC, Swain S, Dowling JP, Wolfe R, Simpson P, Kelly JW. The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma: experience of an Australian tertiary referral service. Arch Dermatol 2010; 146(3):234-9.
3. McCarthy SW, Scolyer RA. Melanocytic lesions of the face: diagnostic pitfalls. Ann Acad Med Singapore 2004; 33(4 Suppl):3-14.
4. van Dijk MC, Aben KK, van Hees F, Klaasen A, Blokx WA, Kiemeney LA, et al. Expert review remains important in the histopathological diagnosis of cutaneous melanocytic lesions. Histopathology 2008; 52(2):139-46.
5. Scolyer RA, Murali R, McCarthy SW, Thompson JF. Histologically ambiguous (“borderline”) primary cutaneous melanocytic tumors: approaches to patient management including the roles of molecular testing and sentinel lymph node biopsy. Arch Pathol Lab Med 2010; 134(12):1770-7.
6. Murali R, Sharma RN, Thompson JF, Stretch JR, Lee CS, McCarthy SW, et al. Sentinel lymph node biopsy in histologically ambiguous melanocytic tumors with spitzoid features (so-called atypical spitzoid tumors). Ann Surg Oncol 2008; 15(1):302-9.
7. Barnhill RL, Argenyi ZB, From L, Glass LF, Maize JC, Mihm MC, Jr., et al. Atypical Spitz nevi/tumors: lack of consensus for diagnosis, discrimination from melanoma, and prediction of outcome. Hum Pathol 1999; 30(5):513-20.
8. Cerroni L, Barnhill R, Elder D, Gottlieb G, Heenan P, Kutzner H, et al. Melanocytic tumors of uncertain malignant potential: results of a tutorial held at the XXIX Symposium of the International Society of Dermatopathology in Graz, October 2008. American Journal of Surgical Pathology 2010; 34(3):314-26.
9. Zembowicz A, Carney JA, Mihm MC. Pigmented epithelioid melanocytoma: a low-grade melanocytic tumor with metastatic potential indistinguishable from animal-type melanoma and epithelioid blue nevus. Am J Surg Pathol 2004; 28(1):31-40.
10. Barnhill RL, Argenyi Z, Berwick M, Duray PH, Erickson L, Guitart J, et al. Atypical Cellular Blue Nevi (Cellular Blue Nevi With Atypical Features): Lack of Consensus for Diagnosis and Distinction From Cellular Blue Nevi and Malignant Melanoma (“Malignant Blue Nevus”). Am J Surg Pathol 2008; 32(1):36-44.
11. Harris GR, Shea CR, Horenstein MG, Reed JA, Burchette JL, Jr., Prieto VG. Desmoplastic (sclerotic) nevus: an underrecognized entity that resembles dermatofibroma and desmoplastic melanoma. Am J Surg Pathol 1999; 23(7):786-94.
12. Mandal RV, Murali R, Lundquist KF, Ragsdale BD, Heenan P, McCarthy SW, et al. Pigmented Epithelioid Melanocytoma: Favorable Outcome After 5-year Follow-up. Am J Surg Pathol 2009; 33(12):1778-1782.
13. Ludgate MW, Fullen DR, Lee J, Lowe L, Bradford C, Geiger J, et al. The atypical Spitz tumor of uncertain biologic potential: a series of 67 patients from a single institution. Cancer 2009; 115(3):631-41.
14. Bastian BC, LeBoit PE, Hamm H, Brocker EB, Pinkel D. Chromosomal gains and losses in primary cutaneous melanomas detected by comparative genomic hybridization. Cancer Res 1998; 58(10):2170-5.
15. Bastian BC, Olshen AB, LeBoit PE, Pinkel D. Classifying melanocytic tumors based on DNA copy number changes. Am J Pathol 2003; 163(5):1765-70.
16. Curtin JA, Fridlyand J, Kageshita T, Patel HN, Busam KJ, Kutzner H, et al. Distinct sets of genetic alterations in melanoma. N Engl J Med 2005; 353(20):2135-47.
17. Gerami P, Jewell SS, Morrison LE, Blondin B, Schulz J, Ruffalo T, et al. Fluorescence in situ hybridization (FISH) as an ancillary diagnostic tool in the diagnosis of melanoma. Am J Surg Pathol 2009; 33(8):1146-56.
18. Morey AL, Murali R, McCarthy SW, Mann GJ, Scolyer RA. Diagnosis of cutaneous melanocytic tumours by four-colour fluorescence in situ hybridisation. Pathology 2009; 41(4):383-7.
19. Gerami P, Li G, Pouryazdanparast P, Blondin B, Beilfuss B, Slenk C, et al. A highly specific and discriminatory FISH assay for distinguishing between benign and malignant melanocytic neoplasms. Am J Surg Pathol 2012; 36(6):808-17.
20. Nardone B, Martini M, Busam K, Marghoob A, West DP, Gerami P. Integrating clinical/dermatoscopic findings and fluorescence in situ hybridization in diagnosing melanocytic neoplasms with less than definitive histopathologic features. J Am Acad Dermatol 2012; 66(6):917-22.
21. Moore MW, Gasparini R. FISH as an effective diagnostic tool for the management of challenging melanocytic lesions. Diagn Pathol 2011; 6:76.
22. Vergier B, Prochazkova-Carlotti M, de la Fouchardiere A, Cerroni L, Massi D, De Giorgi V, et al. Fluorescence in situ hybridization, a diagnostic aid in ambiguous melanocytic tumors: European study of 113 cases. Mod Pathol 2011; 24(5):613-23.
23. North JP, Vetto JT, Murali R, White KP, White CR, Jr., Bastian BC. Assessment of copy number status of chromosomes 6 and 11 by FISH provides independent prognostic information in primary melanoma. Am J Surg Pathol 2011; 35(8):1146-50.
24. Balch CM, Gershenwald JE, Soong SJ, Thompson JF, Atkins MB, Byrd DR, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol 2009; 27(36):6199-206.
25. Azzola MF, Shaw HM, Thompson JF, Soong SJ, Scolyer RA, Watson GF, et al. Tumor mitotic rate is a more powerful prognostic indicator than ulceration in patients with primary cutaneous melanoma: an analysis of 3661 patients from a single center. Cancer 2003; 97(6):1488-98.
26. In ‘t Hout FE, Haydu LE, Murali R, Bonenkamp JJ, Thompson JF, Scolyer RA. Prognostic importance of the extent of ulceration in patients with clinically localized cutaneous melanoma. Ann Surg 2012; 255(6):1165-70.
27. Gershenwald JE, Soong SJ, Balch CM. 2010 TNM staging system for cutaneous melanoma…and beyond. Ann Surg Oncol; 17(6):1475-7.
28. Scolyer RA, Shaw HM, Thompson JF, Li LX, Colman MH, Lo S, et al. Interobserver reproducibility of histopathologic prognostic variables in primary cutaneous melanomas. American Journal of Surgical Pathology 2003; 27(12):1571–1576.
29. Barnhill RL, Katzen J, Spatz A, Fine J, Berwick M. The importance of mitotic rate as a prognostic factor for localized cutaneous melanoma. Journal of Cutaneous Pathology 2005; 32(4):268–273.
30. Gimotty P, Elder D, Fraker D, Botbyl J, Sellers K, Elenitsas R, et al. Identification of high-risk patients among those diagnosed with thin cutaneous melanomas. Journal of Clinical Oncology 2007; 25(9):1129–1134.
31. Ostmeier H, Fuchs B, Otto F, Mawick R, Lippold A, Krieg V, et al. Can immunohistochemical markers and mitotic rate improve prognostic precision in patients with primary melanoma? Cancer 1999; 85(11):2391–2399.
32. Retsas S, Henry K, Mohammed MQ, MacRae K. Prognostic factors of cutaneous melanoma and a new staging system proposed by the American Joint Committee on Cancer (AJCC): validation in a cohort of 1284 patients. European Journal of Cancer 2002; 38(4):511–516.
33. Gimotty P, Van Belle P, Elder DE, Murry T, Montone KT, Xu X, et al. Biologic and prognostic significance of dermal Ki67 expression, mitoses, and tumorigenicity in thin invasive cutaneous melanoma. Journal of Clinical Oncology 2005; 23(31):8048–8056.
34. Nagore E, Oliver V, Botella-Estrada R, Morena-Picot S, Insa A, Fortea J. Prognostic factors in localized invasive cutaneous melanoma: high value of mitotic rate, vascular invasion and microscopic satellitosis. Melanoma Research 2005; 15(3):169–177.
35. Francken AB, Shaw HM, Thompson JF, Soong SJ, Accortt NA, Azzola MF, et al. The prognostic importance of tumor mitotic rate confirmed in 1317 patients with primary cutaneous melanoma and long follow-up. Annals of Surgical Oncology 2004; 11(4):426–433.
36. Clark W, Jr, Elder D, Guerry D, Braitman L, Trock B, Schultz D, et al. Model predicting survival in stage I melanoma based on tumor progression. Journal of the National Cancer Institute 1989; 81(24):1893–904.
37. Thompson JF, Soong SJ, Balch CM, Gershenwald JE, Ding S, Coit DG, et al. Prognostic significance of mitotic rate in localized primary cutaneous melanoma: an analysis of patients in the multi-institutional American Joint Committee on Cancer melanoma staging database. J Clin Oncol. 2011 Jun 1; 29(16):2199-205.
38. Allen AC, Spitz S. Malignant melanoma; a clinicopathological analysis of the criteria for diagnosis and prognosis. Cancer 1953; 6(1):1-45.
39. Tompkins VN. Cutaneous melanoma: ulceration as a prognostic sign. Cancer 1953; 6(6):1215-8.
40. Balch CM, Soong SJ, Gershenwald JE, Thompson JF, Reintgen DS, Cascinelli N, et al. Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol 2001; 19(16):3622-34.
41. Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Coit DG, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol 2001; 19(16):3635-48.
42. Clemente CG, Mihm MC, Jr., Bufalino R, Zurrida S, Collini P, Cascinelli N. Prognostic value of tumor infiltrating lymphocytes in the vertical growth phase of primary cutaneous melanoma. Cancer 1996; 77(7):1303-10.
43. Tuthill RJ, Unger JM, Liu PY, Flaherty LE, Sondak VK. Risk assessment in localized primary cutaneous melanoma: a Southwest Oncology Group study evaluating nine factors and a test of the Clark logistic regression prediction model. Am J Clin Pathol 2002; 118(4):504-11.
44. van Houdt IS, Sluijter BJ, Moesbergen LM, Vos WM, de Gruijl TD, Molenkamp BG, et al. Favorable outcome in clinically stage II melanoma patients is associated with the presence of activated tumor infiltrating T-lymphocytes and preserved MHC class I antigen expression. Int J Cancer 2008; 123(3):609-15.
45. Mihm MC, Jr., Clemente CG, Cascinelli N. Tumor infiltrating lymphocytes in lymph node melanoma metastases: a histopathologic prognostic indicator and an expression of local immune response. Lab Invest 1996; 74(1):43-7.
46. Hillen F, Baeten CI, van de Winkel A, Creytens D, van der Schaft DW, Winnepenninckx V, et al. Leukocyte infiltration and tumor cell plasticity are parameters of aggressiveness in primary cutaneous melanoma. Cancer Immunol Immunother 2008; 57(1):97-106.
47. Mandala M, Imberti GL, Piazzalunga D, Belfiglio M, Labianca R, Barberis M, et al. Clinical and histopathological risk factors to predict sentinel lymph node positivity, disease-free and overall survival in clinical stages I-II AJCC skin melanoma: outcome analysis from a single-institution prospectively collected database. Eur J Cancer 2009; 45(14):2537-45.
48. Bogunovic D, O’Neill DW, Belitskaya-Levy I, Vacic V, Yu YL, Adams S, et al. Immune profile and mitotic index of metastatic melanoma lesions enhance clinical staging in predicting patient survival. Proc Natl Acad Sci U S A 2009; 106(48):20429-34.
49. Burton AL, Roach BA, Mays MP, Chen AF, Ginter BA, Vierling AM, et al. Prognostic significance of tumor infiltrating lymphocytes in melanoma. Am Surg 2011; 77(2):188-92.
50. Azimi F, Scolyer RA, Rumcheva P, Moncrieff M, Murali R, McCarthy SW, et al. Tumor-infiltrating lymphocyte grade is an independent predictor of sentinel lymph node status and survival in patients with cutaneous melanoma. J Clin Oncol 2012; 30(21):2678-83.
51. Murali R, Thompson JF, Scolyer RA. Sentinel lymph node biopsy for melanoma: aspects of pathologic assessment. Future Oncol 2008; 4(4):535-551.
52. Scolyer RA, Murali R, McCarthy SW, Thompson JF. Pathologic examination of sentinel lymph nodes from melanoma patients. Semin Diagn Pathol 2008; 25(2):100-11.
53. Karim RZ, Scolyer RA, Li W, Yee VS, McKinnon JG, Li LX, et al. False negative sentinel lymph node biopsies in melanoma may result from deficiencies in nuclear medicine, surgery, or pathology. Ann Surg 2008; 247(6):1003-10.
54. Morton DL, Cochran AJ, Thompson JF. The rationale for sentinel-node biopsy in primary melanoma. Nat Clin Pract Oncol 2008; 5(9):510-1.
55. Morton DL, Thompson JF, Cochran AJ, Mozzillo N, Elashoff R, Essner R, et al. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med 2006; 355(13):1307-17.
56. Amersi F, Morton DL. The role of sentinel lymph node biopsy in the management of melanoma. Adv Surg 2007; 41:241-56.
57. Haydu LE, Holt PE, Karim RZ, Madronio CM, Thompson JF, Armstrong BK, et al. Quality of histopathological reporting on melanoma and influence of use of a synoptic template. Histopathology 2010; 56(6):768-74.
58. Karim RZ, van den Berg KS, Colman MH, McCarthy SW, Thompson JF, Scolyer RA. The advantage of using a synoptic pathology report format for cutaneous melanoma. Histopathology 2008; 52(2):130-8.
59. Frishberg DP, Balch C, Balzer BL, Crowson AN, Didolkar M, McNiff JM, et al. Protocol for the examination of specimens from patients with melanoma of the skin. Arch Pathol Lab Med 2009; 133(10):1560-7.
60. Viros A, Fridlyand J, Bauer J, Lasithiotakis K, Garbe C, Pinkel D, et al. Improving melanoma classification by integrating genetic and morphologic features. PLoS Med 2008; 5(6):e120.
61. Torres-Cabala CA, Wang WL, Trent J, Yang D, Chen S, Galbincea J, et al. Correlation between KIT expression and KIT mutation in melanoma: a study of 173 cases with emphasis on the acral-lentiginous/mucosal type. Mod Pathol 2009; 22(11):1446-56.
62. Long GV, Menzies AM, Nagrial AM, Haydu LE, Hamilton AL, Mann GJ, et al. Prognostic and clinicopathologic associations of oncogenic BRAF in metastatic melanoma. J Clin Oncol 2011; 29(10):1239-46.
63. Handolias D, Hamilton AL, Salemi R, Tan A, Moodie K, Kerr L, et al. Clinical responses observed with imatinib or sorafenib in melanoma patients expressing mutations in KIT. Br J Cancer 2010; 102(8):1219-23.
64. Handolias D, Salemi R, Murray W, Tan A, Liu W, Viros A, et al. Mutations in KIT occur at low frequency in melanomas arising from anatomical sites associated with chronic and intermittent sun exposure. Pigment Cell Melanoma Res 2010; 23(2):210-5.
65. Curtin JA, Busam K, Pinkel D, Bastian BC. Somatic activation of KIT in distinct subtypes of melanoma. J Clin Oncol 2006; 24(26):4340-6.
66. Bollag G, Hirth P, Tsai J, Zhang J, Ibrahim PN, Cho H, et al. Clinical efficacy of a RAF inhibitor needs broad target blockade in BRAF-mutant melanoma. Nature 2010; 467(7315):596-9.
67. Flaherty KT, Puzanov I, Kim KB, Ribas A, McArthur GA, Sosman JA, et al. Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med 2010; 363(9):809-19.
68. Hodi FS, Friedlander P, Corless CL, Heinrich MC, Mac Rae S, Kruse A, et al. Major response to imatinib mesylate in KIT-mutated melanoma. J Clin Oncol 2008; 26(12):2046-51.
69. Carvajal RD, Antonescu CR, Wolchok JD, Chapman PB, Roman RA, Teitcher J, et al. KIT as a therapeutic target in metastatic melanoma. JAMA 2011; 305(22):2327-34.
70. Minor DR, Kashani-Sabet M, Garrido M, O’Day SJ, Hamid O, Bastian BC. Sunitinib therapy for melanoma patients with KIT mutations. Clin Cancer Res 2012; 18(5):1457-63.
71. Colombino M, Capone M, Lissia A, Cossu A, Rubino C, De Giorgi V, et al. BRAF/NRAS Mutation Frequencies Among Primary Tumors and Metastases in Patients With Melanoma. J Clin Oncol 2012; 30(20):2522-9.
72. Pollock PM, Harper UL, Hansen KS, Yudt LM, Stark M, Robbins CM, et al. High frequency of BRAF mutations in nevi. Nat Genet 2003; 33(1):19-20.
73. Amanuel B, Grieu F, Kular J, Millward M, Iacopetta B. Incidence of BRAF p.Val600Glu and p.Val600Lys mutations in a consecutive series of 183 metastatic melanoma patients from a high incidence region. Pathology 2012; 44(4):357-9.
74. Capper D, Berghoff AS, Magerle M, Ilhan A, Wohrer A, Hackl M, et al. Immunohistochemical testing of BRAF V600E status in 1,120 tumor tissue samples of patients with brain metastases. Acta Neuropathol 2012; 123(2):223-33.
75. Satzger I, Schaefer T, Kuettler U, Broecker V, Voelker B, Ostertag H, et al. Analysis of c-KIT expression and KIT gene mutation in human mucosal melanomas. Br J Cancer 2008; 99(12):2065-9.
76. Metzker ML. Sequencing technologies – the next generation. Nat Rev Genet 2010; 11(1):31-46.
77. Rizzo JM, Buck MJ. Key principles and clinical applications of “next-generation” DNA sequencing. Cancer Prev Res (Phila) 2012; 5(7):887-900.
78. Schuster SC. Next-generation sequencing transforms today’s biology. Nat Methods 2008; 5(1):16-8.

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