Case Number : Case 1991 - 23 Jan 2018 Posted By: Uma Sundram

STUMP-related recommendations. Also FISH. But no sentinel lymph node. 

STUMP - but "probably" benign. Needs complete excision, 3 to 5mm (depending on clinical features). Clinical colleagues need education - see my prior diatribe!

I may ask a stupid question but I never made the diagnosis of STUMP in my practice. The reason is if I make that diagnosis, the case will go out of the door to an expert dermatopathologist. Besides, if there is a dermal component like in this case, I got to be sure because there is always a risk of metastasis, although very small. So I might get into a lawsuit easily if that happens from where I practice. Is it more common practice in the part of the world to use STUMP? Or outside of Florida?

Just now, anh said:

I may ask a stupid question but I never made the diagnosis of STUMP in my practice. The reason is if I make that diagnosis, the case will go out of the door to an expert dermatopathologist. Besides, if there is a dermal component like in this case, I got to be sure because there is always a risk of metastasis, although very small. So I might get into a lawsuit easily if that happens from where I practice. Is it more common practice in the part of the world to use STUMP? Or outside of Florida?

I mean other parts of the world

Dear anh,

STUMP to me translates to "I don't know" the biological potential i.e. it's a sit on the fence. It's easier to do if you have a national or international reputation! But the honest answer in many cases is "don't know" particularly when lesions are small, thin, recently grown and clinically un-defined.  I use "don't know" quite a bit and I get referrals from colleagues around the UK so I guess they don't mind me apparently admitting defeat!  If I issue such a report to a clinical colleague who has never heard of me I'm asked to send it to someone else, who they have heard of, and they think will be able to make a proper diagnosis!  You have to just smile and relax about it although I can't resist letting them know I do organise a National & International melanocytic slide club and it's not necessarily a sign of incompetence to say don't know. I usually try to give a UMP "probably benign" or "probably malignant" to help guide management although I suspect I'd be happy with 5mm margins in either case.  Problem is some of the cases are thick childhood Spitzoid tumours and the stakes are quite high.  Then it's nice to have friends with access to CGH!

Agree with all comments above, and thanks especially to Dr Carr for his detailed comments. I don't necessarily have an easy way to handle Spitzoid lesions in general, but I almost always recommend re excision, especially in anyone over the age of 10. Pediatric dermatologists have often told me that they can easily diagnose Spitz nevi in children and it baffles me why people want to dig themselves into the hole after biopsying a lesion like this in a child. Having said that, in adolescents and adults it can be tricky. STUMP is a fancy way of saying 'take it out' and I find clinicians (more often then not) like to return to the lesion for a re excision. The liability of a Spitz diagnosis extends to them as well and they feel quite comfortable returning to re excise a lesion which promises to be a headache in the future (unless something is done now).

BTW, if I can at all, I try to avoid ancillary testing such as FISH (unless the stakes are high, as in thick Spitz lesions in an adolescent). They never seem to answer the question and often muddy the waters. 

On ‎1‎/‎24‎/‎2018 at 09:40, Dr. Richard Carr said:

Dear anh,

STUMP to me translates to "I don't know" the biological potential i.e. it's a sit on the fence. It's easier to do if you have a national or international reputation! But the honest answer in many cases is "don't know" particularly when lesions are small, thin, recently grown and clinically un-defined.  I use "don't know" quite a bit and I get referrals from colleagues around the UK so I guess they don't mind me apparently admitting defeat!  If I issue such a report to a clinical colleague who has never heard of me I'm asked to send it to someone else, who they have heard of, and they think will be able to make a proper diagnosis!  You have to just smile and relax about it although I can't resist letting them know I do organise a National & International melanocytic slide club and it's not necessarily a sign of incompetence to say don't know. I usually try to give a UMP "probably benign" or "probably malignant" to help guide management although I suspect I'd be happy with 5mm margins in either case.  Problem is some of the cases are thick childhood Spitzoid tumours and the stakes are quite high.  Then it's nice to have friends with access to CGH!

Dr. Carr,

Great comments. Thank you very much. Make me feel a lot better.