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and they affirm that the introduction of this term has led to confusion about the meaning of biologic behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; recent articles suggest that many pathologists accept this concept of intermediate lesions<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and that there is a range of genetic mutations in these lesions &#40;see part 2&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The overall incidence of Spitz nevi is not well documented&#44; but it is thought to lie between 1&#46;4 and 7 cases per 100 000 persons per year&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a> These lesions represent fewer than 1&#37; of melanocytic tumors that are excised during childhood&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Spitz nevi generally appear during childhood or in young adults&#44; although they can affect all age groups&#46; They are extremely uncommon in individuals aged over 30 years&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Congenital cases&#44; present at birth or presenting in the first 24 months of life&#44; are exceptional&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> One study of 349 patients found that 40&#37; of lesions appear in children under 15 years and 77&#37; present at ages below 30 years&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The risk that a lesion with a spitzoid appearance is in fact melanoma increases with increasing age&#44; whereas the probability that it is a Spitz nevus decreases&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There is generally no difference in incidence by sex&#44; although between 15 and 30 years&#44; there is a slight predominance in females &#40;3&#58;1&#41;&#46; It has been suggested that this difference could be associated with a possible hormonal influence&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;12&#44;15&#44;16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Spitz nevi are more common in whites than in Asian or African individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Features</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Spitz Nevus</span><p id="par0035" class="elsevierStylePara elsevierViewall">Spitz nevi generally appear in childhood as a solitary well-defined&#44; dome-shaped papule or mass&#44; with a solid consistency and a color ranging from flesh color&#44; pink&#44; red&#44; to brown &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The color&#44; often reddish&#44; is due to the low melanin content and high vascularization&#44; although 10&#37; of lesions are pigmented &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The lesions grow rapidly for a period of 3 to 6 months and&#44; although their size is generally less than 5-6&#8239;mm&#44; they can reach a diameter of 1-2&#8239;cm&#46; After this phase of rapid growth&#44; the lesion can remain static for years&#44; showing a progressive transformation until acquiring the aspect of a common melanocytic nevus or involving until completely disappearing&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> In adults&#44; the lesion is usually pigmented with a color between brown and black&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Although the lesion can be located anywhere&#44; including the mucosae&#44; in children there is a predilection for the head and neck &#40;37&#37;&#41;&#44; whereas in young adults it is preferentially located on the lower limbs &#40;28&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Reed Nevus or Pigmented Spindle-Cell Nevus</span><p id="par0045" class="elsevierStylePara elsevierViewall">Reed nevus was described in 1975 as a benign&#44; highly pigmented&#44; melanocytic lesion&#44; with a dark or black color and a size generally less than 8&#8239;mm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> These lesions usually present on the legs of older children and adolescents&#44; more frequently on the thighs in young women and on the trunk in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Some authors consider that Reed nevus is a subtype of Spitz nevus whereas others consider it as an independent entity&#46; Detection may have increased with the introduction of dermatoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Multiple Spitz Nevi</span><p id="par0050" class="elsevierStylePara elsevierViewall">Multiple Spitz nevi are characterized by the presence of 2 or more Spitz nevi in the same patient&#46; This presentation is uncommon and&#44; depending on the distribution of the lesions&#44; the condition can be divided into 2 subgroups&#58; grouped or disseminated&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Multiple grouped Spitz nevi can develop over a caf&#233;-au-lait spot<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44; on normal skin&#44; or&#44; less frequently&#44; on a hypopigmented background&#46; When multiple Spitz nevi appear with a disseminated pattern&#44; if they develop over a short period of time&#44; they are known as multiple eruptive Spitz nevi&#46; Their etiology is unknown&#44; although it has been postulated that their appearance could be related to a genetic predisposition or trigger factors&#46; Cases have been reported after sunburn&#44; perioperative stress&#44; pregnancy&#44; drug abuse&#44; Addison disease&#44; chemotherapy&#44; and allogeneic hematopoietic stem cell transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Desmoplastic Spitz Nevus</span><p id="par0055" class="elsevierStylePara elsevierViewall">Desmoplastic Spitz nevus is a rare subtype&#44; more common in individuals in late adolescence or in adults than in children&#46; Clinically&#44; lesions present as papules with limited or no melanocytic pigmentation&#44; poorly defined borders&#44; and woody consistency&#46; They are most frequently located on the limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Atypical Spitz Tumor</span><p id="par0060" class="elsevierStylePara elsevierViewall">Atypical Spitz tumors are usually larger &#40;&#62; 10&#8239;mm&#41; than classic Spitz nevi and&#44; unlike the latter lesions&#44; are usually asymmetric&#44; generally with irregular borders&#44; and the surface may be ulcerated<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; In a retrospective study of 72 spitzoid neoplasms in patients aged between 1 and 18 years&#44; 7&#37; were found to be atypical Spitz tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Spitzoid Melanoma</span><p id="par0065" class="elsevierStylePara elsevierViewall">Melanoma is uncommon in children&#59; however&#44; most melanomas diagnosed in children are spitzoid melanomas&#46; These are an uncommon variant of melanoma that&#44; in pathology study&#44; may resemble Spitz nevi&#46; In general&#44; these are usually amelanotic or pigmented lesions with different colors that show a progressive growth&#59; they can grow to more than 1&#8239;cm in diameter&#44; often with ulceration&#46; The lesions are usually located on the head&#44; neck&#44; or limbs&#46; Their biological behavior is similar to conventional melanoma&#44; although more favorable outcomes have been observed in spitzoid melanomas in children under 10 years of age or prepubescent children&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Diagnosis of Spitz nevus can be difficult given its similarity with other skin tumors and differential diagnosis is necessary &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The introduction of dermatoscopy has enabled greater diagnostic precision for Spitz nevi given the identification of a variety of patterns that provide additional information about their morphology &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> Although the identification of these patterns has contributed to improved tumor detection&#44; none of them are specific to Spitz nevi and they can also be present in melanoma&#44; and so careful interpretation is of great importance&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Classic Spitz nevi have been more frequently associated with the presence of a dotted vascular pattern&#46; This consists of dotted and monomorphic vessels&#44; distributed regularly over a pinkish background &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; This pattern is present in 51&#37; of Spitz nevi&#46; In pigmented Spitz nevi&#44; a starburst or globular pattern is more frequently observed&#46; This pattern is characterized by a homogeneous central pigmentation with colors ranging between greyish&#44; blueish&#44; and black&#44; with radial projections at the periphery in the case of the starburst pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41; and round or oval structures of brown-black color&#44; distributed regularly at the periphery in the case of a globular pattern&#59; these patterns are present in 51&#37; and 17&#37; of Spitz nevi&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31&#44;33</span></a> Another pattern&#44; initially associated with melanoma&#44; but which is present also in Spitz nevi&#44; is the reticular depigmentation pattern&#44; which consists intersecting lines surrounding the pigmented globules or vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> This latter pattern may present in association with a dotted or comma vascular pattern&#44; or the globular pattern&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> It is interesting to highlight that if the globular pattern is not associated with reticular depigmentation&#44; it is not characteristic of Spitz nevi&#44; as these regular round or oval structures at the periphery are frequently observed in melanocytic nevi in children&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;36</span></a> Other patterns&#44; such as the homogeneous one&#44; which is characterized by brown or black pigmentation in absence of other structures&#44; or the reticular pattern&#44; in which a network of pigment is observed similar to other acquired melanocytic nevi&#44; may be present in the natural course of Spitz nevi&#46; A sequential course has been described in which Spitz nevi may go through a series of different dermatoscopic patterns&#44; with a progressive transformation from a globular pattern to a starburst one&#44; and even to a homogeneous pattern before involution and spontaneous disappearance in more than 50&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;37&#8211;39</span></a> The multicomponent pattern is characterized by an uneven distribution of colors and structures&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;40</span></a> In a study that assessed the dermatoscopic features of atypical Spitz tumors&#44; it was observed that most lesions showed this pattern and 16&#46;4&#37; showed an overall dotted vascular pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Although dermatoscopy is a useful technique&#44; it is not always sufficient to differentiate between Spitz nevus and melanoma&#46; The symmetry of the arrangement of structures and colors throughout the lesion is characteristic of the spitzoid pattern and should suggest to us diagnosis of Spitz nevus&#44; whereas asymmetry&#44; presence of a multicomponent pattern&#44; or visualization of chrysalis&#44; although potentially present in Spitz nevi&#44; force us to consider melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> In a case-control study conducted in children in which dermatoscopic features were compared according to age group &#40;0-6&#44; 7-12&#44; and 13-18 years&#41;&#44; it was observed that the vascular and globular patterns were more prevalent in preschool children&#44; whereas the starburst or multicomponent pattern predominated in children of school age&#44; and a reticular depigmentation pattern was observed more frequently in adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> However&#44; a systematic review that included 15 case-control studies and case series with patients of all ages&#44; but with more adults than children&#44; concluded that the type of pattern was not associated with the age of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Histopathology</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Spitz Nevus</span><p id="par0090" class="elsevierStylePara elsevierViewall">Spitz nevi are symmetric&#44; well-delimited&#44; melanocytic lesions&#44; generally with a compound presentation although like other melanocytic nevi&#44; they can be located at the dermal-epidermal junction or within the dermis&#46; They are characterized by the presence of epithelioid &#40;rounded or polygonal&#41; or spindle-shaped melanocytes with enlarged regular nuclei with peripheral margination&#46; These show abundant cytoplasm and prominent central nucleoli&#46; The cells are distributed in the form of uniform nests with a vertical orientation and&#44; occasionally&#44; a pagetoid spread of isolated melanocytes can be present at the uppermost layers of the epidermis or the junction&#46; The dermal component matures with depth and&#44; to a lesser extent&#44; towards the periphery&#46; The epidermis can be preserved or show regular hyperplasia&#59; the dermal vessels are usually dilated and clefts can be seen among the melanocyte nests&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;41&#8211;44</span></a> In the epidermis or papillary dermis&#44; there is often a presence of eosinophilic globules&#44; which contain proteins of the basal membrane&#59; these structures are also known as Kamino bodies&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> They are characteristic of Spitz nevi&#44; but they can also be present in melanoma&#44; although in this latter case&#44; they are not usually very big or well formed&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Lymphocytic inflammatory infiltrate can also be observed in the base and perivascular region&#46; Typical mitosis can also occasionally appear &#40;generally less than 2&#47;mm<span class="elsevierStyleSup">2</span>&#41; in the mid or upper part of the lesion&#59; this finding is rare in the deep dermis and atypical mitosis is not observed&#46; The pigment can be granulated and located in the superficial part of the lesion<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;41&#8211;44</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Figs&#46; 8</a>&#8211;<a class="elsevierStyleCrossRef" href="#fig0050">10</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Atypical Spitz Tumors</span><p id="par0095" class="elsevierStylePara elsevierViewall">Atypical Spitz tumors do not exhibit all the typical histopathological features of Spitz nevi but they also do not meet the criteria for melanoma&#46; Atypical Spitz tumors show at least 1 of the following features&#58; asymmetry&#44; poor lateral delimitation&#44; greater extension downwards&#44; lack of maturation in the dermis&#44; ulceration&#44; absence of Kamino bodies&#44; presence of mitosis in the dermis &#40;generally more than 2-6 mitosis&#47;mm<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41;&#44; and abundant isolated melanocytes in the superficial dermis instead of nests<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;47&#44;48</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46;</p><elsevierMultimedia ident="fig0055"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of a high number of mitosis at depth&#44; asymmetry&#44; high-grade cytological atypia&#44; and ulceration are considered histopathological criteria that correlate with a higher risk of metastasis&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Pigmented Spindle-Cell Nevus or Reed Nevus</span><p id="par0105" class="elsevierStylePara elsevierViewall">Pigmented spindle-cell nevus is a small&#44; well-defined&#44; melanocytic lesion consisting of a symmetric proliferation of spindle cells with intense pigmentation&#46; The cells are present in rounded nests in a vertical arrangement or a horizontal one at the dermal-epidermal junction&#46; The cells are usually smaller than the spindle cells of most conventional Spitz nevi &#40;<a class="elsevierStyleCrossRef" href="#fig0060">Fig&#46; 12</a>&#41;&#46; Although mitotic activity may be present&#44; atypical mitosis figures are not usually seen&#46; If they are&#44; we can rule out spindle-cell melanoma&#44; which is extremely uncommon in childhood&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><elsevierMultimedia ident="fig0060"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Desmoplastic Spitz Nevus</span><p id="par0110" class="elsevierStylePara elsevierViewall">Desmoplastic Spitz nevus is an intradermal proliferation of spindle-cell melanocytes surrounded by abundant thickened collagen strands that form nests at the surface of the skin&#46; The cells are more widely dispersed at the periphery&#46; Mitosis can be found in the superficial parts of the lesion but not in deeper layers&#46; Differential diagnosis should include desmoplastic melanoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;49</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Combined Spitz Nevus</span><p id="par0115" class="elsevierStylePara elsevierViewall">Combined Spitz nevus is characterized by the presence of 2 different subtypes of nevi&#58; Spitz nevus and another type of nevus&#44; such as acquired melanocytic nevus or blue nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Recurrent or Persistent Spitz Nevus</span><p id="par0120" class="elsevierStylePara elsevierViewall">Recurrence of Spitz nevus after partial or complete excision can resemble melanoma&#59; histological criteria for classic Spitz nevus overlap in terms of presence of asymmetry and pagetoid spread over scarred areas&#46; Diagnosis can be difficult&#44; particularly when multifocal recurrence occurs&#46; It can be useful to reassess the initial biopsy material&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;51</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Halo Spitz Nevus</span><p id="par0125" class="elsevierStylePara elsevierViewall">The architecture of Spitz nevus is observed with conspicuous inflammatory lymphocytic infiltrate&#46; Clinically&#44; the halo is manifest as erythema&#44; an increase in size&#44; or pruritus at the site of the Spitz nevus&#59; the lesion is usually excised before it reveals the depigmentation halo&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Pagetoid Spitz Nevus</span><p id="par0130" class="elsevierStylePara elsevierViewall">Pagetoid Spitz nevus is characterized by abundant isolated melanocytes with intradermal pagetoid spread&#59; it can be difficult to distinguish this lesion from in situ melanoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;53</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Tubular Spitz Nevus</span><p id="par0135" class="elsevierStylePara elsevierViewall">Tubular Spitz nevus is a rare variant of Spitz nevus with a tubular appearance&#46; Intradermal nodules are arranged around an optically empty center&#46; These nodules are composed of the epithelioid cells of the nevus&#46; The lesion can be associated with an intense inflammatory infiltrate&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;44&#44;54</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Several theories have been put forward to explain the tubular appearance&#46; Initially the tubular form was considered the product of apoptosis of the central cells of the nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> Subsequently&#44; it was proposed to be an artefact of retraction after fixing in formaldehyde rather than a true variant of Spitz nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Balloon Cell Spitz Nevus</span><p id="par0145" class="elsevierStylePara elsevierViewall">Balloon cell Spitz nevi are characterized by the presence of large cells with vacuolated cytoplasm and small basophil nuclei&#44; called balloon cells&#44; in addition to conventional Spitz nevus cells&#46; Balloon cells account for at least 50&#37; of the cells in the nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Myxoid or Hyalinizing Spitz Nevus</span><p id="par0150" class="elsevierStylePara elsevierViewall">Myxoid or hyalinizing Spitz nevi occur when myxoid or hyalinizing changes occur in a Spitz nevus&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">57&#44;58</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Plexiform Spitz Nevus</span><p id="par0155" class="elsevierStylePara elsevierViewall">Plexiform Spitz nevi exhibit the architecture of Spitz nevus with melanocytes that form nests with a conspicuous fascicular dermal growth&#46; Some authors have considered them as a type of atypical Spitz tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Other Variants</span><p id="par0160" class="elsevierStylePara elsevierViewall">Other variants include polypoid Spitz nevus and verrucous Spitz nevus&#44; both of which are characterized by a markedly exophytic growth pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Angiomatoid Spitz nevus&#44; originally considered a variant of desmoplastic Spitz nevus&#44; is a classic Spitz nevus with notable vascular proliferation&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;61</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Spitzoid Melanoma</span><p id="par0165" class="elsevierStylePara elsevierViewall">As mentioned earlier&#44; spitzoid melanomas can closely resemble Spitz nevi&#44; with nests of epithelioid or spindle-shaped melanocytes associated with a larger number of atypical features than atypical Spitz tumors&#44; such as poor delimitation&#44; asymmetry&#44; extensive pagetoid spread&#44; dermal growth with maturation with depth and no or limited atypical mitoses&#44; as well as high-grade cellular atypia &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a></p></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Immunohistochemistry</span><p id="par0170" class="elsevierStylePara elsevierViewall">Immunohistochemical markers are used as a complementary tool in cases when histopathological diagnosis of Spitz nevus is in doubt&#44; with the aim of better differentiating between Spitz nevus on the one hand and atypical Spitz tumor and melanoma on the other &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; Although immunohistochemistry is useful for identifying malignant characteristics&#44; interpretation can be subjective according to the pathologist&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">MIB1&#58;</span> This is a monoclonal antibody that reacts with the protein Ki-67&#44; a nuclear protein implicated in regulation of the cell cycle&#46; It is a marker of proliferation and is more strongly expressed in nuclei of melanomas and atypical Spitz tumors compared with Spitz nevi&#46; Expression decreases progressively from malignant lesions to benign ones&#44; with expression in 37&#37; of melanomas&#44; 10&#37; of atypical Spitz tumors&#44; 5&#37; of Spitz nevi&#44; and 0&#46;5&#37; of conventional nevi&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#44;63</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">HMB45</span>&#58; This is a marker of maturation with depth&#46; It is expressed in superficial areas with a decreasing gradient towards the base of the lesion in Spitz nevi while it is destructured with loss of gradient &#40;more uniform distribution&#44; persisting in the dermis&#41; in melanoma&#46; The pattern of expression in atypical Spitz tumors has not been established and a negative result does not rule out diagnosis of melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">p53</span>&#58; This protein is expressed more weakly in Spitz nevi than in melanoma&#44; although the expression pattern is not constant&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">p21</span> and <span class="elsevierStyleItalic">cyclin D1</span>&#58; These proteins are overexpressed in Spitz nevi while their expression is decreased in nonspitzoid melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">p16</span>&#58; This protein regulates the cell cycle&#44; coding for the <span class="elsevierStyleItalic">CDKN2A</span> gene&#44; located on chromosome 9p&#46; It shows more intense reactivity in the dermis in Spitz nevi than in melanoma&#46; It stains intensely in desmoplastic Spitz nevi&#44; unlike desmoplastic melanoma&#44; where it is usually absent&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67&#8211;69</span></a> Three patterns have been identified in spitzoid melanocytic tumors&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#9702;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Homogeneous expression&#58; this pattern is usually observed in Spitz nevi and represents loss of heterozygosity at chromosome 9p or an intact chromosome 9p&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#9702;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Complete loss of expression&#58; this is common in melanoma and corresponds to loss of homozygosity at chromosome 9p&#44; a point mutation in <span class="elsevierStyleItalic">CDKN2A</span>&#44; or methylation of the <span class="elsevierStyleItalic">CDKN2A</span> promotor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#9702;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Heterozygous loss of expression&#58; this can be observed in compound tumors with mixed clones&#46; It is doubtful whether this is of use for differentiating between atypical Spitz tumors and melanoma&#44; as loss in atypical Spitz tumors can be very variable&#59; 67&#37; of lesions with loss of heterozygosity at 9p21 show expression of p16&#44; whereas those with loss of homozygosity do not express it&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#44;71</span></a></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">E-cadherin&#58;</span> This is an antigen that is diffusely expressed in Spitz nevi and other benign lesions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">CD99</span>&#58; This is a transmembrane glycoprotein more often expressed in melanoma &#40;56&#37;&#41; than in Spitz nevus &#40;5&#37;&#41;&#46; In melanoma&#44; staining can be diffuse&#44; unlike in Spitz nevus where the pattern is generally focal when expressed&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">MART1</span>&#58; This is a melanocytic differentiation antigen that is expressed both in Spitz nevus and in melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S100</span>&#58; Weak staining in Spitz nevi compared with melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S100A6</span>&#58; Staining is more intense and diffuse in Spitz nevus&#44; with a patchy pattern or negativity in Reed nevus&#44; whereas the pattern is weaker and uneven in melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a></p></li></ul></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres1327534"
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          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Clinical Features"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Spitz Nevus"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Reed Nevus or Pigmented Spindle-Cell Nevus"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Multiple Spitz Nevi"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Desmoplastic Spitz Nevus"
            ]
            4 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Atypical Spitz Tumor"
            ]
            5 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Spitzoid Melanoma"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Diagnosis"
        ]
        8 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Histopathology"
          "secciones" => array:14 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Spitz Nevus"
            ]
            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Atypical Spitz Tumors"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Pigmented Spindle-Cell Nevus or Reed Nevus"
            ]
            3 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Desmoplastic Spitz Nevus"
            ]
            4 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Combined Spitz Nevus"
            ]
            5 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Recurrent or Persistent Spitz Nevus"
            ]
            6 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Halo Spitz Nevus"
            ]
            7 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Pagetoid Spitz Nevus"
            ]
            8 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Tubular Spitz Nevus"
            ]
            9 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Balloon Cell Spitz Nevus"
            ]
            10 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Myxoid or Hyalinizing Spitz Nevus"
            ]
            11 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Plexiform Spitz Nevus"
            ]
            12 => array:2 [
              "identificador" => "sec0120"
              "titulo" => "Other Variants"
            ]
            13 => array:2 [
              "identificador" => "sec0125"
              "titulo" => "Spitzoid Melanoma"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0130"
          "titulo" => "Immunohistochemistry"
        ]
        10 => array:2 [
          "identificador" => "sec0135"
          "titulo" => "Conflicts of interest"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
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    "fechaRecibido" => "2019-01-14"
    "fechaAceptado" => "2019-02-03"
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          "palabras" => array:2 [
            0 => "Spitz nevus"
            1 => "Spitzoid tumors"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1223719"
          "palabras" => array:2 [
            0 => "Nevo de Spitz"
            1 => "Tumores spitzoides"
          ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">A Spitz nevus is a melanocytic neoplasm of epithelioid and&#47;or spindle cells that usually appears in childhood&#46; These lesions are by nature benign&#44; but their features can sometimes make them difficult to distinguish from melanomas&#46; Spitzoid melanocytic lesions have been grouped into 3 types in recent decades&#58; Spitz nevi&#44; atypical Spitz tumors&#44; and spitzoid melanomas&#46; Atypical Spitz tumors are spitzoid melanocytic proliferations that have atypical histopathologic features that are insufficient to support a diagnosis of melanoma&#46; The malignant potential of these lesions is at present uncertain&#46; This review examines the clinical&#44; dermoscopic&#44; and histopathologic features of this group of lesions&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">El nevo de Spitz es una neoplasia melanoc&#237;tica de c&#233;lulas epitelioides y&#47;o fusiformes que suele aparecer en la infancia&#46; Su naturaleza es benigna&#44; aunque en ocasiones puede mostrar unas caracter&#237;sticas dif&#237;ciles de distinguir del melanoma&#46; En las &#250;ltimas d&#233;cadas se han clasificado las neoplasias melanoc&#237;ticas spitzoides en tres tipos&#58; nevus de Spitz&#44; tumor de Spitz at&#237;pico y melanoma spitzoide&#46; El tumor de Spitz at&#237;pico hace referencia a las neoplasias melanoc&#237;ticas spitzoides que tienen unas caracter&#237;sticas histopatol&#243;gicas at&#237;picas insuficientes para realizar el diagn&#243;stico de melanoma y cuyo potencial maligno&#44; actualmente&#44; es incierto&#46; Nuestro objetivo es revisar los aspectos cl&#237;nicos&#44; dermatosc&#243;picos&#44; histopatol&#243;gicos e inmunohistoqu&#237;micos de este conjunto de tumores&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sainz-Gaspar L&#44; S&#225;nchez-Bernal J&#44; Noguera-Morel L&#44; Hern&#225;ndez-Mart&#237;n A&#44; Colmenero I&#44; Torrelo A&#46; Nevo de Spitz y otros tumores spitzoides en la infancia&#46; Parte 1&#58; aspectos cl&#237;nicos&#44; histol&#243;gicos e inmunohistoqu&#237;micos&#46; Actas Dermosifiliogr&#46; 2020&#59;111&#58;7&#8211;19&#46;</p>"
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr10.jpeg"
            "Alto" => 1692
            "Ancho" => 2000
            "Tamanyo" => 835478
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Figure 1"
            "rol" => "short"
          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Intradermal Spitz nevus&#46; Although most Spitz nevi are compound lesions&#44; a small portion of them can be limited to the dermal-epidermal junction&#46; Cytological features&#44; however&#44; are similar to those of compound Spitz nevi&#46; A&#44; Under low magnification&#44; of note is an intradermal lesion composed of large blocks of spindle-shaped nevus cells&#46; B and C&#44; Under higher magnification&#44; spindle cells can be observed without atypia and limited cytoplasmatic melanin pigment&#44; as well as presence of Kamino bodies&#46;</p>"
        ]
      ]
      10 => array:8 [
        "identificador" => "fig0055"
        "etiqueta" => "Figure 11"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr11.jpeg"
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            "Ancho" => 1750
            "Tamanyo" => 587605
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0055"
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            "rol" => "short"
          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Spitzoid tumor&#46; A&#44; Proliferation of epithelioid melanocytes with a central nodular area that contains atypical melanocytes &#40;B&#41; and frequent mitosis &#40;C&#41;&#46; The central nodular area shows increased Ki67 expression &#40;D&#41;&#46;</p>"
        ]
      ]
      11 => array:8 [
        "identificador" => "fig0060"
        "etiqueta" => "Figure 12"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr12.jpeg"
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            "Ancho" => 2000
            "Tamanyo" => 900398
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          0 => array:3 [
            "identificador" => "at0060"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Reed nevus&#46; A&#44; Proliferation of spindle-shaped nevus cells without atypia arranged in clumps at the dermal-epidermal junction&#46; B&#44; C&#44; and D&#44; Images showing absence of atypia and abundant intracytoplasmic melanin pigment and dermal melanophages&#46;</p>"
        ]
      ]
      12 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0065"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Adapted from Luo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical Features&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Classic Spitz Nevus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Atypical Spitz Tumor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#8239;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;&#8239;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Face&#44; neck&#44; and extremities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#8239;10&#8239;mm &#40;generally 5-6&#8239;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;&#8239;10&#8239;mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Well-defined and regular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poorly-defined and irregular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smooth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irregular&#44; ulcerated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Color&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pink&#44; reddish&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irregular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275673.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clinical Features of Conventional Spitz Nevi and Atypical Spitz Tumors&#46;</p>"
        ]
      ]
      13 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0070"
            "detalle" => "Table "
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Conventional or hypopigmented Spitz nevus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pyogenic granuloma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mastocytoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemangioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiofibroma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Juvenile xanthogranuloma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Molluscum contagiosum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Amelanotic melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pigmented Spitz nevus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Congenital and acquired melanocytic nevus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desmoplastic Spitz Nevus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Keloid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dermatofibroma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple Spitz Nevi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metastatic melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275677.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Main Differential Diagnoses for Spitz Nevi&#46;</p>"
        ]
      ]
      14 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0075"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Adapted from Lallas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pattern in Pigmented Spitzoid Lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Starburst pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central pigmentation with homogeneous greyish&#44; blueish&#44; and black color with regular radial projections &#40;streaks or pseudopods&#41; at the periphery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Globular pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central blue-black pigmentation and presence of regularly distributed round or oval structures of brown-black color at the periphery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Homogeneous pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diffuse&#44; brown&#44; grey-blue&#44; or grey-black pigmentation in the absence of other structures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atypical or multicomponent pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Uneven distribution of colors and structures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reticular pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pigment network similar to that present in acquired melanocytic nevi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reticular depigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Network of hypopigmentation &#40;white lines surrounding pigmented globules&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275676.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pattern in Hypopigmented Spitzoid Lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Punctiform vascular pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dotted vessels with regular distribution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glomerular vascular pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tortuous or coiled capillaries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular pattern with hairpin vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Looped or bending vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular starburst pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regular radial vascular lines at the periphery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Homogeneous pinkish color&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pinkish tone with or without remnants of brownish pigmentation in absence of other structures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reticular depigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Whitish network surrounding the vessels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chrysalis structures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Linear&#44; orthogonal&#44; or disordered lines of bright white color&#46; These can be seen with dermatoscopy under polarized light&#44; associated with the previous pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275674.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Dermatoscopic Patterns Present in Spitzoid lesions&#46;</p>"
        ]
      ]
      15 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0080"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spitz Nevus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spitzoid Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Symmetry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymmetry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Well delimited&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poorly delimited&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intact or hyperplastic epidermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epidermis can be ulcerated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kamino bodies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Absence of Kamino bodies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maturation with depth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Absence of maturation with depth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Limited pagetoid spread&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extensive pagetoid spread&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fewer than than 2 mitosis&#47;mm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequent mitosis in the dermis&#59; these can be atypical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low nucleus&#47;cytoplasm ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High nucleus&#47;cytoplasm ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nuclei increased in size&#44; but absence of nuclear pleomorphism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cellular pleomorphism&#44; high degree of cytological atypia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275675.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Clinical Features of Conventional Spitz Nevi and Atypical Spitz Tumors&#46;</p>"
        ]
      ]
      16 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0085"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antigen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spitz Nevus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ki-67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Limited expression &#40;5&#37;&#41;&#44; junction and papillary dermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extensively expressed &#40;37&#37;&#41;&#44; diffuse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HMB45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Superficial expression&#44; less intense with depth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Loss of gradient&#44; expression maintained with depth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intense expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Expression is often lost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High expression&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E-cadherin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diffuse expression &#40;also in other benign lesions&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Expression is lost&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Weak expression&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intense expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">S100A6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Weak and uneven expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">p21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intense expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low expression in nonspitzoid melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diffuse expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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