Benign or aggressive? Understanding spinal melanocytomas in comparison to malignant melanoma

Introduction Spinal melanocytic tumors are rare, with limited data on their clinical course and aggressiveness. Since intraoperative dark pigmentation and infiltrative margins can lead to misclassification of MC as MM—especially in the absence of a known primary—this multicenter study characterizes melanocytomas (MC) and contrasts them with malignant melanoma (MM). Methods We retrospectively analyzed 56 patients with spinal intradural melanocytic tumors (2010–2024) from seven European neurosurgical centers. Clinical, radiological, histological, and surgical features were analyzed. Univariate and multivariate analyses were performed to identify prognostic risk factors. Results The study included 22 patients with spinal MC and 34 patients with MM. Median age was comparable (61 vs. 58 years, p = 0.09), but MC patients had a longer symptom history (13 vs. 1.3 months, p = 0.0001) and more often intramedullary tumors (72.7% vs. 2.9%, p < 0.0001). Gross total resection was achieved in 40.9% of MC cases and 61.8% of MM cases ( p = 0.07), with instrumentation required more often for MM ( p = 0.0022). Ki-67 proliferation index was significantly higher in MM than MC (26.7% vs. 6.6%, p < 0.0001). Postoperative deficits were more frequent in MC (54.6% vs. 14.7%, p = 0.002) and MCs showed higher frequency of ataxia postoperatively (36.4% vs. 11.8%, p = 0.04). MM patients received more adjuvant therapy (88.2% vs. 31.8%, p = 0.0001), with a trend toward higher local recurrence (26.5% vs. 14.7%, p = 0.31). Conclusion Our study demonstrates that MC, though considered benign, carries a high risk of postoperative deficits. Furthermore, GTR was achieved in only 40% of cases, underscoring its locally infiltrative nature and potential for semi-benign biology.