Practical Management of Atypical Melanocytic Lesions

Caroline C. Kim, MD, Director Assistant Professor, Department of Dermatology

Harvard Medical School Director, Pigmented Lesion Clinic

Associate Director, Cutaneous Oncology Program Beth Israel Deaconess Medical Center, Boston, MA

Inova Melanoma and Cutaneous Oncology Primer Conference, Falls Church, VA, October 14, 2017

Disclosures

No relevant conflicts of interest

Relationships Hoffmann-La Roche, Ltd.

Investigator, Consultant

Overview: Practical Management of Atypical

Melanocytic Lesions

1.  Background 2.  Examination of the atypical nevus patient 3. Management/ biopsy

Atypical Nevi Background:

--First described in 1978: clinicopathologic entity, which identified patients at increased risk for melanoma

•  Mole larger than 5 mm •  Variegated pigmentation •  Irregular borders

Pathology features: Architecture: •  nests bridge rete ridges •  elongated rete ridge Cytology: •  larger, atypical cells •  larger nucleoli Host response: •  lymphocytic infiltrate

Elder DE, Murphy GF. Melanocytic tumors of the skin. In: Rosai J, Sobin LH, eds. Atlas of Tumor Pathology; 3rd series, part 2. Washington DC: Armed Froces Institute of Pathology; 1991

Atypical Nevi (Dysplastic Nevi) Background: 1992: National Institute of Health (NIH) Consensus Statement

Paper •  Clinical term: Atypical nevus

•  Pathologic term: Nevus with architectural disorder

Dysplastic nevus

Atypical/ Dysplastic Nevi Significance: Increased risk of developing MM

http://seer.cancer.gov/statfacts/html/melan.html

Slade J, Marghoob AA, Salopek TG, et al. Atypical mole syndrome: risk factor for cutaneous malignant melanoma and implications fo rmanagement. J Am Acad Dermatol 1995; 32: 479-94.

Greene MH. Genetics of cutnaeous melanoma and nevi. Mayo Clin Proc 1997; 72: 467-74.

Marghoob AA, Kopf AW, Rigel DS et al. Risk of cutaneous malignant melanoma in patients with ‘classic’ atypical-mole syndrome. A case-control study. Arch Derm 1994; 130(8): 993-998.

•  General population: ~1.93% lifetime risk •  Atypical nevi: ~2-12 x risk •  Atypical Mole Syndrome:

--10 yr cumulative risk for developing MM 10.7% vs. 0.62% for controls

Benign nevus

Melanoma Mild

dysplasia

Severe

dysplasia

???

Mod

dysplasia

Atypical/ Dysplastic Nevi and Risk of Melanoma

•  ~50-75% of melanomas arise de novo •  Similar rate may be observed of melanoma arising in association

with dysplastic nevi (21-56%) vs. common nevi (44-79%) •  Actual transformation rate of dysplastic nevus cells into

melanoma: ????

Bevona et al. Archives of Dermatology. 139(12):1620-4, Dec. 2003 Friedman RJ et al. The “dysplastic” nevus. Clin Dermatol. 2009; 27(1): 103-115 Sagebiel RW.. J Invest Dermatol 1993;100:322S-5S. Marks R, Dorevitch AP, Mason G.. Australas J Derma- tol 1990;31:77-80. Crucioli V, Stilwell J. J Cutan Pathol 1982;9:396-404.

Skender-Kalnenas TM, English DR, Heenan PJ. J Am Acad Dermatol 1995;33:1000-7. Tsao et al. Arch Dermatol 2003; 139(3):282-2

Examination of the

Atypical Nevus Patient

Clinical Pearls

•  Look for signatures and the ugly duckling!

Clinical Pearls

•  Look for signatures and the ugly duckling

•  Use dermoscopy

Epiluminesence Microscopy

•  Clinical exam alone: 65-80% melanomas correctly diagnosed

•  With dermoscopy: 70-95%

Training necessary!

Without training, dermoscopy decreased rate of melanoma detection • Grin 1990, Miller and Ackerman 1992, Wolf 1998

• Mayer 1997

• Binder et al. 1997

• 

“Signature” Nevi

Wu TP et al. The importance of dedicated dermoscopy training during residency: A survey of US dermatology chief residents. J Am Acad Dermatol. 2013 Jan 29.

Noor O 2nd et al. A dermoscopy survey to assess who is using it and why it is or is not being used. Int. J. Dermatol 2009 Sept; 28(9): 951-2.

Terushkin et al. Use and beliefs about total body digital photography and dermatoscopy among US dermaotology training programs: an update. JAAD 2010;62:794-803.

Tripp JM, Kopf AW, Marghoob Aaet al. Management of dysplastic nevi: A survey of fellows of the American Academy of Dermatology. J Am Acad Dermatol 2002; 46: 674-82).

Use of Dermoscopy in US

Published survey studies: 2002 2013 23% 94%

Dermoscopy: Beauty and the Beast

Marghoob AA1, Korzenko AJ, Changchien L, Scope A, Braun RP, Rabinovitz H. The beauty and the beast sign in dermoscopy. Dermatol Surg 2007; 33(11):1388-91.

(personal experience of AAM, RPB, and HR). Thus,

knowledge of these benign patterns may be helpful

in identifying those melanocytic lesions that deserve

further diagnostic work-up.

Melanoma, symbolized by the beast, is by definition

a melanocytic lesion that deviates from one of the

nine benign patterns described above (Figure 2). Mel-

anomas almost invariably display at least some degree

of asymmetry of pattern, color, and structure and elicit

a sense of displeasure in the viewer. In addition, most

melanomas will display at least one of the following

dermoscopic structures: atypical network, atypical

dots and globules, streaks (radial streaming or pseu-

dopods), off-center blotches, blue-white veil, negative

pigment network, regression structures, and/or omi-

nous vascular structures (Figure 2).7 Strictly requiring

the presence of a melanoma-specific

Figure 1. Nine benign patterns representing ‘‘beauty.’’ Experience has shown that one rarely, if ever, will encounter amelanoma that mimics one of these benign patterns (i.e., a wolf in sheep’s clothing).

3 3 : 1 1 : N O V E M B E R 2 0 0 7 1 3 8 9

M A R G H O O B E T A L

structure, however, should not be mandatory in all

cases. As dermatologists we do not practice in a

vacuum; patient history, patient age, lesion location,

clinical examination including examination of sur-

rounding lesions, history of evolution of the lesion

(changes observed over time), and gut feeling all play

an integral part in arriving at a correct diagnosis.

Thus, prudence may dictate obtaining biopsies of

melanocytic lesions that fail to conform to one of the

nine benign patterns, even in the absence of any

melanoma-specific structures.11,12

Exceptions of course exist. It has been demonstrated

that the specificity of dermoscopic diagnosis of mel-

anoma ranges from 79% to 98%.13 Indeed, many

dysplastic nevi can be categorized into one of the nine

benign patterns, obviating the need for a biopsy.

However, some dysplastic nevi are dermoscopically

Figure 2. Melanoma (‘‘beast’’) will deviate from the nine benign patterns and will often reveal one of the eight globaldermoscopic patterns shown in the figure, and at least one of eight dermoscopic structures listed in the text. Exceptions,of course, exist: some dysplastic nevi are indistinguishable from the beast (i.e., a sheep in wolf’s clothing).

D E R M AT O L O G I C S U R G E RY1 3 9 0

B E A U T Y A N D T H E B E A S T S I G N

Benign patterns Malignant patterns

Clinical Pearls

•  Look for signatures and the ugly duckling

•  Use dermoscopy

•  Beware of de novo and changing lesions

Clinical Pearls

•  Look for signatures and the ugly duckling

•  Use dermoscopy

•  Beware of de novo and changing lesions

•  A picture is worth a thousand words

-- can detect subtle changes and de novo lesions: detection of early melanoma

--can reduce the number of lesions excised --can reduce patient anxiety

Total Body Digital Photography

Kelly JW, Yeatman JM, Regalia C, et al. A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. Med J Aust 1997; 167: 191-4

Rhodes AR. Intervention strategy to prevent lethal cutaneous melanoma: use of dermatologic photography to aid surveillance of high-risk persons. J Am Acad Dermatol 1998; 39: 262-7.

Goodson et al. Comparative analysis of total body and dermatoscopic photogrphic monitoring of nevi in similar patient populations at risk for cutaneous melanoma . Dermatol Surg. 2010 Jul; 36(7):1087-98

Zakiya M et al. J Am Acad of Dermatol 2008; 58 (2): AB102

Canfield Scientific, Inc.

-- can detect subtle changes and de novo lesions: detection of early melanoma

--can reduce the number of lesions excised

•  Reviewed records of all patients in 2 pigmented lesion clinics who received TBP and had 2 or more f/u visits over at least 2 years.

•  Before PLC/TBP vs. after PLC/TBP: --mean rate of of biopsies: 1.62 vs. 0.34 per year. -- 3.8-fold reduction in nevus biopsies

Total Body Digital Photography

Truong A, Strazzulla L, March J, Boucher KM, Nelson KC, Kim CC, Grossman D. Reduction in nevus biopsies in patients monitored by total body photography (JAAD 2016 March E pub ahead of print)

Diagnosis Future directions: Further development of diagnostic devices: --Multispectral imaging / computer analysis --Confocal microscopy --Automated change detection --Optical coherence tomography --Teledermoscopy --Smartphone applications

Clinical Pearls

•  Look for signatures and the ugly duckling

•  Use dermoscopy

•  Beware of de novo and changing lesions

•  A picture is worth a thousand words

•  Listen to the patient!

Management / Biopsy

Atypical Nevi Education: --significance of AN (avoid word “precancerous”) --rationale for biopsy/excisions --self-skin exam: abcds, ugly duckling --sun protection --notify family members

Caonline.amcancersoc.org

Follow-up: q6 or 12 mo Decide if total body photography would be beneficial Consider sharing care with a local pigmented lesion clinic

Atypical Nevi

When to biopsy? --Diagnosis of atypical nevus can be made clinically --Biopsy suspicious lesions concerning for melanoma --Removal also option for nevi in areas difficult to monitor

Biopsy Variable types of biopsies performed

my.webmd.com

When you biopsy suspicous atypical pigmented lesions, what method do you tend to use the most?

1. Incisional shave biopsy 2. Excisional scoop shave w/ 1-3 mm clear clinical margin 3. Incisional punch biopsy 4. Punch excision w/ 1-3 mm clear clinical margin 5. Elliptical excision w/ 1-3 mm clear clinical margin

FROM THE ACADEMY

Guidelines of care for the management of primarycutaneous melanoma

Work Group: Christopher K. Bichakjian, MD,a Allan C. Halpern, MD (Co-chair),b Timothy M. Johnson, MD(Co-chair),a Antoinette Foote Hood, MD,c James M. Grichnik, MD, PhD,d Susan M. Swetter, MD,e,f

Hensin Tsao, MD, PhD,g Victoria Holloway Barbosa, MD,h Tsu-Yi Chuang, MD, MPH,i,j Madeleine Duvic, MD,k

Vincent C. Ho, MD,l Arthur J. Sober, MD,g Karl R. Beutner, MD, PhD,m,n Reva Bhushan, PhD,o

and Wendy Smith Begolka, MSo

Ann Arbor, Michigan; New York, New York; Norfolk, Virginia; Miami, Florida; Palo Alto, Los Angeles, PalmSprings, San Francisco, and Fairfield, California; Boston, Massachusetts; Chicago and Schaumburg,

Illinois; Houston, Texas; and Vancouver, British Columbia, Canada

The incidence of primary cutaneous melanoma has been increasing dramatically for several decades.Melanoma accounts for the majority of skin cancererelated deaths, but treatment is nearly always curativewith early detection of disease. In this update of the guidelines of care, we will discuss the treatment ofpatients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinicallysuspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneousmelanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workupof patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regardto treatment of primary cutaneous melanoma, we will provide recommendations for surgical marginsand briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinellymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.( J Am Acad Dermatol 2011;65:1032-47.)

Key words: biopsy; follow-up; melanoma; pathology report; sentinel lymph node biopsy; surgical margins.

DISCLAIMERAdherence to these guidelines will not ensure

successful treatment in every situation. Furthermore,these guidelines should not be interpreted as settinga standard of care, or be deemed inclusive of allproper methods of care nor exclusive of othermethods of care reasonably directed to obtainingthe same results. The ultimate judgment regardingthe propriety of any specific therapy must be madeby the physician and the patient in light of all thecircumstances presented by the individual patient,

and the known variability and biological behavior ofthe disease. This guideline reflects the best availabledata at the time the guideline was prepared.

From the Department of Dermatology, University of MichiganHealth System and Comprehensive Cancer Centera; Depart-ment of Dermatology, Memorial Sloan-Kettering Cancer Center,New Yorkb; Department of Dermatology, Eastern VirginiaMedical Schoolc; Department of Dermatology, University ofMiami Health System, University of Miami Hospital and Clinics,Sylvester Comprehensive Cancer Center, Melanoma Programd;Department of Dermatology, Stanford University MedicalCentere and Department of Veterans Affairs Palo Alto HealthCare Systemf; Department of Dermatology, MassachusettsGeneral Hospital and Harvard Medical Schoolg; Department ofDermatology, Rush University Medical Center, Chicagoh; Uni-versity of Southern California, Los Angeles,i and Desert OasisHealthcare, Palm Springsj; Department of Dermatology,University of Texas MD Anderson Cancer Centerk; Division of

Dermatology, University of British Columbial; Department ofDermatology, University of California, San Franciscom, andSolano Dermatology, Fairfieldn; and American Academy ofDermatology, Schaumburg.o

Funding sources: None.The authors’ conflict of interest/disclosure statements appear at

the end of the article.Accepted for publication April 20, 2011.Reprint requests: Reva Bhushan, PhD, American Academy of

Dermatology, 930 E Woodfield Rd, Schaumburg, IL 60173.E-mail: rbhushan@aad.org.

Published online August 26, 2011.0190-9622/$36.00! 2011 by the American Academy of Dermatology, Inc.doi:10.1016/j.jaad.2011.04.031

Abbreviations used:

AAD: American Academy of DermatologyAJCC: American Joint Committee on CancerLND: lymph node dissectionPET: positron emission tomographySLN: sentinel lymph nodeSLNB: sentinel lymph node biopsy

1032

2011: American Academy Dermatology and NCCN Guidelines

the lesion must be included.20-34 The clinical infor-mation in the pathology report should contain thetype of surgical procedure performed (ie, biopsyintenteexcisional or incisional) and size of thelesion. Additional optional, but desirable, clinicalinformation include ABCDE criteria, dermatoscopicfeatures, a clinical photograph, and the presence orabsence of macroscopic satellitosis.

The pathology of melanocytic tumors should beread by a physician experienced in the interpretationof pigmented lesions. The list of histologic features tobe included in the pathology report is based on theirprognostic value (Table VII; strength of recommen-dations shown in Table V). Definitions of histologicfeatures are listed in Table VIII. There is strongevidence to support that 3 histologic features are themost important characteristics of the primary tumorto predict outcome.6,20-23,25,26,30-32,34-40 (1) Maximumtumor (Breslow) thickness is measured from the

granular layer of the overlying epidermis or base of asuperficial ulceration to the deepest malignant cellsinvading dermis to the nearest 0.1 mm, not includingdeeper adventitial extension. Microsatellitosisshould not be included in this measurement, butcommented on separately. (2) Presence or absenceof microscopic ulceration, which is defined as tumor-induced full-thickness loss of epidermis with subja-cent dermal tumor and reactive dermal changes.41

(3) Mitotic rate, measured as the number of dermalmitoses per mm2 (with 1 mm2 approximately equalto 4.5 high-power [340] microscopic fields, startingin the field with most mitoses), was included as aprognostic value in the 2010 AJCC staging system toupstage patients with melanoma less than or equal to1 mm in thickness from IA to IB, replacing Clarklevel.6 Regardless of tumor thickness, a dermalmitotic rate greater than or equal to 1 mitosis/mm2

is independently associated with a worse disease-specific survival. It is essential that these 3 charac-teristics are included in the pathology report. Theanatomic (Clark) level of invasion is only included inthe 2010 AJCC staging system for staging tumors lessthan or equal to 1 mm in thickness when mitotic ratecannot be assessed and is considered optional fortumors larger than 1 mm. An additional essentialelement of the pathology report is the status of theperipheral and deep margins (positive or negative)of the excision. The presence or absence of tumor atthe surgical margin indicates whether the entirelesion was available for histologic evaluation andprovides guidance for further management. It shouldbe emphasized that for the management of primarycutaneous melanoma, treatment recommendationsare based on the clinical measurement of surgicalmargins around the tumor and not on histologicallymeasured clear peripheral margins.1 The presence ofmicrosatellites upstages the tumor to N2c (stage IIIB)

Table III. 2010 American Joint Committee onCancer anatomic stage/prognostic groups

Clinical staging* Pathologic stagingy

Stage 0 Tis N0 M0 0 Tis N0 M0Stage IA T1a N0 M0 IA T1a N0 M0Stage IB T1b N0 M0 IB T1b N0 M0

T2a N0 M0 T2a N0 M0Stage IIA T2b N0 M0 IIA T2b N0 M0

T3a N0 M0 T3a N0 M0Stage IIB T3b N0 M0 IIB T3b N0 M0

T4a N0 M0 T4a N0 M0Stage IIC T4b N0 M0 IIC T4b N0 M0Stage III Any T $N1 M0 IIIA T1-4a N1a M0

T1-4a N2a M0IIIB T1-4b N1a M0

T1-4b N2a M0T1-4a N1b M0T1-4a N2b M0T1-4a N2c M0

IIIC T1-4b N1b M0T1-4b N2b M0T1-4b N2c M0Any T N3 M0

Stage IV Any T Any N M1 IV Any T Any N M1

Used with permission of American Joint Committee on Cancer(AJCC), Chicago, IL. Original source for this material is AJCC CancerStaging Manual, Seventh Edition (2010) published by SpringerScience and Business Media LLC, www.springer.com.*Clinical staging includes microstaging of primary melanoma andclinical/radiologic evaluation for metastases. By convention, itshould be used after complete excision of primary melanoma withclinical assessment for regional and distant metastases.yPathologic staging includes microstaging of primary melanomaand pathologic information about regional lymph nodes afterpartial or complete lymphadenectomy. Patients with pathologicstage 0 or IA are the exception; they do not require pathologicevaluation of their lymph nodes.

Table IV. Recommendations for biopsy

Preferred biopsy technique is narrow excisional biopsy thatencompasses entire breadth of lesion with clinicallynegative margins to depth sufficient to ensure thatlesion is not transected, which may be accomplished byelliptical or punch excision with sutures, or shaveremoval to depth below anticipated plane of lesion.

Partial sampling (incisional biopsy) is acceptable in selectclinical circumstances such as facial or acral location, lowclinical suspicion or uncertainty of diagnosis, or verylarge lesion.

Repeat biopsy is recommended if initial biopsy specimen isinadequate for diagnosis or microstaging of primarylesion.

J AM ACAD DERMATOL

NOVEMBER 20111036 Bichakjian et al

Version 2.2009, 11/17/08 © 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

Practice Guidelinesin Oncology – v.2.2009 Melanoma

Guidelines IndexMelanoma Table of Contents

Staging, Discussion, ReferencesNCCN®

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

PRINCIPLES OF BIOPSY

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Excisional biopsy (elliptical, punch, or saucerization) with 1-3 mm margins preferred. Avoid wider margins to permit accuratesubsequent lymphatic mapping.Full thickness incisional or punch biopsy of clinically thickest portion of lesion acceptable, in certain anatomic areas(eg, palm/sole, digit, face, ear) or for very large lesions.Shave biopsy may compromise pathologic diagnosis and complete assessment of Breslow thickness, but is acceptable when theindex of suspicion is low.Biopsy to be read by a pathologist experienced in pigmented lesions.Minimal elements to be reported should include Breslow thickness (mm), histologic ulceration, Clark level (optional for Breslow > 1 mm),mitotic rate per mm , and peripheral and deep margin status of biopsy.Satellitosis, if present, should be reported.Encourage consistent reporting of these additional factors (compatible with American Academy of Dermatology recommendations):

LocationRegressionTumor infiltrating lymphocytes (TIL)Vertical growth phase (VGP)Angiolymphatic invasionNeurotropismHistologic subtype

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ME-A

1If clinical evaluation of incisional biopsy suggests that microstaging is inadequate, consider narrow margin excision.2For lentigo maligna, melanoma in situ, a broad shave biopsy may help to optimize diagnostic sampling.

High suspicion for melanoma: narrow excisional biopsy preferred

1-3 mm margins

Partial/incisional biopsy:

•  Facial or acral areas •  Very large lesions •  Low suspicion

Be aware of limitations of partial / incisional biopsy

Clinical Pearls

•  Look for signatures and the ugly duckling

•  Use dermoscopy

•  Beware of de novo and changing lesions

•  A picture is worth a thousand words

•  Listen to the patient!

•  Excisional biopsies for lesions suspicious for melanoma are preferred / be aware of limitations of partial biopsies.

Clinical Pearls

•  Look for signatures and the ugly duckling

•  Use dermoscopy

•  Beware of de novo and changing lesions

•  A picture is worth a thousand words

•  Listen to the patient!

•  Excisional biopsies for lesions suspicious for melanoma are preferred / be aware of limitations of partial biopsies.

•  Think about your biopsy / think ahead

Think about your biopsy

•  Degree of suspicion for melanoma

•  Possible need for wide local excision and sentinel lymph node biopsy

http://www.bcm.edu

Dysplastic nevi: after the biopsy Pathology result: --grading system is variable dysplastic vs severely DN

Mild, mod, severely DN Mild, mild-mod, mild-focal mod, mod-focal severe, mod-severe, severe

No guidelines on indications for reexcision

Obs

erva

tion

Eva

l. of

re

exci

sion

Mild: 131 Mod: 47 Severe: 7 ?: 26 Fleming et al. JAMA Derm: 159 -------------- Total 370

Mild: 18 Mild-Mod: 146 Mod: 469 Mod-sev: 55 Sev: 25 --------------- Total 713

Fleming et al. 2016 159 observed 5.5 years 1 (AIMP favor early MMIS)

Clinical decision making based on histopathologic grading and margin status of dysplastic nevi

2009 Survey of 158 members of the Chicago Dermatologic Society: 101 (58%) responded Duffy et al. Arch Dermatol. 2012; 148(2): 259-260.

Clear margins

Mild 100% 0% Mod 91% 9% Severe 45% 55%

Positive margins

79% 21%

19% 81%

5% 95%

Obs Obs Reexc Reexc

Comparison between Chicago dermatologist study and 2014 New England dermatologists survey

Chicago positive margins

Mild 79% 21% Mod 19% 81% Mod-Sev Severe 5% 95%

New England positive margins

95% 5%

39% 61%

5% 95%

0% 100%

Observe or other Reexcise

No consensus

Tong L, Wu P and Kim CC (JAAD 2016)

Pigmented Lesion Subcommittee MPWG/ECOG/SWOG

•  Mild + margins without pigment Observation •  Moderate + margins without pigment Observation may be

reasonable, more data needed •  Severe + margins without pigment Re-excision •  Monitor all biopsy sites for unusual regrowth

Need for large-scale data to further

investigate role of observation vs. re-excision

of dysplastic nevi

Pigmented Lesion Subcommittee MPWG/ECOG/SWOG

Recurrent Pigmentation

•  Recurrent nevi: tend to develop within 8 months with pigmentation confined to scar

•  Melanomas: tend to recur more than 20 months after biopsy, in patients older than 30 years, and with pigmentation crossing into normal skin

Blum A et al. Recurrent melanocytic nevi and melanomas in dermoscopy: results of a multicenter study of the International Dermoscopy Society. JAMA Dermatol. 2014;150(2):138-145.

Recurrent Pigmentation •  58 yo F, h/o prior stage IB melanoma

--history of biopsy of left thigh OSH: mod-severe DN --had re-excisional biopsy 3 years later left thigh: mod-

severe DN, recurrent nevus extending within 0.1 mm of margin

--pt did not agree to additional re-excision --clinical f/u: scar was clear of pigment --gap of 1.5 years lost to f/u --f/u 4 years after last re-excision

Summary

Management of atypical nevus patients can be challenging Clinical pearls: Look for signatures and the ugly duckling

•  Use dermoscopy

•  Beware of de novo and changing lesions

•  A picture is worth a thousand words

•  Listen to the patient!

•  Excisional biopsies for lesions suspicious for melanoma are preferred / be aware of limitations of partial biopsies.

•  Think about your biopsy / think ahead

Dysplastic nevi with positive margins: •  Recent data on observation of dysplastic nevi with positive margins: small, underpowered:

observation may be reasonable option for lower grade dysplastic nevi but more data needed

•  Larger scale data needed

Thank you!

Caroline C. Kim, MD, Director Assistant Professor, Department of Dermatology

Harvard Medical School Director, Pigmented Lesion Clinic

Associate Director, Cutaneous Oncology Program Beth Israel Deaconess Medical Center, Boston, MA

ckim3@bidmc.harvard.edu