Published: March 01, 2006
By Karen Nash
Moles are a basic skin condition seen in medical dermatology. But when those moles exhibit characteristics that are not typical of a so-called “normal” mole, they create issues ranging from what to call them to how to treat them.
Are they a signal of a patient being at higher risk for melanoma? Do they actually increase the risk of melanoma because they, themselves, are pre-malignant lesions?
Clark’s nevi, atypical nevi, dysplastic nevi, nevi with architectural disorder — dermatologists don’t all call the relatively common skin lesions by the same name, and some don’t call them the same thing all the time.
Relative to usage
Jeffrey Knispel, M.D., Danbury, Conn., says, “I call it an atypical mole. Most people don’t call it dysplastic nevi anymore. I think the term is so hard to define that from my experience the term is not used too much anymore. They grade them now, I think, as mildly atypical, moderately atypical and severely atypical nevi.” On the other hand, farther down the coast, in Myrtle Beach, S.C., Robert S. Purvis, M.D., responds, “We usually use dysplastic nevi.”
Why? He laughs. “The terminology for these nevi has come full circle. They were called dysplastic nevi and then it was thought it wasn’t a well-defined term, so the nevi were named after the person who first described them, but at this point, most dermatologists have in their mind what a dysplastic nevus is. The term is so well-known now that it is fairly well-accepted.”
A number of dermatologists have decided that in their practices the term is relative to its usage.
Juanita Pawaney, M.D., Lake Success, N.Y., says, “I actually will interchangeably say ‘atypical nevi’ when I’m looking clinically and ‘dysplastic nevi’ after I get the pathology report back confirming that it is actually dysplastic.”
Erin Scott Gardner, M.D., in St. Louis, Mo., answers, “(I use) both — people are familiar with both terms and it’s still not a completely settled issue. You have proponents on both sides of the debate. Speaking with patients, I would call it atypical nevus. I would typically use ‘dysplastic nevus’ discussing a histologic finding around the microscope.”
The question also brought a laugh from Benjamin Raab, M.D., in Aurora, Ill.
“I call them whatever the pathologist calls them — pretty much dysplastic nevi. To me, that is more of a dermatopathology diagnosis, so as a clinician I look at the lesion and determine whether they follow the ABCD designation. Atypical nevi and dysplastic nevi are the same.”
Treatments
Treatments for these moles also vary. Doctors rely on visual assessment, photography, dermoscopy, shave biopsies and excision to determine whether the moles are atypical or melanocytic. Sometimes their approach depends on whether they consider the moles premalignant or simply an indicator that the patient is at increased risk of developing melanoma.
Dr. Gardner says, “Certainly, regular examination is the cornerstone of monitoring a patient who has many lesions like that. If one has a particularly large number of unusual lesions, then photography can play a role.
“Generally, I think monthly personal examination should go along with physician examination, and patients are instructed how to do that.
“If a patient has five or 10 suspicious lesions, I would say those have got to go. If a patient had so many nevi that they couldn’t all be removed, I would inform them that the gold standard for determining whether a lesion is malignant or not is a histologic examination, but then you have to discuss with them the morbidity of removing large numbers of lesions over the course of time and the usual risks of infection or scarring.”
Dr. Pawaney, in practice for 10 years, tends to view the lesions as a precursor to melanoma.
“I tend to be on the cautious side — removing atypical nevi rather than just monitoring them. If you don’t address it right away, many times patients are lax about following up. They don’t always remember to come in to be checked, so I feel like I’m doing something definitive for them. By the time they come to me and point out specific lesions, patients want a very definitive answer.”
Dr. Pawaney generally starts with a shave excision.
“If it turns out that the margins are not clear, certainly I will do a full excision. Obviously, we can’t remove a hundred lesions if the patient has a lot, but we pick the most suspicious of lesions and biopsy a few, then periodically we’ll biopsy a few more of the most suspicious lesions over time.”
Neither Dr. Gardner nor Dr. Pawaney has the facilities to do full-body photography, but they will refer patients to hospitals that do.
Remove as many as possible
A practitioner for 23 years and assistant clinical professor at Northwestern University, Dr. Raab likes to remove as many of the lesions as he can.
“I guess my philosophy is that I take the most atypical first, and keep going until I hit ‘normal.’ That reassures me that the rest are not malignant. I stop and watch the other lesions to see if anything changes from the baseline. I try to be practical.”
He prefers a full excision to either a shave or a punch biopsy.
“That way I get the whole picture of the whole nevus. I don’t know what corner of the house those bad cells are hiding in. Too often there is no uniform depth or uniform transition throughout the nevi. Obviously, they are atypical in the variegation of their border — so I want a picture of the entire lesion.”
Dr. Raab follows his patients visually.
“I see them every six months to a year and urge them to take inventory of their body. People are pretty good about checking themselves if you teach them how. I give them a little body map — something to keep inventory on, and I put a little fear into them that there’s nothing more important for them to watch than that.”
He would refer patients exhibiting large numbers (50 to 100) of atypical nevi.
Warning sign
Dr. Knispel, in practice six years and a clinical instructor at Yale University, considers the atypical nevi more of a warning sign that a patient is at an increased risk of developing melanoma than as actually being pre-malignant themselves.
“Most melanomas don’t start from atypical moles. Having them just means the patient is a higher risk, and we have to keep a closer eye on them.
“You have to take into account the family history of melanoma, degree of sun exposure, the number of blistering sunburns, fairness of the skin — all of these determine the likelihood of the patient developing melanoma in the future.”
He generally tracks the moles following the CD rule.
“When a mole is darker, irregular in shape, has more than one color — those are the moles we like to target and take off,” he says.
Dermoscopy helpful
He has also started using dermoscopy to help determine when to remove specific lesions, and he thinks it may be helpful.
“I don’t use it all the time, but with certain atypical lesions, it is a good idea. I just started and I think there is something of a learning curve. I don’t rely on it yet, but I think people who are really experienced can — and they may not biopsy certain lesions as a result, but if I find something that is clinically questionable, I’d still rather take it off than rely on dermoscopy.
“I usually take a shave biopsy of those moles because you can shave the mole superficially so that you don’t get a depressed area that can occur if you go too deep. I think shaves heal better than punch biopsies, too. If the lesion is over 6 or 7 mm, I will excise it.”
Routine surveillance
Along with the cycles of the designation of these lesions, Dr. Purvis says his treatment approach has gone through cycles, also.
He usually does what he calls “routine surveillance,” depending on how atypical the nevi are and how many the patient has, combined with taking the patient’s and the family’s history.
“I used to photograph some patients, but I’ve cut down on that because I think it may actually delay the diagnosis. If you’re concerned about a mole and decide to follow it photographically and then see it changing, you’ve lost time. It can be six months after your first observation when you finally do the biopsy, and if it turns out to be a melanoma, you’ve lost six months of time and the lesion may have progressed to a metastatic stage by that time,” he says.
In practice 10 years, Dr. Purvis thinks dermoscopy may have the same effect — actually delaying the removal of potentially dangerous nevi.
“Generally, I will pick out one or two of the worst-looking nevi and biopsy them. Patients aren’t going to develop 10 melanomas at once, so it usually is going to be the mole that kind of stands out. With a full-body exam, I’ll pick out the nevi with the most extreme of the features and of asymmetry, irregular borders and color variegations and biopsy those — although I will use photography for cosmetically sensitive areas.
“There does have to be a consensus between the physician and the patient. If a patient wants to have all their moles removed, I will probably not argue with them as long as they know they will probably get scars and know the risk of the procedures and they want to do it. If a patient is hesitant to have any biopsy done, I will usually end up doing fewer biopsies.”
Karen Nash, a former TV medical news reporter, has been writing Dermatology Times’ On Call column for nearly 20 years. She covers medical, business and legislative issues relevant to dermatologists. Currently based in Sioux Falls, S.D., she can be contacted at welshman@sio.midco.net
