Dysplastic nevus

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Dysplastic nevus
Dysplastic nevus - add - high mag.jpg
Micrograph of a dysplastic nevus showing the characteristic rete ridge bridging, shouldering, and lamellar fibrosis. H&E stain.
Specialty Dermatology

A dysplastic nevus or atypical mole is a nevus (mole) whose appearance is different from that of common moles. In 1992, the NIH recommended that the term "dysplastic nevus" be avoided in favor of the term "atypical mole". [1] An atypical mole may also be referred to as an atypical melanocytic nevus, [2] atypical nevus, B-K mole, Clark's nevus, dysplastic melanocytic nevus, or nevus with architectural disorder. [3]

Contents

Dysplastic nevi often grow to larger than ordinary moles and may have irregular and indistinct borders. Their color may not be uniform and may range from light pink to very dark brown. They usually begin flat, but parts may be raised above the skin surface. See ABCDE and "ugly duckling" characteristics below.

Dysplastic nevi can be found anywhere, but are most common on the trunk in men, and on the calves in women.

There is some controversy in the dermatology community as to whether or not the "dysplastic"/"atypical" nevus exists. Some have argued that the terms "dysplastic" and "atypical" only refer to diagnostic uncertainty, as opposed to biologic uncertainty, and that the lesion is either a nevus or melanoma from the very beginning, as opposed to some kind of "premalignant stage"; it is only the clinician who is unsure. Some have also argued that even if such nevi do exist, studies have shown that clinicians are unable to reliably identify them anyway, meaning there is no point to even using the concept. [4] [5] [6] [ medical citation needed ]

Cancer risk

As seen in Caucasian individuals in the United States, those with dysplastic nevi have a lifetime risk of developing melanoma of greater than 10%, compared to less than 1% for those without any dysplastic nevus. [7]

Precaution for individuals with dysplastic nevi

A dermatoscope. Dermatoscope1.JPG
A dermatoscope.
A modern polarized dermatoscope. Dermatoscope.jpg
A modern polarized dermatoscope.

Although there are limited data to support its efficacy, skin self-examination is frequently recommended for preventing melanoma (by identifying atypical moles that can be removed) or for early detection of existing tumors. Examination by a dermatologist has been shown to be beneficial for early melanoma detection. Some dermatologists recommend that an individual with either histologic diagnosis of dysplastic nevus, or clinically apparent atypical moles should be examined by an experienced dermatologist with dermatoscopy once a year (or more frequently).

Melanoma on left foot WB032021.JPG
Melanoma on left foot

The abbreviation ABCDE has been useful for helping health care providers and laypersons remember the key characteristics of a melanoma (see "ABCDE" mnemonic below). Changes (in shape, size, color, itching or bleeding) should be brought to the attention of a dermatologist . [8]

A popular method for remembering the signs and symptoms of melanoma is the mnemonic "ABCDE": [9]

The E is sometimes omitted, as in the ABCD guideline. A weakness in this system is the D. Many melanomas present themselves as lesions smaller than 6 mm in diameter. An astute physician will examine all abnormal moles, including ones less than 6 mm in diameter. Unfortunately for the average person, many seborrheic keratoses, some lentigo senilis, and even warts may have ABCD characteristics, and cannot be distinguished from a melanoma without a trained eye or dermatoscopy.

A recent and novel method of melanoma detection is the "Ugly Duckling Sign". [10] [11] It is simple, easy to teach, and highly effective in detecting melanoma. Simply, correlation of common characteristics of a person's skin lesion is made. Lesions that greatly deviate from the common characteristics are labeled as an "Ugly Duckling", and a dermatologist exam is required. The "Little Red Riding Hood" sign [11] suggests that individuals with fair skin and light-colored hair might prove more challenging. These fair-skinned individuals often have lightly pigmented or amelanotic melanomas which will not present with easy to observe color changes and variation in colors. The borders of these amelanotic melanomas are often indistinct, making visual identification without a dermatoscope (dermatoscopy) very difficult. A dermatoscope must be used to detect "ugly ducklings" among those with light skin or blonde/red hair.

People with a personal or family history of skin cancer or of dysplastic nevus syndrome (multiple atypical moles) should see a dermatologist at least once a year to be sure they are not developing melanoma.

Biopsy

Various differential diagnoses of pigmented skin lesions, including dysplastic nevus, showing the relative incidence of biopsied lesions, and malignancy potential. Pie chart of incidence and malignancy of pigmented skin lesions.png
Various differential diagnoses of pigmented skin lesions, including dysplastic nevus, showing the relative incidence of biopsied lesions, and malignancy potential.

When an atypical mole has been identified, a skin biopsy takes place in order to best diagnose it. Local anesthetic is used to numb the area, then the mole is biopsied. The biopsy material is then sent to a laboratory to be evaluated by a pathologist. A skin biopsy can be a punch, shave, or complete excision. The complete excision is the preferred method, but a punch biopsy can suffice if the patient has cosmetic concerns (i.e. the patient does not want a scar) and the lesion is small. A scoop or deep shave biopsy is often advocated but should be avoided due to risk of a recurrent nevus, which can complicate future diagnosis of a melanoma, and the possibility that resulting scar tissue can obscure tumor depth if a melanoma is found to be present and re-excised.

Most dermatologists and dermatopathologists use a system devised by the NIH for classifying melanocytic lesions. In this classification, a nevus can be defined as benign, having atypia, or being a melanoma. A benign nevus is read as (or understood as) having no cytologic or architectural atypia. An atypical mole is read as having architectural atypia and having (mild, moderate, or severe) cytologic (melanocytic) atypia. [12] Usually, cytologic atypia is of more important clinical concern than architectural atypia. Usually, moderate to severe cytologic atypia will require further excision to make sure that the surgical margin is completely clear of the lesion.[ citation needed ]

The most important aspect of the biopsy report is that the pathologist indicates if the margin is clear (negative or free of melanocytic nevus), or if further tissue (a second surgery) is required. If this is not mentioned, usually a dermatologist or clinician will require further surgery if moderate to severe cytologic atypia is present – and if residual nevus is present at the surgical margin.

Dysplastic nevus syndrome

"Dysplastic nevus syndrome" refers to individuals who have high numbers of benign moles and also have dysplastic nevi. A small percent of these individuals are members of melanoma kindreds. [13] Inherited dysplastic nevus syndrome is an autosomal dominant hereditary condition. Dysplastic nevi are more likely to undergo malignant transformation when they occur among members of melanoma families. At least one study indicates a cumulative lifetime risk of nearly 100% in individuals who have dysplastic nevi and are members of melanoma kindreds.[ citation needed ] Roughly 70% of melanomas arise "de novo" on clear skin growth, whereas the rest arise within atypical moles. [14] Those with dysplastic nevi have an elevated risk of melanoma. [15] [16] Such persons need to be checked regularly for any changes in their moles and to note any new ones. In 40-50% of cases, the disorder has been linked with germline mutations in the CDKN2A gene, which codes for p16 (a regulator of cell division).

Additional images

See also

Related Research Articles

<span class="mw-page-title-main">Melanocytic nevus</span> Medical condition

A melanocytic nevus is usually a noncancerous condition of pigment-producing skin cells. It is a type of melanocytic tumor that contains nevus cells. Some sources equate the term mole with "melanocytic nevus", but there are also sources that equate the term mole with any nevus form.

<span class="mw-page-title-main">Melanoma</span> Cancer originating in melanocytes

Melanoma, also redundantly known as malignant melanoma, is a type of cancer that develops from the pigment-producing cells known as melanocytes. Melanomas typically occur in the skin, but may rarely occur in the mouth, intestines, or eye. In women, they most commonly occur on the legs, while in men, they most commonly occur on the back. About 25% of melanomas develop from moles. Changes in a mole that can indicate melanoma include an increase in size, irregular edges, change in color, itchiness, or skin breakdown.

<span class="mw-page-title-main">Nevus</span> Mole or birthmark; visible, circumscribed, chronic skin lesion

Nevus is a nonspecific medical term for a visible, circumscribed, chronic lesion of the skin or mucosa. The term originates from nævus, which is Latin for "birthmark"; however, a nevus can be either congenital or acquired. Common terms, including mole, birthmark, and beauty mark, are used to describe nevi, but these terms do not distinguish specific types of nevi from one another.

<span class="mw-page-title-main">Acral lentiginous melanoma</span> Medical condition

Acral lentiginous melanoma is an aggressive type of skin cancer. Melanoma is a group of serious skin cancers that arise from pigment cells (melanocytes); acral lentiginous melanoma is a kind of lentiginous skin melanoma. Acral lentiginous melanoma is the most common subtype in people with darker skins and is rare in people with lighter skin types. It is not caused by exposure to sunlight or UV radiation, and wearing sunscreen does not protect against it. Acral lentiginous melanoma is commonly found on the palms, soles, under the nails, and in the oral mucosa. It occurs on non-hair-bearing surfaces of the body, which have not necessarily been exposed to sunlight. It is also found on mucous membranes.

<span class="mw-page-title-main">Seborrheic keratosis</span> Skin disease

A seborrheic keratosis is a non-cancerous (benign) skin tumour that originates from cells, namely keratinocytes, in the outer layer of the skin called the epidermis. Like liver spots, seborrheic keratoses are seen more often as people age.

<span class="mw-page-title-main">Superficial spreading melanoma</span> Medical condition

Superficial spreading melanoma (SSM) is a type of skin cancer that typically starts as an irregularly edged dark spot typically on sun-exposed part of the body. The colour may be variable with dark, light and reddish shades; occasionally no color at all. It typically grows in diameter before spreading to deeper tissue, forming a bump or becoming an ulcer. Itching, bleeding and crust formation may occur in some. The backs and shoulders of males and legs of women are particularly prone.

<span class="mw-page-title-main">Dysplastic nevus syndrome</span> Medical condition

Dysplastic nevus syndrome, also known as familial atypical multiple mole–melanoma (FAMMM) syndrome, is an inherited cutaneous condition described in certain families, and characterized by unusual nevi and multiple inherited melanomas. First described in 1820, the condition is inherited in an autosomal dominant pattern, and caused by mutations in the CDKN2A gene. In addition to melanoma, individuals with the condition are at increased risk for pancreatic cancer.

Ocular melanosis (OM) is a blue-gray and/or brown lesion of the conjunctiva that can be separated into benign conjunctival epithelial melanosis (BCEM) and primary acquired melanosis (PAM), of which the latter is considered a risk factor for uveal melanoma. The disease is caused by an increase of melanocytes in the iris, choroid, and surrounding structures. Overproduction of pigment by these cells can block the trabecular meshwork through which fluid drains from the eye. The increased fluid in the eye leads to increased pressure, which can lead to glaucoma. In humans, this is sometimes known as pigment dispersion syndrome.

<span class="mw-page-title-main">Lentigo maligna melanoma</span> Medical condition

Lentigo maligna melanoma is a melanoma that has evolved from a lentigo maligna, as seen as a lentigo maligna with melanoma cells invading below the boundaries of the epidermis. They are usually found on chronically sun damaged skin such as the face and the forearms of the elderly.

<span class="mw-page-title-main">Lentigo maligna</span> Medical condition

Lentigo maligna is where melanocyte cells have become malignant and grow continuously along the stratum basale of the skin, but have not invaded below the epidermis. Lentigo maligna is not the same as lentigo maligna melanoma, as detailed below. It typically progresses very slowly and can remain in a non-invasive form for years.

<span class="mw-page-title-main">Congenital melanocytic nevus</span> Congenital mole caused by genetic mutations

The congenital melanocytic nevus is a type of melanocytic nevus found in infants at birth. This type of birthmark occurs in an estimated 1% of infants worldwide; it is located in the area of the head and neck 15% of the time.

<span class="mw-page-title-main">Dermatoscopy</span> Medical examination of the skin

Dermatoscopy also known as dermoscopy or epiluminescence microscopy, is the examination of skin lesions with a dermatoscope. It is a tool similar to a camera to allow for inspection of skin lesions unobstructed by skin surface reflections. The dermatoscope consists of a magnifier, a light source, a transparent plate and sometimes a liquid medium between the instrument and the skin. The dermatoscope is often handheld, although there are stationary cameras allowing the capture of whole body images in a single shot. When the images or video clips are digitally captured or processed, the instrument can be referred to as a digital epiluminescence dermatoscope. The image is then analyzed automatically and given a score indicating how dangerous it is. This technique is useful to dermatologists and skin cancer practitioners in distinguishing benign from malignant (cancerous) lesions, especially in the diagnosis of melanoma.

<span class="mw-page-title-main">Becker's nevus</span> Medical condition

Becker's nevus is a benign skin disorder predominantly affecting males. The nevus can be present at birth, but more often shows up around puberty. It generally first appears as an irregular pigmentation on the torso or upper arm, and gradually enlarges irregularly, becoming thickened and often hairy (hypertrichosis). The nevus is due to an overgrowth of the epidermis, pigment cells (melanocytes), and hair follicles. This form of nevus was first documented in 1948 by American dermatologist Samuel William Becker (1894–1964).

Melanocytic tumors of uncertain malignant potential (MELTUMP) are melanocytic lesions in the dermis that cannot be classified by morphology as either benign naevi (moles) or malignant melanomas because the mass shows features of both.

<span class="mw-page-title-main">Blue nevus</span> Type of melanocytic tumor

A blue nevus is a type of coloured mole, typically a single well-defined blue-black bump.

<span class="mw-page-title-main">Skin biopsy</span>

Skin biopsy is a biopsy technique in which a skin lesion is removed to be sent to a pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician's office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists. Skin biopsies are also done by family physicians, internists, surgeons, and other specialties. However, performed incorrectly, and without appropriate clinical information, a pathologist's interpretation of a skin biopsy can be severely limited, and therefore doctors and patients may forgo traditional biopsy techniques and instead choose Mohs surgery. There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy. The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion. Like most biopsies, patient consent and anesthesia are prerequisites.

A benign melanocytic nevus is a cutaneous condition characterised by well-circumscribed, pigmented, round or ovoid lesions, generally measuring from 2 to 6 mm in diameter. A benign melanocytic nevus may feature hair or pigmentation as well.

Pseudomelanoma is a cutaneous condition in which melanotic skin lesions clinically resemble a superficial spreading melanoma at the site of a recent shave removal of a melanocytic nevus.

Oral pigmentation is asymptomatic and does not usually cause any alteration to the texture or thickness of the affected area. The colour can be uniform or speckled and can appear solitary or as multiple lesions. Depending on the site, depth, and quantity of pigment, the appearance can vary considerably.

Animal-type melanoma is a rare subtype of melanoma that is characterized by heavily pigmented dermal epithelioid and spindled melanocytes. Animal-type melanoma is also known to be called equine-type melanoma, pigment synthesizing melanoma, and pigmented epithelioid melanocytoma (PEM). While melanoma is known as the most aggressive skin cancer, the mortality for PEM is lower than in other melanoma types. Animal-type melanoma earned its name due to the resemblance of melanocytic tumors in grey horses.

References

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