AAD
Author: Willhemenia Loremipsum Special session: Lorem ipsum dolor sit amet Category: Lorem ipsum View all results

Please login or create an account. If you do not have access to this content, you will be shown a 30 second preview and licensing options.

  • Presentation

Management of Histologically Dysplastic Nevi and AIMP

Description

In this presentation, Dr. Natalie Spaccarelli addresses the management of histologically dysplastic nevi and atypical intrapidermal melanocytic proliferations (AIMP). She emphasizes the lack of randomized control trials in the field and acknowledges the variability in management approaches among dermatologists, as drawn from surveys conducted over the years. Key findings from these surveys indicate that most dermatologists do not re-excise mildly to moderately dysplastic nevi with negative margins; however, the tendency to re-excise severely dysplastic nevi has increased. Consensus recommendations assert that mildly and moderately dysplastic nevi with negative margins can be monitored without re-excision, while severely dysplastic nevi with positive margins should be excised. Recent studies on re-excision versus observation indicate low melanoma development rates in both groups, underscoring the importance of individualizing patient management. Regarding AIMP, evidence suggests that these lesions generally warrant excision after biopsy. Dr. Spaccarelli also emphasizes the importance of communication with pathologists regarding excision decisions, documenting the complete removal of visible lesions, and educating patients about monitoring for changes. She concludes with practical recommendations for managing dysplastic nevi based on the existing consensus and her clinical experience.

View more

Conclusions

  • Management of histologically dysplastic nevi (HDN) varies among dermatologists, with most agreeing that mildly dysplastic nevi do not require re-excision if margins are negative.
  • Increased rates of re-excision of severely dysplastic nevi with negative margins were noted between 2015 and 2021 surveys.
  • Consensus recommendations suggest that mildly and moderately dysplastic nevi with negative margins do not require re-excision, while severely dysplastic nevi with positive margins do.
  • Recent studies indicate that biopsy margin status is not always a reliable predictor of complete lesion removal in dysplastic nevi, with up to 30% showing positive margins upon further sectioning.
  • The risk of melanoma development at biopsy sites is low, with similar rates for re-excised versus observed dysplastic nevi.
  • Moderately dysplastic nevi can be safely monitored when the entire visible lesion is removed, but patients should be counseled about increased melanoma risk elsewhere.
  • Pathologists' re-excision recommendations may vary, thus maintaining communication with them is crucial for appropriate management.
  • Atypical intraepidermal melanocytic proliferations (AIMP) often warrant re-excision due to their potential overlap with melanoma, highlighted by studies showing significant upstaging in excised specimens.
  • Winkelmann RR, Rigel DS. Management of dysplastic nevi: A 14-year follow-up survey assessing practice trends among US dermatologists. J Am Acad Dermatol. 2015 Dec;73(6):1056-9. doi: 10.1016/j.jaad.2015.06.061. PMID: 26568339.
  • Brownstone N, Zakria D, Rigel D. Management of dysplastic nevi: a 6 year follow-up survey assessing practice trends among US dermatologists. J Dermatolog Treat. 2023 Dec;34(1):2089324. doi: 10.1080/09546634.2022.2089324. Epub 2022 Oct 18. PMID: 36256525.
  • Nelson KC, Grossman D, Kim CC, et al. Management strategies of academic pigmented lesion clinic directors in the United States. J Am Acad Dermatol. 2018 Aug;79(2):367-369. doi: 10.1016/j.jaad.2017.12.069. Epub 2018 Jan 4. PMID: 29307637.
  • Kim CC, Swetter SM, Curiel-Lewandrowski C, et al. Addressing the knowledge gap in clinical recommendations for management and complete excision of clinically atypical nevi/dysplastic nevi: Pigmented Lesion Subcommittee consensus statement. JAMA Dermatol. 2015 Feb;151(2):212-8. doi: 10.1001/jamadermatol.2014.2694. PMID: 25409291.
  • Chang TT, Somach SC, Wagamon K, et al. The inadequacy of punch-excised melanocytic lesions: sampling through the block for the determination of "margins". J Am Acad Dermatol. 2009 Jun;60(6):990-3. doi: 10.1016/j.jaad.2008.09.037. PMID: 19467370.
  • Zakhem GA, Terushkin V, Mu EW, et al. Margin Assessment for Punch and Shave Biopsies of Dysplastic Nevi. J Drugs Dermatol. 2018 Jul 1;17(7):810-812. PMID: 30005107.
  • Cohen LM, Hodge SJ, Owen LG, et al. Atypical melanocytic nevi. Clinical and histopathologic predictors of residual tumor at reexcision. J Am Acad Dermatol. 1992 Nov;27(5 Pt 1):701-6. PMID: 1430391.
  • Reddy KK, Farber MJ, Bhawan J, et al. Atypical (dysplastic) nevi: outcomes of surgical excision and association with melanoma. JAMA Dermatol. 2013 Aug;149(8):928-34. doi: 10.1001/jamadermatol.2013.4440. PMID: 23760581.
  • Strazzula L, Vedak P, Hoang MP, Sober A, et al. The utility of re-excising mildly and moderately dysplastic nevi: a retrospective analysis. J Am Acad Dermatol. 2014 Dec;71(6):1071-6. doi: 10.1016/j.jaad.2014.08.025. Epub 2014 Sep 26. PMID: 25262175.
  • Duncan JR, Purnell JC, Stratton MS, et al. Negative predictive value of biopsy margins of dysplastic nevi: A single-institution retrospective review. J Am Acad Dermatol. 2020 Jan;82(1):87-93. doi: 10.1016/j.jaad.2019.07.037. Epub 2019 Jul 19. PMID: 31326466.
  • Vuong KT, Walker J, Powell HB, et al. Surgical re-excision vs. observation for histologically dysplastic naevi: a systematic review of associated clinical outcomes. Br J Dermatol. 2018 Sep;179(3):590-598. doi: 10.1111/bjd.16557. Epub 2018 Jun 21. PMID: 29570779.
  • Kim CC, Berry EG, Marchetti MA, Swetter SM, et al; Pigmented Lesion Subcommittee, Melanoma Prevention Working Group. Risk of Subsequent Cutaneous Melanoma in Moderately Dysplastic Nevi Excisionally Biopsied but With Positive Histologic Margins. JAMA Dermatol. 2018 Dec 1;154(12):1401-1408. doi: 10.1001/jamadermatol.2018.3359. PMID: 30304348; PMCID: PMC6583364.
  • Zhang J, Miller CJ, Sobanko JF, Shin TM, Etzkorn JR. Diagnostic Change From Atypical Intraepidermal Melanocytic Proliferation to Melanoma After Conventional Excision-A Single Academic Institution Cross-Sectional Study. Dermatol Surg. 2016 Oct;42(10):1147-54. doi: 10.1097/DSS.0000000000000877. PMID: 27598440.
  • Blank NR, Hibler BP, Tattersall IW, Ensslin CJ, Lee EH, Dusza SW, Nehal KS, Busam KJ, Rossi AM. Melanoma and melanoma in-situ diagnosis after excision of atypical intraepidermal melanocytic proliferation: A retrospective cross-sectional analysis. J Am Acad Dermatol. 2019 May;80(5):1403-1409. doi: 10.1016/j.jaad.2019.01.005. Epub 2019 Jan 14. PMID: 30654079; PMCID: PMC6857840.
  • Bou-Prieto A, Sarriera-Lázaro CJ, Valentín-Nogueras SM, Sánchez JE, Sánchez JL. Defining the Histopathological Term Atypical Intraepidermal Melanocytic Proliferation: A Retrospective Cross-Sectional Study. Am J Dermatopathol. 2021 Apr 1;43(4):252-258. doi: 10.1097/DAD.0000000000001851. PMID: 33201012.