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Background/objectives: Although excision of melanocytic nevi with high-grade dysplasia is recommended by the World Health Organization (WHO), clinical studies investigating the approach based on the grading dysplasia of melanocytic lesions with peripheral globules (PGs) are lacking. We investigated the grades of dysplasia and their distinguishable dermoscopic and clinical features to provide accurate data for managing these lesions., Methods: We retrospectively classified histologically confirmed melanocytic lesions with PGs according to the 2018 WHO Classification of Skin Tumours criteria in a university hospital in Turkey. Dermoscopic features, lesions, and patient characteristics were recorded., Results: Sixty-six lesions of 56 patients were included. After classification, 9.1% (n: 6) of lesions were melanomas, 39.4% (n: 26) were high-grade dysplastic nevi, and 50% (n: 33) were low-grade dysplastic nevi (n: 33, 50%). There was one nevus with no dysplasia (n: 1, 1.5%). Univariate analysis revealed that ≥31 years of age, irregular shape of peripheral globules, black colour, total colour count, and maximum diameter of the lesion were associated with high-grade dysplasia and melanoma. In the multivariate analyses, ≥31 years of age (OR = 3.80, 95% CI, 1.17-12.37), irregular shape of peripheral globules (OR = 3.90, 95% CI, 1.15-13.2), and total colour count (OR = 3.21, 95% CI, 1.2-8.5) were significant predictive factors for the lesions with high-grade dysplasia and melanomas., Conclusions: To avoid the underdiagnosis of both melanomas and high-grade dysplastic nevi with PGs, the irregular shape of peripheral globules and multiple colours after the third decade may be useful in making an excision decision. The risk increases every 1-year increase in age. Excision is suggested for all melanocytic lesions with PGs for patients 60 years or older because of the high risk of melanoma and melanocytic nevus with high-grade dysplasia., (© 2024 Australasian College of Dermatologists.)

Background and Objectives: There are no clinical guidelines on the management of dysplastic nevus (DN). The aims of this study were to determine the percentage of dermatologists in the center-Spain section of the Spanish Academy of Dermatology and Venereology (AEDV) who would manage a histologically confirmed DN with a watch-and-wait approach or with wider surgical margins and to investigate whether their attitudes would vary depending on whether or not the patient had a personal and/or family history of melanoma., Material and Methods: We collected data from an anonymous survey sent to 738 dermatologists between June 15 and July 31, 2022. The independent variables were degree of dysplasia (low vs. high), margin status (positive vs. negative), and a personal or family history of melanoma (yes vs. no in both cases). The dependent variables were attitude towards management (watch-and-wait vs. re-excision with a surgical margin of 1 to 4mm or re-excision with a surgical margin of 5 to 10mm)., Results: We obtained 86 responses to the questionnaire. When pathology indicated a low-grade DN, 60.5% of dermatologists stated they would obtain a surgical margin of 1 to 4mm if the first margins were positive, and 97.7% would watch and wait if the report described negative margins. For high-grade DNs, 1.2% of dermatologists would watch and wait to manage DN with positive margins; 68.8% would use this approach for negative margins. A family or personal history of melanoma had no influence on most of the dermatologists' attitudes., Conclusions: Management strategies for DN among dermatologists from the center-Spain section of the AEDV varied, particularly when faced with low-grade DN with positive margins and high-grade DN with negative margins. A family or personal history of melanoma did not influence clinical attitudes in most cases., (Copyright © 2023 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Malignant melanoma is an oncologic disease, whose current management among others includes surgical and immunological therapy. According to the current recommendations of the American Joint Committee on Cancer, the surgical excision of the primary tumor should be performed in two operative sessions, which has several consequences. The following paper will present and discuss six cases of pigmented lesions and the advantages of the one-step melanoma surgery in their management., (© 2020 Wiley Periodicals, Inc.)

Background: Biopsies of dysplastic nevi processed by bread-loafing allow for limited margin assessment; however, reported biopsy margins often influence management., Objective: To evaluate the negative predictive value of biopsy margins of dysplastic nevi., Methods: A retrospective search of a single academic institution's pathology database was conducted to identify all biopsy specimens of dysplastic nevi between January 1, 2015, and December 31, 2017. Biopsy specimen margin assessments were compared with excision pathology reports to calculate negative predictive value and to assess the frequency of residual nevus on excision after positive biopsy margins., Results: A total of 1245 dysplastic nevi from 934 patients were identified. Clear biopsy margins had a negative predictive value for the absence of residual nevus on excision of 87.3% for dysplastic nevi of moderate atypia or greater. Residual nevus was identified on excision in 29.41% of cases of dysplastic nevi of moderate atypia or greater when initial biopsy margins were positive., Limitations: This was a retrospective, single-institution study. The calculations likely overestimate the true negative predictive value of biopsy margins because of processing of excision specimens by bread-loafing., Conclusions: This study provides additional evidence that reported biopsy margins are not representative of true margin status., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Cyclin dependent kinase inhibitor 2A gene (CDKN2A) germline mutations have recently been associated with poor survival in patients with melanoma. Despite the high mutation rate in our cohort (up to 10% in patients with apparently sporadic melanoma), information on the impact of CDKN2A on survival in this cohort is lacking., Objective: To investigate whether poor survival associated with CDKN2A germline mutations was confirmed in a high mutation-prevalence cohort of Italian patients with melanoma undergoing a mutation-based follow-up., Methods: A total of 1239 patients with cutaneous melanoma were tested for CDKN2A mutational status and then assigned to a follow-up scheme according not only to family history but also to CDKN2A mutational status, as follow-up intervals were more frequent for CDKN2A germline mutation-positive (MUT + ) patients. From this cohort, we selected 106 MUT + patients (with familial melanoma or apparently sporadic melanoma) and 199 CDKN2A germline mutation-negative (MUT - ) patients with sporadic melanoma who were matched by age and sex and had a similar tumor stage distribution., Results: We found no difference in overall survival (hazard ratio, 0.85; 95% confidence interval, 0.48-1.52; P = .592,) or melanoma-specific survival (hazard ratio, 0.86; 95% confidence interval, 0.38-1.95; P = .718,) between MUT + and MUT - patients. MUT + patients were more likely to develop multiple melanomas and to undergo surgical excision of dysplastic nevi than were MUT - patients., Limitations: Retrospective study., Conclusion: CDKN2A mutations were not associated with survival in our cohort., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Importance: Little evidence exists to guide the management of moderately dysplastic nevi excisionally biopsied without residual clinical pigmentation but with positive histologic margins (hereafter referred to as moderately dysplastic nevi with positive histologic margins)., Objective: To determine outcomes and risk for the development of subsequent cutaneous melanoma (CM) from moderately dysplastic nevi with positive histologic margins observed for 3 years or more., Design, Setting, and Participants: A multicenter (9 US academic dermatology sites) retrospective cohort study was conducted of patients 18 years or older with moderately dysplastic nevi with positive histologic margins and 3 years or more of follow-up data collected consecutively from January 1, 1990, to August 31, 2014. Records were reviewed for patient demographics, biopsy type, pathologic findings, and development of subsequent CM at the biopsy site or elsewhere on the body. The χ2 test, the Fisher exact test, and analysis of variance were used to assess univariate association for risk of subsequent CMs, in addition to multivariable logistic regression models. To confirm histologic grading, each site submitted 5 random representative slide cases for central dermatopathologic review. Statistical analysis was performed from October 1, 2017, to June 22, 2018., Main Outcomes and Measures: Development of CM at a biopsy site or elsewhere on the body where there were moderately dysplastic nevi with positive histologic margins., Results: A total of 467 moderately dysplastic nevi with positive histologic margins from 438 patients (193 women and 245 men; mean [SD] age, 46.7 [16.1] years) were evaluated. No cases developed into CM at biopsy sites, with a mean (SD) follow-up time of 6.9 (3.4) years. However, 100 patients (22.8%) developed a CM at a separate site. Results of multivariate analyses revealed that history of CM was significantly associated with the risk of development of subsequent CM at a separate site (odds ratio, 11.74; 95% CI, 5.71-24.15; P < .001), as were prior biopsied dysplastic nevi (odds ratio, 2.55; 95% CI, 1.23-5.28; P = .01). The results of a central dermatopathologic review revealed agreement in 35 of 40 cases (87.5%). Three of 40 cases (7.5%) were upgraded in degree of atypia; of these, 1 was interpreted as melanoma in situ. That patient remains without recurrence or evidence of CM after 5 years of follow-up., Conclusions and Relevance: This study suggests that close observation with routine skin surveillance is a reasonable management approach for moderately dysplastic nevi with positive histologic margins. However, having 2 or more biopsied dysplastic nevi (with 1 that is a moderately dysplastic nevus) appears to be associated with increased risk for subsequent CM at a separate site.

An automated melanocytic lesion image-analysis algorithm is described that aims to reproduce the decision-making of a dermatologist. The utility of the algorithm lies in its ability to identify lesions requiring excision from lesions not requiring excision. Using only wavelet coefficients as features, and testing three different machine learning algorithms, a cohort of 250 images of pigmented lesions is classified based on expert dermatologists' recommendations of either excision (165 images) or no excision (85 images). It is shown that the best algorithm utilises the Shannon4 wavelet coupled to the support vector machine, where the latter is used as the classifier. In this case the algorithm, utilising only 22 othogonal features, achieves a 10-fold cross validation sensitivity and specificity of 0.96 and 0.87, resulting in a diagnostic-odds ratio of 261. The advantages of this method over diagnostic algorithms-which make a melanoma/no melanoma decision-are twofold: first, by reproducing the decision-making of a dermatologist, the average number of lesions excised per melanoma among practioners in general can be reduced without compromising the detection of melanoma; and second, the intractable problem of clinically differentiating between many atypical dysplastic naevi and melanoma is avoided. Since many atypical naevi that require excision on clinical grounds will not be melanoma, the algorithm-in contrast to diagnostic algorithms-can aim for perfect specificities without clinical concerns, thus lowering the excision rate of non-melanoma. Finally, the algorithm has been implemented as a smart phone application to investigate its utility in clinical practice and to streamline the assimilation of hitherto unseen tested images into the training set., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Biopsies of atypical melanocytic nevi are among the most commonly performed procedures by dermatologists. Margin assessment is often used to guide re-excision, but can be a point of confusion as negative margins reported in the planes of sections examined do not always reflect complete removal of a lesion. This study investigates the rates of false negative margins after both punch and shave biopsies., Methods: We performed a retrospective analysis of 50 consecutive punch and shave biopsy specimens (1) diagnosed as DN, and (2) reported as having clear margins in the planes of section examined. Identified specimen blocks were then sectioned through to examine true margin involvement., Results: Of the 50 specimens identified, 20% (n = 10) were found to have positive margins upon additional sectioning. We found no difference between the groups with respect to biopsy technique, type of nevus, degree of atypia, or gender., Conclusion: This study observed false negative peripheral margin status in a sizeable proportion of biopsy specimens, which did not vary significantly based on biopsy technique or pathologic characteristics. This finding reflects a limitation of standard tissue processing, in which a limited proportion of the true margin is evaluated, and may be of note to many dermatologists who base their decision to re-excise on the reporting of margin involvement. J Drugs Dermatol. 2018;17(7):810-812.

Objective There remains confusion between Langer's lines and wrinkle lines with respect to the optimal orientation of elliptical excisions on the trunk. This study sought to determine the directions of wound closure that would result in least wound tension after skin lesion excisions. Materials and methods Some 1181 consecutive skin lesion excisions were investigated (age range 13-95 years, median 64 years) using a tensiometer to determine directions of least wound tension. These lines were mapped. Skin tension measurements were taken during the procedure and analysed. The clear majority of excisions were for skin cancer and the others were for cysts or dysplastic naevi. Lesions such as lipomas, which entail incisional rather than excisional surgery (i.e. where overlying skin was not excised) were excluded. All lesions were cut out in a circular fashion following tension measurements. Closure was undertaken in the direction of least tension (biodynamic excisional skin tension line) and this was illustrated. This process was repeated in all cases where body site and direction of closure was mapped. Statistical analyses were undertaken on a series on the scalp and lower limb. Results Biodynamic excisional skin tension lines have a clear directional preference: scalp-coronal direction, limbs--vertical orientation of ellipses and trunk - mostly horizontal except oblique at the shoulder and scapular regions. Discussion Skin cancer excisions often end up with poor cosmetic results, owing to inconsistency in identifying the correct excisional wound closure lines. This has not been helped by the (hitherto) lack of large in vivo biomechanical studies, and because incisional lines and excisional lines have not been considered separately in surgical practice. Orientating ellipses or wound closures using biodynamic excisional skin tension lines offers a guide to reducing wound tension and minimising wound complications or scarring after cutaneous surgery.

Background: Complete removal of individual dysplastic nevi (DN) is often accomplished by a second surgical procedure after the initial biopsy. The choice to perform the second procedure is strongly influenced by histopathologic margin status of the initial biopsy specimen., Objective: To evaluate the clinical and histopathologic outcomes of in toto biopsy of DN using a predetermined margin of normal skin., Methods: We conducted a prospective study of a saucerization method using a defined 2-mm margin in patients undergoing biopsy of a pigmented skin lesion., Results: We performed 151 biopsies in 138 patients. Overall, 137 of 151 lesions subjected to biopsy (90.7%) were melanocytic: 86 DN (57.0%), 40 nevi without atypia (26.5%), and 11 melanomas (7.3%). Of 78 DN, 68 (87.2%) were removed with clear histopathologic margins (8 DN were excluded because of inadequate processing). There was no clinical evidence of recurrence at any of the biopsy sites that were simply observed (i.e., not re-excised) over a median of 16.9 months., Limitations: There were few biopsies performed on the face., Conclusions: The complete histopathologic removal of nearly 9 of 10 DN using a peripheral margin of 2 mm of normal skin and a depth at the dermis and subcutaneous fat junction has the potential to decrease second procedures at DN biopsy sites, thereby decreasing patient morbidity and saving health care dollars., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background/objectives: The management of dysplastic naevi based on histopathological grading is a contentious issue. Comprehensive management guidelines are lacking and the approach taken varies between clinicians. The authors sought to understand how Australian dermatologists approach the management of biopsy-proven dysplastic naevi, and the impact of grading of dysplasia upon this management., Methods: In total, 547 Fellows of the Australasian College of Dermatologists were surveyed and 218 responses were collected (40% response rate)., Results: Although all dermatologists surveyed would re-excise an incompletely removed severely dysplastic naevus, opinion was divided over whether to treat such a lesion as an in situ melanoma or a dysplastic naevus, with 55% of respondents using a 5-mm margin and the remainder opting for narrow margin re-excision. When the same lesion was reported to be clear of margins by 1 mm after biopsy and the clinical suspicion for melanoma was high, 44% would re-excise with a 5-mm margin., Conclusions: The approach of Australian dermatologists to the management of dysplastic naevi varies between clinicians, reflecting the problems raised by the validity of histopathological grading., (© 2017 The Australasian College of Dermatologists.)

Background: Dysplastic nevi with severe atypia (severely dysplastic nevi [SDN]) are frequently re-excised because of the concern that these lesions may in fact represent early melanoma. Data on long-term follow-up of these patients are limited., Objective: We sought to determine the rate of subsequent melanoma development in patients with SDN who underwent re-excision versus those who did not and to determine factors associated with decision to re-excise., Methods: A retrospective single institutional study was conducted with 451 adult patients (mean age 41.3 years) with SDN biopsied between November 1994 and November 2004, with clinical follow-up of at least 5 years., Results: In 451 patients with SDN, re-excision was performed on 36.6%. Two melanomas were diagnosed in the re-excision specimens. Subsequent metastatic melanoma developed in 7 patients, all of whom had a history of melanoma. Margin comments influenced decision to re-excise., Limitations: This was a retrospective study at a single institution., Conclusion: Re-excision of all SDN may not be necessary., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Epithelial sheath neuroma is a rarely recognized but established entity in the medical literature. First described in 2000 by Requena et al, there have only been 7 published cases to date, mostly in female patients and presenting as symptomatic solitary lesions on the back without a known history of trauma. In 2006, Beer et al described and reviewed a dozen cases in which epithelial sheath neuroma-like features were seen in the advent of a surgical procedure, which was termed "re-excision perineural invasion" and attributed to possible eccrine duct implantation during surgery. Our case is a 66-year-old male patient who underwent an excision of a melanocytic neoplasm in which a reactive epithelial sheath neuroma was incidentally discovered in the excision specimen, adjacent to the biopsy site cicatrix. Histologically, there was benign cutaneous nerve hyperplasia with a proliferation of squamous epithelium in intimate apposition to the nerve bundles in the superficial dermis. We postulate that the process active in the formation of re-excision perineural invasion is the same as in epithelial sheath neuroma and that minor trauma not appreciable on histologic examination is responsible in the latter entity. We performed IL-6 staining and documented that IL-6 was upregulated at the interface of the nerve and reactive epithelium, but was absent in nerves distant from the site of surgery, suggesting that IL-6 may be essential to the lesion's development. The recognition of reactive epithelial sheath neuroma including the subcategory of re-excision perineural invasion is crucial for the dermatopathologist to prevent mislabeling this reactive entity as a perineural squamous cell carcinoma, which has clinical consequences for the patient such as wider re-excision and radiation treatment. Additionally, we have identified a potential pathophysiologic basis for this lesion.

Importance: Controversy persists regarding the appropriate management of incompletely excised, biopsy-proven, mild and moderate dysplastic nevi (DN)., Objective: To determine long-term risk of associated melanoma in biopsied mild or moderate DN with positive histologic margins that were clinically observed vs reexcised with negative margins., Design, Setting, and Participants: Retrospective cohort study of mixed referral and community patients from an academic pigmented lesion clinic and dermatology clinics of the affiliated Veteran Affairs medical center with biopsy-confirmed DN with positive histologic margins diagnosed from May 15, 1991, to July 8, 2015, and followed up through May 30, 2016. A consecutive sample of 1473 histologically confirmed DN was identified using surgical pathology databases at the study sites; 590 cases in 498 patients met eligibility criteria., Main Outcomes and Measures: The primary outcome was the proportion of biopsied DN that progressed to histologically confirmed invasive or in situ melanoma. Secondary outcomes included local nevus recurrence and development of primary melanoma at other anatomic sites., Results: The 498 patients had a mean (range) age of 57.6 (14-93) years and 90% were male. Among 590 positive-margin DN, 191 were reexcised and 399 clinically observed without further surgery; 170 reexcised and 304 observed DN had available follow-up data, with mean (SD) follow-up of 5.5 (4.6) years. Cases in the observation group were more likely to demonstrate nevus recurrence than those that were reexcised (3.3% vs 0%; P = .02). Six of 304 (2.0%) observed DN subsequently developed melanoma at the same site, compared with 1 of 170 (0.06%) that were reexcised (P = .43). Five of 6 observed patients who developed melanoma initially underwent partial biopsy with grossly positive margins; 1 melanoma in situ evolved from an excisionally biopsied moderately dysplastic nevus 5 years later. Only 1 case of thin invasive melanoma (≤1 mm) was observed, and no deaths from melanoma arising from biopsy-proven DN occurred through the latest dermatology follow-up. New primary melanoma developed at other sites in 9.9% of excised and 9.4% of resected DN., Conclusions and Relevance: In cases of mild and moderate DN with microscopically positive margins and no concerning clinical residual lesion, observation, rather than reexcision, was a reasonable management option. Partial biopsies of pigmented lesions suspicious for melanoma may lead to delayed melanoma diagnosis and should be discouraged.

Methods: We conducted a retrospective chart review and identified 186 Veterans in the VA Corporate Data Warehouse as having malignant melanomas or severely dysplastic nevi during the four-year period of observation from 1 July 2009 to 30 June 2013 and met inclusion and exclusion criteria for analysis., Results: Three hundred and sixty-six surgical procedures were performed for diagnosis and treatment of these conditions including biopsy and wide-local excision, of which 189 carefully selected cases were performed by primary care clinicians with 2.0% biopsy complication rate and a 7.7% wide-local excision complication rate. Cases not performed by primary care providers were referred to specialists (e.g. dermatologists, general surgeons or specialty surgeons) who had a 2.5% complication rate in biopsies and wide-local excision complication rate of 13.5% in severely dysplastic nevi and pTis and pT1a lesions and a 10.7% complication rate for lesions pT1b and greater., Discussion: These results show that a significant fraction of surgical procedures for diagnosis and treatment of malignant melanoma and severely dysplastic nevi can be safely performed in rural clinics by trained primary care providers., (© The Author(s) 2015.)

Background: Despite a lack of evidence that dysplastic nevi are precursors to melanoma, a large proportion of dermatologists continue to treat them as such. Emerging data suggest that histologic grading approach may result in many unnecessary excisions., Objective: Using a nongrading approach to diagnosis of Clark/dysplastic nevi, the current study sought to define and determine the diagnostic uncertainty rate, and to report on the results of re-excisions of such lesions., Methods: All melanocytic nevi submitted to an academic dermatopathology laboratory between January 1, 2007, and December 31, 2013, were categorized. The number of Clark nevi recommended for re-excision divided by the total number of Clark nevi was taken to be the diagnostic uncertainty rate., Results: This nongrading approach resulted in an excision recommendation/diagnostic uncertainty rate of 11.1%. In 2% of the excised specimens, the diagnosis was changed to melanoma., Limitations: The study was performed at a single institution, and assigned diagnoses could not be verified other than by the diagnosing dermatopathologists. Lesions that were not submitted as re-excision specimens could have altered the results had they been available for evaluation., Conclusion: Compared with previously reported excision rates, the current study shows that the nongrading approach to Clark nevi results in a lower excision rate while still maintaining a low rate of change in diagnosis similar to the grading approach., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Importance: The management of clinically atypical nevi/dysplastic nevi (CAN/DN) is controversial, with few data to guide the process. Management recommendations for DN with positive histologic margins were developed by the Delphi method to achieve consensus among members of the Pigmented Lesion Subcommittee (PLS) of the Melanoma Prevention Working Group (MPWG) after reviewing the current evidence., Objectives: To outline key issues related to the management of CAN/DN: (1) biopsies of CAN and how positive margins arise, (2) whether incompletely excised DN evolve into melanoma, (3) current data on the outcomes of DN with positive histologic margins, (4) consensus recommendations, and (5) a proposal for future studies, including a large-scale study to help guide the management of DN with positive margins., Evidence Review: The literature, including recent studies examining management and outcomes of DN with positive margins between 2009 to 2014, was reviewed., Findings: A consensus statement by the PLS of the MPWG following review of the literature, group discussions, and a structured Delphi method consensus., Conclusions and Relevance: This consensus statement reviews the complexities of management of CAN/DN. A review of the literature and 2 rounds of a structured Delphi consensus resulted in the following recommendations: (1) mildly and moderately DN with clear margins do not need to be reexcised, (2) mildly DN biopsied with positive histologic margins without clinical residual pigmentation may be safely observed rather than reexcised, and (3) observation may be a reasonable option for management of moderately DN with positive histologic margins without clinically apparent residual pigmentation; however, more data are needed to make definitive recommendations in this clinical scenario.

Dysplastic nevus is still a controversial entity both clinically and histologically. The occurrence of dysplastic nevus especially in the context of dysplastic nevus cell syndrome is associated with an increased risk for melanoma. The following minimal histological criteria should be fulfilled: nests of melanocytes varying in size and shape, bridging and confluent, proliferation of single melanocytes basal and suprabasal, cytoplasmic and nuclear atypia of melanocytes and subepidermal fibroplasia. The biological behavior (common nevus variant or precursor of melanoma?) is difficult to evaluate by presently available methods. The further development of new molecular biology techniques may allow a better prognosis of dysplastic nevi in an objective and reproducible manner. Against this background complete excision followed by clinical surveillance has to be recommended for the routine practice.

Background: The management of dysplastic nevi (DN) is a highly debated and controversial topic within the dermatology community. Clinicians agree that margin-positive severely DN should be removed with a surgical margin, however, there is disagreement surrounding the appropriate management of margin-positive mildly and moderately DN., Objective: We sought to evaluate the utility of re-excising margin-positive mildly and moderately DN., Methods: A retrospective chart review was conducted on all adult patients given the diagnosis of a biopsy-proven DN from 2010 through 2011. The primary outcomes were defined as the presence of melanocytic residuum in re-excisional specimens and a clinically significant change in diagnosis., Results: A total of 1809 mildly and moderately DN were diagnosed from 2010 through 2011. In all, 765 (42.3%) of these lesions were found to have positive surgical margins during biopsy, and 495 (64.7) of the 765 lesions were subsequently re-excised. Melanocytic residuum was present in 18.2% of re-excisional specimens. Re-excision resulted in a clinically significant alteration of the diagnosis in only 1 case (0.2%)., Limitations: Limitations include retrospective design and inability to assess for malignant transformation given limited follow-up., Conclusions: Re-excising mildly and moderately DN results in a low histopathological yield and rarely results in a clinically significant change in diagnosis. As such, clinical monitoring of margin-positive lesions may be warranted., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Despite their frequency in clinical practice, controversy exists regarding the significance and management of dysplastic nevi (DN). Although the perception of DN as precursors to melanoma is questionable, excisions of biopsy-proven DN are commonplace in clinical practice. The management of dysplastic acral nevi is of interest given the challenge of surgery at acral sites., Objective: To determine the outcomes of biopsies of clinically atypical acral nevi and excisions of histologically dysplastic acral nevi (HDN)., Materials and Methods: Retrospective review of consecutive patients at a private dermatology practice who had a biopsy of an atypical acral nevus from December 2004 to July 2012., Results: One hundred eighty-seven atypical acral nevi were biopsied from 168 patients (77 (41%) HDN, 108 (58%) common nevi). Based on initial histology, 30 (39%) HDN were recommended for excision and eight (10%) for clinical observation. Twenty-seven of the 77 HDN were excised; 23 (85%) revealed scar only, and four (15%) revealed residual DN not involving the margin., Conclusion: Routine excision of biopsy-proven dysplastic acral nevi may not be necessary., (© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Dysplastic nevi (DN) have been a matter of controversy since their initial description in 1978 because of differences in the clinical and histological terminology, and large studies on histological outcomes of excising moderate to severely DN have not previously been described., Objective: To determine the clinical characteristics of DN and histologic outcomes of excised moderate and severe DN., Methods: Retrospective chart review of patients with DN or Clark's nevi at the Dermatology Department at Rutgers-Robert Wood Johnson Medical School in Somerset, New Jersey, from January 2009 to June 2012. Three hundred ninety-three lesions from 380 patients were included in this study., Main Outcome Measure: Histologic results of excised moderate and severe DN., Results: Thirty-four percent of DN were excised because of the presence of moderate or severe atypia, personal history of melanoma, or both. None of the excised lesions showed evidence of melanoma; 81.6% of excisions showed scar or granulation tissue. Only 14% of excised lesions were found to have residual lesions, and 4.4% showed recurrent nevi., Conclusion: In 134 excisions of moderate to severe DN, no melanoma was identified. Most of the excisions showed scar or granulation tissue. The rate of residual lesions after shave biopsy of moderate or severe DN was lower than after punch biopsy., (© 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Dermatopathology reports influence clinical management, but it is not clear to what extent comments on margin involvement of histopathologically dysplastic nevi (HDN) influence decisions about re-excision or complete excision., Objective: We sought to determine if standardized margin comments (MCs) on HDN influence re-excision rates., Methods: By reviewing medical records, we compared re-excision rates of HDN reported with (May 2011 to December 2012) and without (January 2007 to December 2010) standardized MCs, and surveyed clinicians to assess perceptions of the impact of MCs on their management of HDN., Results: Of 584 HDN, 302 had MCs and 282 did not. Re-excision was recommended or performed at a significantly higher rate for patients in the group without MCs (51.8%, 146 of 282) than in the MC group (39.4%, 119 of 302); P = .003 regardless of margin status. This difference was observed among HDN diagnosed as mildly and moderately dysplastic but not for severely dysplastic nevi. In all, 40% (16 of 40) of clinicians responded that they are more likely to biopsy pigmented lesions with a clinical margin of normal-appearing skin than they were before MCs were routinely included in dermatopathology reports., Limitations: This was a retrospective study., Conclusions: Re-excision rates were significantly lower in patients who had HDN reported with standardized MCs. MCs may help reduce re-excision rates, with associated reduction in health care use, cost, and morbidity., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Objective: To evaluate the effect of surgical excision, performed after biopsy diagnosis of dysplastic nevus, on final diagnosis, melanoma prevention, and melanoma detection., Design, Setting, and Participants: Outcome study using retrospective review conducted in an academic dermatopathology practice (Boston Medical Center Skin Pathology Laboratory) that receives specimens from community and academic practices across the United States. Consecutive patient pathology samples of dysplastic nevi and cutaneous melanomas evaluated between September 1, 1999 and March 1, 2011, and identified using systematized nomenclature of medicine codes were included., Main Outcomes and Measures: In dysplastic nevi cases, the rate of clinically significant change in diagnosis and the rate of melanoma detection as a result of excision. In melanoma cases, the rate and characteristics of association with dysplastic nevus., Results: Of dysplastic nevi, 196 of 580 (34%) showed a positive biopsy margin, increasing with grade of atypia (P < .001); 127 of 196 with positive biopsy margin received excision (65%), performed more often as grade of atypia increased (P < .001). Two excisions (2 of 127, 1.6%) resulted in a clinically significant change in diagnosis, from biopsy-diagnosed moderately-to-severely dysplastic nevi before excision to melanoma in situ after excision. In melanomas (n = 216), in situ and superficial spreading subtypes were more often associated with dysplastic nevi (20% and 18%, respectively) (P = .002), most often of moderate-to-severe or severe grade., Conclusions and Relevance: Excision of biopsy-diagnosed mildly or moderately dysplastic nevi is unlikely to result in a clinically significant change in diagnosis, and risk of transformation to melanoma appears very low. Moderately-to-severely and severely dysplastic nevi are more often associated with melanoma, and excision may be beneficial for melanoma detection or prevention.

Background: Studies have shown low satisfaction levels among dermatology residents with respect to dermoscopy training. Many desire additional instruction., Objective: We surveyed graduating chief residents to assess current education practices among US dermatology training programs with respect to the role of dermoscopy as an aid in the management of pigmented lesions., Methods: An online survey was sent to 139 chief residents of US dermatology training programs., Results: A 59% response rate was achieved. Of responding chief residents, 94% use dermoscopy. Although 92% of chief residents received dermoscopy training, only 48% trained with a pigmented lesion specialist. Among those training without a specialist, less than half received classroom or bedside teaching compared with 77% of those who trained with a specialist. Of those who trained with a specialist, 77% were satisfied with their training compared with only 30% who trained without a specialist (P < .0001). Those who trained with a specialist were more likely to agree that dermoscopy can help differentiate melanoma from benign lesions (77% vs 47%; P = .0065)., Limitations: Response bias and limiting the survey to chief residents potentially limits our ability to generalize these results to all US dermatology trainees., Conclusion: Although many residents use dermoscopy as a diagnostic tool, the lack of dedicated dermoscopy training remains a potential barrier to increasing residents' diagnostic confidence in the management of pigmented lesions. Increasing the amount of dedicated instruction on this topic is one possible approach to enhance resident satisfaction, potentially increasing their competency in the management of atypical nevi., (Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Melanocytic nevi in certain anatomic locations can display unusual histopathologic features potentially creating diagnostic uncertainty. Benign melanocytic nevi in sites such as acral, genital, and flexural areas may show unusual architecture and cytologic atypia, which can mimic dysplastic nevi and, sometimes, melanoma. Twenty-nine benign melanocytic skin lesions were identified in the thigh of 26 women and 3 men who showed atypical histologic features, including both dysplastic and spitzoid features. All lesions measured less than 1 cm in diameter. Eighteen cases showed features of compound nevi, and 11 were junctional. In all cases, the lesions displayed spitzoid features including large epithelioid and/or spindle cells, some melanocytes with ganglion-like cytomorphology, and focal suprabasilar upward migration. All cases showed dysplastic features. Clinical follow-up was available in 26 patients; no recurrences or metastases were observed. The demographic features and the anatomical sites of these melanocytic nevi appear to be reproducible, and in the assessment of histologically difficult cases, these data are helpful. It is our opinion that the malignant potential of these lesions with hybrid patterns (spitzoid/dysplastic) has yet to be determined, and although we favor these lesions to be benign, longer follow-up may yield a more complete understanding of their biologic potential., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Patients with multiple clinically dysplastic nevi are at increased risk for development of melanoma. However, the risk of melanoma arising in a histologically dysplastic nevus (HDN) is unknown., Objective: We sought to determine the rate of melanoma development in patients with HDNs that approached a microscopic border but were not re-excised., Methods: We performed a retrospective study of patients evaluated in our dermatology department from January 1, 1980, to December 31, 1989, who had a HDN that extended to within 0.2 mm of a microscopic punch, shave, or excision border and was not re-excised., Results: The average follow-up in our cohort of 115 patients was 17.4 years (range: 0.0-29.9): 82 patients (71.3%) were followed up for longer than 10 years, 78 (67.8%) longer than 15 years, and 73 (63.4%) had more than 20 years of follow-up; 66 of 115 nevi were mildly dysplastic, 42 moderately dysplastic, and 7 had severe dysplasia. No patient developed metastatic melanoma or melanoma at the site of removal of a HDN., Limitations: This was a retrospective study performed at 1 large academic medical center., Conclusion: During a long-term follow-up period, no patient developed melanoma at the site of an incompletely or narrowly removed HDN, providing evidence that routine re-excision of mildly or moderately dysplastic nevi may not be necessary., (Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: The combined use of total-body photography and digital dermatoscopy, named "two-step method of digital follow-up," allowed the detection of incipient melanoma as a result of dermatoscopic or macroscopic changes during follow-up., Objective: We sought to assess dermatoscopic features and dynamic changes leading to excision of melanocytic lesions during our 10-year experience of monitoring patients at high risk for melanoma., Methods: We analyzed 1152 lesions excised during the surveillance of 618 patients at high risk for melanoma from 1999 to 2008., Results: A total of 779 excised lesions had been previously recorded: 728 were removed because of dermatoscopic changes during follow-up and 51 were removed even though no significant change was noted. The remaining 373 excised lesions were new or undetected on previous total-body photography. A total of 98 melanomas were detected, 60 in the monitored lesions, and 38 among the "new" lesions. The most frequent dermatoscopic changes detected were asymmetric enlargement in almost 60% (n = 418), focal changes in structure in 197 (27%) and in pigmentation in 122 (17%), the latter two being more frequently seen in melanomas than in nevi (both P < .001). No significant differences were detected between dermatoscopic or histopathological characteristics of the melanomas in each group, with a considerable proportion of melanomas misclassified as benign in both groups (26.3% and 38.3%, respectively)., Limitations: The dermatoscopy pattern of stable lesions and the histopathology of lesions not removed were not included in the study., Conclusion: The most frequent dermatoscopic features associated with melanoma were focal change in pigmentation or structure. Melanomas detected by dermatoscopic changes were remarkably similar to those detected in total-body photography. Almost 40% of melanomas diagnosed in individuals at high risk corresponded to lesions that were not under dermatoscopic surveillance., (Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: The quality of early malignant melanoma (MM) diagnosis is dependent on the experience of dermatologists, tools like dermoscopy and histopathology, and awareness and education of the studied population. Does a higher rate of excision of pigmented skin lesions (PSL) increase the rate of detected melanomas?, Material and Methods: The DB-MIPS objective tool, able to evaluate mathematical defined variables, has been used to verify the variability of measurements among PSL stored by five different centres located in Italy, Switzerland, and Germany., Results: The objective analysis showed low differences in terms of moles' features among the different groups, arguing for robustness of the dermatological patient's PSL inspection. Differences in terms of false positives and predictive positive values have been detected. The tendency to follow up a lesion was proportional to the percentage of thin MM (<0.75 mm tumour thickness), while the interventism was proportional to the percentage of dysplastic moles. Similar percentage of thin melanoma has been observed in all the centres, indicating a standardization in early diagnosing among experienced dermatologists. The main difference among the centres was their mode of action, i.e. to follow up or remove suspicious PSL., Conclusion: Interventism depends neither on the geographic site nor on the features of the observed moles. Higher removal rates do not correspond to higher MM detections: this means that an in-depth knowledge of melanoma patterns is required and follow-up of suspicious moles is highly suggested., (© 2011 John Wiley & Sons A/S.)

Dysplastic nevus is an acquired or hereditary nevus that clinically seems atypical and pathohistologically dysplastic. The term of dysplastic nevus has changed through history and even until now the dermatologists and pathologists have not found the same conclusion for name and definition of dysplastic nevus. Epidemiology of dysplastic nevus is different depending on geographic lattitude, being three times higher in Australia than in Great Britain. Genetic factors play a role in etiology of dysplastic nevus but are still not well defined. UV radiation is indisputable main etiological factor in developing dysplastic nevus. Many studies confirm that children who have been using sun protection creams with SPF have less dysplastic nevi than those who did not. Nevus with geographic shape and muddy borders, dominately macular, red to brown colored and has 5 mm or more in diameter is clinically dysplastic nevus. ABCDE rules count for dysplastic nevus as well as for melanoma but prefferable diagnostic criteria for dysplastic nevus would be "ugly duckling sign". Pathohistologic analysis is the key in confirming the diagnosis of dysplastic nevus. Great experience and knowledge in dermatopathology field is essential for pathologists to make a distinction between dysplastic nevus and melanoma in situ. Likewise great experience in dermatooncology field is essential in differentiating dysplastic nevus from other nevi. Surgical excision is the only therapy that should be done for dysplastic nevus. Regular follow up is highly recommended for patients with dysplastic nevus and syndroma naevi dysplastic. Education about sun protection measures and self-examination techniques is essential for all patients with dysplastic nevi and their family.

A 16-year-old boy with multiple nevi presented with an enlarging pigmented lesion on his right chest. Previously excised nevi were all benign. Dermoscopy of the symmetrical lesion revealed a trizonal globular-homogeneous pattern. A peripheral rim of brown globules was followed by a zone with homogeneous pigmentation. The centre of the lesion showed black dots and globules. Histopathology confirmed a dysplastic compound nevus and found no diagnostic aspects of pigmented spindle cell nevus (Reed).

Few studies have investigated the impact of dermoscopy on the management of relatives from melanoma families. The objective of this study was to assess the impact of dermoscopy on clinical diagnosis and management decisions in high-risk familial melanoma patients. In a prospective study 132 consecutive patients were recruited from the pigmented lesions clinic of a tertiary reference centre for familial melanoma. Dermatologists expert in dermoscopy identified 49 suspicious pigmented lesions and recorded pre- and post-dermoscopy diagnoses and management decisions. Dermoscopy was performed in 37% of the patients. Two melanomas were identified. Dermoscopy did not influence sensitivity (1.0), but resulted in 42% fewer excisions, increasing specificity from 0.53 to 0.74 (p = 0.031). Dermoscopy resulted in a large reduction in the number of unnecessary excisions. These results suggest that the main effect of dermoscopy in clinical practice for this high risk population is a significant increase in specificity, rather than sensitivity.

Purpose: To determine the efficacy of liquid-based cytology (LBC) and immunohistochemistry in the evaluation of fine needle aspiration biopsy (FNAB) of intraocular melanocytic tumors., Methods: Cytologic diagnosis was necessary in 25 patients with intraocular melanocytic tumors to deliver a therapeutic course of treatment. The patients' clinical, cytologic, and histologic diagnoses were correlated. All samples were stained with hematoxylin and eosin, and studied through standardized monolayer techniques, with a mean cellular concentration of 60,000 cells/mm2. Immunohistochemistry was performed using Vimentin, S 100, HMB 45, Melan A, cytokeratin, and as prognostic factors, B and T lymphocyte, CD68 (macrophage), and antibody Ki 67 (growth factor)., Results: The positive predictive value was 100%; the negative predictive value was 80%. Sensitivity and specificity of LBC for detecting malignancy were 95.2% and 100%, respectively. The FNAB LBC with immunohistochemistry findings resulted in a revision of treatment in 32% of patients. There was no evidence of local tumor dissemination or a recurrence associated with biopsy in any patient., Conclusions: Fine needle aspiration biopsy (LBC and immunohistochemistry) is a safe, sensitive, and specific method of establishing tissue diagnosis in a subset of patients with intraocular melanocytic tumors, particularly in cases where sample material is scarce. The routine use of immunohistochemical stain increases the diagnostic utility, and prognosis factor determination may change clinical management.