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Original Investigation |

Reexamining the Threshold for Reexcision of Histologically Transected Dysplastic Nevi ONLINE FIRST

Nathaniel H. Fleming, BA1,2; Barbara M. Egbert, MD3; Jinah Kim, MD, PhD2,4; Susan M. Swetter, MD1,2
[+] Author Affiliations
1Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
2Pigmented Lesion and Melanoma Program, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Stanford, California
3Pathology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
4Dermatopathology Section, Department of Pathology, Stanford University Medical Center, Stanford, California
JAMA Dermatol. Published online August 17, 2016. doi:10.1001/jamadermatol.2016.2869
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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.

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Figure 1.
Case 437: Initial Biopsy With Focal Lentiginous Extension to the Biopsy Edge

A, Junctional melanocytic proliferation with focal bridging of rete ridges by atypical melanocytes with mild-to-moderate cytologic atypia (originally read as junctional melanocytic nevus with mild dysplasia). B, High-power view of areas of mild-to-moderate cytologic atypia and bridging of melanocytic nests.

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Figure 2.
Case 437: Biopsy of Recurrent Pigmentation 5 Years After Initial Biopsy

A, Irregular nesting and extensive lentiginous proliferation with extension beyond the biopsy scar (read as atypical intraepidermal melanocytic proliferation, favor early melanoma in situ, lentigo maligna type). B, Melan-A stain highlights the confluent junctional atypical melanocytes with irregular nesting and pagetoid upward scatter that extends to the biopsy margin. C, Hyperchromatic, enlarged nuclei of the atypical melanocytes are observed with extensive pagetoid scatter. D, Melan-A stain aids in the identification of the atypical melanocytes present in nests and lentiginous spread within the epidermis.

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