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Original Investigation
December 2018

Risk of Subsequent Cutaneous Melanoma in Moderately Dysplastic Nevi Excisionally Biopsied but With Positive Histologic Margins

Author Affiliations
  • 1Pigmented Lesion Clinic and Cutaneous Oncology Program, Department of Dermatology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
  • 3Division of Dermatology, Atlanta Veterans Administration Medical Center, Decatur, Georgia
  • 4Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
  • 5Pigmented Lesion and Melanoma Program, Department of Dermatology, Stanford University Medical Center, Palo Alto, California
  • 6Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 7Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 8Department of Dermatology, Huntsman Cancer Institute, University of Utah, Salt Lake City
  • 9Department of Oncological Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City
  • 10Pigmented Lesion Clinic and Multidisciplinary Cutaneous Oncology Program, Division of Dermatology, Department of Medicine, University of Arizona, Tucson
  • 11Pigmented Lesion Clinic, Department of Dermatology, University of Pennsylvania, Philadelphia
  • 12University of Massachusetts Medical School, Worcester
  • 13Morehouse School of Medicine, Atlanta, Georgia
  • 14University of Utah, Salt Lake City
JAMA Dermatol. 2018;154(12):1401-1408. doi:10.1001/jamadermatol.2018.3359
Key Points

Question  Can moderately dysplastic nevi that have been excisionally biopsied with no residual clinical pigmentation but with positive histologic margins (hereafter referred to as moderately dysplastic nevi with positive histologic margins) be closely observed instead of reexcised?

Findings  This multicenter cohort study of 467 moderately dysplastic nevi with positive histologic margins found no cases of cutaneous melanoma at the biopsy site after a mean follow-up time of 6.9 years. However, patients with 2 or more biopsied dysplastic nevi had an increased risk of developing a subsequent cutaneous melanoma at a separate site.

Meaning  Observation of moderately dysplastic nevi with positive histologic margins may be reasonable; however, screening for subsequent cutaneous melanoma at separate sites appears to be warranted for individuals with multiple histologic dysplastic nevi.

Abstract

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.

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