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Atypical Mole (Dysplastic Nevus) Workup

  • Author: Manuel Valdebran, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jan 12, 2015
 

Imaging Studies

Dermoscopy (epiluminescence microscopy) can be used to evaluate atypically pigmented lesions. In trained individuals, dermoscopy can improve accuracy in identifying melanoma from atypical nevi.[33] See Dermoscopy for more information.

Total body photography has been shown to aid in detection of evolving melanomas and encourage patients to do self-skin examinations. This is expensive, requires special equipment and training, and may best be used in a pigmented lesion clinic.[30]

Recently, in vivo confocal microscopy has been used to identify dysplastic nevus; pilot studies have shown significant reflectance confocal microscopy correlates. Some of the features identified were the presence of a ringed pattern, meshwork pattern, atypical junctional cells in the center of the lesion, and irregular junctional nests with short interconnections.[34]

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Procedures

All patients who have or had an atypical mole should have an examination of the entire cutaneous surface. A recent change in a pigmented lesion should alert the clinician to consider an excision or a biopsy to rule out the development of malignant melanoma.

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Histologic Findings

Typical histopathologic features, which are superimposed on those of a typical junctional or compound nevus, include the following (Note: Some clinical atypical moles are normal histologically):

  • An increased number of single melanocytes along the basal layer, with elongation of rete ridges
  • Cytologic atypia of melanocytes with enlarged, hyperchromatic nuclei in the junctional component: Atypia is usually confined to the shoulder region of the nevus. Diffuse atypia is more worrisome.
  • A horizontal arrangement of melanocytes, which generally vary in shape from round to spindled, although an occasional epithelioid configuration may also be identified
  • A tendency for melanocytes to aggregate into variably sized nests, which fuse with adjacent rete ridges to produce bridging
  • The presence of lamellar and concentric dermal fibroplasia [35]
  • The presence of a lymphocytic infiltrate (patchy or diffuse) in the superficial dermis
  • Extension of the junctional component many rete ridges beyond the last dermal nest to produce "shoulders"

The above changes may appear focally in any given lesion, and they may not be evident unless multiple histopathologic sections are studied.

The World Health Organization Melanoma Program has proposed a similar list of characteristics/criteria for dysplastic nevi. Criteria are divided into 2 major and 4 minor criteria. An individual lesion requires 2 major and 2 minor criteria to be classified as a dysplastic nevus.[5] Currently, most dermatopathologists are not using this classification scheme. However, the establishment of widely accepted criteria may eventually result in the uniform selection of patients for trials and population studies.

Human leukocyte antigen ( HLA) expression may be useful as an objective biomarker of atypical nevi. In one study, HLA class I heavy chain, β2m, and HLA class II β chain were expressed in 8.6% of common nevi, compared with approximately 72% of atypical melanocytic lesions. The level of HLA expression was correlated with the degree of cytologic atypia and architectural disorder in dysplastic lesions.[36]

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Contributor Information and Disclosures
Author

Manuel Valdebran, MD Visiting Dermatopathology Fellow, University of California, San Francisco, School of Medicine

Manuel Valdebran, MD is a member of the following medical societies: International Dermoscopy Society, Medical Dermatology Society, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Vinod B Shidham, MD, FRCPath Professor, Vice-Chair-AP, and Director of Cytopathology, Department of Pathology, Wayne State University School of Medicine, Karmanos Cancer Center and Detroit Medical Center; Co-Editor-in-Chief and Executive Editor, CytoJournal

Vinod B Shidham, MD, FRCPath is a member of the following medical societies: American Association for Cancer Research, American Society of Cytopathology, College of American Pathologists, International Academy of Cytology, Royal College of Pathologists, United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Robin Travers, MD Assistant Professor of Medicine (Dermatology), Dartmouth University School of Medicine; Staff Dermatologist, New England Baptist Hospital; Private Practice, SkinCare Physicians

Robin Travers, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Informatics Association, Massachusetts Medical Society, Women's Dermatologic Society, Medical Dermatology Society

Disclosure: Nothing to disclose.

Acknowledgements

Scott M Acker, MD Associate Professor, Director of Dermatopathology, Departments of Dermatology and Pathology, University of Alabama at Birmingham

Scott M Acker, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Clinical Pathology, and Southern Medical Association

Disclosure: Nothing to disclose.

Steven Brett Sloan, MD Assistant Professor, Department of Dermatology, University of Connecticut School of Medicine; Residency Site Director, Connecticut Veterans Affairs Healthcare System; Volunteer Clinical Instructor, Yale University School of Medicine

Steven Brett Sloan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Connecticut State Medical Society

Disclosure: Nothing to disclose.

Kimberly A Wenner, MD Assistant Chief of Dermatology, Madigan Army Medical Center

Kimberly A Wenner, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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