Case Number : Case 1935 - 30 Oct - Dr Uma Sundram Posted By: Guest

Moderately dysplastic junctional naevus with epidermal atrophy - I would give measurement to peripheral margin; but in general if the lesion is completely excised the clinicians would not go back. 

Junctional dysplastic nevus with (moderate/severe) atypia; the degree of atypia reported will depend on a thorough examination of the sections for the degree of solar elastosis, cytologic atypia, lentiginous spread, pagetoid scatter, and circumscription, with the aid of MART1 when necessary, and occasionally SOX10.

In a lesion that is sharply circumscribed without internal skip/regressed areas, I would not recommend excision. If there is a concern in my mind about the circumscription in a severely dysplastic nevus, or if I am suspicious of it being MIS/evolving MIS, I would say so in the comment and recommend a modest excision.

Moderately dysplastic junctional nevus. I do not think I will recommend re-excision

Yes! No worrisome features! Margins free. Agree with above. 

On 10/30/2017 at 15:24, Iskander H. Chaudhry said:

Moderately dysplastic junctional naevus with epidermal atrophy - I would give measurement to peripheral margin; but in general if the lesion is completely excised the clinicians would not go back. 

agree

This brings up an extremely interesting point which I would love to explore further. Non capitated care (unlike NHS) and a highly litiginous society in the US leads (in my opinion) to over treatment of melanocytic lesions; hence I like to couple my melanocytic spot diagnoses with queries about recommendations from the audience. In this case, the age of the patient, and drift of cells towards peripheral margins, in a lentiginous, poorly nested, melanocytic proliferation with epidermal atrophy, led us to recommend a modest re excision, which the clinician agreed was a reasonable approach.

I think certainly in my area of the UK we are lucky because we seldom get this sort of specimen!  Usually they will excise formally a clinically "atypical" lesion and then you know it's out so the "classification" becomes academic. I tend to withhold definitive diagnosis in such thin hard to classify cases and especially if partially sampled and recommend management guided by degree of clinical concern commenting on the level of cytological atypia. Here I agree a rather uniform mild atypia (allows a range of diagnoses from mildy atypical junctional lentiginous naevus - favoured up to an early in situ melanoma). Age is against naevus of course. I have started to explain to experienced clinical colleagues who know how to use a dermatoscope they are probably better at diagnosing such thin lesion compared with the histopathologist who is putting a tail on the donkey often blindfolded!