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Department of Dermatology
The State of the Dysplastic
Nevus in the 21st Century
Keith Duffy, MD
Associate professor
Department of Dermatology
University of Utah
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Disclosures
• Myriad Genetics
– Advisory board; honorarium
• Castle Biosciences
– Advisory board; honorarium
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What do I do?
• Clinical
– 60% Mohs micrographic and reconstructive
surgery and high risk skin cancer
– 40% Dermatopathology sign-out
– Multidisciplinary cutaneous oncology
program – Huntsman Cancer Institute
• Administrative
– Residency Program Director, Dermatology
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Department of Dermatology
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Department of Dermatology
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The current(ish) state of
affairs…
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Do you believe dysplastic (Clark) nevi
are truly premalignant lesions?
A. Yes
B. No
C. Unsure
A. B. C.
25%22%
53%
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How do you report “dysplastic
nevi”?
A. Dysplastic nevus
B. Clark nevus
C. Nevus with architectural
disorder
D. Other
A. B. C. D.
62%
12%
19%
7%
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Do you assign a histologic
“grade” to these nevi?
A. Yes
B. No
A. B.
13%
87%
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If yes, what grading system do
you use?A. Cytology as three
grades (mild, moderate, severe)
B. Cytology and architecture as two separate grades
C. Cytology as two grades only
D. Other grading system A. B. C. D.
73%
10%10%8%
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Brief history
• 1978 – Dr. Clark describes nevi associated
with melanoma prone families
– The B-K mole syndrome
• 1978 – Dr. Lynch describes a single multi-
generational family with melanoma and
nevi
– Familial atypical multiple mole melanoma
syndrome (FAMMM)
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Brief history
• 1980 – Dr. Elder and Clark describe
‘dysplastic nevi’ in a non-familial setting
– Introduction of the term ‘dysplastic nevus
syndrome’
• Familial and sporadic variants
• Formally postulated that ‘dysplastic nevi’ are
precursors of melanoma
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Dr. Wallace H. Clark, Jr.
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The concept evolved…
Dr. David Elder
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When you are frustrated by the pathology
report and management of these lesions
please send all complaints to…
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Department of Dermatology
• Recommend abandoning the term “dysplastic nevus.”
• Highlights melanoma risk is linked to high nevus counts and large
nevus size
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Department of Dermatology
J Am Acad Dermatol 2015;73:513-4
J Am Acad Dermatol 2015;73:514-5
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• “Dysplastic nevi are benign neoplasms of melanocytes that
are significant in relation to melanoma in 3 ways: as potential
precursors, markers of increased risk, and simulants.”
• “Dysplastic nevi are intermediate between common nevi and
melanoma – clinically, microscopically and genomically.”
• …in my opinion the term “mild dysplasia” should be
abandoned.”
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• “I believe that most so-called ‘severely dysplastic’ are
either melanoma or melanoma in situ arising in a
nevus.”
• “I believe it would be reasonable to change the name
‘dysplastic’ nevus.”
• “I do not believe the name ‘dysplastic’ nevus will
change anytime soon.”
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What is a dysplastic nevus?
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Duffy K, Grossman D, J Am Acad Dermatol. 2012 Jul;67(1):1-16
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Duffy K, Grossman D, J Am Acad Dermatol. 2012 Jul;67(1):1-16
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Duffy K, Grossman D, J Am Acad Dermatol. 2012 Jul;67(1):1-16
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Duffy K, Grossman D, J Am Acad Dermatol. 2012 Jul;67(1):1-16
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Shea CR, Vollmer RT, Prieto VG, Correlating architectural disorder and cytologic
atypia in Clark (dysplastic) melanocytic nevi, Hum Pathol 1999, 30:500-5
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“I know one when I see one.”
Duncan et. al., J Invest Dermatol 1993 100:318S-321S
Piepkorn et. al., J Am Acad Dermatol 1994,30:707-714
Weinstock et. al., Arch Dermatol 1997,133:953-958
Clemente et.al., 1991 Hum Pathol 22:313-319
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Mutations in nevi
• Common nevi have a high rate of BRAF
V600E mutations
• Sporadic dysplastic nevi appear to be
enriched for NRAS and BRAF non-V600E
mutations
• Recurrent TERT promoter mutations in a
significant portion of dysplastic nevi
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Department of Dermatology
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Department of Dermatology
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Department of Dermatology
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Department of Dermatology
Cockerell et al. Medicine (2016) 95:40
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What do we do now?
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Department of Dermatology
Arch Dermatol. 2012 Feb;148(2):259-60
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Department of Dermatology
The decision to re-excise
moderately dysplastic nevi
inverted from a minority
(9%) to a majority (81%) as
a function of positive margin
status.
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Department of Dermatology
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Results
• 467 moderately dysplastic nevi with
positive histologic margins observed for
>3 years
– Median f/u 6.9 years
• NO cases of cutaneous melanoma
developed at those sites
• 100 patients (22.8%) developed a
cutaneous melanoma at a separate site
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Department of Dermatology
41 year old female left lower back
40x
Do you think there is a TERT promoter mutation in this lesion?
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Department of Dermatology
100xDx: Compound dysplastic nevus with moderate cytological atypia, narrowly excised
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Department of Dermatology
49 year old, left lower back
40x
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Department of Dermatology
100xDx: Malignant melanoma, superficial spreading type, Breslow depth 0.32 mm
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Study results
• 17,024 Total nevi
• 8654 cases Clark nevi (50.8%)
• 959 recommended for re-excision
(11.1%)
• 765 re-excised (79.8%)
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Study results
• Of those re-excised 765
– 621 no residual nevus (81.2%)
– 123 identifiable benign component (16.1%)
– 6 not classifiable as benign or malignant
– 15 melanoma (2.0%)
• 12 MIS
• 3 superficially invasive
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My dermatopathologic
approach?• Less use of the term dysplastic nevus,
Clark’s nevus or nevus with architectural
disorder
– Use of the terms ‘junctional or compound
lentiginous nevus’
– Atypical junctional/compound melanocytic
proliferation
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How do I practice?
• I never diagnose a lesion with moderate or
severe dysplasia
• In my estimate this is unfair to the clinician
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How do I practice?
• Make specific recommendations to the
clinician on management of the lesion
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Report example
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How do I practice?Always another set of eyes…pair
of expert eyes
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Conclusions
• Dysplastic nevi appear to be different
histologically and genomically
• Still…only a small number progress to
melanoma
– Which ones?
– Will the genomic and personalized medicine
revolution make our job better/easier/more
conclusive?
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Conclusions
• We are still stuck in The (seemingly)
Eternal Debate
• Pigmented lesions are a team sport
– Clinician concern
– Concensus dermatopathology opinion
– Photographs!
• Molecular medicine is coming
commercially to a lab near you
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