Mild, Moderate and Severe Moles: Should They All be Removed?

Moles can be classified based on how dysplastic they appear.  They are graded by atypia from mild to moderate to severely atypical (or dysplastic).  If the pathologist did not read these moles as melanoma than they are not.  What it means is that the cells have changed and left untreated they could go on to become a melanoma.  You do not need an oncologist, just a good board certified dermatologist who is familiar with skin cancer treatments.

Moles and melanoma appear to be on a continuum under the microscope, from the most benign garden-variety moles to dysplastic nevi with mild atypia, moderate atypia, severe atypia and then melanoma.

The concept of dysplastic nevus is controversial.  We know dysplastic nevi are a marker for higher risk of developing a melanoma, but we don't have any evidence showing that they themselves (the dysplastic nevi) are precancerous lesions. 

There is no good scientific way of studying it prospectively, meaning there is no way to know something is a dysplastic mole without biopsying it, and biopsying it means you are changing the nature and behavior of the lesion, so what it will do in the future is not necessarily what it would have done had it not been disturbed by the biopsy.  So we can only analyze things by looking back.  And looking back, melanomas arise primarily on normal skin, and much less often in a mole.  The statistics are about 20% of melanomas are seen in association with a mole under the microscope.  So theoretically if one removes all the moles they have, they are decreasing their risk of melanoma by approximately 20%.  Not great numbers.

So my approach is that I remove lesions that I find suspicious for melanoma, such as those with Asymmetry, Border irregularity, Color irregularity, Diameter greater than 1/4 inch (not the most reliable indicator) and any Evolving or changing moles. This is the so called ABCDE rule.

When I remove suspicious moles, it is because I am concerned they may be cancerous, and I excise them with sutures in an attempt to remove the entire lesion with a margin of 1-2 mm of normal tissue. Most of the time, that way the entire lesion is removed. However, I recommend re-excision of all moderately and severely atypical moles that were not completely removed by the initial procedure.

For people with a large number of atypical appearing moles, one of the best ways of follow-up, aside from regular total body skin examinations by a dermatologist, is total body imaging with a system such as Melanoscan, where the skin is imaged and photographs are taken so that they can be compared easily on subsequent visits.  Early and subtle changes can be detected this way.

Not everyone needs such a sophisticated screening method, but people with a large number of large atypical moles, particularly if they also have a family history of melanoma, would benefit from such imaging.

The degree of atypia is diagnosed under the microscope.  Having many atypical moles does increase the risk of a melanoma so total body  skin checks are a must. As to what to do with these lesions, there is a continuum under the microscope of benign mole ranging to melanoma with the steps being normal mole , mild atypia , moderate atypia , severe atypia , melanoma.  Whether to cut more depends on both the margins (whether they are clear or not) as well as what the dermatologist thought when the lesions were removed.  To be clear (based on the information you provided), you (your husband) do not have a diagnosis of melanoma .   Some doctors call these atypical moles "premelanomas" which can be misleading as well.  Many dermatologists will give you many different answers as to whether or not to cut more out .  You need to make this decision with your dermatologist as to which can be followed and which need to be removed.  The one that almost all derms would agree needs further excision is the severe atypia as this is a way of the dermatopathologist indicating that this is as close to a melanoma you can get without having one.  Again, how the biopsy was performed and how close to the margins it came, and whether it is still positive at the margins etc will dictate how to proceed.  As long as you are with a board certified dermatologist or a Mohs surgeon who is board certified and fellowship trained you are in the most experioenced hands when it comes to management of these lesions.