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.

You may be talking anout mild, moderate and severe dysplasia.

If it is DYSPLASTIC NEVI, all should be removed.

and MUST have a full body check now and every 6 months.

I believe you are describing the amount of atypia or dysplasia of your husband's moles.  The more atypical or dysplastic they are, the more likely the will become malignant.  I would suggest your husband be regularly checked by a dermatologist, to monitor all of his moles and have any suspicious ones excised and examined by a pathologist.  If any mole should suddenly change, he should should see his dermatologist immediately.  I would follow your doctor's advice.  The only way to be certain a mole is not a melanoma is to have it removed and examined microscopically. 

In our office, we will do an excision with suture closure to get clear margins for all moles that have moderate to severe atypia. Far a mildly atypical mole we will observe the area and, if any pigmentation recurs in the biopsy site in the future, a very small excision is done (often with a small punch biopsy tool) for a minimal scar. We also follow all of our "atypical mole" patients by doing full skin examinations every six months. I recommend you see a board certified dermatologist for both your surgery options as well as your follow-up examinations twice yearly. As these growths are pre-cancerous, you do not need to visit an oncologist.

 

First, let us dispose of the idea of a trip to the oncologist. Oncologists don't remove moles: some may NEVER have removed a mole in their career; others maybe 1-2 during  a dermatology rotation. Your husband's trip to the oncologist might be the source of brief levity in an otherwise depressing day, but nothing more.

The classifying  of atypical nevi from mild to moderate to severe is a histopathologic grading system. As Dr. Allen mentions, atypical nevi are best regarded as a continuum ranging between totally benign nevi and melanoma. Most dermatopathologists and dermatologists have adapted the term atypical nevi, as dysplastic nevi and before it the B-K Mole syndrome were felt to cause confusion. ( B-K was named after the original patient when Drs. Wally Clark and the affable and brilliant Marty Mihm first described these odd moles with a tendency to turn bad).

 The pathologist looks at the architecture of the mole and the nevus (mole) cells themselves. This information is often buried in the description of the report, but is actually quite crucial. Architectural disorder is not nearly as serious as dysplasia. The atypical mole will generally be graded on the degree of dysplasia. The pathologist carefully looks at the cells: are they larger than the should be? Is the nucleus bigger or darker than normal. In looking at slides with Dr. Mihm, he always stressed the color of the nucleoli.  Others, like the late Bernie Ackerman, tended to look at the way cells were grouped, what they were trying to do, their cohesion or lack of cohesion.

Taking all this information into consideration  the pathologist will determine the degree of atypia ( dysplasia) and convey his or her impression to the dermatologist. I would say all dermatologists believe in a total excision of lesions described as having severe atypia and the vast majority would extend that action to those designated as moderate atypia.

It is in the realm of the mild that there may be some disagreement. Many pathologists will call a mole with only architectural disorder mild atypia. Some will note a few cells that look a bit strange as mild dysplasia or atypia. Some dermatologists will then opt for a total excision, while others will not. Some, like myself, on many occasions, will call the pathologist who interpreted the slide for some guidance. 

One advance that should relieve you ( I know it does me and doubly true for the pathologists of the world) is the cocktail of stains available now for the pathologist. These immunoperoxidase stains will help the pathologist determine whether the mole is benign or malignant. This takes away some of the human judgement. Thus, if a nevus is graded as mild dysplasia,  and the stains confirm a benign diagnosis, one is more comfortable in leaving a mildly atypical nevus alone.

These stains, should also re-assure you and your husband, that he does not have melanoma.

Of course, another factor, is that the report will tell you whether the whole lesion has been removed...that the margins are clear. Perhaps, in your husband's case, they were on the mild dysplasia and certainly nothing more need be done. It should be noted that sometimes, the pathologist will advise ( or even urge) us to re-exise, even with clear margins if there was very severe dysplasia ( and say inflammation and a few nevus cells transversing up the epidermis where they shouldn't be). 

So, in your husband's case, maybe the dermatologist had already obtained clear margins on the mildly atypical nevi and felt no need to subject your husband to another excision. Maybe, there was only architectural disorder, another reason to keep the scalpel in the drawer.

One thing we would all agree on is that you should examine your husband's skin for moles once a month. With a documented severely dysplastic nevus, he should also be examined by your dermatologist every six months. You both should listen as the dermatologists goes over the A ( asymmetry) B (Border irregularity C ( color variegation ) D (greater than 6 mm) and E ( Evolving or changing) warning signs. I would also consider Mole Mapping in which digital photographs are kept in a computerized camera of all the moles, looking for changes in subsequent visits. 

Vigilance is the key.