Is a Punch Biopsy Enough for Atypical Moles?

Question

I had a few shave biopsies done 2 weeks ago. Two came back with mild atypia. The PA said they would do a punch biopsy to get the rest out. I asked if I could do an excision and she said its not really necessary. That the punch biopsy would get a wider and deeper sample and the margins would be tested. Is this enough of a precautionary measure to prevent this atypical mole from coming back/turning into melanoma? Btw I'm Asian, dark hair, have about 25 moles on body, no family history. Thank you.

Gary Goldenberg, MD · Answer

This is more than enough. In fact, I don't recommend removal of mild atypia at all. Despite what plastic surgeons will tell you, these lesions don't need to be removed. Moreover, if you look at medical literature, shave biopsy is a perfectly appropriate tool for diagnosis. Go see a dermatologist for follow up and make sure to use sunscreen.

Naomi Donnelley, MD · Answer

For small, mildly, atypical moles, using a punch biopsy to remove the entire nevus is reasonable. The specimen will be reviewed by a pathologist to confirm that the margins are clear. Larger, atypical moles often require excisions because the punch biopsy instrument may not be large enough to completely remove the lesion. Severely atypical moles are often treated like melanoma in situ (the earliest form of non-invasive melanoma), and excised with 5 mm margins. Your dermatologist will usually get a report from the pathologist identifying how atypical/concerning the mole is which guides further treatment. In your case, it sounds like they are proceeding appropriately.

Samir Shureih, MD · Answer

The PA can not be more wrong.

	You have atypical moles by shave biobsy. Moles should be completely excised No shaving of moles , only complete excision of moles. Shaveing of moles will interfer with staging of melanoma, and you would loose that opportunity which is important in planning for treatment. Puch biobsy does not examine the entire mole.

	Find a plastic surgeon to excise your moles and submit for pathology testing.

Arnold R. Oppenheim, MD (retired) · Answer

How to proceed in a patient whose mole's biopsy report has been diagnosed as mildly atypical, depends on the philosophy of the dermatologist.

	Atypia can be either architectural or cellular. Architectural disorder means that there are some irregular features in the general shape and configuration of the mole. Cellular atypia means that some of the cells may have a nucleus that is too large for the size of the cell, or the nucleoli look off-color. Cellular atypia is more serious than architectural disorder. 

	 Many dermatologists will consult with the pathologist. If the pathologist is confident that the mole will not behave badly, he/she may advise us to leave the mole alone, that no further surgery is necessary.  These dermatologists will request that the patient return if there is a sign of pigment recurring.  Some dermatologist are not comfortable with this approach, and will excise the entire mole. 

	I prefer an excision of an atypical mole rather than a punch biopsy.  I feel there is a better cosmetic result, especially on the larger excisions. I disagree with the PA that the punch biopsy goes deeper; the depth of the excision and the depth of the punch biopsy would  be the same. However, if the punch biopsy is well around the scar of the mole, and the pathology as returned that there are no residual nevus cells, then, otherwise it would not matter.

	One other thing. I find nothing wrong with a PA examining you first. However, I hope that a dermatologist followed up this examination. There are too many practices where a PA is acting as a dermatologist...not with the goal of improving medical care, but for the economic benefit of the dermatologist. If the PA examined you and THEN the dermatologist, that is fine, since four eyes can be better than two. 

	In regards to the shave, I would assume that your pigmented lesions drew little suspicion of a melanoma. In such cases a shave biopsy can be safely performed. The vast majority of melanomas begin high up in the skin. However, if a melanoma is suspected, either a saucerization technique ( essentially a deep shave) or a total excision should be done, not a superficial shave biospy. Dr. June Robinson showed in a paper in 2008, that a saucerization technique was as effective as an excision. In some cases, with a large atypical pigmented lesion such as a lentigo maligna ( Hutchinson's freckle), this method  may even be preferred.

Mitchell Schwartz, MD - Account Suspended · Answer

A shave biopsy is often the best way to go to have a mole checked for cancer. If the biopsy results show it to be cancerous or pre-cancerous then a second step, a complete excision with uninvolved margins, is necessary to ensure its complete removal. For relatively small moles, especially those that are only "mildly atypical", a punch biopsy may be all that is necessary to get clear margins. This will be determined by the biopsy report. In our office we will do an excision with suture closure to get clear margins for all moles that have moderate to severe atypia. For 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.

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