Pigmented lesions: Diagnosis, treatment standards needed

Abel D. Jarell, MD: “In America, we biopsy too many lesions unnecessarily — pigmented lesions in particular.”

As the number of melanoma cases increases, the diagnosis and treatment of pigmented lesions has become a sore point in dermatology, with many questions about the best approaches. Established and developing diagnostic and treatment processes were examined July 27 during “Pigmented Lesions, Shedding Light on the Blackness” (F003).

Among the successful approaches reviewed were watching atypical nevi before excising them, increasing the use of photography and dermoscopy, and studying the genetic signatures of pigmented lesions. Updated recommendations in the Eighth Edition of the American Joint Committee on Cancer (AJCC) Staging Manual were also reviewed.

Overtreating

“In America, we biopsy too many lesions unnecessarily — pigmented lesions in particular. We over-treat a great number of pigmented lesions, particularly so-called dysplastic nevi with mild, moderate, and severe atypia,” said the session director, Abel D. Jarell, MD. “In the last three years or so, particularly in the last year, there has been an onslaught of publications confirming that we over-treat some pigmented lesions, yet providers are still doing it.”

Rather than make judgments based on the naked eye, a step in the right direction would be for every dermatologist to use dermoscopy, he said.

“Many clinically atypical pigmented lesions become quite obviously benign under dermoscopy,” Dr. Jarell said in an interview about the session. “Too many providers are failing to use dermatoscopes, and others who do have dermatoscopes do not know how to use them. So, as a group, we are cutting off too many lesions unnecessarily, and that has implications for the overall health care costs and what we do as physicians in taking care of patients and doing unnecessary procedures.”

New cancer staging manual

Another important management tool is the new edition of the AJCC Cancer Staging Manual, which will take effect Jan. 1, 2018. Dr. Jarell, a dermatologist and dermatopathologist at Northeast Dermatology Associates in Portsmouth, New Hampshire, said that the important changes in the new edition are:

  • The measured Breslow depth of melanomas will be rounded to the 10th of a millimeter; they are now measured to 1/100th millimeter.
  • T1a melanoma will be < 0.8 mm; they are now < 1.0 mm without ulceration or mitoses.
  • T1b melanoma is > 0.8 mm regardless of ulceration, or < 0.8 mm and ulcerated.
  • Mitoses are no longer taken into consideration in grading invasive melanoma, regardless of thickness.
  • The N category now has four categories, an increase of one category.

 

Genomics holds key to future

Tammie C. Ferringer, MD, discussed the growing case for classifying some melanoma subtypes at the genetic level based on their mutations. She is section head for dermatopathology at Geisinger Medical Center.

“Genomics is the way of the future in terms of determining how a melanocytic nevus is going to behave,” Dr. Jarell said. “It is going to be more telling and precise than what pathologists can tell you they are seeing under the microscope, and this change will happen in the not-so-distant future.”

Atpical nevi examined

Daniela Kroshinsky, MD, MPH, reviewed her recently published research on the treatment of atypical nevi. She is associate professor of dermatology at Massachusetts General Hospital.

Dr. Jarell said, “Moderately atypical nevi do not necessarily need to be re-excised. The clinician needs to make a judgment as to whether they can be watched safely, and most often observation is fine, as opposed to doing an immediate re-excision. The clinician can use photography and dermoscopy to aid in judging if a lesion was completely removed or if it was indeed worrisome for melanoma.”

Keeping pigmented lesions in the picture

Caroline C. Kim, MD, described her processes for using photography to determine how to manage pigmented lesions and how photos can be used during follow-up. She is director of the Pigmented Lesion Clinic at Beth Israel Deaconess Medical Center and assistant professor of dermatology at Harvard Medical School.

“Taking pictures in the clinic used to be a cumbersome process just five years ago,” Dr. Jarell said. “In 2017, it is incredibly easy to transfer a photograph to a medical record. Only now are people beginning to catch on. It is surprising to me in this day and age that a patient who should be followed with digital photography is not.”

Another factor in the management of pigmented lesions is differences in training and in the practice of dermatology among different regions of the U.S., he said. Not all dermatopathologists are using evaluation criteria, which were developed in the early 1990s.

More consensus needed

“You can get an entirely differently diagnosis for the exact same lesion depending on where a dermatopathologist practices or where a dermatopathologist trained. I find that extremely problematic and confusing,” Dr. Jarell said. “We need to meet for consensus. There needs to be a strong movement in that direction.”

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