Melanocytic Nevi


Article Author:
Myron Bodman


Article Editor:
Ahmad Al Aboud


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/8/2019 1:59:39 PM

Introduction

Pigmented lesions of the skin are commonly called freckles. They include solar lentigo, congenital nevi, mucosal nevi, and special nevi of the palms and soles. This chapter will help to differentiate the various pedal nevi from acral lentiginous melanoma clinically. Plantar melanomas are characteristically late to be diagnosed, have a poorer response to treatment and a significantly higher mortality rate when compared to more proximal melanomas.[1]

Etiology

A severe childhood is strongly associated with an increased risk of melanoma, while more incremental occupational exposure does not confer an increased risk. These findings support the hypothesis that melanoma risk is affected primarily by intermittent intense sun exposure that seems to paralyze the normal immune surveillance and destruction of abnormal melanocytes. Sunburn in adolescence damages lifelong immune surveillance and disturbs normal apoptosis of neoplastic cells. Genetic susceptibility also may help account for melanoma in shaded areas. As many as 1 in 10 cases of melanoma may be linked to inherited faulty genes.[2]

Epidemiology

The actual increase in melanoma incidence is most likely due to an overall increase in ultraviolet (UV) light exposure. Although melanoma, in general, is thought to be rare, the incidence of melanoma worldwide is rising dramatically, and despite increased efforts at screening, mortality rates have not appreciably improved. In the United States, melanoma is the fifth leading cancer in men, and the seventh in women and its incidence has doubled in the last ten years. In a study of [3] data (1992 to 2004) researchers found that the actual incidence of melanoma (all thicknesses and among all socioeconomic levels) is increasing case burden. The increase is from 4.7 to 7.7 cases per 100,000 older men, and from 5.5 to 13.9 cases per 100,000 females. Although 5% of all melanomas are located on the foot, pedal melanoma is relatively rare in whites. Among East Asians and darkly pigmented people, acral lentiginous melanoma is the most common subtype.[4]

Pathophysiology

Melanocytes are special dendritic cells derived from neural crest that have the ability to spread over the entire surface of the body. This spreading ability could help account for melanoma’s ability to metastasize across tissue plains and through blood vessels, nerves, and lymphatics. This metastatic passport helps make melanoma more lethal than other skin cancers that are limited to adjacent spread. Although the foot receives less solar exposure, pedal melanoma is more lethal than even more proximal thigh melanoma. Although the 5-year survival rate for melanoma of the calf is 94%, the 5-year survival rate for foot melanoma is 77%. Acral melanoma has a significantly poorer prognosis than the other subtypes of melanomas.[5]

History and Physical

Patients may present with a changing plantar mole. However, acral melanomas typically are discovered only upon focused examination of the soles and toe webs. Anatomically, the palms and soles lack hair follicles and sebaceous gland but have a plethora of sweat ducts. The palms and soles are much thicker, and regular patterns are distorted by walking and grasping pressures. Simple clinical evaluation looking for asymmetry, irregular borders, color variation, diameter greater than 6 mm and change over time or lesion elevation is important. Augmenting these clinical observations with dermoscopy can increase diagnostic acumen by 20%. A complete examination of the soles, toe web spaces, and nail units are important components of a lower extremity examination.[6][7]

Evaluation

In addition to evaluating the A through E characteristics of a pigmented lesion, there are specific dermoscopic patterns to guide examination. There are three benign patterns and one malignant dermoscopic pattern to consider. The parallel furrow pattern of linear pigmentation is benign over 93.2% of the time. The fibrillar pattern with pigmented furrows and fine angulated crossing filamentous, as well as the lattice-like pigment, are benign patterns. Most importantly, the parallel ridge pattern with wide diffuse pigmentation of the ridges predicts melanoma 93.7% of the time. Violation of the normal parallel furrow pattern indicates biopsy.[8]

Treatment / Management

An atypical nevus on the sole can be biopsied with a simple 2 mm punch.  If initial wide excision is chosen, a 1 to 2 mm rim of normal-appearing skin, along with a cuff of sub-dermal fat is recommended. Once melanoma is found by either the punch or total extensional biopsy, wider excision with surgical margins of 1cm for the 0 to 2 mm thick tumors and up to 5 cm for tumors that are over 2.1 mm in thickness can be planned. This may lead to extensive tissue loss that may require amputation. In general, small plantar melanoma excision sites allowed to granulate in. Once primary healing has taken place, plastic skin grafting and flaps can be used to restore weight bearing function. Mohs microsurgery has been used to minimize tissue loss. An experienced oncology team is important to improve outcomes. The Melanoma Staging database is based on the clinical experiences in over 38,900 melanoma patients and incorporates a tumor, node, metastasis (TNM) system. It relies upon assessments of the primary tumor (T), regional lymph nodes (N), and distant metastatic sites (M). The Breslow thickness primarily determines the T and is modified by the mitotic rate of the tumor. The 10-year survival rate decreases progressively, from 96 percent with primary lesions <0.5 mm thick to 54 percent with lesions 4.01 to 6 mm thick. [9]The N or lymphatic node designation assesses regional lymph node spread and has a major negative impact on long-term survival. The sentinel lymph node biopsy (SLNB) is recommended for tumors equal to or greater than 0.75mm thick.  If positive, complete lymph node dissection is recommended. Adjuvant interferon alpha is then recommended in patients that have a life expectancy of greater than ten years. Therapies that target T lymphocytes antigens can induce an anti-tumor immune response. Ipilimumab, is immune checkpoint inhibitor and has extended survival. Complications include exacerbation of pre-existing immune disorders. Anti-programmed cell death (PD-1) monoclonal antibodies like nivolumab and pembrolizumab, have demonstrated more effective results than conventional drugs in clinical trials for a variety of advanced solid tumors including melanoma, non-small cell lung carcinoma, and renal carcinoma. The five-year survival rate for plantar melanoma is 82% for lesions up to 1.49mm and 0% for lesions over 3.5mms[10]

Pearls and Other Issues

Advising patients to use sunscreens, perform self-examinations, and avoid tanning beds helps prevent melanoma of all types. Early detection through complete lower extremity examination aided by dermoscopy should reduce the time to acral melanoma diagnosis and improve survival. [11]

Enhancing Healthcare Team Outcomes

The diagnosis and management of melanocytic nevi is best done with a multidisciplinary team that also includes the pharmacist and nurses; the latter two play a role in educating the public about prevention.

If melanocytic nevi are not diagnosed, the prognosis is poor. Thus to improve patient outcomes, a thorough exam of the skin is vital. Patients may present with a changing plantar mole. Acral melanomas typically are discovered only upon focused examination of the soles and toe webs. Simple clinical evaluation looking for asymmetry, irregular borders, color variation, diameter greater than 6 mm and change over time or lesion elevation is important. If there is ever a doubt about a skin lesion, a biopsy should be performed.


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    Contributed by Myron Bodman DPM
Attributed To: Contributed by Myron Bodman DPM

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Melanocytic Nevi - Questions

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What is the proper first step in treating a nevus (mole) that, after many years, has recently changed color?



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A 12-year-old female presents with a Spitz juvenile melanoma on her lower leg. Which of the following is the most accurate characterization of Spitz nevi?



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A 56-year-old black male presents to the clinic for an annual diabetic foot examination. He has a past medical history of hypertension and type 2 diabetes. His blood pressure is 138/82 mmHg and pulse 76/min. His hemoglobin A1c is 6.9%. The lower extremity physical examination reveals palpable pedal pulses and decreased Semmes Weinstein monofilament sensation bilaterally. There are no open skin lesions. The pedal nails are mycotic, and there are thick callouses on his soles. There is a 0.5 cm mole seen on his right heel. Which of the following best describes the dermoscopic pattern shown in the figure?

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    Contributed by Myron Bodman, DPM
Attributed To: Contributed by Myron Bodman, DPM



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A 45-year-old black male computer programmer presents to the clinic with a nonpainful black streak within the nail of his left index finger. He denies any significant medical history and takes no medications other than an occasional aspirin. He denies a history of skin cancer in himself or his family. His vital signs are within normal limits. He specifically denies any trauma to his fingers. The black streak was first noticed last year and has gotten longer and wider. The solitary band of pigmentation measures 4 mm at its proximal base and narrows to 2 mm wide at the distal free edge. Dermoscopy examination reveals multiple parallel pigmented bands of varying widths that are gray to black in color. No globules are seen. Which of the following is the best course of action?



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A 50-year-old male presents to the clinic with a chief complaint of a mole on his right calf that has increased in size over the past year. He works in maintaining swimming pools. His medical history includes hypertension that is controlled with losartan and hydrochlorothiazide. Lower extremity physical examination reveals palpable pedal and popliteal pulses with intact sensation bilaterally. His flexor and extensor muscle strengths are +5/5 bilaterally. His skin and nails are clear except for a 1 cm black mole on the posterior aspect of his right calf. The mole is comma shaped with a notched border but is not bleeding. Which of the following is the next best step in the management of this patient?



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A 70-year-old white female presents to the clinic with a chief complaint of several moles on her legs. Past medical history includes type 2 diabetes and hypertension. Her blood pressure is 127/76 mmHg while her hemoglobin A1c is 6.5%. She has type I Fitzpatrick skin type. Physical examination reveals three brown to black nevi on both legs. Her skin appears tanned. Each of the nevi is symmetric with smooth borders and measure less than 6 mm in diameter. Dermoscopy examination reveals reticulated melanocytic nevi patterns in all the lesions. Her nails, soles, and toe webs are clear of any pigmented lesions. She reports having had two benign moles removed from her back three years ago. She enjoys sitting in the sun with her legs uncovered. Which the following is the best advice for this patient?



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A 67-year-old black male presents to the clinic for his annual diabetic foot examination. He complains of thick, yellowed toenails that rub in his shoes. Lower extremity physical examination reveals decreased sensation in both feet, palpable popliteal and pedal pulses. There is a small black nevus on his right heel that exhibits a parallel ridge dermoscopic pattern. Which of the following types of skin cancer has the lowest 5-year survival rate?



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Melanocytic Nevi - References

References

Acral melanocytic nevi: prevalence and distribution of gross morphologic features in white and black adults., Palicka GA,Rhodes AR,, Archives of dermatology, 2010 Oct     [PubMed]
The BRAAFF checklist: a new dermoscopic algorithm for diagnosing acral melanoma., Lallas A,Kyrgidis A,Koga H,Moscarella E,Tschandl P,Apalla Z,Di Stefani A,Ioannides D,Kittler H,Kobayashi K,Lazaridou E,Longo C,Phan A,Saida T,Tanaka M,Thomas L,Zalaudek I,Argenziano G,, The British journal of dermatology, 2015 Oct     [PubMed]
Clinical guidelines for the recognition of melanoma of the foot and nail unit., Bristow IR,de Berker DA,Acland KM,Turner RJ,Bowling J,, Journal of foot and ankle research, 2010 Nov 1     [PubMed]
Nevares-Pomales OW,Sarriera-Lazaro CJ,Barrera-Llaurador J,Santiago-Vazquez M,Lugo-Fagundo N,Sanchez JE,Sanchez JL, Pigmented Lesions of the Nail Unit. The American Journal of dermatopathology. 2018 Nov;     [PubMed]
Bristow I,Bower C, Melanoma of the Foot. Clinics in podiatric medicine and surgery. 2016 Jul;     [PubMed]
Wang M,Xu Y,Wang J,Cui L,Wang J,Hu XB,Jiang HQ,Hong ZJ,Yuan SM, Surgical Management of Plantar Melanoma: A Retrospective Study in One Center. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2018 Jul - Aug;     [PubMed]
Wang B,Qu XL,Chen Y, Identification of the potential prognostic genes of human melanoma. Journal of cellular physiology. 2018 Nov 30;     [PubMed]
Bae E,Leone D,Konnikov N,Mahalingam M, Demographics, Risk Factors, and Incidence of Melanoma in Patients in the New England VA Healthcare system. Military medicine. 2018 Nov 5;     [PubMed]
BartoŇ° V,Kullová M, Malignant Melanomas of the Skin Arising on the Feet. Klinicka onkologie : casopis Ceske a Slovenske onkologicke spolecnosti. 2018 Summer;     [PubMed]
Richtig E, ASCO Congress 2018: melanoma treatment. Memo. 2018;     [PubMed]
Crompton JG,Gilbert E,Brady MS, Clinical implications of the eighth edition of the American Joint Committee on Cancer melanoma staging. Journal of surgical oncology. 2018 Dec 21;     [PubMed]

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