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The challenge of congenital nevi: remove or not remove?

Marghoob, A.A.

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doi: 10.1097/01.cmr.0000382748.32506.66
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Many physicians advocate for the surgical removal of congenital melanocytic nevi (CMN) believing that it reduces the risk of developing melanoma while at the same time improving the aesthetic appearance. However, mounting scientific evidence is forcing us to question this long held adage. While the main impetus for the prophylactic excision of CMN stems from the knowledge that the relative risk for developing melanoma in CMN is high (range, 4–1046), apathy towards surgery stems from the knowledge that the absolute risk for developing melanoma in association with CMN is low (range, 0–10%). Other factors that deter physicians from selecting surgical options include the lack of evidence that removal of CMN actually lowers melanoma risk and that the aesthetic/functional outcomes are often less than desirable. Although there is insufficient evidence in the literature to recommend strongly for or against surgery, it is important to remember that the ‘absence of evidence is not evidence of absence (Carl Sagan).’ That being said, potential pros, cons, risks, and benefits of excision must be weighed against each other for each individual patient prior to recommending surgery or steering them away from surgery. In essence, each CMN patient requires a management plan tailored towards the individual based on the size, thickness, and location of the CMN, and based on its potential psychosocial impact. Outlining the management plan for those individuals deciding not to remove their CMN requires attention to methods of optimizing the clinical follow-up examination. This includes determining the value of clinical inspection, palpation, dermoscopy, and/or other imaging modalities. For those patients opting for surgical intervention, the treatment should attempt to reduce risk of developing cutaneous melanoma while simultaneously optimizing the aesthetic and functional outcomes. In addition, issues such as the risk of surgery, anaesthesia, and scarring, just to mention a few, should be disclosed and it is imperative that realistic expectations be set from the start. Lastly, psychosocial support together with attention focused on providing ways of concealing cosmetically sensitive CMN or scars may prove beneficial for many patients.

© 2010 Lippincott Williams & Wilkins, Inc.