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The Shifting Paradigm in the Management of Giant Congenital Melanocytic Nevi: Review and Clinical Applications

Bauer, Bruce S. M.D.; Dickie, Sara R. M.D.; Marghoob, Ashfaq A. M.D.

Plastic and Reconstructive Surgery: October 2014 - Volume 134 - Issue 4 - p 659e–660e
doi: 10.1097/PRS.0000000000000546
Letters

Division of Plastic and Reconstructive Surgery, NorthShore University HealthSystem, Northbrook, Ill.

Correspondence to Dr. Dickie, Division of Plastic and Reconstructive Surgery, NorthShore University HealthSystem, 501 Skokie Boulevard, Suite 250, Northbrook, Ill. 60062, sdickie@northshore.org

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Sir:

It is with marked interest that we read the article by Arad and Zucker discussing current management of giant congenital melanocytic nevi.1 The indications for surgical intervention have always involved striking a balance between oncologic prophylaxis and cosmesis. These discussions are integral to the surgical practice of treating these patients, and we applaud the reexamination of indications based on data showing a lower than previously expected rate of cutaneous malignant melanoma.2 However, we were surprised to see this article’s current treatment philosophy based largely on only one institution’s experience (i.e., Great Ormond Street Hospital), and the opinions of only one clinician, Dr. Veronica Kinsler.3

Dr. Kinsler at Great Ormond Street Hospital has collected a substantial epidemiologic database of patients with congenital melanocytic nevi. The database was derived from parent-completed surveys and reported phenotypic changes in congenital melanocytic nevi and did not include standardized clinical examinations, histopathologic diagnosis, or review of medical records. Thus, these data cannot be relied on as scientifically accurate and their clinical applicability must therefore be questioned. After review of the Great Ormond Street Hospital data, Dr. Kinsler and colleagues conclude that patients who undergo surgical treatment for congenital melanocytic nevi may have an increased melanoma risk, a conclusion that simply defies logic. Gross architectural changes occurring after surgery cannot be used as evidence to indicate atypical, dysplastic, or premalignant processes. Their own data clearly show that surgical patients have no higher rate of negative endpoints related to melanoma or death than those who never underwent treatment.

The histologic correlate they use to support the above theory is an entity called “pseudomelanoma.” This process, first termed by Kornberg and Ackerman in 1975, describes benign recurrent pigmentation of an incompletely excised nevus. Many authors have derided the nomenclature as being misleading. The references used in the article associating pseudomelanoma with a deleterious process do nothing of the sort. They include two case reports of benign recurrent nevus following laser treatment, a benign recurrent acquired nevus in a skin graft donor site, and a letter to the editor describing pigment changes following dermabrasion in a 64-year-old man with rhinophyma and no nevus history. The final “supporting” article describes repigmentation of large congenital melanocytic nevi treated by curettage and dermabrasion, recommending against these treatments in deeper nevi. Partial excision techniques such as laser, dermabrasion, and curettage are known to leave deeper nevus cells behind and therefore commonly result in repigmentation. As such, these methods are being abandoned by most surgeons who routinely treat congenital melanocytic nevi. It also needs to be emphasized that there has never been a report or a suggestion that any of these treatments predisposes individuals to malignancy. It is our contention that the use of the aforementioned references as justification against surgery is completely invalid. Although there are many valid reasons for or against surgery, perpetuation of the aforementioned biases should be discouraged. This is not only harmful to the scientific understanding of congenital melanocytic nevi, but serves to spread misinformation to the lay public, which in turn creates a barrier that hinders rational discussion of treatment options.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Bruce S. Bauer M.D.

Sara R. Dickie, M.D.

Ashfaq A. Marghoob, M.D.

Division of Plastic and Reconstructive Surgery

NorthShore University HealthSystem

Northbrook, Ill.

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REFERENCES

1. Arad E, Zuker RM. The shifting paradigm in the management of giant congenital melanocytic nevi: Review and clinical applications. Plast Reconstr Surg. 2014;133:367–376
2. Krengel S, Hauschild A, Schäfer T. Melanoma risk in congenital melanocytic naevi: A systematic review. Br J Dermatol. 2006;155:1–8
3. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital for Children Registry for Congenital Melanocytic Naevi: Prospective study 1988-2007. Part 2—Evaluation of treatments. Br J Dermatol. 2009;160:387–392
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