The terms mole and nevus (plural: moles and nevi) mean the same thing and can be used interchangeably. In this chapter we will use lots of parentheses to indicate that these words that can mean the same thing. Even the experts in the field of dermatology do not agree on the use of all of these terms. This chapter is a distillation of the maze of terms that plagues this very important corner of dermatology.

Moles can be good or bad, sometimes even experts have difficulty agreeing about which moles are good and bad. However, knowledge of moles is important because, among other reasons at least one out of every three melanoma skin cancers arises in a mole. Because melanoma is lethal if untreated, improved public knowledge of moles and melanoma can and will save lives. The chances that an American will develop melanoma are rapidly rising. If current trends continue, one in every one hundred Americans born today will eventually develop melanoma. One in every five patients who develop melanoma will die from it.

Melanoma tends to occur in adults in the prime of their family and professional lives. Traits and factors associated with melanoma include having many typical (normal) moles, any atypical moles, familial atypical mole syndrome, familial melanoma syndrome, disorders of DNA repair, excessive sun exposure (for your genetic background), freckling, history of severe sunburn, ease of burning, inability to tan, blue eyes and light hair.

Nevi (moles) can look like beauty marks (e.g., Cindy Crawford) or they can protrude like a bump on a witch's chin (common nevus). Most people have between 10 and 40 moles. Darker skinned persons frequently have darker colored moles. Moles can range in color from pink to tan to brown to black to blue to normal skin tone. Nevi are made of cells called nevo-melanocytes. Nevo-melanocytes, as the name suggests, are cells that exist along the spectrum between nevus (mole) cells and melanocytes. These nevo-melanocyte cells can be totally benign in nature (common nevus cells) or they may become or appear more abnormal, resulting in atypical (dysplastic) moles and even melanoma.

The true behavior of a nevo-melanocytic mole is usually best determined by biopsying (cutting a sample of) the mole and examining the biopsy specimen under the microscope. The website author believes that a microscopic result is more important than the doctor's clinical naked-eye diagnosis. However, the dermatologist's clinical examination by eye is also important because it sets up the biopsy in which the true nature of the mole can be discovered. The medical importance of nevi (how they can affect our health) rests in knowing that some nevi can signal or develop into melanoma, a deadly from of skin cancer. Knowing the A, B, C, Ds of pigmented lesions (see Melanoma) can help save a life by finding and curing a melanoma.

Fortunately, the A, B, C, Ds have made teaching patients about "bad moles" and melanoma inspection easier, but the A, B, C, Ds are not foolproof or even "expertproof." They may not be as simple as they sound, or maybe not enough doctors understand them. For example, it has been well shown by many studies and quizzes given to doctors of all specialties using a biopsy-proven, obvious, everyday smattering of important pigmented skin lesions (good and bad moles and melanomas) that most non-dermatologists have a high failure rate at correct diagnosis.

Why is this important? Because missing a melanoma, especially an early melanoma, can kill a patient. Unfortunately, this occurs all too often in real life, as well as in studies, every day in America. A well-known study showed that, of non-dermatologists (doctors who were not specialty-trained in dermatology) only 38% were able to identify all of the melanomas on a well-designed, but simple, standardized test (Cassileth and Clark). Sadly, 60% of the non-dermatologists in the study taking the test could not even identify the atypical moles (dysplastic nevi) correctly. This kind of limited knowledge puts primary care doctors (managed care, HMO, gatekeepers) at risk of killing and harming patients. Again, this has already happened in reality many, many times in America. Primary care doctors are often very talented and intelligent and caring, but no doctor can be a "Jack of all trades." It is impossible to know every medical specialty perfectly, especially dermatology. It is truly rare to find an expert at everything. That (complexity of medical knowledge) is why medicine has specialized more and more over the years. This specialization of medicine may also be contributing a bit to the increasing life spans which many Americans enjoy. If even a great number doctors cannot recognize melanoma and "bad moles" how can patients? One of the reasons that melanomas go unrecognized is because not every bad thing on our skin looks like a "classical" out-of-the-textbook example. Let's see if we can help the identification process with some hints in the remainder of this website subsection.

Melanoma many times arises without the presence of a mole. On-the-other-hand melanoma frequently, but not always, arises inside a "bad mole." Interestingly, melanoma can arise within all three major categories (types) of moles: atypical mole (dysplastic nevus, unusual), congenital nevus (mole existing at birth, sometimes not necessarily erupting to the surface skin for months or years), and plain ordinary garden-variety benign moles (common nevi). Just having a lot of any (common/benign or atypical/dysplastic) types of "moles" has shown to be a major risk factor for the formation of melanoma (Holly & Kelly). The frequent phenomenon (occurrence) of a mole giving rise to a melanoma is shown by finding mole cells next to melanoma cells under the microscope on biopsy, 35 percent of the time. This is a large significant fraction of over one-third. In plain English, at least one out of every three potentially deadly melanomas comes from a mole. Again, knowing a bit about moles (nevi) can save a life.

A nevus (mole) may be congenital, meaning the nevus existed probably at birth or finally arose to the surface and became noticeable within the first year or so of life. Other nevi (moles) are considered acquired. Acquired is probably best thought of as "not being congenital" or occurring sometime after the first years of life. The author personally believes that even acquired nevi are preprogrammed into a patient's genes just as a congenital nevi are. The website author believes that both mole types, acquired and congenital, may in the future, be found to be genetically related. The author seriously doubts that any external event like poison, radiation or trauma actually causes a mole to come into existence and, therefore, considers the "acquired" term to be a misnomer (poorly representative name). Another type of acquired mole is the atypical mole (dysplastic nevus). Some patients and doctors consider the atypical mole (dysplastic nevus) to mean "bad mole."

Common nevi ("normal" or typical acquired moles) usually have a "life span" that relates to that of the rest of the body. Common nevi are also called common moles, common acquired nevi (CAN), common typical moles or common typical nevi. Common acquired nevi (CAN) usually arise within the first few decades of life. CAN usually start out in children as small circular brown or black spots, usually having a diameter smaller than the width of a pea. The mole base may start to rise in young adulthood. As we near 40 years, the dark color may leave the mole and the base may protrude even more. This normal protrusion may be so great that the mole assumes the shape of a dome or floppy ball. While the mole is maturing and protruding, the color may lighten to match the color of the surrounding normal skin. The raised mole may last the rest of ones life.

When a typical common nevus is seen under the microscope (one hopes by a trained dermatopathologist), usually small nests of relatively round fairly clear cells are seen in a large, relatively symmetrical group that is fairly closely bound. Most of the cells are exactly alike and very few, if any, nevus cells are observed to divide. Mole cells are commonly found close to the surface of the skin, sometimes nesting in parts of the epidermis.

Only recently has it been appreciated that there is an association between common acquired moles (CAN's) and melanoma. A 1986 study by Rampen showed that the number of raised CAN's on the arms has the strongest association with melanoma and the total number of CAN's on the body are related to a higher chance of melanoma; men in the Rampen study had more CAN's on the trunk, whereas women had more on the legs. Other studies have shown that the "number of melanocytic nevi (both atypical moles and common moles) occurring on the arms is the strongest single risk factor for melanoma." (Holly) Holly also reported a higher chance of melanoma when over 100 CAN's are found on a given patient. Because of these studies it appears that doctors may have to rethink just how what the words common and benign mean when referring to moles.

Let us now discuss moles that grow back after they are partly removed. If a biopsy is taken of any of the major types of moles and a mole grows back, it is called a nevus recurrens (NR). If a mole that grows back is biopsied again, the cells can look to a trained dermatopathologist even more unusual than they would have looked under a microscope if it had remained undisturbed. The cells of a nevus recurrens (returning mole, mole that comes back) can greatly resemble a melanoma. Diagnosing NR's properly under the microscope can save a patient a large, unnecessary, disfiguring surgery for melanoma. It helps if the patient tells the doctor that a previous mole was removed from the area so that the doctor sending in the biopsy to the dermatopathologist can write down this all-important history on the biopsy form, perhaps helping to determine a NR. Trauma (cutting, tearing, etc.) can also cause part of a mole to look like a NR under the microscope and therefore raise a concern about melanoma prompting unnecessary surgery to remove the suspected melanoma. This history is important, too, as is a possible second dermatopathologist's opinion.

"Congenital" nevi (congenital moles) are usually larger than typical common moles, sometimes to the extent they even cover a bathing trunk area. They usually start dark brown or black and remain so throughout the life of the patient. Congenital moles may rise slightly over time, but usually not as much as acquired moles. It used to be thought that congenital moles that were over 1cm (1/3 of an inch) in diameter had a higher chance of forming a melanoma within them. However, some more recent studies (Kopf) indicate that only congenital moles of greater than 20cm (8 inches) in diameter have an increased chance of forming melanoma. The jury is still out on this issue and the take-home message is to watch all moles for any change within them. When a congenital nevus is seen under the microscope (one hopes by a trained dermatopathologist), usually small nests of relatively round fairly clear cells are seen in a large group that is fairly closely bound at the surface and sides. Most of the cells are exactly alike and very few, if any, nevus cells are seen to divide. The cells are seen close to the surface of the skin and the cells are also sometimes found deeply in and around the sweat glands and down to fat.

Tens of thousands of patients have come to the website author over the years for mole examination. Unfortunately, the vast majority of these patients (some of whom are fellow doctors and dermatologists) know only whether the mole was in the same location on their body 10 years ago. "Yes, it's always been there," even some of the brightest of patients say. Of course, moles don't get up and walk to another location. A magnifier or mirror should be given to such a patient with the questions of whether a particular mole's edges were always notched or whether the color(s) contained within was always uniform. Rarely do patients study the mole(s) in question closely enough to provide adequate answers. Unfortunately, most patients (and even doctors when they are patients) feel that they have become so familiar with their bodies' spots that they can take them for granted and pass only an occasional glance their way. Preventing melanoma requires studying ones own, and ones significant other's, moles in detail as well as watching for the occurrence of new moles and that includes the scalp and private areas. Melanoma is one of the world's most curable diseases if found early. There is only one way to find melanoma early and that is by looking. Looking can mean screening large numbers of people, or encouraging the public to inspect themselves or to visit a well-trained dermatologist's office for a routine checkup. (Going to a poorly trained doctor can do more harm than good, for obvious reasons.)

Now to explore an extremely important but controversial (especially among the experts) and complicated topic: atypical moles. This is one of the most hotly debated and fought-over issues in all of dermatology. Please carefully read the terms and appreciate that many authors of dermatologic medical literature do not even use the same language, although writing in English, when it comes to atypical moles. If you "get lost" or don't understand any of the following material on atypical moles, re-read from the beginning of the next paragraph to where you had difficulty. If this does not help, please press onward and read the rest of this website subsection. Then read the subsection Melanoma. Wait a few days and read about atypical moles again. If that does not help, you may need to try some other sources of information. Please recall that the prefix "a" in front of a word usually means "not." So an "atypical mole" means a "(not)typical mole" or abnormal mole. In this case, the prefix "ab" means "away from" normal. In any case, atypical moles are unusual for one reason or another.

The term "atypical mole" was officially selected by the U.S. National Institutes of Health in 1992 to describe now what used to be called a "dysplastic nevus." "An atypical (unusual, strange) mole is an acquired, usually pigmented (colored) lesion (spot or bump) of the skin that is different from a common mole." (The National Institutes of Health, NIH Melanoma - Consenus Statement, Jan 1992, paraphrased). Unfortunately, this is not a very helpful definition for the public or even for many doctors who are not specialists in the field of dermatology. It is merely a definition of exclusion or elimination. Furthermore, this definition requires knowledge of all the possible ways common moles could look or appear.

So, let us talk about what "classical" (and that does not mean all) atypical moles look like or in what circumstances they occur. In other words, we will be trying to discuss typical atypical moles. (The term "typical atypical mole" is certainly an oxymoron! An oxymoron is a contradiction in terms; after all, what can be typical about something that is not typical (atypical)?

Atypical moles may or may not occur in families. Atypical Moles (AM's) vary in size but are usually larger than common nevi (moles). AM's may be completely flat spots that you could not feel with your eyes closed or they may be papular (bumpy, able to be palpated or felt with the fingers). The borders or edges of AM's are usually irregular (notched or jagged) and ill-defined (not sharp, hazy). As with most moles, the colors of most AM's range from pink to tan to dark brown. Many times these colors blend with or end on an AM's pink background. However, the colors in AM's are usually variegated (mixed together but not uniformly). Although AM's may occur on almost any body location, they favor the trunk. AM's usually take on their characteristic look following puberty (after early to mid teens). New AM's usually continue to arise throughout adulthood, even after 35 years of age. Some doctors feel that observing AM's under an ultraviolet light enhances the characteristics of the moles making unusual features easier to detect, but the author is less impressed with the ultraviolet-examination technique preferring magnification or extreme nearsightedness. The following rare photograph shows the various major types of AM's occurring together in one small area on a patient.

The author prefers another way of describing AM's. An AM is a nevus that shares some or all of the features that should be concerning for malignant melanoma, which are in essence the A, B, C, Ds: "A" for asymmetry, "B" for border irregularity, "C" for variation in color and "D" for diameter over 6mm (1/4 of an inch). The author of this website partially disagrees with requiring for a "D" of 6mm (the size of a pencil-eraser) because he knows from personal experience that melanomas can start in moles or other growths, or on their own in sizes much smaller than 6mm. Why miss any early melanomas just to simplify a set of relatively crude rules? The "D" feature was possibly created to make doctors' jobs easier since many really small moles can look very unusual and be relatively normal; and by weeding out very small spots doctors can examine you quicker and get on to the next patient; this makes screening easier for doctors and removes some of the potential "heat" from a malpractice claim.

Some prominent dermatologists like to include an "E" for elevation. The author of this website strongly disagrees with the inclusion of an "E" because many melanomas are not elevated and the public should not be misled by narrowing their scope of concern (possibly this guideline was proposed for the same reasons as "D" above). The use of "E" should be eliminated. It is obviously important to find melanoma when it is small, because melanomas larger than a dime have a 50% chance of having already metastasized (spread internally inside the body).

Table further explaining A, B, C, D's of pigmented lesions:

Asymmetry	=	not regularly round or regularly oval
Border	=	notching, scalloping or poor definition at the edges
Color variation	=	shades of brown, tan, red, white, blue or black, alone or in any combination
Diameter	=	6mm (or a pencil eraser)
As noted above, this website author disagrees with "D" and advises the public to be wary of the smallest of spots with A, B, and C characteristics.

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One of the factors that the NIH doctors are likely considering is that 30% of nevi that would look very normal to the eye of a trained dermatologist would display, under the microscope, all three of the generally accepted microscopic criteria for AM's, i.e., abnormal cell group architecture, individual cell abnormality and inflammation cell response. Even though the microscopic display of an abnormality is minimal in most instances, it is still present to a degree. That is one of the reasons a trained dermatopathologist should examine biopsy specimens. It should be appreciated that the diagnosis of AM may best be made by combining the atypia seen by the naked eye with that reported under the microscope (clinicopathologically), to avoid the "over-diagnosing" that may otherwise occur. "Over-diagnosing" can lead to too much unnecessary surgery or cutting.

AM's may occur as a "syndrome" which may also run in families. The syndrome can kill if it results in deadly melanoma. It is fortunate that scientists have identified the familial tendency and can sometimes predict the danger in advance, thereby allowing early detection through regular skin-cancer screening of the entire family. It is unfortunate that more doctors are not able to diagnose accurately (recognize correctly) AM's. If a doctor cannot recognize an AM, that failure may result in missing the whole syndrome, placing a whole family at serious risk. The potential to reduce deadly melanoma through early screening of families with AM syndrome tremendous because familial (hereditary) melanoma may account for 50% of all melanoma cases. (Meyer)

The definition of atypical mole syndrome: The atypical mole syndrome just described is also called the Familial Atypical Mole & Melanoma Syndrome and therefore abbreviated (FAM-M). FAM-M is a term offered by the U.S. National Institutes of Health in their 1992 Melanoma - Consensus Statement to name what used to be known as dysplastic nevus syndrome. The FAM-M syndrome is defined by "(1) occurrence of melanoma in one or more first or second degree relatives, (2) large numbers of moles, often greater than 50, some of which are atypical and often variable in size, and (3) moles that demonstrate certain distinct histologic (how a sample of mole looks under the microscope) features." This is a direct quote from the National Institutes of Health, Consensus Statement, Jan 1992." In plain English, FAM-M means many large unusual moles that run together with melanomas in certain families. Specially stained slices of these mole cells display unusual features to a trained doctor when viewed under a microscope. All three criteria should be met to meet the definition. The FAM-M Syndrome is definitely carried on the genes and scientists (doctor researchers) are working to identify just exactly which gene or genes are involved.

Knowing that a person is a member of a FAM-M family is extremely important and can save lives. Their lifetime risk for developing melanoma may be as high as 100%! These families and their members need to learn self-examination. It is estimated that there are about 32,000 people in the United States with FAM-M syndrome. These patients should be seen by a dermatologist every four to six months. High-quality baseline photographs may be taken either digitally or by regular camera and stored. If enough atypical moles are present, body mapping appears helpful. FAM-M members are at a real and high risk for a very deadly disease, melanoma, which is very preventable by early detection. Other cancers have been reported in patients with FAM-M syndrome including pancreas, breast, respiratory tract and eye melanoma (Lynch). FAM-M syndrome is definitely a case where an ounce of prevention is worth a pound of cure. Since melanoma is so curable when caught early empowering a person by telling them if they have FAM-M syndrome has a high chance of saving their like.

Currently, it is difficult to say whether or not sunscreens, even the new super-broad-spectrum sunscreens can reduce or prevent melanoma as it would take years to test a compound that might be old by the end of a 10 year study (melanomas don't arise instantly following sun exposure). Since sunlight or light radiation is somehow related to melanoma, it is likely a good idea to reduce sun exposure in FAM-M patients. Reducing sun exposure is necessary because some studies have shown that sunscreens may not be helpful against melanoma. Sunscreens may instead be lulling the sunscreen-user into a sense of false security causing him/her to increase exposure to rays that are not blocked sufficiently by the sunscreen. Even though Dr. Wallace Clark had indicated in a 1988 article on what was then called "Dysplastic Nevus Syndrome" that family members of FAM-M who do not have dysplastic nevi do not show any apparent melanoma risk, we should still be vigilant.

What about patients who have many AM's themselves but know of no one else in their families with any similar moles or melanoma? Most atypical moles do not occur in families. Non-familial (sporadic) atypical moles occur randomly, or what researchers presently think of as randomly. In the future, as will be discussed, researchers may find some particular cause, possibly a genetic mutation. The chance of a person with these moles developing melanoma is two to eight times greater than that of the general population. The number of sporadic AM's on a given patient may also play a role in melanoma risk. One study showed that the relative risk for persons with one to five AM's was four times greater than the general population's risk and that having more than six AM's increased the relative risk of six times that of the average person on the street. (Holly) The prevalence (chance of having) of AM's in patients who do not have FAM-M is reported to be fifteen percent. The prevalence of AM's in the general population has been reported to be between 2 and 7% (more likely about 5%).

What about patients who have many AM's themselves but know of no one else in their families with similar moles or melanoma. Words that could be used to describe this individual patient's symptoms might include "sporadic" or "isolated," because this person's moles seem to be happening "on their own." One might then think that this person with sporadic AM's does not have a genetic cause for the presence of the abnormal moles. Dr. Raymond Barnhill, a world-renowned melanoma expert, prefers to use the term "Atypical Mole Phenotype," which implies that there is some sort of expression of moles on the surface and avoids the confusion of whether this is a person with "Atypical Mole Genotype" (bad moles determined by genes). Although it is likely that persons with Atypical Mole Phenotype (AMP) have a genetic problem causing the formation of moles as well as putting them at risk of developing deadly melanoma, the final genetic problem apparently is not passed to the children. The final genetic problem in AMP patients may require an accidental mutation in the embryo or exposure to some chemical or energy which causes the formation of moles and risk for melanoma.

Other top dermatologic researchers developed other "classic" criteria for what they called "classic" atypical mole syndrome (which the website author believes, really describes AMP). The criteria that Dr. Kopf prefers include (1) 100 or more melanocytic nevi, (2) one or more melanocytic nevi 8mm or larger in greatest diameter, and (3) one or more melanocytic nevi with clinically (naked-eye) atypical features. Without controversy or difference of opinion what would this topic (atypical moles) be anyway?

It is understandable then that melanoma pioneer Dr. Wallace Clark (personal communication with website author @ 1990) had a different set of criteria: (1) 25 or more melanocytic nevi, (2) two or more greater than 5mm in diameter, and (3) larger ones have varied color, particularly tan, brown and pink. Dr. Clark, arguably the world's most famous melanoma expert, always expresses his concern about the color pink as well as about an irregular, notched or fuzzy outline to the mole. "Wally" often emphasized when teaching the website author how these moles' edges blended almost imperceptibly with the surrounding skin. The website author agrees that pink is a particularly important color when it comes to AM's.

The website author thinks that the pink we see with our naked eyes, on looking at these atypical moles, may caused by the inflammatory cells found on the microscopic exam in concert with the tiny resulting increase in blood flow or vessels.

As mentioned before, one out of every three melanomas looked at under the microscope shows cells of a type of nevus nearby, Dr. Clark states that probably greater than 80% of melanomas come from AM's! Dr. Clark also points out often that you cannot eliminate the problem of melanomas in patients with moles by cutting off all the moles because the moles are many times just a marker for the melanoma. The melanoma can "pop up on its own" without coming from a mole anywhere on these patients. In other words, according to Dr. Clark expensive total-body mole removal surgery is not as effective in stopping melanoma as less expensive exams every six months, total body-mole mapping and photography!

One final comment on FAM-M Syndrome and the Atypical Mole Phenotype. The website author believes these two terms really represent a continuum. This means that patients from one category or another blend somewhere along the line. It may also mean that a somewhat-related genetic problem in the DNA that programs our bodies exists along the spectrum as well. Future research may unlock the secrets of this possible continuum.

The diagnosis (finding) of an AM is best made by combining the clinical findings (naked eye or low-power magnifier) with the findings from a biopsy looked at under a microscope. The present capabilities of dermascope (painless, low power, live surface microscope) are more similar to a clinical finding as rather than a microscopic finding. Unfortunately, the website author believes that sole reliance on dermatoscope findings is a possible problem. This is because as with most tumors or growths with a relationship to cancer in the entire body, the dermatopathologist (doctor specially trained to read the skin slide) must be concerned with the nucleus of the cell. This requires higher (100x) power. The nucleus holds the genes, which are made of DNA. DNA drives much of how cells divide and grow, both controllably and uncontrollably.

When a trained dermatopathologist observes an AM under the microscope, he/she looks for disordered groupings of cells, asymmetry of cell groups across the relative center of the biopsy, fibrous material deposited just below the epidermis and increased numbers of melanocytes along the base of the epidermis with cells that look like spindles (cigars) and epitheloid balls. Nests of melanocytes in AM's tend to fuse and form bridges. As well, melanocytes within the epidermis may extend singly or in nests beyond the main bulk of the nevus. This extension process is called "shouldering." Most of these microscopic findings can be seen with low (40x) power. Also noteworthy to doctors is that the cytoplasm (part of the cell that is not cell wall or nucleus, like a fluid) often has a fine and dusty quality.

AM's are further crudely subclassified (categorized, divided for discussion) based upon the amount of unusual findings about the nuclei (plural of nucleus, the directing blueprint deep within the cell) of the cells that make up the mole. This nuclear result is one of the most important findings in AM's that doctors care about. If the AM's nuclei are very atypical, somewhat resembling melanoma, then the AM will likely be read as "severely dysplastic." The other categories are "moderately" and "mildly" atypical moles (dysplastic nevi). The findings within this range may in turn trigger the decision to surgically remove what is left of the mole.

It is important therefore to have confidence in the reading of the slide. A board-certified dermatopathologist should have signed the biopsy report. If, however, a second opinion is desired, such as when a mole is located on a teenager's face or hand, it may be reasonable to send the glass slide of the biopsy to well-respected dermatopathologists located at the Mayo Clinic, New York University, Harvard, University of Pennsylvania, etc. There are many excellent dermatopathologists in the world. However, the author is especially familiar with the work of the following renowned dermatopathologists: Dr. Raymond Barnhill, Dr. A. Bernard Ackerman, Dr. Neal S. Penneys, Dr. Alexander P. Kowalczyk, and Dr. Bernard Johnson. Confidence in the slide reading is important. Without confidence in the reading, how can one have confidence in the surgical decision that will result from the reading?

Again, if the AM's nuclei are very atypical, somewhat resembling melanoma, then the AM will likely be read as "severely dysplastic." The other categories are "moderately" and "mildly" atypical moles (dysplastic nevi). This range of findings and how to deal with the result is where the controversy arises. There are many schools of thought. The website author's logic is as follows: Various dermatologists and their family members have been patients of the website author. If the biopsy of a mole is read out as "moderate" or "severe," then no matter where the AM is located, the dermatologist-patient requests surgical removal with a margin. See Mole Biopsy & Removal: Cosmetic Considerations. However, when the diagnosis is "mildly dysplastic or atypical," dermatologists usually prefer merely to "watch" what remains of the mole in the biopsied area, without desiring surgery.

Just how should this possible hint relate to patients who are not dermatologists? The website author believes that a compromise is in order. On all patients with a diagnosis of "moderate" or "severe" atypia, surgical removal of the mole remnant with a margin is recommended. When a diagnosis of "severely" atypical mole is made by microscope, experts such as Barnhill recommend that the mole be re-excised with margins of 5mm, similar to the margins recommended for melanoma of Clark's Level I. To patients with a microscopic diagnosis of "mild" atypia, we give the following options: If the mole is in an area that the patient can readily view (e.g., stomach, front leg, front arm, face, front of neck, hand) then the mole can be "watched" by the patient if that is desired. However, if the "mildly atypical" mole is located in an area that a mirror would be necessary to view, then it is politely suggested that the patient consider surgical margin removal. All in all, the patient should be educated about moles, which should make the final decision easier.

The history of AM's or dysplastic nevi and the FAM-M Syndrome may help explain some of the controversy and make the picture clearer for the reader. Back in the year 1820, Norris described what in all probability represented the atypical mole syndrome. Then in 1978, Dr. Wallace Clark with others first formally described what Clark called "dysplastic nevi." They noticed a group of families whose members had a history of melanoma. They also noted that many of the family members had moles that appeared unusual. Clark and his fellow investigators first called the nevi "B-K moles," which were the initials of the last names of the first two families studied. All of the family members were said to have the "B-K mole syndrome." In two of the original family members, Clark was able to document photographically the transformation of these nevi into melanoma.

In 1980, the "B-K mole syndrome" was renamed "dysplastic nevus syndrome." Dysplastic nevi (at that time, not yet called AM's ) were then reported to occur in melanoma patients without a family link of melanoma. A non-familial melanoma risk was thus shown for dysplastic nevi. Then, in 1992 the NIH recommended a name change from "dysplastic nevus" to "atypical mole."

Recommendations for approaching FAM-M Syndrome and AMP patients include frequent, regular total-body exams beginning around puberty, baseline total body photographs, instructions for self-examination, regular eye examinations, a thorough family history for melanoma and moles, sun-exposure reduction and biopsy of any mole that may be suspicious for malignant melanoma. Total-body checking is necessary because AM's tend to form in areas normally covered by underwear. Eye exams are recommended because of a once-reported increase in eye nevi and eye melanomas.

 

In Clark's 1988 article on "Dysplastic Nevus Syndrome" (now FAM-M), he points out that "photographs will detect small, new lesions. All such lesions in the adult should be removed. The majority will be dysplastic nevi [AM's], but some will prove to be melanomas, surprisingly!" Clark also states "There is no indication for the wholesale removal of dysplastic nevi [AM's]. The lesions [moles] are both precursors [things that may turn into] and markers [hints or queues] for the development of melanoma, but they are not obligate [do not always have become] precursors. The vast majority of dysplastic nevi are dead-end lesions that can only remain static or regress."

This quote of Dr. Clark reminds the website author of a story that was once told him by Dr. Clark: One of Dr. Clark's patients in the 1980's with FAM-M had about 100 moles. The patient became tired of being examined every six months and asked the opinion of a Board Certified Plastic Surgeon. The plastic surgeon removed all of the visible moles and charged the patient tens of thousands of dollars. Within two years following this patient's mole-removal surgeries, the patient developed a melanoma in an area that had never had a mole previously. The patient later died of that missed melanoma. As Clark so aptly said, "There is no reason for wholesale removal . . . ." Unfortunately, most plastic surgeons have limited formal in-residency training with FAM-M Syndrome; Board Certified Plastic $urgeons' trade and how they are paid ... is to cut so patients, thus should be careful regarding their choice of specialist for mole problems.

Remember, melanomas may appear without the presence of a nearby nevus in AM patients. As Dr. Clark has said, always look for new spots if you have a history of atypical moles.

Unfortunately, many insurance companies refuse to pay for professional, proper, 1:1 actual size photography for patients. This insurance refusal occurs even when the AM's are biopsy proven. This is concerning to doctors with medical ethics training. Such a patient who has been photography refused should contact the state insurance commissioner, as well as send the company a stern letter citing Kopf and Rigel, Photographs are useful for detection of malignant melanoma in patients who have dysplastic nevi, JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY, 19:1132-4 (1988).

Although a biopsy may be used to test any kind of skin growth, consider the extremely common example of the mole biopsy. Most dermatologists believe that if a mole is changing or suspicious for malignancy, a biopsy should be performed. To again define biopsy: the removal of any size piece of tissue, large or small, and the inquiring analysis of the cells in a specially stained specimen under a microscope.

There are many ways to biopsy many types of moles, and the types of removal or biopsy vary in cost and scar formation. The author is specially trained in all the existing forms of mole removal. The author's philosophy for mole removal is that, to initially test moles, the removal of large pieces of normal tissue (margin excision) around moles, thereby leaving large scars, is NOT helpful. Extra normal tissue in a large specimen makes it more difficult for the average laboratory to examine a mole thoroughly. A small inverted pyramidal sample is probably best. As you can see, the author favors incisional biopsies rather than excisional biopsies for the first evaluation of a lesion (spot or process).

.An INCISIONAL BIOPSY is defined as the taking of a piece of a tissue smaller than the skin area in question (lesion) in order to get an idea of what the process is. The specimen is examined under the microscope, usually after it is stained with special dyes that usually display the nucleus and nuclear material, as well as other parts of the cell(s). Incisional biopsy techniques may include punches with a miniature sharp cookie-cutter like instrument, shaving, snipping with scissors, the author's special inverted-pyramidal-technique and partial scalpel sampling.

In the author's office, FOR INITIAL EXAMINATION or incisional biopsy, a tiny inverted- pyramidal biopsy is taken of small moles. Moles that protrude are tangentially sampled (delicately removed to the level of the skin), and the remaining skin surface is then lightly sanded to match the surrounding body contours. Though the biopsy will be small, it will usually encompass 90% of the mole cells. If the biopsy is read benign, then no further work is necessary. If the biopsy indicates any potential for trouble in the future, then the patient will be advised of the options and a final decision made for or against a margin excision to remove any remaining mole.

Is it dangerous to leave any part of a "bad mole" behind? Isn't it better to always sample moles with a margin excision to avoid spilling potentially malignant cells into the bloodstream? The answer is NO! British and American dermatologists have battled over this question for years, but detailed studies of large and small melanoma biopsies resoundingly favor the American view that small specimens are not dangerous. These studies have shown that the sampling of melanoma by small biopsies does not spread cells into the bloodstream to any greater degree than sampling melanoma by taking large-margin excisions. Melanoma is one of the deadliest forms of skin cancer derived from cells similar to a mole. If melanoma is not spread from small sampling, then mole cells should not be spread by small sampling either.

The proposed small incisional (inverted pyramidal) biopsies that the website author discusses do not apply to all patients or all moles. Your doctor a have an acceptable reason for recommending his/her approach to biopsy. Nothing is etched in stone when it comes to biopsying moles and suspected melanomas. Some moles are so obviously "bad looking" that the surgeon should excise (cut all around) these moles so as to make it easier for a good dermatopathologist to inspect it under the microscope for deep invasion. Some patients "want it all over with at once" and demand the spot be completely cut out, whether or not it is benign or malignant. Again, there are many different factors that go into the choice of whether to cut around or into a "pigmented lesion" or for the purposes of this chapter a "colored, irregular spot or bump." No one treatment or type of biopsy is right for everyone. There are many sides to the biopsy argument.

Certain well-respected dermatopathologists such as Dr. Raymond Barnhill believe that every suspicious pigmented lesion (mole) should be biopsied by completely cutting the growth or spot out of the body. This argument has its merits. First, not all bad pigmented lesions (spots) have the most severe abnormal cells in the areas that most doctors can easily identify as bad portions of the mole. Second, the bigger excisional biopsy may "cure" the spot if it is mildly atypical and of course if it was benign from the beginning. Third, dermatopathologists bear a heavy burden to read a melanoma and come up with a number that determines the Breslow level which largely determines a patient's chances for survival. It would of course be impossible for dermatopathologists to provide a reliable thickness answer if they have been given only a small portion to represent the entire "bad spot." Reading only partial or incisional biopsies of spots suspicious for melanoma is an extra burden for dermatopathologists who pride themselves on accuracy. These are extremely valid reasons for performing excisional samples or biopsies. Many dermatopathologists are purists. This approach however may be one that takes only the individual mole into consideration and not the public in general or individual patients.

Although the website author respects the philosophy of these expert dermatopathologists. Many of these suggestions by dermatopathologists are made to encompass the spectrum of how medicine is practiced: that is to cover the work of good, average and below average doctors who are sending in the samples and whether or not those sending doctors can accurately choose what to sample. However, the website author is at odds with the INITIAL CUTTING IT ALL OUT philosophy in the majority of patients for the following reasons. To begin with, not all melanomas are extremely or even moderately abnormal looking. Performing excisional surgeries that cause scarring sometimes an inch or more long limits the amount of moles most patients will want checked or tested in a lifetime. Even patients at risk will get tired of being cut and scarred - especially if the results keep coming back as "benign." Remember, even in the age of epiluminescence microscopy, the best test for melanoma is a skin biopsy that is read under the microscope. The public and especially the cosmetically conscious patients of the website author do not want numerous noticeable scars on them if at all possible. Cutting out all moles on patients who have anything "suspicious" costs a lot of money, patient transportation, lost work, lost wages, lost productivity, pain of needles (although this can be made extremely minimal), wound care, stitching, etc. Many times managed care only compounds these problems. Tiny incisional biopsies used by the website author have many uses. These incisional biopsies act as a simple "screening tool" because they leave almost unnoticeable marks, allow patients to immediately cover them with make-up, allow immediate return to sports and other activities, are low cost, take less than 20 seconds to do, allow immediate return to work, do not upset the patient's looks, require no stitch removal and still provide some very useful information. Larger excisional biopsies are less of a "screening tool" because they do not share the benefits we just mentioned of tiny incisional biopsies. Judging from the A, B, C, D's put out by the Skin Cancer Foundation and the American Cancer Society and all the other screening programs and from the fact that melanoma is most curable when found early, it seems only logical that the more screening methods, the better.

If an INITIAL incisional (inverted pyramidal) biopsy is read as "moderately" or "severely" atypical under the microscope, which is rare in itself (only 5 ­ 10% of the website author's pigmented lesion biopsies) then an excisional surgery mole removal (which becomes a biopsy and is checked by the laboratory) will be scheduled. If original incisional mole biopsy is read "mild" then the mole will be observed indefinitely (if the patient desires) with annual body checks or suggested to be removed if the mole is in a location that cannot be easily seen by the patient. Since so few incisional biopsies would result in some sort of follow-up excisional surgery, incisional biopsies can be thought of as a tool of mass SCREENING that may end up gaining more information (by wider acceptance and use) than they lose (less ability to determine depth on initial sample). Additionally, since the samples are so small especially at the deeper portions when discussing the inverted pyramidal technique the mole is not disrupted much for a later excisional biopsy. Since the inverted pyramidal technique acts as a SCOUT while causing minimal distortion to the remaining mole or melanoma it may best be considered a special type of incisional biopsy. Additionally, the website author has been very fortunate in telling which areas of a mole may be "bad", never having lost a patient to melanoma in a practice spanning 3 decades dedicated to skin cancer and skin cancer surgery. Warning: not all doctors may be good at the inverted pyramidal technique.

The website author can certainly agree with the dermatopathologists concerns when it comes to incisional biopsy techniques that may damage or partly destroy what remains of a suspicious pigmented lesion. In those cases it may be better to "scout" with the more involved excisional methods to avoid disasters like missing the worst section of the mole, etc. Additionally, when the varying skills of other doctors come into play using the inverted pyramidal technique there may be difficulties as well. WHEN CONSIDERING RULES FOR THE ENTIRE RANGE OF DOCTORS' CAPABILITIES (good, fair and poor) THAT THE PUBLIC MUST SEE IT IS REASONABLE TO respect the thoughts of the puristic dermatopathologists who recommend only excisional removal of moles. Perhaps they have seen too many serious problems as a result of reading thousands of other dermatologists' and plastic surgeons' mole and melanoma biopsies. In malpractice court, as long as a doctor is practicing at a level of the average doctor in a community he is practicing acceptably: putting it in other words... practicing at quality level of the bottom of the upper half of doctors or at the quality level of the top of the bottom half of doctors is OK! That certainly does not sound like the best of care... but, when dealing with large masses of people as in the general public as laws and public health policy must, averages, not bests, must come into play.

If a protruding mole is benign-looking and removal is necessary due to irritation or to enhance cosmetic appearance, a technique called tangential-incisional (shave) biopsy may be performed. This consists of "shaving" the mole with a sharp scalpel parallel to the surface of the skin, following with a light sanding. This biopsy removes the raised portion of the mole; however, some mole cells remain in the skin. Less than 20% of the time, these remaining mole cells will regrow the mole, sometimes even darker than before the biopsy. The tangential biopsy wound generally heals within two to three weeks as a flat scar approximately the same size as the original mole. Initially, the scar can be pink, darker or lighter than the surrounding skin. This color tends to blend in with time so that cosmetic results are usually excellent with a barely perceptible scar. Darkening of the site is minimized if the patient avoids sun exposure or uses at least a number 15 sunscreen on the area for several weeks after the biopsy. It is important to follow good wound care of the area for the best cosmetic result.

All removed moles, even benign-looking ones, should be sent to pathology for microscopic examination, just in case. The microscopic examination helps to tell us whether the mole is harmless. Sometimes moles that are textbook examples of benign or "good" moles turn out to be serious melanoma, discovered incidentally on a 1 of 1000 chance. If a typical doctor's practice sees several thousand such patients every 3 to 5 years, that may be a chance save a life.

10% of melanomas may not fit the classic dermatologists' rules for malignancy. Since early detection and removal is the best way to cure melanoma, the patient can participate actively in his/her own care by self-examination. Signs of concern include a mole's recent change in appearance, size, shape or color, irregularity in color, loss of a uniform border, asymmetry, bleeding and notching of a border. Moles with any of these signs should be brought immediately to the attention of a dermatologist for close scrutiny of the lesion.

Fancier, but not necessarily better, ways for some doctors to diagnose atypical moles and melanoma include epiluminescence (slightly magnified examination below the surface of the skin) and digital computer analysis. Though the sensitivity (ability to detect melanoma) of these methods is very high, the specificity (the ability to be correct in diagnosis once something has been chosen or detected) is around 70%, which is less impressive. See Doctor & Patient Examination.

What about photography and special scanning computers? This certainly may be the future as these techniques are paired with epiluminescence and dermoscopy. Every year, the resolution is even better than the year before. However, computer screens are two-dimensional and are made of pixels (tiny lights). There is currently a tremendous difference between a doctor's careful visual exam of the patient's body and an exam by photography and computers that will narrow as technology progresses. In the real world, skin growths grow in three dimensions. Future computer technology in doctors' offices may be represented three-dimensionally by bar graphs or holograms. A further drawback is the currently finite number of photographic, scanning or recording pixels. Because of this resolution problem and the lack of complete three-dimensional analysis, these hi-tech methods are currently limited in their sensitivity and specificity. An extremely well-trained, nearsighted dermatologist can likely outperform a supercomputer outfitted with today's best lesion-tracking software; the naked eye of this doctor can likely sense depth and see upper tails/roots at the edges of a colored lesion. Additionally, how can you compare what a computer reads out versus reality: a biopsy or leaving the mole on the patient to see what it develops into? That type of study could take years, and what patient wants to be part of the failure rate? See The All-important Skin Biopsy and Mole Biopsy & Removal.

Excisional biopsy methods will be discussed in other subsections of this website. To be brief, an EXCISIONAL BIOPSY may be taken to determine what a particular growth or lesion is, but it is usually performed to determine the chances that any of the growth still remains in a patient. An excisional biopsy is the removal of a suspected lesion plus more normal tissue around it than is seen in the lesion, in the hope of removing the entire lesion, including any small cells of the lesion which may be spreading out and invisible to the naked eye.

© 1997-2003, Paul J. Weber, M.D., P.A., All Rights Reserved