Clear margins on ALL Dysplastic Nevi?

Trauma to the remaing cells could upset the "balance" and cause them to mutate.  My derm only deals with skin cancer (melanoma/Mohs) and as I said, this is his opinion.  Some derms agree, some don't.  Most do agree in 5mm margins for severely atypical lesion, but mild/moderate is more of a gray area.  Since my derm really only sees high risk individuals, his opinion might be more conservative based on his clientele.  But he emphasizes even more getting something checked where there is pigment regrowth.  So if you have a lesion removed years ago and it never grows back, I wouldn't have any concern.  But if it grows back, I'd have it removed again. 

Trauma to the remaing cells could upset the "balance" and cause them to mutate.  My derm only deals with skin cancer (melanoma/Mohs) and as I said, this is his opinion.  Some derms agree, some don't.  Most do agree in 5mm margins for severely atypical lesion, but mild/moderate is more of a gray area.  Since my derm really only sees high risk individuals, his opinion might be more conservative based on his clientele.  But he emphasizes even more getting something checked where there is pigment regrowth.  So if you have a lesion removed years ago and it never grows back, I wouldn't have any concern.  But if it grows back, I'd have it removed again. 

Trauma to the remaing cells could upset the "balance" and cause them to mutate.  My derm only deals with skin cancer (melanoma/Mohs) and as I said, this is his opinion.  Some derms agree, some don't.  Most do agree in 5mm margins for severely atypical lesion, but mild/moderate is more of a gray area.  Since my derm really only sees high risk individuals, his opinion might be more conservative based on his clientele.  But he emphasizes even more getting something checked where there is pigment regrowth.  So if you have a lesion removed years ago and it never grows back, I wouldn't have any concern.  But if it grows back, I'd have it removed again. 

None of this is an exact science and you just have to find a doc and a comfort level that works for you.  I'm sure my doc could give a better explanation about cells left behind, it's been years since I heard it.  However, I just want to comment on two things.  Just because something is moderately dysplastic does not mean much.  A moderately dysplastic lesion is unlikely to change into melanoma.  Have any of the moles you've had biopsied CHANGED?  Have you done some type of mole mapping or body photography?  Most dysplastic nevi are going to stay exactly where they are now.  The highest risk lesions to become melanoma are the severely atypical lesions.  That's why they are removed with the same margins as melanoma in situ.  But lesions that are changing are the ones that are the most suspicious and the ones that I have removed.  In my onc's practice, if you have DNS you are part of the mole mapping project and would be having your atypical moles photographed at every visit.  Those that change would be removed with at least clear margins via punch or excisional biopsy.   In this mole mapping project, they've mapped many thousands of dysplastic moles on people with DNS or a history of melanoma.  After several years of study, 97% of these dysplastic moles never change.  And even the 3% that change, not all of these moles are melanoma.  So the big emphasis there is change, not outward appearance.  I, too, had one of my "normal" moles come back atypical.  All my biopsies to date have been atypical, I just don't have enough moles to qualify for DNS.

Have you had melanoma?  Another area where my cutaneous oncologist disagrees with your derm is biopsy method.  If you've had melanoma, my onc doesn't do shave biopsies.  I'm not exactly sure what his policy is if you haven't had melanoma since it's been too long ago since I was in that position. But I'm sure that anything that has changed or looks quite suspicious would not be removed with a shave regardless of background.  Since melanoma staging is dependent upon depth and depth may be compromised with a shave biopsy, my onc doesn't risk losing information with a shave biopsy – even a deep or scoop shave.   He does punch biopsies if the mole can fit inside a punch.  If it doesn't, he would do an excisional biopsy so a full thickness biopsy can be optained.   And any scar that has pigment regrowth is also biopsied again.  I personally hate shave biopsies because I think they hurt more while healing.  But they are easier and quicker for derms to do and they require no followup to take out stitches so many derms use them.  It may be convenient for a derm, but it's my body they are cutting on and I demand a say in how things are done.  After all, I'm the one that suffers the consequences, not the doc.  I don't have shave biopsies and I want at least clean margins.  This is what works for me.  You have to figure out what works for you and demand that or find a doc more willing to work with you.  It comes down to peace of mind.

Best wishes,

Janner

Why don't you ask someone who goes to MDA and see if their doctors do punches or shaves?  I've never heard any comments here or read anything to the effect that reading a punch versus reading a shave changes anything for the dermatopathologist.  Certainly, they do not read the tissue from a WLE to the same scrutiny as a biopsy, but I've never heard mention that they won't read all the tissue from a punch biopsy.  I'm certain the dermatopathologists at MDA can handle punch biopsy tissue with a good level of certainty in reading all the tissue necessary.  You could call their pathology department and ask them directly — why not?  You have your slides sent there and it is an issue that concerns you.  I'd say it's worth an inquiry.

I'm in Salt Lake so certainly not one of the huge metropolitan areas.  Utah and the Intermountain West see a lot of melanoma cases because of sunny days and high elevation.  My cutaneous oncologist is a big believer in mole mapping and the entire department at Huntsman Cancer Center feels the same.  My doc's take is that there is no way he can just look at a mole and remember it from the last time you were there and know if it has changed at all.  Looks can be deceiving so change is key.  Mole mapping takes memory and guess work out of the equation and you have the camera's independent eye to help monitor things. 

I'd get body photographs – either professional or your own.  Then monthly, you can monitor your own moles.  Just because something changes doesn't mean it is melanoma.  Changes often happen in people with DNS.  But those are the most suspicious moles.  If you take your own photos, get a good camera, choose the macro setting (usually a flower), and take the photos in lighting you can duplicate.  Check your moles against the pictures in that same lighting.  Sometimes lighting can make it appear there are changes when there really isn't, so developing some consistency will help with monitoring.  When I originally had this done, they put numbered stickers by each mole that had a ruler on it for size comparison.  They took a close up shot, then took a more distant shot – say of the front lower left leg.  That way you could orient yourself better to make sure you're looking at the same mole on followups.  If you take some time to make a detailed set of photos you can follow, it will be easier to do your own followup comparisons.  I think I even have a basic body map somewhere on my website linked below for doing your own mapping.  Yes, I think basic photographs are an acceptable alternative to mole mapping where they compare photos each visit.  Official mole mapping machines use software as well as visual reviews by doctors to look for change, but not that many facilities do this.  So having baseline photos is definitely a good alternative.  It's what I use myself now.  I've done the more involved method but just don't feel it's needed for me at this point in time.

Doctors have many different techniques and many different styles.  Who is to say who is right or wrong?  The bottom line is feeling comfortable with your care and your doctor.   I hope you can get to that place too.

Janner

Why don't you ask someone who goes to MDA and see if their doctors do punches or shaves?  I've never heard any comments here or read anything to the effect that reading a punch versus reading a shave changes anything for the dermatopathologist.  Certainly, they do not read the tissue from a WLE to the same scrutiny as a biopsy, but I've never heard mention that they won't read all the tissue from a punch biopsy.  I'm certain the dermatopathologists at MDA can handle punch biopsy tissue with a good level of certainty in reading all the tissue necessary.  You could call their pathology department and ask them directly — why not?  You have your slides sent there and it is an issue that concerns you.  I'd say it's worth an inquiry.

I'm in Salt Lake so certainly not one of the huge metropolitan areas.  Utah and the Intermountain West see a lot of melanoma cases because of sunny days and high elevation.  My cutaneous oncologist is a big believer in mole mapping and the entire department at Huntsman Cancer Center feels the same.  My doc's take is that there is no way he can just look at a mole and remember it from the last time you were there and know if it has changed at all.  Looks can be deceiving so change is key.  Mole mapping takes memory and guess work out of the equation and you have the camera's independent eye to help monitor things. 

I'd get body photographs – either professional or your own.  Then monthly, you can monitor your own moles.  Just because something changes doesn't mean it is melanoma.  Changes often happen in people with DNS.  But those are the most suspicious moles.  If you take your own photos, get a good camera, choose the macro setting (usually a flower), and take the photos in lighting you can duplicate.  Check your moles against the pictures in that same lighting.  Sometimes lighting can make it appear there are changes when there really isn't, so developing some consistency will help with monitoring.  When I originally had this done, they put numbered stickers by each mole that had a ruler on it for size comparison.  They took a close up shot, then took a more distant shot – say of the front lower left leg.  That way you could orient yourself better to make sure you're looking at the same mole on followups.  If you take some time to make a detailed set of photos you can follow, it will be easier to do your own followup comparisons.  I think I even have a basic body map somewhere on my website linked below for doing your own mapping.  Yes, I think basic photographs are an acceptable alternative to mole mapping where they compare photos each visit.  Official mole mapping machines use software as well as visual reviews by doctors to look for change, but not that many facilities do this.  So having baseline photos is definitely a good alternative.  It's what I use myself now.  I've done the more involved method but just don't feel it's needed for me at this point in time.

Doctors have many different techniques and many different styles.  Who is to say who is right or wrong?  The bottom line is feeling comfortable with your care and your doctor.   I hope you can get to that place too.

Janner

Why don't you ask someone who goes to MDA and see if their doctors do punches or shaves?  I've never heard any comments here or read anything to the effect that reading a punch versus reading a shave changes anything for the dermatopathologist.  Certainly, they do not read the tissue from a WLE to the same scrutiny as a biopsy, but I've never heard mention that they won't read all the tissue from a punch biopsy.  I'm certain the dermatopathologists at MDA can handle punch biopsy tissue with a good level of certainty in reading all the tissue necessary.  You could call their pathology department and ask them directly — why not?  You have your slides sent there and it is an issue that concerns you.  I'd say it's worth an inquiry.

I'm in Salt Lake so certainly not one of the huge metropolitan areas.  Utah and the Intermountain West see a lot of melanoma cases because of sunny days and high elevation.  My cutaneous oncologist is a big believer in mole mapping and the entire department at Huntsman Cancer Center feels the same.  My doc's take is that there is no way he can just look at a mole and remember it from the last time you were there and know if it has changed at all.  Looks can be deceiving so change is key.  Mole mapping takes memory and guess work out of the equation and you have the camera's independent eye to help monitor things. 

I'd get body photographs – either professional or your own.  Then monthly, you can monitor your own moles.  Just because something changes doesn't mean it is melanoma.  Changes often happen in people with DNS.  But those are the most suspicious moles.  If you take your own photos, get a good camera, choose the macro setting (usually a flower), and take the photos in lighting you can duplicate.  Check your moles against the pictures in that same lighting.  Sometimes lighting can make it appear there are changes when there really isn't, so developing some consistency will help with monitoring.  When I originally had this done, they put numbered stickers by each mole that had a ruler on it for size comparison.  They took a close up shot, then took a more distant shot – say of the front lower left leg.  That way you could orient yourself better to make sure you're looking at the same mole on followups.  If you take some time to make a detailed set of photos you can follow, it will be easier to do your own followup comparisons.  I think I even have a basic body map somewhere on my website linked below for doing your own mapping.  Yes, I think basic photographs are an acceptable alternative to mole mapping where they compare photos each visit.  Official mole mapping machines use software as well as visual reviews by doctors to look for change, but not that many facilities do this.  So having baseline photos is definitely a good alternative.  It's what I use myself now.  I've done the more involved method but just don't feel it's needed for me at this point in time.

Doctors have many different techniques and many different styles.  Who is to say who is right or wrong?  The bottom line is feeling comfortable with your care and your doctor.   I hope you can get to that place too.

Janner

None of this is an exact science and you just have to find a doc and a comfort level that works for you.  I'm sure my doc could give a better explanation about cells left behind, it's been years since I heard it.  However, I just want to comment on two things.  Just because something is moderately dysplastic does not mean much.  A moderately dysplastic lesion is unlikely to change into melanoma.  Have any of the moles you've had biopsied CHANGED?  Have you done some type of mole mapping or body photography?  Most dysplastic nevi are going to stay exactly where they are now.  The highest risk lesions to become melanoma are the severely atypical lesions.  That's why they are removed with the same margins as melanoma in situ.  But lesions that are changing are the ones that are the most suspicious and the ones that I have removed.  In my onc's practice, if you have DNS you are part of the mole mapping project and would be having your atypical moles photographed at every visit.  Those that change would be removed with at least clear margins via punch or excisional biopsy.   In this mole mapping project, they've mapped many thousands of dysplastic moles on people with DNS or a history of melanoma.  After several years of study, 97% of these dysplastic moles never change.  And even the 3% that change, not all of these moles are melanoma.  So the big emphasis there is change, not outward appearance.  I, too, had one of my "normal" moles come back atypical.  All my biopsies to date have been atypical, I just don't have enough moles to qualify for DNS.

Have you had melanoma?  Another area where my cutaneous oncologist disagrees with your derm is biopsy method.  If you've had melanoma, my onc doesn't do shave biopsies.  I'm not exactly sure what his policy is if you haven't had melanoma since it's been too long ago since I was in that position. But I'm sure that anything that has changed or looks quite suspicious would not be removed with a shave regardless of background.  Since melanoma staging is dependent upon depth and depth may be compromised with a shave biopsy, my onc doesn't risk losing information with a shave biopsy – even a deep or scoop shave.   He does punch biopsies if the mole can fit inside a punch.  If it doesn't, he would do an excisional biopsy so a full thickness biopsy can be optained.   And any scar that has pigment regrowth is also biopsied again.  I personally hate shave biopsies because I think they hurt more while healing.  But they are easier and quicker for derms to do and they require no followup to take out stitches so many derms use them.  It may be convenient for a derm, but it's my body they are cutting on and I demand a say in how things are done.  After all, I'm the one that suffers the consequences, not the doc.  I don't have shave biopsies and I want at least clean margins.  This is what works for me.  You have to figure out what works for you and demand that or find a doc more willing to work with you.  It comes down to peace of mind.

Best wishes,

Janner

None of this is an exact science and you just have to find a doc and a comfort level that works for you.  I'm sure my doc could give a better explanation about cells left behind, it's been years since I heard it.  However, I just want to comment on two things.  Just because something is moderately dysplastic does not mean much.  A moderately dysplastic lesion is unlikely to change into melanoma.  Have any of the moles you've had biopsied CHANGED?  Have you done some type of mole mapping or body photography?  Most dysplastic nevi are going to stay exactly where they are now.  The highest risk lesions to become melanoma are the severely atypical lesions.  That's why they are removed with the same margins as melanoma in situ.  But lesions that are changing are the ones that are the most suspicious and the ones that I have removed.  In my onc's practice, if you have DNS you are part of the mole mapping project and would be having your atypical moles photographed at every visit.  Those that change would be removed with at least clear margins via punch or excisional biopsy.   In this mole mapping project, they've mapped many thousands of dysplastic moles on people with DNS or a history of melanoma.  After several years of study, 97% of these dysplastic moles never change.  And even the 3% that change, not all of these moles are melanoma.  So the big emphasis there is change, not outward appearance.  I, too, had one of my "normal" moles come back atypical.  All my biopsies to date have been atypical, I just don't have enough moles to qualify for DNS.

Have you had melanoma?  Another area where my cutaneous oncologist disagrees with your derm is biopsy method.  If you've had melanoma, my onc doesn't do shave biopsies.  I'm not exactly sure what his policy is if you haven't had melanoma since it's been too long ago since I was in that position. But I'm sure that anything that has changed or looks quite suspicious would not be removed with a shave regardless of background.  Since melanoma staging is dependent upon depth and depth may be compromised with a shave biopsy, my onc doesn't risk losing information with a shave biopsy – even a deep or scoop shave.   He does punch biopsies if the mole can fit inside a punch.  If it doesn't, he would do an excisional biopsy so a full thickness biopsy can be optained.   And any scar that has pigment regrowth is also biopsied again.  I personally hate shave biopsies because I think they hurt more while healing.  But they are easier and quicker for derms to do and they require no followup to take out stitches so many derms use them.  It may be convenient for a derm, but it's my body they are cutting on and I demand a say in how things are done.  After all, I'm the one that suffers the consequences, not the doc.  I don't have shave biopsies and I want at least clean margins.  This is what works for me.  You have to figure out what works for you and demand that or find a doc more willing to work with you.  It comes down to peace of mind.

Best wishes,

Janner

If you were to do an excisional biopsy with wide margins, this is possible.  But in general, doing an excisional biopsy with thoughts to remove the entire lesion shouldn't be much different than a shave or a punch.  It is a good question, though as there really is no way to know when removing tissue affects the drainage paths.

If you were to do an excisional biopsy with wide margins, this is possible.  But in general, doing an excisional biopsy with thoughts to remove the entire lesion shouldn't be much different than a shave or a punch.  It is a good question, though as there really is no way to know when removing tissue affects the drainage paths.

If you were to do an excisional biopsy with wide margins, this is possible.  But in general, doing an excisional biopsy with thoughts to remove the entire lesion shouldn't be much different than a shave or a punch.  It is a good question, though as there really is no way to know when removing tissue affects the drainage paths.