Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California2Pigmented Lesion and Melanoma Program, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Stanford, California.
Pathology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
JAMA Dermatol. 2016 Dec 1;152(12):1327-1334. doi: 10.1001/jamadermatol.2016.2869.
Controversy persists regarding the appropriate management of incompletely excised, biopsy-proven, mild and moderate dysplastic nevi (DN).
To determine long-term risk of associated melanoma in biopsied mild or moderate DN with positive histologic margins that were clinically observed vs reexcised with negative margins.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of mixed referral and community patients from an academic pigmented lesion clinic and dermatology clinics of the affiliated Veteran Affairs medical center with biopsy-confirmed DN with positive histologic margins diagnosed from May 15, 1991, to July 8, 2015, and followed up through May 30, 2016. A consecutive sample of 1473 histologically confirmed DN was identified using surgical pathology databases at the study sites; 590 cases in 498 patients met eligibility criteria.
The primary outcome was the proportion of biopsied DN that progressed to histologically confirmed invasive or in situ melanoma. Secondary outcomes included local nevus recurrence and development of primary melanoma at other anatomic sites.
The 498 patients had a mean (range) age of 57.6 (14-93) years and 90% were male. Among 590 positive-margin DN, 191 were reexcised and 399 clinically observed without further surgery; 170 reexcised and 304 observed DN had available follow-up data, with mean (SD) follow-up of 5.5 (4.6) years. Cases in the observation group were more likely to demonstrate nevus recurrence than those that were reexcised (3.3% vs 0%; P = .02). Six of 304 (2.0%) observed DN subsequently developed melanoma at the same site, compared with 1 of 170 (0.06%) that were reexcised (P = .43). Five of 6 observed patients who developed melanoma initially underwent partial biopsy with grossly positive margins; 1 melanoma in situ evolved from an excisionally biopsied moderately dysplastic nevus 5 years later. Only 1 case of thin invasive melanoma (≤1 mm) was observed, and no deaths from melanoma arising from biopsy-proven DN occurred through the latest dermatology follow-up. New primary melanoma developed at other sites in 9.9% of excised and 9.4% of resected DN.
In cases of mild and moderate DN with microscopically positive margins and no concerning clinical residual lesion, observation, rather than reexcision, was a reasonable management option. Partial biopsies of pigmented lesions suspicious for melanoma may lead to delayed melanoma diagnosis and should be discouraged.
对于不完全切除、活检证实的轻度和中度发育不良痣（DN），适当的处理方法仍存在争议。
比较临床观察到的伴有阳性组织学切缘的活检证实的轻度或中度 DN 与重新切除且切缘阴性的情况下，相关黑色素瘤的长期风险。
设计、地点和参与者：回顾性队列研究，对象为来自学术色素病变诊所和附属退伍军人事务医疗中心皮肤科诊所的混合转诊和社区患者，纳入了 1991 年 5 月 15 日至 2015 年 7 月 8 日期间经活检证实、伴有阳性组织学切缘的 DN，通过研究地点的外科病理学数据库确定了 1473 例组织学证实的 DN，连续样本；498 例患者中有 590 例符合纳入标准。
主要结局是活检证实的 DN 进展为组织学证实的侵袭性或原位黑色素瘤的比例。次要结局包括局部痣复发和其他解剖部位原发性黑色素瘤的发生。
498 例患者的平均（范围）年龄为 57.6（14-93）岁，90%为男性。590 例阳性切缘 DN 中，191 例重新切除，399 例临床观察未进一步手术；170 例重新切除和 304 例观察性 DN 有可用的随访数据，平均（SD）随访时间为 5.5（4.6）年。观察组中痣复发的病例比重新切除的病例更常见（3.3% vs 0%；P=0.02）。在观察组中，6 例（2.0%）观察到的 DN 随后在同一部位发生黑色素瘤，而在重新切除组中仅 1 例（0.06%）（P=0.43）。观察到的 5 例最初行部分活检且大体阳性的患者中，有 1 例黑色素瘤原位从 5 年后切除活检的中度发育不良痣发展而来。仅观察到 1 例薄侵袭性黑色素瘤（≤1 mm），且截至最近的皮肤科随访，未发生由活检证实的 DN 引起的黑色素瘤死亡。在切除的和重新切除的 DN 中，有 9.9%和 9.4%分别在其他部位发生新的原发性黑色素瘤。
对于伴有显微镜下阳性切缘且无明显残留病变的轻度和中度 DN，观察而非重新切除是合理的治疗选择。对疑似黑色素瘤的色素性病变进行部分活检可能会导致黑色素瘤的诊断延迟，应予以避免。
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