Management of dysplastic nevi: A survey of fellows of the American Academy of Dermatology

Management of dysplastic nevi: A survey of fellows of the American Academy of Dermatology Jackie M. Tripp, MD,a Alfred W. Kopf, MD,a Ashfaq A. Marghoob, MD,b,c and Robert S. Bart, MDa New York and Stony Brook, New York Background: Opinions concerning the significance of dysplastic nevi and their management vary among dermatologists. Objective: The purpose of this study was to assess how fellows of the American Academy of Dermatology (AAD) perceive and manage dysplastic nevi. Methods: Questionnaires were sent to 1216 fellows of the AAD; 456 questionnaires were returned. Results: Almost all respondents (98%) accept the dysplastic nevus, or atypical mole, as an entity. Seventy-five percent of respondents perform follow-up total cutaneous examinations on all their patients with dysplastic nevi, and another 22% on some of them; 86% usually intend to do total removals when they perform biopsies of dysplastic nevi; 75% use margins of 2 mm or less when removing dysplastic nevi; 49% order baseline total-cutaneous photographs of some or all of their patients with multiple dysplastic nevi, although only 12% do so routinely; 67% prefer to re-excise dysplastic nevi when margins are positive, some using histologic atypia as a criterion; 60% recommend an ophthalmologic examination for at least some of their patients with many dysplastic nevi, although only 3% do so routinely; 12% always recommend cutaneous examinations of blood relatives of their patients with dysplastic nevi and another 81% recommend such examinations for at least some of their patients with dysplastic nevi; 23% use dermoscopy; 99% recommend self-examination; almost 100% recommend sunscreen use and 93%, sun avoidance. Conclusion: Most respondents, in agreement with the literature, accept the concept that patients with dysplastic nevi are at increased risk for melanoma and that methods for prevention and early detection of melanomas are appropriate for these patients. (J Am Acad Dermatol 2002;46:674-82.)

T

he concept of dysplastic nevi was first described in melanoma-prone families over 20 years ago.1-3 Since that time, the prevailing treatment of patients with such lesions has never been determined. Establishing guidelines for manFrom The Ronald O. Perelman Department of Dermatology, New York University School of Medicine New Yorka; Department of Dermatology, State University of New York at Stony Brook Health Sciences Centerb; and Memorial Sloan-Kettering Cancer Center, New York.c Funding sources: The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, Joseph H. Hazen Foundation, Mary and Emanuel Rosenthal Foundation, Kaplan Comprehensive Cancer Center (Cancer Center Support Core Grant No. 5P30-CA-16087), Blair O. Rogers Medical Research Fund, the Rahr Family Foundation, and Stavros S. Niarchos Foundation Fund of the Skin Cancer Foundation. Conflict of interest: None. Accepted for publication October 1, 2001. Reprint requests: Alfred W. Kopf, MD, The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 550 First Ave, New York, NY 10016. Copyright © 2002 by the American Academy of Dermatology, Inc. 0190-9622/2002/$35.00 ⫹ 0 16/1/121029 doi:10.1067/mjd.2002.121029

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agement of dysplastic nevi has been difficult both because the debate over clinical and histologic characteristics of dysplastic nevi continues and because the different clinical settings in which dysplastic nevi occur affect their significance. Significance depends on the number of “common” melanocytic nevi, the number of dysplastic nevi, and exposure to ultraviolet (UV) radiation, as well as family and personal histories of both dysplastic nevi and melanomas. Nevertheless, the significance of dysplastic nevi has been discussed repeatedly in the literature and involves evidence supporting two hypotheses: (1) dysplastic nevi are precursor lesions for melanomas,4-10 and (2) dysplastic nevi identify persons at increased risk for development of melanomas.11,12 The ultimate goal in the treatment of a patient with dysplastic nevi is the prevention of metastatic melanoma. This means modifying melanoma risk factors when possible and monitoring the patient so that any melanoma can be removed early in its curable phase. Questions raised include the following: (1) Should dermatologists recommend measures as

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such total-cutaneous photography, examination of first-degree relatives, or ophthalmologic examinations? (2) Is dermoscopy useful in differentiating dysplastic nevi from melanomas? (3) What exactly should patients be told concerning the significance of having dysplastic nevi? (4) How should biopsies of dysplastic nevi be performed? The main focus of this study was to assess how dermatologists are currently managing dysplastic nevi. In this study we surveyed dermatologists in the United States concerning this and other issues pertaining to dysplastic nevi.

MATERIALS AND METHODS A questionnaire composed of 20 multiple-choice questions was used for this survey. Space was provided for both general and specific comments. Most questions were designed to address medical management issues, and some questions dealt with the concept and diagnosis of dysplastic nevi. Although the term dysplastic nevus was used, respondents were informed that while answering the questions, they should realize that the queries were also referring to the identical entity known as atypical mole. The questionnaires were mailed out over approximately 2 months to fellows of the American Academy of Dermatology (AAD). Physicians were given at least 8 weeks to respond to them. For the survey, every sixth fellow was selected from an alphabetical list, supplied by the AAD, of 7297 fellows practicing in the United States; thus, 1216 fellows were sent questionnaires. The survey called for anonymous responses.

RESULTS The respondents A total of 456 dermatologists responded to the questionnaire. Eight questionnaires were returned with pages missing and were not used in the study. Five dermatologists stated that they do not make the diagnosis of dysplastic nevus or atypical mole but nevertheless answered the remaining questions pertaining to dysplastic nevi; therefore, it may be inferred that they accept the concept but use a different diagnosis. Six respondents stated that they do not use the diagnosis of dysplastic nevus or atypical mole and did not answer most of the questions pertaining to dysplastic nevi. Thus, although the responses of 448 dermatologists were included in this study, there were only 442 or fewer responses for each of the 17 questions dealing directly with dysplastic nevi. In this survey, 37% of the 1216 recipients returned completed questionnaires. We recognize, as is true with most surveys, that the limited rate of response raises the possibility of bias. For example, perhaps

Table I. Estimation of the number of new patients with dyplastic nevi seen per year Respondents No. of new patients

No.

%

0-5 6-20 21-50 51-100 101-300 ⬎300 Totals

9 39 92 114 118 69 441

2 9 21 26 27 16 100

Note: Multiplying the lowest points of the above ranges by the number of respondents per range, the number of new patients seen by all respondents in 1 year was estimated to be 40,677 (0 ⫻ 9 ⫹ 6 ⫻ 39 ⫹ 21 ⫻ 92 ⫹ 51 ⫻ 114 ⫹ 101 ⫻ 118 ⫹ 301 ⫻ 69). This value was multiplied by 16 (because the number of respondents represented approximately one sixteenth of fellows practicing in the United States), giving an estimate of around 650,000 new patients with dysplastic nevi seen per year by fellows of the AAD.

some of those who did not return the questionnaire do not recognize the concept of dysplastic nevi. Perhaps others have limited experience with these lesions and do not believe that their responses would be meaningful. Of the 448 physicians who responded, excluding their residency training, 220 (49.2%) have been practicing dermatology for more than 15 years; 143 (32.0%) have been practicing for 6 to 15 years, and 84 (18.8%) have been practicing for less than 5 years. Table I summarizes the estimates by the respondents of the number of new patients with dysplastic nevi seen annually. According to these numbers, a conservative rough estimate of new patients with dysplastic nevus seen by the respondents was calculated to be around 41,000 per year, and the number seen by all 7297 AAD fellows was extrapolated to be about 650,000 annually (see footnote to Table I). Diagnosis of dysplastic nevus The vast majority of respondents, 437 (97.5%), use the diagnosis of “dysplastic nevus” or “atypical mole,” whereas only 11 dermatologists (2.5%) do not. Of these 11, 5 answered all the questions pertaining to dysplastic nevi and presumably accept the concept. Of those physicians who do diagnose the entity, 253 (57.8%) use the term dysplastic nevus most often, whereas 177 (40.4%) prefer the term atypical mole, and 8 physicians (1.8%) either did not respond to the question concerning which of these terms they prefer or selected both terms. Of the respondents, 186 (42.1%) stated that they make the diagnosis of dysplastic nevus on a clinical basis alone, whereas 250 (56.6%) stated that they do not

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Fig 1. Use of dermoscopy among respondents in the differential diagnosis of pigmented lesions and their opinion on its helpfulness in differentiating melanomas from dysplastic nevi. *“Other” includes those physicians who stated that they are unsure and those who did not respond to the question.

make the diagnosis on a clinical basis alone; 6 (1.4%) did not respond to this question. Use of dermoscopy for dysplastic nevi The use of dermoscopy (epiluminescence microscopy) among respondents in the differential diagnosis of pigmented lesions was assessed, and those who do use dermoscopy were asked specifically whether the technique is found to be useful in differentiating dysplastic nevi from melanomas (Fig 1). Those who use dermoscopy were questioned as to how the use of the technique affects the number of biopsies performed. Of those 61 physicians who use dermoscopy and state that they find it useful, 40 (65.6%) believe that it leads to fewer biopsies being performed, 8 (13.6%) consider that it leads to more biopsies, and 13 (21.3%) believe that it does not change the total number of biopsies. No attempt was made to assess the level of expertise of those who use dermoscopy. Total-cutaneous examination and totalcutaneous photography in patients with dysplastic nevi When asked whether they perform follow-up total-cutaneous examinations on patients with one or more dysplastic nevi, 333 respondents (75.3%) reported that they do so on all patients and 99 (22.4%) stated that they perform such examinations, but only on certain patients with dysplastic nevi. Nine physi-

cians (2.0%) stated that they either do not perform total-cutaneous examinations on patients with dysplastic nevi or that they do not follow up such patients. In follow-up of patients with multiple dysplastic nevi, 53 physicians (12.0%) reported that they order total-cutaneous photographs for almost all such patients, 165 (37.3%) stated that they order such photographs for some of these patients, and 219 (49.5%) stated that they never order total-cutaneous photographs for patients with dysplastic multiple nevi. Surgical management of dysplastic nevi When asked about their intent during biopsy, 380 (86.0%) reported that most often they intend to remove the dysplastic nevus completely, whereas only 61 (13.8%) stated that it is not usually their intention to remove the lesion completely. These two groups of physicians were then asked which surgical procedure they most often use for biopsy of dysplastic nevi (Fig 2). It should be noted that the distinction between two of the possible responses, “shave” and “saucerization,” is, in practice, not necessarily a sharp one. Surgical margins used most often in the removal of dysplastic nevi are summarized in Table II. Seventy-five percent of respondents stated they use margins of 2 mm or less, 17% use margins of 2 to 3 mm, and 3% use margins of 4 or 5 mm. When asked what they would most often do if the pathology

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Fig 2. Type of biopsy selected for dysplastic nevi: when complete removal is intended and when complete removal is not intended. *“Other” includes those physicians who gave multiple responses.

report on a dysplastic nevus indicated that the margins were positive, 296 (67.0%) respondents reported that they would re-excise and 124 (28.1%) respondents reported that they would observe only. Twenty-two physicians (5.0%) either did not respond to this question or selected both of the answers offered. Although the concept of severe, moderate, or mild atypia was not presented as part of the question, 42 respondents (9.4%) wrote in their comments that their decision about whether to re-excise would be influenced by the degree of histologic atypia reported by the pathologist. Physicians were also asked whether they order step sections on the pathology request forms for dysplastic nevus specimens. Three hundred thirtyfive (75.8%) respondents do not expressly order them, whereas 35 (7.9%) do. Seventy physicians (15.8%) commented that they sometimes order stepsectioning, and two did not respond to the question. Some who do not order step sections commented that the decision to order step sections is made by their laboratories. Risk of cutaneous melanoma in patients with dysplastic nevi Physicians were asked to state whether, based on their experience, they believe that a patient with dysplastic nevi has an increased risk for development of melanoma. Two hundred fifty-nine (58.6%) reported that they believe that this is the case, whereas 31 (7.0%) stated that they believed that it is not. One hundred forty-nine (33.7%) respondents were uncertain as to this relationship and 3 (0.7%) did not respond to the question.

Table II. Surgical margins used in the removal of a dysplastic nevus Respondents

1 mm 1-2 mm 2 mm 2-3 mm 3 mm 4 mm 5 mm Other* No response Totals

No.

%

134 11 187 5 69 6 8 21 1 442

30.3 2.5 42.3 1.1 15.6 1.4 1.8 4.8 0.2 100

* “Other” includes responses of physicians who would decide on the surgical margins on the basis of the clinical or histologic situation (eg, degree of cytologic atypia).

Recommendations and advice given to patients with dysplastic nevi Physicians were asked which recommendations they regularly make to patients with dysplastic nevi concerning prevention and self-examination and what information they give patients regarding the risks associated with dysplastic nevi. Tables IIIA and IIIB summarize their responses. When asked whether they advise their patients with many dysplastic nevi to be examined by an ophthalmologist for ocular melanocytic neoplasms, 13 respondents (2.9%) stated they always do; 51 (11.5%) stated they usually do; 201 (45.5%) stated they do, but infrequently; and 176 (39.8%) stated

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Table IIIA. Number (percentage) of respondents making the following recommendations to patients with dysplastic nevi concerning preventive measures Yes

Sun avoidance Sunscreen use Clothing for sun protection Self-examination

No

No.

%

No.

%

412 441 390 439

93.2 99.8 88.2 99.3

30 1 52 3

6.8 0.2 11.8 0.7

Table IIIB. Number (percentage) of respondents giving the following information to patients with dysplastic nevi concerning risks Always inform patients

Dysplastic nevi mark persons at increased risk for melanoma Dysplastic nevi are precursors of melanoma

Sometimes inform patients

Never inform patients

No.

%

No.

%

313

71.0

121

27.4

7

1.6

246

55.9

152

34.5

42

9.5

that they never do. One physician did not respond to this question. When asked whether they recommend cutaneous examinations for blood relatives of patients with dysplastic nevi, 54 respondents (12.2%) reported that they always do, 187 (42.3%) reported that they usually do, 170 (38.5%) reported that they infrequently do, and 29 (6.6%) reported that they never recommend this. Two physicians did not respond to this question. Follow-up Respondents were asked about the average frequency of follow-up during the first 5 years for patients first seen with dysplastic nevi and no personal history of melanoma. Two hundred sixty physicians (58.8%) responded “about every 12 months,” 145 (32.8%) responded “about every 6 months,” and 6 (1.4%) responded “about every 3 months.” Two physicians recommended no follow-up, and 29 (6.6%) responded “other,” which included comments calling for schedules with decreased frequency as time passed and comments that gave different follow-up frequencies for different clinical situations.

DISCUSSION Currently, there is some controversy concerning the concept of dysplastic nevi. At one extreme, a few authors doubt that what is commonly known as the dysplastic nevus or atypical mole even exists as a distinct clinical-histologic entity.13,14 However, the vast majority of respondents in our survey (98%)

No.

%

believe that the entity does indeed exist, judging by the fact that they use the term dysplastic nevus or atypical mole in their practices. Furthermore, according to the results of this survey, the lesion is common; a conservative rough estimate is that 650,000 new patients with dysplastic nevi are seen annually by AAD fellows practicing in the United States. It is in part due to the perceived prevalence of these lesions that an examination of how they are being managed seemed worthwhile. Concerning the significance of dysplastic nevi, the proportion of cutaneous melanomas that originate from dysplastic nevi relative to those that arise from apparently normal skin and from other melanocytic nevi is not known. However, clinically diagnosed putative dysplastic nevi have been documented by photography to progress to melanomas.4-6 The presence of histopathologic changes considered to be those of dysplastic nevi, found in contiguity with cutaneous melanomas, has also been used to argue the case of dysplastic nevi as precursors of melanomas.7-10 However, because of the differing histopathologic criteria for the diagnosis of dysplastic nevi, the reported frequencies of dysplastic nevi associated with melanomas on histologic examination have ranged from 0.5% to 30%.15 Also, some have made the argument that the observation of a “dysplastic nevus” in histologic sections of a melanoma may simply represent “activation” of melanocytes adjacent to a de novo melanoma.16 The prevalence of dysplastic nevi would appear to be very high, and it has been pointed out

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that most dysplastic nevi do not progress to melanoma.8,17,18 Many agree that prophylactic excision of all dysplastic nevi is impractical and unnecessary.12,15,17,19 When it comes to the issue of dysplastic nevi serving as markers of increased risk for melanoma, the evidence in the literature is compelling. Review articles on the subject11,12 discuss numerous retrospective case-control studies showing an increase in the prevalence of clinically established dysplastic nevi in patients with melanomas. Also discussed are several prospective studies, in which cohorts of patients with dysplastic nevi are monitored, have revealed an increased risk for the development of melanomas. When asked (based on their experience) whether dysplastic nevi identify those patients with an increased risk for melanoma, many more dermatologists in our survey (58%) consider that they do than believe that they do not (7%), and many (34%) stated that they are uncertain. The majority of respondents supported informing patients with dysplastic nevi that dysplastic nevi are markers for melanoma risk and that they are potential precursors of melanomas as well. Additionally, our survey seemed to reflect the fact that the arguments in the literature that dysplastic nevi serve as markers of increased risk for melanoma appear to be stronger than the arguments supporting the progression of dysplastic nevi to melanomas. Seventy-one percent of respondents reported that they always inform patients with dysplastic nevi that they have an increased risk for melanoma, whereas in response to a separate question, only 56% reported that they always inform patients with dysplastic nevi that the dysplastic nevi are precursors of melanomas. The main goal of treating patients with dysplastic nevi is prevention of metastatic melanoma. This means modifying potential melanoma risk factors, when possible, and monitoring the patient so that early detection and cure of melanomas can be achieved. Preventive measures for melanoma in patients with dysplastic nevi, as in the general population, consist of recommending sun-protective measures that include minimizing sun exposure, wearing sunprotective clothing, and using sunscreens on unavoidably exposed skin. As seen in our survey (Table IIIA), almost all physicians stated that they recommend these 3 common sun-protective strategies to patients with dysplastic nevi, with some variation in the support for each. However, the usefulness of sunscreens for the prevention of melanomas is not entirely clear because of many confounding factors.20 Of at least equal importance in the prevention of

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metastatic melanoma are effective means of detecting early melanoma in those with dysplastic nevi. The frequency of follow-up visits recommended in the literature varies; some suggest that those with a familial history of dysplastic nevi or melanoma should be seen every 3 to 6 months,21,22 and those without such a history, every 6 to 12 months.21,23 Others recommend very individualized schedules, with total-cutaneous examinations suggested every 3 to 12 months, depending on the “estimated risk of malignant melanoma.”11 Most of the recommendations in the literature concerning the frequency of follow-up are for persons with a defined set of clinical characteristics (eg, those with atypical mole syndrome). There is a paucity of recommendations in the literature regarding how frequently one should monitor a patient with a few dysplastic nevi and no family history of dysplastic nevi or melanoma. In our study, most respondents (59%) stated that patients (without a personal history of melanoma) are seen on average about once per year during the first 5 years after they are first seen with dysplastic nevi. However, it should be noted that many of the respondents indicated that the follow-up schedule for each patient should be individualized, depending on many factors, such as the number of nevi, the degree of clinical atypia observed in lesions, the degree of cytologic atypia in biopsy specimens of lesions, and a personal or family history of melanoma. In addition to appropriate monitoring of these patients through follow-up visits, many authors11,17,21,24 recommend informing the patients about the benefits of self-examination, and virtually all dermatologists (99%) responding to the questionnaire agreed that this advice should be given to patients with dysplastic nevi. It has been suggested in the literature that examination of first-degree relatives (ie, blood-related parents, siblings, and children) of patients with dysplastic nevi, including those with so-called sporadic (no apparent familial component) atypical mole syndrome, should be performed.4,11,12,21-23 In our study, 55% of respondents stated that they always or usually recommend cutaneous examinations for relatives of patients with dysplastic nevi, 39% stated they do so infrequently, whereas only 7% stated that they never do so. In regard to surgical management of dysplastic nevi, some authors believe that only those lesions that are changing or new lesions suggestive of melanoma require biopsy21,25; that is, one should obtain a biopsy specimen of a lesion that is suspected of being a melanoma, but a biopsy specimen of a

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nevus should not be obtained merely to determine whether it is indeed a “dysplastic” nevus by histologic examination.26 Many authors do not require a biopsy to diagnose a dysplastic nevus (atypical mole).27-30 In our study, a majority of respondents (57%) stated that they do not make the diagnosis of dysplastic nevus on a clinical basis alone, implying that they believe that histologic confirmation is necessary. Some maintain that the use of total excision yields the best specimen for histologic examination of a dysplastic nevus.12,31,32 This approach seems appropriate because it should prevent difficult-to-evaluate recurrences and because melanoma is less likely to be missed on histologic examination of an entire lesion. In our study, when dermatologists were asked about their goal when performing a biopsy on a dysplastic nevus, 86% stated that their intention is most often to remove it completely, whereas only 14% stated that removing it completely is most often not their intention. Physicians were also asked which surgical procedure they usually use to perform biopsies of dysplastic nevi. As seen in Fig 2, dermatologists who stated that they intend to completely remove dysplastic nevi at the time of biopsy preferred saucerizations and excisional biopsies over shave and punch biopsies. Of those who stated their intention was not to completely remove a dysplastic nevus when a biopsy is performed, about half (51%) selected shave biopsy as their procedure of choice. However, it should be noted that the question did not distinguish between biopsies done to rule out melanoma from those done to confirm the diagnosis of dysplastic nevus. We believe that it is generally accepted that the best biopsy for a suspected melanoma is biopsy in toto, circumstances permitting. Some authors recommend that dysplastic nevi be completely removed with margins of 2 mm,31 and others recommmend complete removal with margins of 1 to 2 mm.22 In our study, 30% of the respondents to the question reported using surgical margins of 1 mm, and 75% reported using margins of 2 mm or less. Twenty percent of all respondents reported using margins greater than 2 mm, but only 3% of all respondents stated that they use margins greater than 4 mm. According to the 1992 National Institutes of Health Consensus Conference recommendations,33 when the margins of a removed dysplastic nevus are involved, and if re-excision is indicated, margins of 2 to 5 mm are appropriate. Other authors suggest that if the biopsy specimen of a dysplastic nevus is interpreted as having positive margins, decisions regarding re-excision should be based on the degree

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of histologic atypia present, and those nevi that exhibit severe atypia should be re-excised.34,35 In our study, physicians were asked what they would most often do when the pathology report of a dysplastic nevus indicated that the margins of excision were involved. Sixty-seven percent stated that they would re-excise such lesions, and 28% stated that they would only observe them. It is interesting that although the question involved a dysplastic nevus of unspecified atypia, 9% of respondents commented that the degree of histologic atypia affects their decision about whether to re-excise. The fact that this opinion had to be written in by the respondents suggests that the percentage of dermatologists who are influenced by the degree of atypia is probably higher than 9%. The concept of submitting a dysplastic nevus specimen for step-sectioning is based on the principle that a focus of melanoma may be missed when the usual histologic sectioning is used. This was briefly explored in our questionnaire. Only 24% of respondents stated that they order step-sectioning on dysplastic nevus specimens, whereas 76% stated that they do not. Comments from some of those who do not indicated that the decision to step-section is made by their laboratories. Numerous studies have demonstrated an association between having atypical mole syndrome and development of ocular malignant melanoma, most of which were reviewed in an article by Grin et al.36 This review also discusses the claim by some authors that there is no such association. This split opinion seems to be present among the dermatologists surveyed in this study as well. Many physicians believe that using photographs to monitor patients with multiple dysplastic nevi increases the probability of early detection of melanoma.5,6,12,37,38 In one recent study adults with 5 or more clinically diagnosed dysplastic nevi were monitored by means of baseline total-cutaneous photographs and cutaneous examination every 6 to 12 months; an increased melanoma detection rate attributable to the use of the photographs was found.5 However, there are some who contend that extensive photographic documentation of dysplastic nevi is unnecessary.39-41 It is recognized8 that when there are few dysplastic nevi on the patient, total-cutaneous photography is less likely to be useful, although photographs of individual lesions may prove helpful. When physicians in this survey were asked whether they order baseline total-cutaneous photographs for their patients with multiple dysplastic nevi, the numbers again reflected the disagreement present in the literature. Dermoscopy (epiluminescence microscopy, der-

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matoscopy) may be helpful in the examination of a nevus clinically suggestive of malignant melanoma. A number of published studies explore the efficacy of dermoscopy as a diagnostic tool in the evaluation of pigmented skin lesions by comparing it with conventional clinical methods. Diagnostic improvement was reported in most,42-45 but not all46 of these studies. Nevertheless, to our knowledge, the specific usefulness of dermoscopy for distinguishing dysplastic nevi from melanomas has yet to be evaluated with formal studies. Our survey attempted to explore the current use of dermoscopy among dermatologists in the context of surveillance of dysplastic nevi. Twenty-three percent of the 435 dermatologists who responded to the question stated that they use dermoscopy in their practice in the differential diagnosis of pigmented lesions. Of those using dermoscopy, 59% stated that they find dermoscopy useful in differentiating dysplastic nevi from melanomas, whereas 37% find that it is not useful for that purpose, and 4% are either unsure or did not respond to the question. Even though the majority of respondents who use dermoscopy believe that it is helpful in differentiating dysplastic nevi from melanomas, the opinion on whether it reduces the number of biopsies performed seems to be split. Forty-seven percent of those who use dermoscopy stated that the procedure results in fewer biopsies, 14% stated that it leads to more biopsies, and a rather large percentage (40%) stated that the procedure does not change the number of biopsies performed. Although one of the goals of dermoscopy is to decrease the number of biopsies of benign lesions, it should be noted that the diagnostic accuracy of dermoscopy is very physician-dependent45,47 and that the questionnaire was not designed to gauge each clinician’s ability to use the dermoscope. Despite the controversies regarding nomenclature and the criteria for clinical and histologic diagnosis, both the literature and the results of our survey indicate that many patients have so-called dysplastic nevi and that these nevi are considered to be important determinants of melanoma risk, especially when present in high numbers. In determining which patients are at high risk for melanoma, the clinical diagnosis of dysplastic nevi identifies those individuals who require recommendations for melanoma prevention (ie, avoidance of and/or protection from ultraviolet radiation) and screening for early detection of melanoma. This study gives some indication as to how dermatologists in the United States are monitoring these patients, how they are treating them surgically, what they are telling them

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regarding their risks, and what action they are recommending to them. We thank the many fellows of the American Academy of Dermatology who took the time out of their busy schedules to complete the questionnaire. We also thank Geraldine Richards for her help in the preparation of this manuscript. REFERENCES 1. Clark WH, Reimer RR, Greene M, Ainsworth AM, Mastrangelo MJ. Origin of familial malignant melanomas from heritable melanocytic lesions. ‘The B-K mole syndrome’. Arch Dermatol 1978;114: 732-8. 2. Frichot BC, Lynch HT, Guirgis HA, Harris RE, Lynch JF. New cutaneous phenotype in familial malignant melanoma. Lancet 1977; 1:864-5. 3. Lynch HT, Frichot BC, Lynch JF. Familial atypical mole-melanoma syndrome. J Med Genet 1978;15:352-6. 4. Greene MH, Clark WH, Tucker MA, Elder DE, Kraemer KH, Guerry D, et al. Acquired precursors of cutaneous malignant melanoma. The familial dysplastic nevus syndrome. N Engl J Med 1985;312:91-7. 5. Kelly JW, Yeatman JM, Regalia C, Mason G, Henham AP. A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. Med J Aust 1997;167: 191-4. 6. Rivers JK, Kopf AW, Vinokur AF, Rigel DS, Friedman RJ, Heilman ER, et al. Clinical characteristics of malignant melanomas developing in persons with dysplastic nevi. Cancer 1990;65:1232-6. 7. Duray PH, Ernstoff MS. Dysplastic nevus in histologic contiguity with acquired nonfamilial melanoma. Clinicopathologic experience in a 100-bed hospital. Arch Dermatol 1987;123:80-4. 8. Clark WH, Elder DE, Guerry D, Epstein MN, Greene MH, Van Horn M. A study of tumor progression: the precursor lesions of superficial spreading and nodular melanoma. Hum Pathol 1984;15: 1147-65. 9. Rhodes AR, Harrist TJ, Day CL, Mihm MC, Fitzpatrick TB, Sober AJ. Dysplastic melanocytic nevi in histologic association with 234 primary cutaneous melanomas. J Am Acad Dermatol 1983;9:563-74. 10. Skender-Kalnenas TM, English DR, Heenan PJ. Benign melanocytic lesions: risk markers or precursors of cutaneous melanoma? J Am Acad Dermatol 1995;33:1000-7. 11. Slade J, Marghoob AA, Salopek TG, Rigel DS, Kopf AW, Bart RS. Atypical mole syndrome: risk factor for cutaneous malignant melanoma and implications for management. J Am Acad Dermatol 1995;32:479-94. 12. Greene MH. The genetics of hereditary melanoma and nevi. 1998 update. Cancer 1999;86:2464-77. 13. Ackerman AB. What naevus is dysplastic, a syndrome and the commonest precursor of malignant melanoma? A riddle and an answer. Histopathology 1988;13:241-56. 14. Cook MG, Fallowfield ME. Dysplastic naevi: an alternative view. Histopathology 1990;16:29-35. 15. Rigel DS, Friedman RJ, Kopf AW, Rogers GS, Heilman ER. Precursors of malignant melanoma. Problems in computing the risk of malignant melanoma arising in dysplastic and congenital nevocytic nevi. Dermatol Clin 1985;3:361-5. 16. Tucker SB, Horstmann JP, Hertel B, Aranha G, Rosai J. Activation of nevi in patients with malignant melanoma. Cancer 1980;46: 822-7. 17. Elder DE. Dysplastic nevi. Their significance and management. Dermatol Clin 1988;6:257-69. 18. Marks R, Dorevitch AP, Mason G. Do all melanomas come from “moles”? A study of the histological association between mela-

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19.

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25. 26. 27.

28. 29.

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