Since they were first described, the melanocytic neoplasms called dysplastic nevi, aka atypical moles, have been shrouded in controversy. It is clear, nonetheless, that certain groups of acquired nevi have features in the gray zone between benign nevi and melanoma. Histologically, these nevi display at least some degree of architectural disorder and cytologic atypia. Many also manifest an atypical clinical morphology.
Given the nebulous complexity of these lesions, it should come as no surprise that management recommendations vary widely. Fortunately, controversy spawns research, which in turn slowly peels away the shroud of uncertainty. In their lead story in this issue of The Melanoma Letter,Drs. Reddy and Rogers discuss the key factors involved in choosing between watchful waiting and complete surgical excision of biopsied DN. In their recent research, dysplastic nevi with mild to moderate atypia were rarely associated with melanoma, while those with moderate-to-severe or severe atypia were not uncommonly associated with melanoma. Specifically, when positive margins were found after initial biopsy, only a few moderate-to-severe or severe DN, and no mild to moderate DN, were found to have an associated melanoma. The authors suggest that the former may have a higher propensity for transformation or for harboring a focus of melanoma, with patients benefiting from complete re-excision, while the latter might safely be followed over time.
The second article in this issue, by Drs. Swetter, Clarke, and Keegan, explores the reasons behind the gender differences in melanoma survival. It has been known for some time that the prognosis for men with melanoma is worse than that of women. Much of this has been attributed to men’s lower awareness of and attentiveness to melanoma’s early warning signs. While this lack of awareness in men may contribute to later discovery and thicker tumors, recent work by Swetter and colleagues has suggested that the answer may be much more complex. The authors explore the possibility that female hormones may be protective and/or male hormones deleterious in melanoma biology. They even provide evidence that there may be gender differences in the immune response to melanoma. Their insights and hypotheses are intriguing and clearly warrant further research.
At the very least, the findings of the authors of our stories help to expand our understanding of melanogenesis and progression. If the research by Reddy and Rogers bears out, physicians could have greater certainty about when to pursue an aggressive or conservative surgical approach to DN, thereby reducing morbidity and health care costs, while the work of Swetter, et al could help eliminate the guilt that many men with melanoma assume, blaming their own negligence for their disease state. Removing this extra burden and stigma might offer an important secondary benefit to men as they marshal their energies to fight their disease.
Allan C. Halpern, MD
Ashfaq A. Marghoob, MD