Giant congenital melanocytic nevus

Giant Congenital Melanocytic Nevi: An Update and Emerging Therapies

Giant congenital melanocytic nevi (GCMN) are a rare occurrence. Gain-of-function mutation in the NRAS gene is found to be associated with GCMN, causing abnormal proliferation of embryonic melanoblasts. The two major complications associated with GCMN are malignant melanoma and neurocutaneous melanosis. Treatment of GCMN has conventionally been surgical. However, the role of NRAS inhibitors and inactivation of nevus tissue by high hydrostatic pressure are being explored. We present a case of a 1-day-old neonate born with GCMN, along with a review of the literature.

Medium Sized Congenital Melanocytic Nevus with Suspected Progression to Melanoma during Pregnancy: What's the Best for the Patient?

BACKGROUND:

Congenital melanocytic nevi (CMN) are pigmented skin lesions usually present at birth. Rare varieties can develop and become clinically very large. Although they are benign nevomelanocytic neoplasms, all CMN may be precursors of the melanoma, regardless of their size. Individual risk of malignant transformation of melanocyte is determined by simultaneous action of exogenous and endogenous factors. The major exogenous risk factor is ultraviolet radiation. Leading roles among the endogenous factors are attributed to skin phenotype, gene mutation, sex hormones and their significance.

CASE REPORT:

We present a case of a 27 – year - old pregnant female patient with a congenital melanocytic nevus, which increased significantly in size, during her pregnancy. Estrogen levels increase during pregnancy and clinical evidence has suggested that melanocytes are estrogen - responsive. Nevi in a pregnant patient would exhibit increased expression of estrogen receptor β (ERβ) and thus enhanced the potential to respond to altered estrogen levels.

CONCLUSION:

All pigmented skin lesions should be carefully observed during pregnancy by a dermatologist due to the increased risk of malignant transformation, associated with the endocrine dependence. All lesions with visible changes should be removed surgically with appropriative anaesthesia.

An alternative strategy treated giant congenital melanocytic nevi with epidermis and superficial dermis of the lesions

Giant congenital melanocytic nevi (GCMN) are defined as rare pigmented lesions that are believed to form between weeks 9 and 20 of gestation. It is difficult to reconstruct large defects after the removal of the lesions and it has posed a great challenge to the plastic surgeon and dermatologist.Given all those difficulty reconstructing the defects, we try to explore an alternative way to resurfacing the defect after removal of GCMN.Patients with GCMN received single-stage excision. Following the subcutaneous tissue and deep dermis were discarded, epidermis and superficial dermis were harvested as graft substitutes to reconstruct the defects in situ.All of the grafted tissue survived well and skin color in the surgical area gradually became lighter. During the periodicity of follow-up, neither hypertrophic scars nor recurrence were observed. Furthermore, histopathology examination demonstrated that there are no distinct melanocytes gathered in the postoperation lesions.For those GCMN which is difficult to reconstruct with traditional methods, resection of the lesion followed by reconstruction with epidermis skin and superficial dermis from the lesions in situ may be a feasible and alternative therapy method.

A case report of the first application of culture epithelial autograft (JACE®) for giant congenital melanocytic nevus after its approval in Japan

In Japan, the JACE^® cultured epidermal autograft (CEA) was approved and covered by public healthcare insurance for use in the treatment of giant congenital melanocytic nevus (GCMN) in 2016. We herein report the results of the application of JACE^® after curettage and Q-switched ruby laser therapy. The current patient was the first patient with GCMN to be treated with JACE^® since its approval. A 3-month-old girl had a hairy GCMN of 9.5 cm in diameter from her cheek to her temple on the left side of her face. We first performed curettage of the nevus on the temple and applied irradiation using a Q-switched ruby laser; however, erosion relapsed at 2 months after first surgery. After preparing JACE^®, we performed curettage a second time at 7 months with irradiation of a Q-switched ruby laser and the application of the CEA. The CEA took successfully and the wound was completely epithelized at 1 week after grafting. Re-pigmentation is an important issue that remains to be solved; however, overcoming this would allow for a deeper abrasion or more intense laser irradiation to be performed in cases in which CEA will be subsequently applied.

Giant congenital melanocytic nevi: 40 years of experience with the serial excision technique

Although giant congenital melanocytic nevus is a rare lesion, it causes significant deformity and carries a risk of malignant degeneration. Different surgical techniques for the lesion removal are described, including serial resection, resection with skin grafting, and resection and coverage with expanded skin flap (skin expanders). The aim of this study is to report the author's 40 years of experience with cases requiring at least 4 serial excisions to complete the treatment. Serial resection is an effective, safe, and simple technique that requires a lot of patience. Treatment often results in a single linear scar, requires no donor sites, nor large flaps. It is not subject to potencial complications of expanders and avoid aesthetic deformities depending on the location.

Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy

Melanoma is usually apparent on the skin and readily detected by trained medical providers using a routine total body skin examination, yet this malignancy is responsible for the majority of skin cancer-related deaths. Currently, there is no national consensus on skin cancer screening in the USA, but dermatologists and primary care providers are routinely confronted with making the decision about when to recommend total body skin examinations and at what interval. The objectives of this paper are: to propose rational, risk-based, data-driven guidelines commensurate with the US Preventive Services Task Force screening guidelines for other disorders; to compare our proposed guidelines to recommendations made by other national and international organizations; and to review the US Preventive Services Task Force's 2016 Draft Recommendation Statement on skin cancer screening.

A prospective study of patients with large congenital melanocytic nevi and the risk of melanoma

BACKGROUND:

Large congenital melanocytic nevus (LCMN) is considered a risk factor for melanoma, although the magnitude of this risk is controversial.

OBJECTIVE:

To evaluate the risk of melanoma development in patients with LCMN seen at a dermatology referral center in Brazil during a twelve-year period. To the best of our knowledge, there are no published similar studies on large congenital melanocytic nevus in South America.

METHODS:

Our prospective cohort included only patients with congenital nevi ≥20cm. The cumulative risk of developing melanoma and the standardized morbidity ratio were calculated for patients followed up prospectively for at least 1 month.

RESULTS:

Sixty-three patients were enrolled in this study. One patient who developed melanoma prior to enrollment was excluded, and five were eliminated because of insufficient follow-up time. Mean follow-up for the remaining 57 patients was 5.5 years (median 5.2 years). Median age of entry into the study was 2.6 years. Most patients (75.4%) underwent only clinical observation. Melanomas occurred in 2 (3.5%) patients. Five-year cumulative risk for melanoma was 4.8% (95% CI: 1.9-11.5%). Standardized morbidity ratio was 1584 (95% CI: 266-5232, p<0.001).

STUDY LIMITATIONS:

The small sample size reduces the accuracy of risk estimates.

CONCLUSIONS:

This study analyzed prospectively for the first time data from South America demonstrating that patients with LCMN have a higher risk of developing melanoma than the general population (p<0.001).

Dermoscopic Features of Small, Medium, and Large-Sized Congenital Melanocytic Nevi

BACKGROUND

Congenital melanocytic nevi (CMN) are present at birth. It is well known that the presence of large-sized congenital nevus in early life could predict a major risk of developing melanoma.

OBJECTIVE

To investigate the clinical and dermoscopic features of the CMN, to search for and highlight any differences between small-sized, medium-sized, large-sized CMN.

METHODS

A nonrandomized observational study was performed. A total of 108 melanocytic nevi were analysed by clinical and dermoscopic examination.

RESULTS

Of the subjects, 57.4% were aged less than 16 years, 42.6% were aged 16 and more. Of the nevi, 26 had reticular pattern (24.1%), 35 had globular pattern (32.4%), 13 had reticular-globular pattern (12.0%), 16 had homogeneous pattern (14.8%), 6 had reticular-homogeneous pattern (5.6%), 2 had globular-homogeneous pattern (1.9%), 7 had cobblestone pattern (6.5%), 3 had reticular patchy pattern (2.8%). Atypical dots and globules, focal hypopigmentation and perifollicular hypopigmentation are the most common dermoscopic features of CMN. The rarest dermoscopic feature is the blue-whitish veil.

CONCLUSION

Most of the dermoscopic features related with dysplastic nevi up to the present, such as atypical dots and globules, focal hypopigmentation, perifollicular hypopigmentation were observed in CMN, in our study. Congenital nevus and dysplastic nevi may share the same dermoscopic features, therefore it is important to know it is found at birth or not.

Giant melanocytic nevi with neurocutaneous melanosis masquerading as neurofibromas

Neurocutaneous melanosis is congenital melanocytic nevus with neurological manifestations. We report a 4-year-old female child presenting with hyperpigmented and nodular skin lesion associated with developmental delay and convulsions. The child had multiple brownish-black nevi on the face and chest and giant melanocytic nevi on thoraco-abdomen, back, and gluteal region. Computed tomography scan of the brain showed calcification in the pons, right cerebellar hemisphere, and left medial temporal lobe. Skin biopsy done from nodular hyperpigmented site was suggestive of melanocytic nevi. Electroencephalogram showed multifocal epileptiform discharges.

Verification of the Inactivation of Melanocytic Nevus in vitro Using a Newly Developed Portable High Hydrostatic Pressure Device

High hydrostatic pressure (HHP) technology is a physical method for inactivating tissue. We reported that nevus specimens were inactivated after HHP at 200 MPa and that the inactivated nevus could be used as autologous dermis for covering skin defects. In this study, we verified the inactivation of nevus specimens using a newly developed portable HHP device which will be used in a clinical trial. Nevus tissue specimens were obtained from 5 patients (mean age 7.2 years, range 1-19). We cultured fibroblasts and nevus cells from the tissue specimens and then evaluated their inactivation after HHP at 200 MPa by confirming the attachment of the suspensions and by the live/dead staining of the suspensions, through the dissociation of the cells on chamber slides and by the live/dead staining of the remaining cells. The cells were also quantitatively evaluated by WST-8 assay. We then confirmed the inactivation of the nevus specimens after HHP using explant culture. Our results indicated that fibroblasts and nevus cells were inactivated after HHP at 200 MPa, with the exception of a small percentage of green-colored cells, which reflected the remaining activity of the cellular esterases after HHP. No cells migrated from the nevus specimens after HHP at 200 MPa. We verified the inactivation of fibroblasts and nevus cells cultured from nevus specimens, and in the nevus samples themselves after pressurization at 200 MPa using this device. This device could be used in clinical trials for giant congenital melanocytic nevi and may thus become useful in various medical fields.

Characteristics, treatment, and survival of invasive malignant melanoma (MM) in giant pigmented nevi (GPN) in adults: 976 cases from the National Cancer Data Base (NCDB)

BACKGROUND

Malignant melanoma (MM) arising in a giant pigmented nevus (GPN) is a rare disease in adults with no large series published to our knowledge.

OBJECTIVE

We sought to describe the characteristics, treatment, and survival of MM in GPN for adults.

METHODS

Adults with invasive MM in GPN (n = 976) reported to the National Cancer Data Base from 1998 to 2012 were evaluated for patient and tumor characteristics, treatment, and survival. For comparison, data from adults with invasive superficial spreading melanoma (SSM) (n = 111,870) and nodular melanoma (n = 35,962) were used.

RESULTS

Compared with patients with SSM, patients with MM in GPN had a thicker Breslow depth, more positive lymph nodes, and distant metastasis more frequently. Multivariate analysis identified age older than 65 years, Breslow thickness greater than 2 mm, presence of ulceration, presence of distant metastasis, and positive margins as independent predictors of survival in patients with MM in GPN. At all stages, having MM in GPN has similar overall survival compared with SSM.

LIMITATIONS

The study is retrospective and registry-based.

CONCLUSIONS

Invasive MM in GPN occurs in adults, with overall survival similar to SSM. Clinicians should be aware of the continued risk of MM in adults with GPN with low threshold for biopsy.

Case report of nodular melanoma within congenital melanocytic nevus- primary closure challenge

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Nodular melanoma that arose within congenital melanocytic nevus.

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Total excision and defect reconstruction in a single stage.

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Primary closure with triple Limberg flap.

Introduction

Congenital melanocytic nevi (CMN) are present in 1–2% of newborn infants. The size of CMN defines the risk of developing melanoma which is estimated from 5–10%, especially in lesions that are located across the spine.

Presentation of case

Herein we report a case where nodular melanoma was discovered on the periphery of medium sized CMN in a high risk patient. After complete excision, the defect was reconstructed with random pattern, triple rhomboid flap.

Discussion

Melanoma that arose within medium sized CMN would leave a complex posterior lower trunk defect. We used a triple Limberg flap which was proven to be straightforward and simple method when large defects are to be covered with vital tissue. We have also showed that this type of reconstruction is suitable for high risk patients that could not withstand any complex procedures.

Conclusion

In our case, the method we choose to reconstruct the defect proved to be simple, safe and easy, especially when surgery is performed in a high risk patient.

Congenital nevi versus metastatic melanoma in a newborn to a mother with malignant melanoma - diagnosis supported by sex chromosome analysis and Imaging Mass Spectrometry

A 37-year-old pregnant woman presented with a 2-cm irregular reddish nodule on her left upper arm during pregnancy. A biopsy from the lesion showed a 2.2-mm thick malignant melanoma with intravascular invasion, 25 mitosis/mm(2) and no ulceration. Following induction of labor, the patient underwent re-excision with sentinel lymph node biopsy. This showed no residual melanoma and no lymph node metastasis. The newborn boy had multiple pigmented lesions on the trunk, some of which were large and irregular. Two were biopsied and histologic examination showed dense dermal proliferation of medium sized melanocytes with multiple mitotic figures and no maturation with their descent into the dermis, raising suspicion of transplacental metastases. Examination of the placenta failed to show metastatic lesions. Multiplex polymerase chain reaction (PCR)-based genotyping, including testing for amelogenin locus for sex chromosome determination, demonstrated the presence of Y chromosome material in the melanocytes of the newborn's lesions excluding maternal origin. A diagnosis of congenital nevi was rendered. Subsequently, Imaging Mass Spectrometric analysis of the mother's lesion showed proteomic signature expression indicative of malignant melanoma, whereas the two lesions in the newborn showed changes indicative of nevi. This case demonstrates the utility of genotyping and Mass Spectrometry analysis in this challenging clinical scenario.

Extraordinary Large Giant Congenital Melanocytic Nevus Treated with Integra Dermal Regeneration Template

Garment-like giant congenital melanocytic nevi are very rare, and those being treated are most often offered excision and split-thickness skin transplantation. Due to the risk of restricted mobility secondary to shrinkage and hypertrophic scarring of the transplant, we treated to date the largest reported giant congenital melanocytic nevus (16% total body surface area) with Integra dermal regeneration template (Integra Life Sciences, Plainsboro, N.J.), giving a more functional skin reconstruction. In addition, the dermal regeneration template had to be covered with split-thickness skin transplant including multiple smaller nevi due to lack of larger area with normal skin.

Ocular findings in a case of periorbital giant congenital melanocytic nevus

Giant congenital melanocytic nevus (GCMN) is a large melanocytic nevus that rarely occurs in the periorbital region. Various systemic, as well as ophthalmic associations, have been reported with GCMN. However, there is only one case report describing ophthalmic findings in periorbital GCMN. We describe the ocular findings in a case of periorbital GCMN.