Congenital melanocytic nevi: treatment modalities and management options

Giant congenital melanocytic nevus: report from 30 years of experience in a single department

Giant congenital melanocytic nevi (GCMN) occur in 1:20,000 livebirths and are associated with increased risk of malignant transformation. The treatment of GCMN from 1981 to 2010 in a tertiary referral center was reviewed evaluating the modalities used, cosmetic results, associated complications, and malignant transformation. Of 35 patients, 25 underwent surgery. Curettage was most frequently used (64%) followed by excision and tissue expansion (20%). Six percent of the patients treated with curettage, and 78% of the patients who received excision surgery required more than 1 planned procedure, and 25% versus 44% required unplanned additional surgery, respectively. Complications were noted in 25% and 67% of the patients, respectively. Cosmetic result was satisfying in 76% of patients without difference between the groups. No malignant transformation was found during a mean follow-up of 11 years. Curettage is a gentle alternative to excision with a lower complication rate and good cosmetic outcome.

Burn unit experience treating giant melanocytic nevi: 10-year review

Giant congenital melanocytic nevi (GCMN) are rare lesions that are present in 1 in every 20,000 new births. A 10-year review of all patients treated at a pediatric burn center was performed with the goal of identifying the characteristics of patients with GCMN and the outcomes of the treatment provided in a burn center. Thirty-six patients met the definition of GCMN; 64% were female and 36% were male. The most common ethnicity was white (47%), followed by Latino (19%). Most patients were between the ages of 1 and 10 years at the time of their first procedure (64%), and the mean age of patients at the time of their first procedure was 7 years. Eighty-nine percent had only one lesion. The most common location of lesions was the face (64%), followed by the scalp (17%) and back (17%). Seventy-four percent of the samples sent to pathology were congenital compound melanocytic nevi, and 20% were congenital intradermal melanocytic nevi. None of the lesions contained malignant changes at the time of the pathological examination. The various treatment modalities provided in the burn unit are reviewed. The authors conclude that the burn unit is an ideal setting for the treatment of GCMN.

Clinicopathological characteristics and surgical outcomes of divided nevus of the eyelids: a decade's experience on 73 cases

Currently, there is a lack of comprehensive data regarding clinicopathologic characteristics and surgical treatment of divided nevus of the eyelids. Here clinicopathologic features and reconstructive procedures performed on 73 patients were described. We showed that the lesion was randomly located on both eyes with a predominant incidence in females. Affected regions included the following: eyelid only (n = 40, 54.8%); medial canthus involvement (n = 4, 5.5%); medial canthus, caruncle, and bulbar conjunctiva involvement (n = 5, 6.8%); lateral canthus involvement (n = 18, 24.7%); full eyelids (n = 6, 8.2%); and cheek extension (n = 9, 12.3%). Lesions presented as a pigmented macule (n = 18, 24.7%) or mass (n = 55, 75.3%). Ptosis was present in 26 (35.6%) cases leading to visual field defects (n = 9, 12.3%). The puncta were covered in 13 (17.8%) cases. Overall, surgical results were satisfactory. Pathologically, lesions were either intradermal (n = 40, 54.8%), junctional (n = 15, 20.5%), or compound (n = 18, 24.7%). Because of the lack of systemic data regarding the rare entity of divided nevus of the eyelids, this study improves our understanding of this lesion, and it should be treated with individualized reconstructive procedures. Incorporation of pediatric patient population in the future will further extend our knowledge in dealing with this disorder.

Multiple giant congenital nevi – a case report / Multipli gigantski kongenitalni nevusi – prikaz slučaja

Giant congenital melanocytic nevi are benign nevomelanocytic proliferations of 20 cm or more in diameter, present at birth. They are primarily found on the posterior trunk, but they may arise on any other part of the body, covering more than 2% of the body surface. Giant congenital nevi are major risk factors for the development of melanoma, and the risk has been estimated to be as high as 5-7%. Persons with giant congenital melanocytic nevi on the head, neck and along the midline of the back are at increased risk for leptomeningeal melanocytic lesions. Most patients with neurocutaneous melanosis present with neurologic manifestations of the disease in the first 2 years of life. Melanoma occurs in 62-80% of cases, but even without neoplasms, symptomatic neurocutaneous melanosis has a poor prognosis. This is a report of a 23-year-old female patient who presented with multiple congenital pigmented and pilous nevi covering over 2% of her total body surface, without malignant alterations or association with other abnormalities. At birth, a nevus covered her neck, shoulders and the upper left arm, whereas several nevi over 5cm in diameter were present in the gluteal region, on the abdomen and legs. During the first 2 years of life, the existing nevi increased in size and progressed into darker brown. New, smaller pigmented changes appeared on the whole body and the face, while at the age of 17 they reached their current size and layout. At puberty, nevi over 10cm in size grew dark hairs. There were neither melanoma nor skin tumor cases in the family. Nuclear magnetic resonance imaging was not performed in the childhood or later in life, but other parameters - neurologic and ophthalmologic findings were in normal range all the time, as was growth and development. A complete photo-documentation was made, including macroscopic and dermoscopic images and regular follow-ups continue. Giant congenital melanocytic nevi may cause considerable esthetic and psychosocial problems. Due to their high malignant potential, association with other abnormalities, no consensus on the treatment, and monitoring problems, giant congenital melanocytic nevi represent a therapeutic problem as well.

The feasibility of tissue expanders in reconstruction of giant congenital melanocytic nevi in children

BACKGROUND

Children with giant congenital melanocytic nevi (GCMN) pose a great challenge to pediatric and reconstructive surgeons because they have to cover the widely exposed area after its excision. A variety of treatment options exist for the management of such cases. In this retrospective review of a selected group of children who had a GCMN of their abdominal walls managed with implantation of tissue expanders (TEs) for staged reconstruction, patients were evaluated with respect to complications and general and esthetic criteria for patient and parent satisfaction.

OBJECTIVE

The purpose was to study the feasibility of use of TEs in the management of children who had GCMN, with special emphasis on the complications and children's and parents' satisfaction.

MATERIAL AND METHODS

Retrospective data from the 12 patients' charts, operative data of 86 surgical procedures, and follow up visits were analyzed using the Student's t test, and P < .05 was considered statistically significant.

RESULTS

In a period of 4 years, from 2004 to 2008, the results of using 37 different sizes of TEs and 86 operative procedures in 12 children (9 boys and 3 girls) aged from 2 to 12 years with different types of abdominal wall GCMN are discussed.

CONCLUSION

The TE is a useful and feasible tool for reconstruction of the abdominal wall in cases of GCMN in children. Parents and children are satisfied in general and also with the body image.

Giant congenital melanocytic nevi

BACKGROUND

: Giant congenital melanocytic nevi are rare lesions with the potential to regress into malignant melanoma and/or neurocutaneous melanosis. Appropriate investigations include a screening magnetic resonance imaging scan, neurologic evaluation, and serial clinical observations looking for the development of these complications. Numerous excisional and nonexcisional options have been described for the management of giant congenital melanocytic nevi.

METHODS

: A MEDLINE search was performed to obtain all relevant citations.

CONCLUSIONS

: To successfully treat these complex lesions, the plastic surgeon must understand the disease process, the natural history and complications, and the options for treatment.

A Combination of Dual-mode 2,940 nm Er:YAG Laser Ablation with Surgical Excision for Treating Medium-sized Congenital Melanocytic Nevus

BACKGROUND

There are various treatment options for congenital melanocytic nevus (CMN), including surgical excision, dermabrasions, curettage, laser treatment, chemical peels and cryosurgery. The proper choice of treatment depends on the size, location, thickness and clinical appearance of the nevi, the risk for developing melanoma, the psychological effect and the cosmetic component.

OBJECTIVE

THE PURPOSE OF THIS STUDY IS TO EVALUATE THE OUTCOME OF A COMBINATION OF SURGICAL EXCISION WITH ER: YAG laser ablation for treating CMNs.

METHODS

A total of 13 patients were included in this study. The nevus was excised as much as possible and only dermal suturing was performed, without epidermal suturing, for the primary closure. We then ablated the whole lesion, including the suture lines, by using a dual-mode 2,940 nm Er:YAG laser with three to five passes. All the lesions were followed up for 6 months and they were evaluated with respect to the healing status, infection, erythema, scarring, textural change and pigmentary change. Subject satisfaction was scored at the 16(th) week by the patients.

RESULTS

Eleven (83%) of the 13 patients were clinically rated as having a good to excellent result by the physicians' Global Assessment Scale (GAS) scores for the lesions' reduction of size, the degree of scarring and the pigmentary change with only a one stage procedure. 10 (77%) of the total 13 patients reported a good to excellent result at four months after treatment.

CONCLUSION

A combination of surgical excision with Er:YAG laser ablation as a one stage procedure is a safe, effective modality and it should be considered as one of the options for treating medium-sized CMNs.

Giant congenital melanocytic nevi

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Define what is meant by a giant congenital melanocytic nevus and understand its histologic properties. 2. Know the natural history and potential complications associated with a giant congenital melanocytic nevus. 3. Outline the nonsurgical and surgical options available to treat a giant congenital melanocytic nevus.

BACKGROUND

Giant congenital melanocytic nevi are rare lesions with a propensity to degenerate to malignant melanoma. Certain lesions also may be associated with neurocutaneous melanosis, which can on occasion be symptomatic. Appropriate investigations include a screening magnetic resonance imaging scan, neurologic evaluation, and serial clinical observations for the development of cutaneous melanoma. A variety of nonsurgical and surgical options are possible for the treatment of giant congenital melanocytic nevi.

METHODS

A MEDLINE search was performed to gather all pertinent articles from 1955 to 2005.

RESULTS

Giant congenital melanocytic nevi are a difficult diagnostic and reconstructive challenge, requiring careful preoperative evaluation, staged surgical excision, and lifelong patient monitoring and follow-up. With proper treatment, patients can expect a decreased risk of melanoma, with the possibility for early detection and cure of melanoma, amelioration of symptoms, improved aesthetics and psychosocial sequelae, and maintenance of function.

CONCLUSION

The plastic surgeon treating these challenging lesions must have a solid working knowledge of the disease's histology, its natural history and complications, and the options for treatment.

Congenital melanocytic nevi and nevus spilus have a tendency to follow the lines of Blaschko: an examination of 200 cases

There have been few reports about the characteristics of the pigmentary arrangement of congenital melanocytic nevi (CMN) and nevus spilus (NS). Though the lines of Blaschko, which don't correspond to other lines such as Langer's lines and skin dermatomes, are well known to be followed by some rare pigmentary disorders, the relationship between these two disorders and the lines of Blaschko has not been discussed. Therefore, through an examination of 200 cases, we investigated whether or not the arrangement of CMN and NS follow the lines of Blaschko. Thirty-nine out of 92 cases (42.4%) of CMN and 67 out of 108 cases (62.0%) of NS were considered to follow the lines of Blaschko. Today, the idea is widely accepted that two functionally different cells proliferate during early embryogenesis of the skin which is caused from mosaicism and, as a result, the lines of Blaschko appear visually. In our results, we found that there were some cases of CMN and NS which showed a relationship with the lines of Blaschko, which is meaningful considering that the lesions and the lines are both related to pigmentary gene anomalies. The result was compared with CMN and NS by the chi(2) test. NS showed a predominant tendency to follow the lines with a significant difference (P = 0.0055). This may indicate that the lines of Blaschko reflect more clearly the proliferation of the epidermal cells than other cells in growth of the skin of the embryo. Further studies are required to elucidate the reason why some cases follow these lines and others do not.

Diagnosis and management of a changing congenital melanocytic nevus

A 70-year-old man presented with a birthmark on the right upper arm that had been present for as long as he could remember (Figure). His physician had referred him for a dermatology consultation because the lesion had become larger and darker over the past year. What are the next steps in the evaluation and management of this patient? The authors discuss the diagnosis and management of a changing congenital melanocytic nevus. The epidemiology and risk of transformation into melanoma are reviewed. Techniques of biopsy and indications for follow-up are discussed. A brief review of giant congenital melanocytic nevi in the newborn is also included.

Large or multiple congenital melanocytic nevi: Occurrence of neurocutaneous melanocytosis in 1008 persons

BACKGROUND

There is a dearth of information regarding the occurrence of neurocutaneous melanocytosis (NCM) in a large cohort of persons with large congenital melanocytic nevi (LMCN) or multiple congenital melanocytic nevi (MCMN).

OBJECTIVE

The purpose of this article is to report occurrence of NCM and other complications in 1008 persons having LCMN or MCMN.

METHODS

Evaluation of information obtained from a database of persons with LCMN or MCMN voluntarily submitted by the affected persons to a nevus support group, the Nevus Network.

RESULTS

Of those with truncal LCMN, 6.8% developed significant complications, 4.8% developed symptomatic NCM, and 2.3% died from either benign or malignant NCM or cutaneous melanoma. Of the 4.8% of persons with a truncal nevus who developed symptomatic NCM, 34% died. Of those with head or extremity LCMN, 0.8% developed symptomatic NCM, and, to date, none have died from any cause. Of the small number with MCMN without a giant nevus, 71% developed symptomatic NCM, and 41% died of it.

LIMITATIONS

Attending physician confirmation of submitted information was unavailable.

CONCLUSIONS

LCMN of the trunk were associated with a relatively low occurrence of medical complications and death in our group, considering the large nevomelanocytic burden present. If symptomatic NCM developed in those with truncal nevi, the occurrence of death rose to a third. LCMN of the head or extremity were associated with minimal medical complications and no deaths. In contrast, most of the rare persons (N = 17) with MCMN developed symptomatic NCM, and more than a third died.

Large or multiple congenital melanocytic nevi: occurrence of cutaneous melanoma in 1008 persons

BACKGROUND

There is a dearth of information regarding the occurrence of cutaneous melanoma in a large cohort of persons with large congenital melanocytic nevi (LCMN) or multiple congenital melanocytic nevi (MCMN).

OBJECTIVE

The purpose of this article is to report our experience with 1008 persons having LCMN and MCMN.

METHODS

Information was evaluated that was obtained from a database of persons with LCMN or MCMN voluntarily submitted by the affected persons to a nevus support group, the Nevus Network.

RESULTS

Of those with garment LCMN, 2.9% developed cutaneous melanoma associated with 0.8% deaths. Of those with LCMN on the head or extremity, 0.3% developed cutaneous melanoma associated with no deaths to date. Of the small number with MCMN without a giant nevus, 6.7% developed cutaneous melanoma.

LIMITATIONS

Attending physician confirmation of submitted information was unavailable. Conclusions LCMN and MCMN were associated with a low occurrence of cutaneous melanoma in our group.

Treatment of Congenital Nevomelanocytic Nevi with the CO2 and Q-Switched Alexandrite Lasers

BACKGROUND

A variety of treatment options exist for the management of congenital nevomelanocytic nevi (CNN). Surgical treatment has been the traditional approach, but scarring and cosmetic problems are common. Recently, lasers have been used to treat CNN because, in some cases, surgical excisions are inadequate owing to their inaccessible location, size, and depth.

OBJECTIVE

The effects of the combined use of CO2 laser and Q-switched Alexandrite laser on CNN were evaluated.

METHODS

Eleven patients with CNN were enrolled in this study. The surface epithelium was abraded by a CO2 laser. Subsequently, the lesion was treated by a Q-switched alexandrite laser. Repeated treatments were done every 6 weeks. The results were evaluated clinically by both physicians and patients at 2 and 6 weeks after each treatment using a 5-point grade scale.

RESULTS

By the end of the treatments, the average improvement scale assessed by the physicians, with a 5-point grade scale, was 3.82 and that of the patients was 3.73. There were no cases of hypertrophic scar or postinflammatory hyperpigmentaton persisting beyond 2 weeks. There were no recurrences during the 2-year follow-up period.

CONCLUSION

The combined laser treatment is an effective method for the treatment of CNN. The clinical outcome was favorable; the treatment was safer, less painful, and relatively nonscarring; and there was a quicker recovery period and less of a burden to repeat treatment when necessary compared with conventional treatments.

Asymptomatic neurocutaneous melanocytosis in patients with large congenital melanocytic nevi: A study of cases from an Internet-based registry

BACKGROUND

Recent retrospective studies using magnetic resonance imaging (MRI) to screen for neurocutaneous melanocytosis (NCM) among neurologically asymptomatic children with large congenital melanocytic nevi (LCMN) report high prevalence (23-30%) of asymptomatic NCM. We sought to determine prevalence of asymptomatic NCM, and current application of MRI as a screening tool.

METHODS

Patients with LCMN from an Internet-based registry answered a questionnaire regarding NCM status.

RESULTS

Of 379 patients with LCMN, 26 reportedly had NCM, with 17 reporting neurologic symptoms. Of 186 patients undergoing MRI, 9 reported abnormal findings without neurologic symptoms (4.8%); 80% had LCMN on the posterior axis, whereas 55% had more than 20 satellite nevi.

LIMITATIONS

Study data rely on the registry members' self-reported findings and are limited by lack of independent data verification.

CONCLUSION

Asymptomatic NCM (determined by MRI) may not be common, with much lower prevalence (4.8%) than previously reported. MRI is widely used for screening patients at risk for NCM, such as patients with LCMN involving the posterior axis and greater than 20 satellite nevi.

Giant congenital melanocytic nevi of the trunk and an algorithm for treatment

Giant congenital melanocytic nevi (CMN) are rare, congenital, disfiguring lesions with a risk of degeneration to malignant melanoma. Giant CMN are associated with an increased risk of malignant degeneration. In a minority of cases, patients with giant CMN may have associated neurocutaneous melanosis with leptomeningeal involvement. Giant CMN of the trunk pose difficult diagnostic and reconstructive problems requiring complex multistage treatment. For high-risk cases, diagnostic evaluation in the form of neuro-imaging is an essential component of the planning phase. Although nonsurgical options for the treatment of giant CMN have been advocated, these modalities may decrease the burden of nevus cells but do not result in complete removal of these cells. The ability to monitor nevus cells that remain after nonsurgical management of giant CMN remains questionable. These nonsurgical options include dermabrasion, laser ablation, and chemical peel. In contrast, direct excision of the nevus is the mainstay of treatment of nonsurgical management of giant CMN. There are numerous surgical options to resurface the resultant cutaneous defect after excision of the nevus. The simplest of these options consists of serial excision and direct closure of the defect in stages. However, if the defect cannot be closed by direct cutaneous advancement, other options for wound resurfacing include split- or full-thickness skin graft, tissue expansion, and free tissue transfer. Tissue expansion should be viewed as a category of treatment options because expanders can be used to create an expanded full-thickness skin graft, local expanded flaps adjacent to the lesion, or expansion of a free tissue donor site. Given the diversity of reconstructive options that use tissue expansion, these techniques have evolved as the primary treatment method for giant CMN of the trunk. The authors outline an approach to the evaluation of giant CMN of the trunk, review the risks of melanoma and of neurocutaneous melanosis, describe their preferred treatment regimen, and offer a treatment algorithm for giant CMN of the trunk.

Congenital melanocytic nevi needing treatment

Patients presenting with congenital melanocytic nevi (CMN) need individualized treatment based upon nevus size, thickness, location, risk for developing melanoma, and psychological characteristics of the patient and family. The present authors review CMN types and prognoses, as well as absolute and relative indications for treatment. Risks and benefits of several treatment options are discussed, including surgical options, such as excision, chemical peels, dermabrasion and curettage, and laser therapy. The main focus of treatment is, in all cases, to address the concern for developing melanoma, at the same time optimizing the aesthetic and functional outcomes.