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

Neonatal Curettage of Large to Giant Congenital Melanocytic Nevi Under Local Anesthetic: A Case Series With Long-Term Follow Up

Background

Neonatal curettage of large to giant congenital melanocytic nevi (L-GCMN) is a simple, minimally invasive procedure typically performed within the first 2 weeks of life.

Objectives

To retrospectively review our experience with serial curettage of L-GCMN in the neonatal period performed under local anesthesia and their long-term outcomes.

Methods

Curettage was performed by a single pediatric dermatologist on nine neonates with L-GCMN under local anesthetic and with oral analgesia between 2002 and 2016 in Red Deer, Alberta, Canada. Patient charts were reviewed retrospectively to assess patient and procedure characteristics, tolerability, safety, cosmetic and functional outcomes, and malignant transformation.

Results

Patients were treated with an average of 6 curettage sessions (range 3 to 15) to remove the majority or entirety of the nevus. All patients tolerated local anesthesia well. The most common adverse event of the procedure was transient neutropenia. Two patients developed positive bacterial cultures without clinical signs of infection, treated with antibiotics. All curetted specimens demonstrated benign pathology. Patients were followed annually thereafter, for an average of 6 years. Eight patients with L-GCMN of the trunk had minimal to partial repigmentation with good cosmetic outcome. One patient had recurrence of a facial nevus. None of the patients developed cutaneous malignant melanoma.

Conclusions

Curettage appears to be a safe and effective treatment option for select cases of L-GCMNs of the trunk. We do not recommend the procedure for face or scalp CMN. This procedure can be performed under local anesthesia with serial curettage to avoid potential risks of general anesthesia.

Cultured epithelial autografts for the treatment of large-to-giant congenital melanocytic nevus in 31 patients

Introduction

Giant congenital melanocytic nevus (GCMN) is a large melanocytic nevus, and its full-thickness removal is usually difficult due to the lack of skin available for reconstruction. Curettage is an alternative approach in cases of GCMN to remove the superficial dermis above the cleavage plane with a curette in the neonatal period, and its major complications include repigmentation, retarded epithelization, and hypertrophic scar formation. In Japan, the JACE® cultured epidermal autograft (CEA) was approved and covered by public healthcare insurance for the treatment of congenital melanocytic nevus (CMN) that is difficult to treat with conventional methods in 2016. We have used CEA for wounds after curettage in the neonatal period or following ablation after the neonatal period in combination with laser therapies to reduce the above-mentioned complications.

Methods

In this study, we summarized all consecutive CMN patients treated using CEA from December 2016 to April 2019 and evaluated the duration required for epithelialization, incidence of hypertrophic scar, and color change in the target nevus by comparing the L∗ values one year later between the Curettage group, the non-Curettage group with initial treatment or the subsequent group.

Results

No significant differences were seen in the epithelization period or incidence of hypertrophic scars among the groups, but the color of the target nevus was improved significantly in the Curettage group (p < 0.01) and non-Curettage group with initial treatment (p < 0.01).

Conclusions

In conclusion, CEA seems to accelerate epithelization after curettage or ablation of CMN, and this treatment could improve the color of CMN when applied initially.

Spastic quadriplegia following intradermal use of hydrogen peroxide in the tardive curettage procedure for the treatment of a giant congenital nevus

The possible transformation of a giant congenital melanocytic nevi (GCMN) in malignant melanoma estimated from 0.05% to 40% depend on the size of the lesions. Many are the surgical procedures proposed, including: full or partial-thickness excisions, dermabrasion, curettage in the first weeks of life and laser treatment. The curettage technique has been proposed in the literature for the treatment of GCMN in the first few weeks of life and defined as a relatively atraumatic surgery procedure without general complications. The authors report the first case in the literature of embolization due to use of subcutaneous peroxide infiltration before a tardive curettage procedure in a newborn case of GCMN resulting in spastic quadriplegia with dystonic reaction. Consequently, a lawsuit, due to this medical malpractice, has been opened.

Cosmetically Challenging Congenital Melanocytic Nevi

BACKGROUND

Congenital melanocytic nevi (CMN) have a 1% to 5% lifetime risk for malignant transformation, with 50% of transformations occurring before the age of 5 years.The aim of this study is to assess the risk of melanoma development in pediatric patients with facial CMN involving the eyebrows, eyelid margins, and nasal alae where a margin of CMN was not excised to preserve these structures.

METHODS

A retrospective chart review of all pediatric patients with CMN from 1986 to 2014 was performed to review demographic information, diagnosis, and number of surgeries. Patients' clinical photographs were evaluated for residual nevi after completion of the treatment.

RESULTS

More than 950 medical charts of patients with CMN of the face area were reviewed. We identified 32 patients (13; 41% male) that met the study criteria with pathology-confirmed diagnosis of facial CMN with an average age of 4.4 years (3.3 months-15.8 years) at the time of initial surgery. The CMNs were classified into small (1; 3%), medium (14; 44%), large (14; 44%), and giant (3; 9%) based on their projected adult sizes. No patients developed melanoma within the small residual lesions left over the eyebrows and eyelids and inside nostrils at an average follow-up time of 5.6 (1.0-14.4) years and average age of 9.6 (1.8-19.2) years at the time of last follow-up.

CONCLUSIONS

Although a lifelong risk of malignant transformation of the residual CMN cannot be concluded, our results found no transformation in follow-up visits at an average age beyond the highest risk of melanoma development in childhood. We feel that leaving residual lesions on the face in areas of important anatomic structures for better cosmetic outcome is an acceptable risk.

Multiple Tissue Expansion for Giant Congenital Melanocytic Nevus

OBJECTIVE

Tissue expansion is the preferred technique for the treatment of giant congenital melanocytic nevus (GCMN) located on the face, abdomen, and legs. We believe that the use of multiple tissue expanders in the same surgery is a safe and effective technique for the treatment of GCMN.

MATERIALS AND METHODS

A total of 14 patients were treated between 2013 and 2016 for GCMN removal with placement in the same surgery of 3 or more tissue expanders. We analyzed esthetic results and complications.

RESULTS

The locations of the GCMN on the 14 patients were on the abdomen, thigh, and shoulder. The number of tissue expanders placed was 3 in 5 patients, 4 in 6 patients, 5 in 1 patient, and 6 in 2 patients. The average stay was 4.29 days (1-9 days), and the average time until the removal of the expanders was 84.71 days (47-127 days). Only 2 patients had postoperative complications, with one having dehiscence of the surgical wound and the other an infection of the expander.

CONCLUSIONS

The use of multiple tissue expanders for GCMN is a safe technique that reduces the number of surgical interventions, achieving a total excision of the nevus in less time and at a younger age. The esthetic results are similar, and we have not observed a higher rate of complications.

Efficacy of Cultured Epithelial Autograft after Curettage for Giant Melanocytic Nevus of the Head

Supplemental Digital Content is available in the text.

Cultured epithelial autograft (CEA) is an epithelial sheet prepared from a patient’s own skin using cell culture. In Japan, CEA (JACE; Japan Tissue Engineering Co., Ltd., Gamagori, Japan) was approved and covered by public health care insurance for use in the treatment of giant congenital melanocytic nevus (GCMN) in 2016. There are several treatment options for GCMN; however, the complete removal of a GCMN is usually difficult due to the lack of skin. In this report, we describe a case of GCMN in the occipital region that was treated using CEA after curettage. A 2-month-old boy had a GCMN of 13 × 21 cm in his occipital region. We used full-thickness skin taken from the back of the right auricle to prepare CEA under general anesthesia at 4 months of age. Three weeks after preparing CEA, we performed curettage of the right half of the GCMN, and CEA was grafted onto the wound afterward. CEA took completely, and epithelization was observed at 10 days after surgery. We then performed curettage with subsequent grafting of CEA on the left half of the GCMN at 7 months of age. CEA took completely, and epithelization was observed in this procedure as well with no hair loss at 8 months of age. Whether or not curettage can reduce the risk of malignant transformation into malignant melanoma of GCMN is unclear; however, the application of CEA after curettage may be a promising option for obtaining early epithelization.

Neurocutaneous Melanosis in an Adult Patient with Intracranial Primary Malignant Melanoma: Case Report and Review of the Literature

BACKGROUND

To explore the clinical characteristics of neurocutaneous melanosis (NCM) in adult patients to help improve diagnosis and treatment of this disease, we present a rare case of an adult patient suffering from NCM with malignant melanoma, as well as a review of the relevant Chinese and English literature.

CASE DESCRIPTION

The patient reported here plus the patients identified in our literature review total 30 adults with NCM (20 males [66.7%] and 10 females [33.3%]), age 19-65 years (average, 27.9 years). These include 24 cases of malignant melanoma (80.0%), 3 cases of melanocytoma (10.0%), 2 cases of diffuse melanocytosis (6.7%), and 1 case of unknown pathology (3.3%). Satellite nevi were reported in 25 cases (83.3%) and in 5 cases their presence was unknown (16.7%). Intracranial lesions were present in 28 cases (93.3%), and intraspinal lesions were present in 2 cases (6.7%). There are 4 cases of combined hydrocephalus (13.3%), and 2 cases of combined Dandy-Walker deformity (6.7%).

CONCLUSIONS

NCM is a rare disease, especially in adults. With the onset of symptoms, the diagnosis is generally confirmed. In children with congenital giant nevus, regular periodic surveys of the central nervous system (brain and spinal cord) with magnetic resonance imaging or cerebrospinal fluid analysis should be performed to diagnose NCM. Active treatment should be undertaken to improve the prognosis.

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.

Serial Tissue Expansion at the Same Site in Pediatric Patients: Is the Subsequent Expansion Faster?

Background

Serial tissue expansion is performed to remove giant congenital melanocytic nevi. However, there have been no studies comparing the expansion rate between the subsequent and preceding expansions. In this study, we analyzed the rate of expansion in accordance with the number of surgeries, expander location, expander size, and sex.

Methods

A retrospective analysis was performed in pediatric patients who underwent tissue expansion for giant congenital melanocytic nevi. We tested four factors that may influence the expansion rate: The number of surgeries, expander location, expander size, and sex. The rate of expansion was calculated by dividing the ‘inflation amount’ by the ‘expander size’.

Results

The expansion rate, compared with the first-time group, was 1.25 times higher in the second-or-more group (P=0.04) and 1.84 times higher in the third-or-more group (P<0.01). The expansion rate was higher at the trunk than at other sites (P<0.01). There was a tendency of lower expansion rate for larger expanders (P=0.03). Sex did not affect the expansion rate.

Conclusions

There was a positive correlation between the number of surgeries and the expansion rate, a positive correlation between the expander location and the expansion rate, and a negative correlation between the expander size and the expansion rate.