By Daniel Mark Siegel, MD, MS
Winter is ending and the temptation to shed some layers comes alive.
But if you do show off your body, pay attention -- particularly if you are a mole-y person with dozens of moles, especially funny looking irregular ones all over the place. You may have a condition called "dysplastic nevus syndrome" or "familial atypical multiple mole-melanoma syndrome," which makes you more likely to develop melanoma. Nevus is the fancy Latin word for "mole," which is a benign growth, but melanoma is a skin cancer that if not diagnosed and treated early can be lethal.
The difficulties of diagnosing melanoma
Fortunately, there are a lot more nevi (not nevuses) than melanoma. So how do you tell them apart? Sometimes it is easy for your doctor to reassure you, but other times, even with the use of the skilled eyes of the dermatologist and added magnification, dermoscopy, and other evolving imaging techniques, it's still not clear. In such cases, a biopsy is needed.
A biopsy is where all or part of a mole is removed, sent to the lab, and a report of the analysis comes back. Sometimes the report is straightforward and says "benign mole" with no need for further treatment. Other times it reports a melanoma with descriptive staging terms that guide further therapy.
Often, though you will receive a fence-sitting report that might read like this: "Mildly dysplastic nevus" or "moderately atypical nevus with moderate cytologic atypia and mild architechtural atypia." Or: "nevus with severe cytologic atypia approaching early evolving melanoma in situ," or any of dozen of variations similar to this. These categories are often accompanied by the phrase "Complete removal recommended," when the words "moderate" or "severe" are used in the report.
What the terms mean
What does it all mean to you?
We do like things to be clear: yes-no, on-off, win-lose, benign-malignant... but life is not always that simple. If you get 100 of the best dermatopathologists (doctors who specialize in looking at skin biopsies under a microscope) in a room, they will all likely agree on what's an everyday benign mole and what's obviously melanoma. But everything else can be a bit tricky.
To understand this a bit better, imagine a road called Mole Street. At one end, the junction between Mole Street and Benign Avenue, is a nice, square brick house, perfectly straight and symmetrical, with painted trim and windows all the same size and a nice lawn out front. At the other end of the road, the junction of Mole Street and Melanoma Road, you have an abandoned building that has collapsed on itself, surrounded by garbage. The building looks like it was never a pretty building, even at its best.
Now assume that as you walk down the street from the nice, normal house to the wreck of a home, the houses change gradually. Bricks get replaced by rocks and soda bottles and cinder blocks; the windows get less straight and some are cracked. The house itself is no longer square but may tilt and bulge at some points.
It is obvious that as you take this walk the neighborhood is changing in two ways: the architecture is changing (square to irregular to wobbly to collapsed) and the cytology is changing (all red rectangular bricks to soda bottles, cinder blocks, broken parts, and other unpleasant things). One end is the "normal" benign mole and the other is the "junkyard" melanoma. No argument here.
But as you walk down the street, at what point does the neighborhood go from good (benign) to not as good (mild atypia, cytologic and/or architectural), to bad (moderate atypia), to very bad (severe atypia, approaching early evolving melanoma)? No street signs tell you; it is a judgment call.
After all, dermatopathologists are only human (or so they tell me; one or two may be from Mars) and so must use their own best judgment. They may both look at the same biopsy specimen and see and describe the same features, but based on their own training may have different ways of interpreting what they see.
Dr. Q may think the changes he is seeing are severely atypical and want the dermatologist to be sure the mole is all out so it cannot become a melanoma. Doctor M may call it an early melanoma and also want it all to be removed. Dr. Q does not want to label you as having had a melanoma, as the particular funny mole in question at the time of the biopsy does not have the potential to kill you, while Dr. M may believe the features are indeed those of a melanoma, albeit one early enough so that complete removal assures it cannot grow, spread and do you in. Different words, same outcome. Different words, same meaning.
How to make it less confusing
What can you as the patient do to make it less confusing?
Ask your dermatologist for more information: Ask what he or she would do if the same mole were just biopsied from his or her spouse/child/parent? Would the doctor go back and take more skin to be sure it is out? Would it be ignored and nothing more done? It is truly amazing how these sorts of simple questions can get you clearer answers. Don't be afraid to ask.
So, how do you prevent those atypical moles and melanoma in the first place? Simple. Avoid the damaging ultraviolet (UV) rays from the sun, and stay out of tanning beds. You can do this while still enjoying a normal life.
First, use common sense: avoid the sun in the middle of the day when it is most dangerous, which is 10AM to 3PM in most areas (actual peak dangers vary based on latitude and where in a time zone you are). If you have to be out, cover up. Most clothing (except thin, wet, light-colored clothes) blocks UV rays, but if you want to be very sure, you can buy sun-protective clothing from a variety of manufacturers in many different styles. Long sleeves are better than short, and long pants and skirts protect more than shorts or miniskirts. Don't forget your hat, ideally one with a brim all around to protect the tender delicate ears and noses that we'd all like to keep. Any areas not covered can be protected with a properly applied broad spectrum sunscreen of at least an SPF 30. And wear sunglasses to protect your eyes.
One last thing to think about. When you go to the dentist you are always reminded to floss. My dentist says only to floss the teeth you want to keep. Same goes for skin. Only protect the skin you want to keep. Happy spring!
Dr. Siegel a practicing dermatologist, immediate past president of the American Academy of Dermatology, a past member of the American Cancer Society skin cancer advisory committee, and a member of the American Cancer Society medical editorial review board.