Educational and Practice Gaps in the Management of Volar Melanocytic Lesions

Abstract

Background

The benign and malignant patterns of acral melanocytic nevi (AMN) and acral melanomas (AM) have been defined in a series of retrospective studies. A 3-step algorithm was developed to determine when to biopsy acral melanocytic lesions. This algorithm has only been applied to a Japanese population.

Objectives

Our study aimed to review the current management strategy of acral melanocytic lesions and to investigate the utility of the 3-step algorithm in a predominately Caucasian cohort.

Methods

A retrospective search of the pathology and image databases at Mayo Clinic was performed between the years 2006 – 2016. Only cases located on a volar surface with dermoscopic images were included. Two dermatologists reviewed all dermoscopic images and assigned a global dermoscopic pattern. Clinical and follow-up data was gathered by chart review. All lesions with known diameter and pathological diagnosis were used for the 3-step algorithm.

Results

Regular fibrillar and ridge patterns were more likely to be biopsied (p=0.01). The majority of AMN (58.1%) and AM (60%) biopsied were due to physician-deemed concerning dermoscopic patterns. 39.2% of these cases were parallel furrow, lattice-like, or regular fibrillar. When patients were asked to follow-up within a 3-6-month period, only 16.7% of the patients returned within that interval. The 3-step algorithm would have correctly identified 4/5 AM for biopsy, missing a 6mm, multi-component, invasive melanoma.

Conclusion

We found one major educational gap in the recognition of low risk lesions with high rates of biopsy of the fibrillary pattern. Recognizing low-risk dermoscopic patterns could reduce the rate of biopsy of AMN by 23.3%. We identified two major practice gaps, poor patient compliance with follow up and the potential insensitivity of the 3-step algorithm to small multi-component acral melanocytic lesions.

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