Bilateral Naevus of Ito and Ota With Palatal Involvement

Naevus of Ito and naevus of Ota are benign dermal melanocytoses with similar pathogenic mechanisms of failure in the melanocyte migration to typical locations within the basal layer from neural crest cells and differ in distribution. Bilateral and oral mucosal involvement of naevus of Ota can occur but is infrequent. Naevus of Ito is seldom associated with naevus of Ota and extracutaneous manifestations. A review of the English literature showed 14 cases of naevus of Ota with palatal involvement. None showed bilateral involvement of both naevi with oral involvement. Here we report the case of bilateral naevus of Ito and bilateral naevus of Ota with palatal involvement. A 32-year-old male came to us with naevus of Ito on both sides of his back and naevus of Ota on both sides of his face involving the sclera of both eyes with a bluish lesion along the midline of the hard palate.

A clinical and biologic review of congenital melanocytic nevi

Congenital melanocytic nevi (CMN) are the result of aberrations in the mitogen-activated protein kinase signal transduction pathway caused by postzygotic somatic mutations. The estimated incidence of newborns with CMN is 1%-2%. The main complications of CMN include proliferative nodules, melanomas, and neurocutaneous melanosis, and the latter two are the most troublesome issues to address. Treatments are primarily taken into account for aesthetic purposes and the reduction of melanoma risk. Due to the much lower incidence of malignant transformation observed in recent studies than in previous data, clinical management paradigms for CMN patients have gradually shifted towards conservative observation and close monitoring. Surgery and lasers are still the main treatments, and targeted therapy may be a promising strategy to help manage complications. With the increase in awareness of mental health, increasing focus has been placed on the quality of life (QoL) and psychological issues of both CMN patients and their parents. Recent studies have revealed that families coping with CMN might endure intense pressure, a major loss in QoL, and psychological problems after diagnosis and during treatment. Here, we sought to present an overview of genetic basis, complications, treatments, and psychological issues related to CMN and hope to provide better management for patients with CMN.

Vitamin D status in children with congenital melanocytic nevi

Congenital melanocytic nevi (CMN) are rare, pigmented birthmarks that can predispose patients to melanoma of the central nervous system and skin. Data from non-CMN melanoma cohorts suggest that vitamin D levels may be connected to outcome, prompting this study of 25-hydroxyvitamin D levels in plasma samples from 40 children with CMN. While 27% were insufficient and 13% deficient, this was representative of European populations, and UK supplementation guidelines are already in place. Our data support routine vitamin D supplementation for all CMN patients during winter months, without routine serum measurement.

Non-multiple medium-sized congenital melanocytic nevi: to excise or to follow up?

Introduction

Congenital melanocytic nevi (CMN) are benign lesions composed of clonal proliferations of melanocytes. Although medium-sized CMN are common and generally remain benign throughout a person's lifetime, they may be precursors of melanoma. There is a limited number of studies focused on the risk of melanoma in solitary, medium-sized, congenital melanocytic nevus; therefore, the incidence of malignant transformation and guidelines for treatment are not well established.

Aim

Prompted by the limited data, we conducted this study to gather more information about medium-sized CMN, to optimize clinical care. We share our analysis of surgically removed medium-sized CMN.

Material and methods

A total of 10 patients with non-multiple, medium-sized, congenital melanocytic nevus were included in this study. Lesions were removed using surgical procedures.

Results

In most of the cases the reason for excision of the medium-sized CMN was evolution of the lesion or aesthetic considerations reported by the patients. In 2 cases, due to the large size of the lesions, serial excisions were performed, while other CMN were removed surgically using simple excision technique. Eight of 10 medium-sized CMN were histologically described as benign, and 2 cases of malignant transformations were reported.

Conclusions

According to our clinical experience and knowledge, we recommend managing patients on an individual basis, taking into consideration multiple clinical attributes. In our opinion, long-lasting observation is the management of choice, and if there is need of surgery, we recommend total simple or staged excision depending on nevus size.

Case report: Later onset of NRAS-mutant metastatic melanoma in a patient with a partially-excised giant congenital melanocytic nevus

Despite recent advances in treatment and surveillance, metastatic melanoma still carries a poor prognosis. Large/giant congenital melanocytic nevi (CMNs) constitute a known risk factor for the condition, with the greatest risk for malignant transformation thought to be during childhood (median age at diagnosis of 3 years in a previous cohort). Herein, we present the case of a 30-year-old male who, after undergoing multiple excision/grafting procedures for a giant CMN as a child, was diagnosed with an NRAS-mutant, MDM2-amplified metastatic melanoma more than 20 years later. Response to ipilimumab/nivolumab immunotherapy, cisplatin/vinblastine/temozolomide chemotherapy, and nivolumab/relatlimab immunotherapy was poor. This case highlights the importance of lifetime monitoring with once-yearly dermatological examination (including lymph node palpation) in large/giant CMN patients, as well as the need for further clinical trials evaluating novel therapies for NRAS-mutant melanoma.

Surgical management of facial congenital melanocytic nevi: Experiences and outcomes at an academic center

BACKGROUND

Congenital melanocytic nevi (CMN), benign pigmented birthmarks caused by the mutation of melanocytic cells during embryofetal development, can cause aesthetic problem when it is located on the face. Surgical managements of facial CMN are required by both pediatric patients and their parents. Surgical management, including excision or staged excision, skin grafting, dermabrasion, tissue expansion or multiple re-expansion combined with flaps transplantation, have been reported previously. However, a systematical report about facial CMN management is still scarce.

OBJECTIVE

Herein, we have reviewed our serious of patients with facial CMN, noting their size, location, and histological examination, summarizing the surgical relation behind reconstructive and cosmetic treatment, and proposing a newly classification for facial CMN among pediatric patients, hoping to share a useful surgical algorithm for these lesions on this specific part.

CONCLUSION

Proper surgical strategy should be made based on the size and location of the nevi and the adjacent relationship between the location and relaxed skin tension lines and aesthetic units. Postoperative ant-scar treatment improves aesthetic outcomes. With our experience and surgical algorithm about facial CMN surgery, a favorable outcome can be achieved.

Facial anatomical site-related variation in short-term outcomes of laser treatment for congenital melanocytic nevi

Background

Laser treatment for congenital melanocytic nevi (CMN) is controversial. Correlations between anatomical distribution of facial CMN and efficacy of laser treatment have not been characterized.

Materials & Methods

A total of 90 facial CMN treated with ablative laser (Er:YAG or CO2 laser) were retrospectively reviewed. Clinical assessments were completed by at least two plastic surgeons using the Investigator’s Global Assessment (IGA) score.

Results

The mean IGA score was 4.37. The IGA scores recorded at the periorbital, temple/forehead, nose, cheek and lip/chin areas were 3.68, 5.88, 4.63, 4.52 and 4.92, respectively (p = 0.03). Moreover, facial CMN with uniform pigment distribution showed higher IGA scores than those with a non-uniform pigment distribution. Thickening, hairiness and age at first treatment were not statistically correlated with laser efficacy.

Conclusion

Correlations between anatomical distribution and the efficacy of laser treatment are described for the first time. The subdivided anatomical distribution of facial CMN can yield meaningful information on predicting the efficacy of laser treatment.

Dufourmentel Flap for Surgical Treatment of Medium-sized Congenital Melanocytic Nevi on the Extremities

Congenital melanocytic nevi (CMN) are quite common benign proliferations of cutaneous melanocytes. They are present at birth or arise during the first few weeks of life being upper and lower extremities one of the most common locations. To date consistent guidelines for clinical management of CMN do not yet exist and the main reasons for removing them are medical and cosmetic. Regardless of the cause of having a CMN removed, when it comes to surgical excision of the lesion in daily practice the single most important decision to make is how to properly close the post-excisional defect. The local Dufourmentel skin flap seems to be a reliable solution for surgical treatment of medium-sized CMN on the limbs. It takes advantage of skin laxity adjаcent to thе defect to allоw the transpositiоn of tissuе with similаr charactеristics tо the tissuе еxcisеd which is the key for achieving good aesthetic and functional outcomes. In this brief clinical study the author identified a group of adult patients who had medium-sized CMN located on their extremities. The surgical technique is explained and useful tips are given. No complications and high patient satisfaction rate were registered in the series. Dufourmentel flap is a useful tool in the armamentarium of dermatologic surgery when dealing with medium-sized CMN on the extremities. Furthermore, due to its versatility this flap could also be applied for other clinical indications both benign and malignant.

Neurocutaneous melanocytosis (melanosis)

Neurocutaneous melanosis (NCM; MIM # 249400; ORPHA: 2481], first reported by the Bohemian pathologist Rokitansky in 1861, and now more precisely defined as neurocutaneous melanocytosis, is a rare, congenital syndrome characterised by the association of (1) congenital melanocytic nevi (CMN) of the skin with overlying hypertrichosis, presenting as (a) large (LCMN) or giant and/or multiple (MCMN) melanocytic lesions (or both; sometimes associated with smaller "satellite" nevi) or (b) as proliferative melanocytic nodules; and (2) melanocytosis (with infiltration) of the brain parenchyma and/or leptomeninges. CMN of the skin and leptomeningeal/nervous system infiltration are usually benign, more rarely may progress to melanoma or non-malignant melanosis of the brain. Approximately 12% of individuals with LCMN will develop NCM: wide extension and/or dorsal axial distribution of LCMN increases the risk of NCM. The CMN are recognised at birth and are distributed over the skin according to 6 or more patterns (6B patterns) in line with the archetypical patterns of distribution of mosaic skin disorders. Neurological manifestations can appear acutely in infancy, or more frequently later in childhood or adult life, and include signs/symptoms of intracranial hypertension, seizures/epilepsy, cranial nerve palsies, motor/sensory deficits, cognitive/behavioural abnormalities, sleep cycle anomalies, and eventually neurological deterioration. NMC patients may be symptomatic or asymptomatic, with or without evidence of the typical nervous system changes at MRI. Associated brain and spinal cord malformations include the Dandy-Walker malformation (DWM) complex, hemimegalencephaly, cortical dysplasia, arachnoid cysts, Chiari I and II malformations, syringomyelia, meningoceles, occult spinal dysraphism, and CNS lipoma/lipomatosis. There is no systemic involvement, or only rarely. Pathogenically, single postzygotic mutations in the NRAS (neuroblastoma RAS viral oncogene homologue; MIM # 164790; at 1p13.2) proto-oncogene explain the occurrence of single/multiple CMNs and melanocytic and non-melanocytic nervous system lesions in NCM: these disrupt the RAS/ERK/mTOR/PI3K/akt pathways. Diagnostic/surveillance work-ups require physical examination, ophthalmoscopy, brain/spinal cord magnetic resonance imaging (MRI) and angiography (MRA), positron emission tomography (PET), and video-EEG and IQ testing. Treatment strategies include laser therapy, chemical peeling, dermabrasion, and surgical removal/grafting for CMNs and shunt surgery and surgical removal/chemo/radiotherapy for CNS lesions. Biologically targeted therapies tailored (a) BRAF/MEK in NCM mice (MEK162) and GCMN (trametinib); (b) PI3K/mTOR (omipalisib/GSK2126458) in NMC cells; (c) RAS/MEK (vemurafenib and trametinib) in LCMNs cells; or created experimental NMC cells (YP-MEL).

Proliferative nodule resembling angiomatoid Spitz tumor with degenerative atypia arising within a giant congenital nevus

Proliferative nodules arising within congenital melanocytic nevi often present a diagnostic challenge given a close resemblance to melanoma. Several morphologic variants have been characterized. In difficult cases, ancillary molecular tests can be used to better exclude the possibility of malignant degeneration. Herein, we report a case of an unusual proliferative nodule with overlapping features of angiomatoid Spitz tumor and ancient melanocytic nevus, which demonstrated normal findings on both chromosomal microarray and a gene expression profiling assay.

Management of congenital melanocytic nevi in the plastic surgery clinic: Families' expectations and their persistent concern about malignancy

BACKGROUND

Children with congenital melanocytic nevi (CMN) were historically managed with surgical removal to lower the risk of malignant transformation. The evolving literature over the last decade has indicated a significantly lower risk than previously estimated. Indications for excision currently revolve around aesthetic and psychosocial concerns. This study describes and evaluates the perspectives and expectations of patients and families referred to a pediatric plastic surgery clinic on CMN management.

METHOD

A two-part questionnaire was administered before and after an initial clinic appointment to evaluate patient and family concerns of lesion growth, risk of malignancy, treatment expectations, and stigmatization.

RESULTS

Thirty questionnaires were completed for 11 male and 19 female patients, mean age 9.2 years (1-25). Referring doctors (majority dermatologists) were rarely concerned about malignancy (8%), but parents listed it as a top reason for wanting the CMN removed (37%) and the most common expectation for the visit followed by information about surgical options and outcome. Before the clinic, 93% were at least "slightly" worried about CMN growth and 96% about malignancy, whereas 63% and 72%, respectively, after the clinic.

CONCLUSIONS

Families want information about surgical excision and are concerned about malignancy, indicating lingering misinformation or misconception about melanoma risk. For the majority, CMN removal remains at least slightly important, presumably for aesthetic reasons and remaining concern about malignancy. Involved health care professionals should assure reliable and coherent patient information about MM risk, indications for surgery and expected outcome to best support families' decision-making.

Comparison of treatment options for small to medium congenital melanocytic nevi: A retrospective review of 119 cases

OBJECTIVES

For small to medium sized congenital melanocytic nevi (CMN), the treatment of choice is staged surgical excision. Ablative lasers or pigment-specific lasers have also been recommended for lesions difficult for surgical removal or to avoid surgery. In this study, we retrospectively analyzed the results of several treatment options for CMN to find out the optimal treatment method.

METHODS

Patients with small to medium sized CMN were retrospectively reviewed. Treatment options were categorized into four groups: (i) Excision only; (ii) Excision followed by scar laser; (iii) Excision followed by pigment-specific laser; and (iv) Laser only. Treatment response was assessed by investigator's global assessment (IGA) score on a seven-point scale.

RESULTS

A total of 119 cases were included. Lesions were most commonly located on the face (59/119, 49.6%), measured 2 ∼ 10 cm in size (72/119, 60.5%), and treated with excision only (50/119, 42.0%). Among treatment options, excision followed by scar laser showed the highest IGA score of 6.38. Options including surgical methods showed higher IGA scores compared to laser-only treatment (P < 0.01). Staged excisions and single excisions showed no difference in IGA scores. Patient satisfaction scores increased after scar laser treatment of the staged excision scar.

CONCLUSIONS

For the treatment of small to medium sized CMN, treatment strategies including surgical methods are cosmetically superior to laser-only treatment. Also, the combination of surgical excision with scar laser has the potential for better clinical outcomes and patient satisfaction. Lasers Surg. Med. 51:62-67, 2019. © 2018 Wiley Periodicals, Inc.

Dermoscopy of congenital melanocytic nevi: a ten-year follow-up study and comparative analysis with acquired melanocytic nevi arising in prepubertal age

Dermoscopic characteristics of congenital melanocytic nevi (CMN) have been reported, however, dermoscopic variation during long-term follow-up and direct comparative analyses with acquired melanocytic nevi (AMN) are poorly documented. To assess dermoscopic changes of CMN (including lesions present at birth or appearing within the first two years of age) after a long-term period and evaluate possible dermoscopic differences with AMN arising during prepubertal age. We re-analysed clinical and dermoscopic features of CMN, investigated ten years earlier. New findings were compared with those previously recorded, as well as with those of AMN appearing before puberty in the same group of patients. In total, 493 lesions (86 CMN and 407 AMN) from 71 patients were examined. Except for a greater size (median area: 73.9 vs 22.8 mm²; p<0.001) and higher prevalence of hair (17.4% vs 4.7; p<0.001) in CMN, no significant difference was observed between the two cohorts, including global/local dermoscopic features (p>0.05). The follow-up of CMN revealed that dermoscopic pattern changed in only four lesions (4.7%) (from globular to globular-reticular or reticular) after ten years, though lesions with a globular architecture presented several "local" changes, namely an increase in circumscribed reticular areas (from 20.0% to 41.5%; p = 0.030), irregularly distributed globules (from 15.6% to 34.1%; p = 0.045), and large globules (from 46.7% to 68.3%; p = 0.043). The dermoscopic appearance of CMN is significantly stable during childhood and is similar to that of AMN arising before puberty, thus supporting a possible link between such types of nevi.

Congenital melanocytic nevi in young children: Histopathologic features and clinical outcomes

BACKGROUND

Although only large congenital melanocytic nevi (CMN) are associated with a significantly high risk for malignant transformation, CMN of all sizes are prone to changes in clinical appearance in early childhood and thus are often biopsied or excised. While CMNs typically exhibit benign behavior, atypical histopathologic findings might be common and may prompt additional unnecessary procedures.

OBJECTIVE

To assess the prevalence and associated clinical outcomes of atypical histopathologic features in CMN in children.

METHODS

A single center retrospective study was conducted with patients 0-35 months of age with CMN diagnosed by histopathology between 1993-2013.

RESULTS

One hundred seventy-nine patients with a total of 197 CMNs were identified. Cytologic atypia, architectural disorder, or pagetoid spread were present in 73% of CMN. With a mean follow up of 7.3 years, no cases of melanoma or CMN-related deaths were identified.

LIMITATIONS

Our findings were based on a largely Caucasian population and might not apply to darker skin types. Our findings might not apply to older children or adults with CMN.

CONCLUSION

Atypical histopathologic features of cytologic atypia, architectural disorder, and pagetoid spread are common in benign CMN of young children.

Genetics of melanocytic nevi

Melanocytic nevi are a benign clonal proliferation of cells expressing the melanocytic phenotype, with heterogeneous clinical and molecular characteristics. In this review, we discuss the genetics of nevi by salient nevi subtypes: congenital melanocytic nevi, acquired melanocytic nevi, blue nevi, and Spitz nevi. While the molecular etiology of nevi has been less thoroughly studied than melanoma, it is clear that nevi and melanoma share common driver mutations. Acquired melanocytic nevi harbor oncogenic mutations in BRAF, which is the predominant oncogene associated with melanoma. Congenital melanocytic nevi and blue nevi frequently harbor NRAS mutations and GNAQ mutations, respectively, while Spitz and atypical Spitz tumors often exhibit HRAS and kinase rearrangements. These initial 'driver' mutations are thought to trigger the establishment of benign nevi. After this initial phase of the cell proliferation, a senescence program is executed, causing termination of nevi growth. Only upon the emergence of additional tumorigenic alterations, which may provide an escape from oncogene-induced senescence, can malignant progression occur. Here, we review the current literature on the pathobiology and genetics of nevi in the hope that additional studies of nevi promise to inform our understanding of the transition from benign neoplasm to malignancy.