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Mladeži u dečjem uzrastu: dogma i fakat. Marko B. Lens, MD PhD FRCS. Naevi (Moles). Melanocytic lesions of the skin Children may present a variable spectrum of melanocytic skin lesions and the great majority of them is benign.

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naevi moles
Naevi (Moles)
  • Melanocytic lesions of the skin
  • Children may present a variable spectrum of melanocytic skin lesions and the great majority of them is benign.
  • Naevi can be congenital or acquired developing in childhood and early adulthood
  • New lesions rare after age of 30 to 35, unless belong to very moley family
  • Naeviinvolutes with age

Naevi and age

Heterogeneity between naevi induction and involution processes


Melanocytic naevi

Junctional Compound Intradermal

other types of melanocytic naevi
Other types of melanocytic naevi
  • Dysplastc inaevus (nevus of Clark): usually a compound nevus with cellular and architectural dysplasia. Larger then normal moles and tend to have irregular colour and borders.
  • Blue naevus
  • Spitz naevus – a distinct variant of intradermal nevus, usually in a child. They are raised and reddish (non-pigmented)
other types of melanocytic naevi7
Other types of melanocytic naevi
  • Giant hairy naevus

(with an associated lifetime risk of melanoma in 4%-10% of patients)

  • Naevus of Ito and Naevus of Ota

(congenital, flat brownish lesions on the face or shoulder)

atypical mole syndrome
Atypical mole syndrome
  • More than 100 naevi
  • Naevi on breasts, buttocks, fingers, feet, scalp
  • Affects 2% of normal population
  • 10 to 20 time increased risk of melanoma
  • Up to 15% of melanoma cases
  • Refer to a dermatologist
  • No need to excise lesions for the purpose of confirming dysplasia or as a prophylaxis
  • Strongest risk factor for melanoma
  • Odds ratios between 2 to 20
  • Stable risk across all continents despite different UV exposure
  • Atypical naevi significant risk factor for melanoma
  • Site also important. Legs for females and trunk for males
  • 50 to 60% of all melanomas grow from a mole but also can appear on normal skin with no pre-existing mole
sun and melanocytic naevi mn
Sun and melanocytic naevi (MN)
  • Total sun exposure and tendency to burn are independent risk factors for MN incidence.
  • Lifetime number of sunburns and the severity of sunburns are significantly related to the presence of largeacquired MN.
  • Reducing the total number of hoursof sun exposure is particularly relevant in sun-sensitive childrenand may restrain the development of MN, whereas avoiding sunburnin young children might prevent large MN, subsequently reducingthe risk of melanoma.

Figure 1

Naevus counts equal or above 50 and risk of melanoma

suspicious naevi
Suspicious naevi
  • Change in weeks or months
  • Not years
  • Irregular in colour and/or shape with recent change
  • Bleeding and crusting lately
  • Itching not very specific
  • Geographical border
  • Regression (blueish/grey veil)
  • The “odd” one out

Managing uncertainty: cannot identify lesion





No Diagnosis



Avoid removing any lesion where you are uncertain of the diagnosis

management of naevi
Management of naevi
  • Does it need removing?
  • Can you reassure the patient?
  • Should you remove it?
  • Can you remove it?
  • Consider site, size, experience & patient
management of naevi basic principles
Management of naevi: Basic principles
  • Not everything needs to be removed
  • Diagnosis and reassurance may be enough
  • Stable and unchanging, reassure
  • Draw & measure lesion, review after 6-12 weeks
  • Advise patient to return if any change
  • Time as a diagnostic tool
management basic principles
Management: Basic Principles
  • Send everything for histological examination
  • See and understand the histology report
  • Know how to manage the histology report
melanocytic skin lesions dermatological techniques
Melanocytic skin lesions: Dermatological techniques
  • Ellipse excision
  • Curettage &cautery
  • Shave excision
pyogenic granuloma
Pyogenic granuloma ???
  • Urgent surgery
  • Histology
  • Amelanotic melanoma
melanoma in children
Melanoma in children
  • Melanoma in children is rare
  • Only 0.3% to 0.4% of all melanomas occur in prepubertal age
  • 1.3% to 2% occur in patients younger than 20 years
  • The incidence of MM in children is estimated to be 0.7 per million per year in children aged 0 to 9 years, whereas it is 13.2 per million per year in people aged between 15 and 19 years
  • This incidence is continuing to rise.
  • Recent data suggest an increasing incidence even in young age
pediatric melanoma versus adult melanoma
Pediatric melanoma Versus Adult melanoma
  • Lymph node metastases were more prevalent in young patients with melanoma compared with adult (thickness-matched) control patients
  • 5- and 10-year survival rates were similar.
  • Higher percentage of young melanoma patients have positive family histories and have atypical nevi suggest that a stronger predisposing genetic component may be operant in this group.
risk of melanoma and family history
Risk of melanoma and family history
  • Familial clustering of melanoma occur in around 1% of melanoma cases
  • One parent affected: RR 2.40(2.10-2.72)
  • One sibling affected: RR 2.98(2.54-3.47)
  • One parent plus one sibling: RR 8.92(4.25-15.31)
  • One parent multiple MMs: RR 61.78( 5.82-227)
melanoma and germline mutations
Melanoma and germline mutations

CDKN2A the most common gene altered in melanoma families

  • Can affect the p16 and the p14 protein
  • CDK4 mutations are rare
  • CDKN2A accounts for up to 25% of melanoma families
  • p16 involved in cell cycle and senescence
genes et naevus
Genes et Naevus
  • 60% of the variation in naevus number is determined by genetic factors
  • Twin studies. St Thomas. More than 2000 twins
  • Why is there such a great variation in naevi number in Caucasian populations?
  • Why do genes disappear with age?
naevus and ageing
Naevus and ageing
  • It had been noted in our research in familial melanoma that patients with multiple atypical naevi were less likely to have sun damage
  • Less wrinkles, less solar lentigines and fewer solar keratoses
  • What is the significance of this?
  • Telomeres-DNA sequence at the end of telomeres
  • Non coding DNA
  • Biological clock which shortens with age
  • The speed of telomere shortening with age varies between individuals which is in part genetically determined
  • Smoking, obesity and chronic diseases can shorten telomere further
theory of antagonistic pleiotropy
Theory of antagonistic pleiotropy
  • p53 (“Guardian of the genome”)
  • Skin cancerogenisis Versus skin ageing (cell senescence)
naevus marker of reduced senescence
Naevus marker of reduced senescence
  • Naevus may therefore be a good marker of reduced ageing
  • This may be relevant for tissues other than skin and we are now looking at bones and other tissues
  • This may explain why large number of naevi has remained such a common trait in the normal population
  • May provide a survival advantage in the selective gene pool
vit d and sun exposure
Vit D and sun exposure
  • Is Vitamin D deficiency relevant?
  • Vitamin D protects against osteoporosis, cancer, inflammatory and autoimmune disorders
  • 1400 Caucasian females: 10% had Vit D serum levels below 30 nmol/L
  • Skin type 1 and 2 more prone to Vit D deficiency
  • Vitamin D may also increase melanoma survival
  • Need to be more cautious when recommending sun avoidance