Monitoring of Spitz/Reed nevi in children questioned

09/20/2018

By Marilynn Larkin

NEW YORK (Reuters Health) - Authors of a research letter question recent guidelines stating that any spitzoid-looking lesion in children under age 12 should be monitored.

"Our new data suggest that monitoring flat pigmented Spitz/Reed nevi in children might cause false concern for clinicians and parents, and might result in unnecessary surgical excisions," Dr. Aimilios Lallas of Aristotle University in Thessaloniki told Reuters Health. "This is because these nevi initially have an impressive growth dynamic that might prompt clinicians to question their benign nature."

"Existing evidence does not support any required action after the clinical and dermoscopic recognition of a flat, symmetric pigmented Spitz/Reed nevus in children younger than 12 years," he stated in an email.

Dr. Lallas and colleagues studied 212 children (mean age, 6.1 years at baseline; 53.3% girls) who received a diagnosis of Spitz or Reed nevus at their institution between 2015 and 2017.

As reported online September 12 in JAMA Dermatology, the main sites of tumor development were the lower extremities (45.8%), upper extremities (18.4%), and head and/or neck (13.7%). Children were followed for a mean of 28 months, including a mean of six monitoring visits.

A total of 21.2% of lesions were excised during follow-up. The mean time to excision from the baseline visit was 6.4 months. Spitz or Reed nevus was diagnosed in every case.

"Considering that the accuracy of baseline diagnosis in this group of lesions was perfect and significantly decreased (in terms of specificity) after follow-up, we suggest that the baseline recognition of a flat pigmented dermoscopically symmetric Spitz or Reed nevus in prepubertal patients should not warrant any further action," the authors state.

"In real practice," Dr. Lallas said, "it is very likely that parents observing the fast growth of their child's mole will continue to seek medical advice, even if they were initially reassured about its benign nature by the doctor."

"So, as clinicians, we will most probably continue to monitor Spitz nevi," he acknowledged, "although evidence suggests that it makes little sense. But we should inform the parents at baseline that the follow-up might cause false concern and eventually an unneeded surgical excision."

"Finally, it is necessary to underline that this recommendation applies only until the age of 12 years and only for flat, symmetric pigmented Spitz/Reed nevi," he stressed. "Any spitzoid-looking lesion out of this frame (older age, asymmetry, nodular lesions) should be excised."

Dr. Nnenna Agim, assistant professor of dermatology at UT Southwestern Medical Center in Dallas, disagrees.

"The overstatement, 'Considering that the accuracy of baseline diagnosis in this group of lesions was perfect,' is concerning, as 100% of the identified lesions were not excised," she told Reuters Health. "The true histologic nature of the remaining 80% identified by clinical exam alone remains unknown."

Further, she said by email, "Why did the accuracy of clinical diagnosis decrease with serial exam? Are the examiners the same or is the point that evolution of Spitz nevi is expected over time?"

In Dr. Agim's practice, "All nevi, Spitz or otherwise, are monitored if benign appearing and excised if concern for malignancy is identified," she said. "Monitoring is essential, given the E in the ABCDE approach to melanoma screening (E=evolution)."

"It is well known that no one factor is sufficient evidence for malignancy," she noted. "However, a multiplicity of clinical findings, evolution included, should elevate clinical suspicion and may prompt skin biopsy. Melanomas in children have been demonstrated to have no consistent clinical appearance, so it may be wise to err on the side of caution."

Her advice to clinicians: "Continue to advise sun protection, skin exams at home using ABCDE criteria, along with periodic clinical monitoring."

SOURCE: https://bit.ly/2NZPSZ6

JAMA Dermatol 2018.

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