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October 20, 2015 / molehunter

2 worrying moles on an older white male

This person was referred as he had 2 moles on his trunk which stood out from all his other moles. In particular they were very dark. These are both pointers to risk. The older we are , the greater the risk of skin cancer, and the trunk is a higher risk site in men. ‘Beware of the back’ is a good maxim, since burning occurs there in men particularly, also a developing skin cancer may go unnoticed.

case 77 (1)

Here is a close up of the darker mole above, and of another on the side.

case 77 (2)

case 77 (3)

Yes they are dark and just over 6mm, so worth a careful look, but fairly good symmetry and only really one colour. NB 2 different shades of brown is not the same as multiple colours, if anyone doubts this then spend half an hour looking at the 177 images of melanoma on dermis.net. “multiple colours” in moles in my book means at least 2 of brown + black +red +blue +grey + white .

2 shades of brown with decent symmetry is almost always OK unless there is something else wrong.

dermoscopy was helpful.

case 77 (4)

This is the one on the back. The first thing to notice is that with illumination it seems a much lighter shade of brown than on plain view. The next thing to note is lack of chaos. I can only see one colour, and I am going to call it a medium pinky brown.

using the SCOPE mnemonic (**), I see good Symmetry, Counting colours, only one colour, arguably 3 Patterns and a very unremarkable Edge.

The patterns are worth remarking. I can see amorphous, reticular network and dots. The dots are the only feature that give me the slightest concern, however, these are arranged very evenly and are of similar size and colour. If there was a bunch of dots all in one corner of the mole and they were of variable size and colour, this would have been in the jar for histology fast. As it is, the patient was reassured and advised to take a photo (*) for future reference and report any change (which I think unlikely).

The second mole is even blander.

case 77 (5)

Very good symmetry in 2 planes, only one colour (brown) albeit 2 shades. We tend to call a mole like this a ‘fried egg’ pattern since the darker bit is dead centre and symmetrical. There is only one pattern, reticular network (or ‘lines reticular’ in the new descriptive terminology that is coming in). The edge is very bland with a nice even fade out all round.

the worst these could be would be mildly dysplastic (***), probably not even that.

ACTION:-reassurance and advice.

(*) NB on photographic monitoring, we heard at the World Dermoscopy and Skin Imaging Congress in Vienna last April that digital monitoring of high risk melanoma patients was both cost effective and safe. I may write that up in more detail later. However, this related to HIGH RISK patients (i.e. 100 plus moles and already had at least one melanoma), and a differently funded and managed healthcare system (Australia). There is no way that we in the NHS can digitally monitor more than our highest risk patients. However, nearly everyone in the UK has access to a digital camera, Smartphone or tablet (these pictures were taken with a Dermlite D1 scope attached to an Ipad mini). I am increasingly suggesting to people who worry about their moles that they may wish to photograph themselves as a reference point. Then when in future some kindly person says ‘You should get that mole checked!’ they can check it themselves against the photo. If it hasn’t changed, it’s fine, if it has-they can prove it so will be seen and actioned fast. The evidence that this works is growing, but for now it is not an official recommendation, just homespun common sense that seems unlikely to do any harm and may at least giv e reassurance to the worried well. Fear of melanoma is growing.

(**) SCOPE was introduced by my mentor Dr Catriona Henderson and I, it is not scientifically validated but simply helps the dermoscopist think systematically as they examine a lesion. Look for…

Symmetry

COunt the COlors

count the Patterns

Evaluate the Edge.

the lower the score on all the above, the less worried we are. NB this is not a points system and should not be used in isolation.

(***) dysplastic naevi are NOT pre-malignant. Research presented at Vienna 2015 looking at melanomas that had arisen from existing moles found that usually they arose from harmless looking moles. Most  melanomas (at least 60%) arise from clear skin, but when they do arise from pre-existing moles they can arise from ANY mole including very bland ones that no-one would think of excising. The slightly odd looking mole is NOT more likely to go bad, so we shouldn’t be chopping out lots of slightly off looking flat naevi. Probably the term ‘dysplastic’ should be replaced with ‘atypical’ or acquired naevi over 5mm diameter’ according to Professor Harald Kittler-and he should know. A very clever man, click on the link to see him speak with authority on this subject.

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