'Dysplastic' debate: Terms continue to confuse

October 1, 2007

I am responding to the letter from Craig G. Burkhart, M.D. regarding the issue of dysplastic nevi vs atypical nevi wherein he discusses some comments made by Terry Barrett, M.D. in your May 2007 issue

I am responding to the letter from Craig G. Burkhart, M.D., regarding the issue of dysplastic nevi vs. atypical nevi wherein he discusses some comments made by Terry Barrett, M.D., in your May 2007 issue.

I am puzzled by the proposed "elimination" of this "dysplastic" terminology. To me, in clinical practice, if a mole looks funny, it gets cut off. As a clinician, whether you call it "dysplastic" or "atypical" after reviewing the microscopic slide makes no difference - if there are suspicious microscopic changes, I am concerned. I don't care if you call it a Clark's nevus or whatever - cells that are changing or don't belong there, don't belong there.

My own expert histopathologists at Clinical Pathology Laboratories in Austin, Texas, have previously made the following recommendations: If a mole is mildly dysplastic, but incompletely removed, I will leave it alone. If it does grow back in an atypical fashion, particularly if it extends beyond the margins of the resultant scar, I will re-excise. If a mole is read as either moderately dysplastic or severely dysplastic with cells left after the initial shave excision, I will always go back with an ellipse and confirm by clear borders. Obviously, all melanomas are appropriately removed. If a mole is clinically dysplastic or atypical, no matter what you want to call it, the cells weren't certainly going in the "right" direction - somehow they were going in the wrong direction. Dr. Barrett's fourth paragraph makes absolutely no sense to me. How can he state "nuclear atypia ... should be considered benign and treated accordingly ... "? If there are any abnormal changes - in the nucleus or cytoplasm - is that somehow a good thing?

I resent that implication, as it offends my honor and integrity. If a mole is clinically atypical - I excise it. My pathologists are honorable people who are encouraged and certainly free to read the specimen as they see fit. There is no understood nor agreed nor subtle feedback in any of our relationships other than an honorable doctor removing moles that he would not want to leave on his own family members, and just-as-honorable histopathologists reading slides in a completely financially neutral environment. I don't know Dr. Burkhart or anything about him - I don't know if he practices in academia or not. I am on the front lines every day, doing the best I can in an honorable and ethical fashion. I send my slides to respected, well-trained and just-as-honorable histopathologists - I am sure they would be likewise offended to learn that someone has suggested that they are somehow "appeasing" me.

Sincerely,
Michael H. Coverman, M.D.

P.S. It would be easy for me to remove any mole I wished for profit, as often as I wished. The patient would never know the difference. I am sure some of our colleagues in internal medicine may likewise find it just as tempting to order a CBC "just to check on things" and hence make more profit. I will categorically state that in my 29 years of practice I have never removed a perfectly benign mole (unless it was for requested cosmetic purposes) that did not in my clinical judgment need to be removed. Not once!