BJD

C O N CI S E C O M M U N I C A T I ON British Journal of Dermatology

Postexcisional melanocytic regrowth extending beyond the

initial scar: a novel clinical sign of melanoma
J.W. Kelly,1 S. Shen,1 Y. Pan,1 J. Dowling2 and C.A. McLean2
1
Victorian Melanoma Service and 2Department of Anatomical Pathology, The Alfred Hospital, Commercial Road, Prahran, 3181 Victoria, Australia

Summary

Correspondence Background Recurrent naevi are widely recognized to occur commonly following
John W. Kelly. incomplete removal of melanocytic lesions. These lesions have been generally
E-mail: kellyderm@bigpond.com understood as representing benign imitators of melanoma.
Objectives To provide a formal description of the clinical findings of postexcisional
Accepted for publication
7 December 2013
melanocytic regrowth.
Methods We examined all cases of recurrent pigmentation adjacent to scars from
Funding sources previous excisional biopsies of melanocytic naevi treated at a private dermatology
None. practice from 1995 to 2012.
Results We report nine cases of recurrence of melanocytic lesions that were mela-
Conflicts of interest nomas. The most suspicious clinical feature for melanoma in these cases was the
None declared.
growth of the lesion beyond the confines of the initial scar, into the surrounding
DOI 10.1111/bjd.12780 normal skin.
Conclusions This pattern of recurrence of a melanocytic lesion represents a little
recognized and distinctive clinical presenting sign of melanoma.

What’s already known about this topic?

• Postexcisional repigmentation associated with recurrent naevus is recognized as
remaining confined within the scar of the initial biopsy.

What does this study add?

• This is the largest series of cases formally describing the distinct clinical finding of
postexcisional melanocytic regrowth within and extending beyond the confines of
the previous excisional scar as an indicator of the development of early malignant
melanoma.

Recurrent pigmentation within a scar following incomplete
removal of a melanocytic lesion is a common presentation
seen by dermatologists. In this context, the recurrent naevus
has become widely recognized as a clinical and histopathologi-
cal imitator of melanoma.1–3
Macroscopically, the pigmentation associated with the
benign regrowth is confined within the scar.4,5 However, re-
growth of a melanocytic lesion that extends beyond the
boundary of the original scar has recently been associated with
melanoma.6
We present nine consecutive patients with development of
melanocytic lesions growing into the skin adjacent to exci-
sional biopsy sites of previously diagnosed benign melanocytic
naevi. In each case, the recurrent lesion was melanoma. This
pattern of recurrence of a melanocytic lesion is distinct from
recurrent naevus and is a strong indicator of malignancy.
Patients and methods
All cases of recurrent pigmentation adjacent to scars from pre-
vious excisional biopsies of melanocytic naevi treated at a pri-
vate dermatology practice from 1995 to 2012 were included
in the study. Clinical and histological data relating to each case
were collected.
A subsequent independent expert review of the histological
sections from all original and recurrent lesions was undertaken
by two dermatopathologists (C.A.M. and J.D.) with extensive
experience in the diagnosis of benign and malignant

© 2013 British Association of Dermatologists British Journal of Dermatology (2014) 170, pp961–964 961
962 Postexcisional melanocytic regrowth, J.W. Kelly et al.
melanocytic lesions at a tertiary referral melanoma centre (the
Victorian Melanoma Service).
Results
Case 1
A 59-year-old woman presented with recurrent pigmentation
extending beyond the scar from an excision 8 years earlier
(Fig. 1a). Histological diagnosis of the recurrent lesion was in
situ melanoma. Review of the original sections confirmed the
original histological assessment of severely dysplastic naevus
(Table 1).
Case 2
A 39-year-old woman developed two recurrences, 5 and
8 years after an initial excision. The second recurrence
involved the skin surrounding the previous scar (Fig. 1b) and
was an in situ superficial spreading melanoma. Review of the
initial lesion confirmed the previous diagnosis of dysplastic
naevus and also identified a previously undetected central
focus of in situ superficial spreading melanoma.
Case 3
A 32-year-old woman developed recurrence of a pigmented
lesion 3 months following an excision from her back. The ini-
tial histological diagnosis was a dysplastic junctional naevus.
The recurrence both overlay the scar and extended beyond its
border. Re-excision revealed a 0
6-mm, Clarke level IV superfi-
cial spreading melanoma. Review of the initial lesion revealed a
dysplastic naevus with focal superficial spreading melanoma.
Case 4
A 50-year-old woman developed recurrences 2 and 5 years
after excision of a melanocytic lesion from her back. The sec-
(a) (b)
(c) (d) (e)
British Journal of Dermatology (2014) 170, pp961–964
ond recurrence showed pigmentation within and beyond the
previous scar. This was initially observed over a period of
2 years and its progressive pattern of growth is shown in Fig-
ure 1c–e. An excision demonstrated in situ melanoma. Review
of the initial lesion revealed in situ superficial spreading mela-
noma extending to the excision margins.
Case 5
Three years after an excision, a 49-year-old man developed re-
growth of a melanocytic lesion extending beyond the initial
excision scar. Histopathological diagnosis of the recurrent
lesion was that of a 0
2-mm, Clarke level II superficial spread-
ing melanoma. Reassessment of the original lesion confirmed
a previous diagnosis of dysplastic naevus.
Case 6
Five months following an initial excision, a 22-year-old man
presented with a rapidly enlarging pigmented lesion adjacent
to the scar. Excision of the recurrent pigmented lesion
revealed a 0
3-mm, Clarke level II superficial spreading mela-
noma. Review of the original sections confirmed the original
diagnosis of compound naevus.
Case 7
A 50-year-old woman presented 3 years postexcision with an
enlarging area of recurrent pigmentation adjacent to the scar.
This proved to be a 0
4-mm-thick, Clarke level II superficial
spreading melanoma. Histological reassessment of the original
sections identified a focus of in situ superficial spreading mela-
noma in a previously diagnosed severely dysplastic naevus.
Case 8
A 19-year-old woman developed two recurrences of pigmen-
tation 5 and 7 years following an initial excision. The second
Fig 1. (a) Pigment recurrence extending
beyond the excisional scar; (b) brown macule
contained within and extending beyond the
elliptical scar; (c) serial dermoscopy showing
a melanocytic lesion at baseline, and
increasing asymmetry and pigmentation at
(d) 14 months and (e) 26 months. Pictures
courtesy of Molemap Australia Pty Ltd.
© 2013 British Association of Dermatologists
 Postexcisional melanocytic regrowth, J.W. Kelly et al. 963

Table 1 Summary of cases

Histopathology
Sex, age Time to
Patient (years) Site recurrence(s) Original Recurrence(s) Review of original
1 F, 59 Back 8 years Dysplastic junctional naevus, In situ SSM Severely dysplastic naevus,
completely excised incompletely excised
2 F, 39 Lower 5 years; 3 yearsa Mildly dysplastic naevus, (i) Recurrent junctional Dysplastic naevus with focal
extremity completely excised naevus; (ii) in situ SSM SSM
3 F, 32 Back 3 months Dysplastic junctional naevus, 0
6-mm, Clarke level IV SSM Dysplastic naevus with focal
completely excised SSM
4 F, 50 Back 2 years; 3 yearsa Junctional melanocytic (i) Moderately dysplastic In situ SSM extending to the
naevus, completely excised junctional naevus; margins
(ii) in situ SSM
5 M, 49 Neck 3 years Dysplastic naevus, 0
2-mm, Clarke level II SSM Dysplastic naevus,
incompletely excised incompletely excised
6 M, 22 Abdomen 5 months Compound naevus, 0
3-mm, Clarke level II SSM Compound naevus,
incompletely excised incompletely excised
7 F, 50 Lower 3 years Mildly dysplastic junctional 0
4-mm, Clarke level II SSM Dysplastic naevus with focal
extremity naevus, completely excised SSM
8 F, 19 Lower 5 years; 2 yearsa Dysplastic naevus, completely (i) Compound naevus; Dysplastic naevus with focal
extremity excised (ii) 0
44-mm, Clarke SSM
level II melanoma
9 F, 54 Upper 7 years Dysplastic naevus, 0
4-mm, Clarke level III SSM Clarke level II SSM
extremity incompletely excised

F, female; M, male; SSM, superficial spreading melanoma. aNumber of years after the first recurrence.

recurrence was a spreading erythematous macule extending
from the scar into the surrounding skin. Histological examina-
tion revealed in situ superficial spreading melanoma. Review of
the original sections revealed a dysplastic naevus with focal in
situ superficial spreading melanoma.
Case 9
A 54-year-old woman developed progressive enlargement of a
pigmented lesion adjacent to the scar 7 years after an excision.
The recurrence was a 0
4-mm, Clarke level III melanoma.
Re-evaluation of the initial sections showed a Clarke level II
superficial spreading melanoma that had previously been
misdiagnosed as a dysplastic naevus.
Discussion
Postexcisional regrowth of pigment extending beyond the ini-
tial scar as a sign of melanoma is highlighted by the present
case series. There is scarce mention in the literature of this
presentation of melanoma.7 A study of the dermoscopic fea-
tures of pigment recurrence in scars did not come across this
phenomenon.8 A recent study of the dermoscopic and confo-
cal microscopic assessment of pigmentation associated with a
scar from previous treatment showed extension of pigmenta-
tion beyond the scar in four cases that were melanomas.6
Three cases that were recurrent naevi showed repigmentation
within the scar. However, histological review of the original
lesion by an independent dermatopathologist was not reported
in this study.
The present study describes nine cases of recurrent melano-
cytic lesions in which extension beyond the confines of
postexcisional scarring was an important distinguishing clinical
feature of melanoma. Retrospective review of the original
specimens of all nine melanocytic lesions (Table 1), which
were reported as benign on initial histological examination,
revealed two cases of superficial spreading melanoma and four
cases of dysplastic naevus containing a central focus of mela-
noma. In the remaining three cases, the original naevi were
confirmed as benign with two being dysplastic naevi. The sub-
sequent diagnosis of melanoma may have facilitated the retro-
spective identification of small foci of melanoma that initially
escaped detection in two cases.
The characteristic pattern of postexcisional regrowth of a
melanocytic lesion beyond the scar should arouse clinical sus-
picion of melanoma. In all cases the growth of the lesion
beyond the initial scar was a characteristic clinical feature. The
nine recurrent lesions exhibited typical histological features of
melanoma and concordance was complete between indepen-
dent assessments by two dermatopathologists. However, the
original specimens were more difficult to assess. Small foci of
melanoma were detected that had been overlooked at the ini-
tial assessment. These reviews were not blinded to knowledge
of the later recurrence. The reported final diagnosis of the ini-
tial lesion was achieved by consensus between the two
reviewing dermatopathologists.
We observed no cases of similar lesions arising contiguously
with a previous excision scar that proved to be benign over
the study period. Recurrence of pigmentation within the scar,
on the other hand, is most often benign. However, all of our

© 2013 British Association of Dermatologists British Journal of Dermatology (2014) 170, pp961–964
964 Postexcisional melanocytic regrowth, J.W. Kelly et al.
(a) (b)
cases showed pigmentation within the scar as well as beyond
it, suggesting that recurrent pigmentation within the scar may
not always be benign.
All of these recurrences were growing lesions that had not
stabilized. Recurrent benign naevus, on the other hand, devel-
ops for a limited period and then stabilizes, respecting the
border of the previous excisional scar (Fig. 2). Progressive
growth was another suspicious feature of these lesions.
Three cases experienced multiple recurrences, suggesting
that repeated recurrence might also be a useful indicator of
melanoma. The initial recurrence in these cases was not
observed by us and hence we cannot comment on the rela-
tionship of the initial recurrence to the initial scar.
It should be noted that all of the initial excisions were
attempts at complete removal. On histological review five of
the lesions reached the margins of the initial excision
(Table 1). As all lesions recurred, it is likely that all were
incompletely excised, although this was not evident in four of
the lesions in the sections assessed.
The previous understanding that recurrent naevi are benign
imitators of melanoma needs to be modified to account for
these two patterns of recurrence: recurrence within the scar as
a sign of likely benignity and recurrence within and beyond
the scar as a feature of melanoma. Patients and doctors may
derive inappropriate reassurance from the benign pathology
report of the initial biopsy, which may lead to neglect or
delay in seeking review of the recurrence. Complete excision
British Journal of Dermatology (2014) 170, pp961–964
Fig 2. (a) Benign recurrent naevus confined
within the borders of the previous shave
biopsy scar, outlined in (b).
of dysplastic melanocytic naevi is advocated, as histopathologi-
cal diagnosis of these lesions can prove challenging with the
possibility of areas of malignant change evading detection. In
cases of recurrent pigmentation extending beyond the initial
scar, histological assessment should be undertaken of both the
recurrence and the initial specimen for evidence of melanoma.
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© 2013 British Association of Dermatologists