FROM THE DERMATOLOGY FOUNDATION

A 20-year histopathologic study of Banal nevi, defined as those that histopathologi-

pediatric nevi at an academic
institution
To the Editor: The number needed to biopsy to
diagnose 1 melanoma is substantially higher among
the pediatric population (1035) than among adults
(15.6).1,2 This study sought to characterize the range
and incidence of histopathologic diagnoses yielded
by biopsies of pediatric pigmented lesions in an
academic dermatologic setting.
Massachusetts General Hospital Dermatopathology
records from January 1, 1998, to December, 31, 2018,
were queried for ‘‘skin’’ and ‘‘nevus,’’ ‘‘melanocytic,’’
or ‘‘melanoma’’ in patients younger than 20 years.
Histopathologic diagnoses at care were categorized as
banal, atypical, borderline, and malignant. 2 Tests
compared banal nevi with lesions with report of
histopathologic atypia, dysplastic nevi, borderline
lesions, and melanomas. Lesion banality was
compared between patient gender, patient age group,
and lesion sun exposure, which was categorized
according to prior studies.3
During 20 years, 4872 pigmented lesions were
diagnosed, with 93% sampled in adolescence
(11-19 years). Average age at diagnosis was 15.4 years
(standard deviation 3.5 years). The study included 3055
patients, who underwent 1.6 biopsies per patient on
average (standard deviation 2.7 biopsies). All patients
with greater than or equal to 15 biopsies (n ¼ 14) had
associated large or giant congenital melanocytic nevi.
cally lacked atypical features ( features of congenital
onset and Spitz histology were not considered
atypical), composed 69.2% of lesions (n ¼ 3369)
(Table I), a proportion that remained relatively stable
(65%-72%) (Table II). Of 3296 banal nevi with
available data, 66% were excised and 34% biopsied.
Atypical nevi included dysplastic nevi and those with
separate atypia descriptors (including some congen-
ital and Spitz nevi with atypical features); these were
diagnosed in 1390 cases (28.5%). Congenital features
were reported in 1750 cases (35.9%), 87% of which
were banal nevi. Spitzoid proliferations (including
Spitz nevi and atypical Spitz tumors) composed 109
cases (2.3%), with approximately even numbers of
banal (n ¼ 51) and atypical (n ¼ 58) tumors.
Melanoma was diagnosed in 85 cases (1.7%) and
borderline/indeterminate tumors in 28 (0.6%). The
number needed to biopsy was 57, in which 19.0% of
these melanoma cases underwent initial biopsy
within our institution.
Lesions biopsied from adolescents were
significantly more likely to exhibit histopathologic
atypia than those biopsied from children (\11 years)
(P \ .001). Banal lesions were more likely to be
biopsied from the buttocks (a nonesun-exposed
area) compared with lesions with atypia, and lesions
biopsied in intermittently to regularly sun-exposed
areas (back, legs, and forearms) were more likely to
contain atypia (P \.001) (Table II).

Table I. Histopathologic features of pediatric pigmented lesions

Percentage, n = 4872
Banal nevi 3369 (69.2)
Banal nevi without congenital or spitzoid features 1795 (36.8)
Congenital nevi and nevi with congenital features 1522 (31.2)
Spitz nevi and nevi with spitzoid features 51 (1.0)
Combined compound Spitz nevus and dermal nevus with features of congenital onset 1 (0.02)
Nevi with histopathologic atypia 1390 (28.5)
Dysplastic nevi and nevi with atypical features 1110 (22.8)
Dysplastic nevi with congenital features 136 (2.8)
Congenital nevi with atypia 85 (1.7)
Spitz nevi with atypia and atypical Spitz tumors 58 (1.2)
Combined congenital and sclerosing Spitz nevus with atypia 1 (0.02)
Borderline or indeterminate lesions 28 (0.6)
Melanoma 85 (1.7)
In situ 12 (14.1)
Superficial spreading 33 (38.8)
Nodular 7 (8.2)
Spitzoid 6 (7.1)
Unspecified, ambiguous, or indeterminate 27 (31.8)

J AM ACAD DERMATOL JANUARY 2021 39

40 From the Dermatology Foundation J AM ACAD DERMATOL
JANUARY 2021

Table II. Pediatric banal, atypical, and malignant pigmented lesions

Banal Nevi with Borderline
All nevi nevi atypia lesions Melanomas
Total 4872 3369 1390 28 85
Gender, no. (%)
Female patients 2588 (53) 1810 (54) 715 (51) 14 (50) 49 (58) P = .22
Male patients 2284 (47) 1559 (46) 675 (49) 14 (50) 36 (42)
Age, no. (%), y
Childhood (\11) 342 (7) 280 (8) 55 (4) 1 (4) 6 (7) P \ .001
Adolescence ($11) 4519 (93) 3082 (92) 1331 (96) 27 (96) 79 (93)
Selected locations, no. (%)
Buttocks (nonsun exposed) 96 (2) 80 (2) 16 (1) 0 0 P \ .001*
Back and legs (intermittently sun exposed) 1867 (38) 1074 (32) 748 (54) 11 (39) 34 (40)
Forearms (regularly sun exposed) 104 (2) 84 (2) 20 (1) 0 0
Year of biopsy, no. (%)y
1998e2003 1830 (38) 1287 (70) 494 (27) 17 (1) 32 (2)
2004e2008 1223 (25) 854 (70) 339 (28) 4 26 (2)
2009e2013 1168 (24) 758 (65) 392 (34) 6 (1) 12 (1)
2014e2018 650 (13) 470 (72) 164 (25) 1 15 (2)
Histopathologic documented recurrence, no. (%) 50 (1) 14 (0.4) 36 (3) 0 0
Ancillary testing deployed (FISH or CGH), no. (%)z 5 (0.1) 0 2 (0.1) 2 (7) 1 (1)

CGH, Comparative genomic hybridization; FISH, fluorescent in situ hybridization.

Pearson 2 analyses compared banal nevi with all nevi with any degree of atypia, including borderline lesions and melanomas.
*Location analysis compared nonsun-exposed lesions with those with intermittent to regular sun exposure.
y
Percentages of banal, atypical, and malignant pigmented lesions represent the proportion of all nevi biopsied within the corresponding
years.
z
Four of 5 cases with ancillary testing had negative fluorescent in situ hybridization results. The fifth case, a borderline lesion, had
comparative genomic hybridization performed.

Limitations include a single institution and limited
outcome and clinical suspicion data. Our referral
center’s number needed to biopsy was lower than
that determined from general US pediatric data
(1035)1 or from an Austrian academic center (594).4
Nonetheless, the majority of biopsied pigmented
lesions at our institution were banal nevi. These data
serve to better establish the basis for future studies to
address which pediatric lesions are appropriate for
biopsy versus clinical observation. Our data indicate
that site may play a role, with banal nevi more likely
to be biopsied in nonesun-exposed areas than
atypical lesions. This difference may reflect different
atypia rates or cosmetic inclinations in biopsying
exposed and nonexposed areas.
Danna Moustafa, BS,a,b Lyn M. Duncan, MD,a,c
and Elena B. Hawryluk, MD, PhDa,b
From Harvard Medical School, Bostona; and Depart-
ment of Dermatologyb and Pathology Service,c
Massachusetts General Hospital, Boston.
Funding sources: Supported by a Dermatology
Foundation Career Development Award and
Harvard Medical School Department of Derma-
tology Eleanor and Miles Shore Fellowship Award
(Dr Hawryluk).
Conflicts of interest: None disclosed.
This work was previously presented at the 2019
Pediatric Dermatology Research Alliance
Annual Meeting, Chicago, IL, November 15,
2019.
Correspondence to: Elena B. Hawryluk, MD, PhD,
Massachusetts General Hospital, Department of
Dermatology, 50 Staniford St, Boston, MA 02114
E-mail: ehawryluk@partners.org
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https://doi.org/10.1016/j.jaad.2020.08.018