At Golden State Dermatopathology, our approach to reporting melanocytic lesions continues to evolve in response to emerging evidence and clinical priorities. One recent shift has been our move away from the routine use of the mild, moderate, and severe grading system for dysplastic nevi. This change reflects a broader effort to make our reporting more clinically meaningful for the physicians and patients who rely on it.
As our understanding of melanocytic lesions has advanced, we have taken a close look at whether our long-standing terminology still serves patients well, and concluded that a different approach was warranted.
What Was the Mild Moderate Severe Grading System?
For years, dysplastic nevi were graded along a spectrum described as mild, moderate, or severe atypia.
This system was intended to communicate the degree of a lesion’s atypicality to referring physicians and to help guide decisions about further treatment, including re-excision. Physicians often used this scale as a shorthand for how closely a lesion should be monitored or whether it warranted additional surgical intervention.
Why the Terminology No Longer Held Up
Current evidence does not demonstrate a clear molecular distinction among so-called dysplastic nevi. In practice, the mild, moderate, and severe classification often reflected the pathologist’s level of concern rather than a lesion’s true biologic potential. This meant two lesions with similar underlying biology could receive different grades, depending on subjective impression alone. As a result, reliance on this terminology likely contributed to overtreatment, including unnecessary re-excisions performed out of caution rather than in response to demonstrated risk.
How We Classify Atypical Nevi Now
Given these limitations, Golden State Dermatopathology now applies the term dysplastic nevus more selectively.
We classify the broad spectrum of benign but clinically atypical acquired nevi as lentiginous melanocytic nevi. We reserve the designation nevus with severe atypia for lesions that demonstrate significant histologic atypia.
This narrows the language pathologists use for lesions that carry meaningfully different levels of concern, rather than spreading a wide range of biologic behavior across three broad, subjectively applied categories.
Supporting This Shift With Molecular Testing
This move toward more precise classification is reinforced by our in-house molecular testing capabilities.
Golden State Dermatopathology offers molecular analysis using the Biocartis Idylla platform, a fully integrated, closed cartridge system that detects key molecular alterations, including BRAF mutations and gene fusion events. In the current era of pathway-based classification of melanocytic tumors, access to rapid and reliable molecular data is essential.
The Idylla platform complements histopathologic diagnosis by providing clinically actionable insights that enhance conventional microscopic assessment, giving our classification decisions an additional layer of support.
Why This Framework Is More Precise
In our experience, this refined approach better aligns histopathologic interpretation with biologic risk. It prioritizes re-excision for lesions with a higher likelihood of progression to melanoma, while reducing the number of unnecessary procedures for patients. Ultimately, this represents a more precise and clinically meaningful framework for patient care, one grounded in actual risk rather than a single, concern-driven grading scale.
A More Clinically Meaningful Framework
This shift reflects Golden State Dermatopathology’s broader commitment to precision diagnostics for melanocytic lesions. By retiring the mild, moderate, and severe scale in favor of lentiginous melanocytic nevi and nevus with severe atypia, paired with rapid molecular testing where appropriate, we aim to give referring physicians classifications that reflect biologic risk rather than pathologist judgment alone. It is an approach we expect to keep refining as evidence in this space continues to develop.
Would you like to learn more about this approach? Schedule a virtual meeting with Dr. Tim McCalmont and Dr. Emily Green, or contact Golden State Dermatopathology directly to speak with a physician liaison in your region.
