Cutaneous melanoma: Detecting it earlier, weighing management options

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Applied Evidence

Cutaneous melanoma: Detecting it earlier, weighing management options

J Fam Pract. 2007 January;56(1):18-28

By

Joshua E. Lane, MD

Rory R. Dalton, MD

Omar P. Sangueza, MD

Knowing when and how to biopsy a suspicious is paramount for providing accurate prognosis.

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References

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Practice recommendations

Arrange a biopsy of any pigmented lesion that changes significantly on serial examinations.
Full-thickness excisional biopsy is preferred; for large lesions, incisional or punch biopsy at the deepest point of the tumor may be an option.
For thin lesions, a surgical margin encompassing 1 cm normal skin is recommended.
Specimens submitted in formalin for permanent sections are preferred to frozen sections.

A 51-year-old man of northern European descent who works outdoors for the city asks you to look at a “mole” on his face. The lesion does not have the classic appearance of a melanoma that you have seen before, and it is still fairly small. Should you advise a wait-and-see approach or perform a biopsy?

Opt for early detection

Given the patient’s likely genetic predisposition to skin cancer and his regular, lengthy exposure to sunlight (see Risk factors), you would be wise to follow your cutaneous examination with a biopsy.

The ABCDs of visual assessment. The classic clinical presentation of melanoma is well known. The most publicized means for identifying potentially atypical pigmented skin lesions is the “ABCD” mnemonic (asymmetry, border irregularity, color variegation, and lesion diameter >6 mm) (FIGURES 1 AND 2).^7,8 The ABCDs are primarily an educational tool for patients. This mnemonic was expanded to include E, representing evolution of a pigmented lesion.⁹ Any pigmented lesion observed to change significantly on serial examinations warrants biopsy to exclude melanoma.

Caveat: not all melanomas are pigmented. Amelanotic melanomas are a diagnostic challenge and may be lethal if left unattended.

Routine screening. Large-scale skin cancer screening has been performed and found to be a statistically ineffective means of detection. Moreover, the US Preventive Services Task Force found insufficient evidence to recommend for or against routine counseling by primary care physicians to prevent skin cancer.¹⁰

A large-scale educational and screening campaign was performed in Italy from 1991 to 1996. During this period, 90,000 educational leaflets were distributed to a target population of approximately 243,000. A total of 2050 individuals requested a skin examination, resulting in detection of 13 melanomas.¹¹ However, 92.3% of the melanomas were thin (<1.52 mm deep). Despite the lack of statistical significance for such screenings, many organizations do perform them and find melanomas, which can be life saving for those few individuals.

Anatomic areas to focus on. While melanoma can affect any anatomic region, it is especially common on sun-exposed areas, including the head, neck, and upper extremities. Acral lentiginous melanoma is found on palmar, plantar, and subungual regions. Include the scalp, ocular mucosa, and oral cavity in your examination.

Detailed melanoma classifications

Four primary groups have been traditionally proposed based on a combination of clinical and pathologic features: superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma and acral lentiginous melanoma. Furthermore, additional histopathologic variants including desmoplastic, neurotropic, amelanotic, signet-ring cell, small cell and balloon cell melanoma have been described.

FIGURE 1
Melanoma in situ

Classic presentations of melanoma in situ on the left cheek. Sun-exposed areas are most often affected.

FIGURE 2
Melanoma in situ

Classic presentations of melanoma in situ on the tip of the nose. Sun-exposed areas are most often affected.

Which biopsy technique to choose?

A properly performed biopsy is mandatory to accurately diagnose and microstage the tumor. No other test reliably surpasses routine histologic examination.

When possible, arrange for a full-thickness excisional biopsy with a narrow (2-mm) rim of normal skin, especially for large lesions in which sampling error may be a factor.

FAST TRACK

Biopsy any pigmented lesion with a history of change

Tissue samples are submitted for histologic examination in formalin for permanent sections. Frozen sections are not recommended for the initial diagnosis of melanoma due to artifactual changes from the freezing process.

When lesions are too large for primary excision, or if an optimal cosmetic result is important to the patient, an incisional or punch biopsy may be taken from the area believed to be the deepest portion of the tumor.

FAST TRACK

Horizontal growth is common in sun-exposed sites and occurs slowly; vertical growth is much more aggressive and lethal

For the largest lesions, multiple punch or incisional biopsies may help to reduce the risk of sampling error. Diagnostic and management problems arise when the initial biopsy does not sample the complete skin thickness or when large lesions are not sampled adequately.

Classification of melanoma

The traditional melanoma classification scheme includes several subtypes (see Detailed melanoma classifications). Though these terms have limited clinical utility, we include them for the sake of completeness and because the terminology may arise in consultation with colleagues.