The American Academy of Dermatology has updated its guidelines for the care and management of primary cutaneous melanoma. The guidelines, released in late October 2018, cover the treatment of primary cutaneous melanoma for all age groups.
In this article, we feature the recommendations for surgical management of primary cutaneous melanoma.
The authors of the report, led by Susan M. Swetter, M.D., of the Stanford University Medical Center and Cancer Institute, recommend that high-risk patients consult physicians with expertise in melanoma treatment for further guidance.
Biopsy of Skin Moles
Skin biopsy is the first step to establish a diagnosis of melanoma, which may be assisted by other molecular and imaging techniques. It is important that the surgeon obtains a photograph prior to performing the biopsy for two reasons:
- To document what the mole looked like prior to sampling it
- To prevent wrong-side surgery in case the mole is completely removed during the biopsy
The photograph should include an anatomical landmark (e.g. elbow, shoulder, belly button) to help localize the lesion in the future.
For a mole that is very suggestive of melanoma, the new guidelines recommend that complete excision (removal) of the lesion through a “scoop’ biopsy is performed upfront so that the sample obtained encompasses the entire lesion with clinically uninvolved margins and also extends to a depth sufficient to ensure the lesion is not partially cut through, leaving the deeper part of the tumor in place. Physicians should stay away from performing shave biopsies unless the lesion does not suggest melanoma since this may underestimate the true thickness of the lesion which is important for both staging of the tumor and surgical management.
The guidelines highlight the exception in the case of melanoma in situ lentigo maligna type, where a broad shave biopsy is recommended. The other exception occurs in the case of melanoma in the face, or peripheral body parts, such as toes and fingers, where partial sampling with a punch, shave or an ellipse excision may be performed to decrease the risk of cosmetic deformity or loss of function.
Biopsies of suspicious nail lesions should be performed by practitioners skilled in biopsy of the nail apparatus. In these cases, the nail plate should be sufficiently removed to expose the underlying mole to allow adequate sampling.
New Guidelines on the surgical management of melanoma including lymph node sampling (coming soon)