How Best to Approach a Suspicious Pigmented Lesion?

We read with great interest the "Dermclinic" case of a 44-year-old man with achanging pigmented lesion on his trunk (CONSULTANT, March 2001, page 354).As an initial approach, Dr David Kaplan recommended a small punch or incisionalbiopsy, which he stated was "sufficient to provide enough information for anappropriate course of action."We suggest that a better approach would be to excise the lesion completelywith narrow margins. In a consensus statement, the NIH recommends excisionalbiopsy with a narrow margin of normal-appearing skin for any suspicious lesion.¹
-Scott D. Miller, MD
  Dirk Elston, MD,
  Fort Sam Houston, Tex

REFERENCE:1. NIH Consensus Development Panel on Early Melanoma. Diagnosis and treatment of early melanoma.JAMA. 1992;268:1314-1319.

You have identified the appropriate approach for the treatment ofbiopsy-proven melanoma; however, there are differing opinions as tothe best method for diagnosis of this tumor. One authority has commented:"In some instances, because of constraints on anatomic siteor cosmetic concerns, it may not be possible to perform an excisionalbiopsy. Although less satisfactory, an incisional or punch biopsy may be obtainedthrough what is considered to be the thickest (most elevated) portion ofthe clinical lesion. There is no evidence that biopsy or incision of a melanomaleads to 'seeding' of tissue or metastasis."¹

Pigmented lesions are common, and busy clinicians often do not havetime to completely excise all those that are suspicious. Also, excisional biopsiesmay be beyond the surgical capabilities of some nondermatologists.Thus, I would suggest that in this setting, it is better to perform a biopsy ona suspicious lesion than to run the risk of having the patient lost to follow-up.

In an ideal world, all suspicious pigmented lesions would be completelyexcised at the initial evaluation. However, when complete excision is not an option,physicians can still provide quality care by performing a punch or incisionalbiopsy to diagnose this malignancy.

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David L. Kaplan, MD
  Clinical Assistant Professor of Dermatology
  University of Missouri, Kansas City
  University of Kansas

REFERENCE:1. Langley RGB, Barnhill RL, Mihm MC Jr, et al. Neoplasms, cutaneous melanoma. In: Freedberg IM, EisenAZ, Wolff K, et al, eds. Dermatology in General Medicine. New York: McGraw-Hill; 1999:1099.