Review Question - QID 221251

This patient with increased sun exposure presents with an irregular skin lesion with color variation that has grown in size over time. This presentation is consistent with malignant melanoma, which requires an excisional biopsy for definitive diagnosis.

The diagnosis of melanoma can be aided by the ABCDE criteria: asymmetry, irregular borders, variegated color, diameter (> 6 mm), and evolution. The initial diagnosis of suspected melanoma requires an excisional biopsy with 1-3 mm margins of the surrounding skin and subcutaneous fat for subtype diagnosis and assessment of the Breslow depth. Once a diagnosis is made, patients with confirmed melanoma require additional surgical resection and staging procedures, such as surgical excision with margins or a lymph node biopsy.

Mou et al. studied lymph node biopsy in melanoma. They found that the field is moving from sentinel node biopsy to complete lymph node dissection, representing a paradigm shift in the management approach for melanoma. They recommend that more research is needed to confirm the superiority of complete dissection over sentinel node biopsy.

Figure/Illustration A is a clinical photograph demonstrating a skin lesion with variations in coloration (red circles). These findings are consistent with a diagnosis of melanoma.

Incorrect Answers:
Answer 2: Incisional biopsy requires that only a portion of the skin lesion be removed and is not recommended for melanoma. It may be considered for benign tumors in cosmetically sensitive areas such as the face.

Answer 3: Sentinel lymph node biopsy is indicated in patients with confirmed melanoma who are at increased risk of lymph node spread based on tumor thickness (> 1 mm) as measured from an excisional biopsy. It is not the initial step in management.

Answer 4: Shave biopsy is appropriate for the rapid removal of raised or pedunculated skin lesions. It is not indicated in patients with melanoma because most shave biopsies are performed at the level of the deep dermis and cannot adequately assess the depth of invasion for melanoma.

Answer 5: Surgical excision with wide margins is indicated for the treatment of melanoma once a definitive diagnosis has been made.

Bullet Summary:
In a patient with classic symptoms of melanoma, the most appropriate initial step in management is an excisional biopsy.