Melanoma biopsy - Large Biopsy 3-6 cm

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Skin biopsy for suspected melanoma.

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Melanoma Biopsy - Large Biopsy 3-6 cm

Why is it done?
- Definitive diagnosis of melanoma when clinical suspicion is high and lesions are large (3-6 cm) or have concerning features such as irregular borders, multiple colors, or asymmetry
- Determination of histological subtype (superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, acral lentiginous melanoma) to guide prognosis and treatment
- Assessment of critical prognostic factors including Breslow thickness (depth of invasion), mitotic rate, ulceration, and Clark level of invasion
- Evaluation of dermal/subcutaneous involvement to determine surgical margins and staging requirements
- Identification of sentinel lymph node involvement or in-transit metastases when present in the biopsy specimen
- Performed when excisional biopsy is indicated for lesions that cannot be completely removed in a single excision or when diagnostic confirmation is needed prior to definitive surgery
Normal Range
- Negative/Normal Result: Benign skin lesion with no evidence of malignancy, atypical melanocytic proliferation, or dysplasia. Normal epidermal and dermal architecture without concerning histological features.
- Positive Result: Histologic confirmation of melanoma with key measurements including: • Breslow thickness: measured in millimeters from granular layer to deepest point of invasion (Stage I: <1 mm, Stage II: 1-4 mm, Stage III: >4 mm) • Mitotic rate: expressed as mitoses per mm² (concerning if ≥1 mitosis/mm²) • Clark level: Roman numerals I-V indicating depth within skin layers • Ulceration: present or absent (presence indicates worse prognosis) • Margins status: clear or involved
- Atypical/Borderline Result: Dysplastic nevus, atypical melanocytic proliferation, or melanoma in situ without clear invasion - may require expert dermatopathology review and additional immunohistochemical staining
Interpretation
- Breslow Thickness: The single most important prognostic factor. Thickness <1 mm (Stage IA) has excellent prognosis with 5-year survival >95%; thickness 1-2 mm (Stage IB) has ~90% survival; thickness 2-4 mm (Stage IIA-IIB) has ~70-80% survival; and thickness >4 mm (Stage IIIA-IIIB) has significantly worse prognosis with ~50-60% survival
- Mitotic Rate: Elevated mitotic activity (≥1 mitosis/mm²) indicates higher grade tumor and more aggressive behavior. This is particularly significant in thin melanomas where it upstages prognosis
- Ulceration Status: Presence of ulceration significantly worsens prognosis and increases stage by one level. Ulcerated melanomas have ~50% 5-year survival compared to ~95% for non-ulcerated thin melanomas
- Clark Level: Level I = confined to epidermis; Level II = invades superficial papillary dermis; Level III = fills papillary dermis; Level IV = invades reticular dermis; Level V = invades subcutaneous fat. Higher levels indicate deeper invasion and worse prognosis
- Histological Subtype: Superficial spreading melanoma (most common, generally better prognosis) vs. nodular melanoma (typically deeper at diagnosis, worse prognosis) vs. lentigo maligna melanoma (typically on face, sun-exposed areas) vs. acral lentiginous melanoma (palms, soles, subungual; historically worse outcomes due to late diagnosis)
- Surgical Margins: Clear margins (typically ≥5 mm recommended) indicate adequate removal; positive or close margins (<5 mm) require re-excision to reduce recurrence risk
- Factors Affecting Interpretation: Specimen orientation and adequacy; crush artifact or thermal injury from cauterization; use of immunohistochemical stains (S-100, SOX10, Melan-A, HMB-45); desmoplastic features; presence of regression; lymphocytic infiltration; and sentinel lymph node status all factor into interpretation
Associated Organs
- Primary Organ System: Integumentary system (skin). The lesion involves epidermal and dermal melanocytes. Large biopsies may involve subcutaneous tissue and regional structures.
- Regional Lymph Nodes: Sentinel lymph nodes draining the area are the first site of potential metastatic spread. Depending on location and stage, sentinel lymph node biopsy may be indicated (Breslow thickness >1 mm, presence of ulceration, high mitotic rate).
- Common Sites of Metastatic Disease: Lungs (most common distant site), liver, brain, bone, and gastrointestinal tract. Skin, subcutaneous tissue, and lymph nodes are common sites of regional metastases.
- Potential Complications Associated with Diagnosis: Confirmed melanoma may lead to need for wide local excision creating skin defect; potential lymphedema if regional nodes are removed; systemic metastatic disease requiring chemotherapy/immunotherapy; psychological impact of cancer diagnosis.
- Conditions Associated with Positive Results: Cutaneous melanoma (primary diagnosis); dysplastic nevus syndrome (increased risk for melanoma); family history of melanoma; previous melanoma or nonmelanoma skin cancers; extensive sun exposure or sunburns; immunosuppression; and fair skin phenotype.
Follow-up Tests
- Sentinel Lymph Node Biopsy (SLNB): Indicated for melanomas with Breslow thickness >1 mm, ulceration, high mitotic rate (≥1/mm²), or younger age with intermediate-thickness tumors. Helps with staging and identifies occult nodal disease.
- Wide Local Excision (WLE): Definitive surgical treatment with margins based on Breslow thickness (1 cm for <1 mm, 1-2 cm for 1-2 mm, 2 cm for >2 mm tumors) to reduce recurrence risk.
- Staging Imaging: For Stage IIIB or higher melanomas, consider CT chest/abdomen/pelvis or PET-CT to evaluate for distant metastatic disease. Brain MRI if high-risk features or neurological symptoms present.
- Molecular Testing/Genetic Analysis: BRAF, NRAS, KIT, or other mutation testing may be performed on biopsy specimen or primary tumor for prognostic and therapeutic guidance (targeted therapy options available for BRAF-mutant melanomas).
- Clinical Surveillance: Regular skin examinations every 3-6 months for first 2 years, then annually. Patient self-examination of skin using ABCDE criteria (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution/changes).
- Adjuvant Therapy Consideration: Stage IIB-III melanomas may benefit from adjuvant immunotherapy (checkpoint inhibitors like nivolumab or pembrolizumab) or targeted therapy (for BRAF-mutant tumors). Multidisciplinary tumor board review recommended.
- Repeat Biopsy: If margins are positive or involved and re-excision needed, repeat histologic evaluation is required. Any new or changing skin lesions warrant biopsy.
- Lab Work: Baseline LDH (lactate dehydrogenase) levels for Stage III-IV disease; periodic labs to monitor for metastatic disease or treatment toxicity if receiving systemic therapy.
Fasting Required?
- Fasting Required: No
- Patient Preparation: Cleanse the biopsy area with antiseptic solution (usually 70% isopropyl alcohol or povidone-iodine). Mark or photograph the lesion if possible for documentation.
- Local Anesthesia: Local anesthesia (typically 1% or 2% lidocaine with or without epinephrine) will be injected into the biopsy site. Inform provider if you have lidocaine allergy (alternatives available).
- Medications to Avoid/Disclose: Inform provider of all medications, particularly anticoagulants (warfarin, apixaban, dabigatran), antiplatelet agents (aspirin, clopidogrel), NSAIDs, and herbal supplements (ginkgo, garlic, ginger). These may need temporary discontinuation depending on bleeding risk assessment. Generally can be continued if bleeding risk is low.
- Special Instructions: Schedule biopsy during a time when you can avoid strenuous activity for 24 hours post-procedure. Wear loose, comfortable clothing to allow access to biopsy site and minimize irritation. Avoid sun exposure to the area for at least 2 weeks after biopsy. Do not apply makeup, lotions, or deodorant to the area on the day of biopsy.
- Post-Procedure Care: Keep the biopsy site clean and dry. If sutures are placed, keep the area clean until suture removal (typically 7-14 days depending on location). Watch for signs of infection (increasing redness, warmth, pus, fever) and contact provider if they develop. Mild discomfort and bruising are normal.

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