Biopsy of the pigmented lesion—When and how

Mind the Gap: A Questionnaire on the Distance between Diagnostic Advances and Clinical Practice in Skin Cancer Treatment

Background and Objectives: Significant progress has been made in skin cancer diagnosis, with a surge in available technologies in recent years. Despite this, the practical application and integration of these technologies in dermatology and plastic surgery remain uneven. Materials and Methods: A comprehensive 20-question survey was designed and distributed using online survey administration software (Google Forms, 2018, Google, Mountain View, CA, USA) from June 2023 to September 2023. The survey aimed to assess the knowledge and utilization of dermatologic diagnostic advancements among plastic surgeons in various European countries. Results: Data were obtained from 29 plastic surgeons across nine European countries, revealing a notable gap between diagnostic technologies and their routine use in surgical practice. The gap for some technologies was both cognitive and applicative; for electrical impedance spectroscopy (EIS) and multispectral imaging, only 6.9% of the sample knew of the technologies and no surgeons in the sample used them. In the case of other technologies, such as high-frequency ultrasound (HFUS), 72.4% of the sample knew about them but only 34.5% used them, highlighting a more significant application problem. Conclusions: Spotlighting this discrepancy provides a valuable foundation for initiating collaborative efforts between units and facilitating knowledge exchange among diverse specialists. This, in turn, contributes to advancing clinical practice by integrating the innovative opportunities presented by ongoing research.

Preoperative Ultrasound-Guided Incisional Biopsy Enhances the Pathological Accuracy of Incisional Biopsy of Cutaneous Melanoma: A Prospective Clinical Trial in Chinese Patients

OBJECTIVES

To assess the feasibility of preoperative ultrasound (US)-guided incisional biopsy through a prospective controlled clinical trial.

METHODS

This was a prospective, double-arm, single-center study of Chinese patients. Thirty patients were enrolled in the study. Fourteen patients received incisional biopsies for which the choice of biopsy area relied on a clinical evaluation, and 16 patients received incisional biopsies for which the choice of biopsy area relied on a US-guided evaluation. The following procedure was used in the US-guided incisional biopsy group: 1) clinical and dermoscopic evaluation of skin lesions; 2) US examination; 3) incisional biopsy; 4) surgical excision; and 5) histopathological examination. The same procedure was used in the non-US-guided group except without US examination.

RESULTS

In the non-US-guided group, the mean tumor thicknesses obtained from incisional biopsy and postoperative histopathological examination were 2.1 and 4.1 mm, respectively. Seven melanomas were underestimated by incisional biopsy, resulting in margins narrower than currently recommended. In the US-guided group, the mean tumor thicknesses obtained from US, incisional biopsy, and postoperative histopathological examination were 3.4, 2.9, and 2.7 mm, respectively. In only 3 melanomas was the tumor thickness of the incisional biopsy less than that of the postoperative histopathological examination, demonstrating that US-guided biopsy obtains the maximum thickness area.

CONCLUSIONS

Preoperative US-guided incisional biopsy can enhance the pathological accuracy of incisional biopsy, which may allow us to better perform surgical excision with safe peripheral surgical margins.

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD) and the European Federation for Colposcopy (EFC) consensus statements on pre-invasive vulvar lesions

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD) and the European Federation for Colposcopy (EFC) Consensus Statements on Pre-invasive Vulvar Lesions

ABSTRACT

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).

Operative Therapie des malignen Melanoms

Die operative Therapie ist maßgeblich im Behandlungskonzept des malignen Melanoms. Sie ist essentieller Bestandteil der Diagnosesicherung, des Stagings und der Therapie in allen Stadien der Erkrankung. Die optimale Planung und Durchführung der Primärexzision, der Sentinel-Lymphknoten-Biopsie und der Nachexzision mit Sicherheitsabstand legen den Grundstein einer erfolgreichen Behandlung, die neben oder auch in Kombination mit einer modernen Systemtherapie die Metastasen-Chirurgie miteinschließt.

Non-invasive diagnostic techniques in pigmentary skin disorders and skin cancer

BACKGROUND

Diagnosis of pigmentary skin disorders, pre-cancerous and cancerous skin diseases is traditionally relied on visual assessment. The most widely applied invasive diagnostic technique is the skin biopsy. There have been significant technological advances in non-invasive diagnostic methods for skin disorders.

OBJECTIVE

The objective of this article is to discuss different non-invasive diagnostic modalities, used in the diagnosis of pigmentary skin disorders and cutaneous cancers.

METHODS

Comprehensive literature search was performed to screen articles related to non-invasive diagnostic techniques in pigmentary skin disorders and cutaneous cancers. Articles published in journals indexed in PubMed were searched along with those in Google Scholar. Clinical trials, review articles, case series, case reports and other relevant articles were considered for review. References of relevant articles were also considered for review.

RESULTS

Dermoscopy and ultrasonography were the only non-invasive diagnostic and imaging techniques available to dermatologists for many years. The advent of computed tomography (CT) and magnetic resonance imaging (MRI) augmented the visualization of deeper structures. Confocal laser microscopy (CLM) and reflectance spectrophotometers have showed promising results in the non-invasive detection of pigmented lesions. Optical coherence tomography (OCT), electrical impedance spectroscopy (EIS), multispectral imaging, high frequency ultrasonography (HFUS) and adhesive patch biopsy aid in the accurate diagnosis of benign, as well as neoplastic skin diseases.

CONCLUSION

There have been significant advancements in non-invasive methods for diagnosis of dermatological diseases. These techniques can be repeatedly used in a comfort manner for the patient, and may offer an objective way to follow the course of a disease.

Grafting and Other Reconstructive Options for Nail Deformities: Indications, Techniques, and Outcomes

This article reviews the nomenclature, anatomic components, and physiologic growth involving the perionychium. Fingertip and nailbed injuries are commonly encountered problems in hand surgery. This article focuses primarily on dealing with chronic nailbed deformities following traumatic injury such as nonadherence, split nails, avulsion loss, and hook nails. Nail deformities secondary to pincer nail, mass effect, and pigmented lesions are reviewed as well. The underlying pathology and treatment options are examined for each deformity. The senior author highlights technical pearls and surgical planning for his preferred methods of reconstruction.

Skin tissue sample collection, sample homogenization, and analyte extraction strategies for liquid chromatographic mass spectrometry quantification of pharmaceutical compounds

Quantification of pharmaceutical compounds in skin tissue is challenging because of low expected concentrations, small typical sample volumes, and the hard nature of the skin structure itself. This review provides a comprehensive overview of sample collection, sample homogenization and analyte extraction methods that have been used to quantify pharmaceutical compounds in skin tissue, obtained from animals and humans, using liquid chromatography-mass spectrometry. For each step in the process of sample collection to sample extraction, methods are compared to discuss challenges and provide practical guidance. Furthermore, liquid chromatographic-mass spectrometry considerations regarding the quality and complexity of skin tissue sample measurements are discussed, with emphasis on analyte recovery and matrix effects. Given that the true recovery of analytes from skin tissue is difficult to assess, the extent of homogenization plays a crucial role in the accuracy of quantification. Chemical or enzymatic solubilization of skin tissue samples would therefore be preferable as homogenization method.

A Review of Noninvasive Techniques for Skin Cancer Detection in Dermatology

As a result of increasing melanoma incidence and challenges with clinical and histopathologic evaluation of pigmented lesions, noninvasive techniques to assist in the assessment of skin lesions are highly sought after. This review discusses the methods, benefits, and limitations of adhesive patch biopsy, electrical impedance spectroscopy (EIS), multispectral imaging, high-frequency ultrasonography (HFUS), optical coherence tomography (OCT), and reflectance confocal microscopy (RCM) in the detection of skin cancer. Adhesive patch biopsy provides improved sensitivity and specificity for the detection of melanoma without a trade-off of higher sensitivity for lower specificity seen in other diagnostic tools to aid in skin cancer detection, including EIS and multispectral imaging. EIS and multispectral imaging provide objective information based on computer-assisted diagnosis to assist in the decision to biopsy and/or excise an atypical melanocytic lesion. HFUS may be useful for the determination of skin tumor depth and identification of surgical borders, although further studies are necessary to determine its accuracy in the detection of skin cancer. OCT and RCM provide enhanced resolution of skin tissue and have been applied for improved accuracy in skin cancer diagnosis, as well as monitoring the response of nonsurgical treatments of skin cancers and the determination of tumor margins and recurrences. These novel approaches to skin cancer assessment offer opportunities to dermatologists, but are dependent on the individual dermatologist's comfort, knowledge, and desire to invest in training and implementation of noninvasive techniques. These noninvasive modalities may have a role in the complementary assessment of skin cancers, although histopathologic diagnosis remains the gold standard for the evaluation of skin cancer.

Re-biopsy of partially sampled thin melanoma impacts sentinel lymph node sampling as well as surgical margins

AIM

To assess the impact of re-biopsy on partially sampled melanoma in situ (MIS), atypical melanocytic proliferation (AMP) and thin invasive melanoma.

MATERIALS & METHODS

We retrospectively identified cases of re-biopsied partially sampled neoplasms initially diagnosed as melanoma in situ, AMP or thin melanoma (Breslow depth ≤0.75 mm).

RESULTS & CONCLUSION

Re-biopsy led to sentinel lymph node biopsy (SLNB) in 18.3% of cases. No patients upstaged from AMP or MIS had a positive SLNB. One out of nine (11.1%) initially diagnosed as a thin melanoma ≤0.75 mm, upstaged with a re-biopsy, had a positive SLNB. After re-biopsy 8.5% underwent an increased surgical margin. Selective re-biopsy of partially sampled melanoma with gross residual disease can increase the accuracy of microstaging and optimize treatment regarding surgical margins and SLNB.

Reflectance confocal microscopy in the diagnosis of pigmented macules of the face: differential diagnosis and margin definition

Here we review the state-of-the-art of RCM morphologic descriptors, standardized terminology, and diagnostic algorithms for the assessment of pigmented macules of the face, for their correct diagnosis and management.

Guidelines of care for the management of primary cutaneous melanoma

The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.

Screening for malignant melanoma-a critical assessment in historical perspective

Screening for melanoma has been advocated for many years because early detection and excision have been regarded as the most important measure to lower mortality from that neoplasm. In the past decade, concern has been raised by epidemiologists that screening might result in excision chiefly of "inconsequential cancer," i.e., melanomas that would never have progressed into life-threatening tumors, a phenomenon referred to by the misleading term "overdiagnosis." Without any firm evidence, that speculation has been embraced worldwide, and incipient melanomas have been trivialized. At the same time, efforts at early detection of melanoma have continued and have resulted in biopsy of pigmented lesions at a progressively earlier stage, such as lesions with a diameter of only 2, 3, or 4 mm. Those tiny lesions often lack sufficient criteria for clinical and histopathologic diagnosis, the result being true overdiagnoses, i.e., misdiagnoses of melanocytic nevi as melanoma. This is especially true if available criteria for histopathologic diagnosis are diminuished even further by incomplete excision of lesions. The reliability of histopathologic diagnosis is far higher in excisional biopsies of lesions that were given some more time to develop changes that make them recognizable. Biopsy of pigmented lesions with a diameter of 6 mm has been found to result in a far higher yield of melanomas. In addition to better clinical judgment, slight postponement of biopsies bears the promise of substantial improvement of the reliability of histopathologic diagnosis, and of alleviating true overdiagnoses.

Acral melanoma detection using a convolutional neural network for dermoscopy images

Background/Purpose

Acral melanoma is the most common type of melanoma in Asians, and usually results in a poor prognosis due to late diagnosis. We applied a convolutional neural network to dermoscopy images of acral melanoma and benign nevi on the hands and feet and evaluated its usefulness for the early diagnosis of these conditions.

Methods

A total of 724 dermoscopy images comprising acral melanoma (350 images from 81 patients) and benign nevi (374 images from 194 patients), and confirmed by histopathological examination, were analyzed in this study. To perform the 2-fold cross validation, we split them into two mutually exclusive subsets: half of the total image dataset was selected for training and the rest for testing, and we calculated the accuracy of diagnosis comparing it with the dermatologist’s and non-expert’s evaluation.

Results

The accuracy (percentage of true positive and true negative from all images) of the convolutional neural network was 83.51% and 80.23%, which was higher than the non-expert’s evaluation (67.84%, 62.71%) and close to that of the expert (81.08%, 81.64%). Moreover, the convolutional neural network showed area-under-the-curve values like 0.8, 0.84 and Youden’s index like 0.6795, 0.6073, which were similar score with the expert.

Conclusion

Although further data analysis is necessary to improve their accuracy, convolutional neural networks would be helpful to detect acral melanoma from dermoscopy images of the hands and feet.

Histopathological diagnosis of small melanocytic lesions suspicious for malignant melanoma

The concern about malignant skin neoplasms leads to the excision of smaller lesions. This study on small melanocytic lesions aims to evaluate the range of possible histopathological diagnoses, describe histopathological aspects, and assess the usefulness of serial histological sections. We performed a cross-sectional descriptive histopathological study examining 76 pigmented skin lesions up to 6 mm in diameter. Histopathological diagnoses included atypical melanocytic nevi (n=38), common melanocytic nevi (n=18), atypical lentiginous melanocytic hyperplasia with architectural features of atypical melanocytic nevi (n=7), lentigo simplex (n=2), and malignant melanoma (n=1). Ten cases were non-diagnostic. Cytological atypia was not an exclusive finding of atypical lesions. Examination of serial sections did not change histopathological impression. Early detection of malignant melanoma is important, but clinical and dermoscopy exams may be leading to the resection of a great number of benign lesions. Strict attention to histopathological criteria results in a large number of non-diagnostic cases.

The Ram Relaxation Technique: A Painless Biopsy Method. A Shave Biopsy Approach Without Injectable Anesthesia or Needles

BACKGROUND

Shave skin biopsies are essential procedures wherein physicians diagnose dermatologic lesions. The protocol for skin biopsies entails a lidocaine/epinephrine injection. This study suggests an alternative, novel method of performing a shave biopsy that avoids pain, needles, and injectable anesthesia, termed the Ram Relaxation Technique (RRT).

OBJECTIVE

To present a new technique that physicians may chose to form when faced with dermatological biopsies that are painless and needle free.

PATIENTS AND METHODS

Randomly selected, patients were presented to the authors' offices with abnormal skin lesions that required a shave biopsy. The patients were offered the choice of having an anesthetic injection (1% lidocaine, 1:100,000 epinephrine) or the alternative method (RRT) before the biopsy. Twenty patients (n = 20, 10 men, 10 women) chose the alternative method (RRT) and were the focus of this study. These patients who chose RRT were asked to scale their pain on a scale of 0 to 10 (0 = no pain, 1-3 = mild, 4-6 = moderate, and 7-10 = severe pain).

RESULTS

Fourteen of the 20 patients stated that they experienced no pain (0), 5 experienced mild pain, and 1 patient experienced moderate pain.

CONCLUSION

This study demonstrates an alternative and nearly pain-free method for superficial shave biopsies of the skin for certain patients in the appropriate clinical setting with the appropriate, superficial papule lesions. Dermis lesions, melanocytic lesions, and macular lesions are not ideal candidates given the risk for misdiagnosis, and more pain, respectively.

Efficacy and Tolerability of a Novel Biopsy Device for Removing Benign Epidermal Skin Lesions

BACKGROUND

The shave biopsy using a razor with an open blade is the current standard of care for sampling superficial skin lesions.

OBJECTIVE

To enhance safety, the authors developed a novel biopsy device with a closed blade design for removing the epidermal layer of skin and evaluated against the open razor blade for tolerability, scarring, and accuracy in histological diagnosis.

MATERIALS AND METHODS

Shave biopsies were performed using the novel device or razor blade on benign epidermal skin lesions in 10 patients on comparable body parts. Digital photography, colorimetry, scar scale evaluations, and questionnaires were used to evaluate the efficacy and tolerability of the devices.

RESULTS

For all patients, accurate histological diagnoses were made regardless of device type. No statistically significant differences were detected between the novel device and razor blade in terms of scar scale assessments, colorimetry, and questionnaire responses. Both patients and the participating dermatologist reported satisfaction with the safety and performance of the novel device. No injuries to the provider occurred with either instrument.

CONCLUSION

The rotating sphere biopsy device is a potential alternative to the razor blade with comparable tolerability, scarring, and accuracy in histological diagnoses, offering improved safety for patients and health care providers.

Pigmented Pre-malignant and Malignant Lesions of Skin with Special Reference to Atypical Presentations

BACKGROUND

Cutaneous melanocytic proliferations are diverse both morphologically as well as in their behavioural patterns. Both dermatologists and pathologists regularly encounter diagnostic dilemmas while interpreting such lesions.

AIM

To study all cutaneous premalignant and malignant lesions with respect to their clinical features and histopathological findings.

MATERIALS AND METHODS

A retrospective study was done in the Department of Pathology over a period of 10 years (2004-14) on all the clinically pigmented lesions that were biopsied or excised. Out of these only premalignant and malignant melanocytic lesions were analysed with respect to their important clinical and histologic features. Immunohistochemistry was carried out using HMB-45 and S-100 where indicated.

RESULTS

A total of 338 skin cancers were reported, out of these 27, 7.9% were cutaneous malignant melanoma. Premalignant lesions were 33. The mean age for premalignant lesions and melanomas was 43 years and 50.7 years respectively with a male predominance in both groups. The sole of foot/ankle was the most common site of involvement by melanoma (n=8,29.6%) while sun exposed sites like face and scalp were common sites for development of premalignant lesions like dysplastic nevi, lentigo simplex, pigmented seborrheic keratosis and Bowens disease. One case presented as post-traumatic scar tissue which turned out to be desmoplastic melanoma. One case of amelanotic melanoma presented as recurrent painful penile ulcers. Both cases were confirmed on Immunohistochemistry.

CONCLUSION

All pigmented lesions should be regarded as tumours of uncertain malignant potential and treated with complete excision if possible with long term follow up.

[Malignant head and neck melanoma: Part 2: Therapy]

Resection margins of melanomas in the head and neck region often have to be adapted according anatomical circumstances. In the case of thicker primary tumors or after complete resection of locoregional lymph node metastases, adjuvant therapy with interferon-α can be performed; in some cases, adjuvant radiotherapy may also be indicated. In the case of inoperable lymph node or distant metastases, systemic treatment is required. Beside well-established mono- or polychemotherapy regimens, newer targeted therapies with BRAF inhibitors (vemurafenib, dabrafenib), mitogenic-activated protein kinase (MEK) inhibitors (trametinib, binimetinib, and cobimetinib), and kinase inhibitors (imatinib, sunitinib, nilotinib, dasatinib) are also available.

Spanish consensus on vulvar disorders in postmenopausal women

INTRODUCTION

The consequences of vulvar disorders in terms of health, sexuality, and quality of life are usually undervalued, with disparities in the conceptual, diagnosis and treatment criteria.

AIM

The objective of this guide will be to analyse the factors associated with the diagnosis and treatment of vulvar disorders and to provide recommendations for the most appropriate diagnostic and therapeutic measures.

METHODOLOGY

A panel of experts from various Spanish scientific societies related to sexual health (Spanish Menopause Society [SMS] and the Asociación Española de Patología Cervical y Colposcopia [AEPCC]) met to reach a consensus on these issues and to decide the optimal timing and methods based on the best evidence available.

RESULTS

We recommend a biopsy of all vulvar lesions with an uncertain diagnosis, especially with asymmetry, irregular borders, variegated and irregular colour and diameter >6mm. For vulvodynia, we recommend the use of lubricants or topical treatments with lidocaine or bupivacaine, amitriptyline, baclofen or triamcinolone. For vulvar epithelial disorders, we recommend beginning with topical corticosteroids of moderate to high potency. For sexual dysfunction, a multidisciplinary approach is the best management strategy in these patients.

Melanoma: diagnosis, staging, and treatment. Consensus group recommendations

The incidence of malignant melanoma is increasing worldwide. In Spain, its incidence is increasing faster than any other cancer type, with a 5-year survival rate of about 85%. The impact and characteristics of malignant melanoma in the Spanish population can be ascertained from the national melanoma registry of the Academia Española de Dermatología y Venereología. This review presents consensus group recommendations for the diagnosis, staging and treatment of malignant melanoma in Spain. Incidence and mortality are discussed, as well as evaluation of various prevention and treatment strategies. Prognostic factors, such as BRAF and C-KIT mutations, which are expected to become routine staging procedures over the next few years, are outlined, especially in relation to treatment options. The use of recently approved targeted agents such as ipilimumab, a cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) inhibitor, and vemurafenib, a BRAF inhibitor, in metastatic disease are also discussed.

Surgical management of suspicious melanocytic lesions in Italy

OBJECTIVE

In melanoma, the surgical approach is important for both diagnosis and therapy. Although surgery is relatively simple, the methods should be performed by experts in melanoma management. We analyze the techniques and methods used in the Italian hospital network for suspicious skin lesions and confirmed melanomas.

METHODS

A nationwide survey was conducted of a representative sample of 120 hospitals with ≥ 200 beds.

RESULTS

Excision biopsies remove suspected melanomas. However, some approaches to excision margins and sentinel lymph node procedures differ from international protocols. Overall, 21% of centers perform excisional biopsy of a suspicious lesion using 1 cm margins, and 22% of centers perform sentinel node procedures concurrently with removal of primary melanoma.

CONCLUSIONS

Standardized treatment protocols are needed for suspicious lesions and clinically evident melanoma, particularly regarding the critical aspect of excision margins. The sentinel lymph node procedure may be distorted by initial margins that are too wide.

Biopsy guided by dermoscopy in cutaneous pigmented lesion -- case report

It may be clinically difficult to differentiate early-stage melanoma from benign tumors, specially pigmented seborrheic keratosis. Dermoscopy can help; however, the findings are not always conclusive. Therefore, histopathology may be necessary for a correct diagnosis. We describe a melanocytic lesion with dubious clinic and dermoscopic findings. An incisional biopsy of a suspicious area, guided by dermoscopy, was performed to clarify the findings.

The art and science of surgical margins for the dermatopathologist

Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and primary cutaneous melanoma (PCM) are the major forms of skin cancer. Surgical excision is one of the most frequently utilized treatment modalities for these tumors.

METHODS

literature review.

RESULTS

recommendations for lateral surgical excision margin (LEM) for BCCs is 4 mm for low-risk BCCs and Mohs surgery or resection with complete circumferential peripheral and deep margin assessment for high risk. Recommended LEM is 4-6 mm for low-risk SCCs and Mohs surgery or resection with complete circumferential peripheral and deep margin assessment for high risk BCCs. If SCC or BCC is >20 mm in area L with no other high-risk factors and can be repaired primarily, 10-mm clinical margins may be used. Recommended LEM is 5 mm for melanoma-in-situ; 1 cm for PCM <1 mm (Breslow); 1-2 cm for PCM 1.01-2 mm (Breslow); and, 2-3 cm for high-risk PCM >2.01 mm (Breslow). Tumor subtype-specific recommendations for histologic margins are offered which provide the greatest degree of certainty regarding the completeness of excision.

CONCLUSION

Recommendations can be made regarding appropriate surgical excision margins by classifying skin cancers as low-risk or high-risk based on histopathological and clinical factors. Ascertaining that histopathologic margins are free of tumor is not a perfect science and requires thoughtful sampling, grossing, and staining procedures.

The rate of melanoma transection with various biopsy techniques and the influence of tumor transection on patient survival

BACKGROUND

Depth of melanoma invasion is critical because it dictates patient treatment and prognosis. Recent reports indicate melanoma transection with initial biopsy does not impact patient survival; however, tumor transection can lead to misdiagnosis and inaccurate staging.

OBJECTIVE

This study assessed the rate of melanoma transection with various biopsy techniques and the impact of tumor transection on patient survival.

METHODS

We conducted a retrospective review of all melanoma cases at our institution between 2000 and 2008. Of the 490 melanoma cases identified, 479 met inclusion criteria for the study. The transection rates of biopsy techniques were determined. Cases of transected tumors were matched with nontransected cases in a retrospective case-control fashion to evaluate survival.

RESULTS

The rate of melanoma transection was 1.5% for excisional biopsies, 4.1% for punch biopsies, and 9.0% for saucerization biopsies. The means of disease-free survival for the control and transected groups were 911 days and 832.7 days, respectively (P value .67). Overall survival for the control group was 1073.7 days versus 1012.4 days for the transected group (P value .72).

LIMITATIONS

The study used a select population. The sample size of transected biopsies was limited, in turn limiting the power of the study. Residents performed the majority of biopsies.

CONCLUSION

Punch and saucerization biopsies were more likely to transect tumors than excisional biopsies. The transection of melanoma did not affect overall disease-free survival or mortality in the population studied.

Dysplastic nevi

Dysplastic nevi have been a subject of much debate since their original description in 1978. Although some question the biological potential of dysplastic nevi themselves, several studies have shown that their presence confers substantial risk for melanoma. In addition to predisposing patients to melanoma, dysplastic nevi have been shown to harbor genetic mutations, indicating their position on a continuum between banal nevi and melanomas. Dysplastic nevi are also clinically relevant as mimickers of melanoma, and can be challenging diagnostically. This article reviews the history, epidemiology, biology and genetics, clinical features, histopathologic features, and management guidelines for patients with these lesions.

Skin cancers of the hand and upper extremity

Skin cancers represent the most common primary malignancies of the hand. They typically present as painless lesions on areas of high sun exposure, such as the dorsum of the hand and upper extremity. The most common malignancy is squamous cell carcinoma, followed by basal cell carcinoma and melanoma. The key to successful treatment is early and accurate diagnosis and treatment. Unlike open biopsies, which are indicated for deep soft tissue and bone lesions, biopsies for skin cancer can be performed under local anesthesia in the office setting in the form of shave or punch biopsies. A number of nonsurgical treatment options are available for treatment. However, when surgical excision is indicated, appropriate margin resections are dictated by the grade and stage of the malignancy.

Longitudinal melonychia: clinical evaluation and biopsy technique

Longitudinal melonychia is a brown streaking of the nailbed. It is often benign but can be a subungual melanoma. Subungual melanoma is a rare malignancy. Diagnosis is often delayed, resulting in a higher staging and poorer prognosis than other cutaneous melanomas. We provide an update on the evaluation of longitudinal melonychia and biopsy technique.

Pigmented lesion pathology: what you should expect from your pathologist, and what your pathologist should expect from you

The first part of this review examines the reliability of histologic diagnosis in pigmented lesions, as measured by concordance studies and medicolegal analysis. It emphasizes the role of clinicians in maximizing that reliability, by providing adequate clinical descriptions, using appropriate biopsy technique, and critically interpreting pathology reports. It identifies those entities that are especially problematic, either because they cannot be reliably recognized by the histopathologist or because their histology is a poor guide to their biologic behavior. The second part of the review is a guide to some of the more difficult and controversial pigmented lesions, including dysplastic nevus, spitzoid nevi and melanomas, cellular blue nevus, animal-type melanoma, and deep penetrating nevus.

The influence of surgical procedure and the effect of chemotherapy on nodal and distant metastases of human malignant melanomas that have been grafted into nude mice

Malignant melanoma of the oral mucosa is common in Japan. The effects on metastasis of puncturing the tumor before surgery or using chemotherapy after extirpation of the tumor were studied using animal models. G-361 cells were transplanted subcutaneously into mice. In half the animals, the subcutaneous tumor was punctured with an 18G needle twice a week from 2 weeks after transplantation until death. In the other mice, the subcutaneous tumor was extirpated 6 weeks after transplantation; the animals were killed 2 weeks later. Dimethyl triazeno imidazole carboxamide (DTIC) or cisplatin (CDDP) were injected into the peritoneal cavity 3 days before extirpation or during extirpation. Metastases to the axilla lymph node and the lung were examined in both groups. The animals that received puncturing developed lymph node and pulmonary metastasis earlier and more frequently than those without puncturing. 50% of mice that received no anticancer agent, had lymph node and pulmonary metastases after tumor extirpation. Preoperative DTIC or CDDP reduced the frequency of metastasis to 25-35%. DTIC or CDDP administration during extirpation, significantly reduced the metastasis rate to 7-10%. Prognosis for oral melanoma patients may be better when surgery and postoperative chemotherapy are performed simultaneously without preoperative surgical procedures.

Malignant skin neoplasms

Skin cancers may be derived from any part of the skin, and the classification of all variants is extensive. Overall they are the most common cancers of the body, and include those that are highly mortal and those that are associated with an increased morbidity. In this review the most common skin cancers confronted by the clinician and their management are discussed. New associations are highlighted, as well as new information that can help the clinician to better understand the pathogenesis of many of these entities.