When Should You Biopsy?

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Tracey C. Vlahovic, DPM

   After performing a thorough history and physical exam, and prior to the biopsy, one may consider adding dermoscopy and confocal microscopy to the exam when trying to determine if and where to biopsy. Dermoscopy requires special instrumentation and education, but it is a valuable technique in refining the decision of whether or not to biopsy. As with any technique, there are limitations and the dermoscopy exam can yield questionable and vague results.

   Therefore, the in vivo reflectance confocal microscope is a tool that physicians increasingly use to evaluate pigmented lesions. The microscope works in a similar principle to ultrasound but instead of sound waves, it uses laser optics to visualize melanocytic lesions. The confocal microscope is mainly in use in large academic medical centers and is a valuable resource for dermatologists specializing in identifying and managing pigmented lesions.

Key Questions To Ask For The Patient History

Beyond these advanced instruments available to specialists, it is still important to ask the patient pertinent questions regarding the lesion, look at the lesion carefully and then biopsy when appropriate to have the best overall outcome.

   What questions should the clinician ask of patients with a suspicious lesion?

• Has the lesion changed? If so, how has it changed?
• Did the lesion develop after the patient was over the age of 40?
• Is the lesion pruritic?
• Is the lesion in a previous (or current) site of a nevi, ulcer or scar?
• Has the lesion failed to heal?

   For lesions that have not healed despite conventional therapies, one should obtain a biopsy to rule out a malignant process.

Pertinent Insights On The ABCs Of Melanoma

Following the patient interview, the clinician should subsequently perform the exam utilizing the ABCs of melanoma and the “ugly duckling” sign. The ABCs of melanoma are a guide when investigating a suspicious melanocytic lesion.

A–Asymmetry. One side of the lesion is different from the other side.

B–Border. Notching and irregularity are uncommon in benign lesions.

C-Color. Shades of red, white and blue along with black may indicate a superficial spreading melanoma type.

D-Diameter. Lesions under 6 mm in diameter are more likely to be benign.

E–Evolving. Any changing mole warrants careful observation and probable biopsy.

F-Family or personal history of skin cancer.

   The ABCs of subungual melanoma are as follows:

A-Age (fifth to seventh decade is peak)

B-Brown to black discoloration with a breadth of 3 mm or greater

C-Change in the nail plate or lack of change with treatment

D-Digit most commonly affected (hallux)

E-Extension of pigment into proximal nail fold or lateral nail fold (Hutchinson’s sign)

F-Family or personal history of skin cancer

   The “ugly duckling” sign is also relevant. Most nevi in an individual tend to resemble each other. One should view with suspicion a melanocytic lesion that appears grossly different from the others. Both of these visual techniques are guides and are not perfect. However, they are solid places to begin the decision making process of whether or not to biopsy a lesion.

   If you have used the ABCs of melanoma and the “ugly duckling” sign as guidelines and still have doubts about a lesion, I recommend a referral to a dermatologist.

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