Diagnosis and Management of Suspected Melanoma

Introduction to Melanoma Diagnosis

The American Academy of Dermatology recommends that any change in a previously stable lesion warrants tissue diagnosis, regardless of initial clinical impression 1, 2
Clinical appearance alone cannot reliably distinguish benign from malignant lesions, highlighting the need for biopsy in suspicious cases 2

A full body skin examination should be performed to detect any additional suspicious lesions or primary melanoma 1, 2
Palpation of all regional lymph nodes (axillary, cervical, supraclavicular) is necessary as regional lymph node enlargement is highly suggestive of melanoma with nodal metastasis 1
The entire lesion must be removed intact for accurate histopathological assessment, using a surgical scalpel and not laser or electrocautery 5, 2

If melanoma is confirmed, the pathology report must include Breslow thickness in millimeters, Clark level of invasion, presence and extent of ulceration, surgical margin clearance status, mitotic rate, and presence of regression 5, 2, 1, 8

If melanoma is confirmed, staging workup with complete lymph node examination and consideration of imaging (CT chest/abdomen/pelvis, brain MRI) should be performed if Breslow thickness ≥1 mm or other high-risk features 4, 8
Wide local excision with margins based on Breslow thickness should be performed: 1 cm for <1 mm, 1-2 cm for 1-2 mm, 2-3 cm for >2 mm 4, 6
Sentinel lymph node biopsy should be discussed if thickness ≥0.8-1.0 mm or if ulceration/high mitotic rate present 6
Referral to a multidisciplinary melanoma team is recommended for stage IB or higher disease 4