Management of Suspected Melanoma in Primary Care

Introduction to Guidelines

The British guidelines explicitly state that there is no place for incisional biopsy in primary care when melanoma is suspected, and punch biopsy falls into this category of partial sampling techniques 1, 2

Punch biopsies make pathological staging impossible in the majority of cases, preventing accurate measurement of tumor thickness, which is a critical prognostic factor 1, 2
Punch biopsies should only be performed by specialists within a skin cancer multidisciplinary team, not in primary care, and only in highly select circumstances such as certain types of skin lesions where complete excision is not feasible 3

The appropriate action is urgent referral without biopsy, according to the British Journal of Dermatology guidelines 1, 2
Refer patients with suspicious pigmented lesions urgently to a dermatologist or surgeon with expertise in pigmented lesions 1, 2
Ensure the patient is seen within a short time frame of the referral letter 1, 2
Do not attempt biopsy in primary care - even when melanoma is suspected, the family doctor should refer without performing any biopsy procedure 1, 2, 3

When specialists perform biopsies for suspected melanoma, the gold standard is narrow excisional/complete biopsy with margins that includes the entire lesion as a full-thickness specimen 1, 2, 3
This can be accomplished through fusiform/elliptical excision or deep removal of the entire lesion 3

Recognize that even when performed by specialists, certain biopsies have high upstaging rates - meaning the initial biopsy underestimates the true depth and stage of the melanoma 3