Management of primary cutaneous melanoma: A retrospective audit of 349 cases and literature review of current clinical guidelines

Background: Excisional biopsy is the gold standard for accurate histological assessment of cutaneous primary melanoma, although shave and punch biopsies are commonly used for initial diagnosis. Following shave biopsy, the current guidelines recommend narrow excisional biopsy to plan definitive melanoma management. Shave biopsy however may provide sufficient information to proceed directly to definitive treatment, thus avoiding subsequent narrow excisional biopsy. Previous literature has demonstrated limited evidence on the benefits of direct wide local excision (WLE) following diagnostic shave biopsies.
Objective: To evaluate partial biopsies in providing sufficient information to plan for WLE, thus eliminating narrow excisional biopsy prior to definitive treatment and to assess the accuracy of partial biopsies for diagnosis and microstaging.
Methods: Initial biopsy and subsequent excisions were collected retrospectively, from 349 consecutive cases of cutaneous melanoma, from patients who attended a tertiary referral centre between January 2014 and January 2015.
Results: 40 patients underwent shave biopsy, with 7 cases proceeding to narrow excision. Final staging was similar to initial biopsy in all 7 cases. Among the 33 cases that proceeded directly to WLE after shave biopsy, no residual tumour was found in 26 cases, similar T stage was noted in 2 cases and in 5 cases the T stage was upstaged.
Conclusion: In most cases shave biopsy alone is adequate to plan definitive management, but in approximately 15%, melanoma management was significantly underestimated by initial biopsy, and in these cases management was subsequently altered by WLE. Factors leading to upstaging are to be investigated

Dr. Brent Doolan