Atypical Moles and Pigmented Lesions

Elliptic full-thickness excisional biopsies are preferred for any suspicious pigmented mole. Punch biopsies can easily miss a high number of positive findings because of fusiform invasion of the margins (Chang et al., 2009).

Management of dysplastic nevi with positive margins remains controversial. Although a National Institutes of Health (NIH) Consensus Conference established margin guidelines for reexcision of dysplastic nevi (0.2-0.5 cm), it did not specify indications for reexcision. No clear guidelines exist regarding whether an incompletely removed nevus with a mild or moderate degree of dysplasia should be reexcised. Dermatopathologists are discordant in identifying dyspla-sia and differing degrees of atypia, further complicating

Figure 28-14 Dog-ear repair.

(Modified from Simon BC. Skin and subcutaneous tissue. In Rosen P et al [eds]: Atlas of Emergency Procedures. St Louis, Mosby, 2001; and Simon B, Hern HG. Soft tissue injuries. In Marx JA. Rosen's Emergency Medicine, 7th ed. Philadelphia, Mosby-Elsevier, 2009.)

decision making. Most dermatologists recommend that nevi with severe atypia should be reexcised because they may represent early melanoma or a lesion evolving into melanoma (Goodson et al., 2009).

Despite recurrence rates of 8% to 20% and a growing body of literature suggesting the inadequacy of a 5-mm marginal excision, a definitive change has not been made in recommended guidelines. In 2008 the National Cancer Comprehensive Network published guidelines indicating that a 5-mm excisional margin may be inadequate for lentigo maligna and lentigo maligna melanoma (Bosbous et al., 2009).

Melanomas account for 90% of the deaths associated with cutaneous tumors. Confirmed melanomas are initially excised with 10-to 20-mm safety margins both in depth and laterally if possible. Full-thickness depth is therefore important in diagnosis and prognosis of melanomas. Unsuspected melanomas found in excisional biopsies should have their bases reexcised for appropriate 1- to 2-cm margins as a second procedure. Sentinel lymph node dissection is routinely offered as a staging procedure in patients with tumors more than 1 mm in thickness, although there is as yet no resultant survival benefit. Interferon-a can be offered as adjuvant therapy to patients with melanoma more than 1.5 mm thick and stage II to III because it increases relapse-free survival.

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