From the Guidelines
I strongly recommend performing a complete excisional skin biopsy of the non-healing lesion on the patient's right shoulder, as this approach is crucial for accurate diagnosis and treatment planning, particularly for primary cutaneous melanoma. Given the patient's advanced age (81 years) and the prolonged duration of the lesion (over one year), this approach is appropriate to rule out skin cancer, particularly basal cell carcinoma, squamous cell carcinoma, or melanoma 1. The biopsy should include the entire lesion with adequate margins, ideally 1 to 3 mm around the concerning skin lesion, to ensure complete histopathological evaluation 1.
Pre-Biopsy Considerations
Prior to the procedure, it is essential to obtain informed consent, clean the area with antiseptic solution, and administer local anesthesia (1-2% lidocaine with epinephrine). Prebiopsy photographs are also an important aid to clinical/pathologic correlation and help to prevent wrong-site surgery if further treatment is required 1.
Biopsy Technique
The diagnostic excisional biopsy can be accomplished in 3 ways: (1) elliptical (fusiform) excision; (2) punch excision around the clinical lesion; or (3) deep shave/saucerization to a depth below the lesion 1.
Post-Procedure Care
After excision, the specimen should be placed in formalin and sent for pathological examination. Post-procedure care includes applying petroleum jelly and a sterile dressing, which should be kept dry for 24 hours. The patient should be instructed to watch for signs of infection such as increasing pain, redness, swelling, or discharge. Non-healing lesions in elderly patients, especially in sun-exposed areas like the shoulders, warrant thorough investigation as they have a higher likelihood of being malignant, and early diagnosis significantly improves treatment outcomes 1.
Key Considerations
It is crucial to note that partial biopsy may inaccurately stage CM at the outset and negatively affect treatment planning 1. Therefore, an excisional/complete biopsy is ideally performed to encompass the entire breadth of the lesion with clinically negative margins, and to extend to a depth sufficient to ensure that the lesion is not histologically transected at the deep margin 1.
From the Research
Skin Biopsy for Non-Healing Lesion
The decision to perform a skin biopsy on the 81-year-old male patient is justified due to the non-healing nature of the lesion, which has been present for over a year. Key considerations for the biopsy include:
- The size and location of the lesion, as well as the suspected clinical diagnosis, will influence the choice of biopsy technique 2
- Initial tissue sampling for diagnosis can be achieved through various methods, including shave technique or punch biopsy of the most abnormal-appearing area of skin 3
Diagnostic Considerations
Given the patient's age and the duration of the lesion, it is essential to consider the possibility of skin cancer, including basal cell carcinoma and cutaneous squamous cell carcinoma. Characteristics of these conditions include:
- Basal cell carcinoma: shiny, pearly papule with a smooth surface, rolled borders, and arborizing telangiectatic surface vessels 3
- Cutaneous squamous cell carcinoma: firm, smooth, or hyperkeratotic papule or plaque, and may have central ulceration 3
Treatment Options
If the biopsy confirms a diagnosis of skin cancer, treatment options will depend on the type and severity of the cancer, as well as the patient's overall health. Possible treatments include:
- Surgical excision, Mohs micrographic surgery, cryosurgery, electrodesiccation and curettage, topical application of imiquimod or fluorouracil, photodynamic therapy, or radiation therapy 4
- For metastatic or locally advanced lesions, smoothened inhibitors may be considered 4
Biopsy Techniques
The choice of biopsy technique will depend on the size and location of the lesion, as well as the suspected clinical diagnosis. Common techniques include: