Do oncologists (oncology specialists) remove melanomas and test them for cancer?

Role of Oncologists in Melanoma Diagnosis and Testing

No, oncologists typically do not remove melanomas for testing - this is usually performed by dermatologists, surgeons, or surgical oncologists who specialize in skin cancer removal, with subsequent pathological examination to confirm cancer diagnosis.

Initial Diagnosis and Biopsy Process

The diagnosis of melanoma follows a specific pathway:

1. Initial Detection and Biopsy:

   • Suspicious lesions are identified using the ABCD rule (Asymmetry, Border irregularities, Color heterogeneity, Dynamics) 1
   • Full thickness excisional biopsy with a small side margin (2-5mm) is the recommended approach 1
   • This initial biopsy is typically performed by:
     • Dermatologists
     • Surgeons/plastic surgeons with expertise in pigmented lesions
     • Surgical oncologists

2. Pathological Examination:

   • The excised tissue is sent to pathology for histological examination
   • Pathology report should include 1:
     • Maximum thickness in millimeters (Breslow)
     • Mitotic rate
     • Presence of ulceration
     • Presence and extent of regression
     • Clearance of surgical margins
     • Melanoma type (superficial spreading, lentigo maligna, acrolentiginous, nodular)

Role of Different Specialists

Dermatologists

• Primary role in initial diagnosis and biopsy of suspicious lesions
• Often perform wide local excision for thin melanomas
• May coordinate follow-up care

Surgical Oncologists

• Perform wide excisions with appropriate margins based on Breslow thickness
• Conduct sentinel lymph node biopsies when indicated
• Manage complex or advanced cases

Medical Oncologists

• Become involved primarily after diagnosis is confirmed
• Manage systemic therapy for advanced disease
• Do not typically perform the initial biopsy or removal of melanomas
• May order additional molecular testing for treatment planning in advanced disease

Staging and Additional Testing

After initial diagnosis, further testing may be required based on staging:

1. Sentinel Lymph Node Biopsy (SLNB):

   • Recommended for intermediate-thickness melanomas (1-4mm) 1
   • May be recommended for thick melanomas (>4mm) for staging and regional disease control 1
   • Not routinely recommended for thin melanomas (<1mm) unless high-risk features are present 1
   • Performed by surgical oncologists or surgeons with expertise in the procedure

2. Molecular Testing:

   • For metastatic disease, mutation analysis for BRAF, NRAS, and c-Kit may be necessary 1
   • Testing should be performed in accredited/certified institutes 1
   • Medical oncologists typically order these tests to guide systemic therapy decisions

Common Pitfalls to Avoid

1. Inappropriate Biopsy Techniques:

   • Shave and punch biopsies are not recommended as they make pathological staging impossible 1
   • Incisional biopsies should be limited to specific situations (e.g., lentigo maligna on face, acral melanoma) 1

2. Delayed Referral:

   • Suspicious lesions should be referred urgently to specialists 1
   • Patients should be seen within 2 weeks of referral 1

3. Inadequate Pathology Assessment:

   • The entire lesion should be adequately sampled with serial transverse slicing 1
   • Processing should be done by experienced pathology institutes 1

Follow-up Care

After treatment of primary melanoma:

• Regular follow-up examinations are recommended
• Imaging studies may be appropriate for higher-risk patients
• Rising serum S-100 has higher specificity for disease progression than LDH 1

In summary, the diagnosis and treatment of melanoma involves a multidisciplinary approach with different specialists handling different aspects of care. While oncologists play a crucial role in the overall management of melanoma patients, particularly those with advanced disease, the initial removal and testing of suspicious lesions is typically performed by dermatologists or surgeons with subsequent pathological examination.