What is the next step in managing a dermal nodule?

Management of a Dermal Nodule

The next step in managing a dermal nodule is to perform a complete excisional biopsy with a 2-3 mm margin to ensure accurate diagnosis and proper histological assessment. 1

Initial Assessment of the Dermal Nodule

Before proceeding with biopsy, a thorough evaluation should be performed:

• Visual inspection: Assess size, color, border characteristics, symmetry, elevation, and any signs of ulceration or bleeding 1
• Palpation: Evaluate mobility, consistency, tenderness, and depth of invasion 1
• Risk factor assessment: Consider patient age, history of melanoma, family history, and presence of multiple nevi 1

Biopsy Technique for Dermal Nodules

The optimal approach for dermal nodules is:

1. Complete excisional biopsy with a narrow margin (2-3 mm) elliptical excision 1

   • Ensure incision follows skin lines
   • Include full thickness with subdermal fat
   • Use a scalpel rather than laser or electrocautery to preserve histological features

2. Avoid suboptimal biopsy techniques:

   • Shave biopsies risk misdiagnosis from partial examination
   • Punch biopsies may not adequately assess depth/thickness
   • Incisional biopsies may compromise histological prognostic factors 1

Special Considerations for Dermal Melanocytic Nodules

For dermal nodules suspected to be melanocytic in origin:

• Isolated dermal melanoma should be treated as a primary cutaneous melanoma of similar thickness 2
• Wide excision with a 2-cm margin is recommended 2
• Sentinel node biopsy should be performed to stage clinically negative regional nodes 2

This approach is supported by evidence showing that solitary dermal melanomas exhibit less-aggressive behavior than cutaneous metastases from known primaries, with a median survival of 8.3 years 2.

Documentation and Pathology Requirements

When submitting the specimen:

• Document exact anatomic location, laterality, dimensions, and excision margins 1
• Send specimen fresh or in appropriate fixative with proper labeling 1
• Include relevant clinical information for the pathologist (patient age, sex, duration of lesion) 1

The pathology report should include:

• Confirmation of benign vs. malignant nature
• For melanocytic lesions: maximum tumor thickness, Clark level, presence/absence of ulceration, margin status 2

Follow-up Based on Pathology Results

After pathological diagnosis:

• For confirmed melanoma: Additional wide local excision with appropriate margins based on Breslow thickness and sentinel lymph node biopsy if indicated 2
• For benign lesions: Routine follow-up
• For atypical lesions: Consider re-excision to ensure negative margins 2

Pitfalls to Avoid

• Don't perform shave biopsies of suspicious pigmented lesions as they may underestimate depth 1
• Don't use electrocautery or laser for primary excision as this destroys tissue architecture 1
• Don't delay evaluation of nodules showing concerning changes (rapid growth, bleeding, pain, ulceration) 2
• Don't assume benignity based solely on clinical appearance - histopathological confirmation is essential 2

Complete excisional biopsy remains the gold standard for diagnosis of dermal nodules, providing the most accurate assessment of the lesion's nature and guiding appropriate further management.