What is the recommended course of action for a mole on the left lower abdominal area that has been present for years?

Management of a Mole on the Left Lower Abdominal Area

For a mole on the left lower abdominal area that has been present for years, a full thickness excisional biopsy with a 2 mm margin of normal skin is recommended for proper diagnosis and management. 1

Initial Assessment

When evaluating a mole that has been present for years, apply the ABCDE criteria to determine if the lesion is suspicious:

• Asymmetry: Is the mole asymmetrical?
• Border irregularities: Are the edges ragged or blurred?
• Color heterogeneity: Does the mole have varying colors?
• Diameter >6 mm: Is the mole larger than 6 mm?
• Evolution: Has there been recent change in color, elevation, or size? 1, 2

Additionally, consider the "ugly duckling" concept - a mole that looks different from other moles on the body is more concerning. 3

Biopsy Approach

If the mole shows any concerning features or if diagnosis is uncertain:

1. Perform a complete excisional biopsy with a 2 mm margin of normal skin and include a cuff of subdermal fat 1, 2
2. Orient the excision to facilitate possible subsequent wide local excision (along the long axis on limbs) 1
3. Ensure proper handling of the specimen for pathological examination 2

Important caveats:

• Avoid shave biopsies for suspicious pigmented lesions as they may underestimate depth and make accurate pathological staging impossible 1, 2
• Avoid punch or incisional biopsies except in specific circumstances (e.g., facial lentigo maligna) and only when performed by specialists 1
• Never assume benignity based solely on clinical appearance; histopathological confirmation is essential 2

Histopathological Evaluation

The pathology report should include:

• Maximum tumor thickness (Breslow)
• Level of invasion (Clark levels I-V)
• Clearance of surgical margins
• Presence of ulceration
• Presence and extent of regression 1, 2

Management Based on Pathology Results

If the lesion is confirmed to be melanoma, further management depends on Breslow thickness:

Breslow thickness	Recommended excision margins
In situ	0.5 cm
< 1 mm	1 cm
1.01-2 mm	1-2 cm
2.1-4 mm	2-3 cm
> 4 mm	3 cm
[1]

Follow-up Recommendations

Follow-up depends on the pathology results:

• Benign mole: No specific follow-up needed
• In situ melanoma: No follow-up required 1
• Stage IA melanoma: 2-4 visits over 12 months, then discharge 1
• Stage IB-IIIA melanoma: Every 3 months for 3 years, then every 6 months to 5 years 1

Risk Assessment and Prevention

For patients with multiple moles or atypical moles:

• Teach self-examination techniques
• Provide education about concerning changes
• Consider total body photography for monitoring
• Recommend sun protection measures 1, 2, 4

Patients with more than 50 atypical moles and a family history of melanoma have the highest risk of developing melanoma and require more intensive surveillance. 3, 4

Key Pitfalls to Avoid

1. Delaying biopsy of suspicious lesions
2. Using inappropriate biopsy techniques (shave, punch) for suspicious pigmented lesions
3. Assuming benignity without histopathological confirmation
4. Failing to examine the entire skin surface for other suspicious lesions
5. Neglecting to educate patients about self-examination and sun protection

Remember that early detection of melanoma is crucial for improving outcomes, as prognosis is directly related to tumor thickness at the time of diagnosis. 5