What is the next best step for a 45-year-old female with a lump on her left back that has doubled in size and become painful over 2 months, has a family history of melanoma, and no other symptoms such as cough, fever, or weight loss?

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Immediate Excisional Biopsy is Required

This patient requires urgent excisional biopsy of the back lump within 2 weeks, performed by a dermatologist or surgeon with expertise in pigmented lesions, given the rapid growth, new pain, and family history of melanoma. 1, 2

Why This is Urgent

  • Progressive change in lesion size is a major red flag for melanoma that mandates immediate referral or excision 1
  • The doubling in size over 2 months with new pain represents concerning evolution that cannot be dismissed as a benign lipoma 2
  • Family history of melanoma significantly increases this patient's risk and lowers the threshold for aggressive evaluation 3
  • Even if this appears clinically like a lipoma, rapidly changing soft tissue masses require tissue diagnosis to exclude malignancy 2

Critical Next Steps

1. Urgent Specialist Referral (Within 2 Weeks)

  • Refer to dermatologist or surgeon experienced in pigmented/suspicious lesions 1, 2
  • Do not delay for imaging or other workup first 2

2. Complete Physical Examination Before Biopsy

  • Full body skin examination to detect any additional suspicious lesions or primary melanoma 1, 2
  • Palpate all regional lymph nodes (axillary, cervical, supraclavicular) as regional lymph node enlargement is highly suggestive of melanoma with nodal metastasis 1
  • Document exact lesion location, size, color, borders, and any associated skin changes 2

3. Proper Biopsy Technique is Critical

  • Full-thickness excisional biopsy with 2-5 mm margin of normal skin and subcutaneous fat is mandatory 3, 2
  • Use a surgical scalpel, never laser or electrocautery, as tissue destruction compromises diagnosis 3, 2
  • The entire lesion must be removed intact for accurate histopathological assessment 3
  • Shave or punch biopsies are absolutely contraindicated as they prevent accurate Breslow thickness measurement if melanoma is present 4, 2

Why the Initial "Lipoma" Assessment Was Inadequate

  • Clinical appearance alone cannot reliably distinguish benign from malignant lesions 2
  • Any change in a previously stable lesion warrants tissue diagnosis, regardless of initial clinical impression 1, 2
  • Amelanotic melanomas and other aggressive subtypes can mimic benign lesions 5
  • Deep melanomas can present as subcutaneous nodules without overlying pigmentation changes 3

Required Histopathology Information

If melanoma is confirmed, the pathology report must include 3, 2:

  • Breslow thickness in millimeters (most important prognostic factor) 1
  • Clark level of invasion 3
  • Presence and extent of ulceration 2
  • Surgical margin clearance status 2
  • Mitotic rate 3
  • Presence of regression 3

Post-Biopsy Management Depends on Results

If Benign (e.g., confirmed lipoma):

  • No further treatment needed if completely excised 2
  • Continue routine skin surveillance given family history 3

If Melanoma Confirmed:

  • Staging workup with complete lymph node examination and consideration of imaging (CT chest/abdomen/pelvis, brain MRI) if Breslow thickness ≥1 mm or other high-risk features 3
  • Wide local excision with margins based on Breslow thickness: 1 cm for <1 mm, 1-2 cm for 1-2 mm, 2-3 cm for >2 mm 3, 4
  • Sentinel lymph node biopsy should be discussed if thickness ≥0.8-1.0 mm or if ulceration/high mitotic rate present 4, 6
  • Referral to multidisciplinary melanoma team for stage IB or higher disease 3

Common Pitfall to Avoid

Do not reassure and observe based on clinical appearance alone. The combination of rapid growth, new symptoms, and family history overrides any benign-appearing clinical features 1, 2. Delayed diagnosis of melanoma significantly worsens prognosis, as survival correlates directly with Breslow thickness at diagnosis 1, 6.

References

Guideline

Diagnosis and Management of Melanoma

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Evaluation and Management of Suspicious Skin Lesions

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Acral Lentiginous Melanoma Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Research

Amelanotic melanoma.

Melanoma research, 2019

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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