What are the recommended evaluation and treatment steps for a male patient in his 50s with a mole on his head?

Evaluation and Management of a Mole on the Head in a Male in His 50s

This patient requires immediate clinical evaluation using the ABCDE criteria, followed by full-thickness excisional biopsy with 2mm margins if any suspicious features are present, as this demographic carries elevated melanoma risk. 1

Initial Clinical Assessment

Perform a focused examination of the specific lesion looking for these features 1:

• Asymmetry: One half differs from the other
• Border irregularities: Edges are ragged, notched, or blurred
• Color heterogeneity: Multiple colors or uneven pigmentation
• Dynamics: Recent changes in color, elevation, or size (this criterion must coexist with at least one other) 1
• Diameter: Many melanomas are >6mm, though early lesions can be <5mm 1

The "ugly duckling" sign—a lesion that looks different from other moles—is another valuable assessment tool. 1

Dermoscopy by an experienced examiner significantly improves diagnostic accuracy and should be used if available. 1

Complete Skin and Nodal Examination

Examine the entire skin surface including the scalp for 1:

• Additional suspicious pigmented lesions
• Satellite lesions near the primary mole
• In-transit metastases
• All regional lymph node basins (cervical, supraclavicular, axillary nodes for head lesions) 1

Biopsy Technique for Suspicious Lesions

If any ABCDE criteria are present, proceed with full-thickness excisional biopsy with 2mm margins of normal skin around the lesion. 1

Critical technical points 1:

• Use a scalpel, never laser or electrocautery (tissue destruction compromises diagnosis)
• Orient the elliptical incision to facilitate potential re-excision with minimal skin loss
• For scalp lesions, consider cosmetic and functional implications in incision planning
• Never perform shave biopsy or partial sampling—this risks missing the maximum Breslow thickness 1, 2
• Send all tissue to an experienced pathology institute 1

Required Pathology Report Elements

The histopathology report must include 1:

• Maximum tumor thickness in millimeters (Breslow depth)—the single most important prognostic factor
• Level of invasion (Clark levels I-V)
• Presence and extent of ulceration
• Clearance of surgical margins
• Presence and extent of regression
• Mitotic rate per mm²

If Benign: No Further Action Required

If the lesion is benign (seborrheic keratosis, benign nevus, etc.), no additional treatment is needed. 1

If Melanoma In Situ

Wide excision with 0.5-1.0 cm margins is standard. 1, 2

For head/scalp location specifically 1:

• Modifications may be needed for cosmetic preservation
• Radiotherapy should be considered if adequate margins cannot be achieved due to anatomic constraints 1
• No imaging or sentinel node biopsy is required 1, 3

If Invasive Melanoma (Any Breslow Thickness >0 mm)

Staging Workup Based on Thickness

For melanoma ≤1.0 mm thick 1, 3:

• No imaging required
• Physical examination only
• Consider sentinel lymph node biopsy if ulcerated or ≥0.8mm thick 4, 5

For melanoma >1.0 mm thick 1, 3:

• Chest X-ray, complete blood count, LDH, alkaline phosphatase 1
• Ultrasound of regional lymph nodes (cervical chains for head lesions) 1, 3
• Sentinel lymph node biopsy is standard—provides critical staging information 1, 4
• PET-CT is NOT useful for initial staging of clinically localized melanoma 1, 3

For melanoma ≥4.0 mm thick or Stage IIB-IIC 3, 4:

• Consider cross-sectional imaging (CT chest/abdomen/pelvis) to evaluate for distant metastases
• Sentinel lymph node biopsy strongly recommended (30-40% positivity rate) 3, 4

Definitive Surgical Treatment

Wide excision margins based on Breslow thickness 1:

• In situ: 0.5 cm margins
• ≤2.0 mm: 1 cm margins
• >2.0 mm: 2 cm margins (may use 2-3 cm for very thick lesions)

For head/scalp melanomas, functional and cosmetic modifications are often necessary, and radiotherapy can be used as adjuvant treatment when re-excision with adequate margins is not feasible. 1

Sentinel Lymph Node Biopsy Details

Perform SLNB at the same time as definitive wide excision for melanomas ≥1.0 mm or ulcerated melanomas ≥0.8 mm. 4, 5

This procedure 4:

• Should only be performed by experienced teams in specialized centers 1, 4
• Carries 5% morbidity (significantly less than complete nodal dissection)
• Provides critical prognostic information: negative SLNB = 90-97.9% 5-year survival; positive SLNB = 75% 5-year survival
• Approximately 20% of melanomas ≥1.0 mm will have positive sentinel nodes 4

Common Pitfalls to Avoid

• Never perform shave biopsy on a suspicious pigmented lesion—this prevents accurate Breslow depth measurement and can lead to understaging 1, 2
• Do not order PET-CT for initial staging of clinically localized melanoma—it has very low yield and is not cost-effective 3, 4
• Do not skip sentinel node biopsy in eligible patients—it provides the most important staging information after Breslow thickness 4, 5
• Ensure pathology is reviewed by an experienced dermatopathologist—melanoma diagnosis requires expertise 1, 2

Risk Factors Relevant to This Patient

Males in their 50s have elevated melanoma risk due to 1, 6, 5:

• Male sex (melanoma mortality has doubled in males over 25 years)
• Cumulative UV exposure over lifetime
• Higher likelihood of delayed presentation

The head/scalp location is particularly concerning as these anatomic sites often present diagnostic and surgical challenges. 1