For a patient with a suspicious skin tumor that has high‑risk features (size ≥2 cm, depth ≥4 mm, poor differentiation, perineural or lymphovascular invasion, ear/scalp/lip location), should the first referral be to a dermatologist or directly to an oncologist?

Referral Destination for High-Risk Skin Tumors

For a patient with a suspicious skin tumor exhibiting high-risk features (size ≥2 cm, depth ≥4 mm, poor differentiation, perineural or lymphovascular invasion, ear/scalp/lip location), the first referral should be to a dermatologist or surgeon/plastic surgeon with specialized expertise in pigmented and skin cancer lesions. 1

Primary Referral Pathway

Dermatologist as First-Line Specialist

• UK guidelines explicitly recommend urgent referral to a dermatologist or surgeon/plastic surgeon with an interest in pigmented lesions for all suspicious skin tumors. 1
• These specialists should have systems enabling patients to be seen within 2 weeks of referral receipt. 1
• The dermatologist will perform complete skin examination, document lesion characteristics, assess for lymphadenopathy and hepatomegaly, and coordinate appropriate biopsy or excision. 1

Why Not Direct to Oncologist Initially

• Oncologists typically become involved after histopathological diagnosis is confirmed and staging is complete. 1
• The initial diagnostic workup, including proper excisional biopsy technique (2 mm margin with subcutaneous fat for suspected melanoma, or 4-6 mm margins for squamous cell carcinoma), requires dermatologic or surgical expertise. 1
• Dermatologists and specialized surgeons are trained in the nuanced clinical assessment and appropriate biopsy techniques that preserve diagnostic accuracy and staging capability. 1

Critical Pitfalls to Avoid

Do NOT Attempt Primary Care Excision

• Lesions suspicious for melanoma should never be removed in primary care, as clinicopathological correlation is vital for diagnostic accuracy, prognosis determination, and adjuvant treatment planning. 1
• Diagnostic shave or punch biopsies are contraindicated for suspected melanoma, as they make accurate pathological staging impossible due to sampling error. 1
• For squamous cell carcinoma with high-risk features, inadequate margins or improper technique significantly increases local recurrence risk (approximately 4.6% with incomplete excision). 2

Proper Documentation Language

• Document as "lesion suspicious for melanoma" or "pigmented lesion concerning for possible melanoma" rather than using definitive diagnostic terminology before histopathological confirmation. 3
• Include specific concerning features in the referral: size, depth if known, location, presence of ulceration, bleeding, color changes, or rapid growth. 1, 3

When Oncology Involvement Occurs

Multidisciplinary Team Engagement

• Oncologists join the care team through the Local Skin Malignancy Multidisciplinary Team (LSMDT) after diagnosis is confirmed. 1
• For high-risk squamous cell carcinoma (≥2 cm, depth ≥4 mm, perineural invasion, high-risk anatomic sites), the multiprofessional team including oncology should be consulted for treatment planning. 1
• Radiation oncology may be involved as adjuvant therapy for perineural disease or when surgical margins are compromised. 1

High-Risk Patient Populations Requiring Closer Coordination

• Organ transplant recipients, immunosuppressed patients, and those with xeroderma pigmentosum require urgent diagnosis and treatment with lower threshold for multidisciplinary involvement. 1
• These patients have 2-3 times higher metastatic risk and may develop multiple aggressive tumors requiring coordinated specialist care. 1, 2

Practical Algorithm

1. Identify high-risk features (size ≥2 cm, depth ≥4 mm, poor differentiation, perineural/lymphovascular invasion, ear/scalp/lip location). 1
2. Refer urgently to dermatologist or specialized surgeon with pigmented lesion expertise within 2 weeks. 1
3. Dermatologist performs complete skin exam, proper excisional biopsy with adequate margins, and histopathological staging. 1
4. LSMDT reviews confirmed diagnosis and coordinates multidisciplinary care including oncology as needed. 1
5. Oncology becomes involved for adjuvant therapy planning, systemic treatment, or radiation therapy based on final pathology and staging. 1