In a 71-year-old woman with a 1 cm painful, enlarging, mildly discolored cutaneous nodule, is ultrasound indicated as the primary work‑up?

Ultrasound Is Not Indicated for Primary Workup of This Cutaneous Nodule

The primary workup for a 1 cm painful, enlarging, mildly discolored cutaneous nodule in a 71-year-old woman should be complete excisional biopsy with 2 mm margins, not ultrasound imaging. 1, 2

Why Excisional Biopsy Is the Standard of Care

Complete excisional biopsy with a scalpel is mandatory for any suspected malignant cutaneous lesion because:

• Partial examination or imaging cannot provide definitive diagnosis of malignancy or assess critical histological parameters, particularly maximum tumor thickness (Breslow depth) 1
• The entire lesion must be examined histologically to determine if it is melanoma, basal cell carcinoma, squamous cell carcinoma, or another malignancy 1, 2
• Tissue destruction from alternative methods (laser, electrocautery) or inadequate sampling compromises final diagnosis and assessment of prognostic factors 1

Clinical Features Requiring Immediate Excision

This patient's presentation is concerning for malignancy:

• Progressive enlargement is a major sign requiring excision, as it suggests melanoma or other skin cancer 2
• Pain in a cutaneous nodule is atypical but may reflect deeper invasion, ulceration, or aggressive behavior 2
• Age 71 years places the patient in a high-risk demographic for both melanoma and non-melanoma skin cancers 2, 3
• Mild discoloration could represent melanoma (even amelanotic variants), basal cell carcinoma, or other malignancies 3, 4

When Ultrasound Has a Role (But Not Here)

Ultrasound of superficial regional lymph nodes is indicated only for cases of clinical uncertainty about nodal involvement after a primary melanoma diagnosis has been established histologically 1, 2

High-frequency ultrasound (HFUS) can provide supplementary information about tumor depth and margins in already-diagnosed skin cancers, but it cannot replace histopathological examination for initial diagnosis 5, 6, 7

Critical Pitfalls to Avoid

• Do not perform imaging before tissue diagnosis—ultrasound cannot confirm malignancy or provide the histological parameters needed for staging and treatment planning 1
• Do not use frozen sections for pigmented or suspicious cutaneous lesions, as they are insufficient for definitive diagnosis 1, 2
• Do not assume pain indicates a benign process—melanoma and other skin cancers can be painful, especially when ulcerated or rapidly growing 2

Correct Diagnostic Algorithm

1. Document the lesion precisely: size, shape, color, borders, symmetry, and associated symptoms (pain, bleeding, ulceration) 2
2. Perform full-thickness excisional biopsy with 2 mm margins of normal skin using a scalpel 1, 2, 3
3. Send all tissue to pathology with patient age, sex, and anatomic site documented 1
4. Require comprehensive histopathology report including: diagnosis and confirmation of malignancy, maximum tumor thickness (Breslow), level of invasion (Clark), presence of ulceration, mitotic rate, and margin status 1, 2
5. Consider ultrasound of regional lymph nodes only if melanoma is confirmed histologically and there is clinical uncertainty about nodal involvement 1, 2