What is the appropriate management for a 79-year-old man presenting with a bleeding pigmented skin lesion (mole)?

Management of a Bleeding Mole in a 79-Year-Old Male

A bleeding pigmented lesion in a 79-year-old man requires urgent referral for complete excisional biopsy with 2-5 mm margins, as bleeding is a major warning sign for melanoma and diagnostic accuracy depends on full-thickness histological assessment. 1

Immediate Clinical Assessment

The presence of bleeding in a pigmented lesion is one of the seven major warning signs for melanoma and mandates urgent specialist evaluation. 1 Specifically assess for:

• Major signs (any one warrants referral): change in size, change in shape, change in color 1
• Minor signs (support referral): inflammation, sensory change (itching), crusting or bleeding, diameter ≥7 mm 1
• Duration of the lesion and timeline of changes 1
• Complete skin examination for additional atypical lesions and assessment of lymphadenopathy 1

The revised seven-point checklist emphasizes that bleeding falls under "crusting or bleeding" as a minor sign, but when combined with any major sign (which is present in 89-95% of melanomas), urgent referral is mandatory. 1

Urgent Referral Criteria

This patient meets urgent referral criteria and should NOT have the lesion removed in primary care. 1 Lesions suspicious for melanoma require specialist evaluation because:

• Clinicopathological correlation is vital for diagnostic accuracy 1
• Diagnostic surgery requires specialist training 1
• Improper biopsy techniques (shave, punch) make pathological staging impossible and compromise prognosis determination 1, 2

Appropriate Biopsy Technique

Complete excisional biopsy is the only acceptable approach for suspected melanoma. 1, 2 The procedure must include:

• Full-thickness skin biopsy including the entire lesion 1
• 2-5 mm clinical margin of normal skin laterally 1, 2
• Cuff of subcutaneous fat deep to the lesion 1, 2
• Scalpel excision (never shave or punch biopsy) 2

Shave and punch biopsies are explicitly contraindicated because they prevent accurate Breslow thickness measurement, which is the single most important prognostic factor and determines subsequent treatment margins. 1, 2

Critical Pathology Requirements

The pathology report must include these minimum data points for proper staging and treatment planning:

• Breslow thickness (measured to nearest 0.1 mm from granular layer to tumor base) 1
• Presence or absence of ulceration 1, 2
• Clark level of invasion 1
• Mitotic rate (vertical growth phase) 1, 2
• Margin status (clear vs. involved) 1, 2
• Presence of regression, lymphatic/vascular invasion 1

Age-Specific Considerations

At 79 years old, this patient requires careful consideration of:

• Lentigo maligna as a differential diagnosis if the lesion is on sun-exposed facial skin, though complete excision remains the gold standard treatment due to risk of invasive change 1
• In very elderly patients with lentigo maligna specifically, non-surgical options (radiotherapy, cryotherapy, observation) may be appropriate in select cases, though recurrence risk is higher 1
• However, for a bleeding lesion suggesting possible invasive melanoma, age alone does not preclude standard surgical management 1

Common Pitfalls to Avoid

Never perform partial biopsy or "sampling" of a suspected melanoma - this risks missing the thickest portion of the tumor, leading to understaging and inadequate initial treatment. 2

Do not delay referral for lesions with bleeding, as early detection of thinner lesions significantly improves survival outcomes. 1, 3

Avoid reassuring the patient without specialist evaluation when any major warning sign is present, as diagnostic accuracy based on clinical assessment alone is only approximately 85%. 1