Primary Cutaneous Melanoma Diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anum Ijaz M.B.B.S., M.D.[2]

2019 AAD Guidelines for Diagnosis of Primary Cutaneous Melanoma

Recommendations for Diagnostic Biopsy Techniques

Class B
1. Preferred biopsy technique is a narrow excisional/complete biopsy with 1- to 3-mm margins that encompass the entire breadth of the lesion and is of sufficient depth to prevent transection at the base. This may be accomplished by fusiform/elliptical or punch excision or deep shave/saucerization removal to depth below the anticipated plane of the lesion.(Level of Evidence:Ⅱ)
2. Partial/incomplete sampling (incisional biopsy) is acceptable in select clinical circumstances such as facial or acral location, very large lesion, or low clinical suspicion or uncertainty of diagnosis. (Level of Evidence:Ⅱ)
3. Narrow-margin excisional biopsy may be performed if an initial partial biopsy is inadequate for diagnosis or microstaging, but it should not generally be performed if the initial specimen meets the criteria for consideration of sentinel lymph node biopsy. (Level of Evidence:Ⅱ)

Recommendations for documentation of Pathology Report

Once the biopsy of a suspected lesion is performed, the American Academy of Dermatology(AAD) recommends that information be provided to the pathologist and clinician performing the biopsy, with the notations as illustrated below:

Recommended clinical information to be provided to the pathologist

Class C
Essential	Age of patient Sex Anatomic location(including laterality) (Level of Evidence: Ⅲ,Expert Opinion)
Strongly Recommended	Biopsy intent (excisional/complete vs partial/incomplete) and technique(elliptical, punch shave/saucerization) Size of lesion Clinical impression/differential diagnosis Macroscopic satellites; Clinical photograph (if possible) (Level of Evidence: Ⅲ,Expert Opinion)
Optional	Clinical description/level of suspicion for melanoma/prior change or biopsy (if applicable) Dermoscopic features (with or without photograph) (Level of Evidence: Ⅲ,Expert Opinion)

Recommended histologic features of primary cutaneous melanoma for inclusion in the pathology report

Class A
Essential	Tumor thickness (Breslow), nearest 0.1 mm (Level of Evidence:Ⅰ/Ⅱ) Ulceration (Level of Evidence:Ⅰ/Ⅱ) Dermal mitotic rate; ‘‘hotspot’’ method; No. of mitoses/mm2 (Level of Evidence:Ⅰ/Ⅱ)

Class B
Essential	Microsatellitosis (Level of Evidence:Ⅱ)
Optional	Anatomic level of invasion (Clark level) (Level of Evidence:Ⅱ) Angiolymphatic invasion/lymphovascular invasion (Level of Evidence:Ⅱ) Histologic subtype (Level of Evidence:Ⅱ) Tumor-infiltrating lymphocytes (Level of Evidence:Ⅱ) Regression (Level of Evidence:Ⅰ/Ⅱ)

Class C
Optional	Clinical information such as gross description of lesion, tumor category for staging (Level of Evidence:Ⅲ) Neurotropism/perineural invasion (Level of Evidence:Ⅲ) Against testing for oncogenic mutations in the absence of metastatic melanoma or outside of a clinical study (Level of Evidence: Expert Opinion)

Recommendations for diagnostic, prognostic, and therapeutic molecular testing

Class C

1. Ancillary diagnostic molecular techniques (eg, CGH, FISH, GEP) may be used for equivocal melanocytic neoplasms(Level of Evidence:Ⅲ)

2. Routine molecular testing, including GEP, for prognostication is discouraged until better use criteria are defined. The application of molecular information for clinical management (eg, sentinel lymph node eligibility, follow-up, and/or therapeutic choice) is not recommended outside of a clinical study or trial.(Expert Opinion)

3. Testing of the primary CM for oncogenic mutations (eg, BRAF, NRAS ) is not recommended in the absence of metastatic disease.|(Level of Evidence:Ⅲ,Expert Opinion)

*BRAF= B-Raf proto-oncogene, serine/threonine kinase gene; CGH= comparative genomic hybridization; CM= cutaneous melanoma; FISH= fluorescence in situ hybridization; GEP= gene expression profiling; NRAS= NRAS proto-oncogene, GTPase gene.

References

Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T (January 2019). "Guidelines of care for the management of primary cutaneous melanoma". J Am Acad Dermatol. 80 (1): 208–250. doi:10.1016/j.jaad.2018.08.055. PMID 30392755.