Shave biopsies, for instance, can potentially impact the downstream surgical planning of the patient. Choosing the appropriate biopsy technique with some foresight for the future surgical procedure would be advantageous, Dr. Gabriel says, as it can affect surgeons later on when addressing wound closure, particularly in terms of how much tissue needs to be removed.
“If a patient comes in with a shave biopsy on a melanoma, typically we are going to perform a wide local excision based on whateverscar is left over. So, the choice of biopsy technique impacts how we are going to close the wound afterwards,” Dr. Gabriel says. “We can potentially have less tissue resected following a punch biopsy, which may have a critical aesthetic role for the patient depending on the location of the primary tumor.”
One of the main controversies among the currently used excision techniques for melanoma is Mohs surgery. Although the technique is considered more for melanoma in situ, Dr. Gabriel says, the NCCN and the Society of Surgical Oncology (SSO) do not support the procedure for invasive melanoma.
“There are trials that are incorporating different margins for certain T stages of tumors, and clinicians are currently using the Mohs technique in certain cases. However, although there are retrospective studies reporting equivalent outcomes of Mohs to wide local excision, it is still not level one evidence. In the absence of prospective trials, Mohs is not generally endorsed for the treatment of primary invasive melanoma for now,” Dr. Gabriel says.
And, when polled for how they would remove the primary lesion, 85% of attendees at Dr. Gabriel’s presentation chose wide excision, he says.