If you believe the lesion could be a cutaneous melanoma, the ideal option is full excision (to reduce sampling error pathologically), with a narrow margin (to preserve lymphatics, should sentinel node biopsy be considered later) and full thickness (to subcutaneous fat for prognostic staging; remember the dermis on the back is very thick). If you are confident the lesion is BCC, an initial shave biopsy preserves the option for treatment via curettage should the histology reveal superficial or nodular BCC. Pathology findings that indicate infiltrative, morpheaform, or micronodular BCC require excision; curettage is not adequate treatment for these lesions.
Treating the 2 patients
The patient in FIGURE 1A had no symptoms and no history of skin cancer. Because he was skeptical of the diagnosis, I performed a shave biopsy for histologic verification. The pathology report confirmed nodular BCC. We discussed options, and the patient elected excision.
In the case of the second lesion (FIGURE 2B), the diagnosis of BCC was fairly certain. Because of the patient’s advanced age, declining health, and difficulty arranging transportation, we decided to perform a primary excision at the outset. Had histology shown BCC with micronodular architecture or infitrative features, a shave biopsy for diagnosis, plus curettage, would not have been ideal treatment. Histology showed a nodular BCC.
Acknowledgements
The author thanks the St. Vincent Mercy Medical Center (Toledo) staff for its expert assistance.
Correspondence
Gary N. Fox, MD, Defiance Clinic, 1400 E 2nd Street, Defiance, OH 43512; foxgary@yahoo.com