LAUSR

The article by Zenga et al1 in this issue of JAMA Facial Plastic Surgery is a timely addition to the literature for those clinicians who treat patients with pigmented lesions of the face, scalp, and neck. While many of the brown lesions we see in our practices will be benign, the incidence of melanoma is increasing. In young adults, melanoma is second only to breast cancer in frequency.2 Early detection of melanoma is crucial to improved outcomes, with 5-year survival rates in excess of 94% for early melanoma (<1 mm) that drop to less than 50% when Breslow depth exceeds 4 mm.3 Facial plastic surgeons are in an excellent position to have a meaningfully impact on melanoma outcomes by having a high index of suspicion for lesions that are a cause for concern, given that early diagnosis followed by curative surgery is the cornerstone of melanoma management. So which lesions are a cause for concern? The diagnostic utility of the ABCDE mnemonic has endured the test of time since originally being proposed in 1985 and remains a highly useful tool for clinicians: (A)symmetry; (B)orders that are irregular, scalloped, or poorly defined; (C)olor that is different within the lesion; (D)iameter that is greater than 6 mm; and (E)volution of the lesion with a change in size, shape, or color.4 When used by an experienced clinician, the sensitivity and specificity of detecting a melanoma in a pigmented lesion are 89% and 63% for 2 criteria and 66% and 81% for 3 criteria.4 As pointed out by Zenga et al,1 a narrow excisional biopsy for suspicious lesions is preferred because it is crucial that the true depth of the lesion is assessed to accurately determine the Breslow depth of invasive melanomas. In addition, not altering the regional lymphatics by performing wider excisions is important to preserving the option of sentinel lymph node biopsy (SLNB). Incisional biopsy or deep saucerization may be appropriate for larger lesions (ie, melanoma in situ [lentigo maligna] typically found on the face, head, and neck). However, the incisional biopsy specimens of larger lesions may suffer from sampling bias and may not accurately predict the invasiveness or the ultimate Breslow depth of the entire lesion. In our 9-year series of 834 head and neck melanoma in situ and invasive melanoma at the University of Michigan, 32 of 834 lesions (3.8%) still had unsuspected, deeper residual disease at the time of definitive resection. Sixteen of these 32 lesions were originally diagnosed as melanoma in situ and had occult invasive disease ranging from 0.20 to 1.12 mm Breslow depth (mean, 0.48 mm) on the staged excision. The other 16 lesions, those with invasive melanoma at initial diagnosis, had deeper invasive disease from a mean preprocedure Breslow depth of 0.47 mm (range, 0.20-0.65 mm) to poststaged excision mean depth of 0.85 mm (range, 0.32-2.47 mm). Many of the patients whose disease was upstaged to a higher Breslow depth at definitive resection became candidates for SLNB (unpublished data). The article by Zenga et al1 also clearly illustrates that melanoma clinical care delivery and research is evolving rapidly and that it is impossible for an individual clinician to be an expert in all facets of melanoma management. The multidisciplinary care model is central to the delivery of the very best care of these patients.5 This model is based on a coordinated, team-based program of experts in melanoma who use consensus and best-evidence guidelines to deliver the most upto-date care. Dermatopathologists with experience interpreting melanoma and the changes in skin that portend evolving melanoma are crucial to this team because an accurate tissue diagnosis dictates appropriate treatment. The incidence of melanoma is clearly increasing, and it is incumbent on specialties that treat this population to be knowledgeable of the most current diagnostic and management guidelines. The evidence-based approach outlined in the article by Zenga et al1 is an excellent reminder that life-long learning is exactly that, life-long. The changing treatment paradigms require active and ongoing engagement by clinicians if we are to offer maximally beneficial care to our patients.