The Impact of Initial Biopsy Modality and Provider Credentials on Upstaging and Management Changes in Cutaneous Melanoma.

Background

A timely, high-quality biopsy is essential for the accurate staging and prompt treatment of invasive cutaneous melanoma. While excisional biopsies are considered to be the gold standard, biopsy techniques vary. In parallel, the proportion of Advanced Practice Providers (APPs) in dermatologic practice has increased. We aimed to evaluate the relationship between biopsy type, deep margin status, and pathologic T (pT) category upstaging on an individual patient level as well as regional biopsy trends stratified by provider credentials.

Patients and methods

Medical records of patients referred to our academic center for invasive melanoma treatment from 2017 to 2022 were retrospectively reviewed.

Results

Shave biopsies (67%) were most commonly used for diagnosing melanoma and were significantly more likely to yield a positive deep margin (74%) compared with punch (46%) and excisional biopsies (34%). Despite our high overall positive deep margin rate, pT category upstaging (9%) and hypothetical management changes after definitive excision (4%) represented single-digit percentages. Provider-dependent differences in biopsy technique were also observed, with physicians performing significantly more excisional biopsies and APPs performing significantly more punch biopsies.

Conclusions

Although excisional biopsy remains the gold standard for melanoma diagnosis, universal excisional biopsy of all suspicious melanocytic lesions is impractical. Our observational findings suggest no significant increase in pT upstaging associated with shave biopsies, supporting their use in appropriate clinical contexts. However, in cases of high clinical suspicion for melanoma, excisional biopsy should be strongly considered to optimize pT staging accuracy and minimize the risk of subsequent management changes.