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Umbilical lesion appears in a woman with a history of sun exposure

Joe R. Monroe, PA-C, MPAS

The author practices in the dermatology department of the Warren Clinic, Tulsa, Okla, and is the founder and president of the Society of Dermatology Physician Assistants. He has indicated no relationships to disclose relating to the content of this article.

A 26-year-old woman presents with a lesion in her umbilical area. The patient had never seen it before, so she assumed it was new. She had a history of excessive sun exposure, although it was fairly well tolerated. Her health was good in other respects, and there was no family history of skin cancer.

On examination, the patient had to spread the periphery of the umbilicus in order to show us the lesion (see Figure 1). The lesion was a 6.5-mm, irregularly bordered, chocolate-brown macule hidden by the edges of the umbilicus. There was no raised portion to the lesion, and no focal ulceration was noted. Further examination showed little evidence of sun damage and no other worrisome lesions.

What would be the appropriate next step?

Take a 4-mm punch biopsy from the lesion
Refrain from biopsy since this could make the lesion spread
Measure the lesion carefully, document the size in the patient’s record, and measure again in 3 months
Refer the patient to a plastic surgeon

Discussion

The correct answer is to sample the lesion with a 4-mm punch tool, close the wound with silk sutures, and submit the specimen for pathologic examination. This was done, and the biopsy report indicated that the lesion was a benign melanocytic nevus.

There is abundant evidence that biopsy does not increase the chance of metastasis of melanoma. Fear of causing metastasis is the most frequent reason nondermatology health care providers give for not doing a biopsy of suspicious lesions.

Measuring, documenting, and rechecking this lesion makes little sense, given its size and location. It is much simpler to do the biopsy and obtain a definitive diagnosis. Since this lesion was new, it could easily have been a melanoma—in which case, waiting and watching could be fatal. Finally, if you have enough concern about a lesion to schedule a follow-up visit, there is reason enough to warrant a biopsy.

Referral to plastic surgery after biopsy makes some sense. However, if this patient is to be referred to anyone, it should be to someone who specializes in dermatology. Such specialists are the only ones with the expertise to discriminate benign from malignant lesions.

Treatment After considering the treatment options, the benign nature of the lesion, and its location, the patient opted to do nothing further at this time. Aside from the discussion above, another pearl to be gleaned from this case is that even though melanoma is unquestionably caused by sun exposure, it can and does appear in nonexposed areas. I have seen melanomas on feet, in the scalp, on genitals, on breasts, and even in the eyes and in the mouth. Suspected melanomas should be taken seriously, and the only way to do that is to obtain an adequate tissue sample for pathologic examination.