The Question: I suspect I have acral melanoma on my foot and I want an excision biopsy done. Most family practitioners are unaware of what it is, and they simply did not know what it is. I waited for a long time and saw a dermatologist who wasn’t sure what it is either. He said it’s a birthmark even after telling him that I only had it for 1.5 years and it grew over the period of time. After reading some suggestions from melanoma survivors (who strongly think this doesn’t look good and need to be removed), I am trying to get an excision biopsy from a melanoma specialist, regardless of what it is for peace of mind.
The Answer: Right off the bat, doctors will tell you any new lesion is worrisome – especially one that is growing – and that it definitely needs to be seen. I like that you have reached out to melanoma survivors for advice and it sounds like they have been able to confirm for you that this mark on your foot looks suspicious.
The only part of your question that gives me pause is that two physicians have already seen and dismissed it – your family physician and a dermatologist, the latter of whom would be particularly well placed to spot a suspicious lesion. I do think you are correct to pursue a biopsy as you require a definitive answer only a biopsy can provide that to you. Your preference for a total removal of the lesion for “peace of mind” may be extreme, given that the growth is on the foot and if it’s large, it could involve a skin graft or a rotational flap to reconstruct the area, according to Frances Wright, a surgical oncologist at Sunnybrook, who specializes in melanoma.
“He needs to have someone look at it,” Dr. Wright said in an interview. “If it needs a biopsy, then it may need to be an incisional biopsy (removing the most suspicious area) rather than an excisional biopsy (removing the whole area) to minimize the morbidity of the reconstruction. Most general surgeons can biopsy the foot.”
There are four major types of melanoma: superficial spreading, which is the most common making up 70 per cent of all diagnosed cases, nodular, lentigo maligna and acral lentiginous, the latter of which accounts for about five per cent of all diagnosed melanomas. [Nodular melanoma accounts for 15 per cent of cases, while lentigo maligna represents 10 per cent of cases].
The type you wrote about – acral lentiginous melanoma – is a common form of melanoma in Asians and those with dark skin. It is sometimes referred to as a “hidden melanoma” because the lesions occur on parts of the body that are typically not easy to examine – or that even one necessarily thinks to examine. These melanomas present on the palms of the hands, soles of the feet and mucous membranes, including those that line the mouth, nose, female genitals, anus and underneath or near the toenails and fingernails.
In your case, the lesion has appeared on the sole of your foot. Typically, melanoma looks like a black spot. Sometimes people mistakenly believe the mark is due to bruising or a recent injury.
Doctors are taught the classic signs of a melanoma are asymmetric lesion, irregular borders, change in colour or multi-coloured, diameter >6mm or ulcerated/ bleeding.
“If it looks suspicious, you need to do a biopsy,” said Dr. Wright, associate professor of surgery at University of Toronto. “Something new that is changing can be worrisome. In the end it’s going to be a discussion between the physician and the patient on how worrisome it is.”
Sunnybrook’s Odette Cancer Centre is the only place in Canada that has a pigmented skin lesion clinic that runs every Monday. There, you can have your suspicious lesion looked at by a dermatologist and an oncologist, if need be. You can access it if you are referred by a family physician through our central referral fax number 416- 480-6179 or referral telephone number 416-480-4205.
“The majority – 70 per cent of melanomas, – present with a depth of less than 1 mm and have a very good outcome,” according to Dr. Wright. “There are a proportion of melanomas that do present deeper and can be life threatening.”
Another alternative is that you return to your family physician and ask to be referred to a general or plastic surgeon to do a biopsy and if necessary, have it removed. Many dermatologists perform these biopsies as well.
I agree you need to vigorously pursue this, get a biopsy and a definitive finding. The biopsy alone will likely give you that peace of mind you seek.