Efficacy

There have been no randomised controlled trials (RCTs) of incisional versus excisional surgery. Retrospective studies of large numbers of patients have reported different results. A large study in 1985 of 472 patients with stage I cutaneous MM reported on the survival rate with different modalities of surgery. A total of 119 patients initially underwent an incisional or punch biopsy and 353 patients had their lesions excised. Survival in the two groups did not differ, regardless of the depth of invasion. Of 76 patients who had an incisional biopsy of a lesion <1-7 mm in depth none died. In the intermediate-thickness group (1-7-3-64 mm) there was a 35% mortality rate compared with 18% in the excision group, and in the thick-lesion group (>3-65mm) the mortality rates were 64% and 50% respectively. Cox regression analysis showed that the best predictors for outcome were tumour thickness and anatomical location, but not biopsy type.11 In a further study of 1086 patients followed up for 5 years, 96 of these underwent an incisional biopsy initially. The mortality was 48-9% in the incisional-biopsy group (mean thickness 3-47 mm) and 39-2% in the wide-excision group (mean thickness 2-77 mm), compared with 33-9% in the narrow-margin group (mean thickness 2-34 mm). After correcting for tumour thickness there was no

QUESTIONS

What is the place of a diagnostic incisional biopsy?

statistical difference in survival rates or local recurrence between those having an incisional biopsy and those who had their lesions fully excised initially.12 A more recent and larger case-control study from Scotland of 5727 patients identified 265 patients who had undergone an incisional biopsy. These were matched to 496 controls. The survival analysis of time to recurrence and time to death revealed no differences between the groups.13

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