1. Examine the entire skin surface of every patient on whom a complete examination is done. This is often not accomplished because:

(a) The patient may not be required to disrobe entirely.

(b) There may be overmodesty on the part of the patient and acquiescence on the part of the doctor even when the patient is appropriately draped, (c) In progressing in orderly sequence from the head and neck to the breast to the chest, etc., the skin may never be considered as a separate and integral whole.

2. Concentrate on certain areas of predilection:

(a) For carcinoma, the exposed surfaces of the head and neck, dorsum of the hands, etc.

(b) For melanoma, the palms of the hands, the soles of the feet, and the region of the genitalia.

3. Insist on biopsy and/or removal of all lesions which are even remotely suspicious or potentially dangerous.

Infiltrate the periphery of the area with local anesthetic. Demarcate an elliptical incision with suitable margins. Orient the long axis of the incision in lines of natural skin folds whenever possible.

Assure a balanced incision by initiating tho procedure at both sides.

Carry the incision through the full thickness of skin.

Place the specimen in 10% formalin. Approximate the skin edges with silk sutures.

Fig. 36. Technique of biopsy of skin lesions.

Biopsy (Fig. 36): Whenever possible, the entire lesion is removed with a rim of surrounding normal-appearing skin and subcutaneous tissue. Local anesthesia is obtained by infiltrating the area about, but not into, the lesion with 1% procaine. An elliptical incision with a margin of 2 to 4 mm. of normal skin is made about the lesion. The incision is carried through the full thickness of the skin down to, and often including, a small portion of the subcutaneous fat. The skin edges are approximated with silk sutures. The specimen is placed in a bottle containing 10% formaldehyde and is submitted to the pathologist.

Partial biopsy may be necessary for large lesions. In such instances, a wedge of tumor is excised, including a portion of normal-appearing skin at the margin of the lesion. Partial excision of a pigmented lesion should be avoided unless disfigurement resulting from a complete excisional biopsy outweighs the advantages of a prophylactic excision. If the lesion is suspicious, complete removal is mandatory.

4. Be certain that all such tissue removed is examined pathologically.

5. Do not desiccate, fulgurate, cauterize or otherwise destroy any lesion which is even remotely suspicious of cancer. In the case of potentially suspicious pigmented lesions this injunction is particularly true.

(a) By doing this one destroys the tissue, thereby eliminating any possibility of making an accurate diagnosis by pathological examination. The final diagnosis of skin cancer lies under the pathologist's microscope, not in the clinician's eye.

(b) Furthermore, if the lesion is cancer this is usually inadequate treatment.

(c) Finally, it has been suggested by some that such a maneuver may potentiate or accelerate the growth and spread of a cancerous or precancerous lesion.