Performance of the “if in doubt, cut it out” rule for the management of nodular melanoma

BACKGROUND: The recognition of nodular melanoma is clinically challenging, and the diagnostic accuracy of dermoscopy and confocal microscopy is lower than for superficial spreading melanoma. OBJECTIVES: To test a management strategy consisting in the excision of any nodular lesion that cannot be confidently and precisely classified as a benign tumor after clinical and dermoscopic examination. METHODS: Clinical and dermoscopic images of excised nodular lesions were retrospectively collected and evaluated. The evaluators were asked to record the level of diagnostic confidence for each lesion, by declaring if they were confident or doubtful about the given diagnosis. The NNE (number needed to excise) value was used to evaluate the efficacy of the proposed method. RESULTS: A total of 1,319 excised nodular lesions formed the study set. The NNE for any malignancy was 3.9 (634/164), while the NNE for melanoma was 13.2 (634/48). NNE for hypo and amelanotic melanoma was 27.3 (327/12). CONCLUSIONS: Excising doubtful nodular lesions seems to be an effective management strategy not to miss nodular melanoma, resulting in an acceptable rate of unnecessary excision of benign lesions.