Biopsies for skin cancer detection: Dispelling the myths

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Applied Evidence

Biopsies for skin cancer detection: Dispelling the myths

J Fam Pract. 2018 May;67(5):270-274

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From The Journal of Family Practice | 2018;67(5):270-274.

References

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Avoid partial biopsies. For tumors that have been partially biopsied with a punch or shallow shave biopsy, evaluation of the remaining neoplasm after subsequent excision leads to tumor upstaging in 21% of patients, with 10% qualifying for an SLNB.⁶Thus, the goal should always be to obtain the entire depth of the tumor with the initial biopsy.

In addition, surgical margins are determined by primary tumor depth. To ensure a depth greater than 1 mm, aim to obtain a tissue specimen that is at least as thick as a dime (1.3 mm).

Because the goal is to avoid partial sampling, a challenge exists when the suspicious growth is large. Many melanomas are broader than a centimeter. And while punch biopsies ensure a depth of 1 mm or more, they risk missing the thickest portion of the tumor.⁷

Partial sampling of large melanocytic tumors with punch biopsies can lead to sampling error.⁸ Ng et al⁹ found there was a significant increase in histopathologic misdiagnosis with a punch biopsy of part of a melanoma (odds ratio [OR]=16.6; 95% confidence interval [CI], 10-27; P<.001) and with shallow shave biopsy (OR=2.6; 95% CI, 1.2-5.7; P=.02) compared with excisional biopsy (including saucerization).⁹ Punch biopsy of part of a melanoma was also associated with increased odds of misdiagnosis with an adverse outcome (OR=20; 95% CI, 10-41; P<.001).

Punch biopsies do, however, offer a reasonable alternative when the melanoma is too broad for a complete saucerization. In these cases, consider multiple 4- to 6-mm punch biopsies to reduce the risk of sampling error.

Avoid performing punch biopsies <4 mm, as the breadth of tissue is inadequate. For example, even with dermoscopy, facial lentigo maligna melanoma is often difficult to differentiate from pigmented actinic keratosis and solar lentigines. (See JFP’s Watch and Learn Video on dermoscopy.) A broad shave biopsy is the preferred method of biopsy for lentigo maligna melanoma in situ according to the NCCN.³ And there have been several reports showing that the results of shave biopsies of melanocytic lesions are cosmetically acceptable to patients.^10,11

If the biopsy confirms malignancy, a larger surgery with suturing will be needed. The most important issue to keep in mind is that if partial sampling leads to a benign diagnosis of a suspicious lesion, then the remainder of the lesion must be excised and sent for pathology.