When Should You Biopsy?

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Author(s): 
Tracey C. Vlahovic, DPM

   After making the determination to sample a suspicious pigmented lesion, the clinician should determine the type of biopsy to occur. The American Academy of Dermatology and National Comprehensive Cancer Network have suggested, when possible, to perform a total excisional biopsy (see the table “What The National Comprehensive Cancer Network And The American Academy Of Dermatology Recommend For Biopsies” at right). Fully realizing that larger lesions and various anatomical areas (soles, digits, subungual) are not always amenable to a total excision with a 1 to 3 mm border, their recommendations then include incisional and punch biopsies. They reserve a deep shave technique for when the index of suspicion for melanoma is low to none.

   Throughout the years, clinicians have shared the concern of creating metastasis during the initial biopsy procedure of a melanocytic lesion. Various studies have been unable to show differences in survival and sentinel lymph node metastasis between those who had an excisional procedure versus those who had an incisional, punch or deep shave biopsy procedure.4 The major concern that the National Comprehensive Cancer Network and American Academy of Dermatology have regarding the non-excisional procedures is the possible lack of procuring the deep margin of the tumor. The deep margin helps to determine the Breslow’s depth, which allows for staging of the lesion and ultimately the prognosis. Ultimately, the guidelines recommend excision when possible and non-excisional biopsy of an area that best represents the lesion in difficult anatomic areas and large lesions.4

Final Words

In general, choosing when to biopsy can prove to be a challenge to the practitioner. After a thorough history and clinical examination, the clinician needs not only to choose which lesion to biopsy, but also what type of biopsy to perform. Overall, a wound, rash or lesion that does not meet general criteria should have a biopsy. Also, regard a lesion that hasn’t responded to standard therapy with suspicion and obtain a sample.

   In conclusion, biopsy of these aforementioned conditions is a valuable technique that allows the practitioner to refine a diagnosis and direct the further course of treatment.

   Dr. Vlahovic is an Associate Professor and J. Stanley and Pearl Landau Fellow at the Temple University School of Podiatric Medicine.

References
1. Cocchetto V, Magrin P, de Paula RA, et al. Squamous cell carcinoma in chronic wound: Marjolin ulcer. Dermatol Online J. 2013; 19(2):7.
2. Pavlovic S, Wiley E, Guzman G, et al. Marjolin ulcer: an overlooked entity. Int Wound J. 2011; 8(4):419-24.
3. Alavi A, Niakosari F, Sibbald RG. When and how to perform a biopsy on a chronic wound. Adv Skin Wound Care. 2010; 23(3):132.
4. Tran KT, Wright NA, Cockerell CJ. Biopsy of the pigmented lesion-When and how. J Am Acad Dermatol. 2008; 59(5):852-71.
5. Sina B, Kao G, Deng A, Gaspari A. Skin biopsy for inflammatory and common neoplastic skin diseases: optimum time, best location, and preferred techniques. A critical review. J Cutan Pathol. 2009; 36(5):505-10.

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