Should We Biopsy Everything?

June 02, 2009

By William Fishco DPM FACFAS

Tissue biopsy is underutilized in our profession. Can you think of a reason not to biopsy tissue? Are we that concerned about saving health care dollars?

Consider getting a biopsy for everything. Let us think of the obvious reasons you should. First and foremost, you do not want to miss something serious like a skin cancer such as melanoma. Secondly, even if you use the biopsy to confirm your presumed diagnosis, it cannot hurt to have it documented in the patient’s chart. I know there are cases in which I have been proved wrong on the original clinical diagnosis when I obtained a tissue biopsy.

Intraoperatively, I send all tissue that I remove from the body for biopsy even if it is segments of diseased tendon, bone spurs, or bone and cartilage fragments. Again, this practice can further support your choice of treatment or a surgical procedure such as fusion of an arthritic joint.

In the office, I biopsy all thick toenails that I am considering for Lamisil treatment. It is very simple to take a sample of nail, put it in a jar of formalin and have a PAS stain done.

I usually tell my patients this story. When I first started practicing years ago, I thought I knew everything. I could look at a yellow, thick, diseased-looking toenail and determine there is fungus in the nail. At that time, the insurance companies were reluctant to pay for Lamisil because it was only available in brand name and was very expensive. The insurance companies required proof that there was fungus in the nail before they would agree to pay for it. So, as a matter of necessity, I had to biopsy all toenails.

To my surprise, I learned very quickly that I could not tell the difference between a fungal toenail and non-fungal toenails. Even after all these years and now that terbinafine is available as a generic medication (and costs about $4 a month), I still biopsy nails before prescribing terbinafine so we know we are treating the right problem and not administering a drug that may have potential side effects.

There are not many skin disorders that commonly cause itching, scaling, and redness to the skin. Tinea pedis is very common and I generally biopsy skin as well to confirm the diagnosis. I am sure you have heard from colleagues who say they prescribe Lotrisone, a combination drug of antifungal medication and steroid, to “cover all the bases.” Alternately, you can prescribe a topical antifungal and tell the patient that if that does not help, then you can prescribe something else (a topical steroid).

Why not find out for sure by doing a skin scraping and sending it to the lab for a PAS stain? If there is no fungus, then the correct diagnosis is most likely eczema. Then you can appropriately prescribe a steroid.

It has been my personal experience that biopsying tissue makes me more confident as a clinician and allows for rapid, accurate diagnoses that improve patient care. After all, that is what it is all about.

Comments

Where do I begin. First of

Where do I begin. First of all I agree that biopsies are underutilized. Now, PAS is more expensive than a KOH and culture. I have not found the PAS to be more accurate than a culture. As I have tried culturing negative PAS's and placed those patients on oral and sometimes topical treatment with success. Most Cultures are negative because patients use nail polish remover before the appointment causing disruption of the hyphal structures on KOH and death to the topical organisms. I repeat all primary negative cultures and have those patients use nothing but dilute soap and water on the toes for 6 weeks before reculturing and 2/3 of my negative cultures are then positive. So maybe you thought your clinical judgment was wrong, but as it turns out you are smarter than you have since given yourself credit. Next, $4 is generally the patients copay, generic terbenifine is still around $275 /month according to a pharmacist I have asked. I would take a punch or shave on any skin lesion that is "too" dark, irregular, different from prior exam, textured, too anything. As far as tinea vs dermatitis goes. If I have to biopsy wait 7 days bring the patient back review biopsy and treat, the patient still has two visits, 2 copays etc. The difference is, if I treat via antifungal/ cortisone treatment combo or pick one and change it, there is no 2 or 3 mm hole on the patients foot. No painful anesthetic injected. No portal for a post procedure infection. Would you really want a biopsy done on you for athletes foot, if you were paying for it. I took my daughters to the ER a few years ago, I absolutely refused to let them give my child Tylenol and charge me for medication administration. I try and treat my patients and even the insurance companies with the same respect. Does anyone wonder why we can't contain health care costs??