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//Choice of Site to Biopsy

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Choice of Site to Biopsy
When the decision has been made to biopsy a lesion, along with choosing the method of biopsy, the clinician must
also choose the site (exact spot in the lesion) that will be biopsied.
If a “rash” or inflammatory process is present, select a “fresh” lesion that has recently appeared rather than one that
has been present longer. Oftentimes, older lesions have been excoriated or secondarily infected, obscuring the
primary pathology. Choose a lesion on the upper body rather than the lower body whenever possible (Figure 8-4).
The histology may be easier to interpret and the healing should be more rapid. Biopsies of the lower legs are more
likely to get infected or have delayed healing. Also avoid the axilla and groin if possible because these areas are
more prone to infections.

FIGURE 8-4 Erythroderma in a 19-year-old woman from head to toe. A 4-mm punch biopsy was performed on her arm rather than the

(Copyright Richard P. Usatine, MD.)

If a vesicular-bullous reaction is present, it is best to biopsy an intact bulla with some normal tissue (Figure 8-5). It is
helpful for the pathologist to examine the edge of the bulla to characterize the exact etiology of the disease process.

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There are only a few autoimmune diseases in which lesional skin is preferred (see Table 8-1). Also. A 4-mm punch is adequate.. biopsies are usually taken from perilesional skin (Figure 8-6). MD. See Table 8-1 for more information on the DIF biopsy. When direct immunofluorescence (DIF) testing is to be done.) 1/23/2013 11:20 AM . The specimen is generally obtained with a shave or punch biopsy next to the visible pathology. it is probably still usable. It must be sent to the lab in special Michel's media (or on saline-soaked gauze). avoid the face) and where scarring is less likely.. MD. choose a site where aesthetic considerations are less of a concern (e. (Copyright Richard P. FIGURE 8-5 A shave biopsy of an intact blister in a patient with suspected bullous pemphigoid. upper back. The sternum. choose a lesion on the upper body rather than the lower body whenever possible.//Choice of Site to Biopsy 2 of 4 If lesions are scattered throughout the body. MD. They do not have to be done on the initial biopsy but may be performed to clarify and add data to a standard biopsy for hematoxylin and eosin (H&E) staining. If the cap is on tight and the media has just expired.. This media should be kept in the refrigerator and can expire. The specimen shows that the blister remained intact and there is sufficient perilesional skin to the left of the blister to cut from the specimen and send separately for direct immunofluorescence. Usatine.) FIGURE 8-7 Immunofluorescence microscopy of a skin biopsy displays prominent intercellular “fish-net” deposition of C3 as well as a suprabasilar cleft within the epidermis. Usatine. That means the biopsy will not include the bulla or erosion at all. This confirms the diagnosis of pemphigus vulgaris. FIGURE 8-6 A shave biopsy was performed of an intact blister including perilesional skin in a patient with suspected bullous pemphigoid.g. (Copyright Richard P.expertconsultbook. DIF studies are especially helpful for autoimmune bullous diseases because antibodies will light up in the skin (Figure 8-7). and areas of skin tension are more likely to scar. (Courtesy of Robert Law. shoulders.

IgG is Herpes gestationis Perilesional generally less pronounced. and C3 around vessels and dermalPerilesional cutanea tarda epidermal junction. Intercellular deposition of IgG. Unfortunately choosing the darkest and most raised area does not guarantee the correct diagnosis. Lesional or normal skin Dermatitis herpetiformis Granular IgA within dermal papillae. from disease-prone area Inflamed. sooner or later. Of course. it is best to provide a specimen with adequate depth. Porphyria/pseudoporphyria Linear IgG. and treatment can be performed immediately (electrodesiccation and curettage ×3) (see Chapter 14. in some circumstances this is not desirable... Perilesional skin. Curettement and punch methods can also be used. IgM. It may be better in some instances to sample the whole lesion with a broad deep shave than to do one or more punch biopsies. biopsy centrally and try to obtain a deep sample so the pathologist can determine the extent of invasion.expertconsultbook. a broad shave provides a better sample than a few punch biopsies and is less deforming that a large full-thickness biopsy. If a squamous cell carcinoma is suspected. Linear basement membrane staining with IgG and/or Bullous pemphigoid Perilesional C3. In cases of suspected lentigo maligna melanoma on the face. and the lesion is too large to shave off in its entirety. Heavy IgG and/or C3 along the basement membrane Bullous lupus erythematosus Perilesional skin zone. Vasculitis Early lesion Perivascular IgM/IgG/C3: other forms of vasculitis. Source: Courtesy of Robert Law. an unsuspecting melanoma may be biopsied with a shave that misses the true depth of the lesion.//Choice of Site to Biopsy 3 of 4 http://www. mucosa. and/or IgA along the Discoid lupus erythematosus Lesional skin basement membrane zone in conjunction with cytoid bodies. TABLE 8-1 -. Salt split samples show variable localization. MD. A broad deep shave is usually adequate for a biopsy. that it is far better to biopsy a lesion—regardless of the method—and find a melanoma early than to delay and 1/23/2013 11:20 AM . A second biopsy/excision may be needed if the pathologist reports that there is squamous dysplasia and a SCC cannot be ruled out. Peripheral areas may only involve actinic change. Salt split samples will localize to the dermal side. Granular IgG or IgM along the basement membrane Lupus band test Normal skin zone. Note. Heavy IgG and/or C3 along the basement membrane Epidermolysis bullosa acquisita Perilesional zone. it feels “soft” with curetting and also has a classic appearance. IgA pemphigus Perilesional Intercellular deposition of IgA. Systemic lupus erythematosus Lesional skin Same as for discoid lupus. The appearance and feel can confirm the initial for Direct Immunofluorescence Biopsies Disease Location of Biopsy Findings Pemphigus vulgaris Perilesional Intercellular deposition of IgG. almost any area can be biopsied but it is better to select a raised-up border rather than an ulcerated portion. missing the most advanced pathology. Biopsying the latter may inaccurately provide a pathology specimen that shows only inflammation and reparative debris if not sampled deeply enough. it is often easy to shave off the whole lesion. in a large pigmented lesion on the face. however. Antibodies also Paraneoplastic pemphigus Perilesional directed to simple or transitional epithelium (rat bladder). but nonulcerated Clumps of cytoid bodies and fibrinogen in the Lichen planus mucosa or skin basement membrane zone. It is also just not practical to perform an elliptical excision on every potentially malignant pigmented lesion. Electrosurgery). Linear basement membrane staining with C3. for instance. If a basal cell carcinoma is suspected. An advantage with curettement is that if the tissue is necrotic. Perivascular IgA: Henoch Schoenlein purpura. Granular deposition of IgG. If a melanoma is suspected. Linear basement membrane staining with IgG and/or Cicatricial pemphigoid (MMP) or conjunctiva C3. Pemphigus foliaceus Perilesional Intercellular deposition of IgG. Linear IgA deposition at the basement membrane Linear IgA dermatitis Perilesional skin zone. Although a full elliptical excision has been considered the gold standard. If the lesion is large. Salt split samples will localize to the epidermal side.

. Copyright © 2013 Elsevier Inc. Then the prebiopsy photo can be found by searching the electronic files by do closely correlate with the true depth of the lesion. Some clinicians photograph the patient label at the same time to make it easier to locate a preop photo. Read our Terms and Conditions of Use and our Privacy 1/23/2013 11:20 AM .com/expertconsult/b/book. Biopsy sites may heal quickly and can be difficult to find later when definitive treatment is necessary. a deep sample will be needed to find the Breslow level and plan the definitive surgery. thus missing an opportunity for early detection and treatment.[5. Dermoscopy (see Chapter 32) is a tool that can help you choose the most suspicious area to biopsy in a large lesion if it is impractical to biopsy the whole lesion.//Choice of Site to Biopsy 4 of 4 http://www.6] Documentation of Biopsy Site With all biopsies (especially if multiple lesions are obtained). For problems or suggestions concerning this service. please contact: online. All rights reserved.. Fortunately. make sure the camera is set to record the correct date of the photo. If it is not easy to place photographs in the medical record. in general.expertconsultbook. include a diagram or photo in the medical record.[4] Suspected early thin melanomas can easily be biopsied with a deep shave technique. if possible. Photos can aid in identifying correct locations. When sampling a suspected thick nodular melanoma. Adequate privacy protection is necessary to ensure that photo storage options are HIPAA compliant (password protected and data encryption) if a computer is record a detailed description of the biopsy site and. nonexcisional biopsies do not negatively influence melanoma patient survival and. procrastinate.