http://informahealthcare.

com/jdt
ISSN: 0954-6634 (print), 1471-1753 (electronic)

J Dermatolog Treat, Early Online: 1–3

! 2015 Informa UK Ltd. DOI: 10.3109/09546634.2015.1034083

ORIGINAL ARTICLE

Excision versus incision biopsy in the management of malignant

melanoma*
Kavita S. Sharma, Philip Lim, and Micheal T. Brotherston

Plastic Surgery Department, Royal Hallamshire Hospital, Sheffield, UK

J Dermatolog Treat Downloaded from informahealthcare.com by Nyu Medical Center on 07/13/15

Abstract Keywords
Introduction: The incidence of melanoma has increased over the last decade. The Breslow Breslow thickness, excision biopsy, incision
thickness is one of the most important histological parameters. The gold standard for biopsy, malignant melanoma
histological diagnosis is an excision biopsy. Incisional, punch or shave biopsies are not
recommended as they are often incomplete and can result in false negatives. Objective: To History
assess the validity of incision versus excision biopsies in the prediction of Breslow thickness in
the histopathological analysis of malignant melanoma. Methods: A retrospective review of Received 19 March 2015
histopathological records was conducted for all patients undergoing incision biopsy for Accepted 22 March 2015
malignant melanoma. The Breslow thicknesses of the incisional biopsies were matched to the Published online 17 April 2015
later corresponding excisional biopsies. The demographical data, site of melanoma and
histological subtype were also examined. Results: Sixty patients between 1st January 2005 and
31st December 2013 were identified. The most common area biopsied was the upper and lower
For personal use only.

limbs – 50%. The Breslow thickness and Clark’s level were found to be significantly increased in
excision versus incision biopsy specimens. Nine patients had differing mitotic rates which were
all higher in the excision biopsy samples. Conclusion: Our data supports the UK national
guidelines on the management of malignant melanoma in that incisional biopsies are not
indicated in the diagnostic pathway of malignant melanoma.

Introduction Furthermore, the guidelines highlight that there is no role for

using incision biopsy outside the recommendation of the multi-
The incidence of cutaneous melanoma is on the rise and this is set
disciplinary team, as they do not allow for complete histological
to continue in the coming years (1). Furthermore, it is becoming
staging. It is only acceptable for large lesions in cosmetically
more evident that there has been a rapid increase in melanoma
sensitive areas where clinical doubt exists about the diagnosis.
and its associated morbidity and mortality amongst the elderly
This is not as pertinent in non-melanoma skin cancers as
population (465 years) (2). With an ageing population as that of
guidelines in these areas recommend the use of incision biopsy
the United Kingdom and many other developed countries,
in these circumstances (5).
melanoma will undoubtedly become an increasingly important
With the increasing number of excisions of thin melanomas,
national health issue.
dysplastic nevi and other pigmented lesions suspicious of
The most important predictors of mortality according to the
melanoma this raises the question of whether the standard
American Joint Committee on Cancer (AJCC) are tumor charac-
excisional biopsies can be replaced in some cases by incisional
teristics, such as Breslow thickness, ulceration, mitotic rate and the
biopsies, which are easier to perform. Many studies have looked at
presence of metastases (3). Therefore, an accurate biopsy is crucial
patient mortality and recurrence as outcomes in those who have
as an initial step in assessment. The current guidelines on the
had excisional versus incisional biopsies. It is not surprising that
management of malignant melanoma in the United Kingdom set
many of these studies showed no significant difference. However,
out a defined pathway to the clinician from screening and clinical
differences in the variability of histological data obtained by
assessment in primary care to follow-up after the completion of
incisional versus excisional biopsies have not been thoroughly
treatment (4). According to the current guidance, patients with a
investigated. As a result, the aim of our study was to determine if
suspicious pigmented lesion should proceed to have an excision
the Breslow thickness, Clark’s level and mitotic rates in the
biopsy. The recommendation is for a 2 mm peripheral margin
histological assessment of malignant melanoma were significantly
with a deep margin consisting of a rim of subcutaneous fat.
different in incision versus excision biopsy specimens from the
This enables diagnosis, staging and determines the need for
same sample.
further investigations like computed topography scans.

Methods
*This paper was presented in the ESPRAS International Plastic Surgery
Conference, Edinburgh, July 2014. A retrospective review of pathology records was undertaken in a
Correspondence: Miss. K. Sharma, Plastic Surgery Department, Royal regional plastic surgery unit. The inclusion criteria consisted
Hallamshire Hospital, Sheffield, Glossop Road, Sheffield, of pathological specimens with a diagnosis of invasive malig-
South Yorkshire S10 2JF, UK. E-mail: kssharma@doctors.org.uk nant melanoma where an incisional biopsy was performed.
 2 K. S. Sharma et al. J Dermatolog Treat, Early Online: 1–3

Incision biopsy was defined as a specimen obtained as part of, but
not the entire suspected lesion. Other biopsies considered as part
of the spectrum of incisional biopsy included punch and shave
biopsies.
Furthermore, in order to be included in the review each
incisional biopsy sample had to have a matching excisional biopsy
performed at a later date. The Breslow thickness, mitotic rates and
Clark’s level were collected for the two samples and analyzed for
significant differences. Other histological data collected included
patient demographics, subtype of melanoma, mitotic rate and
Clark’s level.
Statistical analysis was performed using the sign test to
determine if there was a significant difference in the two reported
values of the Breslow thicknesses, Clark’s levels and mitotic rates
between incision and excision biopsies.
Results
Sixty patients met the inclusion criteria between 1st January 2005
J Dermatolog Treat Downloaded from informahealthcare.com by Nyu Medical Center on 07/13/15
pathways and national guidelines, these practices have been
standardized and patient care in melanoma is centered on
decisions made at the level of the multidisciplinary team.
There has been concern that incision biopsy techniques lead to
incomplete excision of the melanoma resulting in local, regional
or systemic tumor dissemination. Punch biopsies have been
postulated to increase the level of tumor invasion.
A study by Griffiths et al. concluded that incisional biopsies
resulted in an unacceptably high incidence of tumor distortion,
which precluded measurement of maximal tumor thickness in
almost one-third of cases. As a result it is to be regarded as an
unacceptable procedure for skin lesions suspicious of malignant
melanoma (6).
This was later supported by Lees et al. In their cohort, 8.8% of
patients were initially diagnosed with incision biopsy type
technique and found that it rendered 40% of the lesions not
fully assessable on the histopathological criteria needed for the
reporting of melanomas at that time. This was significantly higher

than the other techniques. They also concluded that suspicious

and 31st December 2013. The male to female ratio was 1:1 and
lesions should be subjected to excision rather than incision biopsy
the median age at diagnosis was 70.5 years (range 41–97 years).
techniques in order to avoid compromising histological assess-
The most common sites in which an incision biopsy was
ment, as tumor thickness is a key prognostic factor in treatment
undertaken included the upper and lower limbs (50%), head and
and prognosis (7).
neck region (38%) and trunk (12%). The most common
It has been well established that tumor thickness is one of the
histological subtypes found are illustrated in Figure 1.
most significant predictors of survival and therefore accurate,
The mean Breslow thickness recorded for the incision biopsy
consistent determination of this is crucial in the management of
specimens was 2.004 (s.d. ¼ 2.419). The corresponding value for
malignant melanoma (8). There are practical advantages of
the excision biopsy was 2.998 (s.d. ¼ 4.166). The sign test was
performing incision biopsies to aid diagnosis. Firstly, it is less
2.774 (p ¼ 0.0055) (Table 1).
time consuming and technical, requiring less equipment and
Forty-eight percent of the excisional biopsy specimens had a
resources. This makes it ideal for it to be undertaken in between
For personal use only.

Clark’s level between II and III and 52% between IV and V. This
larger reconstructive cases. It is advantageous if the lesion turns
was similar for the incision biopsy specimens as 50% had an
out to be benign in a cosmetically sensitive area like the face or
average Clark’s level II–III and 50% between IV and V.
Nine samples in our study had differing mitotic rates in the
excision versus incision biopsy samples. The excision biopsy Table 1. Illustrating mean, standard deviation, median and range of
samples had in all cases a higher mitotic rate. Most of the incision Breslow thickness and Clark’s level in excision versus incision biopsies.
biopsies were noted to be carried out in the primary care setting,
with the referral being made when sample indicated a diagnosis of Excision Incision
malignant melanoma (Figure 2). biopsy biopsy Sign. test p Value
Breslow thickness (mm) 2.774 0.0055
Discussion Mean 2.998 2.004
In the past, the type of biopsy technique utilized in the initial SD 4.166 2.419
Median 1.4 1
diagnosis of malignant melanoma depended on the location and Range 0.2–22 0.1–12
size of the pigmented lesion and the physician’s experience and Clark’s level 5.824 50.0001
judgment. However with the advent of more structured patient II–III 48% (25) 50% (26)
IV–V 52% (27) 50% (26)

8%

10% 25% Superficial Spreading

20, 38% Lengo Maligna
6% Nodular
26, 50% Lenginous
Superficial
9% spreading/lengo
mixed
17% Misc

Extremity
25%
6, 12% Trunk
Head and Neck

Figure 1. Pie chart illustrating the site distribution of melanoma. Figure 2. Pie chart illustrating pathological subtypes of melanoma.
 DOI: 10.3109/09546634.2015.1034083
scalp region. Furthermore for larger indeterminate lesions, a
tissue sample can be beneficial as it can allow planning and
possibly wide excision and reconstruction in the same setting,
which saves additional procedures. For the elderly or infirm or
medically unfit this technique has proven to be quite useful as it is
of a short duration using local anesthetic.
Most published studies have focused on recurrence and
survival after excisional versus incisional biopsies. Some of
these studies hypothesized that tumor cells could be displaced
deep to the deep dermis in the incisional biopsy specimens (9).
Furthermore, it was postulated that due to the small amount of
subcutaneous fat in the head and neck region, cutting into tumor
in this region could seed cells directly into the blood vessels (10).
On the other hand, some studies found no significant
differences in survival between the two groups and these bore
the recommendations of performing it in large lesions and those in
cosmetically sensitive areas (6,7,11).
In this study, we aimed to compare matched samples from the
J Dermatolog Treat Downloaded from informahealthcare.com by Nyu Medical Center on 07/13/15
same specimen biopsied at two different points in time to
determine if there was a difference in the Breslow thickness
reported between the incision and excision biopsy samples. In
addition, other prognostic indicators like Clark’s level and mitotic
rates were also assessed. Our data show that there was a significant
difference in these values between the incision and excision biopsy
samples. The excision biopsy samples were of a greater Breslow
thickness and Clark’s level compared to the initial incision biopsy
counterpart. This suggests the validity of current recommendations
however there are several points that can explain the observed
differences. Firstly, the part of the specimen that is biopsied in the
incision sample may not represent the true lesion. The darkest or
For personal use only.
ulcerated part of a pigmented lesion may not be the deepest area of
invasion. Furthermore, there is a great deal of variability in
technique, tissue handling and storage. As a result the tested
sample may not be a true indication of the entire lesion.
Given the degree of variability associated with this technique,
the question of its usefulness comes into play. Ultimately
histological data represented in this study show that there is a
significant difference therefore treatment is ideally based on the
standard excision biopsy sample unless the lesion has an
exceptionally large surface area. In these situations multiple
incision biopsies have a role as they can indicate a diagnosis.
However for lesions in cosmetically sensitive areas, definitive
treatment is ideal, not only for staging purposes but to offer the
patient more definitive care. In these situations it may be
beneficial to refer the patients to a plastic and reconstructive
surgeon for the primary excision biopsy.
Incisional biopsy in malignant melanoma 3
This study supports the recommendations made by Marsden
et al. in not performing incisional biopsies in the initial
management of malignant melanoma unless the case has been
discussed and recommended at the level of the local or regional
multidisciplinary team. The recommendation to perform an
incision biopsy may be justified in very large, ulcerated lesions,
which is not amenable to complete excision for an initial
histological analysis.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
References
1. de Vries E, van de Poll-Franse LV, Louwman WJ, et al. Predictions
of skin cancer incidence in the Netherlands up to 2015. Br J
Dermatol. 2005;152:481–8.
2. Gaudette LA, Gao RN. Changing trends in melanoma incidence and
mortality. Health Rep. 1998;10:29–41.
3. Balch CM, Bunzaid AC, Soong SJ, et al. Final version of the
American Joint Committee on Cancer staging system for cutaneous
melanoma. J Clin Oncol. 2001;19:3635–48.
4. Marsden JR, Newton-Bishop JA, Burrows L, et al.; British
Association of Dermatologists (BAD) Clinical Standards Unit.
Revised UK guidelines for the management of cutaneous melanoma
2010. J Plast Reconstr Aesthet Surg. 2010;63:1401–19.
5. Telfer NR, Colver GB, Morton CA. Guidelines for the management
of basal cell carcinoma. Br J Dermatol. 2008;159:35–48.
6. Griffiths R, Briggs JC. Biopsy procedures, primary wide excisional
surgery and long term prognosis in primary clinical stage I invasive
cutaneous malignant melanoma. Ann R Coll Surg Engl. 1985;67:
75–8.
7. Lees VC, Briggs JC. Effect of initial biopsy procedure on prognosis
in Stage 1 invasive cutaneous malignant melanoma: review of 1086
patients. Br J Surg. 1991;78:1108–10.
8. Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic factors
analysis of 17,600 melanoma patients: validation of the American
Joint Committee on Cancer melanoma staging system. J Clin Oncol.
2001;19:3622–34.
9. Epstein E, Bragg K, Linden G. Biopsy and prognosis of malignant
melanoma. JAMA. 1969;208:1369–71.
10. Austin JR, Byers RM, Brown WD. Influence of biopsy on the
prognosis of cutaneous melanoma of the head and neck. Head Neck.
1996;18:107–17.
11. Lederman JS, Sober AJ. Does biopsy type influence survival in
clinical stage I cutaneous melanoma? J Am Acad Dermatol. 1985;
13:983–7.