PART 6: Therapeutic considerations in the management of patients
with cancer of the skin
Chapter
40 Biopsy Techniques
Joseph F. Sobanko, Justin J. Leitenberger, Neil A. Swanson, and Ken K. Lee
Key Points
• Proper biopsy is critical in the diagnosis and
management of skin cancers.
• Melanocytic lesions should be removed with an
excisional biopsy where possible in order to obtain
the most accurate diagnosis and prognostic factors
although there is no evidence that an incisional biopsy
adversely affects prognosis.
• Non-melanocytic lesions can be removed with a shave
biopsy or other incisional techniques.
INTRODUCTION
The biopsy is a critical start to the diagnosis of skin cancer. It
is ‘the process of removing tissue from patients for diagnos-
tic examination’.1 Fortunately, the accessibility of the skin
simplifies the biopsy process relative to other organ sys-
tems. Experienced clinicians can often identify skin cancers
during physical examination using both visual and tactile
clues. Nevertheless, a properly performed biopsy is para-
mount to the diagnosis and eventual management of the
skin cancer. The numerous biopsy techniques available to
a clinician include: excisional, incisional, shave, sauceriza-
tion and punch. Each of these modalities serves a different
purpose and clinicians who manage skin cancers should
understand and master all of them. Correctly biopsying pig-
mented lesions illustrates this importance, as there may be
significant ramifications beyond the initial diagnosis of mel-
anoma. Factors such as depth of invasion, ulceration, micro-
satellitosis, angiolymphatic invasion, and mitotic index can
impact prognosis and proper management. The decision to
implement additional prognostic and therapeutic techniques
such as sentinel lymph node biopsy and systemic adjuvant
therapies is often determined by the results from the initial
biopsy. Therefore, procurement of an adequate specimen for
presentation to the dermatopathologist is critical to assure a
correct and complete diagnosis. Conversely, aesthetic out-
comes should be considered since many suspicious lesions
are in fact determined to be benign. This chapter reviews the
decision-making process and discusses in detail the biopsy
techniques and rationales for their use.
DECISION-MAKING PROCESS
There are many different types of skin cancers which are
frequently divided into two categories: melanoma and
non-melanoma skin cancers. This division stems from the
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relative difficulty and controversy surrounding the his-
tologic diagnosis of melanoma. The controversy arises as
similar-appearing melanocytes, the pigment-forming cells
of the skin, can be found in a benign nevus, atypical or dys-
plastic nevus, and invasive melanoma. Since the progno-
sis and management of melanoma is based primarily on
the Breslow depth of invasion, an adequate deep margin is
necessary in the diagnosis. Thus, a proper initial biopsy is
critical to correctly diagnose and characterize melanoma.
This type of information is best obtained in the initial
biopsy. There is more flexibility in the type of biopsy tech-
nique chosen for diagnosis of non-melanoma skin cancers,
with respect to important factors such as location, appear-
ance, and the size of the lesion.
Types of biopsies
An excisional biopsy refers to en toto removal of a suspi-
cious lesion. This is performed with a margin (as defined
below) of clinically normal tissue. It is the preferred
method of removing a pigmented lesion for histologic
interpretation.
An incisional biopsy is used to sample only a part of a
suspicious lesion for histologic evaluation. It is an appro-
priate method to biopsy a suspicious non-melanoma skin
cancer.
Shave biopsy refers to a shallow removal of a lesion at
a depth confined to the dermis. It can be performed by a
­scalpel, a Dermablade®, a razor blade, or scissors.
A saucerization is a biopsy which occurs through viable
dermis into subcutaneous fat. It is performed by angling a
scalpel at approximately 45 degrees to the skin and remov-
ing a disc of tissue, including all or part of the suspicious
lesion, well into the subcutaneous fat.
Punch biopsy refers to the use of a sharp circular instru-
ment to remove tissue well into the subcutaneous fat. It is
usually sutured.
Fusiform ellipse allows for full-thickness removal of the
suspicious lesion, as well as a margin of surrounding skin.
It is sutured.
The margin removed is defined as the area of normal-
appearing tissue surrounding the lesion to be removed
and has two components. The peripheral margin is the area
of normal skin extending radially from the clinically suspi-
cious lesion while the deep margin is the depth to which skin
and subcutaneous tissue is entered and removed during the
biopsy.
 Decision-Making Process

Equipment ­ rocedure. On or near the tray should be the formalin-­containing

p
specimen bottle(s) with the patient’s identifying information
The equipment needed for biopsies need not be elaborate (Fig.  40.3). This cannot be overemphasized, as there have
but should be of good quality. The equipment should be been unfortunate cases of mislabeled specimen bottles
properly maintained and sterilized prior to each use. and/or lost specimens that were left on the tray intended
Following is a list of commonly used equipment (Figs for subsequent transfer. Sterile surgical gloves are generally
40.1 and 40.2): not necessary for biopsies, with the exception of excisional
 Scalpel – #15 blade is the most often used and incisional biopsies needing buried absorbable sutures
 Needle holder – Webster or Halsey to close the biopsied site.
 Forceps – Adson type with teeth
 Scissors – Iris and Metzenbaum Anesthesia
 Skin hook – single or double prong
Lidocaine 1% mixed with epinephrine (adrenaline) at
 Dermablade or Gillette blue blade 1:100,000 is typically used for local anesthesia. The onset of
 Punch – 2, 3, 4, 5, 6, 8 mm action is almost immediate with local injection and the dura-
 Suture material tion of action is 1–2 hours,2 thus making lidocaine 1% with
 Aluminum chloride – 35% epinephrine ideal for short biopsy procedures. However,
 Electrocautery it is optimal to wait 7–10 minutes following local infiltra-
 Gauze tion to optimize the full vasoconstrictive effects of the epi-
 Cotton-tipped applicator. nephrine. Lidocaine and epinephrine mix can be obtained
as a premixed formula or can be freshly mixed on a daily
When performing a biopsy, a tray should be prepared basis. Premixed lidocaine with epinephrine contains pre-
with all the equipment that is needed for that particular servatives and has a low pH of 3.3–5.5. This low pH causes
an increased amount of pain upon injection. Freshly mixed
solution is desirable as it has a more neutral pH of 6.5–6.8,
thus minimizing the pain from local infiltration. Sodium
bicarbonate can be mixed to buffer stock (premixed) lido-
caine by the addition of 1 cm3 NaHCO3 to every 10 cm3 of
lidocaine to neutralize the pH and decrease the pain of
injection.3
Patients may describe a history of heart palpitations and
tremors with local anesthesia, leading them to report this
as an allergy. Very few patients are truly allergic to lido-
caine and most often these symptoms are due to the sys-
temic adrenergic effects of epinephrine. The history should
be carefully assessed and the epinephrine diluted or elimi-
nated accordingly. The most frequent side effect encoun-
tered is a vasovagal reaction manifested by hypotension
and bradycardia. Amide anesthetics do not cross-react with
other drugs and true allergic reactions are extremely rare. If
a true allergy to lidocaine (in the amide family of anesthet-
Figure 40.1  Biopsy equipment. Some of the commonly used equipment,
listed from left to right. (a) Webster needle holder, (b) small Metzenbaum ics) is documented, an anesthetic from the ester family, such
scissors, (c) Adson forceps with teeth, (d) scalpel handle and #15 blade. as procaine, can be used. It is more likely to have an allergy

Figure 40.2  Punch biopsy. Disposable punch device. These range from Figure 40.3  Biopsy tray. A labeled specimen bottle should always be set out
1.5 to 10 mm. Most commonly used sizes are 2, 3, 4, 6, and 8 mm. prior to the biopsy.

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 Part

6 Chapter 40 • Biopsy Techniques

to the ester family anesthetics, however, as these can cross-
react with para-amino benzoic acid, sulfonamides, and thi-
azides. Lastly, diphenhydramine solution (12.5–25 mg/kg)
or normal saline can be used as local anesthesia for smaller
lesions.4 When the medical history is unclear, an evalua-
tion by an allergist to determine a safe local anesthetic is
critical.
The local anesthetic is injected intradermally using a
30-gauge needle (Fig. 40.4). Rapid needle insertion through
the skin and slower infiltration of anesthetic agent causes
less discomfort. Furthermore, it often eases anxiety to
prepare the patient by discussing the technique prior to
injection. In children and very anxious adults, a topical
anesthetic cream can be applied 30 minutes to 2 hours prior
to injection to reduce the pain of needle insertion and injec-
tion pain.5
Figure 40.4  Anesthesia injection. 1% lidocaine with epinephrine is most
commonly used for local anesthesia. A 30-gauge needle is used to infiltrate
slowly into the dermis.
Contraindications to biopsy
There are no absolute contraindications to a skin biopsy.
The main relative contraindication is the potential for bleed-
ing. Many patients requiring skin biopsies are older and
use anticoagulants. While there may be an elevated risk of
postoperative bleeding, the use of warfarin or aspirin is not
contraindicated. Extra measures such as electrocoagulation
and pressure dressings may be needed for enhanced hemo-
stasis in select cases. In patients on chemotherapy or with
diseases that affect platelets, it is best if the platelet count is
above 10,000 per microliter.
BIOPSY TECHNIQUES – ILLUSTRATED
Punch biopsy:  Trephines (handheld punches) are avail-
able in sizes that range from 1.5 mm to 10 mm and may be
used for excisional or incisional biopsies. A proper punch
biopsy size must be chosen in order to obtain an adequate
tissue sample. Determination of trephine size is guided
by whether an incisional or excisional biopsy is indicated
(Table 40.1). For an excisional biopsy, the punch should
be 1.0 to 1.5 mm greater in diameter than the lesion. For
an incisional biopsy, a 2–4 mm punch is commonly used.
After adequate anesthesia, traction is placed across the skin
tension lines, converting a circular region into an elliptical
shape (Fig. 40.5A–E). When traction is released, the resul-
tant elliptical defect allows for an easier and aesthetically
superior closure. The punch is rotated back and forth on
the skin with constant pressure through the full thickness
of the dermis. A characteristic ‘give’ is felt when the sub-
cutaneous fat is reached. The specimen should be carefully
grasped only on one edge so as to minimize crush arti-
fact on histologic examination. The base of the specimen
is cut at the level of the subcutaneous fat. Hemostasis is

Table 40.1 Biopsy Selections for Neoplastic Skin Lesions

Pigmented Lesion
Type of Biopsy Indications Anatomic Locations Use Method of Healing

Shave Suspect non-melanoma skin All No Second intention

cancer (BCC, SCC)

Punch (incisional) Large pigmented lesions Cosmetically sensitive Yes† Simple interrupted, vertical
(when excisional biopsy locations mattress sutures
cannot be performed)

Punch (excisional) Small pigmented lesions (to All Yes Simple interrupted, vertical
be removed en toto) Rare mattress sutures
neoplasms*

Fusiform ellipse Pigmented lesions (with Aligned along relaxed skin Yes Linear layered closure
surgical margin for diagnosis tension lines
and treatment)

Saucerization Pigmented lesions Upper back, shoulders, Yes Second intention

upper arms, and anterior
chest; occasionally, lower
extremities and ears

*Lesions where the differential diagnosis includes amelanotic melanoma, atypical fibroxanthoma, dermatofibrosarcoma protuberans, Merkel cell carcinoma
or other rare neoplasms of the skin should be biopsied with an incisional punch or any excisional biopsy (ellipse or excisional punch), based on the size and
anatomic location, to evaluate the deep margins.

Used when pre-test probability of suspicious lesion is low to moderate. Lesions with a high pre-test probability for melanoma should be excised.
†

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 Biopsy Techniques – Illustrated

A B

C D

Figure 40.5  Punch biopsy. A) Traction is applied using two fingers

perpendicular to the relaxed skin tension lines, providing a rigid surface
for the cutting edge of the punch device. B) The punch is then pushed
through skin while applying a circular back-and-forth motion. C) The
specimen is gently grasped on one edge and transected at the level of
the subcutaneous fat. D) The resultant defect is elliptical because the
circular biopsy was done under traction. This allows for an easier linear
closure. E) After closure with cuticular sutures.

usually achieved with pressure and suture closure. Rarely, benign. The infiltration of anesthesia in the mid-dermis
­electrocauterization may be needed. Punch biopsies, with will ­provide a rigid plane and squeezing the surround-
rare exception, are closed with simple interrupted or verti- ing skin will provide an elevated plane for shave biopsy.
cal mattress stitches for wound edge eversion to obtain the Using a #15 blade scalpel, Dermablade, or razor blade,
best cosmetic result. a shallow horizontal incision is made through the lesion
at the level of the surrounding skin or slightly below.
Shave biopsy:   A shave biopsy is used to remove the Forceps can also be used for gentle countertraction (Fig.
superficial component of a lesion raised above the level 40.6A,B). A Dermablade or a razor blade also allows for a
of the surrounding skin. The level at which the shave is precise shave biopsy. The blade is flexed to match the size
performed is either at that of the surrounding skin or of the lesion and is slid back and forth through the lesion
slightly deeper. The intent is usually not to remove the until the entire lesion is removed (Fig. 40.7). Hemostasis is
entire neoplasm but rather to obtain a representative sam- obtained with aluminum chloride 35%. The resultant scar
ple for histopathologic examination. Accurate sampling is circular and approximates the size of the initial lesion.
and cosmetic outcome are two factors considered when There may be a subtle indentation if the incision was made
performing a shave biopsy, as many ­biopsied lesions are in a deeper plane.
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 Part

6 Chapter 40 • Biopsy Techniques

Figure 40.6  Shave biopsy. A #15 blade scalpel is

used to shave the raised component of the suspected
cancer. The surrounding skin is squeezed together to
provide an elevated and rigid plane (A) or forceps are
used for countertraction (B).

A B

Saucerization:  A saucerization provides an excisional
specimen for the dermatopathologist. This technique is easy
to perform, time efficient, and often preferred by patients
and physicians in areas of the body where it is difficult to
create an elegant scar. These areas include the upper back,
Figure 40.7  Shave biopsy. Dermablade® is flexed to fit the lesion and is slid
side to side through the lesion.
shoulders, upper arms, and anterior chest, where scars
often spread and/or become hypertrophic. Occasionally,
saucerizations are also used to biopsy lesions on the lower
extremities and ears. The key is to perform true sauceriza-
tion, i.e. a biopsy into subcutaneous fat. With saucerization,
a smaller, rounder, and more cosmetically acceptable scar
will replace a longer, linear spread excisional scar while
providing adequate tissue for histologic interpretation.
A #15 blade scalpel is placed approximately 45 degrees
to the skin surface. The incision is made around a 1–2 mm
peripheral margin of the lesion, then angled tangentially
deeper through the dermis to the level of the subcutaneous
fat. This generates a disc- or saucer-shaped piece of tissue
that contains the entire lesion (Fig. 40.8A,B). The defect then
heals by secondary intent without the need for sutures.
Fusiform ellipse:   The fusiform elliptical excision is the
cornerstone of cutaneous surgery. It is easy to perform,
gives excellent cosmetic results, and provides tissue of suf-
ficient depth to aid in an accurate diagnosis by the der-
matopathologist.6 In designing the ellipse, the long axis
should generally be oriented along the relaxed skin ten-
sion lines and the draining ­lymphatics for that site. The
length is approximately three times the width but this
will vary depending on the adjacent skin laxity. The ideal

A B

Figure 40.8  Saucerization. A) The scalpel blade is angled at 45 degrees. The incision is made tangentially to create a disc-shaped specimen B) The specimen
is removed at the level of the fat.
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angle of the apices is 30 degrees in order to minimize puck-
ering of redundant skin. The #15 scalpel blade is angled
perpendicular to the skin surface and the incision is car-
ried through the skin into the subcutaneous fat. The speci-
men is removed in its entirety maintaining a flat-bottomed
­surface (Fig. 40.9A–C).
The fusiform ellipse is usually closed in linear layered
fashion. The defect is undermined at the level of the subcu-
taneous fat to alleviate tension and to promote wound ever-
sion. After adequate hemostasis is achieved, the wound is
carefully re-approximated using absorbable buried dermal
interrupted sutures. The needle insertion should begin at
the deep aspect, allowing the knot to lie deeply, decreasing
the chances of a spitting suture. The superficial or cuticular
layer is generally closed with a non-absorbable monofila-
ment suture (Fig. 40.10A–E).
DIAGNOSIS OF MELANOMA
When examining a patient with one or several suspicious
pigmented lesions, the question often arises, ‘Do I need to
perform a biopsy, and if so, which technique do I choose?’
A clinician must weigh the given risks of a particular lesion
with the patient or family concern (in the case of children)
for scarring, inherent in all biopsy procedures.7
There are several tools available to help decide whether
or not to biopsy a particular pigmented lesion. These
include dermoscopy, precise photography, ‘mole mapping’
by computer, and other tools in developmental stages (see
Chapter 37). As clinicians we develop expertise to deter-
mine which group of patients and which particular lesions
are concerns for the development of melanoma. If our sus-
picion is moderate or high, we will routinely remove the
pigmented lesion and submit it for histologic analysis by a
dermatopathologist. This is both reassuring to the patient
as well as the clinician, and frequently may lead to a diag-
nosis of melanoma in its earlier, less advanced stage.
The excisional biopsy is the preferred method of remov-
ing a clinically suspicious pigmented lesion. It provides
the dermatopathologist with the most adequate tissue
sampling to correctly diagnose a melanoma. If present, the
maximum depth of invasion of the melanoma (Breslow
level) can be measured as well as other histologic ­criteria
A B
Figure 40.9  Fusiform elliptical excision. A) A 1–2 mm margin is delineated around the lesion and oriented along the relaxed skin tension lines and/or direction of
lymphatic drainage. B) Incision is made through the dermis into the fat. C) Defect is ready for layered closure.
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Diagnosis of Melanoma
of importance, which helps define the extent of further
­necessary surgery.
When performing an excisional biopsy, the clinician
should first examine the lymph nodes in the suspected
draining basin(s) from the lesion in question. If the lesion
turns out to be a melanoma, inflammation from the biopsy
procedure can result in a false positive ‘dermatopathic’
node. A Wood’s light is helpful to assess the complete
margin, sometimes extending beyond the obvious clinical
appearance of the lesion. A 1.0–1.5 mm margin is marked
around the lesion and removed at the level of the subcu-
taneous fat.8,9 When possible, the biopsy is aligned along
relaxed skin tension lines and along the draining lymphat-
ics from that site. The former allows for an easier and more
cosmetically acceptable procedure if the lesion is a mela-
noma and requires re-excision. The latter allows for a more
accurate sentinel lymph node biopsy if indicated.
The excisional biopsy can be performed with either a
punch or a fusiform (elliptical) excision. Choosing a punch
1.0–1.5 mm greater in diameter than the lesion to be biop-
sied assures a full-thickness removal of the entire lesion that
is easy and quick to perform with a cosmetically acceptable
scar. If the lesion is larger and/or in a cosmetically sensi-
tive area such as the head and neck, a fusiform (elliptical)
excision with full-thickness closure provides adequate tis-
sue for the pathologist and an excellent cosmetic result if
the pigmented lesion is benign.
A saucerization biopsy can also be used to provide an
excisional specimen for the dermatopathologist. Again,
the key is to make sure this is a true saucerization, i.e. a
biopsy into fatty tissue. Because of their tendency to heal
with hypertrophic or spread scars, the torso and extremi-
ties are often best biopsied by saucerization. Superficial
shave biopsies should not be used for pigmented lesions,
especially if one is attempting to rule out melanoma. The
transection of the specimen base will lead to an uninterpre-
table Breslow level.
An incisional biopsy can be used to diagnose melanoma
in a worrisome pigmented lesion. However, because it does
not sample the entire lesion in question, incisional biop-
sies may lead to an inaccurate diagnosis or an inaccurate
­calculation of the Breslow depth. Incisional biopsies can
be performed on very large lesions and/or in cosmetically
C
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6 Chapter 40 • Biopsy Techniques

A B

C D

Figure 40.10  Fusiform elliptical excision – closure. A) Wound is

undermined using a skin hook and Metzenbaum scissors. B) Dermal
suture is inserted from the deep aspect of the wound, then C) passed
superficial to deep on the other side and D) knotted to create an everted
wound. E) Final appearance.

s­ ensitive regions (Fig. 40.11A,B). The darkest pigmented
and/or raised area of the lesion should be biopsied. This
can be performed using a punch biopsy, small fusiform
ellipse, or a saucerization down to the level of the subcuta-
neous fat. When performed, the incisional biopsy specimen
should be cut and processed along the longitudinal axis to
maximize the cross-section area available histologically for
the dermatopathologist.
Although most clinicians feel that an incisional biopsy
does not ‘spread’ tumor or influence survival,10 there still
exists a theoretical risk that cutting through the tumor may
lead to local spread of the melanoma. Implantation and
seeding of malignant cells with certain surgical procedures
is a phenomenon known to occur with other neoplasms such
as breast and colon cancer.11–13 Most studies indicate that
­performing an incisional biopsy does not influence progno-
sis in patients with melanoma.14–18 Nor does it appear that
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incisional biopsies of melanoma influence recurrence or
mortality when compared to their excisional counterpart.19
Few studies have suggested otherwise.20,21
Most recently, it has been demonstrated that an incisional
biopsy that leaves behind >50% of the initial clinical lesion
may in fact result in false microstaging and significantly
underestimate the depth of the tumor and lead to under-
staging. In a study of melanoma patients diagnosed by sub-
total incisional biopsy, more than 20% required upstaging,
with almost half of those patients then becoming eligible for
sentinel node biopsy by AJCC criteria.22 Inaccurate Breslow
depth estimation from incisional punch biopsies of mela-
nomas has been demonstrated elsewhere.23,24 Lesions sus-
pected to be melanoma in situ are of particular relevance
as up to 25% of cases are ultimately determined to contain
an invasive component upon further review.25 Because his-
tologic evaluation of the entire lesion depth and periphery

Figure 40.11  Incisional biopsy. A) A large and ill-
defined pigmented lesion on the cheek with variegate
pigmentation. Punch biopsies can be taken from the
darker areas, or B) an incisional ellipse is made through
the most suspicious area. The lines demonstrate the
axis of sectioning in order to maximize the cross-section
seen by the dermatopathologist.
A B
are so vitally important to staging and treatment, it must be
advised to perform an excisional biopsy where possible on
a lesion suspicious for melanoma.
DIAGNOSIS OF NON-MELANOMA SKIN CANCER
The two most prevalent non-melanoma skin cancers
(NMSC) are basal cell carcinoma (BCC) and squamous
cell carcinoma (SCC). Incidence of these cancers number
1 million and 250,000 per year, respectively, in the United
States.26 It is thus imperative, given their high incidence,
that the astute clinician recognize them clinically and obtain
a biopsy for correct diagnosis.
Morphologically, NMSC can be exophytic, macular, or ulcer-
ated. They can be pinpoint in size or consume large parts of a
face, trunk, or extremity. These differences impact the choice of
biopsy. An excisional biopsy is rarely needed for NMSCs.
An exophytic lesion such as a nodular BCC, or a hyperker-
atotic SCC can be biopsied using the shave technique. Near-
complete removal of the surface component usually results
in an adequate tissue sample for an accurate diagnosis. One
must be cautious, however, of lesions that have a significant
hyperkeratotic component (e.g. cutaneous horn). A shave
through only the hyperkeratotic component may not remove
the full epidermis, necessary to distinguish SCC from an
actinic keratosis. Occasionally, amelanotic melanoma can
present as a skin-colored papule or nodule. If there is any
concern that a lesion is something other than a clinically rou-
tine BCC or SCC, a deeper biopsy should be considered.
BCC can present as different histologic subtypes.
Sclerosing (morpheaform) and infiltrative types of BCC typ-
ically have a significant component that is below the level of
the skin surface which can be clinically subtle or inapparent
(subclinical extension). When there is minimal or no raised
component, a deeper biopsy is indicated and a punch biopsy
usually results in an accurate diagnosis. Sometimes, how-
ever, multiple punch biopsies may need to be performed on
the same lesion, especially when the cancer is recurrent and
is adjacent to or part of a prior surgical scar.
Many different malignant and non-malignant skin con-
ditions can present as an ulcer. Due to the dense inflamma-
tion invariably present in the ulcer bed, the biopsy should be
taken from the wound edges in order to obtain proper diag-
nosis. As most ulcers are not cancerous, all ­longstanding
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References
ulcers without obvious cause should raise the concern of
possible malignancy.
POST-BIOPSY CARE
Biopsy sites that heal by secondary intent need to be cleaned
daily with soap and water. They should heal under moist
conditions and therefore need to be covered with an oint-
ment and non-adherent bandage. Sutured wounds need
less daily care but should be kept clean. Fusiform excisions
closed with a layered closure should have a pressure ban-
dage placed for 24 hours postoperatively. Postoperative
pain is usually managed effectively with acetaminophen.
Non-steroidal anti-inflammatories and aspirin are not rec-
ommended, as these can increase the risk for postoperative
bleeding.
SUMMARY
Incisional biopsies are appropriate for non-melanoma skin
cancers and can be performed in limited circumstances for
pigmented lesions, but should be done so with caution as
sampling error may lead to missed diagnosis or inaccu-
rate histologic criterion, such as depth. Excisional biopsies
should be considered for pigmented lesions and should
extend to the subcutaneous fat by means of a punch biopsy,
a fusiform ellipse, or a saucerization. The clinician must also
consider the cosmetic result, although not at the expense of
a proper diagnosis.
FUTURE OUTLOOK
Choosing the appropriate biopsy technique for a suspicious
cutaneous lesion will continue to remain critical in estab-
lishing a correct and complete diagnosis, and, in turn, will
influence the extent of further necessary surgery and/or
other adjuvant therapy.
REFERENCES
1 . Stedman’s Medical Dictionary. 24th ed. Baltimore: Williams & Wilkins;
1982.
2. Norris Jr RL. Local anesthetics. Emerg Med Clin North Am.
1992;10(4):707–718.
3. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine
for local anesthesia. J Dermatol Surg Oncol. 1989;15(10):1081–1083.
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6 Chapter 40 • Biopsy Techniques
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