5 Questions to Ask to Help You Decide Biopsy Technique

Last week, I presented this case study to you and I asked, “How would you treat this patient?”...

The patient showed up with a large, non-fixed, smooth, pink tumor superior to his left elbow. 

Here were your choices….

  1. Excision
  2. Punch biopsy
  3. Shave biopsy
  4. Defer to collaborating dermatologist/Mohs surgeon
  5. Defer to outside specialist 
  6. Other

As dermatology providers, it can be confusing to figure out which would be the best type of biopsy to perform.  There are many things that we need to factor in that can influence that decision…

  • Which biopsy technique will provide the best diagnostic answer?
  • Which is the most cost effective?
  • Time efficient?
  • Which would be the most cosmetic approach?
  • Which portion of the lesion is necessary to provide the best information to the pathologist?

Considering all these factors, the treatment option I chose that was best for this particular patient was….an Excision. 

The advantages of performing this technique were the following:

  • He already had a consultation with a fellow colleague of mine and was already placed on my schedule for the excision to be performed. So, time and prep was not an interruption to my work flow. Having the right skilled staff to manage your schedule, set you up, and help your work flow helps tremendously (especially when those surprise patients that, potentially, hold up your clinic walk in!).
  • Because I was concerned of malignancy (DDX: SCC, BCC, Amelanotic Melanoma, Merkel Cell), I knew the benefit of performing the excision is that it would remove enough of the lesion, full-thickness, and the risk of missing the diagnosis from a focal biopsy was minimized.
  • The benefit of an excisional biopsy to a lesion that is highly suggestive of malignancy is, not only will it provide a full-depth sample, but it can potentially clear the skin cancer if appropriate margins were used (3mm margins used in this case study).  
  • If benign (DDX: Neuroma, EIC, others that come to mind?), the patient would be pleased that this growing tumor was removed regardless.

The disadvantages of performing an excisional biopsy were the following:

  • If the pathologist reports malignancy is still present, the patient would have to return back for re-excision.
  • Time, prep, and cost is increased compared to performing a more simpler procedure (e.g. shave/punch biopsy).
  • Patient will require sutures and longer down time.
  • Underlying structures (e.g. nerves, arteries) are at risk of injury.

Now that I've walked you through the advantages/disadvantages of the excisional method, let’s briefly discuss the disadvantages/advantages of the other options relative to this case…

Punch Biopsy

Advantages

  • Minimal equipment is needed
  • Procedure is quick, cost effective, and simple to perform 
  • Provides a full-depth specimen

Disadvantages

  • Sample may not be representative of the entire lesion yielding an inaccurate diagnosis
  • Requires sutures

Shave Biopsy

Advantages

  • Minimal equipment is needed
  • Procedure is quick, cost effective, and simple to perform
  • If entire lesion removed by shave, better diagnostic result
  • Does not require sutures

Disadvantages

  • Lesion can recur
  • If transecting lesion occurs, the interpretation of true depth is missed which is required for treatment for a malignant melanoma
  • Risk of bleeding due to size of tumor

Defer to collaborating dermatologist/Mohs surgeon

  • This is an excellent option if performing a biopsy to a lesion this size is not in your comfort zone. However, time it takes to be seen may prolong treatment.

Defer to outside specialist  

  • This is an excellent option if you do not have a fellow dermatologist/Mohs surgeon available. However, just as mentioned, the availability and access to an outside provider may delay treatment. 

Now, there are many other factors to consider when considering biopsy technique for other types of presentations (e.g. rashes, pigmented lesions).

 For simplicity purposes, these considerations mentioned above are some of the core elements you need to know when approaching a suspicious lesion that are similar to this particular case.

To wrap everything up, if you ever come across a case study similar to this, remember these 5 QUESTIONS when deciding which biopsy technique would be best for your patient?

  1. Which technique will provide the best diagnostic answer? 
  2. Which is the most cost effective and time efficient? 
  3. Which would be the best cosmetic approach? 
  4. Which portion of the lesion is necessary to provide the best information to the pathologist?
  5. Is this in my comfort zone and do I need to defer treatment to another provider?

Next week, I will share with you the SURPRISE diagnosis that came back 😳! 

Let’s just say it was my first time encountering this diagnosis in the 10 years I’ve been in dermatology and, you bet, I deferred care and treatment to our Mohs surgeon!

Hope this helps and I'll follow up with you next week!

Serving with Gratitude,

Theresa Talens, DNP, FNP-C (TheresaSurgDermNP) ❤️

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