DOI: 10.1111/j.1468-3083.2012.04608.x
ORIGINAL ARTICLE
Abstract
Background Diagnosis of clinically suspected basal cell carcinoma (BCC) by histological confirmation with punch
biopsy has been recommended before treatment. Even shave biopsy has been proposed as useful to predict the
correct subtype in primary BCC in 7681%, whereas the agreement between histological BCC subtype on punch
biopsy and subsequent excision specimens in recurrent BCC is 67.1%. However, no large studies on the agreement
between histological BCC subtype seen on punch biopsy and the following surgical excision are performed in
primary BCC.
Objective The aims of this study were (i) to establish the agreement between histological BCC subtype on punch
biopsy and the subsequent surgical excision of primary BCC and; (ii) to investigate the proportion of primary BCCs
in which punch biopsy enables identification of the most aggressive growth pattern.
Methods Retrospective analyses of 243 primary BCCs with both punch biopsy and subsequent surgical excision.
Analyses were based on the most aggressive histological subtype of the tumour.
Results The agreement between BCC subtype on punch biopsy and the subsequent surgical excision of primary
BCCs was 60.9%. A punch biopsy can predict the most aggressive growth pattern of primary BCCs in 84.4%.
Seventy-four percentage of all primary BCCs consisted of more than one histological subtype.
Conclusion Dermatologists and other physicians have to be aware of the limited diagnostic value of a punch
biopsy to determine the histological BCC subtype of the whole lesion. Misdiagnosis of the subtype will lead to
undertreatment in one of six primary BCCs.
Received: 27 March 2012; Accepted: 16 May 2012
Conflict of Interest
None declared.
Funding sources
None declared.
Introduction
Basal cell carcinoma (BCC) is a major problem in Caucasians
worldwide. Incidence rises at an alarming rate by 310% annually.1,2 One in six persons will develop a BCC during their life and
this puts a heavy burden on health care systems.3,4 Treatment of
BCC is based on the histopathological BCC subtype, its location
on the body and whether it concerns a primary or recurrent
BCC.5,6
Three histopathological subtypes can be distinguished for
determining treatment: superficial (sBCC), nodular (nBCC) and
Prior to treatment, punch and shave biopsies have been proposed to confirm the clinical BCC diagnosis and to determine the
histopathological BCC subtype.8 The most aggressive histological
BCC subtype that is identified by biopsy will be an important
determinant of treatment choice. Detecting the most aggressive
subtype can be difficult as 1849% of BCC consist of more than
one subtype.79 Failure to detect aggressive subtypes may result in
under treatment. For this reason, it is important to know in what
proportion of patients a biopsy enables identification of the most
aggressive histological subtype of BCC. Three previous studies,
one on punch biopsies in recurrent BCCs and two on primary
BCCs that were mostly biopsied by a shave biopsy, have suggested
that the agreement between histological subtype on biopsy and the
subsequent surgical excision is limited.1012 The aim of this study
is to evaluate the agreement between punch biopsy and excision
on the most aggressive histological BCC subtype in primary BCCs
and, thereby, determine the true utility of punch biopsies in the
presurgical planning.
895
Results
Patient characteristics
Roozeboom et al.
896
Discussion
The proportion of punch biopsies that correctly predicts the most
aggressive growth pattern of the entire BCC is 84.4%. As treatment
choice of BCC is based on the most aggressive histological subtype
seen on punch biopsy, this means that in one out of six BCCs the
most aggressive growth pattern is missed in an adequately taken
punch biopsy. These tumours might not be properly treated and a
higher percentage of re-excision or recurrences may occur.
Only three previous studies reported on the agreement between
histological BCC subtype on biopsy and the subsequent surgical
excision in BCC.1012 These studies included mainly shave biopsies
in primary BCCs or reported on punch biopsy in recurrent BCC.
Table 1 Histological diagnosis of the most aggressive BCC subtype on punch biopsy compared to surgical excision
Biopsy
Surgical excision
Superficial BCC
Superficial BCC
Nodular BCC
Aggressive BCC
Total
Nodular BCC
Aggressive BCC
Total
5 (2.1)
2 (0.8)
2 (0.8)
9 (3.7)
31 (12.8)
85 (35.0)
34 (14.0)
150 (61.7)
2 (0.8)
24 (9.9)
58 (23.9)
84 (34.6)
38 (15.6)
111 (45.7)
94 (38.7)
243 (100)
897
Table 2 Mixed histological BCC subtypes (n = 180); punch biopsy vs. surgical excision.
Punch biopsy
Superficial (4)
Surgical excision
Nodular (1)
100% (4 4)
Superficial (10)
0% (0 31)
19% (8 43)
0% (0 31)
Superficial (1)
Nodular (7)
Nodular + superficial (2)
Aggressive (4)
Mixed with aggressive (17)
Superficial (21)
Nodular (3)
Nodular + superficial (11)
Aggressive (2)
Mixed with aggressive (6)
Superficial (1)
Nodular (10)
Nodular + superficial (6)
Aggressive (5)
Mixed with aggressive (26)
Total (180)
Underlying the numbers in the last two columns is the assumption that the most aggressive histological subtype of the tumour, seen on either
punch biopsy or surgical excision, defines the definite histological subtype of the tumour.
BCC, basal cell carcinoma.
Acknowledgements
None reported.
References
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