Biopsy Techniques: Skin Lesions

Indications (indikasi)
To make or confirm histopathologic diagnoses (utk membuat atau mengkonfirmasi diagnosis histopatologi ) Definitive treatment of abnormal, malignant, and atypical lesions Elective removal for cosmetic reasons

Contraindications

Infection at biopsy site Bleeding disorder Allergy to local anesthetics

Risks
Bleeding
Avoid NSAIDs or ASA 10 days before large excisions Switch from warfarin to heparin for large excisions

Infection Scar
More common in children, young adults Higher risk areas: mandible, chest, neck, shoulders, hands, feet Previous history of keloid formation

Nerve damage
Face high risk area: facial motor nerve runs very close to dermal layer. Nerves run in subcutaneous fat plane.

Risks
Allergy to local anesthetics
Type I
can occur w/o previous exposure. Rare

Type IV: delayed hypersensitivity.

Needs previous exposure Usually local reactions, rash, contact dermatitis.

Amide agents
lidocaine, mepivicaine, bupivicaine, etidocaine Most commonly used agents Allergy is EXTREMEMLY rare.

Ester agents
procaine, tetracaine, chloroprocaine

Bacteriostatic saline or injectable diphenhydramine

Mild anesthetic effect. Lasts 15 minutes.

Risks
Allergy to topical antibiotics
Neomycin. 3rd most common contact allergen in U.S. Bacitracin. 6th most common contact allergen in U.S.

Description of Lesion
Flat Macule < 1 cm Patch > 1 cm Raised Papule < 1 cm Nodule 1-2 cm Tumor > 2 cm Plaque. Flat, elevated with surface area > height. Indurated. Firm

Pedunculated

How to chose your biopsy type ?

Flat
Punch or ellipse

Raised
Punch or ellipse if worried about melanoma Shave in other cases

Indurated
Punch or ellipse

Pedunculated
Shave or scissors

Where should I biopsy?

Pigmented lesion
Excise entire specimen. 1-3 mm margins

Rash
Developed but not excoriated lesion Multiple biopsies Biopsy at edge of lesions 4 mm punch

Blistering disorder
Excise entire blister or at blister edge
Formalin for histopathology

Biopsy peri-lesional normal skin

Saline soaked gauze for Direct Immunoflorescence (DIF)

How deep should you go?

Through epidermis/dermis into subcutaneous fat

Through epidermis & dermis

Punch & elliptical biopsies When concerned about melanoma Prognosis based on depth
Easier extraction of specimen

Shave biopsies
Raised or pedunculated Not worried about melanoma

Supplies & Instruments

Prep solution
Isopropyl alcohol, povidone-iodine, chlorhexadine

Drapes Gauze Syringes Needles

18 or 20 G to draw up. 25 or 30 G to inject.

Anesthetic
Lidocaine (0.5, 1 or 2%) with or without epinephrine Epinephrine okay to use on digits/acral areas

Supplies & Instruments

Punch biopsy (3mm-8mm) # 15 blade scalpel Iris scissors, forceps with teeth, needle driver Suture
Nylon, absorbable or prolene (blue) 4-0 or 5-0 with P-3 or FS-3 needle. 6-0 on face.

Hemostatic agent
Aluminum chloride (Drysol) Silver nitrate sticks. May stain skin brown

Processing solution (formalin, saline, etc) Dressing supplies

Shave biopsy
Create wheal to elevate lesion Stretch & stabilize skin #15 blade held parallel to skin
Smooth sweeping strokes Near end of excision, place forceps on top of lesion to stabilize and prevent tearing with exit of blade

Punch Biopsy
Determine direction of skin tension lines Stabilize skin with thumb/forefinger Consider stretching skin perpendicular to skin lines to create ellipse Place punch perpendicular to skin Apply firm downward pressure with a circular motion until reach sub-Q fat. Will feel give Forceps to remove lesion. Cut at base

Fusiform (Elliptical) Excision

Align long axis of excision parallel to skin tension lines Draw ellipse
2-5 mm wound margins 30 degree angles at each apex Length is 3-4 times the width

#15 blade scalpel Undermine at level of sub-Q fat with scalpel or scissor Place stitch at one end of biopsy sample
Helps to identify orientation of sample

Undermine wound edges in preparation for suturing

Processing biopsy specimens

Histopathology
10% buffered formalin

Direct immunoflorescence
Dx of blistering disease, SLE, etc. Michels solution Saline soaked gauze. Do not let specimen dry out

Bacterial or fungal cultures

Sterile container with nonbacteriostatic saline

Viral studies
Viral transport media

To suture or not to suture?

Does this biopsy need a stitch?
RCT comparing primary (suture) vs secondary healing in 4 mm vs. 8 mm punch biopsies.
Doctors: no difference in healing or cosmesis in 4 mm or 8 mm biopsies. Patients: no difference in healing or cosmesis in 4 mm biopsy. Better cosmesis with suture in 8 mm bx.

Sutures

-- Monofilament nylon (Ethilon) -- Polypropylene (Prolene)

What about absorbable sutures?

Some evidence: absorbable polyglactin (Vicryl) sutures equal to nylon sutures in rates of infection, redness, dehisence, scar hypertrophy, patient satisfaction.

Simple Suture

Vertical Mattress Suture

Post Procedure Care

Wounds heel faster when moist
Vaseline or antibiotic ointment

Occlusive or semi-occlusive dressing Remove bandage after 12-24 hrs Cleanse with soap/water twice daily Bandage for approx 5 days or until re-epithelialized Shower okay with sutures. Avoid soaking Avoid activities that will put stress on sutures

Suture Removal
Face
4-6 days; apply Steri-Strips

Chest, abdomen, upper extremities, scalp

7-10 days

Back, lower extremities

12-20 days

Pathology Forms: Essential Information

The 6 Ds
Demographics: age, gender, ethnicity Description: -location, color, symptoms, other areas of involvement, previous therapy or biopsy. Diseases & Drugs Duration of condition Diameter of lesion or eruption Diagnosis: in order of likelihood -Can be broad categories such as malignancy, dermatitis, infection. -Avoid terms like rule out

Documentation
Diagnosis: Reason for procedure Description and location of lesion Procedure: Shave vs. Punch vs. Ellipse Consent: Risks and benefits reviewed Prep and Anesthesia Description of procedure Specimen disposition Patient education and follow-up

Follow-up of pathology results

No uniform recommendations Interpretation requires understanding of clinical scenario Work closely with your dermatologist Get to know YOUR dermatopathologist

The End