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    Deep shave biopsy remains efficient, useful technique

    Tampa, Fla. — Although there is concern about a slight risk of under-staging caused by technique inaccuracy, benefits outweigh all of the risks when conducting a deep shave biopsy, says Mary H. Lien, M.D., department of dermatology & cutaneous surgery, University of South Florida College of Medicine and the H. Lee Moffitt Cancer Center, Tampa.

    Dr. Lien
    Currently, several techniques are used in the workup of suspicious lesions, including excisional, punch and shave biopsies. According to Dr. Lien, deep shave biopsies (also known as deep scallop biopsies) are commonly used because they are simple and efficient and can save valuable time.

    "The excisional biopsy is the recommended diagnostic procedure to sample a skin lesion suspicious for melanoma. Many clinicians may choose this technique because of the concern that other biopsy methods, including superficial shave biopsies, deep scallop shave biopsies and punch biopsies, can potentially cause inaccurate staging of the melanoma due to inadequate sampling of the tissue. However, we believe that this conclusion may be premature," Dr. Lien says.

    Study details

    A retrospective analysis conducted at Dr. Lien's institution involved 600 consecutive patients who underwent a shave biopsy for suspicious skin lesions. The analysis showed that deep shave biopsies were accurate in determining diagnosis and microstaging melanoma when compared with the final diagnosis at wide excision, she says.

    The data obtained on shave biopsy of melanoma was reliable and accurate in 97 percent of cases, she adds. The study also found that in the great majority of cases where shave biopsy was performed for melanoma, melanoma was not in the stated differential diagnosis (Zager JS, Hochwald SN, Marzban SS, et al. J Am Coll Surg. 2011;212(4):454-462).

    Biopsy options

    Dr. Lien's biopsy technique of choice during a routine office visit would be to perform a deep scallop technique when addressing suspicious pigmented lesions, particularly when time is in short supply. This technique may not be ideal for lesions on the face or in those patients who may be cosmetically sensitive, however, as the potential resultant depressed round scar may be cosmetically unacceptable, she explains.

    Dr. Lien says that some clinicians consider the linear scar resulting from an excisional biopsy an unnecessary cosmetic defect because it is a much longer scar than necessary. In cosmetically sensitive cases and where considered appropriate, Dr. Lien says she may opt for a punch biopsy. A punch biopsy has a very discrete metallic hub that is consistent, and once the hub of the punch biopsy apparatus is completely submerged, the punch should be expected to reach the adipose layer, she says.

    When performing a deep shave biopsy, Dr. Lien says she always tries to reach at least the deep reticular dermis, which is usually where the furthest expansion of pigmented cells may reside. "Using this deep shave biopsy technique, we rarely get any pathology reports back stating insufficient tissue specimen. I believe that with proper diligent supervision, this technique can be taught, learned and reproduced consistently," Dr. Lien says.

    Though the excisional biopsy technique is the optimal approach, Dr. Lien says, it is very time consuming, making the deep shave biopsy a practical and still efficient technique choice.

    "In an ideal world where time was not so important, an excisional biopsy technique would be the best approach. Unfortunately, we have time restraints and it is not always the most ideal circumstance to have the patient prepped and scrubbed for an excisional biopsy and yet still maintain the clinic schedule if you want to fit the patient in on that day. The scallop technique is a much quicker technique and can save the clinician much valuable time, while at the same time manage to biopsy enough tissue of suspicious lesions," Dr. Lien says.

    Safety concerns

    According to Dr. Lien, shave biopsy, scallop shave biopsy and excisional biopsy techniques are all safe in terms of removing sufficient tissue for histology. Whenever possible, however, Dr. Lien says she will usually reserve the shave biopsy technique for nonmelanoma skin cancers such as basal cell carcinoma and squamous cell carcinoma.

    In cases where melanoma is suspected, Dr. Lien likes to choose the excisional biopsy technique. Nevertheless, the deep scallop technique can also offer the pathologist enough epidermis to comment on the whole lesion, including the circumscription, the symmetry and the pattern of the lesion, she says.

    Disclosures: Dr. Lien is on the speakers bureau for Abbott Laboratories and PharmaDerm.

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