Mr. Andy Pay FRCS (Plast), Consultant Plastic Surgeon
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There are many different strategies in relation to skin lesion biopsies. In the simplest terms, a biopsy is a piece of tissue which is removed and sent to the laboratory for microscopic assessment. There are different types of biopsy available and these are chosen dependent on a number of factors.
This is the most commonly used technique; the principle being that the entire lesion is removed with a cuff (or margin) of tissue around the lesion, to try to optimise the chances of complete excision. It is therefore often diagnostic and therapeutic as it is used with an intention to treat. The margin may vary in size depending on the site, size and type of lesion. The intention in most cases with this technique is to achieve complete excision as well as obtaining a diagnosis.
This is a less frequently used technique; it utilises a small circular cutting device which removes only a small sample from the tumour. They are less often used as often the piece of tissue is relatively small and can’t be orientated in the laboratory as easily as Excision or Incision biopsies.
This is utilised when there are factors associated with the tumour which may preclude complete excision of the lesion. This may be relating to site, size of the lesion or where there is some clinical diagnostic uncertainty. Commonly where the tumour is quite large, it is prudent to simply sample a part of the tumour, to obtain a histological diagnosis which can then inform the decision making process regarding further treatment. Multiple “mapping” biopsies are often used where a lesion is quite large and may be indistinct. An incision biopsy will most commonly involve taking a full thickness elliptical section from the periphery of the lesion, incorporating a sample of adjacent “normal” tissue. This enables the pathologist to compare and contrast the abnormal tissue against the section of normal skin.
A less frequently used technique than Excision or Incision Biopsy, as by definition this often removes only the upper portion of a lesion and will therefore result in a greater rate of incomplete excision, as residual tumour may be left behind. It should be avoided in situations if there is any concern that the lesion could be a Clinically Atypical Naevus or possibly a Melanoma.
In some situations however, this technique can be quite useful if there is more certainty and clarity about the diagnosis and also if the lesion itself is small, well circumscribed or in an area of functional or aesthetic sensitivity. It is often used in conjunction with a cauterising device and if a suitable lesion is treated by shave, curettage and cautery for three cycles, then there is a “cure” or control rate of approximately 80 to 90% in selected cases. It is particularly useful for facial lesions that are obviously benign but can also be utilised for premalignant conditions and small BCCs if other options are less favourable due to other factors and considerations.