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Choice of Site to Biopsy

When the decision has been made to biopsy a lesion, along with choosing the method of biopsy, the clinician must
also choose the site (exact spot in the lesion) that will be biopsied.
If a rash or inflammatory process is present, select a fresh lesion that has recently appeared rather than one that
has been present longer. Oftentimes, older lesions have been excoriated or secondarily infected, obscuring the
primary pathology. Choose a lesion on the upper body rather than the lower body whenever possible (Figure 8-4).
The histology may be easier to interpret and the healing should be more rapid. Biopsies of the lower legs are more
likely to get infected or have delayed healing. Also avoid the axilla and groin if possible because these areas are
more prone to infections.

FIGURE 8-4 Erythroderma in a 19-year-old woman from head to toe. A 4-mm punch biopsy was performed on her arm rather than the
leg.

(Copyright Richard P. Usatine, MD.)

If a vesicular-bullous reaction is present, it is best to biopsy an intact bulla with some normal tissue (Figure 8-5). It is
helpful for the pathologist to examine the edge of the bulla to characterize the exact etiology of the disease process.

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FIGURE 8-5 A shave biopsy of an intact blister in a patient with suspected bullous pemphigoid.

(Copyright Richard P. Usatine, MD.)

If lesions are scattered throughout the body, choose a site where aesthetic considerations are less of a concern
(e.g., avoid the face) and where scarring is less likely. The sternum, shoulders, upper back, and areas of skin
tension are more likely to scar. Also, choose a lesion on the upper body rather than the lower body whenever
possible.
When direct immunofluorescence (DIF) testing is to be done, biopsies are usually taken from perilesional skin
(Figure 8-6). That means the biopsy will not include the bulla or erosion at all. The specimen is generally obtained
with a shave or punch biopsy next to the visible pathology. DIF studies are especially helpful for autoimmune bullous
diseases because antibodies will light up in the skin (Figure 8-7). They do not have to be done on the initial biopsy
but may be performed to clarify and add data to a standard biopsy for hematoxylin and eosin (H&E) staining. There
are only a few autoimmune diseases in which lesional skin is preferred (see Table 8-1). A 4-mm punch is adequate.
It must be sent to the lab in special Michel's media (or on saline-soaked gauze). This media should be kept in the
refrigerator and can expire. If the cap is on tight and the media has just expired, it is probably still usable. See Table
8-1 for more information on the DIF biopsy.

FIGURE 8-6 A shave biopsy was performed of an intact blister including perilesional skin in a patient with suspected bullous
pemphigoid. The specimen shows that the blister remained intact and there is sufficient perilesional skin to the left of the blister to cut from
the specimen and send separately for direct immunofluorescence.

(Copyright Richard P. Usatine, MD.)

FIGURE 8-7 Immunofluorescence microscopy of a skin biopsy displays prominent intercellular fish-net deposition of C3 as well as a
suprabasilar cleft within the epidermis. This confirms the diagnosis of pemphigus vulgaris.

(Courtesy of Robert Law, MD.)

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TABLE 8-1 -- Location for Direct Immunofluorescence Biopsies

Disease
Location of Biopsy
Findings
Pemphigus vulgaris
Perilesional
Intercellular deposition of IgG.
Pemphigus foliaceus
Perilesional
Intercellular deposition of IgG.
IgA pemphigus
Perilesional
Intercellular deposition of IgA.
Intercellular deposition of IgG. Antibodies also
Paraneoplastic pemphigus
Perilesional
directed to simple or transitional epithelium (rat
bladder).
Linear basement membrane staining with IgG and/or
Bullous pemphigoid
Perilesional
C3. Salt split samples will localize to the epidermal
side.
Perilesional skin, mucosa, Linear basement membrane staining with IgG and/or
Cicatricial pemphigoid (MMP)
or conjunctiva
C3. Salt split samples show variable localization.
Linear basement membrane staining with C3, IgG is
Herpes gestationis
Perilesional
generally less pronounced.
Heavy IgG and/or C3 along the basement membrane
Epidermolysis bullosa acquisita Perilesional
zone. Salt split samples will localize to the dermal
side.
Lesional or normal skin
Dermatitis herpetiformis
Granular IgA within dermal papillae.
from disease-prone area
Inflamed, but nonulcerated Clumps of cytoid bodies and fibrinogen in the
Lichen planus
mucosa or skin
basement membrane zone.
Granular IgG or IgM along the basement membrane
Lupus band test
Normal skin
zone.
Granular deposition of IgG, IgM, and/or IgA along the
Discoid lupus erythematosus
Lesional skin
basement membrane zone in conjunction with cytoid
bodies.
Systemic lupus erythematosus Lesional skin
Same as for discoid lupus.
Heavy IgG and/or C3 along the basement membrane
Bullous lupus erythematosus
Perilesional skin
zone.
Perivascular IgA: Henoch Schoenlein purpura.
Vasculitis
Early lesion
Perivascular IgM/IgG/C3: other forms of vasculitis.
Linear IgA deposition at the basement membrane
Linear IgA dermatitis
Perilesional skin
zone.
Porphyria/pseudoporphyria
Linear IgG, IgM, and C3 around vessels and dermalPerilesional
cutanea tarda
epidermal junction.
Source: Courtesy of Robert Law, MD.

If a basal cell carcinoma is suspected, it is often easy to shave off the whole lesion. If the lesion is large, almost any
area can be biopsied but it is better to select a raised-up border rather than an ulcerated portion. Biopsying the latter
may inaccurately provide a pathology specimen that shows only inflammation and reparative debris if not sampled
deeply enough. Curettement and punch methods can also be used. An advantage with curettement is that if the
tissue is necrotic, it feels soft with curetting and also has a classic appearance. The appearance and feel can
confirm the initial impression, and treatment can be performed immediately (electrodesiccation and curettage 3)
(see Chapter 14, Electrosurgery).
If a squamous cell carcinoma is suspected, and the lesion is too large to shave off in its entirety, biopsy centrally and
try to obtain a deep sample so the pathologist can determine the extent of invasion. Peripheral areas may only
involve actinic change, missing the most advanced pathology. A broad deep shave is usually adequate for a biopsy.
A second biopsy/excision may be needed if the pathologist reports that there is squamous dysplasia and a SCC
cannot be ruled out.
If a melanoma is suspected, it is best to provide a specimen with adequate depth. Unfortunately choosing the
darkest and most raised area does not guarantee the correct diagnosis. Although a full elliptical excision has been
considered the gold standard, in some circumstances this is not desirable, for instance, in a large pigmented lesion
on the face. In cases of suspected lentigo maligna melanoma on the face, a broad shave provides a better sample
than a few punch biopsies and is less deforming that a large full-thickness biopsy. It is also just not practical to
perform an elliptical excision on every potentially malignant pigmented lesion. It may be better in some instances to
sample the whole lesion with a broad deep shave than to do one or more punch biopsies. Of course, sooner or later,
an unsuspecting melanoma may be biopsied with a shave that misses the true depth of the lesion. Note, however,
that it is far better to biopsy a lesionregardless of the methodand find a melanoma early than to delay and

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procrastinate, thus missing an opportunity for early detection and treatment.[4] Suspected early thin melanomas can
easily be biopsied with a deep shave technique. When sampling a suspected thick nodular melanoma, a deep
sample will be needed to find the Breslow level and plan the definitive surgery. Dermoscopy (see Chapter 32) is a
tool that can help you choose the most suspicious area to biopsy in a large lesion if it is impractical to biopsy the
whole lesion. Fortunately, nonexcisional biopsies do not negatively influence melanoma patient survival and, in
general, do closely correlate with the true depth of the lesion.[5,6]

Documentation of Biopsy Site

With all biopsies (especially if multiple lesions are obtained), record a detailed description of the biopsy site and, if
possible, include a diagram or photo in the medical record. Biopsy sites may heal quickly and can be difficult to find
later when definitive treatment is necessary. Photos can aid in identifying correct locations. If it is not easy to place
photographs in the medical record, make sure the camera is set to record the correct date of the photo. Then the
prebiopsy photo can be found by searching the electronic files by date. Some clinicians photograph the patient label
at the same time to make it easier to locate a preop photo. Adequate privacy protection is necessary to ensure that
photo storage options are HIPAA compliant (password protected and data encryption) if a computer is used.

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