Method of biopsy and incidence of positive margins in primary melanoma

Considerations in geriatric dermatopathology

This review provides an overview of considerations in geriatric dermatopathology. The nuances of specimen collection and reporting in this population, including the importance of obtaining adequate tissue, providing detailed clinical information and ethical considerations surrounding specimen collection will be discussed. The histopathologic changes associated with aging and the morphologic features of common lesions related to photoaging are outlined followed by a discussion of common interpretation pitfalls, specifically entities at risk of overinterpretation and those related to hyper- and hypopigmentation. Finally, the recent literature is reviewed regarding special cases and what this implies for future research both in dermatology and dermatopathology.

Deep Margins Melanoma: How Deep Is Deep Enough?

BACKGROUND

Wide excision (WE) to muscular fascia for invasive melanoma is common practice but excision to subcutaneous tissue may be adequate. We evaluated practice patterns regarding depth of biopsy and excision as well as risks for recurrence.

METHODS

Retrospective review of patients with pT1-4 melanoma (cN0) treated with WE at a single institution was performed. Patient factors were evaluated. Biopsy and excision techniques were compared to pathology and reviewed for recurrence.

RESULTS

385 patients from 2006 to 2020 were included. Lesions were on the extremity (n = 189), head/neck (n = 48), trunk (n = 148). Biopsy techniques included shave (n = 330), excisional (n = 36), punch (n = 10), incisional (n = 9). Deep biopsy margins were positive for IM/melanoma in situ in 139 patients. WE specimens were taken to muscular fascia (n = 218) or mid/deep fat (n = 144). 51 patients had recurrent disease or a new primary lesion: locoregional (n = 31), distant (3), or new lesions (n = 17).

DISCUSSION

Patient characteristics associated with recurrence include older age and female gender. Tumor characteristics associated with recurrence include lesions located on the trunk, superficial spreading melanoma, ulceration, perineural invasion, and clinical T and P stage. Patients that recurred were more likely to have WE taken to or including muscular fascia. Biopsy type, deep margin on biopsy, and depth of dissection was not associated with recurrence.

Case volume regionalization and volume-based outcome differences in cutaneous head and neck melanoma

BACKGROUND

Hospital volume has emerged as a prognostic factor in oncology but is not currently known whether volume is associated with improved outcomes for cutaneous head and neck (HN) melanoma.

METHODS

A total of 556 079 cutaneous melanoma cases reported by the 2004-2016 National Cancer Database were separated into two cohorts (HN and non-HN) and facilities within each cohort were classified by case volume. Analysis employed chi-square, analysis of variance, Kaplan-Meier, and Cox proportional hazards models.

RESULTS

Only 41 facilities (3.1% of 1326) treating HN melanoma and 50 facilities (3.7% of 1344) treating non-HN melanoma were classified as high-volume facilities (HVFs). The estimated 5-year overall survival (OS) was 62.7% (standard error [SE]: 0.4%) for patients with HN at low-volume facilities (LVFs), 69.3% (SE: 0.4%) at IVFs, and 71.8% (SE 0.4%) at HVFs (p < 0.001). Differences in OS remained significant between HVFs versus LVFs after adjusting for confounders.

CONCLUSION

Volume is independently associated with OS and improved surgical outcomes for HN melanoma.

Operative Therapie des malignen Melanoms

Die operative Therapie ist maßgeblich im Behandlungskonzept des malignen Melanoms. Sie ist essentieller Bestandteil der Diagnosesicherung, des Stagings und der Therapie in allen Stadien der Erkrankung. Die optimale Planung und Durchführung der Primärexzision, der Sentinel-Lymphknoten-Biopsie und der Nachexzision mit Sicherheitsabstand legen den Grundstein einer erfolgreichen Behandlung, die neben oder auch in Kombination mit einer modernen Systemtherapie die Metastasen-Chirurgie miteinschließt.

Photoacoustic imaging of periorbital skin cancer ex vivo: unique spectral signatures of malignant melanoma, basal, and squamous cell carcinoma

Radical excision of periorbital skin tumors is difficult without sacrificing excessive healthy tissue. Photoacoustic (PA) imaging is an emerging non-invasive biomedical imagi--ng modality that has potential for intraoperative micrographic control of surgical margins. This is the first study to assess the feasibility of PA imaging for the detection of periocular skin cancer. Eleven patients underwent surgical excision of periocular skin cancer, one of which was a malignant melanoma (MM), eight were basal cell carcinomas (BCCs), and two squamous cell carcinomas (SCCs). Six tumors were located in the eyelid, and five in periocular skin. The excised samples, as well as healthy eyelid samples, were scanned with PA imaging postoperatively, using 59 wavelengths in the range 680-970 nm, to generate 3D multispectral images. Spectral unmixing was performed using endmember spectra for oxygenated and deoxygenated Hb, melanin, and collagen, to iden--tify the chromophore composition of tumors and healthy eyelid tissue. After PA scanning, the tumor samples were examined histopathologically using standard hematoxylin and eosin staining. The PA spectra of healthy eyelid tissue were dominated by melanin in the skin, oxygenated and deoxygenated hemoglobin in the orbicularis oculi muscle, and collagen in the tarsal plate. Multiwavelength 3D scanning provided spectral information on the three tumor types. The spectrum from the MM was primarily reconstructed by the endmember melanin, while the SCCs showed contributions primarily from melanin, but also HbR and collagen. BCCs showed contributions from all four endmembers with a predominance of HbO₂ and HbR. PA imaging may be used to distinguish different kinds of periocular skin tumors, paving the way for future intraoperative micrographic control.

Rates of Upstaging, Between Diagnosis and Surgery, and Clinical Management of Metastatic Cutaneous Squamous Cell Carcinoma: A Case-Control Study

BACKGROUND

Cutaneous squamous cell carcinomas (cSCC) have upstage rates of approximately 10.3% to 11.1%. Data are currently limited on the rate of upstaging for metastatic cSCC.

OBJECTIVE

The aim of this study was to determine the rates of upstaging, between diagnosis and surgery, and differences in management for metastatic and non-metastatic high-risk cSCC.

MATERIALS AND METHODS

This was a retrospective, case-control, single institution, multi-center study. Univariate analysis was used.

RESULTS

Sixty-eight subjects (34 metastatic & 34 non-metastatic) with 69 tumors were included. The overall rate of upstaging was 46.4%. The most common reasons for upstage were undocumented tumor size and under-diagnosis of poor differentiation. There were no differences in rates of upstaging. Preoperative imaging was performed in 43.6% of wide local excisions (WLE) versus 3.3% of Mohs micrographic surgery (MMS; p < .001). The median days from surgery to sentinel lymph node biopsy (SLNB), or nodal dissection was shorter for WLE versus MMS (0 vs 221 days, p < .001).

CONCLUSION

Improved clinical documentation, including documenting tumor size, and the identification of pathologic risk factors, including poor differentiation and depth of invasion, are needed for proper staging. Preoperative imaging and discussion of SLNB may be beneficial for high-risk T2b and T3 tumors.

[Pitfalls in dermatohistology : Stumbling blocks and problems in routine dermatopathology]

Excisions and biopsies are firmly anchored in everyday dermatology. The biopsy, excision or diagnostic-therapeutic confirmation of the clinical diagnosis of neoplasms or inflammatory diseases is decisive for the dermatopathological diagnosis of tissue samples. Dermatopathology, however, is not a magic box into which a tissue sample can be placed without comment or information and receive-within 24 h at the latest-a complete, high-quality diagnosis. The present article describes problems, hurdles, and challenges in everyday dermatopathology that occur on the way to the microscope, even before the actual dermatopathological diagnosis takes place.

Comparison of photoacoustic imaging and histopathological examination in determining the dimensions of 52 human melanomas and nevi ex vivo

Surgical excision followed by histopathological examination is the gold standard for the diagnosis and staging of melanoma. Reoperations and unnecessary removal of healthy tissue could be reduced if non-invasive imaging techniques were available for presurgical tumor delineation. However, no technique has gained widespread clinical use to date due to shallow imaging depth or the absence of functional imaging capability. Photoacoustic (PA) imaging is a novel technology that combines the strengths of optical and ultrasound imaging to reveal the molecular composition of tissue at high resolution. Encouraging results have been obtained from previous animal and human studies on melanoma, but there is still a lack of clinical data. This is the largest study of its kind to date, including 52 melanomas and nevi. 3D multiwavelength PA scanning was performed ex vivo, using 59 excitation wavelengths from 680 nm to 970 nm. Spectral unmixing over this broad wavelength range, accounting for the absorption of several tissue chromophores, provided excellent contrast between healthy tissue and tumor. Combining the results of spectral analysis with spatially resolved information provided a map of the tumor borders in greater detail than previously reported. The tumor dimensions determined with PA imaging were strongly correlated with those determined by histopathological examination for both melanomas and nevi.

Non-radical primary diagnostic biopsies affect survival in cutaneous head and neck melanoma

BACKGROUND

It is unclear if a non-radical diagnostic biopsy entails a higher risk for metastasis and poorer survival for patients with cutaneous head and neck melanoma (cHNM).

AIMS/OBJECTIVES

To assess whether or not initial diagnostic biopsy modality and radicality (clear, positive, or narrow histopathological margins) influence recurrence and survival in patients with cHNM.

MATERIALS AND METHODS

Histopathological radicality of initial diagnostic biopsies and outcome for 368 consecutive cHNM patients, clinically asymptomatic of metastatic disease and referred to a tertiary care academic center for sentinel lymph node staging from 2004 through 2018, were retrospectively analyzed.

RESULTS

Patients with positive (n = 133) or narrow (0.1-0.5 mm) (n = 34) histopathological margins had significantly worse loco-regional (p=.004) and distant control (p=.004) as well as lower overall (p=.017) and melanoma specific (p=.0002) survival than 201 patients with clear margins. Multivariate analysis indicated positive or narrow histopathological margins as independent negative prognostic factors for melanoma specific survival (HR 2.16, p=.015), together with deeper Breslow (HR 1.17, p=.00001) and ulceration (HR 2.49, p=.003).

CONCLUSIONS AND SIGNIFICANCE

Non-radical primary diagnostic biopsies increase the risk for metastatic disease and impair survival in cHNM. Accordingly, radical melanoma diagnostic procedures should be encouraged in the head and neck region when possible.

Prospective study of pigmented lesions managed by shave excision with no deep margin transection of melanomas

Shave excision is a simple and cost-effective technique for the removal of suitable skin lesions. We performed a prospective study over six months, collecting data from pigmented lesions that were treated with shave excision by dermatologists. Only shave excisions with the intent to remove the lesion in toto were included. A total of 349 lesions were included in this study, 50 (14%) of these were melanomas and no melanoma diagnosed had deep margin involvement, while 13 (26%) had lateral margin involvement.

Update on Current Treatment Recommendations for Primary Cutaneous Melanoma

Primary cutaneous melanoma describes any primary melanoma lesion of the skin that does not have evidence of metastatic disease. This article reviews the current workup, treatment, and follow-up recommendations for primary cutaneous melanoma (stages 0, I, and II). Specific attention is focused on recent updates with regard to staging, sentinel lymph node biopsy, and surgical modalities.

Re-biopsy of partially sampled thin melanoma impacts sentinel lymph node sampling as well as surgical margins

AIM

To assess the impact of re-biopsy on partially sampled melanoma in situ (MIS), atypical melanocytic proliferation (AMP) and thin invasive melanoma.

MATERIALS & METHODS

We retrospectively identified cases of re-biopsied partially sampled neoplasms initially diagnosed as melanoma in situ, AMP or thin melanoma (Breslow depth ≤0.75 mm).

RESULTS & CONCLUSION

Re-biopsy led to sentinel lymph node biopsy (SLNB) in 18.3% of cases. No patients upstaged from AMP or MIS had a positive SLNB. One out of nine (11.1%) initially diagnosed as a thin melanoma ≤0.75 mm, upstaged with a re-biopsy, had a positive SLNB. After re-biopsy 8.5% underwent an increased surgical margin. Selective re-biopsy of partially sampled melanoma with gross residual disease can increase the accuracy of microstaging and optimize treatment regarding surgical margins and SLNB.

Guidelines of care for the management of primary cutaneous melanoma

The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.

Preoperative measurement of cutaneous melanoma and nevi thickness with photoacoustic imaging

Photoacoustic imaging (PAI) is an emerging biomedical imaging technology, which can potentially be used in the clinic to preoperatively measure melanoma thickness and guide biopsy depth and sample location. We recruited 27 patients with pigmented cutaneous lesions suspicious for melanoma to test the feasibility of a handheld linear-array photoacoustic probe in imaging lesion architecture and measuring tumor depth. The probe was assessed in terms of measurement accuracy, image quality, and ease of application. Photoacoustic scans included single wavelength, spectral unmixing, and three-dimensional (3-D) scans. The photoacoustically measured lesion thickness gave a high correlation with the histological thickness measured from resected surgical samples (r=0.99, P<0.001 for melanomas, r=0.98, P<0.001 for nevi). Thickness measurements were possible for 23 of 26 cases for nevi and all (6) cases for melanoma. Our results show that handheld, linear-array PAI is highly reliable in measuring cutaneous lesion thickness in vivo, and can potentially be used to inform biopsy procedure and improve patient management.

Risk Factors Predicting Positive Margins at Primary Wide Local Excision of Cutaneous Melanoma

BACKGROUND

A small percentage of patients will have positive histological margins after primary wide local excision (WLE) of cutaneous melanoma (CM). Risk factors that predict marginal involvement at WLE remain unclear.

OBJECTIVE

To identify risk factors associated with positive margins after WLE of CM.

MATERIALS AND METHODS

A retrospective review of patients treated at a single institution for CM with sentinel lymph node biopsy from 1997 to 2011 was conducted.

RESULTS

Positive margins occurred in 6% of patients. Patients with positive margins were older (72.4 vs 60.7, p < .001), had thicker tumors (3.6 vs 1.9 mm, p < .001), and often involved the head and neck region (p < .001). Patients with positive margins at WLE had positive margins on initial biopsy (p = .012) and a higher rate of a melanoma in situ component on initial biopsy (24% vs 11%, p = .02). The 5-year local recurrence rate was significantly different between those with positive and negative margins at WLE (16.0% vs 6.9%; p = .047).

CONCLUSION

Positive margins after WLE are uncommon. When a patient has multiple risk factors for positive margins at WLE, histologically clear margins should be obtained through mapped serial excision or Mohs micrographic surgery.

Surgical Management of Melanoma

The surgical management of melanoma has undergone considerable changes over the past several decades, as new strategies and treatments have become available. Surgeons play a pivotal role in all aspects of melanoma care: diagnostic, curative, and palliative. There is a high potential for cure in patients with early-stage melanoma and the selection of an appropriate operation is very important for this reason. Staging the nodal basin has become widespread since the adoption of sentinel lymph node biopsy (SLNB) for the management of melanoma. This operation provides the best prognostic information that is currently available for patients with melanoma. The surgeon plays a central role in the palliation of symptoms resulting from nodal disease and metastases, as melanoma has a propensity to spread to almost any site in the body.

Accuracy of diagnostic biopsy for cutaneous melanoma: implications for surgical oncologists

BACKGROUND AND OBJECTIVES

While excisional biopsy is recommended to diagnose cutaneous melanoma, various biopsy techniques are used in practice. We undertook this study to identify how frequently final tumor stage and treatment recommendations changed from diagnostic biopsy to final histopathology after wide local excision (WLE).

METHODS

We compared the histopathology of the dermatopathologist-reviewed diagnostic biopsy and final WLE in 332 cutaneous melanoma patients.

RESULTS

Tumor sites were extremity (51%), trunk (33%), and head/neck (16%). Initial biopsy types were excisional (56%), punch (21%), shave (18%), and incisional (5%). Most diagnostic biopsies were margin positive regardless of technique, and 36% of patients had residual melanoma on WLE. T-stage changed in 8% of patients, of whom 59% were diagnosed by punch biopsy, 15% by incisional biopsy, 15% by shave biopsy, and 11% by excisional biopsy (P < 0.0001). Treatment recommendations changed in 6%: 2% after excisional biopsy, 5% after shave biopsy, 18% after punch biopsy, and 18% after incisional biopsy (P < 0.0001).

CONCLUSIONS

Although most biopsy margins were positive, T-stage and treatment changed for only a minority of melanoma patients. Our data provide valuable information to inform patient discussion regarding the likelihood of a change in prognosis and the need for secondary procedures after WLE. These data support the superiority of dermatopathologist-reviewed excisional biopsy when feasible.

Effect of biopsy type on outcomes in the treatment of primary cutaneous melanoma

BACKGROUND

Surgical excision remains the primary and only potentially curative treatment for melanoma. Although current guidelines recommend excisional biopsy as the technique of choice for evaluating lesions suspected of being primary melanomas, other biopsy types are commonly used. We sought to determine the impact of biopsy type (excisional, shave, or punch) on outcomes in melanoma.

METHODS

A prospectively collected, institutional review board-approved database of primary clinically node-negative melanomas (stages cT1-4N0) was reviewed to determine the impact of biopsy type on T-staging accuracy, wide local excision (WLE) area (cm(2)), sentinel lymph node biopsy (SLNB) identification rates and results, tumor recurrence, and patient survival.

RESULTS

Seven hundred nine patients were diagnosed by punch biopsy (23%), shave biopsy (34%), and excisional biopsy (43%). Shave biopsy results showed significantly more positive deep margins (P < .001). Both shave and punch biopsy results showed more positive peripheral margins (P < .001) and a higher risk of finding residual tumor (with resulting tumor upstaging) in the WLE (P < .001), compared with excisional biopsy. Punch biopsy resulted in a larger mean WLE area compared with shave and excisional biopsies (P = .030), and this result was sustained on multivariate analysis. SLNB accuracy was 98.5% and was not affected by biopsy type. Similarly, biopsy type did not confer survival advantage or impact tumor recurrence; the finding of residual tumor in the WLE impacted survival on univariate but not multivariate analysis.

CONCLUSIONS

Both shave and punch biopsies demonstrated a significant risk of finding residual tumor in the WLE, with pathologic upstaging of the WLE. Punch biopsy also led to a larger mean WLE area compared with other biopsy types. However, biopsy type did not impact SLNB accuracy or results, tumor recurrence, or disease-specific survival (DSS). Punch and shave biopsies, when used appropriately, should not be discouraged for the diagnosis of melanoma.

Prognosis of patients with transected melanomas

BACKGROUND

The management of melanoma is directly related to Breslow's depth. Biopsying melanomas in a fashion that transects the deep margin precludes an accurate measurement of the true depth.

OBJECTIVE

To examine the prognosis of melanomas transected along the deep margins, as well as cases where no residual melanoma was seen on re-excision after transection.

METHODS

Records from a cohort of patients at one institution were examined from 1996 through 2007. Patients were considered to have "transected" melanomas if tumor cells were present on the deep margin of the biopsy. Overall survival was determined.

RESULTS

Seven hundred fourteen patients were examined. 171 (24%) of all melanomas were transected. 101(59%) of those lacked tumor cells on re-excision. Patients with transected melanomas were older (OR = 1.03, p < .001), and had higher Breslow's depths (OR = 1.21, p < .001) than those without transected tumors. Those with no residual melanoma after transection were younger (OR = 0.98, p = .010) and more likely to have no lymph node involvement (OR = 2.23, p = .037). Neither transection (p = .760), nor lack of residual melanoma on re-excision after transection (p = .793) influenced survival.

CONCLUSION

A high number of melanomas are transected at diagnosis, many of which lack visible tumor. The original Breslow's depth of transected melanomas without residual tumor on re-excision accurately predicts survival and prognosis.

Choosing to biopsy or refer suspicious melanocytic lesions in general practice

Background

General practitioners (GPs) are involved in the management of most melanocytic skin lesions in Australia. A high quality biopsy technique is a crucial first step in management, as it is recognized that poor techniques can mislead, delay, or miss a diagnosis of melanoma. There has been little published on the biopsy decisions and techniques of GPs. This study aims to describe the current management choices made by GPs for suspicious melanocytic skin lesions and to compare their choices with the best practice guidelines.

Methods

An anonymous survey of GPs presented with three clinical scenarios with increasing complexity of melanoma in which a referral or biopsy decision was specified.

Results

391 mailed surveys with a 76.3% response rate. Mean biopsy experience was 4.14 biopsies per GP per month. The rates of choosing to refer among the three scenarios were 31%, 52% and 81% respectively, with referral to surgery being the most common choice (81%). Most biopsy techniques (55%) were chosen according to best practice guidelines, although non-guideline biopsy techniques chosen included shave (n = 10), punch biopsy (n = 57), wide excisions (n = 65), and flaps (n = 10). The few GPs (n = 5) who identified themselves as skin specialist GPs were no more likely to adhere to guidelines than their colleagues.

Conclusion

A majority of referrals and biopsies were chosen by GPs according to best practice guidelines, but concern remains for the high proportion of GPs making non-guideline based choices. How GPs choose to biopsy or refer needs further training, audit, and research if Australia is to improve the outcome of melanoma management in general practice.

The pathology of melanoma

Although melanoma represents only 10% of all skin cancer diagnoses, it accounts for at least 65% of all skin cancer-related deaths. The number of new cutaneous melanoma cases projected during 2010 was 68,000-a 23% increase from the 2004 prediction of 55,100 cases. In 2015, the lifetime risk of developing melanoma is estimated to increase to 1 in 50. As the incidence of melanoma continues to rise, now more than ever, clinicians and histopathologists must have familiarity with the various clinical and pathologic features of cutaneous melanoma.

Guidelines of care for the management of primary cutaneous melanoma. American Academy of Dermatology

The incidence of primary cutaneous melanoma has been increasing dramatically for several decades. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is nearly always curative with early detection of disease. In this update of the guidelines of care, we will discuss the treatment of patients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinically suspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneous melanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workup of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, we will provide recommendations for surgical margins and briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinel lymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.

The Impact of Shave Biopsy on The Management of Patients with Thin Melanomas

Disagreement persists regarding the role that various biopsy methods should play in the diagnosis of primary cutaneous melanoma. We analyzed the indications for sentinel lymph node (SLN) biopsy and the rates of SLN involvement among biopsy techniques and deep margin status to attempt to determine impact of shave biopsy on surgical management of patients with thin melanoma. All patients who underwent SLN biopsy for melanoma with Breslow thickness less than 1 mm between 1998 and 2006 were identified. Patient and tumor characteristics were compared using χ2 tests for categorical variables. Continuous variables were reported as a mean ± standard deviation and analyzed using t test. Of the 260 patients diagnosed with thin melanomas, 159 (61.2%) were diagnosed by shave biopsy; 101 (38.8%) were diagnosed by other techniques. Of the 159 patients diagnosed by shave biopsy, 18.2 per cent (n = 29) underwent SLN biopsy with the only indication being positive deep margin. The frequency of SLN positivity did not differ between the biopsy groups (3.1% vs 4.0%, P = 0.726) or between groups that had positive or negative deep margins (3.0% vs 3.3%, P = 0.839, respectively). For patients unable to undergo general anesthesia, the increased rate of performing SLN biopsy resulting from shave biopsy should limit its use in these patients. However, shave biopsy is a reasonable diagnostic method for patients at low risk for general anesthesia, particularly because it results in comparably low rates of positive SLN. Thus each patient's unique clinical situation should be considered when deciding which biopsy technique is appropriate.

Shave biopsy is a safe and accurate method for the initial evaluation of melanoma

BACKGROUND

Shave biopsy of cutaneous lesions is simple, efficient, and commonly used clinically. However, this technique has been criticized for its potential to hamper accurate diagnosis and microstaging of melanoma, thereby complicating treatment decision-making.

STUDY DESIGN

We retrospectively analyzed a consecutive series of patients referred to the University of Florida Shands Cancer Center or to the Moffitt Cancer Center for treatment of primary cutaneous melanoma, initially diagnosed on shave biopsy to have Breslow depth < 2 mm, to determine the accuracy of shave biopsy in T-staging and the potential impact on definitive surgical treatment and outcomes.

RESULTS

Six hundred patients undergoing shave biopsy were diagnosed with melanoma from extremity (42%), trunk (37%), and head or neck (21%). Mean (± SEM) Breslow thickness was 0.73 ± 0.02 mm; 6.2% of lesions were ulcerated. At the time of wide excision, residual melanoma was found in 133 (22%), resulting in T-stage upstaging for 18 patients (3%). Recommendations for additional wide excision or sentinel lymph node biopsy changed in 12 of 600 (2%) and 8 of 600 patients (1.3%), respectively. Locoregional recurrence occurred in 10 (1.7%) patients and distant recurrence in 4 (0.7%) patients.

CONCLUSIONS

These data challenge the surgical dogma that full-thickness excisional biopsy of suspicious cutaneous lesions is the only method that can lead to accurate diagnosis. Data obtained on shave biopsy of melanoma are reliable and accurate in the overwhelming majority of cases (97%). The use of shave biopsy does not complicate or compromise management of the overwhelming majority of patients with malignant melanoma.

[Skin biopsy with histopathologic analysis: why? what for? how? part II]

Skin biopsy is a common procedure in dermatology practice. The cost-benefit ratio, though, can be unfavorable if attention is not paid to specific details in performing a skin biopsy. For example, proper selection of anatomical site and best lesion to perform a biopsy are very important. The present article discusses those and other variables that directly influence the satisfaction level of the dermatologist who undertakes it, the pathologist who analysis it and the patient of whom the biopsy is taken.

Benign versus malignant parakeratosis: a nuclear morphometry study

Parakeratosis is relatively common in both benign and malignant skin diseases. It is a useful feature for classifying certain types of dermatitis; however, its value in distinguishing benign from malignant neoplastic squamous lesions has not been investigated. Parakeratotic nuclei are pyknotic and often elongated, regardless of the underlying disease. However, we have noticed a quite consistent difference in nuclear morphology between benign and malignant parakeratosis, which has not been formally described in the literature. To test the hypothesis that morphological differences may aid in the discrimination between certain benign and malignant dermatopathological lesions, we used computer-aided nuclear morphometry to analyze parakeratosis from 28 cases of squamous cell carcinoma, 19 cases of verruca vulgaris, and 23 cases of psoriasiform dermatitis. Significant differences in nuclear area and area variability were observed between benign and malignant cases. These two parameters together could separate most squamous cell carcinomas from benign cases. Through this study, we hope to raise the awareness that even parakeratosis, the most superficial morphological datum available for histopathological evaluation, may harbor distinct changes of nuclear atypia in squamous cell carcinoma. In some overly superficial shave biopsies, parakeratosis may be the only material available for evaluation. For such cases, if squamous cell carcinoma is in the differential diagnosis, then the parakeratotic nuclei should be examined carefully to determine the likelihood of malignancy. Computer-aided nuclear morphometry may have potential diagnostic value for such cases.

Pigmented lesion pathology: what you should expect from your pathologist, and what your pathologist should expect from you

The first part of this review examines the reliability of histologic diagnosis in pigmented lesions, as measured by concordance studies and medicolegal analysis. It emphasizes the role of clinicians in maximizing that reliability, by providing adequate clinical descriptions, using appropriate biopsy technique, and critically interpreting pathology reports. It identifies those entities that are especially problematic, either because they cannot be reliably recognized by the histopathologist or because their histology is a poor guide to their biologic behavior. The second part of the review is a guide to some of the more difficult and controversial pigmented lesions, including dysplastic nevus, spitzoid nevi and melanomas, cellular blue nevus, animal-type melanoma, and deep penetrating nevus.

Skin biopsy for inflammatory and common neoplastic skin diseases: optimum time, best location and preferred techniques. A critical review

The diagnosis of skin diseases, particularly inflammatory dermatoses, is based primarily on clinical information. Pathologic examination of the biopsied specimen often serves as a complementary or confirmative part of the diagnosis. However, the clinical diagnosis of skin diseases may be challenging, as the clinical information and appearance of skin lesions invariably overlap. Evidence for a correct diagnosis may be lacking without histopathologic examination of skin biopsies. It is well known that the histologic diagnosis of inflammatory and other skin diseases requires clinicopathologic correlation, and there is evolution of skin lesions into different stages as the diseases progress. Other factors important for accurate dermatopathologic diagnosis are optimum time, best location and preferred techniques of skin biopsy. In searching for available information concerning when, where and how to take skin biopsies, it is noted that there are only limited practical guidelines currently available. We present this review article in hopes that our collective dermatopathologic and dermatologic experience can provide a quick reference for accurate diagnosis and proper management of skin diseases.

Intraoperative techniques and tumor margin status--room for improvement for cervical cancer patients of childbearing age

OBJECTIVE

Inadequate tumor margin status in cervical cancer and pre-cancer patients is associated with repeat procedures and an increased risk of recurrence and progression. This review will outline information regarding the current treatment options for women who wish to maintain fertility, the methods currently used in practice to evaluate tumor margin involvement, and a look at potential solutions to this critical issue.

METHOD

We performed a PUBMED literature search of relevant research articles pertaining to tumor margin evaluation for multiple cancers, current treatment options for patients of cervical dysplasia and the effects of those treatments on fertility.

RESULTS

Previous studies have correlated cancer recurrence and progression to obtaining clear margins upon resection. The most common need to obtain clear margins with respect to conservative treatment in patients with cervical neoplasia occurs with women who wish to preserve fertility. However, current detection methods are limited and current treatments present additional fertility concerns.

CONCLUSION

In order to provide the best care for patients wishing to retain fertility post-treatment for cervical dysplasia, a superior option for detecting tumor margins accurately at the microscopic scale must be further explored.