Novel Uses of Skin Biopsy Punches in Dermatosurgery

The skin punch or surgical punch is an instrument which is used almost exclusively by dermatologists. It is a circular hollow blade attached to a pencil-like handle ranging in size from 0.5 to 10 mm. It is available as a disposable, reusable, and automated instrument. The punch can be used as a diagnostic, therapeutic, and cosmetic tool in dermatology. We have used punch as a diagnostic, therapeutic, and cosmetic tool in our dermatosurgery practice in our hospital. Various original research articles, text book publications, and review articles were studied and compiled. Techniques used by various authors and our own experiences with punch have been described. This article aims at providing the novel usefulness of skin biopsy punch in dermatology as the basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal.     

C‐punch excision: a novel technique

A conventional skin punch biopsy instrument has a circular hollow blade, which can be used to make a full circular incision to evacuate subcutaneous abnormalities such as lipomas. Here, we present a modified punch instrument, in which the cutting element has a C‐shape to form a pivotal skin fragment (miniflap) to access subcutaneous tissues. The “C” part comprises almost half of a circle. The C‐punch incision gives access to subcutaneous abnormalities, while keeping a connecting neck to the surrounding skin, which allows for efficient resealing of the skin surface. Therefore, there is less potential for subsequent scarring.     

Comparison of basal cell carcinoma subtypes observed in preoperative biopsy and Mohs micrographic surgery

BackgroundThe treatment of basal cell carcinoma depends on its histological subtype. Therefore, a biopsy should be performed before definitive treatment. However, as the biopsy is only a sample of the tumor, it does not always shows every histological subtype present in the neoplasm. Few studies have compared the histological findings of biopsies with the findings of Mohs micrographic surgery. By evaluating the totality of the peripheral margins, in addition to sampling large tumor areas, this technique provides a more representative amount of tissue than preoperative biopsy.Objectivesa) Determine the agreement between the histological subtype of basal cell carcinoma from punch biopsy and the findings of Mohs surgery; b) To assess, among the discordant cases, the prevalence of non-aggressive tumors in the preoperative biopsy that were reclassified as aggressive by Mohs surgery.MethodsRetrospective analysis of 79 cases of basal cell carcinomas submitted to punch biopsy and subsequent Mohs surgery.ResultsThe agreement between the classification of the subtypes in the biopsy and in Mohs surgery was 40.5%. Punch biopsy was able to predict the most aggressive basal cell carcinoma growth pattern in 83% of cases.Study limitationsRetrospective nature, sample size, and biopsies performed by different professionals.ConclusionsThe agreement between the histopathological subtypes of basal cell carcinoma as seen in preoperative biopsy and Mohs surgery was low. However, preoperative biopsy presented good accuracy (83%) in detecting aggressive histopathological subtypes.     

A case of perforating pilomatricoma

Pilomatricoma is a rare skin neoplasm, most commonly seen in the head and neck region, and occurring in the first two decades of life. It is usually solitary and varies from 0.5 to 2 cm in diameter. Its etiology is unknown. Perforating pilomatricoma is a rare clinical variant that presents as a draining, crusted nodule or ulcer, and is reported to arise faster than the classic pilomatricoma. Herein, we report a case of 35-year-old female, who had a 4-month history of a growing mass on her leg. On physical examination, a 4-cm diameter, asymptomatic, erythematous, ulcerated mass was noted on the left anterio-lateral upper leg. The first histopathological analysis of a punch biopsy from the lesion was reported as basal cell carcinoma. Therefore, the lesion was totally excised. There were shadow cells, squamoid cells, and basaloid aggregations more prominently in the one area in the tumor. In addition, calcification, foreign body giant cells and inflammatory cells were present. Punch or excisional biopsies are preferred as a method of diagnosis for the majority of cutaneous neoplasms. If total excision is not the method of choice, multiple punch biopsies should be made from different areas in large skin tumors for correct diagnosis.     

High discordance between punch biopsy and excision in establishing basal cell carcinoma subtype: analysis of 500 cases

Background Basal cell carcinoma (BCC) is the most frequently occurring cancer in humans. Worldwide incidences rise about 10% each year, increasing the burden on dermatologists, general practitioners and pathologists as well as increasing costs for the health care system. Increasingly non‐surgical treatment options are used in the treatment of BCC, without histological confirmation of BCC subtype, potentially resulting in under‐treatment. Objective We evaluated the diagnostic accuracy of a punch biopsy for the BCC histological subytpe in a primary BCC and the prevalence of biopsy‐based under‐diagnosis of aggressive subtypes. Accuracy of a punch biopsy was defined as concordance of the diagnosis of subtype of BCC at punch biopsy and excision. Methods A retrospective chart‐review was performed of primary BCC, which were proven by punch biopsy and subsequently treated by excision. The first 100 consecutive BCCs per year during the years 2004–2009 were included, yielding a total of 500 evaluated BCCs. Results The overall accuracy of punch biopsy for BCC subtype at excision was 69%, in single‐type BCC 83% (n = 343) and in mixed‐type BCC 37% (n = 157). Accuracy varied substantially according to BCC subtype, being highest in the superficial subtype (84%) and subsequently in infiltrative (69%), nodular (63%) and micronodular subtype (38%). In 11% of all cases, an unsuspected more aggressive subtype was present. Conclusion Punch biopsy has a high accuracy in single‐type BCCs and a considerably lower accuracy in mixed‐type BCCs for establishing BCC subtype compared to excision. The presence of an unsuspected aggressive subtype could explain therapy failure of non‐surgical treatments like imiquimod or photodynamic therapy.     

Diagnostic accuracy of punch biopsy in subtyping basal cell carcinoma

Background Basal cell carcinoma (BCC) is the most common skin cancer in humans. The histological subtype reported by punch biopsy may influence the type of treatment. Few studies have investigated the accuracy of punch biopsy in diagnosing the true BCC subtype. Objective To determine the accuracy, sensitivity and specificity of punch biopsy in BCC subtype diagnosis. Methods In this retrospective study, 333 biopsy specimens and excisions were reviewed. Histological subtypes present in the initial biopsy were compared with tumour subtypes of the total excision. Results The concordance between the BCC subtype present in the biopsy specimen and in the subsequent excision specimen was 72.3%. The most common BCC patterns were nodular (158, 47.5%) and mixed subtype (90, 27%). Most mixed tumours contained one or more aggressive subtype (63/90, 70%). In 47/120 (39.1%) aggressive tumours (14.1% of the total), punch biopsy failed to correctly identify the aggressive component. The most commonly missed aggressive subtype was mixed aggressive including nodular/micronodular and nodular/infiltrative (30/47, 63.8%). In 45/213 (21.1%) non‐aggressive BCCs (13.5% of total cases), punch biopsy incorrectly reported an aggressive subtype. The most commonly misidentified non‐aggressive subtype was nodular (39/45, 86.6). The sensitivity and specificity of punch biopsy in diagnosing aggressive vs. non‐aggressive BCC subtypes 60.8% (95% CI, 51.9–69.1) and 78.9% (95% CI, 72.8–83.8), respectively. The positive and negative predictive values were 61.9% and 78.1%, respectively. Conclusion Punch biopsy has serious pitfalls in differentiating aggressive and non‐aggressive BCC subtypes. Dermatologists should consider the possibility of aggressive components within non‐aggressive BCCs reported using punch biopsy.     

Simple modification to the punch biopsy technique to minimize handling and crush artefact

A number of techniques have been described to retrieve the tissue core after punch biopsy. We describe a simple modification to the punch-biopsy technique that minimizes instrumentation, handling and the subsequent risk of crush artefact. Our technique is simple, quick and economical and essentially involves rotation of the punch through 90 degrees then lateral extraction with a degree of upward traction, which usually leaves the tissue core deposited beside the skin defect. At this point it can be easily grasped with a square of gauze or detached if required using scissors or a scalpel blade.     

Surgical approach to benign small papular and dome-shaped melanocytic naevi on the face

Patients frequently request removal of benign papular and dome-shaped naevi for cosmetic or functional reasons. Melanocytic naevi can be removed by elliptical, round, punch or shave excision or destroyed using electrodessication or cryotherapy. Total elliptical excision is probably the most widely used method of removal. If malignancy is suspected, adequate specimens for histological interpretation are required. When malignancy is not suspected, the cosmetic result becomes the first priority. Smaller incisions minimize tissue trauma and so give cosmetically superior results. Round excision has been recommended for the removal of moles but has not been widely practised. Round excision and punch excision may be better alternatives than conventional fusiform excision of benign dome-shaped or papular naevi of the face, as more tissue is preserved. Shave excision of naevi may be preferable to elliptical excision in sites where the incidence of hypertrophic scarring is high, as preservation of some thickness of the dermis may result in a more acceptable scar or even avoid a scar entirely. Expedient and simple surgery with excellent cosmetic results can be accomplished by the use of punches. Cryotherapy with cutting or curetting and electrodesiccation combined with shaving have been described. Round excision may be a better alternative to conventional fusiform or shave excision of benign papular or dome-shape nevus of the face because it leaves an almost imperceptible scar. In this technique, less skin is excised and histopathological examination can be done.     

Circumferential scouting punch biopsies to delineate surgical margin for dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor involving the dermis and subcutaneous tissue with a high local recurrence rate after standard excision. Mohs micrographic surgery offers a lower recurrence rate. However, the procedure requires multiple stages of excision with intraoperative histopathological mapping, which is time consuming and expensive. We report our experience of using circumferential scouting punch biopsy technique in five patients to determine in advance the resection margins for DFSP prior to wide excision. Multiple 4 mm punches, usually eight in number, were performed 1–2.5 cm around the palpable borders of DFSP to delineate the resection margins in five consecutive patients. Tumors were excised at a later date along the margin defined by these biopsies and the wounds were repaired with skin graft. The operation was completed in 2 hours in all cases excluding one that required frozen sections for deep margin. No recurrence was noted 2–10 years after the operations. The results suggest that circumferential scouting punch biopsies before wide excision may be an alternative method to define the resection margins for DFSP when Mohs surgery is not available.     

Diagnosis and Management of Uncommon Cutaneous Cancers

Uncommon types of cutaneous cancers are mainly cited in the literature as case reports and their etiology, pathogenesis and prognosis have to be surmised because of their rarity. Within this group exist the rare and also the unusual, for instance a relatively common carcinoma arising in a strange circumstance. Initial management of such tumors involves taking a history and performing a thorough examination, allowing a diagnosis to be made. These tend to follow one of three patterns: the lesion is confidently recognized; the lesion is unknown but a likely diagnosis can be made and; the lesion is unknown. It is within the latter two groupings that the uncommon cutaneous cancers exist. A biopsy is then performed to confirm the diagnosis. For large lesions a punch or incisional biopsy is taken which must include a portion of normal skin at the lesion edge. If the lesion is small enough to allow direct closure, an excision biopsy is performed, with a minimum margin of 2mm. Shave biopsy can be employed to confirm a diagnosis, but care must be taken that the subsequent management of the lesion is not adversely affected. With the rare tumors diagnosis can be difficult and there may not be enough tissue in a biopsy for a definitive diagnosis. The whole lesion may therefore need to be excised to obtain a confident diagnosis with further surgical treatment planned as required. Once the diagnosis is established a decision on the method of treatment can be made. The limited literature would suggest that rare skin tumors are unresponsive to radiotherapy and chemotherapy, so the mainstay of treatment is surgery. When there are no established guidelines for the treatment of a particular rare tumor a pathologist can usually provide advice as to the probable nature of the lesion. This allows surgical treatment to be positioned into one of three main groups: lesions that behave like basal cell carcinomas (BCC); lesions that behave like squamous cell carcinomas (SCC) and; lesions that behave like soft tissue sarcomas (STS). It is helpful to have a management plan into which each variety of rare tumor can be fitted, giving guidance as to the best and most appropriate management. Grouping treatment into BCC, SCC or STS-like treatment has been useful. As more becomes known regarding these malignancies their subsequent management can be adjusted accordingly. Currently, it would appear wise to treat each under a broader subgroup.     

Occult neurofibroma and increased S100 protein in the skin of patients with neurofibromatosis type 1: new insight to the etiopathomechanism of neurofibromas

BACKGROUND: Neurofibromas represent proliferation of the connective tissue cells of peripheral nerves and deposition of collagenous extracellular matrix. There is evidence that the appearance and growth of neurofibromas may be associated with prior or ongoing mechanical trauma in patients with neurofibromatosis type 1 (NF1). OBJECTIVE: To study the histologic characteristics of apparently healthy skin of patients with NF1. DESIGN: The histologic features of healthy-looking skin of patients with NF1 were analyzed. SETTING: University hospital. PATIENTS: Ten patients who fulfilled the criteria for NF1. INTERVENTIONS: Punch biopsy specimens of healthy-looking skin of the forearm from 9 volunteer patients and of the upper eyelid during cosmetic operation from 1 volunteer patient were obtained. MAIN OUTCOME MEASURES: The main outcomes were not predicted, and the hypothesis was formulated during data collection. RESULTS: Apparently unaffected skin of 5 patients with NF1 was studied by routine histologic testing with respect to expression of S100 protein. Unexpectedly, analysis of the samples revealed the presence of a small neurofibroma tumor in one of the samples. The tumor was located in deep dermis around a hair follicle. In addition, neurofibromatous tissue not large enough to be called a tumor was found on the same anatomical location in another patient. In further studies, 10 punch biopsy specimens of apparently healthy skin from patients with NF1 were similarly sectioned and analyzed. No tumors were found in these additional samples. In 4 patients, however, abundant S100 protein-positive cells were located within collagenous extracellular matrix surrounding hair follicles. CONCLUSIONS: The skin of patients with NF1 might be more widely affected than previously thought and occult neurofibromas are not rare.     

Effects of biopsy-induced wound healing on residual basal cell and squamous cell carcinomas: rate of tumor regression in excisional specimens

BACKGROUND: Wound healing following a partial biopsy of basal cell (BCC) and squamous cell carcinomas (SCC) may induce tumor regression. METHODS: Nonmelanoma skin cancer (NMSC) biopsy and re-excision specimens from 1994 to 2001 were reviewed for histologic evidence of scar vs. presence of residual tumor in excision specimens. Regressed and non-regressed tumors were analyzed to assess the influence of anatomic location, biopsy technique (punch vs. shave), histologic subtype of BCC or SCC, time interval between biopsy and excision, and patient age. RESULTS: Nine hundred and ten excisions were performed for transected BCC or SCC, 217 (24%) of which showed scar with no residual tumor. Logistic regression analysis revealed significant differences in the regressed vs. non-regressed subsets. SCCs were more likely to regress than BCCs (40% vs. 20%, respectively, p < 0.00001). Independent of the NMSC type, tumors regressed more often following shave rather than punch biopsy (34% vs. 15%, respectively, p < 0.00001), as did tumors on the trunk and extremities compared with head and neck cases (31% vs. 21%, respectively, p < 0.01). CONCLUSIONS: In our series, 24% of NMSCs transected on the initial biopsy showed no residual tumor in the excision specimens, implying that some event in the interval between biopsy and excision may lead to the eradication of residual tumor. The exact mechanism is unclear, but wound healing likely plays an important role.     

Histological evaluation of residual basal cell carcinoma after shave biopsy prior to Mohs micrographic surgery

Background Patients who are referred for Mohs surgery after pre‐operative biopsy has been performed show in some cases no clinical or pathological evidence of tumour persistence. We have previously shown that 25% of these patients show no residual skin cancer either basal cell carcinoma or squamous cell carcinoma. The reasons for ‘disappearance’ of the tumour may be true non‐persistence or false non‐persistence because of wrong‐site Mohs surgery. Objective To determine the incidence of residual basal cell carcinoma after shave biopsy of primary nodular basal cell carcinoma prior to Mohs micrographic surgery. Methods A prospective unblinded study was performed on patients undergoing Mohs surgery for primary nodular basal cell carcinoma. The tumour was removed as a shaved excision using a No. 15 blade at the clinical borders like a shave biopsy (Mohs shave). The bases of the tumors were excised and then sectioned vertically at the middle and cut to the periphery at 10–15 μm intervals till the edge. Results Fifty‐one patients were evaluated. In 40 patients, residual basal cell carcinoma was found at the base of the shave excision site (78.4%). Conclusions Pre‐operative shave biopsy performed during Mohs surgery for primary nodular basal cell carcinoma is ‘curative’ in 22% of the patients.     

Cytodiagnosis of cutaneous basal and squamous cell carcinoma

OBJECTIVE: We performed a prospective study to evaluate the diagnostic accuracy of cytologic examination in basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs), in order to assess its clinical value. Study design Samples were taken by the "scraping" technique which involves scraping with a scalpel blade directly over the skin tumor surface, smearing the cells onto several glass slides, and fixing them with "citospray." The specimens were stained with the Papanicolaou stain. Punch biopsies were taken to confirm the clinical and cytologic impression. RESULTS: We collected 45 skin tumors in total, clinically presumed to be either BCC (n = 15) or SCC (n = 30). Imprint cytology demonstrated to be of help in the rapid diagnosis of skin tumors. CONCLUSIONS: Cytologic examination is easy to perform, saves time, provides a rapid diagnosis, and can be considered, under experienced hands, reliable in the confirmation of malignant skin tumors. Cytology does not give much information about tumor patterns or subtypes which can be related to aggressive behavior and can be very important in further therapeutic decisions. Therefore, histopathologic confirmation is mandatory before any therapeutic maneuver.     

Lokale An?sthesieverfahren in der Dermatologie

The vast majority of dermatologic surgery is performed with local anesthesia. The different methods provide safe and effective analgesia in circumscribed areas of skin and subcutaneous tissue and allow patients to tolerate otherwise painful diagnostic or therapeutic procedures while remaining conscious. Some forms of local anesthesia are unique, such as topical anesthesia with EMLA? or cryoanesthesia; others offer options to general anesthesia. Tumescent local anesthesia has gained widespread acceptance in the past decade for many indications other than cosmetic liposuction and is used for excising benign and malignant tumors, for extensive skin and soft tissue procedures (such as excision of acne inversa or sweat gland curettage) and in phlebologic surgery.     

Agreement between histological subtype on punch biopsy and surgical excision in primary basal cell carcinoma

Background Diagnosis of clinically suspected basal cell carcinoma (BCC) by histological confirmation with punch biopsy has been recommended before treatment. Even shave biopsy has been proposed as useful to predict the correct subtype in primary BCC in 76–81%, whereas the agreement between histological BCC subtype on punch biopsy and subsequent excision specimens in recurrent BCC is 67.1%. However, no large studies on the agreement between histological BCC subtype seen on punch biopsy and the following surgical excision are performed in primary BCC. Objective The aims of this study were (i) to establish the agreement between histological BCC subtype on punch biopsy and the subsequent surgical excision of primary BCC and; (ii) to investigate the proportion of primary BCCs in which punch biopsy enables identification of the most aggressive growth pattern. Methods Retrospective analyses of 243 primary BCCs with both punch biopsy and subsequent surgical excision. Analyses were based on the most aggressive histological subtype of the tumour. Results The agreement between BCC subtype on punch biopsy and the subsequent surgical excision of primary BCCs was 60.9%. A punch biopsy can predict the most aggressive growth pattern of primary BCCs in 84.4%. Seventy‐four percentage of all primary BCCs consisted of more than one histological subtype. Conclusion Dermatologists and other physicians have to be aware of the limited diagnostic value of a punch biopsy to determine the histological BCC subtype of the whole lesion. Misdiagnosis of the subtype will lead to undertreatment in one of six primary BCCs.     

Bednár tumor associated with dermal melanocytosis: melanocytic colonization or neuroectodermal multidirectional differentiation?

BACKGROUND: Neuroectodermal differentiation or melanocytic colonization are the opposing theories of histogenesis for the Bednár tumor or pigmented dermatofibrosarcoma protuberans (DFSP). OBSERVATION: A 31-year-old African-American woman presented with a 2-cm blue-black shoulder nodule of 1-year duration. Punch biopsy revealed a CD34+, Factor XIIIa-DFSP, harboring numerous, pigmented spindle S100+, Mart-1+ and HMB-45+ cells. Subsequent wide excision demonstrated pigmented dendritic and spindled cells widely scattered throughout the dermis of the 3-cm excisional margins and punch biopsy specimens of normal skin from both shoulders. This latter process was interpreted as dermal melanocytosis (nevus of Ito). The dermal pigmented spindle cells were Mart-1+ and CD34-, and were associated with non-pigmented CD34+, cytologically banal spindle cells, which were more numerous in the excisional margins than the contralateral shoulder. CONCLUSION: Reported herein is a singular case of Bednár tumor associated with dermal melanocytosis. Although the coexistence of these processes implicates colonization of the DFSP by constituent dermal melanocytes, the mixed immunophenotype (CD34+ or Mart-1+ cells) of dispersed dermal spindle cells hints at the possibility of a common cell of origin: the putative neuromesenchymal cell. In effect, the Bednár tumor could represent one part of a spectrum of neural crest-derived dermal tumors that includes dermal melanocytosis, cellular blue nevus and conventional DFSP.     

Local anesthetic procedures in dermatology. Part 2: Practical aspects

The vast majority of dermatologic surgery is performed with local anesthesia. The different methods provide safe and effective analgesia in circumscribed areas of skin and subcutaneous tissue and allow patients to tolerate otherwise painful diagnostic or therapeutic procedures while remaining conscious. Some forms of local anesthesia are unique, such as topical anesthesia with EMLA? or cryoanesthesia; others offer options to general anesthesia. Tumescent local anesthesia has gained widespread acceptance in the past decade for many indications other than cosmetic liposuction and is used for excising benign and malignant tumors, for extensive skin and soft tissue procedures (such as excision of acne inversa or sweat gland curettage) and in phlebologic surgery.     

Cryotherapy for lentigo maligna — is clinical acumen combined with a single punch biopsy good enough for staging?

Aim We aimed to clarity the effectivenes of our staging of LM over a I-year period. Background Cryosurgery has become accepted as a simple and effective treatment for lentigo maligna (LM) but not necessarily lentigo maligna melanoma (LMM). Pigmented epithelial cells are extremely sensitive to cold injury. If adequate freezing is delivered to the proper depth into the dermal appendages, LM should be eradicated. However, if the initial staging does not detect invasion the lesion may be inadequately treated. Methods Over 1 year prospectively. all patients presenting with LM(n= 12) wore stayed clinically by experienced dermatologists and by a single punch biopsy. This was then checked by complete excision of the lesion. Results In 9 patients the clinical and punch biopsy diagnosis was confirmed after excision. Two melanomas were missed clinically but detected on punch biopsy. In one patient the punch biopsy described a “LM with probable invasion elsewhere in the lesion”. Surgical excision yielded a melanoma, 0.8 mm thick. Clark's level 4. In a second patient, punch biopsy diagnosed superficial spreading melanoma (-SSM) in situ, confirmed on excision. Conclusions We therefore feel that clinical diagnosis combined with a single punch biopsy will diagnose invasion when present. We emphasise that cryotherapy should not be performed without punch biopsy confirmation of the clinical diagnosis.     

The use of Terson lens capsule forceps when performing punch biopsy of the skin

When performing skin biopsy using the skin biopsy punch, it is recommended that Terson lens capsule forceps be used as an aid to avoid crush artifact. This is because secure yet gentle purchase of the specimen is allowed by a row of small inwardly directed tines that arise from the 2.5 mm horizontally placed grasping blades, which are inserted into the incision created by a 3mm biopsy punch. The instrument also has the extra advantages of being in the correct working position when held with the hand in the resting position between prone and supine, of allowing an uninterrupted line of vision to the wound during use and is of a shape that minimizes unintentional contact with tissue.