Professor Family and Community Health JCESOMMarshall University November 2014 Goals of this Presentation include discussion of the following Indications amp contraindications of Bx Guidelines for choosing location amp technique ID: 999610
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1. Skin BiopsyKathleen O’Hanlon, M.D.Professor, Family and Community HealthJCESOM/Marshall UniversityNovember 2014
2. Goals of this Presentation include discussion of the following:Indications & contraindications of BxGuidelines for choosing location & techniqueApplication of local anesthesia for BxMaterials needed in your Bx-kitSteps to proper performance of Bx (didactic and hands-on workshop)Submitting your pathology specimenProper coding & billing
3. Indications for BiopsyPurpose – for histopathology; r/o cancerIf “could be a melanoma” – go for full-thicknessQuick, simple, cost-effectiveIf entire lesion can be removed may also serve as treatment (curative or cosmetic)Rapid feedback – a GREAT way to learn Derm!In rare cases, tissue needed for special studies ie: immunofluorescent testing
4. Contraindications for BxSignificant coagulopathy (ASA, warfarin and clopidogrel do not need to be stopped)H/o allergy to anesthetic (dental hx)Partial-thickness bx discouraged if melanoma is suspected; if you biopsy for depth bx does NOT spread disease or compromise future careAtypical nevi can be shaved. It is impractical to remove every nevus with full-thickness excision. *Written consent usually not indicated
5. EquipmentAlcohol wipesNonsterile gloves (sterile if sutures are placed)Lidocaine (0.5 – 1ml, 1% or 2%, w or w/o epi)Punch, blade or curette (minor surgical tray for excisions) PickupsSharp tissue scissors (Metzenbaum)2 X 2sFormalin containerBandaid & antibiotic ointment
6. Anesthesia1 or 2% Lidocaine (Xylocaine) – WITHOUT epi takes effect faster so is the standard for punch or shaveVery safe! Allergy to this very rare. Lido 1% = 10mg/ml; maximum dose is about 5mg/kg; so a 70-kg person could tolerate up to 35mlIn kids or very sensitive –You can buffer the acidic “sting” by adding 1:9 parts sterile sodium chloride 0.9%You can apply a topical ie: EMLA , a 5% lidocaine + 5% prilocaine emulsion which penetrates skin particularly under occlusion for 60 minutes
7. Choosing Biopsy SiteSelect a site that is well developed and representative of the lesion (see next slide)Avoid areas of crusting or signs of secondary infectionIt is not necessary to include normal tissue in the sample except when sampling a vesiculobullous lesionBe mindful of patients with keloid tendencyAreas of poor circulation (ie: pretibial) may suffer from delayed healingThere are no actual limitations on what cutaneous or mucosal part of body you bx, but being a little selective can improve outcome
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9. Site-Specific RecommendationsTrunk/Breast Punch or shaveEyelid Superficial shaveGingiva Shave (may need RF for bleeding)Lip Punch or shave Nail bed Small punchPenis Superficial shavePinna Shave, punch or curetteTongue Punch or curette (+stitch)Vulva Hair-bearing shave; mucosal punch
10. Biopsy TechniquesPunchShaveCurettageExcisionalWedge (Incisional)
11. The Punch BiopsyObtains a full thick-ness cylindrical specimen or “core-sample”Good choice for small lesions (2, 3, 4 mm)Good choice for suspected melanomaWhole lesion does not need to be removed w bx
12. Technique – Punch Bx3mm is my standardStretch skin opposite to natural lines of tension (Langer’s)Push unit vertically into the skin & rotate to cutOnce dermis is penetrated there is dec’d resistanceLift & snip plug
13. Langer’s Lines
14. If you stretch skin perpendicular to Langer’s Lines your circular defect will turn into an ellipse and heal more readily.If you need to throw a stitch, it will be less puckered.
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16. Shave BiopsyBest-suited to remove raised skin lesions when full-thickness not requiredNot advised if melanoma suspectedDermal infiltration of anesthetic can help elevate lesionCan use blade +/or RF loop (or both, use RF to “feather-out” borders of defect)Apply topical hemostatic agent to achieve hemostasis (see later slide)Good for: tags, SKs, AKs, compound nevi, lentigines, small BCs
17. Can also use … Sgl.-edge Razor Blade Flexible “Biopblade”
18. The Deep Saucer-ShaveCentral aspect of biopsy is sampled into mid-dermisWill heal with a depression vs. flatGoal is to entirely remove lesionNot a choice if melanoma suspected Good for: dysplastic nevi, AKs, DFs
19. CurettageDisposable curettes are best, sharpScrape or scoop, multiple fragmentsDermis will feel gritty & will see punctate bleedingPartial-thickness sample well- suited for soft tissue ie BC, SKs or molluscumCan be used with hyperkeratotic lesions ie warts or AKs
20. Excisional BiopsyUsed to remove entire lesion, full-thickness Will require undermining and suture closureNot my technique of choice due to time-limitations and variance in margin recommendations: Benign lesions 1-2mm BC 3mm SC 5mm MIS 10mm
21. Incisional (Wedge) BiopsyRemoves a portion of an abnormal lesionClose with an absorbable subq suture*I think a punch would be quicker; so this is a technique I would not recommend
22. Achieving HemostasisTopical hemostatic agents can help you be more efficient & lessen need for cauteryBest cosmesis: Aluminum Chloride 30% (Drysol) - colorless; no tatooing; apply with cotton-tipped swabSilver Nitrate sticks: black tatoo*Monsel’s 20% (ferric subsulfate): Looks like a pasty dijon mustard but dries dark; tatoos** Not good choice in fair-skinned/cosmetic areas
23. Biopsy Procedure:Alcohol prep skin & Lidocaine bottle stopper1 ml tuberculin syringe w Lidocaineshave or curette – intradermal whealpunch – deeper SQComplete Path formPerform procedure:Punch - Stretch skin; twirl punch through dermis to subQ; pick-up & snip.Shave - shave using a sawing-type action or sharp snip Curettage – scrape w cutting edge of dermal curettePlace sample(s) in formalinApply pressure with 2 x 2 gauzeTopical hemostatic agent if neededBacitracin/Bandaid
24. Post-Procedure Patient EducationPunch/Shave require moist healingCleanse qid w soap/water & apply ab ointment to keep wound moistPain should be insignificant. Itch is usually a reaction to ointment or dressing.Scarring possible. Punch can leave an acne pock-mark.
25. Submitting Path SpecimenDanger: Telling pathologist too little … “7 D’s”Description – papule, vesicle, maculeDemographics – location of lesionDiseases – pertinent PMH (ie: Lupus)Drugs – applied or taken orally which could change lesionDuration – how long lesion has been presentDiameter – size of lesionDiagnosis – Your BEST guess!
26. CPT Code by Anatomical Site11100 Skin Bx, one lesion11101 Skin Bx, each additional lesion67810 Bx eyelid69100 Bx pinna of ear30100 Bx intranasal56605 Bx vulva or perineum54100 Bx penis, cutaneous41100 Bx anterior 2/3’s tongue11755 Bx nail unit
27. ICD Diagnostic CodesPer Internat’l Classification of Diseases …I usually use “Benign Lesion” code 216, followed by decimal & “location”:Skin of face 216.3Skin of trunk 216.5Skin of ear 216.2Skin of eyelid 216.1
28. Equipment SuppliersAny office medical supplier should be able to supply basic bx instruments:MiltexAcuderm, Inc.CooperSurgical, Inc.Curetteblade, Inc.
29. CreditsThe text on these slides is based on information from “Procedures for Primary Care”, 3rd ed., Pfenninger & Fowler.All of the photos were derived from Google Images.THANK YOU! *Questions?*