Using shave biopsies

1. Using shavebiopsies/excisions inpracticeDr Ian KatzDr Ian Katz, Southern Sun Pathology

2. What is a shave? Superficial shave Approximately 1-2 mm Heals really well generally Suacerization shave Deeper More risk of scarringDr Ian Katz, Southern Sun Pathology

3. NHMRC guidelines for diagnosis ofmelanoma Chapter 6 Biopsy 1. The optimal biopsy approach is complete excision with a 2mm margin andupper subcutis (Level C) 2. Partial biopsies may not be fully representative of the lesion and need to beinterpreted in light of the clinical findings (level C) 3. Incisional, punch or shave biopsies may be appropriate in carefullyselected clinical circumstances, for example, for large facial or acrallesions, or where the suspicion of melanoma is low (level c) Good practice point It is advisable to review unexpected pathology results with the reportingpathologistDr Ian Katz, Southern Sun Pathology

4. Level C: Body of evidence provides some support for recommendation(s) but careshould be taken in its applicationDr Ian Katz, Southern Sun Pathology

5. Index of suspicion for melanoma Low ? Watch, annual review High Prefer excision Medium Largest group Excision or shaveDr Ian Katz, Southern Sun Pathology

6. Effect of biopsy type on outcomes inthe treatment of primary cutaneousmelanoma Am J Surg. 2013 May;205(5):585-90. doi: 10.1016/j.amjsurg.2013.01.023. .Mills JK, White I, Diggs B, Fortino J, Vetto JT. Source Department of Surgery, St. Vincents Hospital, Melbourne, Victoria, Australia. Abstract BACKGROUND: Surgical excision remains the primary and only potentially curative treatment for melanoma. Although current guidelines recommend excisional biopsy as the technique of choicefor evaluating lesions suspected of being primary melanomas, other biopsy types are commonly used. We sought to determine the impact of biopsy type (excisional, shave, orpunch) 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 ofbiopsy type on T-staging accuracy, wide local excision (WLE) area (cm(2)), sentinel lymph node biopsy (SLNB) identification rates and results, tumor recurrence, and patientsurvival. RESULTS: Seven hundred nine patients were diagnosed by punch biopsy (23%), shave biopsy (34%), and excisional biopsy (43%). Shave biopsy results showed significantly more positivedeep 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 tumorupstaging) 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), andthis 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 orimpact 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 meanWLE 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 shavebiopsies, when used appropriately, should not be discouraged for the diagnosis of melanoma.Dr Ian Katz, Southern Sun Pathology

7. Effect of biopsy type on outcomes inthe treatment of primary cutaneousmelanoma 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 excisionalbiopsies (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; thefinding of residual tumor in the WLE impacted survival on univariate but not multivariateanalysis.Dr Ian Katz, Southern Sun Pathology

8. Effect of biopsy type on outcomes inthe treatment of primary cutaneousmelanoma CONCLUSIONS: Both shave and punch biopsies demonstrated a significant risk offinding residual tumor in the WLE, with pathologic upstaging of theWLE. Punch biopsy also led to a larger mean WLE area compared withother biopsy types. However, biopsy type did not impact SLNB accuracy or results, tumorrecurrence, or disease-specific survival (DSS). Punch and shave biopsies, when used appropriately, should not bediscouraged for the diagnosis of melanoma.Dr Ian Katz, Southern Sun Pathology

9. Favorable long-term outcomes in patients with histologically dysplastic nevi thatapproach a specimen border.J Am Acad Dermatol. 2013 Apr;68(4):545-51. doi: 10.1016/j.jaad.2012.09.031. Epub 2012 Nov 3.Hocker TL, Alikhan A, Comfere NI, Peters MS.SourceDepartment of Dermatology, Mayo Clinic, Rochester, Minnesota55905, USA.AbstractBACKGROUND:Patients with multiple clinically dysplastic nevi are at increased risk for development of melanoma. However, the risk of melanoma arising in a histologically dysplastic nevus (HDN) is unknown.OBJECTIVE:We sought to determine the rate of melanoma development in patients with HDNs that approached a microscopic border but were not re-excised.METHODS:We performed a retrospective study of patients evaluated in our dermatology department from January 1, 1980, to December 31, 1989, who had a HDN that extended to within 0.2 mm of a microscopic punch, shave, orexcision border and was not re-excised.RESULTS:The average follow-up in our cohort of 115 patients was 17.4 years (range: 0.0-29.9): 82 patients (71.3%) were followed up for longer than 10 years, 78 (67.8%) longer than 15 years, and 73 (63.4%) had more than 20years of follow-up; 66 of 115 nevi were mildly dysplastic, 42 moderately dysplastic, and 7 had severe dysplasia. No patient developed metastatic melanoma or melanoma at the site of removal of a HDN.LIMITATIONS:This was a retrospective study performed at 1 large academic medical center.CONCLUSION:During a long-term follow-up period, no patient developed melanoma at the site of an incompletely or narrowly removed HDN, providing evidence that routine re-excision of mildly or moderately dysplastic nevi may not benecessary.Copyright 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.Dr Ian Katz, Southern Sun Pathology

10. Favorable long-term outcomes in patients with histologicallydysplastic nevi that approach a specimen border.CONCLUSION:During a long-term follow-up period, no patient developedmelanoma at the site of an incompletely or narrowly removedHDN, providing evidence that routine re-excision of mildly ormoderately dysplastic nevi may not be necessary.Dr Ian Katz, Southern Sun Pathology

11. Shave biopsy is a safe and accuratemethod for the initial evaluation ofmelanoma. J Am Coll Surg. 2011 Apr;212(4):454-60; discussion 460-2. doi: 10.1016/j.jamcollsurg.2010.12.021. Zager JS, Hochwald SN, Marzban SS, Francois R, Law KM, Davis AH, Messina JL, Vincek V, Mitchell C, Church A, Copeland EM, Sondak VK, Grobmyer SR. Source Department of Cutaneous Oncology, Moffitt Cancer Center, and the University of South Florida College of Medicine, Tampa, FL 33612, USA. [email protected] Abstract 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 andmicrostaging 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 primarycutaneous 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 ondefinitive 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 was0.73 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 recurrenceoccurred 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 obtainedon 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 ofthe overwhelming majority of patients with malignant melanoma.Dr Ian Katz, Southern Sun Pathology

12. Shave biopsy is a safe and accuratemethod for the initial evaluation ofmelanoma RESULTS: Six hundred patients undergoing shave biopsy were diagnosed withmelanoma from extremity (42%), trunk (37%), and head or neck (21%).Mean ( SEM) Breslow thickness was 0.73 0.02 mm; 6.2% of lesions wereulcerated. 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 nodebiopsy changed in 12 of 600 (2%) and 8 of 600 patients (1.3%), respectively.Locoregional recurrence occurred in 10 (1.7%) patients and distantrecurrence in 4 (0.7%) patients.Dr Ian Katz, Southern Sun Pathology

13. Shave biopsy is a safe and accuratemethod for the initial evaluation ofmelanoma CONCLUSIONS: These data challenge the surgical dogma that full-thickness excisionalbiopsy of suspicious cutaneous lesions is the only method that canlead to accurate diagnosis. Data obtained on shave biopsy of melanoma are reliable and accuratein the overwhelming majority of cases (97%). The use of shave biopsy does not complicate or compromisemanagement of the overwhelming majority of patients withmalignant melanomaDr Ian Katz, Southern Sun Pathology

14. My rules for dealing with atypicalmelanocytic lesions on shavesMildly atypical andpatient happy andwilling to watchWatchDr Ian Katz, Southern Sun Pathology

15. My rules for dealing with atypicalmelanocytic lesionsMildly atypicaland patient giveshistory of changeExciseDr Ian Katz, Southern Sun Pathology

16. My rules for dealing with atypicalmelanocytic lesionsMod or severelyatypicalExciseDr Ian Katz, Southern Sun Pathology

17. My rules for dealing with atypicalmelanocytic lesionsAtypical lesionon markedly sun-damaged skinExciseDr Ian Katz, Southern Sun Pathology

18. Margins with shaves A lottery Depends on orientationDr Ian Katz, Southern Sun Pathology

19. Dr Ian Katz, Southern Sun Pathology

22. When shaves arrive in the lab Generally are shrivelled and folded due to formalin Sectioning is in a random plane Examining and reporting on what is seen on the surface when cutting-up if difficultDr Ian Katz, Southern Sun Pathology

23. The plane of section determines which margins are examined.Dr Ian Katz, Southern Sun Pathology

25. The lesion is clear of marginsIn the plane of sectionsPigmented lesion on surfaceDistance clear Distance clearDr Ian Katz, Southern Sun Pathology

27. Pigmented lesion on surfaceMargins are involved in the planeof sectionsDr Ian Katz, Southern Sun Pathology

28. Random plane of section Can be any one of 360 degrees May or may not include involved margin Pure luckDr Ian Katz, Southern Sun Pathology

29. Positive margins Positive margins in shave mean positive Negative margins mean nothing could still be positiveDr Ian Katz, Southern Sun Pathology

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Using shave biopsies