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Punch biopsy: A useful adjunct in a rapid diagnosis breast clinic
The Breast 19 (2010) 150–151
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Short report
Punch biopsy: A useful adjunct in a rapid diagnosis breast clinic B.N. Modi, J.T. Machin, D. Ravichandran* Breast Unit, Luton & Dunstable Hospital NHS Foundation Trust, Lewsey Road, Luton LU4 0DZ, Bedfordshire, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 October 2009 Received in revised form 16 December 2009 Accepted 16 December 2009
Introduction: Triple assessment of breast lesions usually involves the use of core biopsy (CB) or fine needle aspiration cytology (FNAC). Punch Biopsy (PB) is a technique widely used by dermatologists and can be used in superficial breast lesions with dermal involvement. We studied the utilization of PB in a rapid diagnosis breast clinic. Method: We reviewed patients who underwent a PB over a seven and a half-year period from December 2001 to May 2009. The indications for biopsy and the contribution of PB to final diagnosis were studied. Results: The commonest indications were breast lump with skin involvement or ulceration (n ¼ 27), suspected Paget’s disease (n ¼ 25), discolouration of breast skin (n ¼ 23), and nodules in the breast skin or surgical scar (n ¼ 18). Final diagnosis was benign in 80 patients and malignant in 20. In 74 patients with benign and 7 patients with malignant diagnoses, PB was the only source of histological diagnosis. Conclusion: PB is a valuable adjunct to conventional methods of tissue diagnosis such as CB and FNAC in both benign and malignant breast lesions. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Punch biopsy Breast
Introduction Traditional triple assessment of breast lesions consists of clinical examination, imaging and core biopsy (CB) or fine needle aspiration cytology (FNAC). However, there are some breast lesions, usually those with dermal involvement, were CB or FNAC may be unsuitable or not feasible. For such superficial breast lesions, punch biopsy (PB) is a fast and easy to perform procedure that provides a good histological specimen with minimal scarring and patient discomfort. The technique involves taking a small disk of full thickness skin under local anaesthesia using a circular blade. We reviewed the use of PB in a rapid diagnosis breast clinic. Materials and methods (Fig. 1) We introduced PB to the assessment process in a rapid diagnosis breast clinic in December 2001. In this clinic patients undergo triple assessment in a single clinic visit. We reviewed all PB’s done over a 7 and a half-year period from its introduction to May 2009. The indications for the biopsy and the contribution of PB to final diagnosis were recorded. The punch biopsy was performed under local anaesthesia using a sterile single-use skin punch (Stiefel laboratories (UK) Ltd, Maidenhead, UK). Different diameter (dm) punches
* Corresponding author. Tel./fax: þ44 1582 718 009. E-mail address: [email protected] (D. Ravichandran). 0960-9776/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2009.12.007
are available varying from 2 mm to 8 mm (all with a length of cut of 7 mm) to suit different clinical conditions. We found 3 or 4 mm dm punches were satisfactory for breast/nipple conditions and used these for this study. The technique has been previously described.1,2 Briefly, the site of the biopsy was chosen and infiltrated subcutaneously with 2–5 ml of 1% plain lignocaine. A nipple biopsy usually required injection of the anaesthesia at the base of the nipple to produce a ‘‘nipple block’’. A single disk of full-thickness skin with a layer of underlying adipose tissue is removed and multiple biopsies were performed if required. Pressure was applied to the biopsy site for a few minutes until haemostasis is achieved. No attempt was made to close the wound and a simple dry dressing is applied. If there was a separate lesion within the breast or if the lesion with dermal involvement extended deeper into the breast, CB or FNAC were performed as necessary in addition to the PB and the results were recorded. Results One hundred patients underwent a PB. The commonest indications were to rule out Paget’s disease in patients presenting with itchy/eczematous nipple or breast skin (n ¼ 25), discolouration of the breast skin (n ¼ 23), breast lump with skin involvement (n ¼ 23) or frank ulceration (n ¼ 4) and nodules in the breast skin or a previous surgical scar (n ¼ 18). The mean age was 56 years (range 17–98 years). Eighteen patients had a previous history of breast cancer. Final diagnosis was benign in 80 patients and malignant in
B.N. Modi et al. / The Breast 19 (2010) 150–151
Fig. 1. Patient with a suspected mastectomy scar recurrence having a punch biopsy. Histology confirmed local recurrence.
20. In 80 patients with benign conditions, PB was the only pathological component of the triple assessment in 74. The malignant diagnoses consist of primary breast cancer in 11 (including one ductal carcinoma in-situ), recurrent/metastatic breast cancer in 7, and basal cell carcinoma and radiation-induced angiosarcoma in one patient each. In 7 of these patients PB was the only source of histological diagnosis. In 3 patients the PB was benign and the final diagnosis was malignant. Two patients with breast carcinoma had unrelated benign lesions on the breast skin (eczema in one, sebohoeric keratosis in another): skin lesions underwent PB and breast lesions underwent CB that confirmed breast carcinoma. In one patient FNAC of supraclavicular lymph node confirmed recurrent breast cancer but punch biopsy of a lesion on the chest wall was not diagnostic. Discussion In breast lesions with dermal involvement, a standard core needle biopsy or FNAC may be difficult. Although a CB may be
151
performed after positioning the tip of the needle just on the skin surface which would provide a small portion of the skin, and ulcerated lesions may be amenable to apposition or scraping cytology, PB is a much easier and quicker method of obtaining a representative histological sample. PB is used widely and extensively by dermatologists for the histological diagnosis of skin conditions1 but we have been unable to find any previous publications relating to its use in a breast clinic. An FNA clinic reported PB as useful in ‘‘hard-to-aspirate’’ dermal lesions and the majority of their patients have had previous breast cancer.3 It has also been used by other specialities such as ophthalmologists in the diagnosis of perioccular and facial lesions.2 PB can be performed in the outpatients quickly under local anaesthesia and the resulting wound from a small (<4 mm) punch usually does not require suturing and leaves the patient with a cosmetically acceptable scar.4 It could be the only ‘‘invasive’’ assessment in cases where the abnormality is confined to the breast skin/nipple and in lesions that are ulcerated or adherent to the skin. Our results suggest that it can be a useful adjunct to CB and FNAC in suitable cases. Conflict of interest statement None declared. Funding source None. Ethical approval Not required. References 1. Zuber TJ. Punch biopsy of the skin. Am Fam Physician 2002;65:1155–8. 2. Warren RC, Nerad JA, Carter KD. Punch biopsy technique for the ophthalmologist. Arch Opthalmol 1990;108:778–9. 3. Shin HJC, Sneige N, Staerkel GA. Utility of punch biopsy for lesions that are hard to aspirate by conventional fine needle aspiration. Cancer (Cancer Cytopathol) 1999;87:149–54. 4. Christensen LJ, Phillips K, Weaver AL, Otley CC. Primary closure vs secondintention treatment of skin punch biopsy sites. A randomised trial. Arch Dermatol 2005;141:1093–9.
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Short report
Punch biopsy: A useful adjunct in a rapid diagnosis breast clinic B.N. Modi, J.T. Machin, D. Ravichandran* Breast Unit, Luton & Dunstable Hospital NHS Foundation Trust, Lewsey Road, Luton LU4 0DZ, Bedfordshire, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 October 2009 Received in revised form 16 December 2009 Accepted 16 December 2009
Introduction: Triple assessment of breast lesions usually involves the use of core biopsy (CB) or fine needle aspiration cytology (FNAC). Punch Biopsy (PB) is a technique widely used by dermatologists and can be used in superficial breast lesions with dermal involvement. We studied the utilization of PB in a rapid diagnosis breast clinic. Method: We reviewed patients who underwent a PB over a seven and a half-year period from December 2001 to May 2009. The indications for biopsy and the contribution of PB to final diagnosis were studied. Results: The commonest indications were breast lump with skin involvement or ulceration (n ¼ 27), suspected Paget’s disease (n ¼ 25), discolouration of breast skin (n ¼ 23), and nodules in the breast skin or surgical scar (n ¼ 18). Final diagnosis was benign in 80 patients and malignant in 20. In 74 patients with benign and 7 patients with malignant diagnoses, PB was the only source of histological diagnosis. Conclusion: PB is a valuable adjunct to conventional methods of tissue diagnosis such as CB and FNAC in both benign and malignant breast lesions. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Punch biopsy Breast
Introduction Traditional triple assessment of breast lesions consists of clinical examination, imaging and core biopsy (CB) or fine needle aspiration cytology (FNAC). However, there are some breast lesions, usually those with dermal involvement, were CB or FNAC may be unsuitable or not feasible. For such superficial breast lesions, punch biopsy (PB) is a fast and easy to perform procedure that provides a good histological specimen with minimal scarring and patient discomfort. The technique involves taking a small disk of full thickness skin under local anaesthesia using a circular blade. We reviewed the use of PB in a rapid diagnosis breast clinic. Materials and methods (Fig. 1) We introduced PB to the assessment process in a rapid diagnosis breast clinic in December 2001. In this clinic patients undergo triple assessment in a single clinic visit. We reviewed all PB’s done over a 7 and a half-year period from its introduction to May 2009. The indications for the biopsy and the contribution of PB to final diagnosis were recorded. The punch biopsy was performed under local anaesthesia using a sterile single-use skin punch (Stiefel laboratories (UK) Ltd, Maidenhead, UK). Different diameter (dm) punches
* Corresponding author. Tel./fax: þ44 1582 718 009. E-mail address: [email protected] (D. Ravichandran). 0960-9776/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2009.12.007
are available varying from 2 mm to 8 mm (all with a length of cut of 7 mm) to suit different clinical conditions. We found 3 or 4 mm dm punches were satisfactory for breast/nipple conditions and used these for this study. The technique has been previously described.1,2 Briefly, the site of the biopsy was chosen and infiltrated subcutaneously with 2–5 ml of 1% plain lignocaine. A nipple biopsy usually required injection of the anaesthesia at the base of the nipple to produce a ‘‘nipple block’’. A single disk of full-thickness skin with a layer of underlying adipose tissue is removed and multiple biopsies were performed if required. Pressure was applied to the biopsy site for a few minutes until haemostasis is achieved. No attempt was made to close the wound and a simple dry dressing is applied. If there was a separate lesion within the breast or if the lesion with dermal involvement extended deeper into the breast, CB or FNAC were performed as necessary in addition to the PB and the results were recorded. Results One hundred patients underwent a PB. The commonest indications were to rule out Paget’s disease in patients presenting with itchy/eczematous nipple or breast skin (n ¼ 25), discolouration of the breast skin (n ¼ 23), breast lump with skin involvement (n ¼ 23) or frank ulceration (n ¼ 4) and nodules in the breast skin or a previous surgical scar (n ¼ 18). The mean age was 56 years (range 17–98 years). Eighteen patients had a previous history of breast cancer. Final diagnosis was benign in 80 patients and malignant in
B.N. Modi et al. / The Breast 19 (2010) 150–151
Fig. 1. Patient with a suspected mastectomy scar recurrence having a punch biopsy. Histology confirmed local recurrence.
20. In 80 patients with benign conditions, PB was the only pathological component of the triple assessment in 74. The malignant diagnoses consist of primary breast cancer in 11 (including one ductal carcinoma in-situ), recurrent/metastatic breast cancer in 7, and basal cell carcinoma and radiation-induced angiosarcoma in one patient each. In 7 of these patients PB was the only source of histological diagnosis. In 3 patients the PB was benign and the final diagnosis was malignant. Two patients with breast carcinoma had unrelated benign lesions on the breast skin (eczema in one, sebohoeric keratosis in another): skin lesions underwent PB and breast lesions underwent CB that confirmed breast carcinoma. In one patient FNAC of supraclavicular lymph node confirmed recurrent breast cancer but punch biopsy of a lesion on the chest wall was not diagnostic. Discussion In breast lesions with dermal involvement, a standard core needle biopsy or FNAC may be difficult. Although a CB may be
151
performed after positioning the tip of the needle just on the skin surface which would provide a small portion of the skin, and ulcerated lesions may be amenable to apposition or scraping cytology, PB is a much easier and quicker method of obtaining a representative histological sample. PB is used widely and extensively by dermatologists for the histological diagnosis of skin conditions1 but we have been unable to find any previous publications relating to its use in a breast clinic. An FNA clinic reported PB as useful in ‘‘hard-to-aspirate’’ dermal lesions and the majority of their patients have had previous breast cancer.3 It has also been used by other specialities such as ophthalmologists in the diagnosis of perioccular and facial lesions.2 PB can be performed in the outpatients quickly under local anaesthesia and the resulting wound from a small (<4 mm) punch usually does not require suturing and leaves the patient with a cosmetically acceptable scar.4 It could be the only ‘‘invasive’’ assessment in cases where the abnormality is confined to the breast skin/nipple and in lesions that are ulcerated or adherent to the skin. Our results suggest that it can be a useful adjunct to CB and FNAC in suitable cases. Conflict of interest statement None declared. Funding source None. Ethical approval Not required. References 1. Zuber TJ. Punch biopsy of the skin. Am Fam Physician 2002;65:1155–8. 2. Warren RC, Nerad JA, Carter KD. Punch biopsy technique for the ophthalmologist. Arch Opthalmol 1990;108:778–9. 3. Shin HJC, Sneige N, Staerkel GA. Utility of punch biopsy for lesions that are hard to aspirate by conventional fine needle aspiration. Cancer (Cancer Cytopathol) 1999;87:149–54. 4. Christensen LJ, Phillips K, Weaver AL, Otley CC. Primary closure vs secondintention treatment of skin punch biopsy sites. A randomised trial. Arch Dermatol 2005;141:1093–9.