- Email: [email protected]
Saucerization biopsy of pigmented lesions
Clinics in Dermatology (2005) 23, 631 – 635
COMMENT AND CONTROVERSY Edited by Stephen P. Stone, MD
Saucerization biopsy of pigmented lesions Jonhan Ho, MDa, Robert T. Brodell, MDb,c, Stephen E. Helms, MDb,c,* a
Department of Pathology, University of Pittsburgh Medical Center, UPMC Shadyside Hospital, Pittsburgh, PA 15232, USA Northeastern Ohio University College of Medicine, Rootstown, OH, USA c Case Western Reserve University School of Medicine, Cleveland, OH, USA b
A variety of skin lesions can clinically resemble malignant melanoma, and bearlyQ melanoma often fails to demonstrate classic bABCDQ morphological features.1 Therefore, a definitive diagnosis of any pigmented lesion can only be made after histopathologic examination of an appropriate surgical specimen. If a physician is to bdo no harm,Q it is most important to maintain a high index of suspicion when viewing pigmented lesions and to sample enough lesions to encompass as many potentially lethal melanomas as possible without exposing patients to unnecessary surgery. Physicians should sacrifice some degree of diagnostic specificity to maintain a high degree of sensitivity. The decision to perform a biopsy vs a fullthickness excision of a pigmented lesion has a direct bearing on this issue and has been the topic of spirited debates. Biopsies of several types are commonly used because they are simpler to perform, quicker, less costly, and most often heal with excellent cosmetic results. Some physicians have, historically, worried that a biopsy may lead to hematogenous dissemination of melanoma or deeper implantation of tumor and suggest that all questionable lesions should be completely excised.2 - 4 This approach is supported by those who caution that incisional biopsies may be more prone to sampling error that is avoided when a lesion is completely excised. In addition, complete removal of a lesion benefits patients who might be lost to follow-up. Finally, tangential excision specimens of suspicious pigmented lesions that
T Corresponding author. 735 Niles Cortland Rd, Warren, OH 44484, USA. Tel.: +1 330 856 6365; fax: +1 330 609 5088. E-mail address: [email protected] (S.E. Helms). 0738-081X/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2005.06.004
prove to be benign nevi are more likely to lead to incomplete excision and the development of brecurrent nevusQ that can histopathologically resemble junctional malignant melanoma in situ.5 Many experts, thus, have suggested that all suspicious pigmented lesions should be excised to the subcutaneous fat using the traditional wedge technique.6 - 28
Saucerization is indicated We differ with this conclusion and believe that the saucerization biopsy of a suspicious pigmented lesion is often warranted and offers several distinct advantages when compared with punch biopsy, incisional biopsy, or traditional full-thickness excision.15,29 - 32 A recent case in which the diagnosis of malignant melanoma was considered bveryQ likely illustrates our approach. A 56-year-old white man presented with a large asymptomatic bmoleQ on the posterior aspect of his neck. The mole had been slowly enlarging for about 1 year but was totally asymptomatic. He had been told by a nurse to bget that checkedQ by a dermatologist. An 8 10-mm, somewhat oval-shaped, black plaque showing some variation in dark brown coloration and several notches in the border was seen at the posterior base of his neck (Fig. 1). The clinical impression was superficial, spreading malignant melanoma vs pigmented basal cell carcinoma, and a disc saucerization biopsy was performed instead of a traditional full-thickness excision. Because the lesion was small, flat, and located in an area that is not cosmetically sensitive, it was believed that an adequate specimen could be obtained using the saucerization technique.
632
Fig. 1 A suspicious 1-cm pigmented lesion with variation in color and irregular borders is present in a 56-year-old white man.
Histopathologic examination revealed significant keratinocyte atypia with disordered maturation, compact hyperkeratosis, focal parakeratosis, and a lentiginous proliferation of melanocytes. Melanophages within the papillary dermis accounted for most of the pigmentation within the lesion. No melanocyte atypia or nesting was present, and specifically, no evidence of malignant melanoma was present (Figs. 2 and 3). The diagnosis of pigmented actinic keratosis was made, and a subsequent wider excision was unnecessary. The lesion healed completely with an excellent cosmetic result and did not recur. In this case, a clinician, identifying a clinically bobviousQ melanoma, might have been tempted to proceed along the malignant branch of the pigmented lesion algorithm before obtaining a histopathologic diagnosis with the intent of expediting the patient’s course to wellness. This approach might include a full-thickness wide excision and/or sentinel node biopsy. In fact, several different approaches have been advocated, including a
J. Ho et al.
Fig. 3 Pigmented actinic keratosis (hematoxylin and eosin, 100). A higher power view shows significant keratinocyte atypia with disordered maturation.
complete excisional biopsy with narrow margins and a primary closure, a shave biopsy, an incisional punch biopsy, or a disc saucerization biopsy. We used the latter procedure in this case. A disc saucerization biopsy extends well into the reticular dermis beneath the lesion. This is not the same as a traditional shave biopsy that is used for an elevated superficial hyperkeratotic lesion intending to shave the lesion at the level of the surrounding skin. We define a disc saucerization biopsy as a bscoop-shave,Q that is, an excisional biopsy with narrow (1-2 mm) margins conducted at a 308 to 458 angle to the skin, which results in sampling to the level of the mid reticular dermis. In general, the procedure should reach an optimal depth of 2 to 4 mm. Others have suggested that saucerization procedures should extend into the subcutaneous fat.17,18,32 This is not the standard used on a daily basis by dermatologists and defeats many of the advantages of this procedure because it would necessitate suturing the wound that is created.
Discussion
Fig. 2 Pigmented actinic keratosis (hematoxylin and eosin, original magnification 40). This specimen shows compact hyperkeratosis, focal parakeratosis, and a lentiginous proliferation of benign melanocytes.
The American Academy of Dermatology guidelines of care for primary cutaneous melanoma state that, whenever possible, the lesion should be excised for diagnostic purposes using narrow margins. An incisional biopsy technique is appropriate when the suspicion for melanoma is low, when the lesion is large, or when it is impractical to perform an excision.20 In this instance, we chose to use a disc saucerization biopsy procedure in a clinical setting where our suspicion of melanoma was not blow,Q the lesion was not large, and an excision could have been performed. This case was shown to a dozen of our peers who have trained and practiced in different parts of the United States, and each responded that he/she routinely perform saucerization procedures in lesions of this type. In view of the disconnection between the common practice and the recommendation of the most respected authority, we
Saucerization biopsy of pigmented lesions investigated the advantages and the disadvantages of this type of biopsy technique. The advantages of the disc saucerization approach are significant. First, the procedure is quick, easy, inexpensive, and provides an excellent cosmetic result in most circumstances. Second, when multiple sections are obtained from saucerization specimens, a broad view of lesional architecture and configuration that is particularly helpful in the diagnosis of lentigo maligna (malignant melanoma in situ) in which benign foci can be present within a larger lesion that can lead to sampling error.32 Saucerization is, thus, superior to other biopsy techniques such as punch biopsy and incisional biopsy where only a portion of the lesion is sampled.33 Similarly, Rigel34 feels that the saucerization technique for dysplastic nevi is appropriate in many instances because it is important to visualize the epidermis at the bshouldersQ of the lesions, and this area is superficial.35 In fact, in one study, 86% of saucerization specimens could be assessed histopathologically with regard to diagnosis and thickness of melanoma.18 Third, more aggressive and complex procedures including full-thickness excision and grafting, and sentinel node biopsy may be avoided in the case when a saucerization biopsy excludes the diagnosis of melanoma.18,36 Fourth, patients can submerse the area without the fear of increasing the risk of wound infections as would be the case if stitches are placed in a full-thickness excision wound. There are several potential disadvantages of a saucerization procedure. First, horizontal transection of a potential melanoma complicates the determination of the exact Breslow depth of a tumor needed to gauge prognosis. Second, as noted previously, physicians and patients in the past have feared that transection of a melanoma might lead to metastatic spread. Third, the broad defect of a saucerization biopsy heals more slowly than a traditional excision closed with sutures. Finally, if melanoma is identified, an additional full-thickness excisional procedure with a minimum of 1-cm margin is required. We largely avoid the first disadvantage by only using this technique for relatively flat lesions. If a thick nodule is present within a pigmented lesion, we recommend a traditional excisional procedure. In addition, in the rare instances when transection of a melanoma occurs, the sum of the depth of the tumor extending to the deep margin within the biopsy specimen added to the thickness of the melanoma in the subsequent excision will approximate the Breslow depth. In some cases, if horizontal transection of a melanoma is noted at the time of surgery and pigment is noted within the dermis after removal of the tangential specimen, fullthickness excision may be performed immediately with submission of both specimens for pathological examination. With regard to the second disadvantage, the preponderance of evidence suggests that biopsies of malignant melanoma do not lead to metastatic dissemination of tumor.9,14,21,22,37,38 Disadvantages in healing time are balanced by patient flexibility in being able to submerse
633 partial thickness wounds in water. With regard to the patient who does not follow up after incomplete removal of a lesion by a saucerization procedure, at least a pathological diagnosis can be rendered and attempts made to contact the patient for definitive treatment. In the case where a more complex surgical excision is planned, requiring the patient to return to the office at a later time for the procedure, the noncompliant patient may miss his or her surgical appointment and never have the diagnosis confirmed. In addition, full-thickness excision with narrow borders does not preclude the need for additional surgery when melanoma is found because only 1- to 2-mm margins are obtained in the initial excision to avoid overly aggressive surgery on benign lesions.6,39 Most cases of malignant melanoma that are narrowly excised for diagnostic purposes, thus, still require a second procedure to ensure that adequate margins have been obtained. When a sentinel node procedure is performed, this can easily be combined with the reexcision procedure irrespective of which initial procedure is performed. In fact, it is also interesting to note that full-thickness wedge excision at the time of initial diagnosis may disrupt local lymphatics more than a saucerization procedure and interfere with the accuracy of sentinel node procedures performed at the time of the reexcision. With regard to the confusion created when a tangential specimen of a benign lesion recurs at a tangential biopsy site, review of the original biopsy specimen and careful histopathologic consideration of the features of melanoma in situ and recurrent nevus will usually produce the correct diagnosis. In rare cases where this is not possible, reexcision of the malignant appearing recurrent nevus will be curative.
Conclusions For these reasons, we recommend that a disc saucerization procedure be accepted as a reasonable and acceptable alternative to full-thickness excision to confirm the diagnosis in any pigmented lesion that is relatively flat, and no more than 1.5 cm in diameter regardless of the location. For larger lesions or lesions with clinically defined nodules that may represent the vertical growth phase of melanoma, an incisional biopsy through the nodule representing the thickest portion of the lesion or full-thickness excision with narrow margins can be performed to confirm the diagnosis before more extensive and definitive surgery with wider margins.39 Our case also demonstrates that benign pigmented lesions and malignant melanoma can be difficult to distinguish. In addition to pigmented actinic keratoses, seborrheic keratoses, junctional or compound nevi, congenital nevi, blue nevi, Spitz nevi, dysplastic nevi, pigmented basal cell or squamous cell carcinomas, hemangiomas, lentigines, melanoacanthoma, foreign bodies, thrombosed fibroepithelial polyps, and even engorged ticks attached to the skin can show
634 features that suggest the clinical diagnosis of malignant melanoma.1 If a sufficiently high index of suspicion is maintained to enhance sensitivity, specificity may be sacrificed to some degree. We recognize that some insurance companies will retrospectively deny payment for an excision of a suspected melanoma because the lesion shows a benign histopathology. This in no way should deter the physician from performing a biopsy on any lesion that may possibly be considered to be a melanoma or other malignancy. Any diagnostic procedure is preferable to the alternative of simple observation leading to delayed or missed diagnosis of melanoma, which could result in loss of valuable time that may eliminate the potential for cure. Paradoxically, increased clinical experience has lead us to do more biopsies of pigmented lesions because we have seen many bchangingQ lesions that do not demonstrate ABCD criteria but prove to be early melanoma on histopathology.40 A low threshold for biopsy is an effort to increase our ability to detect as many melanomas as possible at a stage when there is opportunity for cure. Using a procedure that is quick, inexpensive, associated with low morbidity, and cosmetically friendly helps us to efficiently sample relatively flat pigmented lesions in a busy practice setting without the need to reschedule patients for a separate surgical appointment or refer patients for more complex and time-consuming full-thickness excisional surgery. The strict adherence to the dictum that all suspicious pigmented lesions, even remotely suspected to be melanoma, should be removed with full-thickness excision may result in the unintended consequence of raising the biopsy threshold and, therefore, could lead to a delay in the diagnosis of some melanomas.31 This may be particularly true in the case of primary physicians who are trained to act, reassure, or track patients with pigmented lesions.41 They might perform a saucerization procedure of a questionable lesion at a lower threshold than would be the case if they were compelled to perform a full-thickness excision or refer the patient to a dermatologist or plastic surgeon. We reiterate the importance of histopathologically ruling out a melanoma in every clinically suspicious lesion and favor an acceptance of the saucerization technique as a valid alternative, rather than a technique used only when full-thickness excision is not bpractical.Q We hope this will further the trend to diagnose melanoma at the earliest possible stage that has occurred over the past 10 to 15 years.
References 1. Grant-Kels JM, Bason ET, Grin CM. The misdiagnosis of malignant melanoma. J Am Acad Dermatol 1999;40:539 - 48. 2. Rampen FHJ, van der Esch EP. Biopsy and survival of malignant melanoma. J Am Acad Dermatol 1985;12:385 - 8. 3. Ironside P, Pitt TTE, Rank BK. Malignant melanoma: some aspects of pathology and prognosis. Aust NZ Surg 1977;47:70. 4. van der Esch EP, Rampen FHJ. Punch biopsy of melanoma. J Am Acad Dermatol 1985;13:899 - 902.
J. Ho et al. 5. Habif TB, Campbell JL, Campbell JI, Chapman S. Skin disease: diagnosis and treatment. Mosby7 St Louis (Mo); 2001. p. 414. 6. Arndt KA, Bowers KE, Alam M, et al. Manual of dermatologic therapeutics with essentials of diagnosis. Philadelphia7 Lippincott Williams and Wilkins; 2002. p. 214. 7. Maize JC, Ackerman AB. Pigmented lesions of the skin. Philadelphia7 Lea and Febiger; 1987. p. 19 - 25. 8. Roses DF, Harris MN, Ackerman AB. Diagnosis and management of cutaneous malignant melanoma. Philadelphia (Pa)7 WB Saunders Co; 1983. p. 105 - 14. 9. Maddin S, Dodd WA. Malignant melanoma and dysplastic nevi in current dermatologic therapy. Philadelphia7 WB Saunders Co; 1991. p. 135 - 8. 10. Langley RGB, Barnhill RL, et al. Neoplasms: Cutaneous Melanoma. In: Freedberg IM, Eisen AZ, Wolf K, et al, editors. Fitzpatrick’s dermatology general medicine. 5th ed. New York7 McGraw-Hill; 1999. p. 1099. 11. Rigel DS, Friedman RJ. Benign and malignant tumors of pigmentproducing cells. In: Sams WM, Lynch PJ, editors. Principles and practice of dermatology. New York7 Churchill Livingstone; 1990. p. 245. 12. Harris MN, Gumport SL. Biopsy technique for malignant melanoma. J Dermatol Surg Oncol 1975;1:24. 13. Fitzpatrick TB. Early recognition of primary cutaneous melanoma. Hosp Pract 1982;67 - 75. 14. Penneys NS. Excision of melanoma after initial biopsy. J Am Acad Dermatol 1985;13:995 - 8. 15. Salasche SJ, Grabski WJ. Transverse sectioning of a pigmented lesion. Dermatol Surg 1997;23:578 - 82. 16. Lang PG. Current concepts in the management of patents with melanoma. Am J Clin Dermatol 2002;3:401 - 26. 17. Swanson NA, Lee KK, Gorman A, Lee HN. Biopsy techniques: diagnosis of melanoma. Dermatol Clin 2002;20:677 - 80. 18. Cockerell CJ. Biopsy technique for pigmented lesions. Semin Cutan Med Surg 1997;16:108 - 12. 19. Harris MN, Gumport SL. Total excisional biopsy for primary malignant melanoma. JAMA 1973;226:354. 20. Sober AJ, Chuang TY, Duvic M, et al. Guidelines of care for primary cutaneous melanoma. J Am Acad Dermatol 2001;45:579 - 87. 21. Lees VC, Briggs JC. Effect of initial biopsy on prognosis in stage I invasive cutaneous malignant melanoma: review of 1086 Patients. Br J Surg 1991;78:1108 - 10. 22. Lederman JS, Sober AJ. Does biopsy influence survival in clinical stage I melanoma? J Am Acad Dermatol 1985;13:983 - 7. 23. Geisse JK. Biopsy techniques for pigmented lesions of the skin. Pathology: state of the art reviews. Philadelphia7 Hanley and Belfus; 1994. p. 181- 3. 24. Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic factors analysis of 17,600 melanoma patients. Validation of the new AJCC melanoma staging system. J Clin Oncol 2001;19:3622. 25. Lee Yeu-Tsu N. Malignant melanoma: to biopsy or not to biopsy. Ca 1974;24:104. 26. Greenstein DS, Rogers G. Management of stage I malignant melanoma. Dermatol Surg 1995;21:927 - 37. 27. Macy-Roberts E, Ackerman AB. A critique of techniques for biopsy of clinically suspected malignant melanomas. Am J Dermatopathol 1982; 4:391 - 8. 28. Mays SR, Nelson BR. Current therapy of cutaneous melanoma. Cutis 1999;63:293 - 8. 29. Bolognia JL. Biopsy techniques for pigmented lesions. Dermatol Surg 2000;26:89 - 91. 30. Johnson TM, Smith JW, et al. Current therapy for cutaneous melanoma. J Am Acad Dermatol 1995;32:689 - 707. 31. Piepkorn M, Odland PB. Quality of care in the diagnosis of melanoma and related melanocytic lesions. Arch Dermatol 1997;133: 1393 - 6. 32. Stevens G, Cockerell CJ. Avoiding sampling error in the biopsy of pigmented lesions. Arch Dermatol 1996;132:1380 - 2.
Saucerization biopsy of pigmented lesions 33. Silvers DN. Practical tips to prevent the histologic misdiagnosis of melanocytic lesions. Cosmet Dermatol 1999;33 - 8. 34. Rigel DR. Lecture Annual Fall Dermatology Conference Oct. 11, 2004 Las Vegas, Nevada. 35. Gambichler T, Senger E, Rapp S, et al. Deep shave excision of macular melanocytic nevi with the razor blade biopsy technique. Dermatol Surg 2000;26:662 - 6. 36. Witheiler DD, Cockerell CJ. Sensitivity of diagnosis of malignant melanoma: a clinicopathologic study with a critical assessment of biopsy techniques. Exp Dermatol 1992;1:170 - 5. 37. Epstein E, Bragg K, Linden G. Biopsy and prognosis of malignant melanoma. JAMA 1969;208:1369 - 71.
635 38. Drzewieki KT, Ladefoged C, Christensen HE. Biopsy and prognosis for cutaneous melanoma in clinical stage I. Scand J Plast Reconstr Surg 1980;14:141 - 4. 39. Ledwig PA, Robinson JK. Should the excisional biopsy of clinically probable melanomas include a margin that might also serve as adequate for treatment? Arch Dermatol 1990;126:877 - 8. 40. Hazen BP, Bhatia AC, Zaim MT, Brodell RT. The clinical diagnosis of early malignant melanoma: expansion of the ABCD criteria to improve diagnostic sensitivity. Dermatol Online J 1999, http:/matrix.ucdaves. edu/DOJvol5num2/index.html. 41. Weinstock MA, Goldstein MG, Dube CE, Rhodes AR, Sober AJ. [Letter] JAMA 1998;280:881 - 2.
COMMENT AND CONTROVERSY Edited by Stephen P. Stone, MD
Saucerization biopsy of pigmented lesions Jonhan Ho, MDa, Robert T. Brodell, MDb,c, Stephen E. Helms, MDb,c,* a
Department of Pathology, University of Pittsburgh Medical Center, UPMC Shadyside Hospital, Pittsburgh, PA 15232, USA Northeastern Ohio University College of Medicine, Rootstown, OH, USA c Case Western Reserve University School of Medicine, Cleveland, OH, USA b
A variety of skin lesions can clinically resemble malignant melanoma, and bearlyQ melanoma often fails to demonstrate classic bABCDQ morphological features.1 Therefore, a definitive diagnosis of any pigmented lesion can only be made after histopathologic examination of an appropriate surgical specimen. If a physician is to bdo no harm,Q it is most important to maintain a high index of suspicion when viewing pigmented lesions and to sample enough lesions to encompass as many potentially lethal melanomas as possible without exposing patients to unnecessary surgery. Physicians should sacrifice some degree of diagnostic specificity to maintain a high degree of sensitivity. The decision to perform a biopsy vs a fullthickness excision of a pigmented lesion has a direct bearing on this issue and has been the topic of spirited debates. Biopsies of several types are commonly used because they are simpler to perform, quicker, less costly, and most often heal with excellent cosmetic results. Some physicians have, historically, worried that a biopsy may lead to hematogenous dissemination of melanoma or deeper implantation of tumor and suggest that all questionable lesions should be completely excised.2 - 4 This approach is supported by those who caution that incisional biopsies may be more prone to sampling error that is avoided when a lesion is completely excised. In addition, complete removal of a lesion benefits patients who might be lost to follow-up. Finally, tangential excision specimens of suspicious pigmented lesions that
T Corresponding author. 735 Niles Cortland Rd, Warren, OH 44484, USA. Tel.: +1 330 856 6365; fax: +1 330 609 5088. E-mail address: [email protected] (S.E. Helms). 0738-081X/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2005.06.004
prove to be benign nevi are more likely to lead to incomplete excision and the development of brecurrent nevusQ that can histopathologically resemble junctional malignant melanoma in situ.5 Many experts, thus, have suggested that all suspicious pigmented lesions should be excised to the subcutaneous fat using the traditional wedge technique.6 - 28
Saucerization is indicated We differ with this conclusion and believe that the saucerization biopsy of a suspicious pigmented lesion is often warranted and offers several distinct advantages when compared with punch biopsy, incisional biopsy, or traditional full-thickness excision.15,29 - 32 A recent case in which the diagnosis of malignant melanoma was considered bveryQ likely illustrates our approach. A 56-year-old white man presented with a large asymptomatic bmoleQ on the posterior aspect of his neck. The mole had been slowly enlarging for about 1 year but was totally asymptomatic. He had been told by a nurse to bget that checkedQ by a dermatologist. An 8 10-mm, somewhat oval-shaped, black plaque showing some variation in dark brown coloration and several notches in the border was seen at the posterior base of his neck (Fig. 1). The clinical impression was superficial, spreading malignant melanoma vs pigmented basal cell carcinoma, and a disc saucerization biopsy was performed instead of a traditional full-thickness excision. Because the lesion was small, flat, and located in an area that is not cosmetically sensitive, it was believed that an adequate specimen could be obtained using the saucerization technique.
632
Fig. 1 A suspicious 1-cm pigmented lesion with variation in color and irregular borders is present in a 56-year-old white man.
Histopathologic examination revealed significant keratinocyte atypia with disordered maturation, compact hyperkeratosis, focal parakeratosis, and a lentiginous proliferation of melanocytes. Melanophages within the papillary dermis accounted for most of the pigmentation within the lesion. No melanocyte atypia or nesting was present, and specifically, no evidence of malignant melanoma was present (Figs. 2 and 3). The diagnosis of pigmented actinic keratosis was made, and a subsequent wider excision was unnecessary. The lesion healed completely with an excellent cosmetic result and did not recur. In this case, a clinician, identifying a clinically bobviousQ melanoma, might have been tempted to proceed along the malignant branch of the pigmented lesion algorithm before obtaining a histopathologic diagnosis with the intent of expediting the patient’s course to wellness. This approach might include a full-thickness wide excision and/or sentinel node biopsy. In fact, several different approaches have been advocated, including a
J. Ho et al.
Fig. 3 Pigmented actinic keratosis (hematoxylin and eosin, 100). A higher power view shows significant keratinocyte atypia with disordered maturation.
complete excisional biopsy with narrow margins and a primary closure, a shave biopsy, an incisional punch biopsy, or a disc saucerization biopsy. We used the latter procedure in this case. A disc saucerization biopsy extends well into the reticular dermis beneath the lesion. This is not the same as a traditional shave biopsy that is used for an elevated superficial hyperkeratotic lesion intending to shave the lesion at the level of the surrounding skin. We define a disc saucerization biopsy as a bscoop-shave,Q that is, an excisional biopsy with narrow (1-2 mm) margins conducted at a 308 to 458 angle to the skin, which results in sampling to the level of the mid reticular dermis. In general, the procedure should reach an optimal depth of 2 to 4 mm. Others have suggested that saucerization procedures should extend into the subcutaneous fat.17,18,32 This is not the standard used on a daily basis by dermatologists and defeats many of the advantages of this procedure because it would necessitate suturing the wound that is created.
Discussion
Fig. 2 Pigmented actinic keratosis (hematoxylin and eosin, original magnification 40). This specimen shows compact hyperkeratosis, focal parakeratosis, and a lentiginous proliferation of benign melanocytes.
The American Academy of Dermatology guidelines of care for primary cutaneous melanoma state that, whenever possible, the lesion should be excised for diagnostic purposes using narrow margins. An incisional biopsy technique is appropriate when the suspicion for melanoma is low, when the lesion is large, or when it is impractical to perform an excision.20 In this instance, we chose to use a disc saucerization biopsy procedure in a clinical setting where our suspicion of melanoma was not blow,Q the lesion was not large, and an excision could have been performed. This case was shown to a dozen of our peers who have trained and practiced in different parts of the United States, and each responded that he/she routinely perform saucerization procedures in lesions of this type. In view of the disconnection between the common practice and the recommendation of the most respected authority, we
Saucerization biopsy of pigmented lesions investigated the advantages and the disadvantages of this type of biopsy technique. The advantages of the disc saucerization approach are significant. First, the procedure is quick, easy, inexpensive, and provides an excellent cosmetic result in most circumstances. Second, when multiple sections are obtained from saucerization specimens, a broad view of lesional architecture and configuration that is particularly helpful in the diagnosis of lentigo maligna (malignant melanoma in situ) in which benign foci can be present within a larger lesion that can lead to sampling error.32 Saucerization is, thus, superior to other biopsy techniques such as punch biopsy and incisional biopsy where only a portion of the lesion is sampled.33 Similarly, Rigel34 feels that the saucerization technique for dysplastic nevi is appropriate in many instances because it is important to visualize the epidermis at the bshouldersQ of the lesions, and this area is superficial.35 In fact, in one study, 86% of saucerization specimens could be assessed histopathologically with regard to diagnosis and thickness of melanoma.18 Third, more aggressive and complex procedures including full-thickness excision and grafting, and sentinel node biopsy may be avoided in the case when a saucerization biopsy excludes the diagnosis of melanoma.18,36 Fourth, patients can submerse the area without the fear of increasing the risk of wound infections as would be the case if stitches are placed in a full-thickness excision wound. There are several potential disadvantages of a saucerization procedure. First, horizontal transection of a potential melanoma complicates the determination of the exact Breslow depth of a tumor needed to gauge prognosis. Second, as noted previously, physicians and patients in the past have feared that transection of a melanoma might lead to metastatic spread. Third, the broad defect of a saucerization biopsy heals more slowly than a traditional excision closed with sutures. Finally, if melanoma is identified, an additional full-thickness excisional procedure with a minimum of 1-cm margin is required. We largely avoid the first disadvantage by only using this technique for relatively flat lesions. If a thick nodule is present within a pigmented lesion, we recommend a traditional excisional procedure. In addition, in the rare instances when transection of a melanoma occurs, the sum of the depth of the tumor extending to the deep margin within the biopsy specimen added to the thickness of the melanoma in the subsequent excision will approximate the Breslow depth. In some cases, if horizontal transection of a melanoma is noted at the time of surgery and pigment is noted within the dermis after removal of the tangential specimen, fullthickness excision may be performed immediately with submission of both specimens for pathological examination. With regard to the second disadvantage, the preponderance of evidence suggests that biopsies of malignant melanoma do not lead to metastatic dissemination of tumor.9,14,21,22,37,38 Disadvantages in healing time are balanced by patient flexibility in being able to submerse
633 partial thickness wounds in water. With regard to the patient who does not follow up after incomplete removal of a lesion by a saucerization procedure, at least a pathological diagnosis can be rendered and attempts made to contact the patient for definitive treatment. In the case where a more complex surgical excision is planned, requiring the patient to return to the office at a later time for the procedure, the noncompliant patient may miss his or her surgical appointment and never have the diagnosis confirmed. In addition, full-thickness excision with narrow borders does not preclude the need for additional surgery when melanoma is found because only 1- to 2-mm margins are obtained in the initial excision to avoid overly aggressive surgery on benign lesions.6,39 Most cases of malignant melanoma that are narrowly excised for diagnostic purposes, thus, still require a second procedure to ensure that adequate margins have been obtained. When a sentinel node procedure is performed, this can easily be combined with the reexcision procedure irrespective of which initial procedure is performed. In fact, it is also interesting to note that full-thickness wedge excision at the time of initial diagnosis may disrupt local lymphatics more than a saucerization procedure and interfere with the accuracy of sentinel node procedures performed at the time of the reexcision. With regard to the confusion created when a tangential specimen of a benign lesion recurs at a tangential biopsy site, review of the original biopsy specimen and careful histopathologic consideration of the features of melanoma in situ and recurrent nevus will usually produce the correct diagnosis. In rare cases where this is not possible, reexcision of the malignant appearing recurrent nevus will be curative.
Conclusions For these reasons, we recommend that a disc saucerization procedure be accepted as a reasonable and acceptable alternative to full-thickness excision to confirm the diagnosis in any pigmented lesion that is relatively flat, and no more than 1.5 cm in diameter regardless of the location. For larger lesions or lesions with clinically defined nodules that may represent the vertical growth phase of melanoma, an incisional biopsy through the nodule representing the thickest portion of the lesion or full-thickness excision with narrow margins can be performed to confirm the diagnosis before more extensive and definitive surgery with wider margins.39 Our case also demonstrates that benign pigmented lesions and malignant melanoma can be difficult to distinguish. In addition to pigmented actinic keratoses, seborrheic keratoses, junctional or compound nevi, congenital nevi, blue nevi, Spitz nevi, dysplastic nevi, pigmented basal cell or squamous cell carcinomas, hemangiomas, lentigines, melanoacanthoma, foreign bodies, thrombosed fibroepithelial polyps, and even engorged ticks attached to the skin can show
634 features that suggest the clinical diagnosis of malignant melanoma.1 If a sufficiently high index of suspicion is maintained to enhance sensitivity, specificity may be sacrificed to some degree. We recognize that some insurance companies will retrospectively deny payment for an excision of a suspected melanoma because the lesion shows a benign histopathology. This in no way should deter the physician from performing a biopsy on any lesion that may possibly be considered to be a melanoma or other malignancy. Any diagnostic procedure is preferable to the alternative of simple observation leading to delayed or missed diagnosis of melanoma, which could result in loss of valuable time that may eliminate the potential for cure. Paradoxically, increased clinical experience has lead us to do more biopsies of pigmented lesions because we have seen many bchangingQ lesions that do not demonstrate ABCD criteria but prove to be early melanoma on histopathology.40 A low threshold for biopsy is an effort to increase our ability to detect as many melanomas as possible at a stage when there is opportunity for cure. Using a procedure that is quick, inexpensive, associated with low morbidity, and cosmetically friendly helps us to efficiently sample relatively flat pigmented lesions in a busy practice setting without the need to reschedule patients for a separate surgical appointment or refer patients for more complex and time-consuming full-thickness excisional surgery. The strict adherence to the dictum that all suspicious pigmented lesions, even remotely suspected to be melanoma, should be removed with full-thickness excision may result in the unintended consequence of raising the biopsy threshold and, therefore, could lead to a delay in the diagnosis of some melanomas.31 This may be particularly true in the case of primary physicians who are trained to act, reassure, or track patients with pigmented lesions.41 They might perform a saucerization procedure of a questionable lesion at a lower threshold than would be the case if they were compelled to perform a full-thickness excision or refer the patient to a dermatologist or plastic surgeon. We reiterate the importance of histopathologically ruling out a melanoma in every clinically suspicious lesion and favor an acceptance of the saucerization technique as a valid alternative, rather than a technique used only when full-thickness excision is not bpractical.Q We hope this will further the trend to diagnose melanoma at the earliest possible stage that has occurred over the past 10 to 15 years.
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