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Nonspecific Histopathological Diagnoses The Impact of Partial Biopsy and the Need for a Consensus Guideline

Klaus Sellheyer, MD1,2; Paula Nelson, MD2; Wilma F. Bergfeld, MD1
[+] Author Affiliations
1Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
2Nelson Dermatopathology Associates, Atlanta, Georgia
JAMA Dermatol. 2014;150(1):11-12. doi:10.1001/jamadermatol.2013.7227.
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Partial skin biopsies have an impact on histopathological diagnoses. In March 2010, JAMA Dermatology published a study that found increased odds of misdiagnosis and microstaging inaccuracy of punch and shave biopsies for melanomas over excisional biopsies.1 In a subsequent comment on an opinion piece about biopsy technique and specimen size,2 Stratman3 highlighted the lack of consensus guidelines for correct biopsy techniques. Since then, nothing has changed. The American Academy of Dermatology has developed numerous clinical guidelines regarding office-based surgery, liposuction, atopic dermatitis, and so on, but a consensus guideline for adequate biopsy techniques is still missing.

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Two Cases of Shave Biopsies That Led to Nonspecific Histopathologic Diagnoses

A-D, Superficial shave biopsy diagnosed as atypical basaloid neoplasm. The biopsy was taken from the left upper cutaneous lip of a woman in her 70s. The clinician suspected basal cell carcinoma. On the initial section (A), no histopathological abnormalities were noted. Only the initial 6 of a total of 43 step sections revealed the surface of basaloid islands (arrowheads in B). On deeper step sections, only the surface of a hair follicle (C) and mild parakeratosis (D) were noted. The features could represent the surface of a basal cell carcinoma, of a tangentially cut sebaceous hyperplasia, or of the nearby hair follicle found on deeper sections (C). The diagnosis of an atypical basaloid neoplasm was issued, and a deeper biopsy was recommended. E-H, Superficial shave biopsy diagnosed as atypical squamous proliferation. The biopsy was taken from the nasal tip of a man in his 70s. The clinician suspected basal cell carcinoma or squamous cell carcinoma. Dermis was only minimally sampled. The initial sections showed the surface of a crateriform lesion with overlying compact orthohyperkeratosis (E). The initial 6 deeper sections (of a total of 44 performed) displayed additional hemorrhage at the tips of the columns of stratum corneum, as typically seen in a verruca (arrowheads in F). Additional deeper sections uncovered surface ulceration (arrowhead in G). Even on the deepest levels performed the bottom of the squamous proliferation could not be evaluated because the lesion was transected (H). The features could represent the surface of a very well-differentiated squamous cell carcinoma, an irritated verruca vulgaris, or a verrucous keratosis with overlying lichenification changes. The diagnosis of an atypical squamous proliferation was issued, and a deeper biopsy was recommended. (A-H, hematoxylin-eosin. A-D, Original magnification ×25; E-H, original magnification ×50.)

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