Shave Biopsy Is a Safe and Accurate Method for the Initial Evaluation of Melanoma

Hi all

See this recent article about the accuracy and safety of shave biopsies for evaluation of melanoma.

So shave biopsies are not so bad after all. Email if you want a copy of the article.

Ian

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 and microstaging 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 primary cutaneous melanoma, initially diagnosed on shave biopsy to have Breslow depth2 mm, to determine the accuracy of shave biopsy in T-staging and the potential impact on definitive 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 was 0.73  0.02 mm; 6.2% of lesions were ulcerated. At the time of wide excision, residual melanoma was found in 133 (22%), resulting inT-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 recurrence occurred 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 obtained on 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 of the overwhelming majority of patients with malignant melanoma. ( J Am Coll Surg 2011;212:454–462. © 2011 by the American College of Surgeons)

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  1. #1 by Ian McColl on May 24, 2011 - 11:08 am

    Shave biopsy is very popular in the USA and most are done by doctors who have been trained to take a proper shave biopsy. That is not quite the situation in Australia.

  2. #2 by Tony Dicker on May 25, 2011 - 2:48 am

    I agree Ian. It’s more about the ability to do a shave biopsy properly, the clinical knowledge of what can be sampled with a shave, and the competence of the pathology company to handle the specimen properly.

    With those things in place you get the correct answer most of the time. Incorrect shave technique, incorrect lesion selection or poor sample handling will be the cause of most of the errors.

  3. #3 by Dr Ian Katz on May 25, 2011 - 2:57 am

    I think it’s not difficult to teach or do a proper shave biopsy so why are doctors (GP’s mainly) in this country not doing more. Or am I missing something?

  4. #4 by Alan Cameron on May 26, 2011 - 8:10 pm

    You’re absolutely right Ian, it isn’t difficult to teach a proper shave biopsy. I suggest to people I’ve taught to get a few copy slides sent and have a look through the dermatoscope. That’s enough magnification to see general architecture and assess adequacy of shave depth.

    The “anti-shave” literature — at least for assessing melanocytic lesions — often confuses the important distinction between a total shave excision (pretty much as good as excision for thin lesions) and partial shave biopsies (where there is good evidence that biopsies <50% run a significant risk of missing invasion in lentiginous melanoma, and occasionally miss the diagnosis entirely)

    Also frequently ignored is the distinction between flat and nodular lesions. I was surprised to see this paper supporting shaves for melanomas as thick as 2mm!

    There are 2 important pro shave arguments in my mind

    1/ it leaves the surgeon with all reconstructive options. An excision biopsy (particularly one that is oriented inappropriately) does affect choice of reconstruction

    2/ It makes it easier to do biopsies so you do more. In my view this is good; I certainly get surprises every week. 10% of the things I biopsy thinking they are benign, but to "exclude melanoma", turn out to be melanomas. In fact, this group forms 40% of the melanomas I diagnose. No way I'd do all those biopsies is they required formal excision.

  5. #5 by Andrea Shankman on June 26, 2011 - 3:39 pm

    I am writing as a lay person. I am 57. One year ago, a raised pigmented lesion appeared on my left cheek very suddenly. I had many melanoma risk factors. The lesion, which grew from nothing to approximately 2.5 mm ( diameter) in three weeks was shaved off. It was diagnosed as an intradermal melanocytic Nevus. I had it reviewed and the conclusion was similar. I have heard that the appearance of a sudden intradermal melanocytic nevi at my age is rare. I believe that this was a nodular melanoma and presented as such–I do not think clinician was aware of “EFG ” guidelines. I noticed a very tiny subcutaneous nodule behind the biopsy site about a week later. I called the physician with no response. One year later the subcutaneous lesion is much deeper and definitely connected. A recent MRI for something else showed prominent enlarged glands in the submandibular region. I have been suffering from drenching night sweats for the past few months. No one in the medical community will connect the dots.

    I have no doubt in my mind that I have a nodular melanoma (the vertical depth is still there and according to a head and neck surgeon is not able to be excised). I feel that not making a distinction between nodular melanomas and other types of superficial melanomas is totally irresponsible. I have seen melanoma experts who quote me the findings of this study as assurance that the shave was read correctly. I do not want anyone to suffer in the horrendous way that I have. Prima facie–the way this presented and the appearance,my age and risk factors, the unlikelihood of an intradermal melanocytic Nevus arising at my age, the confusion microscopically between the two lesions , etc etc– would point to nodular melanoma. I would even think that you would need to excise the depth to get the diagnosis of nodular melanoma in many cases. I would think that in the case of a shave that just got a bit of the upper dermis, the pathology of an intradermal melanocytic Nevus and a nodular melanoma would look similar–nothing in the epidermis– melanocytic Nevus cells in the upper dermis.

    So again I look pretty crazy to the specialist who reads these findings and sees the 97% accuracy rates. I am starting to think that nodular melanomas and superficial ones should be assessed as two different disease processes. You should all read the studies by Dr. Kelly at the Victorian Melanoma Clinic. They even do studies supporting shaves–however, there are many more caveats.

  6. #6 by Andrea shankman on September 1, 2011 - 12:22 am

    Now I am afraid this is a nevoid melanoma!

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