Dermatol Clin 20 (2002) 677 – 680

Biopsy techniques
Diagnosis of melanoma
Neil A. Swanson, MD*, Ken K. Lee, MD, Annalisa Gorman, MD,
Han N. Lee, MD
Department of Dermatology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road,
Mailcode OP06, Portland, OR 97201,USA

A properly performed biopsy is the first step in include patients with any of the following: a personal
the management of melanoma. It has become in- or family history of melanoma; a fair complexion; the
creasingly important to obtain biopsies of pigmented presence of multiple nevi or atypical (dysplastic)
lesions correctly because there are significant ramifi- nevus syndrome; a history of numerous or severe
cations beyond just making the diagnosis of mela- sunburns; and an advanced aged. Risk factors for
noma. Factors, such as depth of invasion, ulceration, individual lesions include appearance de novo; a
microsatellitosis, angiolymphatic invasion, and mito- change in size, texture, or shape; the ABCD criteria;
tic index, can impact management and prognosis. and the symptom of pruritus. Clinically asympto-
The decision to implement new techniques, such as matic nevi that begin to itch should alert both patient
sentinel lymph node biopsy and new adjuvant ther- and physician to pay closer attention to that particular
apies, is often determined by the initial biopsy. It is lesion. A clinician must also listen to the patient. If
critical that an adequate specimen be presented to the they sense that there is something changing or dif-
dermatopathologist so that a correct and complete ferent in a particular lesion, it is often best to obtain a
diagnosis can be made. Proper biopsy technique im- biopsy of that lesion. Experienced clinicians have
pacts the diagnosis and treatment of melanoma, but many anecdotes of clinically benign lesions removed
it is also important in creating the best aesthetic purely based on patient request that turn out to be
results, because many biopsies are benign. This ar- melanoma. Lastly, a clinician must weigh the given
ticle reviews the decision-making process and dis- risks of a particular lesion with the patient or family
cusses in detail the biopsy techniques and rationales concern (in the case of children) for scarring, inherent
for their use. in all biopsy procedures.
There are several tools available that can help to
decide whether or not to obtain a biopsy of a particular
Decision-making process pigmented lesion. These include dermoscopy, precise
photography, ‘‘mole mapping’’ by computer, and
When examining a patient with one or several others in developmental stages. Dermatologists
suspicious pigmented lesions, the question often develop expertise to determine which group of pa-
arises, ‘‘Do I need to perform a biopsy, and if so, tients and which particular lesions are concerns
which technique do I choose?’’ There are specific for the development of melanoma. If suspicion is
characteristics of patients and individual lesions that moderate or high, dermatologists routinely remove
portend higher risk to develop melanoma. Examples the pigmented lesion and submit it for histologic
analysis by a dermatopathologist. This is both reas-
suring to the patient and clinician, and frequently
* Corresponding author. leads to a diagnosis of melanoma in its earlier, less
E-mail address: [email protected] (N.A. Swanson). advanced stage.

0733-8635/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 7 3 3 - 8 6 3 5 ( 0 2 ) 0 0 0 2 5 - 6
678 N.A. Swanson et al. / Dermatol Clin 20 (2002) 677–680

Biopsy techniques the extent of further surgery necessary based princi-

pally on the depth of the melanoma.
Glossary: definition of terms When performing an excisional biopsy, the cli-
nician should first examine the lymph nodes in the
An excisional biopsy refers to en toto removal of a suspected draining basin from the lesion in question.
suspicious lesion. This is performed with a margin (as If the lesion turns out to be a melanoma, inflam-
defined later) of clinically normal tissue. It is the mation from the biopsy procedure can result in a
preferred method of removing a pigmented lesion for false-positive dermatopathic node. Clinicians often
histologic interpretation. use a Wood’s lamp to help assess the clinical margin,
An incisional biopsy is used to sample only a part sometimes extending beyond the obvious clinical
of a suspicious lesion for histologic evaluation. Be- appearance of the lesion. The authors take a 1- to
cause it does not remove the entire lesion, incisional 1.5-mm margin surrounding the lesion so defined into
biopsies may limit the dermatopathologist’s ability to the subcutaneous fat [1,2]. When possible, the biopsy
detect a melanoma based on sampling error. is aligned along relaxed skin tension lines and along
Shave biopsy refers to a shallow removal of a the draining lymphatics from that site. The former
lesion at a depth confined to the dermis. It can be allows for an easier and more cosmetically acceptable
performed by a scalpel, a dermablade, a razor blade, or procedure if the lesion is a melanoma and requires re-
scissors. Hemostasis is usually obtained with alumi- excision. The latter allows for a more accurate
num chloride, and the biopsy site is allowed to heal sentinel lymph node biopsy if indicated.
by secondary intention. The excisional biopsy can be performed with
A saucerization is a biopsy that occurs through either a punch or a fusiform (elliptical) excision
viable dermis into subcutaneous fat. It is performed by (Fig. 1). By choosing a punch 1- to 1.5-mm greater
angling a scalpel at approximately 45 degrees to the
skin and removing a disk of tissue, including all or part
of the suspicious lesion, well into the subcutaneous fat.
Punch biopsy refers to the use of a sharp circular
instrument to remove tissue well into the subcuta-
neous fat. Punches are available in sizes ranging from
1.5 mm to 1 cm. They are used for excisional or in-
cisional biopsies. Punch biopsies, with rare exception,
are closed with simple interrupted or vertical mattress
stitches for wound edge eversion to obtain the best
cosmetic result.
The fusiform (ellipse) allows for full-thickness re-
moval of the suspicious lesion and a margin of sur-
rounding skin. Closure is obtained with both deep
and cuticular stitches.
The margin removed is defined as the area of
normal-appearing tissue surrounding the lesion to be
removed and has two components. The peripheral
margin is the area of normal skin extending radially
from the clinically suspicious lesion, whereas the deep
margin is the depth to which skin and subcutaneous
tissue are entered and removed during the biopsy.

Excisional biopsy

The excisional biopsy is the preferred method of

removing a clinically suspicious pigmented lesion. It
provides the dermatopathologist with the maximal
opportunity to diagnose a melanoma in a given Fig. 1. (A) Fusiform excisional biopsy outlined with a 1- to
biopsy sample. If present, the maximum depth of 1.5-mm peripheral margin around a suspicious pigmented
invasion of the melanoma can be measured and other lesion. (B) Tissue from the same excisional biopsy illus-
histologic criteria of importance. It also helps define trating the deep margin into subcutaneous fat.
 N.A. Swanson et al. / Dermatol Clin 20 (2002) 677–680 679

in diameter than the lesion to undergo biopsy, a full-

thickness, complete specimen can be removed easily
and quickly, with a cosmetically acceptable scar. If the
lesion is larger or in a cosmetically sensitive area, such
as the head and neck, a fusiform (elliptical) excision
with full-thickness closure provides adequate tissue
for the pathologist and an excellent cosmetic result
if the pigmented lesion is benign.

Saucerization

A saucerization biopsy can be performed to pro-

vide an excisional specimen for the dermatopatholo-
gist (Fig. 2). This technique is easy to perform, time Fig. 3. This figure illustrates two points. First, this is the type
effective, and often preferred by patients and physi- of large pigmented lesion in a cosmetically sensitive area
cians in areas of the body where it is difficult to create where an incisional biopsy might be performed. The authors
an elegant scar. These areas include the upper back, recommend two to three 3- to 4-mm punch biopsies from
shoulders, upper arms, and anterior chest. The the darkest area or a long, thin ellipse from the same. If the
authors often use a saucerization technique on lower latter, the authors ask that the pathologist section the
extremities and ears. The key is to make sure this is a specimen longitudinally instead of the typical ‘‘bread loaf.’’
saucerization (ie, a biopsy into fatty tissue). Because Second, the dotted margin is the clinical margin pre-Wood’s
in areas such as those described scars often spread or lamp, and the solid margin after Wood’s lamp. This tool can
be very useful to determine an accurate clinical margin.
become hypertrophic, a saucerization is often the
biopsy method of choice. It leaves a smaller, round,
cosmetically acceptable scar instead of a longer linear terpart. It should be performed on very large lesions
spread excisional scar, providing adequate tissue for and in cosmetically sensitive regions (Fig. 3). If it is
histologic interpretation (see Fig. 2). performed, the most darkly pigmented or raised area
of the lesion should undergo biopsy. This can be
Incisional biopsy performed using a punch biopsy; small fusiform
excision (ellipse); or a saucerization down to the level
An incisional biopsy can be used to diagnose of the subcutaneous fat. Although most clinicians
melanoma in a worrisome pigmented lesion. Because believe that an incisional biopsy does not spread
it does not sample the entire lesion in question, tumor or influence survival [3], there still exists a
however, incisional biopsies are not as accurate diag- theoretical risk that cutting through the tumor may
nostically or prognostically as their excisional coun- lead to local spread of the melanoma. Studies indicate
that an incisional biopsy does not influence prognosis
[4 – 7]. Others have shown that an incisional biopsy,
especially of a deeper melanoma, may negatively
influence local recurrence or survival [8,9]. When
performed, the tissue specimen should be cut and
processed along the longitudinal axis to increase the
cross-section area available for the dermatopatholo-
gist histologically.

Special circumstances

For the clinically obvious melanoma, often in pa-

tients with a prior personal or family history of
melanoma, the authors choose an excision with ap-
Fig. 2. A saucerization excisional biopsy with 1.5-mm propriate margins (both peripheral and deep) as the
margins surrounding a suspicious pigmented lesion, with a initial biopsy technique. This is used almost exclu-
depth to fat. A duoderm dressing is in place and the wound sively on the trunk or extremities. The margins chosen
is left to granulate pending pathologic findings. are similar to that for a thin melanoma, which is 1 cm
680 N.A. Swanson et al. / Dermatol Clin 20 (2002) 677–680

metic results, bearing in mind that the excisional

technique is ideal because it removes the suspicious
lesion en toto. Excisional biopsies should extend to
the subcutaneous fat by means of a punch biopsy, a
fusiform ellipse, or a saucerization. Incisional biop-
sies can be performed in certain circumstances, but
should be done so with caution because sampling
error may lead to missed diagnosis or inaccurate his-
tologic criterion, such as depth.

References

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