Applied Evidence

Biopsies for skin cancer detection: Dispelling the myths

J Fam Pract. 2018 May;67(5):270-274

From The Journal of Family Practice | 2018;67(5):270-274.

References

1. Kerr OA, Tidman MJ, Walker JJ, et al. The profile of dermatological problems in primary care. Clin Exp Dermatol. 2010;35:380-383.

2. Hosler GA, Patterson JW. Lentigines, nevi, and melanomas. In: Patterson JW, ed. Weedon’s Skin Pathology. Elsevier; 2015:32,837-901.

3. Coit DG, Andtbacka R, Bichakjian CK, et al. Melanoma. J Natl Compr Canc Netw. 2009;7:250-275.

4. Gershenwald JE, Scolyer RA, Hess KR, et al. Melanoma of the skin. In: Amin MB, Edge S, Greene F, et al, eds. AJCC Cancer Staging Manual. Springer International Publishing; 2017;8:563-585.

5. American Joint Committee on Cancer. Implementation of AJCC 8th Edition Cancer Staging System. Available at: https://cancerstaging.org/About/news/Pages/Implementation-of-AJCC-8th-Edition-Cancer-Staging-System.aspx. Accessed April 2, 2018.

6. Karimipour DJ, Schwartz JL, Wang TS, et al. Microstaging accuracy after subtotal incisional biopsy of cutaneous melanoma. J Am Acad Dermatol. 2005;52:798-802.

7. Kaiser S, Vassell R, Pinckney RG, et al. Clinical impact of biopsy method on the quality of surgical management in melanoma. J Surg Oncol. 2014;109:775-779.

8. Montgomery BD, Sadler GM. Punch biopsy of pigmented lesions is potentially hazardous. Can Fam Physician. 2009;55:24.

9. Ng JC, Swain S, Dowling JP, et al. The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma: experience of an Australian tertiary referral service. Arch Dermatol. 2010;146:234-239.

10. Gambichler T, Senger E, Rapp S, et al. Deep shave excision of macular melanocytic nevi with the razor blade biopsy technique. Dermatol Surg. 2000;26:662-666.

11. Ferrandiz L, Moreno-Ramirez D, Camacho FM. Shave excision of common acquired melanocytic nevi: cosmetic outcome, recurrences, and complications. Dermatol Surg. 2005;31(9 Pt 1):1112-1115.

12. D'souza G, Carey TE, William WN Jr, et al. Epidemiology of head and neck squamous cell cancer among HIV-infected patients. J Acquir Immune Defic Syndr. 2014;65:603-610.

13. Edge SB, Byrd DR, Compton CC, et al, eds. AJCC Cancer Staging Handbook. 7th ed. New York, NY: Springer; 2010.

14. Elston DM, Stratman EJ, Miller SJ, et al. Skin biopsy. J Am Acad Dermatol. 2016;74:1-16.

15. Zager JS, Hochwald SN, Marzban SS, et al. Shave biopsy is a safe and accurate method for the initial evaluation of melanoma. J Am Coll Surg. 2011;212:454-460.

16. Chanda JJ, Callen JP. Adverse effect of melanoma incision. J Am Acad Dermatol. 1985;13:519-522.

17. Noroozi N, Zakerolhosseini A. Computerized measurement of melanocytic tumor depth in skin histopathological images. Micron. 2015;77:44-56.

18. Nielsen LJ, Lumholt P, Hölmich LR. [Local anaesthesia with vasoconstrictor is safe to use in areas with end-arteries in fingers, toes, noses and ears]. Ugeskr Laeger. 2014;176(44).

19. Häfner HM, Röcken M, Breuninger H. Epinephrine-supplemented local anesthetics for ear and nose surgery: clinical use without complications in more than 10,000 surgical procedures. J Dtsch Dermatol Ges. 2005;3:195-199.

20. Krunic AL, Wang LC, Soltani K, et al. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol. 2004;51:755-759.

21. Prabhakar H, Rath S, Kalaivani M, et al. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database Syst Rev. 2015;(3):CD010645.

22. Ilicki J. Safety of epinephrine in digital nerve blocks: a literature review. J Emerg Med. 2015;49:799-809.

MYTH #5

Epinephrine cannot be used for biopsies on the fingers, toes, nose, or penis.

Lidocaine with epinephrine is safe to use in areas with end-arteries, such as the fingers, toes, nose (FIGURE 4), and penis. There is no evidence to support the notion that local anesthesia with vasoconstriction can cause necrosis in these areas, and no case of necrosis has been reported since the introduction of commercial lidocaine with epinephrine in 1948.¹⁸

In addition to an absence of complications, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia, as a study of more than 10,000 ear and nose surgeries using epinephrine-supplemented local anesthetics showed.¹⁹ The relative absence of blood in the operating field significantly reduces the duration of surgery and increases the healing rate because less electrocautery is needed.¹⁹

Similarly, the addition of epinephrine in digital blocks minimizes the need for tourniquets and large volumes of anesthetic and provides better and longer pain control during procedures.²⁰ This topic was addressed by Prabhakar et al in a Cochrane Review in 2015.²¹ While digital surgeries are common, there were only 4 randomized controlled studies addressing the use of epinephrine in digital blocks. In these studies, there were no reports of adverse events, such as ischemia distal to the injection site. Evidence suggests that epinephrine in digital blocks can even be used safely in patients with vascular disease.²²

And while the use of epinephrine with lidocaine in sites with end-arteries is beneficial for hemostasis and does not seem to pose a risk of ischemia, it is prudent to use the smallest volume of epinephrine (with lidocaine) needed to achieve anesthesia for the site.

CORRESPONDENCE
Elizabeth V. Seiverling, MD, 300 Southborough Drive, Suite 201, South Portland, ME 04106; vseiverling@gmail.com.