Monterey, Calif. — When Dr. Kenneth G. Gross wants to biopsy an atypical pigmented lesion, he reaches for an old-fashioned razor blade.
Not for a shave biopsy, mind you. He prefers a saucerization biopsy to a shave, punch, or blunt excisional biopsy for these lesions.
“The reason I prefer saucerization for atypical pigmented lesions—and even more for lentigo maligna—is that it takes the least amount of normal tissue. It allows the smallest wide re-excision. It’s fast. It’s easy—there’s no undermining—and it gives adequate histostaging,” he said at the annual meeting of the American Society for Mohs Surgery
He also likes that it requires the biopsy-taker to “engage your brain before you engage your blade,” said Dr. Gross, a dermatologic surgeon practicing in San Diego. “You’ve got to ask yourself, what information do I need to histostage this lesion?” to decide how you’ll bend the razor blade to get the depth and shape of biopsy required to provide the needed information.
A saucerization biopsy leaves a round defect that heals by secondary intention, and the lack of undermining makes wide re-excision relatively simple. A blunt excisional biopsy, on the other hand, takes longer, may violate the deep tissue plane that’s optimal for wide re-excision, and magnifies the size of the eventual wide re-excision.
“Are you really doing your patient a favor to take an excisional biopsy down to the base of the fat? Do you really need to go that far? To me, the answer is, ‘No,’ ” he said.
For his saucerization biopsies, Dr. Gross uses Personna stainless steel, double-edge prep blades designed for old-fashioned razors. Fold the two-blade package in half before opening, and the blades snap in half, providing one blunt edge to hold and a sharp edge for cutting.
“The nice thing about these little blades is that they’re sterile when they come out of the factory, and I have yet to see an infection in a biopsy site using these,” he said.
Fold the blade to any degree desired to do a very small, deep biopsy—“almost like a punch” biopsy—or a wider or more shallow biopsy, he explained. “For a lesion like lentigo maligna, you want a larger but more superficial biopsy.”
To avoid “flipping” a biopsy specimen, unbend the blade and lay it flat immediately after taking the specimen. “I’ve never flipped one yet,” he said.
On one patient with what looked on dermoscopy like a superficial spreading malignant melanoma, Dr. Gross took a saucerization biopsy with a 1- to 2-mm margin down to the middermis. Under the microscope, it looked to be a 0.7-mm superficial melanoma, so he did a wide re-excision. There was no residual tumor on the pathology report, “nor would I expect there to be any residual melanoma in most of these, because this is a saucerization-type excisional biopsy, if you will. It’s not a shave biopsy,” Dr. Gross said.
Razors are not only sharper than scalpel blades, they’re easier to use and can be curved either up or down for convex or concave surfaces, he added. The blades can be used virtually anywhere on the skin, on any type of tissue, to get specimens that are adequate for both diagnosis and histostaging.
Another patient had a lesion in the nail bed. “The patient has had this dystrophic nail for a while, notes some changes in the base, and I want to do a matrix biopsy. I want to see if there is any squamous cell carcinoma going on here,” Dr. Gross explains. “This is really simple task with this blade. I can fold it to any depth I want, any width. It is a simple, quick procedure.”
A small, not-so-deep saucerization biopsy was adequate for another patient with an atypical nevus that was growing and changing rapidly but looked like a benign lesion, and proved to be so. With the saucerization, though, “we’ve got enough depth here to make the diagnosis, and if it were melanoma, to do histostaging,” he noted.
Disclosures: Dr. Gross said he has no pertinent conflicts of interest.