SkinCancerNet Article
Biopsy:  What to Expect

The only way to confirm or exclude the presence of skin cancer is with a biopsy. A biopsy is a diagnostic procedure that involves surgically removing the suspected tumor, or part of it, in order to microscopically examine the tissue. The majority of biopsies performed to diagnose skin cancer involve minor surgery that can be performed under local anesthesia in a dermatologistís office or medical clinic. This type of biopsy should not provoke undue anxiety as the discomfort and risks are minimal. The following explains what to expect.

Step 1: Remove the Tissue
Tissue from the suspect lesion is surgically removed so that it can be microscopically examined when a dermatologist:

  • Suspects skin cancer is present

  • Knows skin cancer is present and needs to determine the stage (extent of the cancer) in order to plan treatment

The biopsy is usually performed in a dermatologistís office or outpatient setting. Before the procedure, the patient is given a local anesthetic unless medical reasons necessitate another type of anesthesia. A local anesthetic provides numbness directly to the tissue. The physician performing the procedure will explain the reason for the biopsy, the type of biopsy to be performed, and how the procedure will be performed.

One of four types of biopsies will be performed, and the type is determined in large part by the size and location of the lesion:

Excisional biopsy: Commonly used to remove a tumor suspected to be skin cancer, an excisional biopsy consists of removing the entire lesion along with a margin (section of skin that appears to be unaffected). The wound created by a small excisional biopsy may not require treatment. In some cases, stitches, a skin graft, or a skin flap are needed to treat the wound.

Incisional biopsy: During this biopsy, only a portion of the lesion is removed. This procedure is considered when a lesion is large or the location requires maximum preservation of tissue (such as on a hand or foot). A portion of the lesion may be removed by using a scalpel; a hollow, circular scalpel-like medical instrument called a ďpunchĒ (punch biopsy); or a razor (shave biopsy). An incisional biopsy generally is not used to remove a suspected melanoma unless the suspicion for melanoma is low, the lesion is large, or an excisional biopsy is impractical.

Nail bed biopsy: When a dermatologist suspects that melanoma may be present under a nail, a nail bed biopsy is performed. During this procedure, part or all of the fingernail or toenail is removed and an excisional or incisional biopsy is performed on the suspect lesion.

Needle biopsy: This procedure is rarely used to remove skin tissue. Rather, it is used to obtain a sample from an internal organ, lymph node, or subcutaneous (beneath the skin) tissue to determine if the skin cancer has spread. To perform the procedure, a surgeon or other specially trained physician, inserts a small, hollow needle, which is guided by an X-ray or other imaging technique, into the area.

After the tissue is removed, the patient should be told how long it will take to get the results.

Step 2: Examine under a Microscope
After the tissue is surgically removed, it is prepared for microscopic examination by one of these methods:

Permanent sections: This preparation is done in a pathology lab. After fixing, the tissue is placed in a paraffin block, sliced into thin sections, and stained with special dyes that aid microscopic examination. This process may take up to 48 hours. Patients should request that a dermatopathologist examine the removed tissue. A dermatopathologist is a physician who has received specialized training in both dermatology and pathology and is considered an expert in the diagnosis of skin conditions. During the microscopic examination, the dermatopathologist will determine if cancer cells are present and if so which kind. If an excisional biopsy was performed, the dermatopathologist also should be able to determine how deeply the cancer has penetrated the skin.

Frozen sections: This may be done in a pathology lab or dermatologistís office (generally only available in offices in which the dermatologist is a Mohs surgeon). Once frozen, the tissue is sliced into thin sections and stained with special dyes that aid microscopic examination. Although creating frozen sections is quicker, it is not appropriate in all cases.

Regardless of the method used to prepare the tissue, a report is written to document the findings after thorough microscopic examination.

Step 3: Discuss the Findings
Waiting for the test results is probably the most difficult part of a biopsy. If the patient does not hear from the dermatologist within the specified timeframe, a follow-up call should be made.

Once the results are received, the dermatologist or dermatologic surgeon will discuss the findings with the patient and explain what the findings mean. Patients should feel free to ask questions and may wish to request their own copy of the pathology report.

When skin cancer is detected, the report will indicate which type of skin cancer is present and contain some of the information necessary to estimate the cancerís stage. The report also may recommend that additional excisions or biopsies be performed or that evaluation of the lymph nodes and internal organs be performed to check for cancer.

Based on the test results, the dermatologist will confer with the patient to plan any further studies or necessary therapy. Some types of skin cancer and those in advanced stages may require referral to a cancer specialist, such as a medical or surgical oncologist or radiation therapist.

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