Oculofacial Biopsy Richard E. Castillo, OD, DO Benign vs. Cancer Evolution of skin cancer Metaplasia Dysplasia Carcinoma-in-situ Invasive carcinoma Intravasation
Overview Preoperative Planning Choosing the appropriate biopsy technique based on tentative diagnosis Incisional vs excision biopsy Shave biopsy technique(s) Punch biopsy technique Full thickness/elliptical biopsy technique Submit specimen to lab Obtain and act on result Notify patient of most common adverse outcomes: Bleeding Infection Scaring Discuss the possibility of the need for additional procedures or therapy based on biopsy results
Be aware of underlying medical conditions and adjust procedure accordingly Underlying medical conditions: Atrial fibrillation Pacemaker Prosthetic heart valve or joint Hypertension Pregnancy Prior vasovagal response Hepatitis HIV MRSA COPD/O2 Be aware of underlying medical conditions and adjust procedure accordingly Take photographs - ALWAYS Be aware of underlying medical conditions and adjust procedure accordingly Take photographs - ALWAYS Consider biopsy location for healing characteristics Eyelid is VERY THIN SKIN! Biopsy may be accomplished with: Westcott Scissors Iris Scissors Gradle Scissors Scalpel (#15, 15c) RFS electrode* DermaBlade/razor blade Curette Know the differences in technique between the upper & lower eyelids, canthi, and periorbital skin *RFS: requires appropriate power, waveform and technique so that tissue sample is not damaged.
Be aware of underlying medical conditions and adjust procedure accordingly Take photographs - ALWAYS Consider biopsy location for healing characteristics AAA (Antibiotics, Antisepsis, Anesthesia) Antibiotics: Preoperative antibiotics are generally not necessary for clean surgical procedures such as skin biopsy when the biopsy is performed through clinically uninfected skin (American Heart Association) Antisepsis: Generally an alcohol wipe for 10 seconds is adequate for small biopsies. Other surgical scrubs may also be used for larger procedures or for patients at higher risk of infection. Anesthesia: Generally lidocaine 0.5% or 1% w/ or w/o epinephrine 1:100,000 or 1:200,000. Be aware of underlying medical conditions and adjust procedure accordingly Take photographs - ALWAYS Consider biopsy location for healing characteristics AAA (Antibiotics, Antisepsis, Anesthesia) Biopsy specimen handling Understand the medico-legal chain of custody Specimen transport fixative Formalin Saline Specific culture media Beware of tissue mishandling Pinch Twist Stretch Crush Burn Freeze Desiccate Follow through on path report Choosing the appropriate biopsy technique Will vary with type of lesion, depth, and location Suspected Melanoma always requires full-thickness biopsy with control of margins Superficial Spreading melanoma Nodular melanoma Acral lentiginous melanoma Broad, thin lamellar dissection or multiple smaller biopsies may show lentigo maligna melanoma best. Lentigo maligna melanoma is the most common subtype in eyelid skin Most common in lower eyelid Usually observed in 50-80 year olds Suspected melanomas should be referred to experienced practitioners Lentigo maligna melanoma of the lower lid
Distribution of Eyelid Tumors Anatomic Site % Total Lower Eyelid 44 Medial Canthus 19 Eyebrow 17 Upper Eyelid 16 Lateral Canthus 4 TOTAL 100 MAJOR OCULOFACIAL BIOPSY TECHNIQUES Incisional Biopsy Excisional Biopsy Goal To remove a part of the lesion for diagnosis To remove entire lesion to subcutaneous plane Considerations Method Too large for excisional biopsy Cosmesis of complete removal not acceptable if benign process Diffuse inflammatory Shave process not Punch Ellipse Cosmesis improved if removed completely Malignant process suspected Deep scoop Shave Punch Ellipse Shave techniques Become comfortable with several biopsy instruments and techniques Scalpel Razor Dermal curette Scissors Practice with a skin substitute Tomatoes Oranges
Shave techniques: scalpel Enter skin with curve of blade (#15 or #15c) while holding skin taught Use short sawing motion with blade parallel to skin surface Depth is controlled by downward pressure on the blade Exit the skin by decreasing downward pressure and angleing slightly upward, allowing blade to resurface smoothly to complete the biopsy A cup-shaped defect is produced in the skin Attend to hemostasis Shave techniques: Razor Curve the blade by applying inward pressure on the balde from both sides Stretch the skin taught for a superficial shave Enter the skin in the center of the curved blade Use a short sawing motion with the center of the blade Depth is controlled by the amount of curve on the blade (more curve, more depth) as well as downward pressure Exit the skin by decreasing downward pressure and angleing slightly upward, allowing the blade to resurface smoothly to complete the biopsy
Shave techniques: dermal curette The desired biopsy area must fit within the area of the curette Stretch skin to provide a firm surface Entry, central depth, and exit are controlled by downward pressure A single fluid motion is preferred, as a fragmented specimen can compromise dingosis and margin analysis Shave techniques: scissors Eyelid biopsy may be performed with Westcott, iris, or Gradle scissors Prep & anesthetize Lift lesion gently with toothed 0.12mm tissue forceps Snip at base with scissors, flush with surrounding skin Attend to hemostasis Pressure Electrocautery Radiofrequency coagulation
Shave techniques: pearls Techniques may be practiced on oranges or tomatoes to simulate required force and motions to achieve even, controlled biopsies of appropriate depth To avoid a cup-like defect and maintain an even skin surface following biopsy of a raised lesion, anesthetic should be placed in the deep dermis, and allowed to diffuse for 10-15 minutes. The skin should be stretched taught during the shave Punch technique Appropriately sized punch should be placed perpendicular to skin surface Stretch the surface of the skin to provide a firm surface (increase sectility of the tissue) Apply even downward pressure while rotating the punch until desired thickness is achieved Withdraw punch Grasp specimen gently with toothed (0.12 mm) forceps or lift with tip of needle. Do not crush! Use tissue scissors to free the base Hemostasis may be achieved with pressure, suture, or gel foam. Apply pressure dressing Punch techniques: pearls To avoid inadvertent crushing with forceps, a 27-gauge or 30-gauge needle may be used to elevate the specimen out of the skin To make an elliptical defect with a circular punch, apply lateral stretch on the skin in the direction in which the short axis of the ellipse is desired (perpendicular to the relaxed lines of skin tension)
Elliptical incisional/excisional technique Place scalpel or RF electrode straight wire perpendicular to skin surface and incise to desired depth along predetermined outline Outline should be elliptical to allow for linear closere or circular to allow for healing by secondary intention Once outline is incised, use tissue forceps or needle to lift tissue to reveal its base Use scalpel, scissors, of RFS electrode wire to free the base of the specimen parallel to the surface Undermine edges for linear closure Achieve hemostats Attend to wound closure with buried absorbable sutures to relieve tensions and superficial sutures to align skin edges Biopsy specimen Each lab has their own specific handling instructions for biopsy At a minimum specimens are labeled with patients name, specimen location, and if multiple specimens submitted, each numbered or lettered for individual identification. Formalin is the transport medium for routine light microscopy Specimens sent for direct immunofluorescence are placed in Michael s solution or taken directly to the lab in saline Suspected sebaceous cell carcinoma is submitted fresh, wrapped in a saline-soaked gauze Clinical history and lesion description must be included so that proper clfinicopathologic correlation can be made
Thank you! castillo@nsuok.edu