Dr Ian Katz, Dermatopathologist, from Southern Sun Skin Cancer Clinic and Southern Sun Pathology, discusses the pro and cons of using shave biopsies in clinical skin cancer practice.

1. Using shave
biopsies/excisions in
practice
Dr Ian Katz
Dr Ian Katz, Southern Sun Pathology

2. What is a shave?
• Superficial shave
• Approximately 1-2 mm
• Heals really well generally
• Suacerization shave
• Deeper
• More risk of scarring
Dr Ian Katz, Southern Sun Pathology

3. NHMRC guidelines for diagnosis of
melanoma
• Chapter 6 Biopsy
• 1. The optimal biopsy approach is complete excision with a 2mm margin and
upper subcutis (Level C)
• 2. Partial biopsies may not be fully representative of the lesion and need to be
interpreted in light of the clinical findings (level C)
• 3. Incisional, punch or shave biopsies may be appropriate in carefully
selected clinical circumstances, for example, for large facial or acral
lesions, or where the suspicion of melanoma is low (level c)
• Good practice point
• It is advisable to review unexpected pathology results with the reporting
pathologist
Dr Ian Katz, Southern Sun Pathology

4. • Level C:
• Body of evidence provides some support for recommendation(s) but care
should be taken in its application
Dr Ian Katz, Southern Sun Pathology

5. Index of suspicion for melanoma
• Low
• ? Watch, annual review
• High
• Prefer excision
• Medium
• Largest group
• Excision or shave
Dr Ian Katz, Southern Sun Pathology

6. Effect of biopsy type on outcomes in
the treatment of primary cutaneous
melanoma• Am J Surg. 2013 May;205(5):585-90. doi: 10.1016/j.amjsurg.2013.01.023.
• .Mills JK, White I, Diggs B, Fortino J, Vetto JT.
• Source
• Department of Surgery, St. Vincent's Hospital, Melbourne, Victoria, Australia.
• Abstract
• BACKGROUND:
• Surgical excision remains the primary and only potentially curative treatment for melanoma. Although current guidelines recommend excisional biopsy as the technique of choice
for evaluating lesions suspected of being primary melanomas, other biopsy types are commonly used. We sought to determine the impact of biopsy type (excisional, shave, or
punch) on outcomes in melanoma.
• METHODS:
• A prospectively collected, institutional review board-approved database of primary clinically node-negative melanomas (stages cT1-4N0) was reviewed to determine the impact of
biopsy type on T-staging accuracy, wide local excision (WLE) area (cm(2)), sentinel lymph node biopsy (SLNB) identification rates and results, tumor recurrence, and patient
survival.
• RESULTS:
• Seven hundred nine patients were diagnosed by punch biopsy (23%), shave biopsy (34%), and excisional biopsy (43%). Shave biopsy results showed significantly more positive
deep margins (P < .001). Both shave and punch biopsy results showed more positive peripheral margins (P < .001) and a higher risk of finding residual tumor (with resulting tumor
upstaging) in the WLE (P < .001), compared with excisional biopsy. Punch biopsy resulted in a larger mean WLE area compared with shave and excisional biopsies (P = .030), and
this result was sustained on multivariate analysis. SLNB accuracy was 98.5% and was not affected by biopsy type. Similarly, biopsy type did not confer survival advantage or
impact tumor recurrence; the finding of residual tumor in the WLE impacted survival on univariate but not multivariate analysis.
• CONCLUSIONS:
• Both shave and punch biopsies demonstrated a significant risk of finding residual tumor in the WLE, with pathologic upstaging of the WLE. Punch biopsy also led to a larger mean
WLE area compared with other biopsy types. However, biopsy type did not impact SLNB accuracy or results, tumor recurrence, or disease-specific survival (DSS). Punch and shave
biopsies, when used appropriately, should not be discouraged for the diagnosis of melanoma.
Dr Ian Katz, Southern Sun Pathology

7. Effect of biopsy type on outcomes in
the treatment of primary cutaneous
melanoma• RESULTS:
• Seven hundred nine patients were diagnosed by punch biopsy (23%), shave biopsy
(34%), and excisional biopsy (43%).
• Shave biopsy results showed significantly more positive deep margins (P < .001).
• Both shave and punch biopsy results showed more positive peripheral margins (P < .001)
and a higher risk of finding residual tumor (with resulting tumor upstaging) in the WLE (P
< .001), compared with excisional biopsy.
• Punch biopsy resulted in a larger mean WLE area compared with shave and excisional
biopsies (P = .030), and this result was sustained on multivariate analysis.
• SLNB accuracy was 98.5% and was not affected by biopsy type.
• Similarly, biopsy type did not confer survival advantage or impact tumor recurrence; the
finding of residual tumor in the WLE impacted survival on univariate but not multivariate
analysis.
Dr Ian Katz, Southern Sun Pathology

8. Effect of biopsy type on outcomes in
the treatment of primary cutaneous
melanoma
• CONCLUSIONS:
• Both shave and punch biopsies demonstrated a significant risk of
finding residual tumor in the WLE, with pathologic upstaging of the
WLE.
• Punch biopsy also led to a larger mean WLE area compared with
other biopsy types.
• However, biopsy type did not impact SLNB accuracy or results, tumor
recurrence, or disease-specific survival (DSS).
• Punch and shave biopsies, when used appropriately, should not be
discouraged for the diagnosis of melanoma.
Dr Ian Katz, Southern Sun Pathology

9. Favorable long-term outcomes in patients with histologically dysplastic nevi that
approach a specimen border.
J Am Acad Dermatol. 2013 Apr;68(4):545-51. doi: 10.1016/j.jaad.2012.09.031. Epub 2012 Nov 3.
Hocker TL, Alikhan A, Comfere NI, Peters MS.
Source
Department of Dermatology, Mayo Clinic, Rochester, Minnesota
55905, USA.
Abstract
BACKGROUND:
Patients with multiple clinically dysplastic nevi are at increased risk for development of melanoma. However, the risk of melanoma arising in a histologically dysplastic nevus (HDN) is unknown.
OBJECTIVE:
We sought to determine the rate of melanoma development in patients with HDNs that approached a microscopic border but were not re-excised.
METHODS:
We performed a retrospective study of patients evaluated in our dermatology department from January 1, 1980, to December 31, 1989, who had a HDN that extended to within 0.2 mm of a microscopic punch, shave, or
excision border and was not re-excised.
RESULTS:
The average follow-up in our cohort of 115 patients was 17.4 years (range: 0.0-29.9): 82 patients (71.3%) were followed up for longer than 10 years, 78 (67.8%) longer than 15 years, and 73 (63.4%) had more than 20
years of follow-up; 66 of 115 nevi were mildly dysplastic, 42 moderately dysplastic, and 7 had severe dysplasia. No patient developed metastatic melanoma or melanoma at the site of removal of a HDN.
LIMITATIONS:
This was a retrospective study performed at 1 large academic medical center.
CONCLUSION:
During a long-term follow-up period, no patient developed melanoma at the site of an incompletely or narrowly removed HDN, providing evidence that routine re-excision of mildly or moderately dysplastic nevi may not be
necessary.
Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.
Dr Ian Katz, Southern Sun Pathology

10. Favorable long-term outcomes in patients with histologically
dysplastic nevi that approach a specimen border.
CONCLUSION:
During a long-term follow-up period, no patient developed
melanoma at the site of an incompletely or narrowly removed
HDN, providing evidence that routine re-excision of mildly or
moderately dysplastic nevi may not be necessary.
Dr Ian Katz, Southern Sun Pathology

11. Shave biopsy is a safe and accurate
method for the initial evaluation of
melanoma.
• J Am Coll Surg. 2011 Apr;212(4):454-60; discussion 460-2. doi: 10.1016/j.jamcollsurg.2010.12.021.
• Zager JS, Hochwald SN, Marzban SS, Francois R, Law KM, Davis AH, Messina JL, Vincek V, Mitchell C, Church A, Copeland EM, Sondak VK, Grobmyer SR.
• Source
• Department of Cutaneous Oncology, Moffitt Cancer Center, and the University of South Florida College of Medicine, Tampa, FL 33612, USA. jonathan.zager@moffitt.org
• Abstract
• BACKGROUND:
• Shave biopsy of cutaneous lesions is simple, efficient, and commonly used clinically. However, this technique has been criticized for its potential to hamper accurate diagnosis and
microstaging of melanoma, thereby complicating treatment decision-making.
• STUDY DESIGN:
• We retrospectively analyzed a consecutive series of patients referred to the University of Florida Shands Cancer Center or to the Moffitt Cancer Center for treatment of primary
cutaneous melanoma, initially diagnosed on shave biopsy to have Breslow depth < 2 mm, to determine the accuracy of shave biopsy in T-staging and the potential impact on
definitive surgical treatment and outcomes.
• RESULTS:
• Six hundred patients undergoing shave biopsy were diagnosed with melanoma from extremity (42%), trunk (37%), and head or neck (21%). Mean (± SEM) Breslow thickness was
0.73 ± 0.02 mm; 6.2% of lesions were ulcerated. At the time of wide excision, residual melanoma was found in 133 (22%), resulting in T-stage upstaging for 18 patients (3%).
Recommendations for additional wide excision or sentinel lymph node biopsy changed in 12 of 600 (2%) and 8 of 600 patients (1.3%), respectively. Locoregional recurrence
occurred in 10 (1.7%) patients and distant recurrence in 4 (0.7%) patients.
• CONCLUSIONS:
• These data challenge the surgical dogma that full-thickness excisional biopsy of suspicious cutaneous lesions is the only method that can lead to accurate diagnosis. Data obtained
on shave biopsy of melanoma are reliable and accurate in the overwhelming majority of cases (97%). The use of shave biopsy does not complicate or compromise management of
the overwhelming majority of patients with malignant melanoma.
Dr Ian Katz, Southern Sun Pathology

12. Shave biopsy is a safe and accurate
method for the initial evaluation of
melanoma
• RESULTS:
• Six hundred patients undergoing shave biopsy were diagnosed with
melanoma from extremity (42%), trunk (37%), and head or neck (21%).
Mean (± SEM) Breslow thickness was 0.73 ± 0.02 mm; 6.2% of lesions were
ulcerated.
• At the time of wide excision, residual melanoma was found in 133 (22%),
• resulting in T-stage upstaging for 18 patients (3%).
• Recommendations for additional wide excision or sentinel lymph node
biopsy changed in 12 of 600 (2%) and 8 of 600 patients (1.3%), respectively.
Locoregional recurrence occurred in 10 (1.7%) patients and distant
recurrence in 4 (0.7%) patients.
Dr Ian Katz, Southern Sun Pathology

13. Shave biopsy is a safe and accurate
method for the initial evaluation of
melanoma
• CONCLUSIONS:
• These data challenge the surgical dogma that full-thickness excisional
biopsy of suspicious cutaneous lesions is the only method that can
lead to accurate diagnosis.
• Data obtained on shave biopsy of melanoma are reliable and accurate
in the overwhelming majority of cases (97%).
• The use of shave biopsy does not complicate or compromise
management of the overwhelming majority of patients with
malignant melanoma
Dr Ian Katz, Southern Sun Pathology

14. My rules for dealing with atypical
melanocytic lesions on shaves
Mildly atypical and
patient happy and
willing to watch
Watch
Dr Ian Katz, Southern Sun Pathology

15. My rules for dealing with atypical
melanocytic lesions
Mildly atypical
and patient gives
history of change
Excise
Dr Ian Katz, Southern Sun Pathology

16. My rules for dealing with atypical
melanocytic lesions
Mod or severely
atypical
Excise
Dr Ian Katz, Southern Sun Pathology

17. My rules for dealing with atypical
melanocytic lesions
Atypical lesion
on markedly sun-
damaged skin
Excise
Dr Ian Katz, Southern Sun Pathology

18. Margins with shaves
• A lottery
• Depends on orientation
Dr Ian Katz, Southern Sun Pathology

19. Dr Ian Katz, Southern Sun Pathology

20. Dr Ian Katz, Southern Sun Pathology

21. Dr Ian Katz, Southern Sun Pathology

22. When shaves arrive in the lab
• Generally are shrivelled and folded due to formalin
• Sectioning is in a random plane
• Examining and reporting on what is seen on the surface when cutting-
up if difficult
Dr Ian Katz, Southern Sun Pathology

23. • The plane of section determines which margins are examined….
Dr Ian Katz, Southern Sun Pathology

24. Dr Ian Katz, Southern Sun Pathology

25. The lesion is clear of margins
In the plane of sections
Pigmented lesion on surface
Distance clear Distance clear
Dr Ian Katz, Southern Sun Pathology

26. Dr Ian Katz, Southern Sun Pathology

27. Pigmented lesion on surface
Margins are involved in the plane
of sections
Dr Ian Katz, Southern Sun Pathology

28. Random plane of section
• Can be any one of 360 degrees
• May or may not include involved margin
• Pure luck
Dr Ian Katz, Southern Sun Pathology

29. Positive margins
• Positive margins in shave mean positive
• Negative margins mean nothing – could still be positive
Dr Ian Katz, Southern Sun Pathology