Biopsy Procedure Instructional Videos
Performance of simple cutaneous biopsies is an essential skill for physicians that practice in an outpatient setting. There are many benefits to having the ability to perform these biopsies in your office, which include:
- Ability to excise suspicious lesions during the patient visit
- No need for patients to schedule a second visit for the procedure or incur the additional cost of a second physician visit.
- Elimination of the “loss to follow up” issue that can occur in some cases
- Providing additional services to your patients during their visit (i.e. “full service”)
- Maintaining simple procedures in your office, rather than sending to other physicians offices.
- Ensuring that suspicious lesions are sent for pathologic evaluation
Providing these services in your office can be a substantial benefit to your office practice. These videos outline several of the most common office based procedures. Please note that these videos are NOT a production of 4path, nor is 4path responsible for the content. The original authors are solely responsible for the content and use of this content of these videos is at your own responsibility. Although instructional, watching these videos is NOT to be considered as training by 4path, nor should be considered “authorization” or “certification” or any other form of authorization by 4path for you to perform these procedures. These videos are provided “as is” to provide an example of procedures that you may consider for your practice, and you alone are responsible for your actions, or lack of actions, in regards to your office practice and any procedures you may or may not perform.
Shave biopsies can be easily performed to completely excise a superficial lesion. They should NOT be used when a malignant melanoma is suspected.
When submitting shave biopsies to pathology for evaluation, you may consider putting a “dot” at the 12 O’Clock location to allow the pathologist to better evaluate the surgical margins. It is best to obtain the shave biopsy as a single specimen for optimal evaluation. Multiple shaves (i.e. specimen and lesion in multiple pieces) can substantially hinder the pathologic evaluation.
Punch biopsies can be easily performed to completely excise a smaller lesion. They should NOT be used when a malignant melanoma is suspected, unless the lesion is too large for complete removal and you are looking to establish a diagnosis for planning purposes for a more extensive excision. Punch biopsies also provide a better sampling of the deeper dermal tissues than a shave biopsy. This is beneficial for dermal lesions, including (but not limited to) dermatofibroma (cutaneous fibrous histiocytoma), inflammatory skin disorders, alopecia evaluation.
Punch biopsies are also ideal for evaluation of chronic wounds.
When submitting punch biopsies to pathology for evaluation, margins are typically not evaluated on smaller punches (under 3 mm). Punch biopsies 4 mm or greater may be able to be evaluated for margins on at least one plane of sectioning. It is difficult to evaluate the full circumference margin on punch biopsies.
Elliptical Skin Biopsy
Ellipse biopsies can be easily performed to completely excise a smaller lesion. They are ideal for complete excision of small to moderate size lesions in the office setting. Ellipse biopsies are well suited for complete excision followed by pathologic evaluation which specifically manages the specimen for margin evaluation (i.e. determine completeness of excision).
When submitting ellipse excisions to pathology, there is typically no need to provide descriptions of “lateral”, “superior” or other anatomic designations. The easiest, and clearest method for orienting the specimen is to designate one of the tips as a “12 O’Clock” margin. Be sure to make notation of this on the operative note for you to refer back to when the final pathology report arrives. The laboratory report should provide you with the diagnosis and the adequacy of excision, with special notation of which margin(s) were involved, if positive. i.e. 12-3 O’Clock margin, 3-6 O’Clock, 6-9 O’Clock or 9-12 O’Clock.
Skin Curetting Technique
For some lesions, curetting of the lesion may be an appropriate alternative other forms of excision biopsies.
Use of this technique precludes the pathologist from evaluating the margins of excision. However, submission of the tissue from the procedure for pathologic evaluation should still be performed for diagnostic purposes.
Nails should be submitted using the 4path nail submission kit, which includes the collection bag, requisition and a pre-paid mailer to send to the laboratory. These can be obtained from you 4path representative, or by calling 4path at 877-884-7284.
Nails clippings and any subungual debris which is curetted for evaluation should be placed into the plastic collection bag and labeled with the patient name and location. Two bags are provided in the collection kit, if right and left foot (or hand) specimens are to be evaluated separately.
Nail evaluations by routine histopathologic evaluation with PAS-F stain (gold standard evaluation) can be submitted without formalin fixative (i.e. dry in plastic bag) or may be submitted in formalin (available from 4path). If you wish to have a reflex GMS stain when the PAS-F stain is negative, then select that option on the requisition. Read more HERE about the diagnostically effective, yet cost effective manner that 4path uses for nail analysis and why we believe that “Molecular PCR testing” is not the best option for your patient.
If FUNGAL CULTURE is also desired, send specimen in plastic bag without fixative. Do NOT place specimen in formalin. Please note that all specimens sent for culture WILL have a routine histopathologic evaluation with PAS-F stain as part of the routine evaluation.
Common Skin Suture Techniques
While the method of EXCISION is an important consideration for the proper removal of a lesion and for the presentation to the pathologist for microscopic evaluation and diagnosis, the REPAIR of the skin after the procedure is significantly important for proper healing of the wound and satisfactory cosmetic repair.
This video provides instructions on the procedure to perform many different types of skin closures.
For infectious (culture and cytology): The fluid should be submitted in a sterile tube without fixative for culture. If the time for transport to the laboratory is prolonged, then placing a small amount of the fluid on a sterile culture transport swab and placing it in universal transport media is optimal. In that case, the remainder of the fluid should be placed into cytology fixative. Two smears (one fixed with alcohol, one air dried) is desirable, but optional. It is better to error on the side of fixation of the fluid in non-gyn cytology fixative.
For unknown processes (cytology and crystal examination…culture should be considered). Handling is similar to that described above, however a single slide for polarization microscopy is recommended. Place 1-2 drops of the fluid on a clean, dry slide and allow it to fully dry. Label and submit to the laboratory WITHOUT FIXATION.
For gout (cytology and crystal examination). Collect fluid in cytology media and prepare a single slide for polarization microscopy (see above).
To obtain cytology fixative for proper fixation of cytologic specimens, place your order on 4path’s supply order page.
Important Pathology Considerations
It’s important to remember that the pathologic evaluation of the specimen is only as good as the specimen that is submitted. Great care should be taken to help eliminate crushing or tearing of the specimen, or removal of the specimen in multiple pieces.
For evaluation of margins, tag one site of the specimen as “12 O’Clock” for orientation purposes.
For multiple lesions, each should typically be submitted separately. When multiple specimens are submitted together in one container, significant problems may arise if there is a lesion that requires follow up or re-excision. If multiple specimens are submitted together, you won’t know which specimen requires the necessary follow up and/or excision, subjecting the patient to additional procedures which are not needed at the other site, or perhaps worse, inability to localize the lesion and provide anatomic direction for other follow up procedures such as lymph node dissection.
Preparation of the specimen
Although most specimens should be submitted in formalin, there are some cases where alternative transport media and/or fixation solutions are indicated. A common procedure which requires alternative transport media is cutaneous immunofluorscent examination or flow cytometry media for suspected cutaneous lymphoma. For these procedures, contact 4path for the necessary media (1-877-884-7284) and to make appropriate transport arrangements, or place an order on 4path’s order page.
Specimens should be placed immediately in formalin or other fixation / transport media to prevent drying out, which may alter the appearance or impact the ability to perform some specialized testing.
For cytologic specimens, submit the fluid or aspiration in non-gyn cytology fixative. Smears of the fluid are optional in most cases, but should be limited to 2 slides per pass, one air dried, one fixed with alcohol.
For gout evaluation, submit fluid in a sterile container without fixative or gel. Alternatively, placing fluid on a clean labeled slide and allowed to dry is acceptable. Transport to 4path for polarization microscopy.
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History and Requisition
When the clinician said, “I didn’t tell the pathologist what I was thinking…because I didn’t want to bias their examination”, the pathologist replied, “I didn’t supply the diagnosis, because I didn’t want to bias the clinician in their treatment and follow up”.
Needless to say this seems silly, but it is true. Clinicians and Pathologists should work cooperatively together to ensure that there is optimal communication for the benefit of the patient.
The submitting physician should provide as much information as is possible, including:
- Location of the lesion on the patient
- History of the lesions. How long has it been there? Has it changed? How?
- Are there other lesions?
- History of the patient. Are there other systemic diseases? Drug treatments? Family history?
Providing clear and comprehensive history of the lesion(s) and the patient can substantially help the pathologist arrive at a correct diagnosis and put the patient on the right pathway to proper treatment. It takes only a minute, but the benefit to the patient’s care is enormous.