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Question about appropriate biopsy type

Forums Cutaneous Melanoma Community Question about appropriate biopsy type

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      It's so wonderful that this forum is here and that even those of us who aren't having to fight as hard as so many of you are still able to get support and our questions answered. Thank you.

      I'm going for my 3-month skin check next week, and in another limb from my initial melanoma (which was only a 1A) a new slightly under the skin growth has popped up in the last couple of weeks. I have multiple dysplastic nevi, and this growth is close to another mole that doesn't look too different from all of my other weird moles. My questions is: if my dermatologist decides to biopsy it, what is the appropriate biopsy type given that it's slight subcutaneous and near another mole? She generally does shave biopsies (I hate how these look after the fact! I litterally look like my body is being nickled and dimed!) but if this is some kind of in-transit thing from another mole, I don't know what kind of biopsy would capture the nature of it, if, indeed, it is anything at all.

      Thanks in advance for your input.

      Oh, and — Go Giants!

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          I'm not an expert, so maybe I'm wrong, but a shave is not the right biopsy for melanoma.  If it's believed to be melanoma, a full excision is recommended and if that's not possible for some reason, a punch biopsy is second best.

          If you don't believe it to be melanoma and/or are concerned about the cosmetics of a scar would be a couple of reasons for doing a shave.



            A derm that does shave biopsies on suspected melanoma is lazy and not doing their job properly. Punch biopsies for small moles that a derm suspects melanoma is most common. For larger lesions, and the answer your question about this subcutaneous situation, excisional biopsy would be best.

            From now on, tell your derm you refuse shave biopsies, if she says too bad that's all I do, then get a different derm. 


              Some derms will argue that a deep shave is totally appropriate for melanoma – especially if the lesion is a larger one.  I'm not a fan.  Shaves can bisect a lesion which compromises staging.  But for me, shaves are also more painful healing and look worse afterwards.  A punch is a full skin thickness biopsy – so better for assessing depth if something were melanoma.  But punches cannot get really large lesions.  Excisional biopsy is also appropriate but most docs won't do that unless they are really positive it is melanoma.  It's a more invasive surgery.  Each biopsy type has its pros and cons depending on the lesion being removed and what is suspected.  Your description of "slightly subcutaneous" reminds me more of a dermatofibroma.

              Discuss the biopsy types with your doc.  This is your body.  For me, a simple punch biopsy (which requires 1-2 stitches to close and possibly a followup appt to remove) heal much cleaner and hurts less.  As for determining the nature of what is being removed, any biopsy type will most likely be fine. 


                  Thanks everyone! I will ask for a punch biopsy.


                  If I am wrong about this, I hope someone will correct me. I have wondered about the whole shave biopsy thing since my surgical oncologist made an offhand remark that "he didn't know why all the South Florida derms prefered shave biopsies". I wonder if extra insurance payment hassle, return scheduling and the more time required to educate the patient (+ complications, etc.) about something the MD would prefer not to do anyway color this alleged preference.

                  The discussion followed my noting to him that there are clinical trials that require preservation of tumor mass. Point 1 for excision. Unusual, but possibly of consequence.

                  Point 2 is really what I wonder about.  Since reading about Decision Dx, my understanding is that with tumor mass you can determine class I or class II metastatic status, which may be of enormous consequence in future decision making.

                  I don't know if you are talking about measurable tumor mass (which you hopefully won't find) or if this test would apply to you personally. But it's for I's and II's and maybe ask the MD about it and what is required. Clearly there are regular experiences where the "standard of care for a dermotological practice" is already sub-optimal for the undiagnosed melanoma population.

                  Being previously diagnosed, previously metastatically "un-classed", and facing possible reoccurance of capturable tumor mass, I wonder if excision isn't "indicated", as they say.

                  Good luck with your benign cyst….



                      Shaves are fast, require less setup, no followup, no stitches and can remove a wider lesion.  On most people, they heal without significant scaring.  Followups to remove stitches?  A hassle.  But docs often cut through a lesion compromising staging.  Shaves are good for derms, but not always good for patients.  They do, however, allow the removal of a wider lesion in one procedure.  Punches have a width limit and excisional biopsies are much more invasive for a simple biopsy – especially when most biopsies are NOT melanoma.  Some derms will do excisional biopsies to start but most don't.

                      I'm not sure I follow your tumor mass discussion.  Clinical trials don't often use the primary site to harvest anything for trials, etc, it is typically from a metastatic tumor once melanoma is determined to be metastatic.  The original poster would not be dealing with a metastatic lesion from the opposite limb.  If the derm was certain this was melanoma, then an excisional biopsy might be done.  (There is some risk with this in terms of the SNB because removing too much skin for the biopsy might alter the drainage paths for the SNB).  The vast majority of primaries removed are in situ or stage 1 and don't progress.  Also, Decision Rx might be helpful but as of yet, it's not universally accepted AND insurance and the FDA are not going to pay/allow treatment for a stage 1 person even if their DRx results show high risk.  I'm not sold on using this test until there is a way to actually apply the results in a clinical setting.  If you were stage I with high risk and could do adjuvant therapy because of that results, that makes sense.  Otherwise, It just adds anxiety but gives you no way to act on the results.  Just my feelings.

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