Actinic Keratosis: biopsy vs excisional biopsy

[DrMetal]

Was doing a board review question (for the medicine boards). The questions was asking about a known lesion on the face, i think 1-2 cm, deemed to be actinic keratosis, refractory to all topical, what do you do next?

Couple of the answers were a) biopsy and b) excisional biopsy. (Mohs was not an option). The answer was "biopsy".

I guess by "biopsy" they mean just taking a small piece of it, as opposed to complete excision. But if it's only a 1-2 cm lesion, wouldn't you want to just take the whole thing (excisional biopsy)? In other words, if its small enough, why not just take the whole thing, especially b/c refractory AK runs a high risk of SCC, right? Are they suggesting only 'biopsy' b/c it's on the face?

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[werd]

there is a lot a dermatologist could get into in response to this question. i'm going to keep it to saying that... I agree with the posted answer - a clinical AK that doesn't respond to usual treatments should be biopsied, that excisional biopsy of a 1-2cm facial lesion would leave a significant scar and isn't warranted for a "refractory AK," and that mohs surgery is considered following histologic confirmation of a malignant diagnosis.
and I guess that refractory AK's don't run a high risk of SCC; it's more correct to say that some fraction of persistent clinical AK's are, in fact, SCC.

 

[zhopv10]

Was doing a board review question (for the medicine boards). The questions was asking about a known lesion on the face, i think 1-2 cm, deemed to be actinic keratosis, refractory to all topical, what do you do next?

Couple of the answers were a) biopsy and b) excisional biopsy. (Mohs was not an option). The answer was "biopsy".

I guess by "biopsy" they mean just taking a small piece of it, as opposed to complete excision. But if it's only a 1-2 cm lesion, wouldn't you want to just take the whole thing (excisional biopsy)? In other words, if its small enough, why not just take the whole thing, especially b/c refractory AK runs a high risk of SCC, right? Are they suggesting only 'biopsy' b/c it's on the face?

Bx would usually be a shave of the lesion, fwiw 2cm is kinda big imo, but that aside you need to know what you are treating. In melanyctic lesions you can do excisional if you suspect melanoma, but for AK, especially on the face, I’d want to see SCCis vs SCC vs hypertrophic AK. Tx could range from mohs to 5-FU to excision depending on what histology shows. Margins would be potentially different too.

Long at short, bx can tell you what the lesion is exactly which can help guide tx. Excision of course would give you the info but might be overkill, especially for the face.


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[Skindoc83]

Correct me if I’m wrong but an excisional biopsy would be an elliptical excision. There is no reason to ever do an elliptical excision on the face for a neoplasm of unspecified behavior. There is even less of a reason for a lesion that has a 0.1-1% chance of malignant transformation per year. I am a mohs surgeon, and the only reason to do an excisional biopsy in my mind is for a suspected melanoma or NMSC on the trunk/extremities in which case you are taking approrpiate margins with the intention of it being diagnostic AND curative. Anything on the face is a shave biopsy, for diagnostic purposes, with definitive treatment to follow. I would also be suspect of a 2cm lesion truly being AK and not at least SCCis

 

[DrMetal]

Thanks for the feedback, makes sense!

 

[doctalaughs]

I’ve been practicing 15 years and almost never do excisional biopsies. I know what they teach about melanoma/pigmented lesions but just don’t agree or find it compelling.

If there is a small suspicious pigmented lesion then you can just shave it off completely. Sure, if you think excision might be better cosmetically- then do so...
You can tell how deep to go depending on the appearance and level of suspicion (and unless you are inexperienced you aren’t going to transect a surprise melanoma).

if it’s huge/thick then you probably already know what it is. No way I’m doing a 6cm long excisional on a 2cm lentigo maligna melanoma that will be reexcised anyway. I’ll do scouting punches (or saucerizations) in the diagnostic areas based on dermoscopy.

who cares if you occasionally transect in a thicker melanoma case (rare and probably very thick)? You’d be stupid to do less than 1 mm anyway to affect a decision of slnb in these cases.

if you excise every pigmented lesion that catches your eye then you’ll end up with a lot of excision scars for mild ATNs...

 

[reno911]

Even if you know nothing about dermatology, "excisional biopsy" pretty much can't be correct, because if that is correct, then the option "biopsy" is also correct by definition.

Unfortunately question writers do stupid things sometimes, so you can't hang your hat on that.

Agree with most of the above comments. Also as very general rule, in dermatology, if you are not sure what something is and it has not already had a biopsy, then taking a biopsy is almost never wrong.

 

[TMP-SMX]

There's no billing CPT for excisional biopsy. It's either tangential (shave), punch, or incisional. Intent matters for biopsy vs excision. The correct answer to the above question is shave biopsy. Actinic keratoses may be called premalignant but it is a 4% chance over someone's lifetime to transform to SCC though it varies in the literature. The biopsy would tell you how thick it is often a shave biopsy on an AK is curative. Even if they go down hair follicles (makes them more resistant to topical or cryosurgical destruction) this is helpful for diagnostic and therapeutic purposes.

 

[MOHS_01]

I’ve been practicing 15 years and almost never do excisional biopsies. I know what they teach about melanoma/pigmented lesions but just don’t agree or find it compelling.

If there is a small suspicious pigmented lesion then you can just shave it off completely. Sure, if you think excision might be better cosmetically- then do so...
You can tell how deep to go depending on the appearance and level of suspicion (and unless you are inexperienced you aren’t going to transect a surprise melanoma).

if it’s huge/thick then you probably already know what it is. No way I’m doing a 6cm long excisional on a 2cm lentigo maligna melanoma that will be reexcised anyway. I’ll do scouting punches (or saucerizations) in the diagnostic areas based on dermoscopy.

who cares if you occasionally transect in a thicker melanoma case (rare and probably very thick)? You’d be stupid to do less than 1 mm anyway to affect a decision of slnb in these cases.

if you excise every pigmented lesion that catches your eye then you’ll end up with a lot of excision scars for mild ATNs...

Same here; you have to know what you're looking at in order to choose the best biopsy method....

 

[zhopv10]

Same here; you have to know what you're looking at in order to choose the best biopsy method....

Some interesting points here, what do you think of actual lesions? I’ve found myself slightly torn before where I had a borderline lesion, wouldn’t do excisional bx elsewhere but on acral surfaces can be tricky to get a shave going down into any level of dermis for dx/stage so have opted for , what do you end up doing in those cases?


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[MOHS_01]

Some interesting points here, what do you think of actual lesions? I’ve found myself slightly torn before where I had a borderline lesion, wouldn’t do excisional bx elsewhere but on acral surfaces can be tricky to get a shave going down into any level of dermis for dx/stage so have opted for , what do you end up doing in those cases?


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Never considered it a problem; pinch your persona more and you'll get the depth you seek.

 

[zhopv10]

Never considered it a problem; pinch your persona more and you'll get the depth you seek.

Just to clarify, you mean you haven’t found doing a shave to be a problem?


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[Skindoc83]

Plantar surfaces are one of the areas where I will consider an excisional biopsy since numbing Is so painful and healing can be so slow/uncomfortable. I usually give patients an option to do a punch with a high probability of having to return at a later date for complete excision versus just doing a WLE. Most patients choose WLE

 

[zhopv10]

Plantar surfaces are one of the areas where I will consider an excisional biopsy since numbing Is so painful and healing can be so slow/uncomfortable. I usually give patients an option to do a punch with a high probability of having to return at a later date for complete excision versus just doing a WLE. Most patients choose WLE

What type of margins do you take for a questionable lesion (not an obvious melanoma)


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[Skindoc83]

What type of margins do you take for a questionable lesion (not an obvious melanoma)


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usually 4mm but it depends upon what I think I am treating

 

[dermie1985]

I occasionally will do "excisional" biopsies on pigmented lesions depending on body site, size, etc. (sometimes a line scar from narrow excision is better than broad shave scar) with the caveat for the patient that we may need to go back for larger margins if the lesion was a melanoma. Some people will simply wait for the path report to come back and code these as "excision benign" if the lesion is, say, a moderately atypical nevus. Though technically these should be incisional biopsies.

Many providers also do something similar for BCCs - partial shave biopsy + ED&C at time of biopsy. Wait for path report, then bill for both the diagnostic shave biopsy + the destruction malignant lesion code for the same visit. For lesions highly suspect to be BCCs, this approach can lead to fewer visits for the patient because the lesion is "already treated". The risk of that approach is, say....you ED&C an amelanotic melanoma. Probably fine 99% of the time, but crazy stuff happens.

For the OP, I would venture to say that there is really no such thing as a 2 cm actinic keratosis (that's too big for an AK - either an SCC or something else). Partial shave biopsy would be the initial work-up.

 

[TMP-SMX]

I occasionally will do "excisional" biopsies on pigmented lesions depending on body site, size, etc. (sometimes a line scar from narrow excision is better than broad shave scar) with the caveat for the patient that we may need to go back for larger margins if the lesion was a melanoma. Some people will simply wait for the path report to come back and code these as "excision benign" if the lesion is, say, a moderately atypical nevus. Though technically these should be incisional biopsies.

Many providers also do something similar for BCCs - partial shave biopsy + ED&C at time of biopsy. Wait for path report, then bill for both the diagnostic shave biopsy + the destruction malignant lesion code for the same visit. For lesions highly suspect to be BCCs, this approach can lead to fewer visits for the patient because the lesion is "already treated". The risk of that approach is, say....you ED&C an amelanotic melanoma. Probably fine 99% of the time, but crazy stuff happens.

For the OP, I would venture to say that there is really no such thing as a 2 cm actinic keratosis (that's too big for an AK - either an SCC or something else). Partial shave biopsy would be the initial work-up.

You can't bill shave biopsy and destruction malignant on the same lesion at the same visit as it is bundled. It's fine to do in practice for a seasoned dermatologist saving a trip for the patient but both can't be billed.

 

[dermie1985]

You can't bill shave biopsy and destruction malignant on the same lesion at the same visit as it is bundled. It's fine to do in practice for a seasoned dermatologist saving a trip for the patient but both can't be billed.

You're right. It should be just the destruction malignant code.

 

[Slack3r]

For the OP, I would venture to say that there is really no such thing as a 2 cm actinic keratosis (that's too big for an AK - either an SCC or something else). Partial shave biopsy would be the initial work-up.

I’ve had a few crusty old VA patients with big hyperkeratotic plaques (>1-2cm) that I’ve biopsied several times where the histo keeps coming back AK, but I’m convinced it’s something more. Excisional specimen ends up showing more AK. These are typically guys with lots of field cancerization though, and certainly not the norm.

 

[username456789]

I’ve had a few crusty old VA patients with big hyperkeratotic plaques (>1-2cm) that I’ve biopsied several times where the histo keeps coming back AK, but I’m convinced it’s something more. Excisional specimen ends up showing more AK. These are typically guys with lots of field cancerization though, and certainly not the norm.

I get those on the scalp not terribly infrequently and it’s usually EPD in disguise and clears with ILK or topical ultra potent steroids.