Dermatologic surgery
Correlation between histologic findings on punch biopsy specimens and subsequent excision specimens in recurrent basal cell carcinoma

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Background

The type of treatment for a basal cell carcinoma (BCC) depends on the histologic subtype. Histologic examination is usually performed on incisional biopsy specimens. In primary BCC, the histologic subtype is correctly identified with a punch biopsy in 80.7% of cases. In recurrent BCC, correct identification is more difficult because of discontinuous growth caused by scar formation. Because an aggressive histologic subtype has a significantly higher risk for recurrence in these tumors, the histologic subtype is at least as important in recurrent BCC as it is in primary BCC.

Objective

To investigate the correlation between histologic findings on punch biopsy specimens and subsequent excision specimens in recurrent BCC. Furthermore, we sought to clarify how often an aggressive histologic subtype was missed, based on the punch biopsy specimen.

Methods

We compared the histologic subtype in a punch biopsy specimen with the subsequent excision specimen in recurrent BCC. All BCCs were coded and judged randomly by the same dermatopathologist.

Results

In 24 of 73 investigated BCCs (32.9%), the histologic subtype of the initial biopsy did not match with the histologic subtype of the subsequent excision. Of the 37 excised BCCs with an aggressive histologic subtype, 7 (19%) were missed by the initial punch biopsy.

Limitations

Intraobserver variation may have affected the results of this study.

Conclusions

Discriminating tumors with any aggressive growth is relevant for treatment. However, in recurrent BCC, the histology of the biopsy specimen does not always correlate with the histology of the definitive excision. This may have important therapeutic implications.

Introduction

Currently, most basal cell carcinomas (BCCs) are treated with conventional surgical excision.1 Other treatments may be preferred, based on specific tumor characteristics. For example, recurrent BCC (high-risk) is more effectively treated with Mohs micrographic surgery (MMS) than with surgical excision.2 Furthermore, noninvasive therapies, such as photodynamic therapy, 5-fluorouracil, and imiquimod 5% cream may be preferred in selected low-risk BCCs because of the excellent cosmetic results seen after these therapies.1 The choice for a treatment is usually based on the localization of the tumor, whether it is a primary or a recurrent BCC and what histologic subtype it constitutes.3 The histologic subtype is established by an incision biopsy of a tumor, either a punch or a shave biopsy. In the past, 26 histologic subtypes of BCCs have been discriminated, but for practical use, those subtypes were combined.4 Rippey5 classified BCCs into 4 subtypes: nodular, infiltrative, superficial, or mixed BCC. More recently Crowson6 classified BCC as belonging to indolent-growth or aggressive-growth subsets, the former including superficial and nodular BCCs and the latter infiltrative, metatypical, and morpheaform or sclerosing BCCs. Three subtypes are relevant to come to an appropriate treatment choice. Superficial BCC and nodular BCC are both indolent-growth subtypes and have a low risk for incomplete treatment and recurrence.3 The third, a high-risk subtype, includes all BCCs that exhibit aggressive growth, such as infiltrative/morpheaform BCC, micronodular BCC, and BCC with squamous differentiation.6, 7

It is known from the literature that histologic findings of a punch biopsy are accurate in predicting the final subset of primary BCCs in 80.7% of cases .8 Inaccurate prediction may occur because in almost 40% of all BCCs there is a mixture of different histologic subtypes.6 To our knowledge, it is unknown how often the histologic subtype in the initial punch biopsy matches with the histologic findings in the final excision specimens in recurrent BCC. Because of discontinuous growth caused by scar tissue following previous treatment, we expect that not all histologic subtypes of one tumor will be recognized by a punch biopsy in recurrent BCCs. The knowledge of the histologic subtype is relevant because an aggressive histologic subtype has a significant higher risk for recurrence in recurrent BCCs.2 Identification of high-risk tumors may underline the preference for treatment with MMS to benefit the prognosis.

We investigated the correlation between histologic findings on punch biopsy specimens and the subsequent excision specimens in recurrent BCC. Furthermore, we investigated how often an aggressive histologic subtype was missed by a 3-mm skin biopsy specimen obtained in recurrent BCC.

Section snippets

Methods

A retrospective analysis was conducted on histologic slides of both the punch biopsy specimen and the following excision specimen obtained from recurrent BCCs treated with surgical excision. Patients were selected from an existing database of participants of a randomized, controlled, multicenter trial performed at the Maastricht University Medical Centre (MUMC), The Netherlands, from October 1999 until February 2002.2 The selected group had facial recurrent BCC that recurred for the first or

Results

A total of 99 BCCs were excised from October 1999 until February 2002. Of those, 26 cases were excluded because either the biopsy or the excision specimen was not available. Of the remaining 73 reviewed cases, the histologic subtype of the biopsy specimen completely corresponded with the excision specimen in 49 cases (67.1%). In the other 24 tumors (32.9%), at least one different histologic subtype was found in the excision specimen compared with the biopsy specimen.

Of all investigated biopsy

Discussion

Our results show that the histologic subtypes found in punch biopsy specimens of recurrent BCCs correspond with the histologic subtypes in the subsequent excision specimens in 67.1% of cases. According to the literature, punch biopsies are accurate in predicting the final subset of primary BCCs in 80.7% of cases.8 Our results therefore confirm that the correlation between histologic findings on punch biopsy specimens and subsequent excision specimens is lower in recurrent BCC than in primary

References (10)

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    Selection of the specific biopsy technique is contingent on the clinical characteristics of the suspected tumor, including morphology, expected histologic subtype and depth, natural history, and anatomic location; patient-specific factors, such as bleeding and wound healing diatheses; and patient preference and physician judgment. Most investigations that have compared biopsy methods for detection of NMSC have studied BCC rather than cSCC.26-32 However, given the similarity in the depth and anatomic distribution of many BCC and cSCC tumors, the findings of these studies are likely applicable also to biopsy of cSCC.

  • Guidelines of care for the management of basal cell carcinoma

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Supported by The Netherlands Organization for Scientific Research ZonMW.

Conflicts of interest: None declared.

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