Smaller tumors are often more amenable to excisional biopsy. Excisional biopsy implies the removal of the entire skin lesion or lump. Small, particularly superficial, mobile tumors can be difficult to obtain with an adequate needle biopsy. Small masses or skin lesions on the extremity or trunk that are potentially malignant are often best approached with an excisional biopsy, as it allows definitive diagnosis without risking violation of tissue planes. Disadvantages include the resultant scar, the need for anesthetic, and the potential need for reexcision for margins. It is important to orientate exci-sional biopsy specimens in three dimensions for the pathologist to determine margins if surgical reexcision is needed. The precautions regarding orientation of incisions, not violating tissue planes, and hemostasis are the same as mentioned in the previous section on incisional biopsies.
figure 4.3. Placement of an incisional biopsy incision in a patient with an extremity soft tissue tumor. These incisions should be placed parallel to the long axis of the extremity. [By permission of Sondak VK. In: Greenfield LJ, et al. (eds). Surgery Scientific Principles and Practice. Philadelphia: Lippincott: Williams & Wilkins, 1993.]
Care should be taken, when biopsying more then one lesion of the same patient, to use separate instrument setups between biopsies in the event that not all the lesions are malignant to avoid cross-contamination of malignant cells between surgical sites. In this setting, precise labeling of each biopsy specimen is needed in the event that only one of the biopsied lesions is malignant to correctly identify the area to be further treated. It is also important to ensure proper handling of specimens. For example, lymph node tissue obtained for the potential diagnosis of lymphoma should go to pathology fresh to procure part of the specimen for flow cytometry.
In addition to obtaining biopsies to make a diagnosis, the surgical oncologist is increasingly called on to do a biopsy to assess response to adjuvant therapy because routine imaging studies do not always reflect what is happening at the tissue level. For example, necrotic tumor may still show as a mass on CT or mammography. In some protocols, serial biopsies are obtained to access response to therapy; this is most often done as a core-needle biopsy.
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