Accuracy of biopsy sampling for subtyping basal cell carcinoma


      Basal cell carcinoma (BCC) is a common skin cancer for which the treatment and recurrence risk correlate with the histologic subtype. Limited information is available regarding the accuracy of biopsy in diagnosing BCC subtypes.


      We sought to determine the correlation between BCC subtypes present in a biopsy specimen and the actual subtypes present in a tumor.


      In this retrospective study, skin biopsy specimens and corresponding excisions were reviewed. All histologic subtypes present in the biopsy specimen were reported and compared with the composite BCC subtype present in the biopsy specimen and excision.


      A total of 232 biopsy specimens and corresponding wide excisions were examined. The biopsy specimen accuracy rate was 82% for punch and shave biopsy specimens. Mixed histologic subtypes were seen in 54% of the cases, half of which contained an aggressive subtype (infiltrative, morpheaform, or micronodular). There was an 18% discordance rate between the biopsy specimen subtype and the composite subtype. Importantly, 40% of these discordant cases (7% of all cases examined) had an aggressive subtype that was not sampled in the initial biopsy specimen. Furthermore, some cases were misidentified as infiltrative subtype in the biopsy specimen as a result of misinterpretation of surface ulceration and reactive stromal changes.


      The limited number of punch biopsy specimens and the fact that Mohs excisions were not included are limitations.


      Punch and shave biopsy specimens provided adequate sampling for correct BCC subtyping in 82% of the cases examined. However, 18% of the biopsy specimens were misidentified, some of which missed an aggressive component. Thus, there are potential pitfalls in the identification of BCC subtypes in biopsy specimens, which may have important implications in treatment outcome.

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        • Rubin A.I.
        • Chen E.H.
        • Ratner D.
        Basal cell carcinoma.
        N Engl J Med. 2005; 353: 2262-2269
        • Miller S.J.
        Biology of basal cell carcinoma (part I).
        J Am Acad Dermatol. 1991; 24: 1-13
        • Snow S.N.
        • Sahl W.
        • Lo J.S.
        • Mohs F.E.
        • Warner T.
        • Dekkinga J.A.
        • et al.
        Metastatic basal cell carcinoma: report of five cases.
        Cancer. 1994; 73: 328-335
        • Crowson A.N.
        Basal cell carcinoma: biology, morphology and clinical implications.
        Mod Pathol. 2006; 19: S127-S147
        • Dixon A.Y.
        • Lee S.H.
        • McGregor D.H.
        Histologic features predictive of basal cell carcinoma recurrence: results of a multivariate analysis.
        J Cutan Pathol. 1993; 20: 137-142
        • Mosterd K.
        • Arits A.H.
        • Thissen M.R.
        • Kelleners-Smeets N.W.
        Histology-based treatment of basal cell carcinoma.
        Acta Derm Venereol. 2009; 89: 454-458
        • Sexton M.
        • Jones D.B.
        • Maloney M.E.
        Histologic pattern analysis of basal cell carcinoma: study of a series of 1039 consecutive neoplasms.
        J Am Acad Dermatol. 1990; 23: 1118-1126
        • Cohen P.R.
        • Schulze K.E.
        • Nelson B.R.
        Basal cell carcinoma with mixed histology: a possible pathogenesis for recurrent skin cancer.
        Dermatol Surg. 2006; 32: 542-551
        • Russell E.B.
        • Carrington P.R.
        • Smoller B.R.
        Basal cell carcinoma: a comparison of shave biopsy versus punch biopsy techniques in subtype diagnosis.
        J Am Acad Dermatol. 1999; 41: 69-71
        • Izikson L.
        • Seyler M.
        • Zeitouni N.C.
        Prevalence of underdiagnosed aggressive non-melanoma skin cancers treated with Mohs micrographic surgery: analysis of 513 cases.
        Dermatol Surg. 2010; 36: 1769-1772
        • Rippey J.J.
        Why classify basal cell carcinomas?.
        Histopathology. 1998; 32: 393-398
        • Freeman R.G.
        • Duncan C.
        Recurrent skin cancer.
        Arch Dermatol. 1973; 107: 395-399
        • Sloane J.P.
        The value of typing basal cell carcinomas in predicting recurrence after surgical excision.
        Br J Dermatol. 1977; 96: 127-132
        • Lang Jr., P.G.
        • Maize J.C.
        Histologic evolution of recurrent basal cell carcinoma and treatment implications.
        J Am Acad Dermatol. 1986; 14: 186-196
        • Swetter S.M.
        • Yaghmai D.
        • Egbert B.M.
        Infiltrative basal cell carcinoma occurring in sites of biopsy-proven nodular basal cell carcinoma.
        J Cutan Pathol. 1998; 25: 420-425
        • Wrone D.A.
        • Swetter S.M.
        • Egbert B.M.
        • Smoller B.R.
        • Khavari P.A.
        Increased proportion of aggressive-growth basal cell carcinoma in the Veterans Affairs population of Palo Alto, California.
        J Am Acad Dermatol. 1996; 35: 907-910