What is the preferred biopsy method, shave or punch biopsy, for a patient with a nodular lesion on the helical rim suspicious for Basal Cell Carcinoma (BCC) vs Squamous Cell Carcinoma (SCC) who is on rivaroxaban (Xarelto)?

Punch Biopsy is Preferred for a Nodular Lesion on Helical Rim in a Patient on Rivaroxaban

For a patient on rivaroxaban with a nodular lesion on the helical rim suspicious for BCC vs SCC, a punch biopsy is preferred over a shave biopsy due to better depth assessment and reduced bleeding risk.

Rationale for Punch Biopsy Selection

Anatomical Considerations

• The helical rim is a cartilaginous structure with limited subcutaneous tissue
• Punch biopsy provides:
  • Better depth assessment for potential cartilage involvement
  • More controlled wound edges in this anatomically challenging area
  • More accurate histologic assessment of tumor depth and subtype 1

Anticoagulation Considerations

• Patient is on rivaroxaban (Xarelto), a direct oral anticoagulant
• Punch biopsy offers:
  • More controlled hemostasis compared to shave biopsy
  • Smaller surface area of bleeding
  • Easier wound closure with suture to control bleeding
  • Better visualization of bleeding vessels during the procedure

Biopsy Technique Recommendations

Punch Biopsy Approach

1. Use a 3-4 mm punch biopsy instrument
2. Select the most representative or thickest portion of the nodular lesion
3. Ensure adequate depth to include subcutaneous tissue
4. Consider:
   • Local anesthesia with 1-2% lidocaine (with epinephrine if no contraindication)
   • Single simple interrupted suture for closure
   • Topical hemostatic agents such as aluminum chloride or ferric subsulfate solution 1

Why Not Shave Biopsy

• Shave biopsy limitations in this scenario:
  • May underestimate depth of invasion, particularly important for SCC staging
  • Creates a broader surface area of potential bleeding
  • More difficult to achieve hemostasis in a patient on anticoagulation
  • Less controlled wound edges on the helical rim

Special Considerations

Anticoagulation Management

• Rivaroxaban does not typically need to be discontinued for minor procedures like skin biopsies
• Enhanced bleeding precautions:
  • Apply prolonged pressure after biopsy
  • Consider hemostatic agents
  • Suture closure is strongly recommended

Histopathologic Assessment

• Provide complete clinical information to the pathologist:
  • Patient age and sex
  • Anatomic location (helical rim)
  • Clinical appearance and size
  • History of anticoagulation (rivaroxaban)
  • Suspected diagnoses (BCC vs SCC) 1

Common Pitfalls to Avoid

1. Inadequate depth sampling - ensure the punch extends to subcutaneous tissue
2. Crushing the specimen - handle gently to avoid artifact
3. Insufficient hemostasis - take extra time for hemostasis given anticoagulation
4. Poor wound closure - secure closure is particularly important in anticoagulated patients

The guidelines from the American Academy of Dermatology support that either punch or shave biopsy can be appropriate for suspected BCC or SCC, but patient-specific factors such as "bleeding and wound healing diatheses" should influence technique selection 1. In this specific case, the combination of the anatomical location (helical rim) and anticoagulation status (rivaroxaban) makes punch biopsy the more appropriate choice.