biopsy

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1. The removal and examination of a sample of tissue from a living body for diagnostic purposes.
2. A sample so obtained.

For more information on biopsy, visit Britannica.com.

Definition

A biopsy is the removal of a small portion of tissue from the body for microscopic examination.

Description

When a physician diagnoses the nature of an ailment, various examinations provide information that is vital to accurately determining the nature of the problem. Blood and urine samples can be examined to determine the amounts of various compounds. As useful as this information can be, it reveals little about the state of tissues. In diseases such as cancer, knowledge of the affected tissue is crucial for diagnosis and the formulation of treatment strategies.

Examination of tissues can be accomplished without obtaining a sample, using techniques like ultrasound and magnetic resonance imaging (MRI). However, the information gained may not be detailed enough for a definitive diagnosis. For example, a physician may be interested in the activity of a particular enzyme in the tissue, as a marker of a disease process, or the presence of a toxin. For such determinations, a tissue sample that can be analyzed in the laboratory is needed.

Similarly, for certain diseases and conditions that involve nerve abnormalities, the ability to directly examine nerves can be advantageous in diagnosis and treatment. For instance, direct microscopic examination of a nerve sample can reveal whether or not the protective myelin sheath that surrounds a nerve is intact or is in the process of degrading. Obtaining a nerve via a biopsy is a valuable aid to these examinations.

Muscle biopsies can serve a similar purpose, since maladies that affect the structure and/or functioning of nerves will ultimately affect the muscles into which the nerve passes. The loss of muscle function or strength can be the direct consequence of nerve damage.

Biopsy

A biopsy describes the procedure that is used to obtain a very small piece of the target tissue. For some tissues, like the lining of the cheek, cells can be obtained just by scrapping the tissue surface. Other samples are collected using forceps that are positioned at the end of an optical device called an endoscope. The physician can view the tissue surface (such as the wall of the large intestine) through the endoscope and use the forceps to pluck tissue from the desired region of the surface. In other cases, the tissue sample needs to be collected as a "plug," using a large hypodermic needle. Examples of the latter include liver or kidney biopsy samples. Samples of muscles and nerves can also be obtained by cutting out a small piece of the target once an incision has been made.

When a biopsy is obtained using a needle, the retrieval of a sample relies on the design of the needle and the energy of its insertion into the tissue. The needle used is a hollow tube with a sharp point capable of puncturing tissue. As the needle is driven deeper into a tissue following puncture, tissue will accumulate in the hollow tube. When the needle is withdrawn from the tissue, the plug of tissue remains in the needle tube and can be retrieved for analysis.

Many biopsy samples are examined using a light microscope to look for abnormalities in the tissues cells. This examination can involve the staining of the sample to specifically detect target molecules. As well, samples can be used for various biochemical tests, and even to test for the presence and activity of particular genes.

A biopsy can remove the entire target region (excisional biopsy) or can remove just a small portion of the target region (incisional biopsy). The latter can be done in three different ways, depending on the sample. A shave biopsy slices off surface tissue. Samples collected by piercing the tissue with a needle represent a punch biopsy. Finally, in fine needle aspiration, a needle is inserted and tissue is subsequently withdrawn into the needle using a syringe.

Muscle biopsy

A muscle biopsy can represent the punch type, in which a plug of tissue is obtained using an inserted needle. Or, in an open biopsy procedure, a small incision is made and a piece of tissue is removed. This biopsy is done for a variety of reasons: to distinguish between nerve and muscle disorders, to identify specific muscular disorders such as muscular dystrophy, to probe muscle metabolic activities, and to detect muscle infections such as trichinosis and toxoplasmosis. Biopsy of a muscle necessarily involves nerves, as muscle is highly infused by nerves. The small amount of muscle that is extracted during a muscle biopsy does not damage nerves to such an extent that muscle function is affected.

Brain biopsy

A brain biopsy is performed following the drilling of a hole in the skull, through which the biopsy needle is subsequently introduced. An MRI or computed tomography (CT) scan is performed prior to the procedure in order to identify the area where the biopsy will be performed. As of the mid-1990s, the patient's head is no longer immobilized during the procedure by a frame device. Instead, the precise location is located by a computer-guided system that is designed to avoid damage to other regions of the brain. In contrast to a skin biopsy, for example, where the sample scraping may affect few nerves, a brain biopsy is a delicate and potentially problematic procedure. Rarely, nerve damage may result, and the puncture site may form scar tissue, causing seizures.

Nerve biopsy

Nerves such as the sural nerve in the ankle and the superficial radial nerve in the wrist are most often used for a nerve biopsy. A nerve biopsy is performed to detect nerve-damaging conditions, including leprosy, necrotizing vasculitis (an inflammation of the blood vessels), other nerve inflammation, and damage or loss of the nerve's protective myelin sheath (demyelination). A nerve biopsy can also be done to try to identify nerve abnormalities that are generically called neuropathies, or to confirm a specific diagnosis relating to a nerve. An example is the progressive wasting away of muscle tissue in the feet and legs that is known as Charcot-Marie-Tooth disease.

When a nerve biopsy is performed, local anesthetic is used. Then a small incision is made and a small piece of the target nerve is removed. Usually, a biopsy of the adjacent muscle is done at the same time. The biopsy procedure carries minimal risks, including allergic reaction to the anesthetic, infection, and permanent numbness. A small degree of persistent numbness is to be expected, however, because a portion of nerve has been removed. As a nerve biopsy is generally performed in the ankle or wrist, the numbness is typically not debilitating and is seldom recognized during normal activities.

Biopsy sample processing and examination

Biopsy specimens are often sliced into thin slices, stained, mounted on a glass slide, and examined using a light microscope. Newer sample preparation techniques involve the rapid freezing of the sample and slicing of the still-frozen material. The latter technique has the advantage of avoiding the removal of water, which can alter the structure of the tissue cells. Microscopic examination focuses on the general appearance of the cells, including their structure, presence of abnormalities, and specific molecules that have been revealed by the use of specialized stains or antibodies. This interpretation can be subjective, and relies on the expertise of the experienced examiner.

Resources

BOOKS

Zaret, B. L. The Yale University School of Medicine Patient's Guide to Medical Tests. New Haven: Yale University School of Medicine and G.S. Sharpe Communications Inc., 1997.

OTHER

National Library of Medicine. "Muscle Biopsy." Medline Plus. May 5, 2004 (May 27, 2004). http://www.nlm.nih.gov/medlineplus/ency/article/003924.htm.

National Library of Medicine. "Nerve Biopsy." Medline Plus. May 5, 2004 (May 27, 2004). http://www.nlm.nih.gov/medlineplus/ency/article/003928.htm.

"What Is a Biopsy?" Netdoctor.co.uk. May 6, 2004 (May 27, 2004). http://www.netdoctor.co.uk/health_advice/examinations/biopsy.htm.

ORGANIZATIONS

American Academy of Neurology. 1080 Montreal Avenue, Saint Paul, MN 55116. (651) 695-2717 or (800) 879-1960; Fax: (651) 695-2791. memberservices@aan.com. http://www.aan.com.

Brian Douglas Hoyle, PhD

Key Terms: Contrast agent, Excision, Incision, Platelets.

Definition

Biopsy is a diagnostic procedure in which a piece of tissue and/or cells are removed to be examined under a microscope by a pathologist.

Purpose

Biopsies are performed to determine the presence of cancer cells, establish tumor grading, and provide more information for treatment.

Precautions

Most biopsies should not be done on patients with blood clotting problems. If the patient has a low blood platelet count, a platelet transfusion can be given as a temporary relief measure, and a biopsy can then be performed. The physician should be notified of any bleeding problems—as well as any allergies, current medications, or pregnancy—well in advance.

Patients receiving IV sedation for a biopsy procedure will continue to feel drowsy for several hours, and should refrain from cooking, driving, or operating any equipment that requires careful attention. A ride home from the clinic should be arranged in advance.

Description

There are several different types of biopsies, and the decision on which one is most effective depends on where the tumor is located and the general health of the patient. Four common categories of biopsy are fine needle aspiration, core needle biopsy, excisional biopsy, and incisional biopsy.

Fine Needle Aspiration Biopsy

Fine needle aspiration biopsy, also known as suction biopsy or needle aspiration biopsy, involves applying negative pressure through the use of a syringe and hollow, hypodermic needle. This type of biopsy is often used as a diagnostic procedure on neck and thyroid masses. It results in the removal of tissue that is fragmented into cells, as opposed to one sample of undamaged tissue. Fine needle aspiration biopsy is a frequently performed procedure that results in minimum discomfort and is less costly than many other types of biopsy.

Core Needle Biopsy

Core needle biopsy, also known as wide-core needle biopsy or cutting core biopsy, involves the use of a large-bore needle and is the simplest method of pathologic diagnosis of cancer. It results in minimal disturbance of surrounding tissues and a solid, intact sample. Tumors located in the liver and breast are commonly biopsied with this technique.

Incisional Biopsy

This refers to the removal of part of the tumor from the larger tumor mass. An incisional biopsy is employed for tumors located deep within the body and after an initial needle biopsy has failed to supply enough tissue for diagnosis. Biopsies of this type are the preferred technique for diagnosing soft tissue cancers and osteosarcomas.

Excisional Biopsy

Also known as surgical biopsy, the excisional biopsy entails the surgical removal of the entire tumor mass and is a diagnostic technique that simultaneously serves as a treatment. For example, a lumpectomy removes the entire primary tumor mass associated with breast cancer. Excisional biopsy is also useful for diagnosing and removing surface tumors of the skin, such as those associated with squamous cell carcinoma, basal cell carcinoma, and malignant melanoma.

Preparation

Many biopsies can be performed in the doctor's office or in the hospital on an outpatient basis. Most do not require much special preparation on the part the patient, but patients should ask their physician for special instructions. Prior to the procedure, most require the use of anesthesia. Prior to and during a biopsy, special imaging techniques may be employed to assist in locating the tumor and guidance of biopsy procedures using a needle. Such imaging techniques include computed tomography scan (CT guided biopsy), fluoroscopy, magnetic resonance imaging (MRI), nuclear medicine scan, and ultrasound (ultrasound guided biopsy). Patients who undergo imaging scans may be injected with or asked to drink a contrast agent (dye) prior to biopsy.

Fine Needle Aspiration Biopsy

Some routine blood work (blood counts, clotting profile) should be completed two weeks prior to biopsy.

Patients may be asked not to eat for a specified time before the procedure. Those taking blood thinners (anticoagulants) or aspirin should talk to their physicians about whether they should discontinue using them prior to biopsy.

Core Needle Biopsy

Women undergoing breast biopsy should not wear talcum powder, deodorant, lotion, or perfume under their arms or on their breasts on the day of the procedure (since these may cause image artifacts or other problems). A comfortable two-piece garment should be worn. Patients may be asked not to eat for a specified time before the procedure. Those taking blood thinners or aspirin should talk to their physicians about whether they should discontinue using them prior to core needle biopsy.

Incisional Biopsy

Patients should follow instructions provided by their doctor and give notification of any allergies. Those expecting general anesthesia should not eat or drink for at least 8 hours before an incisional biopsy. Patients should also bathe thoroughly before the procedure and allow time to rest afterward.

Excisional Biopsy

Patients may be asked to: sign a consent form allowing the physician to perform this test; refrain from eating or drinking for at least 8 hours prior to surgery; and arrange for a ride home from the hospital (most patients can go home on the same day as the surgery). Those taking insulin, aspirin, non-steroidal anti-inflammatory drugs, or any medicines that affect blood clotting should notify their doctor well before the procedure.

Aftercare

Fine Needle Aspiration Biopsy

After the biopsy, patients should be able to drive home, return to work, or perform any other routine activity. This biopsy does not affect medication schedules.

Core Needle Biopsy

Most patients can resume normal activities right after the biopsy. If there is excessive redness, pain, or drainage from the puncture site, patients should call their doctor immediately.

Incisional Biopsy

After recovering from anesthesia, the patient will be observed for a few hours before returning home. During this time, an analysis may come back from the lab and the doctor may explain the nature of the abnormality. This analysis is the result of only one test and will not be 100% accurate. In about two days, lab testing should be complete. Patients should call their doctor immediately if there is drainage from the wound or a fever develops.

Excisional Biopsy

Depending on the invasiveness of the procedure, the patient may receive varied instructions for aftercare. The incision site should be kept clean, dry, and free of lotion, medication, or ointments. The patient may be required to remain in a certain position until sufficient time has passed to warrant the release of the patient from medical care. For example, patients are required to remain on their right side for approximately four hours to allow for healing to occur after a liver punch biopsy. Some patients, however, may be able to return to normal activities on the same day. Those who develop a fever, or notice bleeding, drainage, strong pain, or redness and warmth at the biopsy site should contact their doctor immediately.

Risks

Although most biopsies end with success, there are a certain number of risks to keep in mind. For example, complications can arise if other organs are nicked during a biopsy using a long needle. As with any procedure, there is a slight risk of allergic reaction to anesthesia. To be well informed, patients should consult with their physician about the risks prior to undergoing the procedure.

Fine Needle Aspiration Biopsy

This biopsy poses no significant risks. Some minor bleeding may occur and some patients report a mild, dull, and throbbing sensation in the area of the biopsy, which usually subsides within 30 to 60 minutes. The risk of infection exists any time the skin is penetrated, but is extremely rare with this procedure. The error rate of diagnosis, however, is substantially higher than that of other biopsy procedures; major surgical resections should not be undertaken solely on the basis of the evidence of aspiration biopsy.

Core Needle Biopsy

A lumpy scar called a keloid may form in the area of puncture. Infection and bleeding may also occur at or under the biopsy site; however, this risk is uncommon. Core needle biopsy, like fine needle aspiration, only removes samples of a mass and not the entire area of concern. Therefore, it is possible that a more serious diagnosis may be missed by limiting the sampling of an abnormality.

Incisional Biopsy

A keloid may form in the incision area. In rare cases, infection and bleeding may occur.

Excisional Biopsy

Some patients may experience infection, bleeding, or bruising around the biopsy site. The physician should be consulted about any risks that may be related to a patient's medical history.

Normal Results

The tissue sample obtained from the biopsy needs to be prepared for examination by a pathologist, and results usually are reported to the patient within a few days of the procedure. Normal (negative) results indicate that no malignancy is present.

Abnormal Results

Abnormal results indicate that a malignancy or other abnormality is present. In some cases, results are indeterminate and patients are subject to further diagnostic procedures.

Resources

Books

Bast, Robert C., et al. Cancer Medicine. 5th ed. Hamilton, ON: B.C. Decker Inc., 2000.

Other

"An Alternative to Excisional Breast Biopsy: Core Needle Breast Biopsy." Washington Radiology Associates. [cited June 25, 2001]. .

Harvard Health Online. [cited June 25, 2001]. .

National Cancer Institute. [cited June 25, 2001]. .

Questions to Ask the Doctor

• Why is this particular type of biopsy being performed?
• Is there another type of biopsy that can be used?
• What are the risks associated with the biopsy?
• What level of discomfort is expected?
• Are there any special preparations associated with the biopsy?
• Are there any aftercare requirements?
• When are the results expected?
• Should a return visit be scheduled?

—Sally C. McFarlane-Parrott

A piece of tissue taken from a patient during life to establish a precise diagnosis so that the most appropriate treatment can be initiated. Usually a thin section of the specimen on a glass slide is examined by a pathologist under a microscope, but if the specimen is small and soft it may be more appropriate to make a smear on the slide. On occasion the biopsy may require to be examined biochemically. Biopsies may also be taken, for example, from chorionic villi (the projections of fetal tissue around the early embryo after it is embedded in the womb) for chromosomal analysis when a hereditary disorder is suspected.

The technique of biopsy is vital in all branches of medicine. Various methods are used. The simplest is a scraping from an accessible site such as the skin, or from a mucous membrane, such as in the mouth or the cervix of the womb. One of the commonest is a needle biopsy when a small sample is sucked out into some type of syringe through a needle of a calibre appropriate to the consistency of the tissue. This method is applicable to obtaining tissue from the breast, kidney, liver, brain, or heart.

In other situations a lesion is biopsied by a surgeon either at an operation undertaken just for that purpose, or in the course of an exploratory procedure. Often only part of the lesion being investigated is taken at operation — an incisional biopsy, but if the lesion is small, such as an ulcer, a pigmented spot on the skin, or a lymph node it may be removed in its entirety: an excision biopsy. Procedures of this type involve the use of a scalpel. Other instruments may be appropriate: a curette is used to take scrapings from the inner lining of the womb (the endometrium) ; small biopsies may be obtained by endoscopy — from the lungs during bronchoscopy, or from the lining of the stomach or colon. Occasionally specially designed instruments are used, in the form of ‘punches’ or ‘brushes’.

One of the commonest reasons for undertaking a biopsy is to establish whether a tumour is malignant or benign. A common example of this is the investigation of a lump in a woman's breast. In such circumstances the pathologist often undertakes an immediate microscopical examination while the patient is still in the operating theatre, the surgeon waiting for the result before deciding how extensive an operation is required. This is also a common procedure during operations for tumours of the brain, or for cancers in other sites when lymph nodes need to be examined to establish whether or not they have been invaded by malignant cells.

Apart from the assessment of malignancy, biopsies are taken to examine organs such as the liver or kidneys for evidence of intrinsic disease, or to look for any signs of rejection of a transplanted organ such as a kidney or a heart.

Needle biopsies of skeletal muscles are often taken because of the problems frequently encountered in distinguishing clinically among conditions caused by disease in the muscle itself (myositis, muscular dystrophy) and those secondary to an abnormality in its nerve supply.

Healthy individuals are not always exempt — for example they may be recruited as volunteers for muscle biopsy. Enthusiasm for competitive sport and interest in the health-promoting effects of exercise in recent decades have provided an increasing incentive (and funds) for improving knowledge about skeletal muscle and the effects upon it of various training and dietary regimes. Needle biopsy of muscles has become a standard component of investigations in major research laboratories for sport and exercise science.

— J. Hume Adams

See also cancer; muscle; neoplasm; transplantation.

The removal of a tissue specimen or other material from the living body for microscopic examination to aid in establishing a diagnosis.

Removal and examination, usually microscopic, of tissue from the living body. Biopsies are usually done to determine whether a tumor is malignant or benign; however, a biopsy may be a useful diagnostic aid in other disease processes such as infections.

• aspiration b. — biopsy in which tissue is obtained by application of suction through a needle attached to a syringe.
• bite b. — instrumental removal of a fragment of tissue.
• bone marrow b. — obtaining a sample of bone marrow, usually by needle aspiration, from a long bone, rib or sternum, for cytological examination.

  Needle aspiration of bone marrow. By permission from Ettinger SJ, Feldman E, Textbook of Veterinary Internal Medicine, Saunders, 2004

• brush b. — removal of cells and tissue fragments using a brush with stiff bristles (introduced through an endoscope). Effective in obtaining tissue samples from inaccessible places such as the renal pelvis.
• closed b. — one carried out without access through an open incision such as a laparotomy. An example is a percutaneous, fine needle aspirate.
• cone b. — biopsy in which an inverted cone of tissue is excised, as from the uterine cervix.
• cytological b. — obtaining specimens of cells by various methods including irrigation of a hollow tube.
• b. dart — an alternative to immobilization of large and wild animals; a dart which cuts a skin bipsy, then falls out. Limited to use for superficial lesions.
• endoscopic b. — removal of tissue by appropriate instruments through an endoscope.
• excisional b. — biopsy of tissue removed from the body by surgical cutting.
• exploratory b. — a combination of exploratory surgery to determine size and location of a lesion and the taking of a biopsy.
• fine needle b. — see needle biopsy (below).
• hepatic b. — may be by transperitoneal incision, more commonly by percutaneous needle or trocar and cannula technique.
• incisional b. — biopsy of a selected portion of a lesion.
• needle b. — biopsy in which tissue is obtained by puncture of a tumor, the tissue within the lumen of the needle being detached by rotation, and the needle withdrawn.
• punch b. — see punch biopsy.
• Robson–Heggers b. — a procedure for the collection of a piece of tissue from an infected wound in order to determine the extent and the nature of the infection.
• sternal b. — biopsy of bone marrow of the sternum removed by puncture or trephining (see also sternal puncture).
• surface b. — sample of cells scraped from the surface of a lesion or obtained by impression smears.
• surgical b. — one obtained during a surgical procedure.
• synovial b. — by a needle biopsy technique or through an arthrotomy incision using special forceps for a bite biopsy.
• total b. — obtained by removal of the entire lesion. May be for therapeutic as well as diagnostic purposes.
• ultrasound-guided b. — use of ultrasonography to guide the passage of a needle or biopsy instrument into an internal organ or lesion.

Brain biopsy

A biopsy is a medical test involving the removal of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. When only a sample of tissue is removed with preservation of the histological architecture of the tissue’s cells, the procedure is called an incisional biopsy or core biopsy. When a sample of tissue or fluid is removed with a needle in such a way that cells are removed without preserving the histological architecture of the tissue cells, the procedure is called a needle aspiration biopsy.

Contents 1 Breast Biopsy 1.1 Fine Needle Aspiration 1.2 Core Needle Biopsy 1.3 Vacuum Assisted Biopsy 1.4 Open Surgical Biopsy 2 Skin Biopsy 2.1 Shave biopsy 2.2 Punch biopsy 2.3 Incisional biopsy 2.4 Excisional biopsy 2.5 Curettage biopsy 2.6 Fine needle aspirate 2.7 "Scoop", "scallop", or "shave" excision 3 History 4 Cancer 5 Precancerous conditions 6 Inflammatory conditions 6.1 Kidney disease 6.2 Infectious disease 6.3 Metabolic disease 6.4 Transplantation 6.5 Fertility 7 Commonly biopsied sites 7.1 Bone marrow 7.2 Gastrointestinal tract 7.3 Lung 7.4 Liver 8 Analysis of biopsied material 9 See also 10 References 11 External links

Breast Biopsy

Several methods for a breast biopsy now exist. The most appropriate method of biopsy for a patient depends upon a variety of factors, including the size, location, appearance and characteristics of the abnormality.

Fine Needle Aspiration

Fine needle aspiration (FNA) is a percutaneous ("through the skin") procedure that uses a fine needle and a syringe to sample fluid from a breast cyst or remove clusters of cells from a solid mass. With FNA, the cellular material taken from the breast is usually sent to the pathology laboratory for analysis. A technique similar to FNA can also be used by the radiologist or surgeon to drain fluid from a benign cyst. This procedure is called cyst aspiration. A Fine Needle Aspiration procedure is generally almost painless and takes only a few minutes to perform. Technically this FNA procedure is not a biopsy as the material retrieved is made of fluid coming either from a cystor from the intercellular space and a few cells, when a biopsy is bringing back a piece of tissue where the architecture of the tissue is preserved.

Core Needle Biopsy

Liver core needle biopsy.

A core needle biopsy is a procedure that removes small but solid samples of tissue using a hollow "core" needle. For palpable (“able to be felt”) lesions, the physician fixes the lesion with one hand and performs a freehand needle biopsy with the other. In case of non-palpable lesions stereotactic mammography, or ultrasound, or PEM guidance is used. With stereotactic mammography it is possible to pinpoint the exact location of a mass based on images taken from two different angles of the x-ray machine. With ultrasound, the radiologist or surgeon can watch the needle on the ultrasound monitor to help guide it to the area of concern. With PEM (positron emission mammagraphy), the lesion is targeted in 3D based on a positron emission tomography (PET) image of the breast. The needle used during core needle biopsy is larger than the needle used with FNA. The core biopsy needle also has a special cutting edge allowing removal of a bigger sample of tissue. With Core Needle Biopsy a relatively large sample can be removed through a small single incision in the skin. Typically, the breast area is first locally anesthetized with a small amount of anesthetic fluid. Then, the needle is placed into the breast. As with FNA, the radiologist or surgeon will guide the needle into the area of concern by palpating the lump. If the lesion can’t be felt the core needle biopsy is performed under image-guidance using either stereotactic mammography, ultrasound or even magnetic resonance imaging (MRI). A core needle biopsy procedure takes a few minutes to perform and is almost painless.

Vacuum Assisted Biopsy

Vacuum Assisted Biopsy is a version of Core Needle Biopsy using a vacuum technique to assist the collection of the tissue sample. The needle normally has a lateral (“from the side”) opening and can be rotated allowing multiple samples to be collected through a single skin incision. The Vacuum Assisted Biopsy procedure is similar to normal Core Needle Biopsy. The Vacuum Assisted Biopsy category also includes automated rotational core devices.^[1]

Open Surgical Biopsy

Open Surgical Biopsy means that a large mass or lump is removed during a surgical procedure. Surgical biopsy requires an approximately 3 to 5 centimeters incision and is normally performed in an operating room in sterile conditions. Open surgical biopsy in some cases can be performed with local anesthesia but in most cases general anesthesia may be necessary. Ten years ago, most breast biopsies were open surgical procedures. Today most patients are candidates for less invasive biopsy procedures such as core needle biopsy. Depending on the location of the lesion to be biopsied, a radiologist will often perform needle localization beforehand to guide the surgeon to the site being biopsied.

Skin Biopsy

Multiple methods for skin biopsy exist. Each has its own limitation and problems. Most are done under local anesthesia in a doctor's office. The result is very dependent on the clinical history presented to the pathologist, and also the method utilized. A shave biopsy is absolutely useless in diagnosising vasculitis, whereas an excisional biopsy might be excessive in diagnosing a possible basal cell carcinoma.

Shave biopsy

This is done with either a small scalpel blade, a curved razor blade, or a broken piece of "safety" razor. The technique is very much user skill dependent, as some surgeons can remove a small fragment of skin with minimal blemish using any one of the above tools, while other have great difficulty securing the devices. Ideally, the razor will shave only a small fragment of protruding tumor and leaving the skin relatively flat after the procedure. Hemostasis is obtained using light electrocautery, Monsel solution, or aluminum chloride. This is the ideal method of diagnosis for basal cell cancer. It can be used to diagnose squamous cell carcinoma and melanoma-in-situ, however, the doctor's understanding of the growth of these last two cancers should be considered before one uses the shave method. The punch or incisional method is better for the latter two cancers as false negative is less likely to occur (i.e. calling a squamous cell cancer an actinic keratosis or keratinous debris). Hemostasis for the shave technique can be difficult if one relied on electrocautery alone. A small "shave" biopsy often ends up being a large burn defect when the surgeon tries to control the bleeding with electrocautery alone. Pressure dressing or chemical astringent can help in hemostasis in patients taking anticoagulants.

Punch biopsy

This is done with a round shaped knife ranging in size from 1mm to 8 mm. Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel. The 1 mm and 1.5 mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method. Minimal bleeding is noted with the 1 mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. Disadvantage of the 1 mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5 mm biopsy is preferred in most cases. The common punch size use to diagnose most inflammatory skin condition is the 3.5 or 4 mm punch. Ideally, the punch biopsy include the full thickness skin and subcutanous fat in the diagnosis of skin diseases. The punch biopsy is preferred over the shave biopsy for the diagnosis of squamous cell carcinoma and for melanomas. One or two sutures are required to close most punch biopsies with the exception of the smallest punches. Two "dog ear" defects can result in punch biopsies much larger than 5 mm, thus an incisional biopsy is preferred on larger lesions.

Incisional biopsy

When a cut is made through the entire dermis down to the subcutanous fat. A punch biopsy is essentially an incisional biopsy, except it is round rather than elliptical as in most incisional biopsies done with a scalpel. Incisional biopsies can include the whole lesion (excisional), part of a lesion, or part of the affected skin plus part of the normal skin (to show the interface between normal and abnormal skin). Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutanous tissue can be obtained than a punch biopsy. Long and thin deep incisional biopsy are excellent on the lower extremities as they allow a large amount of tissue to be harvested with minimal tension on the surgical wound. Advantage of the incisional biopsy over the punch method is that hemostasis can be done more easily due to better visualization. Dog ear defects are rarely seen in incisional biopsies with length at least twice as long as the width.

Excisional biopsy

This is essentially the same as incision biopsy, except the entire lesion or tumor is included. This is the ideal method of diagnosis of small melanomas (when performed as an excision). Ideally, an entire melanoma should be submitted for diagnosis if it can be done safely and cosmetically. This "excisional" biopsy is often done with a narrow margin to make sure the deepest thickness of the melanoma is given before prognosis is decided. However, as many melanoma-in-situs are large and on the face, a physician often chose to do multiple small punch biopsies before committing to a large excision for diagnostic purpose alone. Many prefer the small punch method for initial diagnostic value before resorting to the excisional biopsy. An initial small punch biopsy of a melanoma might say "severe cellular atypia, recommend wider excision". At this point, the clinician can be confident that an excisional biopsy can be performed without risking committing a "false positive" clinical diagnosis.

Curettage biopsy

This can be done on the surface of tumors or on small epidermal lesions with minimal to no topical anesthetic using a round curette blade. Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted. The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells.

Fine needle aspirate

This is done with the rapid stabbing motion of the hand guiding a needle tipped syringe and the rapid sucking motion applied to the syringe. It is a method used to diagnose tumor deep in the skin or lymphnodes under the skin. The cellular aspirate is mounted on a glass slide and immediate diagnosis can be made with proper staining or submitted to a laboratory for final diagnosis. A fine needle aspirate can be done with simply a large bore needle and a small syringe (1 cc) that can generate rapid changes in suction pressure. Fine needle aspirate can be used to distinguish a cystic lesion from a lipoma. Both the surgeon and the pathologist must be familiar with the method of procuring, fixing, and reading of the slide. Many center have dedicated team used in the harvest of fine needle aspirate.

"Scoop", "scallop", or "shave" excision

A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion. An author published the result of this method and advocated it as better than standard excision and less time consuming. The added economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy. This save the added time for hemostasis, instruments, and suture cost. The great disadvantage, seen years later is the numerous scallop scars, and a very difficult to deal with lesions called a "recurrent melanocytic nevus". What has happened is that many "shave" excisions does not adequately penetrate the dermis or subcutanous fat enough to include the entire melanocytic lesion. Residual melanocytes regrow into the scar. The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevus gives the perfect dermatoscopic picture of a melanoma. When a second physicians re-examine the patient, he or she has no choice but to recommend the reexcision of the scar. If one does not have access to the original pathology report, it is impossible to tell a recurring nevus from a severely dysplastic nevus or a melanoma. As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of the scar showing residual pigmentation. The second issue with the shave excision is fat herniation, iatrogenic anetoderma, and hypertrophic scarring. As the deep shave excision either completely remove the full thickness of the dermis or greatly diminishing the dermal thickness, subcutanous fat can herniate outward or pucker the skin out in an unattractive way. In areas prone to friction, this can result in pain, itching, or hypertrophic scarring.

History

One of the earliest diagnostic biopsies was developed by the Arab physician Abulcasim (1013-1107 AD). A needle was used to puncture a goiter, and the material issuing was characterized. ^[2]

Cancer

When cancer is suspected, a variety of biopsy techniques can be applied. An excisional biopsy is an attempt to remove an entire lesion. When the specimen is evaluated, in addition to diagnosis, the amount of uninvolved tissue around the lesion, the surgical margin of the specimen is examined to see if the disease has spread beyond the area biopsied. "Clear margins" or "negative margins" means that no disease was found at the edges of the biopsy specimen. "Positive margins" means that disease was found, and a wider excision may be needed, depending on the diagnosis. When intact removal is not indicated for a variety of reasons, a wedge of tissue may be taken in an incisional biopsy. In some cases, a sample can be collected by devices that "bite" a sample. A variety of sizes of needle can collect tissue in the lumen (‘’core biopsy’’). Smaller diameter needles collect cells and cell clusters, fine needle aspiration biopsy. ^[3] Pathologic examination of a biopsy can determine whether a lesion is benign or malignant, and can help differentiate between different types of cancer. In contrast to a biopsy that merely samples a lesion, a larger excisional specimen called a resection may come to a pathologist, typically from a surgeon attempting to eradicate a known lesion from a patient. For example, a pathologist would examine a mastectomy specimen, even if a previous nonexcisional breast biopsy had already established the diagnosis of breast cancer. Examination of the full mastectomy specimen would confirm the exact nature of the cancer (subclassification of tumor and histologic "grading") and reveal the extent of its spread (pathologic "staging").

Precancerous conditions

For easily detected and accessed sites, any suspicious lesions may be assessed. Originally, this was skin or superficial masses. X-ray, then later CT, MRI, and ultrasound along with endoscopy extended the range.

Inflammatory conditions

Please help improve this article by expanding it. Further information might be found on the talk page.

A biopsy of the temporal arteries is often performed for suspected vasculitis. In inflammatory bowel disease (Crohn's disease and ulcerative colitis), frequent biopsies are taken to assess the activity of disease and to assess changes that precede malignancy. ^[4]

Biopsy specimens are often taken from part of a lesion when the cause of a disease is uncertain or its extent or exact character is in doubt. Vasculitis, for instance, is usually diagnosed on biopsy.

Kidney disease

Biopsy and fluorescence microscopy are key in the diagnosis of alterations of renal function.

Infectious disease

Lymph node enlargement may be due to a variety of infectious or autoimmune diseases.

Metabolic disease

Some conditions affect the whole body, but certain sites are selectively biopsied because they are easily accessed. Amyloidosis is a condition where degraded proteins accumulate in body tissues. In order to make the diagnosis, the gingival

Transplantation

Biopsies of transplanted organs are performed in order to determine that they are not being rejected or that the disease that necessitated transplant has not recurred.

Fertility

A testicular biopsy is used for evaluating the fertility of men and find out the cause of a possible infertility, e.g. when sperm quality is low, but hormone levels still are within normal ranges. ^[5]

Commonly biopsied sites

Bone marrow

Since blood cells are formed in the bone marrow, a bone marrow biopsy is employed in the diagnosis of abnormalities of blood cells when the diagnosis cannot be made from the peripheral blood alone. In malignancies of blood cells (leukemia and lymphoma) a bone marrow biopsy is used in staging the disease. The procedure involves taking a core of trabecular bone using a trephine, and then aspirating material.

Gastrointestinal tract

Flexible endoscopy enables access to the upper and lower gastrointestinal tract, such that biopsy of the esophagus, stomach and duodenum via the mouth and the rectum, colon and terminal ileum are commonplace. A variety of biopsy instruments may be introduced through the endoscope and the visualized site biopsied. Until recently, the majority of the small intestine could not be visualized for biopsy. The double-ballon “push-pull” technique allows visualization and biopsy of the entire gastrointestinal tract. ^[6].

Needle core biopsies or aspirates of the pancreas may be made through the duodenum or stomach.^[7]

Lung

Biopsies of the lung can be performed in a variety of ways depending on the location.

Liver

Main article: Liver biopsy

In hepatitis, most biopsies are not used for diagnosis, which can be made by other means. Rather, it is used to determine response to therapy which can be assessed by reduction of inflammation and progression of disease by the degree of fibrosis or, ultimately, cirrhosis.

In Wilson's disease, the biopsy is used to determine the quantitative copper level.

Analysis of biopsied material

After the biopsy is performed, the sample of tissue that was removed from the patient is sent to the pathology laboratory. A pathologist is a physician who specializes in diagnosing diseases (such as cancer) by examining tissue under a microscope. When the laboratory (see Histology) receives the biopsy sample, the tissue is processed and an extremely thin slice of tissue is removed from the sample and attached to a glass slide. Any remaining tissue is saved for use in later studies, if required. The slide with the tissue attached is treated with dyes that stain the tissue, which allows the individual cells in the tissue to be seen more clearly. The slide is then given to the pathologist, who examines the tissue under a microscope, looking for any abnormal findings. The pathologist then prepares a report that lists any abnormal or important findings from the biopsy. This report is sent to the physician who originally performed the biopsy on the patient.

See also

• Bone marrow examination
• Endometrial biopsy
• Lymph node biopsy
• Skin biopsy

References

1. ^ Coding Breast Diseases and Surgery
2. ^ Anderson, J. B., Webb, A.J.: Fine-Needle Aspiration Biopsy and the Diagnosis of Thyroid Cancer. British Journal of Surgery 74:292-6, 1987
3. ^ Sausville, Edward A. and Longo, Dan L.: Principles of Cancer Treatment: Surgery, Chemotherapy, and Biologic Therapy in Harrison's Principles of Internal Medicine, 16th Ed. Kaspar, Dennis L. et al., editors. p.446 (2005)
4. ^ Friedman, S. and Blumberg, R.S.: Inflammatory Bowel Disease in Harrison's Principles of Internal Medicine, 16th Ed. Kaspar, Dennis L. et al., editors. pp. 1176-1789 (2005)
5. ^ Mens health - Testicular Biopsy
6. ^ Saibeni, S., Rondonotti, E., Iozzelli, A., Spina, L., Tontini, G.E., Cavallaro, F., Ciscato, C., de Franchis, R., Sardanelli, F., Vecchi, M.: Imaging of the Small Bowel in Crohn's Disease: A Review of Old and New Techniques World Journal of Gastroenterology 13(24): 3279-87, 2007
7. ^ Iglesias-Garcia, J., Dominguez-Munoz, E., Lozano-Leon, A., Abdulkader, I., Larino-Noia, J., Antunez, J., Forteza, J.: Impact of Endoscopic Ultrasound-Guided Fine Needle Biopsy for Diagnosis of Pancreatic Masses. World Journal of Gastroenterology 13(2): 289-93, 2007

External links

• Testicular Biopsy
• Mybiopsyinfo.com - What is a biopsy? How is a biopsy examination performed? This website gives you answers to these and many other questions.
• MyBiopsy.org - Information about biopsy results for patients. This site is created by pathologists, the physicians who diagnose cancer and other diseases by looking at biopsies under a microscope.
• RadiologyInfo - The radiology information resource for patients: Biopsy
• Fine needle aspiration biopsy on Wikisurgery
• Core needle (Trucut) biopsy on Wikisurgery

This entry is from Wikipedia, the leading user-contributed encyclopedia. It may not have been reviewed by professional editors (see full disclaimer)

Dansk (Danish)
n. - biopsi, vævsprøve

Nederlands (Dutch)
diagnostisch onderzoek van levend weefsel

Français (French)
n. - biopsie

Deutsch (German)
n. - Biopsie

Ελληνική (Greek)
n. - βιοψία

Italiano (Italian)
biopsia

Português (Portuguese)
n. - biópsia (f)

Русский (Russian)
биопсия

Español (Spanish)
n. - biopsia

Svenska (Swedish)
n. - biopsi

中文（简体）(Chinese (Simplified))
活组织检查, 活组织切片检查

中文（繁體）(Chinese (Traditional))
n. - 活組織檢查, 活組織切片檢查

한국어 (Korean)
n. - 생체 조직 절편 검사

日本語 (Japanese)
n. - 生検
v. - 生検を実施する

العربيه (Arabic)
‏(الاسم) فحص العينه الحيه‏

עברית (Hebrew)
n. - ‮בדיקה מן החי, ביופסיה‬

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