Biopsy – Types, Potential risks and Treatments

Biopsy

Also called: Surgical Biopsy, Fine Needle Aspiration, Endoscopic Biopsy, Aspiration Biopsy, Punch Biopsy, Needle Biopsy, Fine Needle Biopsy, Core Biopsy

Reviewed By:
Martin E. Liebling, M.D., FACP

Summary

A biopsy is a procedure to obtain a sample of soft tissue, fluid or bone that is sent to a laboratory for analysis. The analysis is done by a specialized physician known as a pathologist. A biopsy is the definitive procedure for the diagnosis of cancer. There are several major types of biopsies and those most often used to diagnose cancer include:

  • Fine needle aspiration (FNA). A very thin needle and a syringe are used to withdraw small amounts of fluid or a few cells from a tumor mass or a suspected area of abnormality.
  • Core needle biopsy. A larger needle removes a cylinder of tissue.
  • Incisional biopsy. Small portion of tumor is removed through an incision in the skin.
  • Excisional biopsy. Entire tumor is removed through an incision in the skin.

If the suspected area is not in or under the skin, the biopsy may be obtained in one of several ways.

  • Endoscopy. Thin tube with fiber optic light and a viewing lens is inserted into a natural body opening, (e.g., mouth, anus) to view a suspicious area and remove a tissue sample.
  • Laparoscopy. This procedure is similar to endoscopy except the tube is inserted through a small incision in the abdomen to view the inside of the abdomen and remove samples. When the same procedure is performed in the chest, it is called thoracoscopy.
  • Laparotomy. Surgical technique that uses a large incision into the upper abdomen to explore a suspicious area. It is used when a laparoscopy cannot be used to obtain a diagnosis. A thoracotomy is a similar procedure performed in the chest area.

Based on the analysis performed on the biopsy material, the sample can usually be diagnosed as cancerous (malignant) or noncancerous (benign). Additional information, such as the type of cancer and its grade, can also be determined from most biopsies. Treatment will be based on the results of the biopsy as well as other factors.

About biopsies

A biopsy is a procedure in which a sample of soft tissue, fluid or bone is taken from a patient for examination under a microscope. This tissue analysis, sometimes called pathology, is completed by a specialized physician (pathologist). A pathologist has been trained in the diagnosis and classification of diseases. Biopsies can be performed on almost any part of the body and can involve many different techniques. The location and the nature of the suspected cancer, as well as the condition of the patient, determine which biopsy technique will be employed.

In many cases, physicians are able to detect potentially cancerous (malignant) lumps through imaging tests or by feeling a mass during a physical examination. The physician also may detect a suspicious skin lesion through visual examination. The area may be noncancerous, but a biopsy is the definitive method to diagnose cancer. A pathologist can determine whether a tumor is cancerous or benign, and if cancerous, the exact cell type and grade, which is an estimate of the degree of malignancy.

Patients should remember that a physician’s request for a biopsy does not necessarily mean the patient has cancer. Rather, this test is performed to determine the nature of an abnormality. For example, a biopsy may be performed when a lump is discovered in the breast and the physician wishes to rule out breast cancer.  A biopsy also may be used when a man has a high prostate specific antigen (PSA) level that may indicate an irregularity with the prostate.

In some cases, pathological analysis of biopsy material  confirms that cancer is present. At that point, the physician works with cancer specialists to create a diagnostic staging plan. The plan is designed to determine the extent (stage) of the disease and to recommend the appropriate treatment.

Types and differences of biopsies

There are many different types of biopsies. Some biopsies involve surgery to remove an entire organ, while others are much less invasive. The biopsies most often used in diagnosing cancer include:

  • Needle biopsy. In this procedure, a needle is inserted into the suspicious area or body cavity and fluid and cells are aspirated (drawn out) with a vacuum syringe. There are two major types of needle biopsy:

    • Fine needle aspiration (FNA). A very thin needle and syringe are used to withdraw very small amounts of fluid or a few cells from the area in question. If the mass is deeper inside the body and cannot be felt, the needle can be guided into the right spot by using an ultrasound or computed axial tomography (CAT) scan image. The advantage of using FNA is that it does not require an incision in the skin. The disadvantage is that it only removes a few cells from the suspect area. In some cases, this may not be enough tissue for a definitive diagnosis.
  • Core biopsy. Uses a needle larger than that used in a FNA to remove a cylinder of tissue. A local anesthetic is used in advance of the procedure. As with FNA, a core biopsy may be used to obtain samples from a tumor that has been felt by a physician as well as smaller or deeper ones detected by imaging tests.

Surgical biopsy. There are two types of surgical biopsy:

  • Excisional biopsy. Used with smaller, more superficially located tumors. A surgeon makes an incision in the skin and removes the entire tumor. This type of biopsy may be used when a small lump is detected in breast tissue.

  • Incisional biopsy. Used with larger tumors. A surgeon makes an incision through the skin or the involved structure and removes a small part of the tumor.

A local anesthetic is usually used for superficial biopsies. However, if the tumor is located inside the chest, abdomen or pelvic area, a general anesthetic that puts the patient to sleep is likely to be used for the procedure.

  • Laparoscopy and thoracoscopy. Laparoscopy is a minimally invasive procedure in which a small incision is made in the abdomen to examine the contents and remove tissue samples. A thoracoscopy is the same procedure, except it is used to view the inside of the chest.
  • Laparotomy and thoracotomy. Laparotomy is a surgical technique that uses a midline incision from the upper abdomen to the lower abdomen to explore a suspicious area. It is done when less invasive techniques are inconclusive and if more extensive surgery is anticipated for a positive biopsy. This method can reveal information about the location and size of the tumor, and the involvement of surrounding areas. General anesthesia is used in the procedure. Thoracotomy is a similar procedure but used to examine the chest.
  • Endoscopic biopsy. A thin, flexible tube with a fiber optic light and a viewing lens or video camera is inserted into the patient through a natural body opening, such as the rectum or vagina. This allows the physician to see the suspected area up close and to insert an instrument through the tube to remove a sample for analysis.
  • Paracentesis or thoracentesis. A needle is used to remove fluid samples from the abdomen (ascites) or chest (pleural effusion). Paracentesis refers to the removal of abdominal fluid whereas thoracentesis is the medical term for the removal of fluid in the chest.
  • Bone marrow aspiration and biopsy. Small quantities of liquid marrow are removed with a needle and syringe during bone marrow aspiration. During a bone marrow biopsy, the physician uses a larger needle to remove a cylinder of marrow and bone from the hip. These are both done through the skin.
  • Sentinel lymph node biopsy. This is a biopsy of the first node that receives lymphatic drainage from a tumor. This is performed to check if the cancer has spread to the lymphatic system. If cancerous cells are found in this lymph node, other nearby lymph nodes may be removed in a procedure known as a lymph node dissection.

Before, during and after the test

Generally, patients need to make very few preparations before a biopsy test. Preparations that may be necessary include the following:

  • Notify the physician if there has been a vaccination within the preceding two weeks
  • Stop taking anticoagulants (e.g., aspirin) if directed by a physician
  • Take any prophylactic antibiotics if prescribed by a physician for use prior to the biopsy

There may be additional instructions, such as restrictions for eating and drinking, depending on the type of anesthesia to be used in the procedure. It is important to discuss all medication and health issues with the physician prior to a biopsy.

The actual biopsy procedure varies dramatically depending on the nature of the site to be tested and the type of biopsy technique being used. Some cases involve only a local anesthetic and the insertion of a needle, while other biopsies require general anesthesia and a surgical incision. Patients should be aware of the type of anesthesia used because it may affect the recovery time and may necessitate assistance getting home.

After the sample has been removed, it is chemically treated with formalin (a combination of water and formaldehyde) or another preservative. It is labeled with identifying information (e.g., patient’s name, site of biopsy) and it is sent to a pathology laboratory. The sample is then prepared for analysis. It first may be examined without a microscope to obtain a gross description, which can include general information about the size, color and consistency of the sample. The gross examination is important because it may help the pathologist identify areas that may be the most critical to examine under the microscope.

After some additional processing, the tissue sample is sliced into thin sections that are placed on glass slides and stained to enhance contrast. The glass slides are then examined by a pathologist and/or a hematologist (specialist in blood and blood-forming tissues). A biopsy may reveal a great deal of information about a tissue sample, which can be quite complicated when dealing with cancer. Some of the most general information that may be obtained from a biopsy includes:

  • Whether or not the tissue is cancerous (malignant)
  • Overall abnormality of the cancer cells (e.g., size, shape)
  • Organization of cancer cells
  • Classification of cancer (e.g., carcinoma, sarcoma, lymphoma)
  • Primary site (where the cancer originated)
  • Cancer’s grade (an estimate of the cancer’s aggressiveness)

In some cases, a physician performing a surgical procedure needs immediate information about a tissue sample during the surgery itself. For example, the surgeon may want to check to see if the edges (margins) of a sample contain cancer cells. In such cases, a frozen section examination may be performed. This is a procedure in which the fresh tissue sample is sent immediately to a pathologist for examination. The tissue is frozen in a special solution and thinly sectioned. Analysis usually takes 10 to 20 minutes. Although not quite as detailed as a full pathologic examination, the sample usually reveals enough information to tell the physician whether or not additional tissue needs to be removed during the procedure. 

Most traditional tissue analysis yields results within a couple of days. However, in some cases, it may take considerably longer. There can be many different reasons for this, such as:

  • Bone that contains a lot of calcium must be treated with chemicals that remove minerals, allowing the bone to soften enough to be sliced thinly. 
  • Formalin solution used to preserve tissues takes longer to penetrate some samples (such as breast biopsies or others with an abundance of fatty tissue).
  • Large samples – such as entire organs – may require a period longer than 24 hours for the formalin to penetrate the tissue.
  • The pathologist may want to examine more than one sample to corroborate an initial finding.
  • Very complex immunologic or genetic studies of the tissue may be needed and these require longer time to perform.
  • The pathologist may seek a second opinion.

After pathology results become available, they are usually provided to the patient by the primary care physician or oncologist (a physician who specializes in the diagnosis and treatment of cancer). In some cases, the patient may also wish to obtain a second opinion. If the second opinion comes from a physician at the same facility, the patient probably will not have to make any arrangements regarding medical records. Otherwise, the patient will either have to bring their pathology report, slides and other medical records to the second expert, or have them sent by the facility that compiled the original report. The policies and procedures for transferring samples and medical records vary among facilities and federal privacy protection regulations must be followed. Patients should check with the medical facility and their physicians about these policies.

Information contained in a pathology report typically includes:

  • Patient, physician and specimen identification. This includes the patient’s name, hospital-issued medical record number, date when biopsy or surgery was performed and the unique number of specimens issued in the laboratory.
  • Clinical information. Information about the patient from the physician who removed the sample. This may include relevant medical history and special requests made to the pathologist.
  • Gross description. Information about the tissue that was evident without the use of a microscope. This includes elements determined from looking at, measuring or feeling the tissue.
  • Microscopic description. Records what the pathologist observed with the aid of a microscope. Such information includes the appearance of the cells, how they are arranged and the extent to which the cancer penetrates nearby tissues, if cancer is present.
  • Diagnosis. The pathologist’s conclusion based on everything learned in the analysis. The physician uses this diagnosis as a guideline for determining the appropriate staging and treatment options for the patient.
  • Summary. Some pathology reports in which cancer is diagnosed may contain a summary of the results to help with treatment planning. The pathologist also may provide additional comments that might clarify information or recommend additional testing.

Patients may request a copy of their pathology report and additional information compiled by their physician based on the report. It is often helpful to have the report when seeing other physicians. Also, by obtaining a copy of the report, patients may be better equipped to ask questions and participate in any treatment that may be necessary.  

Potential risks with biopsies

Biopsies are relatively safe procedures, but also come with risks typically associated with breaking the skin (such as infection) or surgery (including reactions to anesthetic and other surgical complication).

Following the procedure, patients should notify their physician if they experience any of the following:

  • Persistent bleeding from the biopsy site
  • Fatigue or fever over 100 degrees Fahrenheit (38 degrees Celsius)
  • Increasing or persistent pain

Treatments that may follow biopsies

Patients who are diagnosed with cancer are treated in ways appropriate for their type and stage of cancer. One type of treatment or a combination of treatments may be used to fight the cancer. A treatment plan is typically coordinated by a cancer care team that may include a medical oncologist, radiation oncologist and surgeon. Commonly used treatments include:

  • Surgery. Used for the complete or partial removal of a tumor. 

  • Chemotherapy. Uses one or more powerful drugs to destroy cancer cells and to prevent them from reproducing and spreading throughout the body. 

  • Radiation therapy. Uses an energy called ionizing radiation to kill cancer cells and shrink tumors. Radiation targets dividing cancer cells and disrupts or destroys their genetic material, preventing the cells from continuing to grow and spread throughout the body. Radiation therapy can be provided externally by precise beams from a machine or internally (brachytherapy) with implanted radioactive “seeds.”

  • Biological therapy. Repairs, stimulates or enhances the immune system so that it can better recognize and destroy cancer cells. Biological therapy may also include agents that directly attack the cells to disrupt the metabolic and genetic character of the cancer cell. This therapy is also used in conjunction with other cancer treatments such as chemotherapy.

  • Hormone therapy. Treatment for cancers that depend on hormones to grow and spread. Patients who undergo this treatment sometimes take medications that reduce the levels of certain hormones such as estrogen (in women) and testosterone (in men). In other cases, patients may take drugs that prevent cancer cells from attaching to hormones that help the disease to thrive.

  • Bone marrow transplants. Replaces bone marrow damaged by cancer or cancer treatments with healthy marrow obtained from a donor or from the patient before treatment. Bone marrow contains stem cells that produce red blood cells, white blood cells and platelets necessary for life.

Ongoing research regarding biopsies

New technology is continually being developed and studied for biopsy procedures, including improved imaging techniques and better sampling methods. A targeted approach to biopsy using magnified scopes and cameras is being studied for use with prostate, esophageal and lung cancers.

Researchers continue to examine the effectiveness of a less invasive biopsy, such as the sentinel node biopsy, in staging breast cancer. The development of advanced biopsy technology looks promising for more accurate and less invasive testing.

Questions for your doctor about biopsy

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about biopsy:

  1. Do I need a biopsy for my condition?
  2. What type of biopsy will be performed, by whom and where?
  3. What are the benefits and risks with this biopsy procedure?
  4. Can the biopsy be completed as an outpatient procedure?
  5. What type of anesthesia will be used for the biopsy?
  6. How long is the recuperation period, if any?
  7. What information can be obtained from the biopsy?
  8. Where will my sample be analyzed?
  9. When and from whom will I receive the results of my biopsy?
  10. Will I need additional tests or another biopsy?
  11. How can I obtain a copy of my pathology report?
  12. What is the procedure if I want to obtain a second opinion?
  13. If my biopsy indicates cancer, what is the next step?
  14. Can you recommend additional specialists for my condition?
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