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Updated: Feb 7 2024

Biopsy Principles

Images thigh.jpg
  • Introduction
    • Purpose of the biopsy is to confirm a suspected diagnosis
    • The biopsy is not a substitute for a thorough history, physical exam, and laboratory investigation
      • prerequisites for a biopsy
        • CBC, platelets, coagulation studies
        • cross-sectional imaging to evaluate local anatomy
        • treatment center performing biopsy must be capable of proper diagnosis and treatment
  • Indications for Biopsy
    • Indications
      • aggressive bone or soft tissue lesions
      • soft tissue lesions larger than 5cm, deep to fascia, or overlying bone/neurovascular structures
      • unclear diagnosis in a symptomatic patient
      • solitary bone lesions in a patient with history of carcinoma
    • When a biopsy is not indicated
      • asymptomatic latent bone lesions or a symptomatic active bone lesions which appear entirely benign on imaging don't necessarily need a biopsy
      • soft tissue lesion which are completely benign on MRI don't necessarily need a biopsy (e.g. lipoma, hemangioma)
  • Types of Biopsy
    • Fine Needle Aspiration (FNA)
      • provides cytologic (separated cellular) specimen
      • does not provide adequate tissue samples for tumor architecture or mesenchymal stromal analysis 
      • frequently used for carcinoma
      • not typically used for sarcoma
    • Core biopsy (Tru-cut)
      • allow for tumor structural examination
        • can evaluate both the cytologic and stromal elements of the tumor
      • frequently used for soft tissue sarcoma
      • 85-95% accuracy in diagnosis
    • Incisional biopsy
      • small surgical incision carefully placed to access tumor without contamination of critical structures
      • overall lower rate of non-diagnostic biopsy results compared to core needle biopsy
    • Excisional biopsy
      • select indications: small (<3cm), superficial (relatively to fascia) soft tissue masses
  • Principles of the Open Incisional Biopsy
    • Incision
      • use longitudinal incision in the extremities
        • allows for extension of the incision for definitive management
    • Approach
      • do not expose neurovascular structures
        • all tissue exposed during the biopsy is considered contaminated with tumor
      • maintain meticulous hemostasis
        • post-operative hematomas are considered contaminated with tumor
        • release tourniquet prior to wound closure
    • Biopsy
      • perform through the involved compartment of the tumor
      • for bone lesions with a soft tissue mass, it is ok to perform the biopsy using the soft tissue mass
    • Closure
      • if using a drain, bring drain out of the skin in line with surgical incision
        • allows drain site to be removed with definitive surgical extensile incision
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