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Biopsy Principles

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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 (cellular) specimen
    • 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 sarcoma 
  • Incisional biopsy
    • small surgical incision carefully placed to access tumor without contamination of critical structures
  • Excisional biopsy
    • select indications: small, superficial 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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