BIOPSY IN SURGERY

BABALOLA R N
ORTHOPAEDICS IHU FIRM B

OUTLINE
INTRODUCTION

/ DEFINITION
HISTORICAL PERSPECTIVE
INDICATIONS
CLASSIFICATION
PRINCIPLES
COMPLICATIONS
CONCLUSION

Introduction
Biopsy

is derived from the Greek word

bio: meaning life and
opsy : to look
Is the surgical retrieval of tissue from
part or whole of a lesion in a living
subject for the purpose of patient
management
Is usually the final route in establishing
the nature of disease for both optimal
management & prognosis of the patients

Introduction
Usually

the final arbiter for

diagnosis
Usual clinical, biochemical &
radiological evaluation usually
are not confirmatory
Gives the courage & moral
grounds to carry out
ablative/mutilating surgeries
especially in malignancies

Historical perspective
1870

- Ruge and Joham Vert in Berlin introduced

surgical biopsy as an essential tool for diagnosis.
French dermatologistErnest Besnierintroduced
the word biopsy to the medical community in
1879
1889- Esmarch put forward an argument that
confirmations should be made before surgeries
for malignancies.
Williams Halsted first introduced this principle in
United States.
1941- study of exfoliated cells from female
genital tract by Papanicolaou

INDICATIONS
Diagnostic
Therapeutic
Monitoring
Aid

organ transplant
Research
Medico-legal
Grade and stage tumors
To detect receptors, enzymes and antigens
For screening purposes
Microbiology

Classification
Could

be open or closed
Closed
Percutaneous vs endoscopic
Blind vs image guided
Open

Incisional
Excisional

Classification
BASED ON TECHNIQUE
Cytopathology
Brush cytology
Exfoliative cytology
Scrape cytology
Imprint cytology
Aspiration cytology
Histopathology
Based on urgency: frozen & scheduled
Based on nature of sample: Fresh or
Fixed

OPEN BIOPSY
INCISIONAL:

This involve the

removal of a wedge of lesion with
adjacent normal appearing tissue
margin.
EXCISIONAL: This involve the
removal of entire lesion with
significant margin of contiguous
normal appearing tissue.

OPEN BIOPSY
ADVANTAGE
Good lesion representation in the
sample
DISADVANTAGE
Iatrogenic spread of lesion due to
opening of new tissue planes.
Poor cosmetic outcome.

CLOSED BIOPSY
ENDOSCOPIC:

This is usually done under direct

vision.
Is important in GIT biopsy. This is done with the aid
of a fibre-optic instrument.
Laparoscope could be used to obtain specimens
from abdominal organs. e g. hepatic masses, intraabdominal lymph nodes
Examples:
Sigmoidoscopy

for core needle biopsy of rectal polyps.

Endoscopic biopsy of GIT tumours
Urethroscopy for TUR of the prostate
Bronchoscopy for bronchial or lung biopsy
Cystoscope for urinary bladder,
Arthroscope for joint specimens.

CLOSED BIOPSY
PERCUTANEOUS:

This could be done by a

blind procedure or assisted using imaging X-ray, CT scan, ultrasound, fluoroscopy.
This involves the use wide bore needle. e.g.
Trephine, Turner, Greene, Mandayag.
A specially designed cutting knife could
also be used in select conditions like the
Tru-cut (breast, prostate), Abrams needle
(pleural), Menghinis needle (liver), High
speed drill biopsy needle for bone, Vim
Silvermans needle (kidney)

Menghini Needle

Abrams Needle

Tru-cut needle
Vim Silverman Needle

CLOSED BIOPSY
ADVANTAGES
Less time consuming
G.A may or may not be required
Day case surgery
Minimally invasive
DISADV
Small amt of tissue is obtained
Rate of dissemination is high

Incisional biopsy
Is

the surgical sampling of a lesion where an

incision is made to get a representative part
Indications:
Fairly large lesions
Ulcerated lesions
Hazardous location of the lesion
Great suspicion of malignancy
Representative areas are biopsied in a wedge
fashion.
Margins should extend into normal tissue on the
deep surface.
Necrotic tissue should be avoided.

Excisional biopsy
Implies

the complete removal of

the lesion
Indications:
The lesion on clinical exam appears
benign.
When complete excision with a
margin of normal tissue is possible
without mutilation.

Excisional biopsy
Technique:
Skin incision should be curvilinear and follow the
Langers lines
The entire lesion with 2 to 3mm of normal
appearing tissue surrounding the lesion is excised
if benign; 2 3cm if suspiciously malignant.
Lesions within 5cm of areolar margin - circumareolar
The lesion can be shelled out in cases of
suspected fibro-adenomas
Secure hemostasis
Wound closed in two layers

Contra-indications
Uncontrolled

bleeding diathesis
Anticoagulant therapy
Over-whelming sepsis
Severely impaired lung function
Uncooperative patient
Local infection near the site

Skin biopsies
Biopsy

of skin lesions can be done with punch

biopsy, shave biopsy or excisional biopsy
Punch biopsy is indicated for flat lesions while
shave/excision biopsy is indicated for
pedunculated lesions
Shave biopsy a scalpel/razor is used to
shave off a thin layer of the lesion parallel to
the skin
Punch biopsy-a cylindrical punch is screwed
into the lesion to remove the epidermis,
dermis and subcutaneous tissue

CYTOPATHOLOGY
Its

use is increasing in surgical

practice.
Can be used to stage breast, bladder &
liver carcinomas.
Types:
Aspiration (FNAC)
Brush
Imprint
Scrape
Exfoliative

FINE NEEDLE ASPIRATION

CYTOLOGY BIOPSY
Commonest

form done.
Needle(size 20G-23G) used, (the
smaller the size of the needle, the
better the sample obtained)
Also, aspiration gun is used.
Diagnosis is based on cellular
characteristics.
Its possible to determine estrogen
receptors for breast cancer due to
immuno-histochemical staining.

ADV
Day

case
Economical to patient
No anaesthetic needed
Does not require elaborate patient
preparation
Faster reporting
Disadvantage
Procedure may be repeated several
times.
Tissue diagnosis can not be made.

GUIDELINES FOR REPORTING

CYTOLOGY
C1
C2
C3
C4
C5

:
:
:
:
:

Benign
Probably benign
Equivocal
Probably malignant
Malignant

FROZEN SECTION
Done

whenever report is needed at the

earliest time.
Indications:
Establish nature of a suspected lesion
To ensure disease free margins in
resection
Establish diagnosis if biopsy contains
sufficient materials for a dx.
In this technique, fresh tissue is frozen to
-25oC with C02 or liquid nitrogen &
sectioned in a specialized cabinet
(cryostat) containing a microtome.
Its stained with H & E, for quick reporting .

Frozen section
Advantages:Its quick and surgeons can decide
the further steps to follow
Disadvantages: Technically difficult-Difficult to get
accurate result
It requires the services of an
experienced histo-pathologist,
which may not always be available

Frozen section
Uses:CA breast, follicular CA of thyroid
when FNAC fails
For accessing on-table clearance
margin and depth
Study of lymph nodes and their
positivity for malignancy.

Exfoliative cytology
Is

the histo-pathologic examination

of cells that have been obtained by
their physical removal, followed by
their placement on a glass slide, and
then appropriately stained
The term "Pap smear" is commonly
used for exfoliative cytology, and
refers to the method of staining in
honor of the man who developed the
staining technique, Dr. Papanicolaou

PRINCIPLES OF BIOPSY
Pre-operative,

intra-operative
and post-operative
considerations
Patient preparation
Rules governing biopsy
Tissue handling

Pre-op preparation
A

detailed history
A history of the specific lesion
A clinical examination
A radiographic examination
Laboratory investigations
Patient selection
Proper patient counseling
Obtain informed consent
Optimize patient e.g. stop anticoagulants
Proper pre-op localization of lesion
especially of impalpable lesions

INTRA-OP CARE OF PTS

Anaesthesia
Good

positioning
Aseptic technique
Meticulous tissues handling
Avoidance of excessive dissection and
hemorrhage
Proper amount and quality of pathologic
tissue obtained
Antibiotics if indicated
Haemostasis secured
Tight closure of wound

For

RULES GOVERNING
BIOPSY

larger lesions, a greater number of biopsy is

needed.
Should not be taken at the central crater of
ulcerated lesion because it consist of necrotic
tissue.
Should include the whole thickness of the lesion
e.g. Malignant melanoma, bladder tumor.
In deeply situated lesion, its capsule should be
transgressed to give a better representation of
the lesion.
If electrocautery must be used, blended current
with low setting coagulation mode and biopsy
should be larger.

RULES GOVERNING BIOPSY

Gentle

handling of tissue with minimal grasping

or crushing.
Vascular lesions should be biopsied with extreme
care.
Lymph node biopsy should be left fresh b/c they
require special immunohistochemistry & electron
microscopy.
Better orientation by the surgeon on resected
margins. This is done using stay sutures.
Biopsy should be delayed until imaging studies
has been completed as it may give an idea of the
pre-biopsy anatomy and the position for biopsy
Surgeon should be proficient on flaps & grafts.

POST-OP CARE
Patient Care
Wound care
Analgesia
Antibiotics
Follow up
Specimen care
Immediate fixing, depending on the specimen
Proper labelling of forms i.e. Px biodata, brief
hx, presumptive dx, intra op findings & state if
infected or not.
Allotment of lab nos to specimen for archiving
Transfer to histopath. Lab ASAP

Biopsy in orthopaedics
Indications:
Aggressive bone or soft tissue lesions
Soft tissue lesions larger than 5cm, deep
to fascia, or overlying
bone/neurovascular structures
To diagnose either primary or secondary
bone tumors
Osteoporosis
To distinguish osteoporosis from suspected
osteomalacia and unexplained osteosclerosis

Biopsy in orthopaedics
Renal

osteodystrophy

Unexplained fractures
Unexplained hypercalcemia
Unexplained hypophosphatemia
Persistent bone pain
Suspected aluminum toxicity based
upon clinical symptoms or history of
aluminum exposure
The trans-iliac bone biopsy is
commonly done

TISSUE HANDLING
Some

specimens should not be fixed

like LN.
10% buffered formalin is suitable for
most tissues.
Bouins solution for testicular &
peripheral nerve biopsy.
Chromate solution for chromaffinous
tissues.
Glutaraldehyde for tissues to be
submitted for Electron microscopy.
Zenkers is excellent for bone marrow
specimen.

Complications
Could

be generalized or organ specific

Generalized: Hemorrhage, infection, tumor
upgrading, ulceration, keloids, hypertrophic scar,
deformity
Organ specific:
PROSTATE:- prostatitis, urinary retention, blood in
semen, bleeding rectum.
LUNGS:- Pneumothorax, haemothorax, empyema
thoracis, atelectasis.
LIVER:-Intrahepatic hematoma, obstructive jaundice,
intra peritoneal bleeding and bile leakage
BONE:-Osteoarthritis and joint stiffness
BREAST:-Seroma formation ,deformity or asymmetry

Conclusion
In

this era of evidence-based

medicine, the use of biopsy in
surgery can never be overemphasized
Thus, a careful surgical harvest
of adequate sample of tissue
with pertinent information so as
to assist the pathologist in
making the correct diagnosis is
paramount

THANK
YOU FOR
LISTENING

References
BIOPSY

IN SURGERY A
PRESENTATION BY DR O A
ALADESURU
BIOPSY IN SURGERY A
PRESENTATION BY DR OSHO
BIOPSY IN SURGERY
emedicine.medscape.com

Pain
Capsular

lesions either excise

en bloc or preserve the capsule
Imaging to be done before biopsy
is done it can distort tissue
planes and affect the histoarchitecture on imaging