Biopsies

All biopsies are basically aimed at extracting samples of tissue or fluid. Biopsies can be of various types depending on which manner this fluid or tissue is extracted from your body.

Excisional biopsy: In this type of biopsy, generally performed by a surgeon, an open surgery is performed to remove either a part of a tissue or an entire lump or mass, which is then sent for further investigation. This type of biopsy is generally performed in the operation theatre and involves making a cut or an incision on your body. It require admission, anesthesia and post procedure observation.

Liquid biopsy: In this type of biopsy, your blood or abnormal fluid is collected from your body. This fluid may be abnormal fluid in your lung or abdomen. This is then sent for investigations to identify any abnormal cancer cells or any abnormal DNA. This tests are generally carried out at very special laboratories.

Percutaneous Image guided biopsy: As the name suggests, in this type of Biopsy image guidance either in the form of ultrasound, CT scan or fluoroscopy is used to guide a special biopsy gun (called a coaxial biopsy gun) inside your body through the skin (i.e percutaneously). This biopsy needle is specifically targeted towards the abnormal area or the abnormal mass or tissue. Most biopsies are generally carries on under USG guidance.

However, certain biopsies (like the lung and bone- which are not seen on USG) are carried on under CT guidance. Multiple Samples can then be collected through this special biopsy gun (called a coaxial gun) and sent for further investigations. This type of biopsy is performed by special physicians called interventional radiologists who are trained to perform minimally invasive image guided procedures.

• In these type of biopsies, a very small needle is inserted from your skin using image guidance.
• Therefore this procedure is minimally invasive (like a pinhole surgeries).
• This type of biopsy does not require an operation theatre and can be performed on an outpatient basis.
• They are generally performed under local anaesthesia and do not involve any scar or any incision on your body.
• Therefore they are much more safer, faster and cost effective than open surgical excisional biopsies.

Does a “biopsy” always mean “cancer”?

Most people associate the word Biopsy with cancer and rightfully so. However, this is not true. While most biopsies are generally performed to either diagnose cancer or to check stage of cancer, biopsies are also performed to diagnose benign conditions such as infections, like tuberculosis, and rule out benign non-malignant pathologies. Quite commonly, biopsies from native organs like the kidney and liver are also performed to diagnose organ dysfunction (like liver fibrosis or nephritis affecting your kidneys).

• Generally, guided percutaneous biopsy can be performed on an outpatient basis.
• Admission is generally not required. But it is always better to be under observation for a few hours to prevent any untoward complication.
• For certain complex biopsies (especially lung and liver biopsies) an overnight admission may be required to monitor the patient after the procedure.
• For painful bone biopsies, where sedation may have been given, admission may be required to look for complications of anesthesia.
• Before undergoing a biopsy, imaging either in the form of ultrasound, CT scan, MRI or a PET scan is required.
• Your doctor will first review these scans (which are generally done prior to the procedure) and see if the biopsy is feasible.
• If the lesion/mass is too small, is not approachable or is too close to vital structures like the heart, then a biopsy may not be possible due to high risk of complications. In these cases, your doctor will decide the next line of management and investigation and advise further tests accordingly.
• Your doctor will also speak to the primary referring consultant and make a joint decision as to what is best for you.
• If the biopsy is possible an appointment will be given.
• You would generally be required to be fasting for six hours before the procedure.
• Can take sips of water upto 2 hours prior to the scheduled appointment.
• All your hypertension and diabetic medication is to be taken on the day of the procedure.
• Certain blood tests like a coagulation profile (PTT, PT/INR, aPTT) and a complete blood count (CBC) are required prior to a biopsy. This is done to see how thin or clottable your blood is.
• If you are on blood thinners, then they need to be stopped for approximately 3 to 5 days before the procedure. An accompanying relative is generally required for the procedure.

• The entire procedure will be explained to you prior to performing it.
• An informed written consent will be taken. Consent of your accompanying relative will also be taken.
• An anesthetist will be present to monitor your vitals and for pain control management.
• An iv cannula will be inserted to give you drugs or sedation.
• The area which is to be targeted will be prepared with betadine or cleansing solution.
• The procedure will be performed with the guidance of either ultrasound or CT or rarely both.
• Sometimes, fluoroscopy guidance may be used. Local anesthesia will be infiltrated to numb the part.
• Generally 2% lignocaine is used. The part remains numb for 30-60 minutes.
• Using image guidance, the site will be targeted using a special biopsy gun. This is called a coaxial gun. Using this gun, multiple cores can be taken.
• Around 6-10 samples will be collected depending on the type of lesion.
• A special coil or gelfoam may be inserted along the biopsy tract to prevent bleeding.
• Rarely, a non co-axial gun may be used to remove a single or 2-3 cores only, especially in breast lesions or in non focal liver and kidney biopsies.
• After the procedure, you shall be observed for any complications for around 4-6 hours.
• If all is well, then you shall be sent home. Pain management for home care may be given.

What happens after the procedure?

After most Biopsies, you shall be kept under observation for a few hours. If all is well, you shall be sent home on the same day. You would be kept for observation for around 4 to 6 hours after the procedure. Sometimes, especially after a liver biopsy, you may be asked to sleep in a particular position. After a lung biopsy, O2 may be given via a nasal cannula. Biopsy results generally take 3 to 4 working days to arrive. Certain laboratory tests or special test (like IHC, culture reports etc) may require more time, some upto 6-8 weeks. These reports are generally notified directly to you and the further line of management would depend on the result of the biopsy.

When done in the right manner and by the right doctor, biopsies are generally safe. Some pain is expected after the procedure. Complication rates after a biopsy are upto 3% as per literature and the chance of major complication is less than 1%. The major complication expected is that of bleeding. Internal bleeding will require admission. In rare cases and especially with liver or renal biopsies, sometimes another small procedure may be required to stop the bleeding.

During lung biopsies, one of the complications expected is that of air getting collected around the lung called pneumothorax. If this is causing difficulty in breathing, then a tube may have to be inserted in the lung called an ICD or pigtail to evacuate the air. You may be sent home with the ICD/Pigtail or kept for observation for 24 hours. The tube may be removed in a few days. Rarely the tube may have to be placed for upto a week.

Is a biopsy always accurate?

When performed in a correct manner and with appropriate analysis biopsies are generally accurate. As per literature, image guided biopsies are shown to have a 97% accuracy. In rare cases, for example when the lesion is too small or when the lesion has central necrosis a biopsy may be falsely negative. In these rare cases, a second biopsy may be required or rarely, an open surgical excisional biopsy may be required. This varies from case to case.