Biopsies - Overview

What are biopsies?

A biopsy is the removal of tissue in order to examine it for disease. The tissue samples can be taken from any part of the body. Biopsies are performed in several different ways. Some biopsies involve removing a small amount of tissue with a needle while others involve surgically removing an entire lump, or nodule, that is suspicious.

Often, the tissue is removed by placing a needle through the skin (percutaneously) to the area of abnormality. Biopsies can be safely performed with imaging guidance such as ultrasound, x-ray, computed tomography (CT), or magnetic resonance imaging (MRI). These types of imaging are used to determine exactly where to place the needle and perform the biopsy.

What are some common uses of the procedure?

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When a nodule is detected, imaging tests may be performed to help determine if it is benign (non-cancerous) or malignant (cancerous). If imaging studies cannot clearly define the abnormality, a biopsy may be necessary.

Usually, a biopsy is performed to examine tissue for disease. Biopsies are frequently used to diagnose cancer, but they can help identify other conditions such as infections and autoimmune disorders. They may also be done to match organ tissue before a transplant.

Biopsies are performed in many areas of the body and for many reasons. The following is a list of common biopsy types and why they may be necessary:

• Abdominal biopsy is used to diagnose whether a lump in the abdomen is cancerous or benign. The lumps can be located in the fat, deep within the abdomen. A sample of the lump is removed percutaneously under image guidance (ultrasound or CT), or surgically using a laparoscope or by open surgery.
• Bone biopsy is used to diagnose cancer or infection in the bones. This type of biopsy can be performed through the skin (percutaneously) with a needle or surgically.
• Bone marrow biopsy is used to diagnose cancer in the blood, such as leukemia. A small sample of the bone and bone marrow are removed using a needle. Sometimes, only the bone marrow is removed for examination.
• Breast biopsy is used to determine if a lump in the breast is cancerous or benign. It can be performed a number of ways:
• Stereotactic (mammographically-guided)
• Ultrasound-guided
• MRI-guided
• Endometrial biopsy may be used when looking for the cause of abnormal uterine bleeding, to examine the lining of the uterus and to diagnose cancer. This type of biopsy can be performed by using a small needle-like device to capture a sample or by using a tool to scrape some of the lining for examination.
• Kidney (renal) biopsy is used to examine the condition of a kidney with kidney failure, inflammation in the kidney or a suspected tumor (such as cancer). It can also be used to examine a transplanted kidney for signs of transplant rejection. Kidney biopsies are performed with image guidance (ultrasound or CT) using a needle to remove a small sample of the tissue.

• Liver biopsy is used to diagnose diseases of the liver such as hepatitis C, cirrhosis, infections and cancer. It can also be used to examine a transplanted liver for signs of transplant rejection. This is a frequent indication in children. Liver biopsies are typically performed by inserting a needle through the skin. The liver can also be biopsied via a catheter inserted through the jugular vein (a large neck vein) to capture a tissue sample, or can be biopsied surgically.

• Lung or chest nodule biopsy is performed when an abnormality of the lung is visible on an x-ray or CT scan. Lung biopsies can be performed through bronchoscopy by insertion of an instrument called a bronchoscope through the patient's mouth to reach the area to be biopsied, through the skin by inserting a needle percutaneously, or by surgically removing the lump.
• Lymph node biopsy is performed whenever there are enlarged or abnormal lymph nodes. They can be performed with a needle or surgically.
• Muscle biopsy is used to diagnose infections that affect muscle, defects in the muscle and diseases of the connective tissue and blood vessels. This type of biopsy can be performed using a needle or surgically.
• Nerve biopsy is used to examine damage to small nerves, degeneration and destruction of the nerve and inflammatory nerve conditions. Nerve biopsies are typically performed surgically.
• Skin biopsy examines a growth or an area on the skin, such as a mole, that has changed its appearance. Skin biopsies can be performed by shaving a small sample of the skin, removing a sample with a scalpel or by way of an instrument used to punch through a portion of the skin.
• Testicular biopsy is used when researching male infertility. It is also used to determine if a lump in the testicles is cancerous or benign. Testicular biopsies can be performed using a needle, by a small cut made in the skin or surgically.
• Thyroid biopsy is used to find the cause of a nodule in the thyroid gland. This type of biopsy is typically performed using a needle with ultrasound guidance.

Almost any organ can be biopsied, including the bladder, heart, neck, prostate, parathyroid glands, etc.

How should I prepare?

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Most needle biopsies are performed in an outpatient setting with minimal preparation necessary. When you schedule your biopsy appointment, you will receive detailed instructions about preparation for the biopsy procedure.

If you are having a needle or surgical biopsy, ask your health care provider if you need to stop taking any medications before the procedure.

You may be instructed not eat or drink for eight hours before your biopsy. However, you may take your routine medications with sips of water. If you are diabetic and take insulin, you should talk to your doctor as your usual insulin dose may need to be adjusted.

Prior to a needle biopsy, you should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to anesthesia. Your physician may advise you to stop taking aspirin or a blood thinner for a specific period of time before your procedure.

Also, inform your doctor about recent illnesses and other medical conditions.

You may be asked to wear a gown during the procedure.

Women should always inform their physician if there is any possibility that they are pregnant. Some procedures using image-guidance are typically not performed during pregnancy because radiation can be harmful to the fetus. See the Safety Page (www.RadiologyInfo.org/safety/) for more information on pregnancy and x-rays.

You may want to have a relative or friend accompany you and drive you home afterward. This is necessary if you have been sedated.

What does the equipment look like?

There are many different types of biopsy procedures. The equipment used for each type of biopsy will vary depending on the type of procedure.

In needle biopsy, a sample of tissue or fluid is removed with a needle.

A biopsy needle is generally several inches long and the barrel is about as wide as a large paper clip. The needle is hollow so it can capture the tissue specimen.

There are several types of needles that may be used. Common ones include:

• A fine needle attached to a syringe, smaller than needles typically used to draw blood.
• A core needle, also called an automatic, spring-loaded needle, which consists of an inner needle connected to a trough, or shallow receptacle, covered by a sheath and attached to a spring-loaded mechanism.
• A vacuum-assisted device (VAD), which uses a vacuum to aid in obtaining larger pieces of tissue.

Needle biopsies are often performed with the guidance of computed tomography (CT), fluoroscopy, ultrasound, or MRI.

A mammography unit is a rectangular box that houses the tube in which x-rays are produced. The unit is used exclusively for x-ray exams of the breast, with special accessories that allow only the breast to be exposed to the x-rays. Attached to the unit is a device that holds and compresses the breast and positions it so images can be obtained at different angles.

Ultrasound scanners consist of a console containing a computer and electronics, a video display screen and a transducer that is used to do the scanning. The transducer is a small hand-held device that resembles a microphone, attached to the scanner by a cord. The transducer sends out inaudible high frequency sound waves into the body and then listens for the returning echoes from the tissues in the body. The principles are similar to sonar used by boats and submarines.

The ultrasound image is immediately visible on a video display screen that looks like a computer or television monitor. The image is created based on the amplitude (loudness), frequency (pitch) and time it takes for the ultrasound signal to return from the area of the patient being examined to the transducer (the device used to examine the patient), as well as the type of body structure and composition of body tissue through which the sound travels. A small amount of gel is put on the skin to allow the sound waves to travel back and forth from the transducer.

The CT scanner is typically a large, box-like machine with a hole, or short tunnel, in the center. You will lie on a narrow examination table that slides into and out of this tunnel. Rotating around you, the x-ray tube and electronic x-ray detectors are located opposite each other in a ring, called a gantry. The computer workstation that processes the imaging information is located in a separate control room, where the technologist operates the scanner and monitors your examination in direct visual contact and usually with the ability to hear and talk to you with the use of a speaker and microphone.

A vacuum-assisted device (VAD) is a vacuum-powered instrument that uses pressure to pull tissue into the needle.

A thin guide wire may be placed or marking dye injected with x-ray, ultrasound, or CT guidance to aid the surgeon in locating the correct area for a surgical biopsy.

Other sterile equipment that may be involved in a biopsy procedure includes syringes, sponges, forceps, scalpels and a specimen cup or microscope slide.

How does the procedure work?

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The type of procedure used to perform the biopsy depends on the location of the tissue that needs to be examined.

Most areas of the body can be biopsied with a needle device. This is the least invasive option, and usually allows for the patient to return home the same day. Imaging guidance with x-ray, ultrasound, CT or MRI allows for accurate placement of the needle to locate the best place to take a tissue sample.

In hard to reach places, biopsies using surgery in a hospital operating room may sometimes be necessary. A surgeon will perform surgery to remove the tissue needed for the biopsy. The surgeon may use an instrument with a camera to help locate the best place to biopsy and remove the tissue sample.

Using imaging guidance, the physician inserts the needle through the skin, advances it into the lesion.

Tissue samples will then be removed using one of several methods.

• In a fine needle aspiration, a fine gauge needle and a syringe withdraw fluid or clusters of cells.
• In a core needle biopsy, the automated mechanism is activated, moving the needle forward and filling the needle trough, or shallow receptacle, with 'cores' of tissue. The outer sheath instantly moves forward to cut the tissue and keep it in the trough. This process is repeated several times.
• In a vacuum-assisted biopsy, the needle is placed into the site of abnormality. The vacuum device is activated, pulling the tissue into the needle trough, and then cutting it with the sheath. The tissue is then retracted through the hollow core of the needle. This procedure may be repeated several times.

How is the procedure performed?

Imaging-guided, minimally invasive procedures, such as needle biopsies, are most often performed by a specially trained radiologist, an interventional radiologist or a neuroradiologist.

Needle biopsies are usually done on an outpatient basis.

A nurse or technologist may insert an intravenous (IV) line into a vein in your hand or arm so that sedation or relaxation medication may be given intravenously during the procedure. You may be also given a mild sedative prior to the biopsy.

A local anesthesia will be injected to numb the path of the needle.

Some biopsies, such as breast or thyroid biopsies, may be performed without sedation. The nurse or technologist will advise you at the time of the procedure regarding the sedation.

If the procedure is being performed with fluoroscopy, you will lie down or stand for the procedure.

If the procedure is performed with CT or MRI, you will lie down during the procedure. A limited CT or MRI scan will be performed to confirm the location of the nodule and the safest approach. Once the location of the nodule is confirmed, the entry site is marked on the skin. The skin around the insertion site will be scrubbed and disinfected, and a clean and sterile drape will be applied.

A very small nick is made in the skin at the site where the biopsy needle is to be inserted.

Using imaging guidance, the physician will insert the needle through the skin, advance it to the site of the nodule and remove samples of tissue. Several specimens may be needed for complete analysis.

After the sampling, the needle will be removed.

Once the biopsy is complete, pressure will be applied to stop any bleeding and the opening in the skin is covered with a dressing. No sutures are needed.

You may be taken to an observation area for several hours. X-ray(s) or other imaging tests may be performed to monitor for complications.

Depending on the type of biopsy performed, you may be able to return home immediately after the procedure.

This procedure is usually completed within one hour. You may be required to stay in an area for observation for several hours after the biopsy depending on the type of biopsy performed.

For stereotactic breast biopsies, you may lie face down or sit up on a moveable exam table and the affected breast or breasts will be positioned into openings in the table.

In a fine needle aspiration, a fine gauge needle and a syringe withdraw fluid or clusters of cells.

In a core needle biopsy, the automated mechanism is activated, moving the needle forward and filling the needle trough, or shallow receptacle, with 'cores' of breast tissue. The outer sheath instantly moves forward to cut the tissue and keep it in the trough. This process may be repeated several times.

In some breast biopsies, the tissue is removed with a vacuum-assisted device (VAD). Vacuum pressure is used to pull tissue from the breast through the needle into the sampling chamber. Without withdrawing and reinserting the needle, it rotates positions and collects additional samples. Typically, several samples of tissue are collected from around the lesion. After this sampling, the needle will be removed.

If a surgical biopsy is being performed, a wire may be inserted into the suspicious area as a guide for the surgeon.

A small marker may be placed at the site, so that it can be located in the future if necessary.

Once the biopsy is complete, pressure will be applied to stop any bleeding, and the skin will be covered with a dressing or bandage.

What will I experience during and after the procedure?

In a needle biopsy, you will feel a small sharp pinch at the site of the biopsy. In an open or closed biopsy that requires surgery, you will be given anesthesia to help with the pain.

When you receive the local anesthetic to numb the skin, you will feel a slight pin prick from the needle. You may feel some pressure when the biopsy needle is inserted. The area will become numb within a short time.

You may be given a mild sedative prior to the biopsy, and sedation or relaxation medication may be given intravenously during the procedure if needed.

You may feel sore at the area of the biopsy for a few days. Your doctor can prescribe pain relief medication if you have significant pain from the biopsy.

Aftercare instructions vary, but generally your bandage may be removed one day following the procedure, and you may bathe or shower as normal.

Who interprets the results and how do I get them?

After the tissue is collected, it is sent to a laboratory for analysis. A pathologist will examine the biopsy tissue under a microscope. A full report from the pathologist will be sent to your doctor in a few days.

You should ask the doctor performing the procedure how you will receive your results.

If you underwent a breast biopsy, it is likely the radiologist will discuss your results with you.

Your interventional radiologist may recommend a follow-up visit after your procedure or treatment is complete.

The visit may include a physical check-up, imaging procedure(s) and blood or other lab tests. During your follow-up visit, you may discuss with your doctor any changes or side effects you have experienced since your procedure or treatment.

What are the benefits vs. risks?

• Needle biopsy is a reliable method of obtaining tissue samples that can help diagnose whether a nodule is benign (non-cancerous) or malignant.
• A needle biopsy is less invasive than open and closed surgical biopsies, both of which involve a larger incision in the skin and local or general anesthesia.
• Generally, the procedure is not painful and the results are as accurate as when a tissue sample is removed surgically.
• Recovery time is brief and patients can soon resume their usual activities.
• Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.

What are the limitations of biopsies?

In some cases, the amount of tissue obtained from a needle biopsy may not be sufficient and the biopsy may have to be repeated. This may be particularly true with trying to make a diagnosis of lymphoma.

Rarely, less invasive breast biopsy procedures may be unable to detect some lesions or determine the extent of disease present. If the diagnosis remains uncertain after a technically successful procedure, surgical biopsy will usually be necessary.

Any imaging-guided procedure will not be able to be used unless the area of abnormality can be seen. Some lesions, such as clustered calcifications on mammography are not as clearly shown with ultrasound as they are with mammography. Therefore, stereotactic biopsy is usually used in breast imaging to biopsy calcifications. Fluoroscopy sometimes will not be able to locate chest nodules, and CT will be used for guidance. Your radiologist will use the image guidance best suited to biopsy the area in question.