Surgical biopsies

ALSO KNOWN AS: Tissue sampling, incisional biopsy, excisional biopsy, endoscopic or laparoscopic biopsy, open biopsy, transvenous biopsy

DEFINITION: A surgical biopsy removes tissue through an incision during an open or laparoscopic surgical procedure. A pathologist examines the tissue sample in the laboratory to detect the presence of cancer cells and determine the grade of the tumor.

Cancers diagnosed or treated: Various, including breast cancer, bone cancer, carcinoid tumors, germ-cell tumors, liver cancer, lung cancer, sarcoidosis, Hodgkin disease, myasthenia gravis, neurogenic tumors, thymic cancer and thymomas, mesothelioma, mediastinal tumors, pericardial tumors, lymphoma, skin cancer, and thyroid cancer

Why performed: Surgical biopsies are performed to diagnose a variety of conditions and to assess the degree of organ damage (disease staging). Surgical biopsies may be performed when abnormalities are found during other tests, such as an ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI), or a nuclear scan. Surgical biopsies also may be performed to determine the cause of unexplained symptoms or to match organ tissue before a transplant.

An excisional biopsy may be used to remove some types of tumors or suspected cancers that need to be entirely removed for an accurate diagnosis, such as the removal of lymph nodes to diagnose lymphoma accurately. A surgical biopsy procedure also may be recommended when other, less invasive biopsy procedures do not provide conclusive results for an accurate diagnosis.

Patient preparation: Preprocedure tests may include a chest X-ray, electrocardiogram (EKG), CT, MRI, and other imaging tests. Urine and blood tests are also performed before the procedure to evaluate the patient’s blood count, platelet count, and blood clotting ability. Additional tests may be required depending on the type of surgical biopsy procedure to be performed.

The patient's preparation for a biopsy varies depending on the type of procedure and biopsy location. One week before the procedure, patients must stop taking aspirin and products containing aspirin, ibuprofen, and anticoagulants, as directed by the physician. Other anticoagulant medications may be prescribed as needed. In most cases, the patient must not eat or drink for eight to twelve hours beforehand. The patient will receive specific preparation instructions from the healthcare team.

Patients at most healthcare facilities must sign an informed consent form stating their willingness to permit diagnosis and medical treatment.

Steps of the procedure: An intravenous (IV) line is inserted into a vein in the patient’s arm to deliver medications. For some surgical biopsy procedures, such as liver biopsy and some laparoscopic procedures, the patient is given a sedative, and the procedure is performed under conscious sedation. With conscious sedation, the patient is awake but relaxed and can respond to the physician’s instructions during the procedure. The majority of surgical biopsy procedures, however, are performed while the patient is under general anesthesia.

The biopsy site is cleansed, and sterile drapes may be placed around the area. A local anesthetic is injected into the area. In some cases, such as with sentinel node biopsy, a radioactive substance or dye is injected into the tumor, and a scanner is used to locate the lymph node or tissue containing the radioactive substance or stained with the dye.

A laparoscope is inserted into a small abdominal incision during a laparoscopic biopsy. The laparoscope transmits magnified images onto a video monitor to guide the physician as laparoscopic instruments are inserted through additional small abdominal incisions to remove tissue samples. Ultrasound or CT guidance may also aid the surgeon during the procedure.

Transvenous biopsy is a technique used to remove a tissue sample via a inserted into a vein in the neck. This technique is not common, but it may be used for certain high-risk patients, including those who have a blood-clotting disorder, fluid in the abdomen, or liver failure or who are morbidly obese.

During an incisional biopsy, the surgeon uses a scalpel to remove a tissue sample from the area. During an excisional biopsy, the lesion and surrounding margin of normal tissue are removed. During an open surgical biopsy, an incision is made in the abdomen (laparotomy), upper chest (thoracotomy or mediastinoscopy), or breast, allowing visualization of the area. The location and size of the tumor are identified, and a tissue sample or lymph nodes can be removed for analysis. Ultrasound or CT guidance may aid the surgeon during the procedure.

After removing the tissue, a pathologist sends it to a laboratory for microscopic analysis to determine how much the tissue sample differs from normal tissue. A variety of methods can be used to process tissue samples. Histologic sections prepare stained, thin “slices” of tissue mounted on slides. The histologic method may take up to forty-eight hours to produce results. With this method, the tissue sample is placed in a machine that replaces all water in the sample with paraffin wax. The sample is embedded into a larger paraffin block, sliced into very thin sections, and stained with dye to aid microscopic analysis. Frozen tissue analysis involves freezing the tissue, slicing it into thin sections, and staining the sections to aid analysis. Smears are tissue samples that are spread onto a slide for examination. The results of smears can usually be obtained very quickly, although the smear technique cannot be used on all biopsy samples.

After the procedure: The length of a patient’s recovery and the steps for recovery vary depending on the biopsy procedure, biopsy location, and type of anesthesia. The patient may stay in an intensive care unit (ICU) or recovery room after the procedure. The incision is closed with sutures, and the biopsy site is usually covered with a bandage or dressing. A catheter may remain after surgery to drain urine. Drains or chest tubes may stay at the incision site to remove fluid or air accumulated during the procedure. Pain medication is prescribed as needed, which may include discomfort at the biopsy site or muscle pain. The patient usually stays in the hospital overnight but may need to recover for three to four days, depending on the biopsy site, type of procedure, and type of anesthesia given during the procedure.

Specific instructions for driving, activity, incision care, medications, nutrition, and managing emergencies, as applicable, and a follow-up care schedule are provided to the patient. In most cases, the patient is not permitted to drive home after the procedure, and driving or operating machinery may be limited for a specific time. Depending on the physician’s instructions, the patient may be required to stay on bed rest for a certain amount of time after the procedure.

The patient should avoid vigorous physical activity and heavy lifting after the procedure, as directed by the physician. For one week after the procedure, the patient should avoid aspirin and products containing aspirin, ibuprofen, and anticoagulants, as these medications decrease blood clotting, which is necessary for healing. Other anticoagulant medications may be prescribed if necessary after the procedure. The patient may take acetaminophen (Tylenol) to relieve pain as needed.

Risks: The risks of biopsy procedures depend on the procedure type performed and the biopsy location. Possible risks of all surgical biopsy procedures include allergic reactions to the anesthetic, bleeding, infection, and scarring, and these risks are more significant with open surgical biopsy procedures.

The risk of death associated with biopsy procedures is generally very low. The physician can discuss specific mortality rates and risks with the patient, depending on the type of procedure performed.

Results: Biopsy results are available immediately or within twenty-four to forty-eight hours after the tissue removal, depending on the type of biopsy analysis. The tissue sample removed during the procedure is either standard, which means it is benign or noncancerous, or abnormal, which means it has unusual characteristics and may be malignant or cancerous. The grade of the tumor may also be determined from the biopsy sample, indicating how quickly the cancer is likely to grow and spread. Surgical biopsy procedures remove a larger tissue sample than other biopsy methods, increasing the accuracy of a diagnosis. The type of cancerous cells and the extent of the disease will help guide the patient’s treatment.

Bibliography

Altaleb, Ahmad. Surgical Pathology: A Practical Guide for Non-Pathologist. Springer, 2021.

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Feig, Barry W. The MD Anderson Surgical Oncology Handbook. 7th ed., Lippincott Williams & Wilkins, 2023.

Govindan, Ramaswamy, and Daniel Morgensztern. Devita, Hellman, and Rosenberg’s Cancer Principles and Practice of Oncology Review. 5th ed., Wolters Kluwer Health, 2021. 

Grady, Denise. "Study of Breast Biopsies Finds Surgery Used Too Extensively." New York Times, 2011, www.nytimes.com/2011/02/19/health/19cancer.html. Accessed 20 July 2024.

Lester, Susan Carole. Manual of Surgical Pathology. 4th ed., Elsevier, 2023.

Skandalakis, Lee J., and John E. Skandalakis. Surgical Anatomy and Technique: A Pocket Manual. 5th ed. Springer, 2021.

"Surgical Breast Biopsy." American Cancer Society, 14 Jan. 2022, www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/breast-biopsy/surgical-breast-biopsy.html. Accessed 20 July 2024.