Definition / IntroductionHistoric PerspectiveAimIndicationsContra-indicationsClassification/TypesPrinciples and TechniquesComplicationsSituation in our Sub-regionConclusion

Biopsy is derived from a Greek word (By-op-see) = Bio – meaning LIFE and Opsy – TO LOOK

This is the surgical removal of a tissue specimen in a living body for the purpose of examination and diagnoses.

It could also be therapeutic

Invaluable in the mgt of certain surgical lesions

Any organ in the body can be biopsied using a variety of techniques.

Proper patient evaluation is paramount.

The need for biopsy in surgery can not be over-emphasize

1870, Ruge and Joham Vert in Berlin introduced surgical biopsy as an essential tool for diagnosis.

1889, Emarch put forward an argument that confirmations should be made before surgeries for malignancies.

Williams halsted 1st introduced this principle in United States.

1941, study of exfoliated cells from female genital tract by Papanicolaou.

This was adapted to study cells from other body systems

Along with this were innovations in various kinds of tissue preparations and staining techniques

To establish tissue diagnosis

Grade tumors

To detect receptors

For screening purposes

Detecting enzymes and antigens

Monitoring, treatment, recurrence and prognosis

Research purposes

Microbiology

Medicolegal

Any lesion that persists for more than 2 weeks with no apparent etiologic basis

Any inflammatory lesion that does not respond to local treatment after 10 to 14 days.

Persistent hyperkeratotic changes in surface tissues.

Any persistent tumescence, either visible or palpable beneath relatively normal tissue.

Evaluation and monitoring of tissue rejection after transplantion –kidney and liver

Inflammatory changes of unknown cause that persist for long periods

Lesion that interfere with local functionBone lesions not specifically identified by

clinical and radiographic findingsAny lesion that has the characteristics of

malignancy

Uncontrolled bleeding diasthasisAnticoagulant therapyOver-whelming sepsisSevere impaired lung functionUncoperative patientLocal infection near the site

CLOSED INDIRECT BIOPSY - FNABC - Core needle biopsy (tru-cut,Abram’s,vim silverman,menghini) - Punch biopsy - Loop biopsy - Endoscopic biopsyCLOSED IMAGE GUIDED BIOPSY - Stereotactic - Ultrasound, CT, MRI

OPEN DIRECT BIOPSY - Incisional - Excisional * marginal * wide local * radical

Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration if its contents.

Indications:To determine the presents of fluid within a lesionTo ascertain the type of fluid within a lesionWhen exploration of an intraosseous lesion is

indicated

Outpatient procedureInfiltrate the site with LA22G needle attached to a 10ml

syringe(syringe holder)Place the needle in the massApply suction while the needle is move back

and forth within the massRelease the suction and withdraw needle

once cellular aspirate is seen

The cellular material is then expressed unto the microscope slide

Air-dry or fixed with 95% ethanol

Skin cleansing + LASmall skin incisionLesion approach at an angle 450

Stabilize the lesion and introduce the needle via the skin until it abuts against the lesionFully mechanical biopsy gun is then firedTissue fixed in formalinBleeding usually not a problem,apply pressure

Incision covered by an occlusive dressingSensitivity of 80 – 90%

An incisional biopsy is the surgical sampling of a lesion(representative part).

If a lesion is large or has different characteristics in various locations more than one area may need to be sampled

Indications:Size limitations and ulcerated lesion Hazardous location of the lesionGreat suspicion of malignancy

principle:Representative areas are biopsied in a wedge

fashion.Margins should extend into normal tissue on the

deep surface.Necrotic tissue should be avoided.A narrow deep specimen is better than a broad

shallow one.

An excisional biposy implies the complete removal of the lesion.

Indications:lesions Less than 1cmThe lesion on clinical exam appears benign.When complete excision with a margin of normal

tissue is possible without mutilation.

Technique:Skin incision shld 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 malignant.Lesions within 5cm of areolar margin ----

circumareolarTissue forceps shld only be applied when the

lesion has been clearly defined

The lesion can be shelled out in cases of suspected fibro adenomas

Secure hemostasisDrains shld not be usedWound closed in two layers

Gastroscopic or colonoscopic or through ERCP or cystoscopic,arthroscopic

-Laparotomy-Thoracotomy-Craniotomy using dandy`s brain cannula

Done whenever report is needed at the earliest time. Here an unfixed fresh tissue is frozen (using CO2) in a metal and sections are made and stained.

PIT FALLS-Technically difficult-Difficult to get accurate result

ADVANTAGES:-Its quick and surgeons can decide the further

steps to follow

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.

This uses image intensifier to enhance the accuracy of the site of the biopsy.

Radiological images of the site of the lesion, the location the size and the shape the dept and other characteristics are employed in order to increase the accuracy of the procedure this involves ultrasound CT-scan MRI and mammography.

Exfoliative cytology is the histopathologic 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, but it only refers to the method of staining and is in honor of the man who is credited with developing the staining technique, Dr. Papanicolaou.

It is important to develop a systematic approach in evaluating a patient with a lesion in the body.

Pre-operativeIntra-operativePost-operative

A detailed health historyA history of the specific lesionA clinical examinationA radiographic examinationLaboratory investigationsPatient selectionProper patient counselingObtain informed consentOptimize patient e.g. stop anticoagulants

Proper pre-op localization of lesion especially of impalpable lesions

Surgeon should be competent and preferably be the one to perform the definitive surgery

Congenital heart defects Coagulopathies Hypertension Poorly controlled diabetics Immunocompromised patients Renal compromise

Erythroplasia- lesion is totally red or has a speckled red appearance.

Ulceration- lesion is ulcerated or presents as an ulcer.

Duration- lesion has persisted for more than two weeks.

Growth rate- lesion exhibits rapid growthBleeding- lesion bleeds on gentle manipulationInduration- lesion and surrounding tissue is firm to

the touchFixation- lesion feels attached to adjacent

structures

The anatomic location of the lesion/massThe physical character of the lesion/massThe size and shape of the lesion/massSingle vs. multiple lesionsThe surface of the lesionThe color of the lesionThe sharpness of the boundaries of the lesionThe consistency of the lesion to palpationPresence of pulsationLymph node examination

Anesthesia - General, regional, or local - block anesthesia is preferred to

infiltration - when block anesthesia is not possible,

distant infiltration may be used - Do not inject directly into the lesion

POSITIONINGANTIBIOTICSROUTINE CLEANING AND DRAPPING

Incisions should be made with a scalpel. They should be converging Should extend beyond the suspected depth of the

lesion They should parallel important structures Margins should include 2 to 3mm of normal

appearing tissue if the lesion is thought to be benign.

5mm or more may be necessary with lesions that appear malignant, vascular, pigmented, or have diffuse borders.

Longitudinal in the extremities

. Ulcers; - avoid central necrotic areas - include adjoining normal tissue

. In deeply situated tissue take whole thickness and normal tissue

. Handle tissues gently to preserve architecture

Avoid electrocautery for cutting if possibleHaemostasis

Artery forceps, ligation, diathermy etcSuction devices should be avoidedDrain when indicated, must be within the

incisionAim at primary closure of wound

Primary closure of the surgical site is necessaryIn oral cavity mucosal undermining may be necessary Elliptical incision on the hard palate or attached gingiva may be left to heal by secondary intention.

Wound careAnalgesiaAntibioticsFollow up

Direct handling of the lesion will expose it to crush injury resulting in alteration the cellular architecture.

Specimen should be immediately placed in 10% formalin solution and should be completely immersed

Boin’s solution for testicular biopsy and peripheral nerves

Chromate solution for chromafinomasGluteraldehyde for tissues for electron

microscope

A biopsy data sheet should be completed and the specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed.BiodataUnit and consultant in chargeNature of specimen and provisional diagnosisDate of specimen collection Previous histology results if anyClinical features and operative findings

This could be generalized or organ specificGeneralized :Infection;Hemorrhage;Pain;

Tumor upgrading; Ulceration; keloids; Hypertrophic scar; Deformity

Specific organ compl.-PROSTATE:-prostatitis,urinary retention,blood in semen,bleeding rectum.LUNGS:-pneumothorax, heamothorax,empyoma thorases,atelectases.

LIVER:-Intrahepertic hematoma,obstructive jaundice,intra peritonal bleeding and bile leakage

BONE:-Osteoarthritis and joint stiffness etcBREAST:-Seroma formation ,deformity or

assymetry

They don’t corroborate your clinical impressionRepeat the biopsy!!!Determine if the tissue was looked at by a

PathologistThe results show malignancy

Inadequate facilitiesFew number of experienced PathologistPatient associated factors e.g poverty,

ignorance, religious beliefs

As we are in the era of evidence-based medicine the use of biopsy in surgery can never be over-emphasize.

A careful surgical harvest of a sample of tissue with pertinent information so as to assist the pathologist in making the correct diagnosis is paramount.

THANK YOU FOR YOUR TIME