Biopsy in surgery


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Biopsy in surgery

  1. 1. Definition / IntroductionHistoric PerspectiveAimIndicationsContra-indicationsClassification/TypesPrinciples and TechniquesComplicationsSituation in our Sub-regionConclusion
  2. 2. Biopsy is derived from a Greek word (By-op-see) = Bio –meaning LIFE and Opsy – TO LOOKThis is the surgical removal of a tissue specimen in aliving body for the purpose of examination anddiagnoses.It could also be therapeuticInvaluable in the mgt of certain surgical lesions
  3. 3. 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
  4. 4. 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.
  5. 5. This was adapted to study cells from other body systemsAlong with this were innovations in various kinds of tissue preparations and staining techniques
  6. 6. To establish tissue diagnosisGrade tumorsTo detect receptorsFor screening purposesDetecting enzymes and antigens
  7. 7. Monitoring, treatment, recurrence and prognosisResearch purposesMicrobiologyMedicolegal
  8. 8.  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
  9. 9. Inflammatory changes of unknown cause that persist for long periodsLesion that interfere with local functionBone lesions not specifically identified by clinical and radiographic findingsAny lesion that has the characteristics of malignancy
  10. 10. Uncontrolled bleeding diasthasisAnticoagulant therapyOver-whelming sepsisSevere impaired lung functionUncoperative patientLocal infection near the site
  11. 11. CLOSED INDIRECT BIOPSY - FNABC - Core needle biopsy (tru-cut,Abram’s,vimsilverman,menghini) - Punch biopsy - Loop biopsy - Endoscopic biopsyCLOSED IMAGE GUIDED BIOPSY - Stereotactic - Ultrasound, CT, MRI
  12. 12. OPEN DIRECT BIOPSY - Incisional - Excisional * marginal * wide local * radical
  13. 13. 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 lesion  To ascertain the type of fluid within a lesion  When exploration of an intraosseous lesion is indicated
  14. 14. Outpatient procedureInfiltrate the site with LA22G needle attached to a 10ml syringe(syringe holder)Place the needle in the massApply suction while the needle is move back and forth within the massRelease the suction and withdraw needle once cellular aspirate is seen
  15. 15. The cellular material is then expressed unto the microscope slideAir-dry or fixed with 95% ethanol
  16. 16. Skin cleansing + LASmall skin incisionLesion approach at an angle 450Stabilize the lesion and introduce the needle via theskin until it abuts against the lesionFully mechanical biopsy gun is then firedTissue fixed in formalinBleeding usually not a problem,apply pressure
  17. 17. Incision covered by an occlusive dressingSensitivity of 80 – 90%
  18. 18. 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
  19. 19. Indications:  Size limitations and ulcerated lesion  Hazardous location of the lesion  Great 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.
  20. 20. An excisional biposy implies the complete removal of the lesion.Indications:  lesions Less than 1cm  The lesion on clinical exam appears benign.  When complete excision with a margin of normal tissue is possible without mutilation.
  21. 21. 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 ---- circumareolar  Tissue forceps shld only be applied when the lesion has been clearly defined
  22. 22. The lesion can be shelled out in cases of suspected fibro adenomasSecure hemostasisDrains shld not be usedWound closed in two layers
  23. 23. Gastroscopic or colonoscopic or through ERCP orcystoscopic,arthroscopic
  24. 24. -Laparotomy-Thoracotomy-Craniotomy using dandy`s brain cannula
  25. 25.  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
  26. 26.  ADVANTAGES:-Its quick and surgeons can decide the further steps to follow
  27. 27.  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.
  28. 28. 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.
  29. 29.  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.
  30. 30. It is important to develop a systematic approach in evaluating a patient with a lesion in the body.Pre-operativeIntra-operativePost-operative
  31. 31. A detailed health 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
  32. 32. Proper pre-op localization of lesion especially of impalpable lesionsSurgeon should be competent and preferably be the one to perform the definitive surgery
  33. 33.  Congenital heart defects Coagulopathies Hypertension Poorly controlled diabetics Immunocompromised patients Renal compromise
  34. 34.  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 growth Bleeding- lesion bleeds on gentle manipulation Induration- lesion and surrounding tissue is firm to the touch Fixation- lesion feels attached to adjacent structures
  35. 35.  The anatomic location of the lesion/mass The physical character of the lesion/mass The size and shape of the lesion/mass Single vs. multiple lesions The surface of the lesion The color of the lesion The sharpness of the boundaries of the lesion The consistency of the lesion to palpation Presence of pulsation Lymph node examination
  36. 36. 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
  38. 38.  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
  39. 39. . Ulcers; - avoid central necrotic areas - include adjoining normal tissue. In deeply situated tissue take whole thickness andnormal tissue. Handle tissues gently to preserve architecture
  40. 40. Avoid electrocautery for cutting if possibleHaemostasis  Artery forceps, ligation, diathermy etcSuction devices should be avoidedDrain when indicated, must be within the incisionAim at primary closure of wound
  41. 41. Primary closure of the surgical site is necessaryIn oral cavity mucosal undermining may be necessaryElliptical incision on the hard palate or attachedgingiva may be left to heal by secondary intention.
  42. 42. Wound careAnalgesiaAntibioticsFollow up
  43. 43. 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 chromafinomasGluteraldehyde for tissues for electron microscope
  44. 44. A biopsy data sheet should be completed and the specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed.  Biodata  Unit and consultant in charge  Nature of specimen and provisional diagnosis  Date of specimen collection  Previous histology results if any  Clinical features and operative findings
  45. 45. This could be generalized or organ specificGeneralized :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.
  46. 46. LIVER:-Intrahepertic hematoma,obstructive jaundice,intra peritonal bleeding and bile leakageBONE:-Osteoarthritis and joint stiffness etcBREAST:-Seroma formation ,deformity or assymetry
  47. 47. They don’t corroborate your clinical impression  Repeat the biopsy!!!  Determine if the tissue was looked at by a Pathologist  The results show malignancy
  48. 48. Inadequate facilitiesFew number of experienced PathologistPatient associated factors e.g poverty, ignorance, religious beliefs
  49. 49. 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.