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 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
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 systemsAlong with this were innovations in various kinds of tissue preparations and staining techniques
Monitoring, treatment, recurrence and prognosisResearch purposesMicrobiologyMedicolegal
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 periodsLesion 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
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 lesion To ascertain the type of fluid within a lesion When 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 slideAir-dry or fixed with 95% ethanol
Skin cleansing + LASmall skin incisionLesion approach at an angle 450Stabilize the lesion and introduce the needle via theskin 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 lesion Great suspicion of malignancyprinciple: 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 1cm The 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 ---- circumareolar Tissue forceps shld only be applied when the lesion has been clearly defined
The lesion can be shelled out in cases of suspected fibro adenomasSecure hemostasisDrains shld not be usedWound closed in two layers
Gastroscopic or colonoscopic or through ERCP orcystoscopic,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 lesionsSurgeon should be competent and preferably be the one to perform the definitive surgery
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
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
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 andnormal 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 necessaryElliptical incision on the hard palate or attachedgingiva 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 immersedBoin’s solution for testicular biopsy and peripheral nervesChromate 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. 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
This could be generalized or organ specificGeneralized :Infection;Hemorrhage;Pain; Tumor upgrading; Ulceration; keloids; Hypertrophic scar; DeformitySpecific 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 leakageBONE:-Osteoarthritis and joint stiffness etcBREAST:-Seroma formation ,deformity or assymetry
They don’t corroborate your clinical impression Repeat the biopsy!!! Determine if the tissue was looked at by a Pathologist The 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.