ALL ABOUT BIOPSIES
Edward 0. Uthman, MD ()
Diplomate, American Board of Pathology
INTRODUCTION
Many medical conditions, including all cases of cancer, must be diagnosed by removing a sample
of tissue from the patient and sending it to a pathologist for examination. This procedure is called
a biopsy, a Greek-derived word that may be loosely translated as “view of the living.” Any organ
in the body can be biopsied using a variety of techniques, some of which require major surgery
(e.g., staging splenectomy for Hodgkin’s disease), while others do not even require local
anesthesia (e.g., fine needle aspiration biopsy of thyroid, breast, lung, liver, etc). After the biopsy
specimen is obtained by the doctor, it is sent for examination to another doctor, the anatomical
pathologist, who prepares a written report with information designed to help the primary doctor
manage the patient’s condition properly.
The pathologist is a physician specializing in rendering medical diagnoses by examination of
tissues and fluids removed from the body. To be a pathologist, a medical graduate (M.D. or D.O.)
undertakes a five-year residency training program, after which he or she is eligible to take the
examination given by the American Board of Pathology. On successful completion of this exam,
the pathologist is “Board-certified.” Almost all American pathologists practicing in JCAHO-
accredited hospitals and in reputable commercial labs are either Board-certified or Board-eligible
(a term that designates those who have recently completed residency but have not yet passed the
exam). There is no qualitative difference between M.D.-pathologists and D.O.-pathologists, as
both study in the same residency programs and take the same Board examinations.
TYPES OF BIOPSIES
1. Excisional biopsy A whole organ or a whole lump is removed (excised). These are less
common now, since the development of fine needle aspiration (see below). Some types of tumors
(such as lymphoma, a cancer of the lymphocyte blood cells) have to be examined whole to allow
an accurate diagnosis, so enlarged lymph nodes are good candidates for excisional biopsies.
Some surgeons prefer excisional biopsies of most breast lumps to ensure the greatest diagnostic
accuracy. Some organs, such as the spleen, are dangerous to cut into without removing the whole
organ, so excisional biopsies are preferred for these.
2. Incisional biopsy Only a portion of the lump is removed surgically. This type of biopsy is most
commonly used for tumors of the soft tissues (muscle, fat, connective tissue) to distinguish
benign conditions from malignant soft tissue tumors, called sarcomas.
3. Endoscopic biopsy This is probably the most commonly performed type of biopsy. It is done
through a fiberoptic endoscope the doctor inserts into the gastrointestinal tract (alimentary tract
, endoscopy), urinary bladder (cystoscopy), abdominal cavity (laparoscopy), joint cavity
(arthroscopy), mid-portion of the chest (mediastinoscopy), or trachea and bronchial system
(laryngoscopy and bronchoscopy), either through a natural body orifice or a small surgical
incision. The endoscopist can directly visualize an abnormal area on the lining of the organ in
question and pinch off tiny bits of tissue with forceps attached to a long cable that runs inside the
endoscope.
4.Colposcopic biopsy This is a gynecologic procedure that typically is used to evaluate a patient who has had an ab
pathologist.
5.Fine needle aspiration (FNA) biopsy This is an extremely simple technique that has been used in Sweden for dec
(aspirated) into a syringe. These are smeared on a slide, stained, and examined under a
microscope by the pathologist. A diagnosis can often be rendered in a few minutes. Tumors of
deep, hard-to-get-to structures (pancreas, lung, and liver, for instance) are especially good
candidates for FNA, as the only other way to sample them is with major surgery. Such FNA
procedures are typically done by a radiologist under guidance by ultrasound or computed
tomography (CT scan) and require no anesthesia, not even local anesthesia. Thyroid lumps are
also excellent candidates for FNA.
6.Punch biopsy This technique is typically used by dermatologists to sample skin rashes and small masses. After a
7.Bone marrow biopsy In cases of abnormal blood counts, such as unexplained anemia, high white cell count, and
underlying the “bikini dimples” on the lower back/upper buttocks. Hematologists do bone
marrow biopsies all the time, but most internists and pathologists and many family practitioners
are also trained to perform this procedure.
With the patient lying on his/her stomach, the skin over the biopsy site is deadened with
a local anesthetic. The needle is then inserted deeper to deaden the surface membrane
covering the bone (the periosteum). A larger rigid needle with a very sharp point is then
introduced into the marrow space. A syringe is attached to the needle and suction is
applied. The marrow cells are then drawn into the syringe. This suction step is
occasionally uncomfortable, since it is impossible to deaden the inside of the bone. The
contents of the syringe, which to the naked eye looks like blood with tiny chunks of fat
floating around in it, is dropped onto a glass slide and smeared out. After staining, the
cells are visible to the examining pathologist or hematologist.
This part of procedure, the aspiration, is usually followed by the core biopsy, in which a
slightly larger needle is used to extract core of bone. The calcium is removed from the
bone to make it soft, the tissue is processed (see “Specimen Processing,” below) and
tissue sections are made. Even though the core biopsy procedure involves a bigger
needle, it is usually less painful than the aspiration.
Edward 0. Uthman, MD ()
Diplomate, American Board of Pathology
INTRODUCTION
Many medical conditions, including all cases of cancer, must be diagnosed by removing a sample
of tissue from the patient and sending it to a pathologist for examination. This procedure is called
a biopsy, a Greek-derived word that may be loosely translated as “view of the living.” Any organ
in the body can be biopsied using a variety of techniques, some of which require major surgery
(e.g., staging splenectomy for Hodgkin’s disease), while others do not even require local
anesthesia (e.g., fine needle aspiration biopsy of thyroid, breast, lung, liver, etc). After the biopsy
specimen is obtained by the doctor, it is sent for examination to another doctor, the anatomical
pathologist, who prepares a written report with information designed to help the primary doctor
manage the patient’s condition properly.
The pathologist is a physician specializing in rendering medical diagnoses by examination of
tissues and fluids removed from the body. To be a pathologist, a medical graduate (M.D. or D.O.)
undertakes a five-year residency training program, after which he or she is eligible to take the
examination given by the American Board of Pathology. On successful completion of this exam,
the pathologist is “Board-certified.” Almost all American pathologists practicing in JCAHO-
accredited hospitals and in reputable commercial labs are either Board-certified or Board-eligible
(a term that designates those who have recently completed residency but have not yet passed the
exam). There is no qualitative difference between M.D.-pathologists and D.O.-pathologists, as
both study in the same residency programs and take the same Board examinations.
TYPES OF BIOPSIES
1. Excisional biopsy A whole organ or a whole lump is removed (excised). These are less
common now, since the development of fine needle aspiration (see below). Some types of tumors
(such as lymphoma, a cancer of the lymphocyte blood cells) have to be examined whole to allow
an accurate diagnosis, so enlarged lymph nodes are good candidates for excisional biopsies.
Some surgeons prefer excisional biopsies of most breast lumps to ensure the greatest diagnostic
accuracy. Some organs, such as the spleen, are dangerous to cut into without removing the whole
organ, so excisional biopsies are preferred for these.
2. Incisional biopsy Only a portion of the lump is removed surgically. This type of biopsy is most
commonly used for tumors of the soft tissues (muscle, fat, connective tissue) to distinguish
benign conditions from malignant soft tissue tumors, called sarcomas.
3. Endoscopic biopsy This is probably the most commonly performed type of biopsy. It is done
through a fiberoptic endoscope the doctor inserts into the gastrointestinal tract (alimentary tract
, endoscopy), urinary bladder (cystoscopy), abdominal cavity (laparoscopy), joint cavity
(arthroscopy), mid-portion of the chest (mediastinoscopy), or trachea and bronchial system
(laryngoscopy and bronchoscopy), either through a natural body orifice or a small surgical
incision. The endoscopist can directly visualize an abnormal area on the lining of the organ in
question and pinch off tiny bits of tissue with forceps attached to a long cable that runs inside the
endoscope.
4.Colposcopic biopsy This is a gynecologic procedure that typically is used to evaluate a patient who has had an ab
pathologist.
5.Fine needle aspiration (FNA) biopsy This is an extremely simple technique that has been used in Sweden for dec
(aspirated) into a syringe. These are smeared on a slide, stained, and examined under a
microscope by the pathologist. A diagnosis can often be rendered in a few minutes. Tumors of
deep, hard-to-get-to structures (pancreas, lung, and liver, for instance) are especially good
candidates for FNA, as the only other way to sample them is with major surgery. Such FNA
procedures are typically done by a radiologist under guidance by ultrasound or computed
tomography (CT scan) and require no anesthesia, not even local anesthesia. Thyroid lumps are
also excellent candidates for FNA.
6.Punch biopsy This technique is typically used by dermatologists to sample skin rashes and small masses. After a
7.Bone marrow biopsy In cases of abnormal blood counts, such as unexplained anemia, high white cell count, and
underlying the “bikini dimples” on the lower back/upper buttocks. Hematologists do bone
marrow biopsies all the time, but most internists and pathologists and many family practitioners
are also trained to perform this procedure.
With the patient lying on his/her stomach, the skin over the biopsy site is deadened with
a local anesthetic. The needle is then inserted deeper to deaden the surface membrane
covering the bone (the periosteum). A larger rigid needle with a very sharp point is then
introduced into the marrow space. A syringe is attached to the needle and suction is
applied. The marrow cells are then drawn into the syringe. This suction step is
occasionally uncomfortable, since it is impossible to deaden the inside of the bone. The
contents of the syringe, which to the naked eye looks like blood with tiny chunks of fat
floating around in it, is dropped onto a glass slide and smeared out. After staining, the
cells are visible to the examining pathologist or hematologist.
This part of procedure, the aspiration, is usually followed by the core biopsy, in which a
slightly larger needle is used to extract core of bone. The calcium is removed from the
bone to make it soft, the tissue is processed (see “Specimen Processing,” below) and
tissue sections are made. Even though the core biopsy procedure involves a bigger
needle, it is usually less painful than the aspiration.
