HISTOPATHOLOGY LEC

LECTURE 5: BIOPSY AND AUTOPSY

PROF. CHARLIE A. CLARION, RMT, MD, FPCP
June 19, 2021
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BIOPSY ● Idiopathic Etiology

● Biopsy is from Greek word ○ Do biopsy in those lesions which have unclear or
○ “Bios” meaning life unknown etiology
○ “Opsis” meaning vision ○ If we don’t know by clinical scenario
● It is a procedure which involves taking a tissue form a living
organism for the purpose of microscopic examination and ● Systemic illness
arrive with histopathologic diagnosis ○ Lupus, amyloidosis,
● Dealing with alive patients scleroderma, or
Sjogren’s syndrome
AUTOPSY ○ Instances where in
● Autopsy comes from the Greek words the doctor is confused
○ “Auto” and “Opsis” which literally means “to see on what diagnosis or
for oneself” disease the patient
● It determines which disease or injury caused the death, has = do biopsy
confirm or exclude a diagnosis, help understand how a ○ Diagnosed with lupus
disease progresses (manner, cuase, or mechanism of nephritis
death), or evaluate possible public health issues
● Dealing with a dead patient ● Infectious Origin
○ Tb, syphilis, leprosy
BIOPSY ○ Chronic inflammation
with caseous
Indications and Contraindications
necrosis at the center
○ If you see caseous
Indications
necrosis even if the
● Cystic Lesion
sputum afb or other
○ Various cyst may
test like MTB/RIF
have different
genexpert or TB PCR is negative but u can see
prognosis, or
causation necrosis it will tell u it is tuberculosis
aggressive nature
○ Will affect the management; doctor will start
which will change
patient with anti-tb medications
the treatment plan
○ Can be a malignant
Contraindications
cyst or benign cyst
● Not only lesions should be biopsied
○ Confirm using
● There are also contraindications to do biopsy
biopsy
● Seriously ill patients
○ Biopsy procedure may secondary infect the
● Hard Tissue Lesions
lesions
○ Bone lesions accompanied by pain, sensitivity
○ We need to weigh the risk and benefit
alteration, or rapid expansion or growth
○ If doing the biopsy will put the patient at risk, then
○ Mass in the bone
we will forgo biopsy and manage the patient
clinically or accordingly
● Persistent Lesions
○ Lesions that persist for
● Deep Lesions
a longer time even after
○ Very deep lesions in
the removal of irritating
which there are
factor
chances of damage to
adjacent structures
● Pre-malignant Lesions
○ Lesion at the midbrain
○ Lesions in which
malignant
● Highly vascular Lesions
transformation is
○ Changes of excessive
suspected
bleeding
○ High suspicions for
○ Patient might die because of hemorrhage
malignancy
○ Transformation zone in
● Aesthetic Reasons
the cervix = most
○ Biopsy procedure that may cause aesthetic
common site of
changes
malignancy
○ Doing a biopsy will alter the anatomy of the
patient.
● Level of Malignancy
○ If the patient think that the post-biopsy is not
○ Define the extent of a disease process
acceptable to him/ her then we forgo the biopsy
○ To stage the malignancy
and manage the patient clinically
○ Ex. malignancy in colon & mass in the liver or
○ Even if it’s too risky to do the biopsy and the
lungs = Do biopsy to see if the bass or lesion in
patient has risks to develop bleeding, doing a
the liver and lungs are metastasis from the
primary colon cancer
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 biopsy can change the management of the ● Any other part apart from the skin
patient. Then, we will push for a biopsy. ● Mammogram of the breast; u can see whitish
calcifications all throughout the breast
TYPES OF BIOPSY ● We will not be talking
out the entire breast first
SKIN BIOPSY ● Only take a portion of
● Skin or cutaneous biopsy remove cells from the surface of the mass
the body ● Give a diagnosis
● Used to diagnose skin conditions like skin cancer whether benign or
● Not only limited to skin cancer malignant (cancer)
○ Ex. Psoriasis ● Malignant = removal or
● Subtypes: breast = mastectomy or
○ Shave biopsy, Punch biopsy, Incisional biopsy, chemotherapy/
Excisional biopsy radiotherapy
1. Shave Biopsy
● Uses a razor-like tool 2. Excisional Biopsy
that scrapes the skin ● Complete removal of
lesion that is above the affected lesion
the level of the usually a tumor for
surface of the skin, both the diagnostic
excluding deeper and therapeutic
tissues purposes
● Mostly recommended
2. Punch Biopsy in those cases in
● A small, tube-shaped piece of skin and other which the size of the
tissue underneath are removed using a sharp biopsy is small
circular blade that is rotated down through the ● Remove entire lesion
epidermis and dermis and into the subcutaneous
fat, yielding a 3 to 4 mm cylindrical core of tissue Needle Biopsy
sample 1. Fine-Needle Aspiration Biopsy (FNAB)
● Cytologic technique involving the use of a
fine-gauge (usually 21 to 25 gauge) needle to
aspirate individual tumor cells and microfragments
from the mass
● Doctor uses a special needle to extract cells from
a suspicious area
● Cytologic technique involving the use of fine
gauge

2. Core Needle Biopsy

● Biopsy procedure to remove a small amount of
suspicious tissue using a needle with a larger
3. Incisional Biopsy “core” or ”hollow”
● Involves taking a part of the skin lesion for ● Getting a bigger sample/specimen
confirming the diagnosis ● The core needle biopsy has a better yield than
● Taking a part of the skin lesion FNAB
● You will not be removing the entire lesion ● The specimen can be submitted for
immunohistochemical staining & checking the
receptors that might be helpful in the choice of
immunotherapy or chemotherapy for the patient

3. Vacuum-Assisted Biopsy
● Uses ultrasound or mammogram, and vacuum
assisted biopsy probe as handheld device with
needle
● Probe is advanced to the location of the tumor
● Vacuum system retrieves the tissue in one single
pass

4. Excisional Biopsy
● Removal of the
entire skin lesion
completely and
deeply
● Preferred if skin ● Mass on the breast
cancer is ○ Ultrasound and mammogram to locate
suspected the mass inside
○ Puncture where the mass is located
SURGICAL BIOPSY ○ Use vacuum to locate and get the
1. Incisional Biopsy sample
● Only a sample of the suspicious tissue is cut from ○ Remove sample and submit to lab for
a mass (incise) and removed for purposes of HP diagnosis
diagnosis
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4. Image-Guided Biopsy
● Uses ultrasound, or CT Scan, or MRI as guide to
locate the lesion or tumor
● Can be CT Scan guided aspiration biopsy,
ultrasound guided, MRI guided, X-Ray guided
biopsy
● Ex. Chest CT Scan
○ Presence of mass
○ Interventional
radiologist or
pulmonologist will do
the biopsy
○ CT Scan
○ Locate mass,
puncture, and get ● Atypia on the tongue = brushing
sample ○ Smear on the slide and submit to HP Lab for
○ There are diagnosis
complications =
rupture the lung, Frozen Section
having pneumothorax ● Rapid diagnosis during intraoperative period, the sampled
tissue is processed without fixations, frozen with dry ice
● This is quick and gives the surgeon immediate information
Endoscopy Biopsy regarding the malignancy of a piece of tissue generating
● Uses a flexible tube with a light on the end to see structures reports while on-going OR
inside the body ● Surgeons are doing a surgical procedure to a patient (ex.
○ Insert a tube (at the end of this tube, there’s a Thyroid gland - take a sample from the thyroid gland)
camera with light) ○ While operation is still ongoing (thyroid gland is
○ Explore the canal (GIT or airway passages) and still exposed), the sample will be submitted to the
look for a mass laboratory
● Special tool is passed through the tube to take a small ○ Pathologist will process the sample and tell the
sample of tissue to be analyzed surgeon after 5-15 mins and have a diagnosis
● Ex. colonoscopy with biopsy, (benign or cancer)
esophagogastroduodenoscopy with biopsy, bronchoscopy ○ If the biopsy revealed malignancy, surgeons may
with biopsy do total thyroidectomy (remove the entire thyroid),
lymph node dissection
○ If benign = subtotal thyroidectomy, remove one
lobe of the thyroid ‘
● Frozen section is important because the patient is still at
the operating table and surgeons are waiting for the result
○ It dictates what particular surgical intervention will
proceed

● Left picture: Mass in the colon AUTOPSY

○ Using colonoscope (colonoscopy)
○ Bite of the mass for tissue specimen
○ Colon cancer
● Right picture: Bronchoscopy
○ Mass on the right main bronchus
Bone Marrow Aspiration and Biopsy
● Used to diagnose a variety of blood problems both
cancerous and noncancerous including leukemia,
lymphoma, multiple myeloma, or cancer metastasis
● Done by the internal medicine specialist or hematologist
● Painful - aspiration part
○ Like a vacuum
Classic Autopsy Techniques
1. Virchow Technique
● First step was to expose the cranial cavity, and
from the back, the spinal cord, followed by the
thoracic, cervical, and abdominal organs, in that
order
● Organs are removed one by one and individual
organs are studied
● Used most widely, often with modifications
2. Rokitansky Technique
● Characterized by “in situ” dissection, in part
combined with the removal of organ blocks
○ In situ - the organ is still attached to the
cadaver
● Dissection starts at the neck and trails down, and
the organ is removed as a block as well
● The first cut pierces the larynx to separate the
esophagus and pharynx, then the larynx and
trachea, followed by the chest organs that are cut
to expose those in the abdomen

3. Ghon Technique
● Thoracic and cervical organs, abdominal organs,
and the urogenital system are removed as organs
blocks (“en bloc” removal)
● Right picture - core biopsy
● Ex.
● Upper left picture - aspiration biopsy
○ Entire thorax
■ Trachea, lungs, heart removed
Brush Biopsy
as a block
● Non-invasive method of evaluating lesions for cellular
○ GIT
dysplasia and atypia using a stiff brush
■ Intestine, colon, liver, etc.
removed in one block
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 ○ Urogenital system cardiopulmonary functions are
■ Kidney, bladder, urethra as a maintained
block ○ Vegetative state, or deep coma for
○ Brain and spinal cord as a block indefinite time, sometimes for years
○ Patient still has a beating heart and can
4. Letulle Technique breathe on his/her own, however patient
● Thoracic, cervical, is in vegetative state or deep coma
abdominal, and pelvic ○ No movement, no respond
organs are removed as ● Brain stem death
one organ block (“en ○ Loss of vital centers that control
masse” removal) and respiration and consciousness
subsequently dissected ○ No longer breathing, patients that are
into organ blocks usually ventilated
● Dissection commences at ● Combination of both
the abdomen
● The body can be made Post-mortem Changes
available to the undertaker ● Post - after
in less than 30 minutes ● Mortem - dead
without having to rush ● Can be seen in the naked eye
dissection ● Constitute the natural progression of the body’s
○ Not so tedious; not individual organ nor decomposition after death involving complex cellular and
block organ biological phenomena
■ Remove everything ● Understanding postmortem changes is essential for
● Ex. from the larynx down to GIT, Thorax, Airway, estimating the postmortem interval or time since death
GIT Tract, colon intestine 1. Immediate
○ Remove everything as a mass ● Stoppage of Function of Nervous System
● Stoppage of Respiration
Types of Death ● Stoppage of Circulation
1. Somatic Death (or Clinical Death or Systemic Death) 2. Early
● Cessation of the functions of nervous, circulatory, ● Eye changes (Tache Noire)
and respiratory systems ● Pallor and loss of skin elasticity
● Irreversible loss of sentient personality, unable to ● Primary flaccidity
be aware of environment, unable to appreciate ● Rigor Mortis
any sensory stimuli, unable to initiate any ● Livor Mortis
voluntary movement ● Algor Mortis
● Reflexes may still be present, respiratory may still 3. Late (Decomposition)
persist with help of artificial support (mechanical ● Putrefaction
ventilator) ● Adipocere
● Cells and tissues are still alive and functioning ● Mummification
apart from damaged tissues ● Skeletonization
● Fossilization
2. Cellular Death (or Molecular Death)
● Death of the individual cells Early Changes
● Following ischemia and anoxia, tissues and 1. Changes in the Eye
constituents are dead due to cardiorespiratory ● Loss of Clear Glistening
failure ● Dry, Cloudy and opaque
○ Ischemia - decreased blood supply to ● Loss of reflexes
particular organ/ organs ● Light reflex abolished
○ Anoxia - no oxygen supply to particular ● Intraocular tension falls, eyeballs become flaccid and
tissue or organs sink in the orbit approx. 2 hours
○ Heart and lungs are no longer ● Blood flow in the retina becomes dotted and
functioning properly segmented look
■ Entire body will not be ● Optic disc looks pale
receiving blood and oxygen ● Pupils fully dilated in the early stage and constricted
■ RBC contains hemoglobin later due rigor mortis.
carrying oxygen ● Brownish discolouration of the sclera due to cellular
■ No blood = no oxygen debris and dust
● Takes place 1-2 hours after death ○ Taches Noires
● No longer have aerobic metabolism
○ Due to no oxygen 2. Changes in the Skin
○ Resorts to anaerobic metabolism which ● Pallor Mortis: pale and ashy white appearance
is not quite effective ○ Because there is no more blood circulation
○ No energy supply = cells will die ● Loss of its translucency
● Molecular deaths of different organs (no blood ● Loss of Elasticity
and oxygen supply) ● Wounds will not gape if it is inflicted after death
○ Brain cells: 5 mins ● Wounds caused during life will retain their
○ Muscles: > 1 hour characteristic features
○ Blood cells, cornes: > 5 hours
■ Patient can still donate cornea PRIMARY FLACCIDITY
if recovered within 5 hours ● Flaccid period starts immediately after death
○ Fibrous tissue (bone, cartilage): late ○ generally , if the patient dies, the patient is not yet
in rigor mortis
3. Brain Death ● All the muscles begin to relax
● Cortical death ○ Lower jaw begins to fall
○ Higher cerebral activities are lost; brain ○ Eyelids loose tension
stem is preserved, therefore ○ Joints are flexible
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 ○ Smooth muscle relaxations resulting to urine and Circumstances Modifying Onset and Duration of Rigor Mortis
fecal incontinence ● The earlier the rigor mortis, the shorter the duration
● Extend up to 3-6 hours before rigor mortis ● The more delayed the rigor mortis is, the longer the
duration of rigor mortis is
LIVOR MORTIS ● Age
● Discolouration or staining of the skin and organs after death ○ Rapid in children and old age
due to accumulation of fluid blood in the dependent parts of ● Nature of Death
the body as a result of gravity ○ Diseases causing exhaustion and wasting
● Initially faint pink erythema, that eventually becomes purple (cholera, cancer, TB) or violent death
● Will tell you the position of the patient when that patient (electrocution) onset of rigor is early and duration
died is shorter
● Absent in pressure points ○ Asphyxial death
● After death, ○ onset is delayed
○ Starts 1-3 hours ○ Widespread bacterial infection (sepsis), onset if
■ When you change the position of the very rapid
dead body, accumulated blood and fluid ● Atmospheric Conditions
will move to the new dependent area ○ Cold weather: onset is slow, duration is longer
○ Fixes 6-8hours ○ Hot weather: onset is rapid, duration is short
■ Fixation - when you change the position Conditions simulating rigor mortis
of the dead body, the accumulated blood Heat Stiffening
or fluid will no longer move onto a new ● When exposed to temperature >65C, rigidity is produced
dependent area and more than in rigor mortis
○ Rigidity is more explosive compared to the usual
LIVOR MORTIS VS BRUISE rigor mortis
LIVOR MORTIS BRUISES ● Rigor mortis never occurs

Seen in dependent areas Anywhere Cold Stiffening

● Upon exposure to freezing temperature, tissues are frozen
Blood is retained in intact Blood escapes through ruptures and stiff, body fluids are freezing
capillaries capillaries ● Difference from heat stiffening: Once replaced in a warm
Well defined edges Ill-defined edges temperature, stiffness will vanish, flaccidity occurs
(primary), and not long after that rigor mortis occurs
Superficial Deep into skin ● There is rigor mortis
Same level on surface raised
Cadaveric Spasm
Pale over pressure areas red ● Affects only a group of muscle like flexor of one arm
When incised, blood flows from the When incised, blood coagulates in ● Failure of normal relaxation of a group of muscle in the
cut vessel tissue midst of intense emotional or physical activity
● Only involve a particular body part.
No swelling May be with swelling
Secondary Flaccidity
RIGOR MORTIS ● After rigor mortis, the body relaxes due to onset of
● Stiffening of the muscles of the corpse due to depletion of putrefaction, occurring after 24-48 hours from death
adenosine triphosphate (ATP) ● Relaxation of the entire body after the rigor mortis
● Grossly follows primary flaccidity ○ Due to the onset of the putrefaction
● Occurs in both voluntary and involuntary muscles
Algor Mortis (Postmortem Cooling)
● Loss of body heat by means of conduction, convection,
TIME OF ONSET DURATION and radiation, until it balances with the temperature of
surroundings
TROPICAL CLIMATE 1-2 HOURS 1-2 DAYS ● Rate of cooling is fast during first few hours and later slows
until it reaches ambient temperature
TEMPERATE CLIMATE 3-6 HOURS 2-3 DAYS ● Our body will slowly equilibiriate with the temperature of the
environment.
● Rate of Algor Mortis
○ First 1-3 hours:
TIME EVENT APPEARANCE ■ Rate is slow in case of outer core
Stiffening of eyelids and (external or skin)
2-6 hrs Rigor begins ■ Inner core temperature may rise due to
jaws
anaerobic glycolysis
After 2 hrs Center of the body stiffens ● When there is an ongoing
metabolism, there is no more
oxygen and the body will
12 hrs Complete rigor Entire body is rigid resort to anaerobic glycolysis
and the product of AG is heat.
Slow loss of rigor, small Lost in head and neck, last ○ Next 6-9 hours:
15-36 hrs
muscles first bigger leg muscles ■ Rate is rapid
● Because there is no more
36-48 hrs Rigor disappears anaerobic glycolysis
■ Flow through core layer is established ,
thus, cooling of inner core become rapid
- There is primary flaccidity because of relaxation of muscles ○ By 15-20 hours
- Secondary flaccidity - after rigor mortis ■ Body temperature approaches the
surroundingFactors Affecting the Rate of
Cooling Late Changes

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 ○ Bacteria located mainly in the lower intestine
begin decomposition, giving a greenish color to
the lower abdomen
FACTORS AFFECTING THE RATE OF COOLING ○ Individual cells break down(autolysis)
○ No gross deformity of the skin
Factors Event Effect Circumstances ● Stage 2: Putrefaction
affecting
Algor mortis

Temperature Cold Accelerate Lose heat faster

temperature algor

Warm Slows algor Lose heat

temperature slower

Wind windy Accelerate Faster heat loss

algor

calm Slow algor Slower heat loss

○ 4-10 days after death
Body fat obese Slows algor Slow down heat ○ Bacteria grow throughout the body, releasing
loss gases, including cadaverine (thats why its smelly),
which in turn bloat the body and causes an
thin Accelerate Speed up hea unpleasant odor
algor loss ○ Buildup of fluids from ruptured cells
○ Skin blisters, skin begins slipping
Clothing Presence of Slows algor Slow down heat ● Stage 3: Black Putrefaction
clothing loss

Absence of Accelerate Speed up heat

clothing algor loss
Naked

LATE CHANGES
Decomposition

○ 10-20 days after death

○ This stage brings further discoloration and black
surfaces are exposed due to H2S formed by
microorganisms
○ The gases from bacterial decay begin to escape,
causing a strong odor
○ Bloated body collapses and leaves a flattened
body
○ Loss of body fluids
● Stage 4: Butyric Fermentation
● Mixture of Process
○ Autolysis of individual cells by chemical
breakdown
○ External process of bacteria, predators, maggots
○ Reduction of the body into simpler forms of
matter, accompanied by a strong, unpleasant odor

Five Stages of Decomposition

● Stage 1: Initial Decay

○ 20-50 days after death

○ The internal organs liquefy and the body begins to
dry out
○ Little no no flesh
○ Cheesy smell caused by butyric acid
○ Surface of the body in contact with the ground
may mold as body ferments
● Stage 5: Dry Decay

○ 0-3 days after death

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 Mummification

● This results from tissue desiccation and is a phenomenon

○ 50-365 days after death the occurs when the corpse is in an environment that is hot
○ In a hot, dry climate the body may dehydrate, and dry
inhibiting bacterial decay ● This preserves the corpse for a more extended period
○ The skin dries to a dark leathery appearance (decades or centuries).
○ Slowest of the five stages because of lack of
moisture Skeletonization
○ Mostly reduced to hair and bones, eventually the
hair will disappear
Marbling

● The end of decomposition where all soft tissues have

decomposed leaving only the skeleton

Fossilization
● Arborescent pattern of discoloration of vessel walls due to
pigmentation from decomposed blood

Adipocere

● The natural preservation of the skeletal remains formed

● Waxy substance caused by hydrolysis and hydrogenation over a very long period
of adipose tissues ● This stage may not occur depending on the circumstances
● Contains palmitic, oleic, and stearic acid + glycerol ● Not all cadaver will undergo fossilization
● Most occur in wet graves, damp vaults, cold water
● If the patient dies in a wet area or wet grave the body will
go adipocere.
● IMPORTANCE: Clostridium perfringens assists in
hydrolysis and hydrogenation process
● Importance: may preserve the body for decades or
centuries

Maceration

● Aseptic autolysis of a fetus, which has died in utero and

remained within the closed amniotic fluid
● Occurring as early as 6 hours of death, and most definitely
within 12 hours