BIOPSY

INTRODUCTION

 The word biopsy is derived from Greek word ‘bios’ and ‘opsis’ meaning life and
vision respectively. Tissue taken from a living organism for the purpose of
microscopic examination is known as biopsy.

 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
NEED OF BIOPSY?

 Biopsy is usually indicated for obtaining a final diagnosis on the basis of

histopathological features
INDICATIONS

 For lesions that exist for more than 2 weeks in the sit even after removal of the
irritating factor and etiology, biopsies are strongly indicated. After a 2- week
period, any remaining abnormality or any lesion that proves refractory to local
therapy is indicated for biopsy
INDICATION FOR BIOPSY

 Cystic lesion
 Hard tissue lesions
 Oral mucosal lesions
 Persistent lesions
 Premalignant state
 Level of malignancy
 Systemic illness:
 Infectious origin
 Idiopathic etiology
CONTRAINDICATIONS

 Few conditions that contradict the biopsy are.

 Seriously ill patients: Contraindicated in those lesions in which biopsy could
secondary infect the lesion.
 Deep lesion: In very deep lesions in which there are chances of damage to
adjacent structures.
 Multiple neurofibromas: there is a risk of malignant transformation in these
cases.
 There is no need to biopsy inflammatory or infectious lesions that respond to
specific local treatment, as pericoronitis, gingivitis or periodontal abscesses.
 Vascular lesions: there are chances of excessive bleeding
CONTINUE

 Esthetical reasons: Biopsy is contraindicated in lesion in which biopsy can cause

esthetical changes
 Site with difficult homeostasis: Sites which are richly supplied by vasculature and
in which there are chances of improper healing, biopsy should be done with great
caution
TYPES OF BIOPSY

 CLOSED INDIRECT BIOPSY

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

 OPEN DIRECT BIOPSY

 - Incisional
 - Excisional
 * marginal
 * wide local
 * radical
ASPIRATION BIOPSY

 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
CORE NEEDLE BIOPSY

 Skin cleansing + LA
 Small skin incision
 Lesion approach at an angle 450
 Stabilize the lesion and introduce the needle via the skin until it abuts against the
lesion
 Fully mechanical biopsy gun is then fired
 Tissue fixed in formalin
 Bleeding usually not a problem, apply pressure
 Incision covered by an occlusive dressing
INCISIONAL BIOPSY

 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
 Only a portion of the lump is removed surgically.
 This type of biopsy is most commonly used for tumours of the soft tissues
(muscle, fat, connective tissue) to distinguish benign conditions from malignant
soft tissue tumours, called sarcomas.
EXCISIONAL BIOPSY

 An excisional biopsy 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.
 Enlarged lymph nodes are good candidates for excisional biopsies
SCALPEL BIOPSY

 Tissue sampling is most commonly done using a scalpel blade.

 Advantage: Recommended in cases of peripheral benign lesions.
 In cases of oral mucosal lesion.
PUNCH BIOPSY

 Punch biopsies involve taking a deeper sample of skin with a biopsy instrument
that removes a short cylinder, or "apple core," of tissue.
 After a local anesthetic is administered, the instrument is rotated on the surface
of the skin until it cuts through all the layers, including the dermis, epidermis, and
the most superficial parts of the subcutis (fat).
OPEN BIOPSY

 An open biopsy is a surgical procedure in which an incision is made through the

skin to expose the tumor and allow a sample of tissue to be cut or scraped away.
Depending upon the lab findings, further surgery may be performed.
SHAVE BIOPSY

 This type of biopsy involves removing the top layers of skin by shaving it off.
Shave biopsies are also performed with a local anesthetic.
ENDOSCOPIC BIOPSY

 This type of biopsy is performed through a fiberoptic endoscope (a long, thin tube
that has a close focusing telescope on the end for viewing) through a natural body
orifice (i.e., rectum) or a small incision (i.e., arthroscopy).
 The endoscope is used to view the organ in question for abnormal or suspicious
areas, in order to obtain a small amount of tissue for study.
 Endoscopic procedures are named for the organ or body area to be visualized
and/or treated. The physician can insert the endoscope into the gastrointestinal
tract (alimentary tract endoscopy), bladder (cystoscopy), abdominal cavity
(laparoscopy), joint cavity (arthroscopy), mid-portion of the chest
(mediastinoscopy), or trachea and bronchial system (laryngoscopy and
bronchoscopy).
BONE MARROW BIOPSY

 In cases of abnormal blood counts, such as unexplained anemia, high white cell
count hematologists do bone marrow biopsies
RENAL BIOPSY
INTRODUCTION

 Percutaneous renal biopsy was first described in the early 1950s .

 These early biopsies were performed with the patient in sitting position by use of a
suction needle and intravenous urography for guidance.
 An adequate tissue diagnosis was achieved in less than 40%of these early cases.
 In1954, Kark described a modified technique using the Franklin modified Vim-Silverman
needle, with the patient in a prone position and an exploring needle used to localize the
kidney before insertion of the biopsy needle.
 These modifications yielded a tissue diagnosis in 96%of cases, and no major
complications were reported.
 More recent prospective studies suggest that : Renal biopsy identifies a diagnosis
different from that predicted on clinical grounds in 50% to 60% of patients and leads to
a treatment change in 20% to 50%.
INDICATION FOR RENAL BIOPSY
BIOPSY ADEQUACY

 The number of glomeruli in the sample is the major determinant of whether the
biopsy will be diagnostically informative

 A typical diagnostically useful biopsy sample will contain 10 to 15 glomeruli

 An adequate biopsy should provide samples for :immunohistology and electron
microscopy (EM).
 It is helpful for the biopsy cores to be viewed immediately after being taken under
microscope to ensure that they contain cortex and when cores are divided,
immunohistology and EM samples both contain glomeruli.
RENAL BIOPSY TECHNIQUE

 Biopsy is performed by nephrologists with continuous (real-time) ultrasound

guidance and disposable automated biopsy needles.
 Use 16-gauge needles and the trend toward fewer bleeding complications of
smaller needles.
 For most patients, premedication or sedation is not required.
The patient is prone, and a pillow is placed under the abdomen at the level of the
umbilicus to straighten the lumbar spine and to splint the kidneys.
TECHNIQUE

 While the anesthetic takes effect, the ultrasound probe is covered in a sterile sheath. Sterile
ultrasound jelly is applied to the skin
 Under ultrasound guidance, a 10-cm, needle is guided to the renal capsule.
 A stab incision is made through the dermis to ease passage of the biopsy needle. This is passed
under ultrasound guidance to the kidney capsule .
 As the needle approaches the capsule, the patient is instructed to take a breath until the kidney is
moved to a position such that the lower pole rests just under the biopsy needle, and then to stop
breathing.

 The biopsy needle tip is advanced to the renal capsule, and the trigger mechanism is released,
firing the needle into the kidney .
 The needle is immediately withdrawn, the patient is asked to resume breathing, and the contents
of the needle are examined
CONTINUE

 Examine the tissue core under an operating microscope to ensure that renal
cortex has been obtained .
 A second pass of the needle is usually necessary to obtain additional tissue for
immunohistology and EM.
 if insufficient tissue is obtained, further passes of the needle are made.
 However, passing the needle more than four times is associated with a modest
increase in the post biopsy . complication rate.
 Once sufficient renal tissue has been obtained, the skin incision is dressed and the
patient rolled directly into bed for observation.
 RENAL BIOPSY MICROGRAPHS

A Low-power view shows two good-sized cores.

B Higher-magnification view shows typical appearance
of glomeruli (arrows).
CONTINUE…

 renal tissue is divided into three samples and placed in

 #Formalin for light microscopy
 #Normal saline for immunofluorescence
 #Glutaraldehyde for EM
FOR OBESE PATIENTS AND PATIENTS WITH
RESPIRATORY CONDITIONS WHO FIND THE
PRONE POSITION DIFFICULT
 Supine anterolateral approach has recently described.
 Patients lie supine with the flank on the side to be sampled elevated by 30 degrees
with towels under the shoulder and buttocks. The biopsy needle is inserted
through the Petit (inferior lumbar) triangle, bounded by the latissimusdorsi
muscle, 12th rib, and iliac crest.
 •This technique provides good access to the lower pole of the kidney, is better
tolerated than the prone position by these patients.
RENAL TRANSPLANT BIOPSY

 Biopsy of the transplant kidney is facilitated by the proximity of the kidney to the anterior
abdominal wall and the lack of movement on respiration.
 It is performed under real-time ultrasound guidance with use of an automated biopsy needle.

 In most patients, renal transplant biopsy is performed to identify cause of acute allograft
dysfunction (acute rejection), therefore diagnosis can be made on a formalin fixed sample
alone for light microscopy.
 If vascular rejection is suspected, a snap-frozen sample for C4d immunostaining should also
be obtained (although some laboratories are able to detect C4d on formalin-fixed material).

 If recurrent or de novo GN is suspected in patients with chronic allograft dysfunction,

additional samples for EM and immunohistologyshould be collected.
POST BIOPSY MONITORING

 After the biopsy, the patient is placed supine and subjected to strict bed rest for 6
to 8hours.
 •The blood pressure is monitored frequently
 •urine examined for visible haematuria and the skin puncture site examined for
excessive bleeding.
 If there is no evidence of bleeding after 6 hours, the patient is sat up in bed and
subsequently allowed to move.
 •If visible haematuria develops, bed rest is continued until the bleeding settles
PLASMA PHERESIS
INTRODUCTION

 Therapeutic plasma exchange (TPE, plasmapheresis) is an extracorporeal

treatment that can be performed by centrifugation or filtration and is designed for
the removal of plasma along with pathogenic substances, such as antibodies,
immune complexes, or large molecular weight substances from the plasma.
SEPARATION TECHNIQUES

 Automated separator device are used for both component preparation &
therapeutic application of apheresis
 In manual apheresis, whole blood is collected in multiple bags & centrifuged to
separate the desired component, which is separated/ retained into satellites bag &
the reminder is infused through the same vein which is kept patent with the
normal saline/ heparinised saline, The process is repeated.
CONT…..

 Adv: this procedure simple & inexpensive

 Disadv: The amount component prepared/ harvested per procedure is than
automated device.
APHERESIS MECHINE

 There are several types of aphersis machines, they are mainly of two types
 Intermittent flow centrifugation
 Continuous flow centrifugation
IFC

 Haemonetic Model S-30, V-50,MCS

 Dideco Progress
MCS+

 The MCS+ fills the disposable centrifuge bowl with anticoagulated whole blood.
 Sterile air is displaced from the bowl into the air bag.
 During the filling bowl phase, substitution fluid flows into the substitution fluid
bag on the weigher.
 The bowl will fill up and a cellular separation will occur.
 The plasma begins to overflow from the bowl into the waste
CONTINUE

 When the buffy coat is detected by the Bowl Optic Sensor end of collection
algorithm.
 Packed cells from the bowl and fluid from the temporary substitution fluid bag are
mixed and returned to the patient (if substitution is enabled).
CFC

 Cobe spectra
 Fenwal CS 3000, Amicus
 Dedico Viva
 Fresenius
CONT…..

 The procedure for performing the apheresis varies according to the blood
component to be harvested & the equipment that is used. There are certain
machines ( cell separators) which are exclusively used for plasmapheresis
 Eg: Haemonetic PCS
 Baxter Autopheresis C
CONTIN.
ADVANTAGES OF INTERMITTENT
CENTRIFUGATION
 Include relative simplicity of operation,
 Portability of the machines and adequacy of a single-needle peripheral
venipuncture.
 The disadvantages are
 slowness (typically > 4 hr) and the relatively large
 extracorporeal blood volume required (>225 ml).
CFC

 With continuous-flow equipment, blood is fed continuously into a rapidly rotating

bowl in which red cells, leukocytes, platelets, and plasma separate into layers. Any
layer or layers can be removed, and the remainder is returned to the patient with
replacement fluid
ADVANTAGE
 Continuous-flow centrifugation is faster and most operations
(anticoagulation, collection procedures, and fluid replacement) are
automated.
 Disadvantages
 include higher cost, relative immobility of the equipment, and the
 requirement for either two venipuncture's or insertion of a dual
lumen catheter.
PLASMA VOLUME CALCULATION

 Total Plasma Volume (TPV) to be removed is calculated by

 obtaining the total blood volume (TBV) multiplied by (100% - Hct%)
  Total blood volume is between 5.5-7.5% of body mass for most adults and may
be estimated as 70ml/kg for males and 65 ml/kg for female . Because TBV increase
with muscle mass.
 Example: Patient Wt:70 kg and Patient Hct40%
 TBV: 70 kg x 70ml/kg = 4900ml
 TPV: 4900 ml x (100% -40%) = 2940 ml
CONTINUE…

 Kaplan's equation
 [0.065 x weight (kg)] x (1- Hct)
 A course of plasma exchange consist of 3-5 exchanges of 1-1.5 volumes each,
with an interval of 1-2 days between procedures.
REPLACEMENT FLUID

 5% Albumin
• Most common used replacement fluid
 Dilute only with Saline

 • GBS, MG, Goodpasture’s Syndrome

 Combination of saline and albumin
 FFP (Fresh Frozen Plasma)
 Used when necessary to replace clotting factors
 Typically used with TTP patients
 Cryo poor Plasma
• Cryoprecipitate has been removed
 Useful in refractory TTP patients
CONTRAINDICATIONS
CONTINUE

 Patients with hypocalcemia are at risk for worsening of their condition because
citrate is commonly used to prevent clotting and can potentiate hypocalcemia
 Patients taking angiotensin-converting enzyme (ACE) inhibitors are advised to
stop taking the medication for at least 24 hours before starting plasmapheresis