Does biopsy mean cancer? Are there different types of biopsies?

What is a biopsy? 

A biopsy is the procedure in which a piece of tissue is obtained and examined under the microscope to determine whether cancer or other disease is present. This microscopic examination of the biopsy specimen is accepted by doctors in determining the nature of a tumor with complete accuracy. Therefore, whenever possible a doctor insists on obtaining a sample of every tumor that could be cancer before treatment is attempted. The biopsy provides the most reliable basis for a diagnosis of cancer.

Who determines if the biopsy cells are cancerous? 

The biopsy is "read" by a pathologist a physician who specializes in the study of normal and diseased body tissues.

What kind of training does a pathologist have? 

In order to be certified by the American Board of Pathology, the person must be a licensed doctor of medicine or osteopathy and have four years of training in both clinical and anatomic pathology or three years of training in either specialty or eight years of practical experience under circumstances acceptable to the board. The doctor must also successfully complete the examinations administered by the board. The pathologist is a vital member of the healthcare team, especially in the field of cancer.

Are all pathologists skilled in diagnosing cancer from slides? 

As in all other specialties, the skill and the competence of pathologists vary. A decision regarding whether cancer is the disease in the tissue being examined depends on the interpretation the individual pathologist makes of the cellular structure of the biopsy. Frequently, tissue or slides are sent to experts of larger institutions for consultation, especially by pathologists practicing alone in small communities. If your diagnosis of cancer is based on the single pathological report of a single pathologist in a small community, be sure to ask that the slides or tissues be sent to other pathologists for confirmation. As important is the relationship between the patient's doctor and the pathologist. They need to be talking with each other and working together as a team.

How can the pathologist tell if cells are benign? 

When a piece of tissue is taken from the body and examined microscopically, the normal cells have an orderly appearance. They possess the distinctive features ofthe organ from which they came. The cells from the thyroid gland, for example, are very different from those of the lymph nodes. Normal cells from different organs carry genetic "messages" that determine their structure and function.

What does the pathologist look for when he reads the biopsy? 

The pathologist does many things. First he looks to see whether the specimen is malignant or benign. If it is malignant, he tries to identify the specific type of cancer cells present in the tumor and attempts to determine just how fast they reproduce themselves. With special stains and fixes, he can tell much from the tissue samples. He looks to see if the blood vessels or lymph channels have been invaded. With some kinds of tumors, he may test for hormone dependency. The pathologist gives the other doctors information which will allow them to determine the proper course of treatment.

How important is the pathologist in a cancer diagnosis? 

The pathologist is the key to the entire diagnosis, since a diagnosis is nothing more or less than a carefully considered opinion. It is important first of all that there be adequate and properly prepared biopsy material, since no diagnosis is better than the evidence that it came from. Sometimes, it is found that the kind of specimen presented to the pathologist is inadequate for a true diagnosis to be made or the cellular structure is difficult to identify. Further, like everyone else, the pathologist is just one individual with the same burdens and problems we all have. He may be swamped with work and may not have the time to do an adequate job of preparation in, or reflection upon, the reports he makes. His relationship with the physician in charge of the patient may be poor. All these factors have a bearing on the kind of pathological study and report that is done on your biopsy and underlines the need for a second pathological opinion. As was noted earlier, in large hospitals and medical centers where there is more than one pathologist, second opinions on biopsies are often routinely done.

What are the different kinds of biopsies? 

There are three general techniques for getting the tissue for a biopsy: incisional, excisional, and needle.

What is an incisional biopsy?

In an incisional biopsy, a part of the tumor is cut out and looked at microscopically. This method is usually favored if the suspicious mass is a large one. The object is to get as large a sample as possible, cutting down on the chances of getting a false reading from a bit of tissue that is not representative of the whole.

Incisional Biopsy Demo

What is an excisional biopsy? 

In an excisional biopsy, the tumor is removed totally. This method is selected when the tissue has been identified as cancerous, when strong suspicion exists that part of it maybe or become cancerous, or when the tumor is small. Many skin tumors, for example, are totally removed before the biopsy is performed.

Excisional Biopsy

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What is a needle or aspiration biopsy? 

In a needle biopsy, a needle is used to extract either fluid or tissue for a biopsy. In the United States, the usual needle biopsy is performed by inserting a fine needle into the lump to draw out fluid or tissue juice. A smear of this fluid is then examined for cancer cells. This method is also called an aspiration biopsy. In some places in the country, thin needle aspiration is being used by urologists to take tissue samples to detect prostate cancer and by other physicians to detect breast cancer.

What is a wide bore needle biopsy? 

A wide bore needle is sometimes used to extract tissue for liver and bone marrow samples. This biopsy method is used extensively in the Scandinavian countries and in Great Britain. A tiny cutting instrument is inserted through the needle to obtain a tissue sample of the tumor and its immediate surroundings.

What are the advantages and disadvantages of the needle biopsy? 

The advantages of the needle biopsy are that generally it can be performed in the doctor's office and requires only local anesthesia. It is a simpler and less expensive way to get the biopsy done. The big disadvantage, especially of the thin needle biopsy, is that it is easy to get the needle in the wrong place and miss the tumor completely, especially if the growth is a small one. The wide bore needle biopsy is more reliable.

How does the physician decide which kind of biopsy to perform? 

There are no set rules. The size of the lesion, the location of it, and the suspected diagnosis affect the doctor's decision on the type of biopsy to perform.

I keep hearing the term frozen section. What kind of biopsy is that? 

The frozen section can be done with either an excisional biopsy or an incisional biopsy. It refers to the procedure of preparing the tissue for the pathologist to read. There are two ways to prepare the tissue via the frozen section, which is a quick procedure taking 15 to 20 minutes, or via a permanent section, which takes several days. The frozen section is a quick reference method of determining whether or not cancer is present. The permanent section is a more accurate method.

When is a frozen section biopsy used? 

The frozen section is performed while the patient is in the operating room. It is used when a suspicious mass cannot be reached to obtain tissue by means other than an operation. The patient is prepared for the major surgery; the tissue is obtained, but the surgeon does not proceed with the operation until the report is relayed to him from the pathologist.

How is the frozen section done? 

The surgeon sends the section of tissue he has cut to the pathology laboratory. The tissue is cut and a "touch prep" slide is made by touching a slide against the tissue so it makes an imprint. Solutions are added to another slice of tissue (about Vie inch thick), which is put into a machine (cryostat) for fast freezing. In about 3 minutes it is frozen and cut into thin slices. The cut sections are placed on slides and dipped in wood alcohol for about 10 seconds. These slides and the touch-prep slide are stained. The frozensection slides are used to look quickly at the structure of the tissue and the touch prep slide is used to look at the cellular structure. The two types of slides should agree.

How does the permanent section differ from the frozen section? 

The permanent section biopsy takes considerably longer than a frozen section biopsy. In this process, the tissue is put through a time consuming multistage procedure that is highly complicated and that gives a high quality slide. The tissue is put through a series of solutions to take out the water and fatty substances from it. It is then saturated with warm liquid paraffin. When it has cooled and hardened, the tissue in paraffin is sliced into thin slices. The slices are placed on slides and stained so that the tissue can be studied under the microscope. Proper staining, which brings out cell formations and their nuclei, requires exact timing.

How is the permanent section done on an outpatient basis? 

When the permanent section is being performed on an outpatient basis, the patient is told not to eat or drink after midnight and checks into the hospital in the morning. The patient receives a premedication injection for relaxation and a small amount of local anesthetic in the area to be biopsied. The lump or suspicious tissue is excised, and the wound sutured closed. The patient returns home after a few hours and the pathologist returns a complete report within 3 or 4 days.

What are the disadvantages of the frozen section? 

In the frozen technique, there can be some distortion of cells because of the freezing process, shrinking in alcohol, and the fact that the stain is a rapidly performed one. The technical appearance of the tissue may not be of the highest quality. The tissue can be wrinkled, torn, and fractured by the cutting processes of the frozen section. The pathologist must be able to understand which of the changes he sees are processing distortions and which changes are due to the actual abnormalities of the tissue.

Are there any advantages to a frozen section? 

It depends upon the kind of cancer and the extent of it. If it is in an area where a permanent section cannot be done under local anesthetic, then the frozen biopsy eliminates a second operation. If general anesthesia must be administered to do the permanent section, then a frozen biopsy is called for because no anesthetic agent is perfect and each anesthetic entails a risk. In the area of breast cancer, however, since permanent sections can be done under local anesthetic and the risk of general anesthesia is not involved, it is usually to the patient's advantage to have a permanent section.

What are the advantages of a permanent section? 

The advantages of this method are many. The tissue is first fixed in formaldehyde for from 3 to 12 hours. The fix is better, the tissue shrinkage is more uniform, and the whole process is slower and therefore reduces tearing of the tissue and distortion of its structure. The tissue cuts thinner in this manner. The method of fixation allows tissue to take up the stain better than the frozen section. The pathologist has the whole tissue block available for cutting samples at a later date. The definition and character of a single cell is much clearer and more precise than in a frozen section. The pathologist usually has better tissue to work with, and therefore you are assured of a more technically correct diagnosis.

Is a second opinion ever called for on a biopsy? 

If the diagnosis is malignant, some surgeons send the slides to another pathologist, without including the conclusions of the first, for a second, uninfluenced decision. It is not possible to do this with a frozen section, only with a permanent section. You, as a patient, can request that the slides be sent to a consulting pathologist at another medical center for a second opinion.

Have there been advances in the kinds of microscopes being used by the pathologists? 

The electron microscope sorts out tumor cells by exposing fine structures visible only at magnifications at least ten times as high as a light microscope provides. It gives information which the standard microscope cannot give and permits the pathologist to tell the difference between primary and metastatic tumors and often to identify where in the body the cancer began.

What is bone marrow aspiration? What is bone marrow biopsy? 

These are two similar tests. A whole piece of the marrow is required for the biopsy. For both tests, the doctor, using novocaine, inserts a long, hollow needle through the skin and other tissues into the bone marrow the soft, spongy center of the bone which produces blood cells. A small specimen of the marrow is then removed by suction. The specimen is examined under the microscope for the presence of cancer cells. For a bone marrow biopsy, the doctor pushes the needle in farther until there is a piece of whole marrow in it.