How are biopsies performed, and which biopsy is best for me? Question 12

A patient with a large, unexplained fluid accumulation in the chest or abdomen and who has a small or moderate amount of thickening of the pleura should have a biopsy performed, using semi-invasive techniques (techniques that require only local anesthesia and that do not involve cutting into the chest or abdomen). For example, the biopsy might involve an initial thoracentesis (drainage of fluid in the chest) or paracentesis (drainage of fluid in the abdomen) and a pleural biopsy

Thoracentesis  (thor-a-sen-TEE-sis)  Removal of fluid from the pleural cavity through a needle inserted between the ribs.
Paracentesis  Insertion of a thin needle or tube into the abdomen to remove fluid from the peritoneal cavity. Commonly used to make the diagnosis of peritoneal mesothelioma in patients with ascites or to diagnose recurrence of the disease in the belly  

These are relatively safe procedures that can be performed by a pulmonologist (lung physician), a radiologist, or a surgeon. A local anesthetic (a numbing medicine such as lidocaine) is given to temporarily reduce the feeling in the area before the needle is inserted.

Local anesthetic  The use of an injectable drug in the area of a biopsy to deaden the area  

A pleural biopsy with a special needle may help in getting a diagnosis of mesothelioma, and it is generally performed by a pulmonologist. Since mesothelioma is usually diffuse (widely scattered) in the chest, a random sample of the pleura may give tissue with mesothelioma cells in it. 

A thoracentesis can be performed after the pleural biopsy is completed. The doctor inserts a needle into the pocket of fluid in the chest or abdomen to draw off some of the fluid. Many times, the needle is simply used to insert a flexible catheter (a tube the size of thin spaghetti) which is then used to draw off the fluid. After the fluid is drawn out through this catheter, the catheter is removed. 
Biopsy (BY-op-see)  The removal of cells or tissues for examination under a microscope. When only a sample of tissue is removed, the procedure is called an incisional biopsy or core biopsy. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. When a sample of tissue or fluid is removed with a needle, the proce dure is called a needle biopsy or fine-needle aspira tion. Pleural biopsies are used to make the diagnosis of mesothelioma

The fluid and the tissue from the pleural biopsy will be sent to a pathologist and/or cytologist who will look under the microscope at the cells and determine whether mesothelioma is present. In the past, a diagnosis of mesothelioma from fluid alone was possible only a third of the time because of the difficulty of distinguishing between reactive or noncancerous cells and tumor cells. 

By staining the fluid with a special substance, pathologists can now make a diagnosis more easily. Your doctor will refer to these stains as “immunos,” short for immunohistochemistry. You should make sure that any material used in the biopsy has been studied using these immuno stains. 

A chest x-ray is  always performed after these procedures to make sure there were no complications from the biopsies, such as an accumulation of air in the chest (pneumothorax). The chest x-ray is also very important to see whether the majority of the fluid has been removed and if the lung is now able to expand with air and fill the chest cavity, as it normally should. 

More-invasive testing may be needed if the initial results of the semi-invasive tests do not provide adequate information or if the CT scan indicates that it would be difficult to do the semi-invasive tests. The latter situation would occur if the fluid is not free flowing but is hidden in pockets that are difficult to reach. In such cases, it is better to inspect the chest directly to find out where to do the biopsy. 

A thoracoscopy (the use of a lighted scope, with or without a camera, to look into the chest) is performed in patients who are at risk for mesothelioma and who develop a large fluid accumulation, with or without associated solid tumor masses in the chest. 

Thoracoscopy  The use of a thin, lighted tube (called an endoscope) to examine the inside of the chest.  

In patients who are at risk or mesothelioma but whose thoracentesis does not reveal cancer cells, or who experience a recurrence of fluid after the initial thoracentesis is performed, a thoracoscopy should probably be performed. 

This procedure involves using a special lighted instrument called a thoracoscope to look inside the chest cavity. The scope is placed into the chest between two ribs after a small (1-inch) cut is made through the chest wall. If the doctor finds any tissue that looks abnormal, he or she will cut out a piece, or biopsy a piece, of it to have it looked at under the microscope. This tissue will then be examined for cancer cells. 

A thoracoscopy can provide information crucial for deciding how to treat the patient. It gives great insight  into the amount of disease that is present as well as where the disease is present—for example, on the parietal pleura alone or on both the parietal pleura and the visceral pleura, on the diaphragm, or on the pericardium. 

The status of the lung can also be assessed with a thoracoscopy. For example, it will show whether the lung does not expand because it has a concretelike layer of tumor on it which restricts the lung from filling with air with each breath. A laparoscopy is similar to a thoracoscopy but involves looking into the abdomen. 

Lastly, if the radiologic tests indicate that there is more solid tumor than fluid, or if there is no longer a space where fluid can accumulate because of previous attempts to control the fluid, an “open” biopsy may be indicated. The incision does not have to be large if the pleura is thickened, but the procedure should be performed by a thoracic surgeon who understands the principles of mesothelioma treatment. 

This surgeon will usually suggest a 3- or 4-inch incision on the side of the chest, overlying an area of pleura that is thickened. The surgeon may or may not remove a small piece of rib at this site to allow a direct view of the thickened pleura. Many times, a good-sized piece of pleura (1 to 1 1/2 inches in diameter) can be removed at this site. 

Getting a quick freeze of the tissue in the operating room, with the pathologist looking at the biopsy, will ensure that there’s enough tissue to perform all the required testing and to make a diagnosis. Surgeons performing these biopsies should pick the right place for the biopsy, and the cut (incision) for this biopsy should be in line with the longer incision that would be used later if the patient is a surgical candidate. That way, this shorter incision can be removed. 

Although this operation is performed under general anesthesia (putting the patient to sleep), many times a chest tube to drain the air out of the chest is not needed because the surgeon never enters the chest cavity itself. 

The patient may need some pain medicine for about a week after the procedure if he or she was not having pain before the biopsy. Finally, mesothelioma can “set up shop” and grow tumors at biopsy sites. Radiation therapy is sometimes used after a thoracoscopy or open biopsy to prevent the disease from growing at those sites. If the biopsy results indicate mesothelioma, discuss this option with your physician.
  
  
  
  
  
 

  

How are biopsies performed, and which biopsy is best for me? Question 12 How are biopsies performed, and which biopsy is best for me? Question 12 Reviewed by Ari on 6:15 PM Rating: 5

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