Image Guided Biopsies - The Why, What, and When

by Jane Ashley

Solid tumors discovered with mammography or CT scans may or may not be cancer. If benign tumors are small and not pressing on nerves, blood vessels, or an organ, it might be best for a patient to leave the tumor alone and not perform surgery (where there is always a risk for complications).

Biopsy

But how do our doctors tell the difference between a cancerous tumor and a benign tumor? They use a biopsy — a procedure where the cells of a tumor are examined under a microscope. If the cells are cancerous, then the pathologist performs additional tests to determine specific characteristics of the cancerous cells. For example, the pathologist can look for estrogen and progesterone receptors. This information determines the specific treatment that a patient needs. For prostate cancer, the urologist usually removes 12 core samples from the prostate to determine the grade, commonly called the Gleason score.

How do physicians pinpoint the location of a tumor?

Physicians use different types of imaging to determine the exact location of a patient’s tumor. The most commonly used imaging types used for biopsy are:

Computed tomography (CT) scan. A CT scan uses X-rays taken from various angles. A computer puts these images together to provide a 3-dimensional image of the area scanned. CT scans are frequently used to detect the presence of tumors or other abnormalities of the abdomen, chest, head, limbs, neck, or pelvis. Sometimes, a contrast dye improves the details of the images. Contrast may be given by mouth or injected in the blood stream via an IV line.

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Fine-needle aspiration biopsy of the lung; drawing shows a patient lying on a table that slides through the computed tomography (CT) machine with an x-ray picture of a cross-section of the lung on a monitor above the patient. Drawing also shows a doctor using the x-ray picture to help place the biopsy needle through the chest wall and into the area of abnormal lung tissue. Inset shows a side view of the chest cavity and lungs with the biopsy needle inserted into the area of abnormal tissue. Image-National Cancer Institute.


Magnetic resonance imaging (MRI) scan. An MRI utilizes powerful magnetic and radio waves to produce detailed images. Because an MRI doesn’t use radiation, MRIs can be used if a woman is pregnant. MRIs are safe to use when imaging our reproductive organs, an especially important consideration for women of child-bearing age and even older men who want to preserve their fertility. MRI imaging is used to image the abdomen, brain, breast, chest, and spinal column. MRI is particularly helpful in the imaging of soft tissue areas. Just as with CT scans, radiologists may use contrast dye to enhance the images.

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Magnetic resonance image (MRI) of individual breast, demonstrating marked enhancement (bright area) which was confirmed to be cancer. Image-National Cancer Institute.

Ultrasound. Ultrasound uses high-frequency sound waves to generate detailed images of our internal organs. The sound waves bounce off our organs into a transducer, which creates images. Ultrasound doesn’t use radiation, providing a safe way to image women who are pregnant.

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Ultrasound transrectal biopsy of the prostate. An ultrasound probe is inserted into the rectum to show where the tumor is. Then a needle is inserted through the rectum into the prostate to remove tissue from the prostate. Image-National Cancer Institute.

How is the sample of the tumor obtained?

Radiologists use many different methods to obtain a tissue biopsy. The choice of technique is dependent on the location and size of the tumor and how much tissue is needed for the biopsy.

• Core needle biopsy (CN). If the pathologist needs a larger tissue sample, a radiologist uses a large, hollow needle attached to a syringe.
• Fine needle aspiration biopsy (FN). A very thin hollow needle is used if fluid or only a small amount of tissue is required for the biopsy.
• Vacuum-assisted biopsy. Radiologists use a specialized suction instrument to collect a tissue sample.
What happens during the procedure?
Most patients are anxious about these biopsy procedures. They worry about pain and discomfort, and if they will have to remain still. Because image-guided biopsies are a standard procedure, the team performing our biopsy knows how to minimize discomfort and help us relax. The team chooses the best pain relief for our particular type of biopsy.
• Conscious sedation. Patients receive a relaxing medicine via an IV. You might also have local or regional anesthesia, such as a nerve block.
• General anesthesia. Patients are unconscious during the biopsy procedure – this is usually used for a major surgical procedure to obtain a biopsy sample.
• Local anesthesia. A doctor injects numbing medicine with a needle around the area to be biopsied. You might feel a “stinging” sensation during the injection.

For some biopsies, you might be asked to hold your breath or stay still and quiet. Your medical team will explain before the procedure what to expect.

How long does it take to get the results?

Many cancer patients say that waiting was the worst part of having an image-guided biopsy. A simple biopsy result is usually available in two or three days. If your biopsy requires more complex analysis, it might be 7-to-10 days before you get the results. Since treatment decisions are based on the biopsy results, try not to worry if the results take time … pathologists follow your doctor’s instructions as to what tests are needed for the type of cancer you have.

Your doctor evaluates your pathology report and develops a treatment plan. Ask for a copy of your pathology report. You might not understand all of the language contained within the report when you first read it. But later on, once treatment begins, you’ll start to understand more about your type of cancer, and your biopsy/pathology report will help you understand your treatment options.

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