Diagnostic Biopsy Procedures


Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Bleeding or haematoma formationa

1–5 %

Pain/discomfort/tendernessa

20–50 %

Pneumothorax (for trans-thoracic needle biopsy passes)a

1–5 %a

Rare significant/serious problems

Neural injury (minor)a

0.1–1 %

Neural injury (major)a

<0.1 %

Infectiona

0.1–1 %

Failure to diagnosea

0.1–1 %

Spread of malignancya

<0.1 %

Pneumothorax (superficial chest biopsies accidental pleural entry)a

<0.1 %

Less serious complications

Bruising

50–80 %


aDepends on underlying pathology, situation, technique preferences, and location in the body





Major Complications


Major complications are rare, including nerve injury, bleeding, and infection, which are rarely a problem for more than a few days if they should occur. Rare instances of longer-term pain due to nerve injury can occur, but careful anatomical approaches can often reduce this possibility. Malignant spread is possible; however, such instances must be rare, as the literature would indicate that local recurrences after FNAB are infrequent if they occur at all. Many subsequent operative approaches incorporate excision of the FNAB site, which is a reason for the FNAB to be performed by the operating surgeon who can plan the definitive surgery. Failure to diagnose is a potentially very serious risk using FNAB, but this procedure should be combined with clinical assessment and imaging. It is worth explaining to the patient that FNAB is not always capable of diagnosing with absolute accuracy. False negative and even false positive diagnoses can occur. The level of risk of both failure to diagnose, or spread of malignancy, is determined by many factors, and is given here as an overall guide only. Careful planning, explanation, and follow-up with a cooperative patient approach is often very useful in reducing these risks substantially. Pneumothorax is a risk of FNAB performed close to pleura or across/within lung, diaphragm, mediastinal tissues, or at the root of the neck. If risk of pneumothorax is high, admission to hospital for close observation may be wise. The patient should be informed to actively seek the results to avoid inadequate followup, and to return if the lump changes or enlarges, even if the FNA is not diagnostic, depending on the circumstances.



Consent and Risk Reduction: Fine Needle Aspiration



Main Points to Explain






  • Discomfort


  • Bruising


  • Bleeding


  • Perforation (deep biopsies)


  • Infection


  • Failure to diagnose


  • Return for results


  • Further procedures/surgery


Core Needle Biopsy



Description


Local anesthetic is usually required. Core needle sampling utilizes a large gauge solid needle (usually 10 g or greater) with a notch in one side connected to a biopsy instrument, often with automatically firing. The needle is passed into a lump and the sheath automatically advances over the needle to excise a core of tissue. The core sample is then withdrawn for histopathological examination. Approximately a 2 mm diameter cylindrical hole corresponding to the removed core is created, but this tends to collapse aiding hemostasis.


Anatomical Points


The location and consistency of the lump may vary depending on the underlying disease process. Mobile, very deep, or small lumps are often difficult to core sample, as they may be difficult to easily define and secure. Masses close to vascular, neural, or other important structures can increase the risk of complications (Table 2.2).


Table 2.2
Core needle biopsy estimated frequency of complications, risks, and consequences























































Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Bleeding/haematoma formationa (all)

20–50 %

 Majora

0.1–1 %

Pain/discomfort/tendernessa

20–50 %

Infectiona

1–5 %

Rare significant/serious problems

Neural injury (minor)

0.1–1 %

Neural injury (major)

<0.1 %

Dimpling/deformity of the skin

0.1–1 %

Spread of malignancy

<0.1 %

Failure to diagnose

0.1–1 %

Alteration of the subsequent pathology

0.1–1 %

Pneumothorax (superficial chest biopsies accidental pleural entry)a

<0.1 %

Less serious complications

Bruising

>80 %

Scarring

1–5 %


aDepends on underlying pathology, surgical technique preferences, and location on the body


Perspective


CNB has been used more widely over recent decades as a useful method for obtaining diagnosis of masses and offers a generally high degree of safety with few major known side-effects. Pain and discomfort are usually only moderate, especially with local anesthesia, although considered more than for FNAB. Bruising is frequent, especially when a blood stained sample or leakage occurs. The patient should be warned of the risks above, but reassured that the risks usually do not outweigh the benefits. There are considerations of possible spread of malignant cells, thought due to transection of vessels within the tumor mass. The benefits and risks need to be weighed. As for FNAB, trans-scrotal core biopsy of testicular lesions is also often avoided because of the risk of spread of malignancy across scrotal tissue planes. Failure to diagnose is dependent on many factors, including the site of the mass, the tumor characteristics, operator experience, the sample, the pathologist, and the number of samples taken. Repeated core biopsy samples can be performed and may possibly reduce the risk of a failed diagnosis. This largely determines the level of risk and frequency. Close clinical follow-up and/or the use of repeated imaging, FNAB or CNB with imaging guidance, may be helpful.

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Mar 25, 2017 | Posted by in HEAD AND NECK SURGERY | Comments Off on Diagnostic Biopsy Procedures

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