Biopsies – tissue is the issue!

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Biopsies for suspected cancer 

13 years ago on 19th July 2010, I had a liver biopsy.  Following some low hemoglobin and some weight loss reported to my GP surgery in May, I met with a specialist on 8th July and after sending me straight for a CT scan on the same day, I eventually had to have a liver biopsy done to confirm the cancer.  

I won’t lie and say it was an enjoyable experience.  I vividly remember a lot of discomfort including pain.  At the time no-one knew I had metastatic Neuroendocrine Tumours; no-one knew I had associated carcinoid syndrome.  I suspect that may have played a part in the discomfort of that important procedure.  The doctor carrying out the biopsy had several assistants in the room and sent for a nurse whose sole job was to hold my hand and reassure me.  It’s not that I was frightened or scared or anxious (not overtly), but my body was reacting to the discomfort despite a mild sedative.   I suspect the doctor was worried my discomfort was making me move slightly while he was attempting to carry out this precise procedure, I get that.   He used a guided core needle biopsy with 3 attempts. 

Biopsies for suspected cancer

Blood tests and scans can really help pin down the location of cancer plus other valuable information and “liquid biopsies” (a type of blood test) are often hyped in the newspapers and media but mostly remain experimental and in clinical studies.  Putting liquid biopsies to one side, most people will continue to have biopsies done in the conventional way for some time. 

This is true for Neuroendocrine Cancer where it provides diagnostic certainty and is able to measure the aggressiveness of the disease including whether the tumour is well or poorly differentiated. 

Additionally, specific markers can be tested to add diagnostic and prognostic information and molecular tests, while immature as of July 2023, this is an area advancing all the time. 

Like scans, there are different types of biopsies for different scenarios, and I’ll cover the most common below.  I was surprised to find that I have had many of them to date since my initial diagnostics in 2010.

Needle biopsy

Many people will be familiar with this term but “Needle biopsy” is a general phrase for taking samples in easily or fairly easy locations on and in the body.  Also known as a percutaneous tissue biopsy. The main types of needle biopsy includes:

  • Fine-needle aspiration (FNA). During fine-needle aspiration, a long, thin needle is inserted into the suspicious area. A syringe is used to draw out fluid and cells for analysis. An ultrasound is normally used to assist but this is not an image guide procedure (see below).
  • Core needle biopsy. A larger needle with a cutting tip is used during core needle biopsy to draw a column of tissue out of a suspicious area. An ultrasound is normally used to assist but this is not an image guide procedure (see below).
  • Vacuum-assisted biopsy. During vacuum-assisted biopsy, a suction device increases the amount of fluid and cells that is extracted through the needle. This can reduce the number of times the needle must be inserted to collect an adequate sample.
  • Image-guided biopsy. Image-guided biopsy combines an imaging procedure — such as a CT, MRI or ultrasound. Image-guided biopsy allows your team to access suspicious areas that can’t be felt through the skin, such as on the liver, lung or prostate. Using real-time images, your interventional radiologist or surgeon can make sure the needle reaches the intended target.

You may receive a local anesthetic to dull any pain.

Patients with complications

Transvenous biopsy

Less commonly and to protect those with certain conditions e.g. ascites.  A sample tissue from your liver could be taken through a vein in your neck or groin –  transjugular for neck, transfemoral for the groin. 

Plugged biopsy

This is a modification of the percutaneous approach that can be used in patients who are at high risk for bleeding (coagulopathy or thrombocytopenia). Although a transvenous biopsy can be obtained in this subset of patients, the plugged approach is used when a larger specimen size is desirable.

Endoscopic biopsy

This comprises a thin, flexible tube (endoscope) with a light on the end to see structures inside your body. Special tools are passed through the tube to take a small sample of tissue to be analyzed.  For lung investigations, this is often called a bronchoscopy. 

What type of endoscopic biopsy you undergo depends on where the suspicious area is located. The endoscope can be inserted through your mouth, rectum, urinary tract or a small incision in your skin.

Examples of endoscopic biopsy procedures include cystoscopy to collect tissue from inside your bladder, bronchoscopy to get tissue from inside your lung and colonoscopy to collect tissue from inside your colon. Depending on the type of endoscopic biopsy you undergo, you may receive a sedative or anesthetic before the procedure.

There is also an endoscopic ultrasound capability, In NET, this is commonly used for the pancreas and known as EUS. An endoscopic tube may also have a small needle to remove fluid or tissue samples (biopsy) for examination in a lab. This procedure is called EUS-guided fine-needle aspiration or EUS-guided fine-needle biopsy.  The EUS is also able to provide detailed images of the digestive tract and surrounding organs and tissues, including the lungs, gall bladder, liver and lymph nodes.

Surgical biopsy

Sometimes due to the location, your doctor may recommend a surgical biopsy if the cells in question can’t be accessed with other biopsy procedures or if other biopsy results have been inconclusive. Where possible, this is normally carried out by ‘keyhole’ surgery (laparoscopy).

During a surgical biopsy, a surgeon makes an incision in your skin to access the suspicious area of cells. Examples of surgical biopsy procedures include surgery to remove a breast lump for a possible breast cancer diagnosis and surgery to remove a lymph node for a possible lymphoma diagnosis.  Sometimes a surgical biopsy may remove all of the cells.

You may receive local anesthetics to numb the area of the biopsy. Some surgical biopsy procedures require general anesthetics to put you to sleep. 

Following a planned surgery to remove tumours, a tissue sample may be taken from the removed tumours to clarify or update the tumour grading and/or staging. 

Miscellaneous biopsies

Other biopsies are available but less commonly in NET.  

  • Skin biopsy – A skin biopsy removes cells from the surface of your body. A skin biopsy is used most often to diagnose skin conditions, including melanoma and other cancers. The type of skin biopsy you undergo will depend on the type of cancer suspected and the extent of the suspicious cells. This could include a type of Neuroendocrine Carcinoma known as Merkel Cell Carcinoma.  Different types of skin biopsies are used for specific purposes. 
    • Shave biopsy. Uses a tool similar to a razor to scrape the surface of your skin.
    • Punch biopsy. A circular tool removes a small section of your skin’s deeper layers.
    • Incisional biopsy. Involves the use of a scalpel to remove a small area of skin. Whether you receive stitches to close the biopsy site depends on the amount of skin removed.
    • Excisional biopsy. During an excisional biopsy, an entire lump or area of skin that appears suspicious is removed. You’ll likely receive stitches to close the biopsy site.
  • Bone marrow biopsy – this type is normally recommended based on your blood test results or if your provider suspects cancer is affecting your bone marrow which is inside some of your larger bones where blood cells are made. Analyzing a sample of bone marrow may reveal what’s causing your blood problem. A bone marrow biopsy is commonly used to diagnose a variety of blood problems, both cancerous and not cancerous. A bone marrow biopsy can diagnose blood cancers, such as leukemia, lymphoma and multiple myeloma. It can also detect cancers that started elsewhere and traveled to the bone marrow. You’ll receive a local anesthetic or other medicine to minimize discomfort during the procedure.

The biopsy confirmed a grade 2 Neuroendocrine Tumour (NET) in my liver which was considered metastatic.  That then confirmed the mass in my mesentery was indicative of a small intestine NET.  That has driven my treatment and surveillance for the past 13 years.  

I went on to have other biopsy experiences:

1. During recovery in hospital, I had a CT guided FNA fluid removal for a post operative seroma.
2. I had post-surgical tissue samples from my primary surgery and a later lymph node removal/exploratory biopsy (all clearly doubling up as the surgery). Read more here on the latter. 
3. I once had a bout of acid reflux and some tissue was taken via endoscopy. Thankfully that was clear. 


I am not a doctor or any form of medical professional, practitioner or counsellor. None of the information on my website, or linked to my website(s), or conveyed by me on any social media or presentation, should be interpreted as medical advice given or advised by me. 

Neither should any post or comment made by a follower or member of my private group be assumed to be medical advice, even if that person is a healthcare professional.   

Please also note that mention of a clinical service, trial/study or therapy does not constitute an endorsement of that service, trial/study or therapy by Ronny Allan, the information is provided for education and awareness purposes and/or related to Ronny Allan’s own patient experience. This element of the disclaimer includes any complementary medicine, non-prescription over the counter drugs and supplements such as vitamins and minerals.

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