Many types of biopsy exist. Click on a link below to go directly to a description of that type of biopsy:

• Aspiration or FNA Biopsy
• Cone Biopsy
• Core Needle Biopsy
• Suction Assisted Core Biopsy
• Endoscopic Biopsy
• Punch Biopsy
• Surface Biopsy
• Surgical Biopsy (or Excisional Biopsy)

The primary physician, radiologist, surgeon or other physician will determine the most appropriate method of biopsy and guidance based on various factors including:

• the tissue, organ or body part to be sampled
• how suspicious the abnormality appears
• the size, shape and other characteristics of the abnormality
• the location of the abnormality
• the number of abnormalities
• other medical conditions a patient may have
• the preference of the patient, and
• the imaging and biopsy systems available at a given hospital or healthcare location

Biopsies are usually guided by the method that identifies the abnormality best. Palpable lumps can be felt and therefore no additional guidance is needed in most cases. Lesions discovered by an imaging test, for example, mammography or CT, will often need biopsy that is guided by the modality that shows the lesion the best. For example, CT is usually the method of choice for imaging the lungs, so CT imaging is used to guide most lung biopsies. If an abnormality is seen well on multiple imaging tests, the modality that provides the safest, most accurate, fastest and/or least expensive route will be used to guide the biopsy. Lesions discovered by a screening test such as PSA may require blind sampling biopsy since there is often no focal visible or palpable abnormality to target.

Aspiration or FNA Biopsy is performed with a fine needle attached to a syringe. Aspiration biopsy is often referred to as Fine Needle Aspiration (FNA). FNA biopsy is a percutaneous (through the skin) biopsy. FNA biopsy is typically accomplished with a fine gauge needle (22 gauge or 25 gauge). The FNA procedure is often performed, for example, to diagnose nonpalpable breast abnormalities (Click here to learn more about FNA on the breast). FNA may be performed under image guidance such as ultrasound. The area is first cleansed and then usually numbed with a local anesthetic. The needle is placed into the region of the abnormality such as a cyst or tumor. Once the needle is placed, a vacuum is created with the syringe and multiple in and out needle motions are performed. The cells to be sampled are sucked into the syringe through the fine needle. Three or four samples are usually taken.

Before microscopic examination is made, the sample of fluid and cells is sometimes spun at high speed in a centrifuge (a device for separating substances in a liquid by spinning the mixture at high speeds) then a small amount is placed on a slide and covered with a plastic slip. A smear is prepared by spreading samples of fluid and cells onto glass slides. The specimens are then fixed (preserved) and stained to improve viewing. The preservation (fixing) is often performed by heating the slide with a Bunsen burner or by using a methanol solution. A cytologist (pathologist who examines cells) then uses a microscope to examine individual cells for abnormalities, paying particular attention to the size, shape and structure of the cell and cell nucleus.

Tumors of deep, hard-to-get-to structures such as the pancreas, lung, and liver are good candidates for FNA. Such FNA procedures are typically done by a radiologist under guidance by ultrasound or computed tomography (CT) imaging and usually require no anesthesia or only local anesthesia. Thyroid abnormalities are also excellent candidates for FNA.

Cone Biopsy removes a piece of tissue which is cylindrical or cone shaped. Cone biopsy is performed to diagnose cervical cancer. Cone biopsy is often done following a pap smear, colposcopy (examination of the cervix under illuminated magnification), and a punch biopsy.

After the tissue is removed, it is analyzed in the pathology laboratory to determine whether cancer is present. Cone biopsy may also be performed as a treatment if a cancer is small enough to be completely removed during biopsy. There are two main methods used to perform cone biopsy. The LEEP (also called LLETZ) method, short for loop electrosurgical excision procedure, removes the tissue by using a wire that is heated by an electrical current. Patients are given local anesthesia and the procedure can be performed quickly in a physician's office. Another method of cone biopsy involves using a surgical scalpel or laser to remove the tissue. This procedure typically requires general anesthesia and may be performed in a hospital or outpatient facility. However, an overnight hospital stay is not usually required.

The most common side effects of cone biopsy include cramping/discomfort and moderate or mild bleeding for a few weeks after the procedure. Patients should avoid sexual intercourse, tampons, and douching until the incision is completely healed, which may take several weeks. Patients should also discuss other possible side effects of cone biopsy prior to the procedure.

The advantages of cone biopsy are that it provides a large sample of tissue for analysis and it can sometimes completely remove the cancer so the patient does not need additional surgery. However, because complications from cone biopsy are possible, women should discuss all aspects of the procedure with their physician before undergoing biopsy. If a cone biopsy is recommended after abnormal Pap smear results, a patient may wish to ask if a colposcopy (looking at the cervix with magnification) or cervical biopsy would be an appropriate alternative for her (if they have not already been performed), based on her individual case.

Core Needle Biopsy (or core biopsy) is performed by inserting a small hollow needle through the skin and into the organ or abnormality to be investigated. The needle is then advanced within the cell layers to remove a sample or core. Needle biopsy is also a type of percutaneous (through the skin) biopsy. The needle may be designed with a cutting tip to help remove the sample of tissue. Core biopsy is often performed with the use of spring loaded gun to help remove the tissue sample.

Core biopsy is typically performed under image guidance such as CT imaging, ultrasound or mammography. The needle is either placed by hand or with the assistance of a sampling device. Multiple insertions are often made to obtain sufficient tissue, usually multiple samples are taken. Patients may experience a slight pressure, but usually do not experience significant pain. As tissue samples are taken, a click may be heard from the sampling instrument. The core tissue samples will be sent to the pathology laboratory for diagnosis. In some cases, the pathologist can attend the biopsy to examine imprints of the samples with a microscope. This can allows the pathologist to determine the adequacy of the sample and perhaps offer preliminary results.

Click here to learn more about core needle biopsy on the breast.

This mammogram image shows the vacuum assisted breast biopsy probe (Biopsys Mammotome) is positioned in the breast and aligned with calcifications (white specs above needle opening)

Vacuum Assisted Biopsy: Core biopsy is sometimes suction assisted with a vacuum device. This method enables to removal of multiple samples with only one needle insertion. Vacuum assisted core biopsy is being used more and more in breast biopsy procedures and is guided via stereotactic mammography or ultrasound imaging. However, unlike core biopsy, the vacuum assisted biopsy probe is inserted just once into the tissue through a tiny skin nick. Multiple samples are then taken using a rotation of the sampling needle aperture (opening) and with the assistance of suction. Click here for more information on vacuum assisted breast biopsy.

Endoscopic Biopsy is a very common type of biopsy. Endoscopic biopsy is done through an endoscope (a fiber optic cable for viewing inside the body) which is inserted into the body along with sampling instruments. The endoscope allows the physician to visualize the abnormality and guide the sampling. Endoscopic biopsy may be performed of the gastrointestinal tract (alimentary tract endoscopy), urinary bladder (cystoscopy), abdominal cavity (laparoscopy), joint cavity (arthroscopy), mid-portion of the chest (mediastinoscopy), or trachea and bronchial system (laryngoscopy and bronchoscopy), either through a natural body orifice or a small surgical incision. The endoscopist can directly visualize an abnormal area on the lining of the organ in question and pinch off tiny bits of tissue with forceps attached to a long cable that runs inside the endoscope.

Punch Biopsy is typically used by dermatologists to sample skin rashes, moles and other small masses. After a local anesthetic is injected, a biopsy punch, which is similar in function to a small (3 mm to 4 mm or 0.15 inch in diameter) version of a cookie cutter, is used to cut out a cylindrical piece of skin. The opening is typically closed with a suture (small stitches) and heals with minimal scarring. Punch biopsy may also be performed when removing small tissue samples from the cervix.

Surface Biopsy involves sampling or scraping the surface of a sore or tumor to remove cells for pathologic testing. Surface biopsy is often performed by dermatologists to remove a small piece of skin to test for carcinoma (cancerous tissue).

Surgical Biopsy (or Excisional Biopsy): surgical biopsy can be excisional (removal of an entire lesion) or incisional (removal of a piece of a lesion). Until about a decade ago, most biopsies performed were open surgical procedures. However, surgical biopsy is less common now. Surgical biopsies can be performed on abnormalities that can be seen or felt by the surgeon or pre-operative imaging can help provide a road map to the lesion. In cases of non-palpable breast lesions, a percutaneous wire can be placed in or near the lesion using mammogram or ultrasound for guidance. This marker wire provides a target for the surgeon. The removed tissue is then histologically analyzed by a pathologist (a special laboratory physician uses microscopic analysis of the tissue to determine its type).

Click here to learn more about open surgical biopsy on the breast.

Some types of tumors (such as lymphoma, a cancer of the lymphocyte blood cells) need to be examined whole to allow an accurate diagnosis. Thus enlarged lymph nodes are good candidates for excisional biopsy.

Surgical biopsy has some disadvantages versus percutaneous needle biopsy. Surgical biopsies require sutures (stitches) and can leave a disfiguring scar, they carry a small risk of mortality (due to risks of anesthesia) and moderate chances of bleeding, infection, wound healing problems and even fracture or migration of the localizing wire. Surgical biopsy usually requires one day of recuperation at home and usually is significantly more expensive than the alternative methods. Advantages of surgical biopsy include the ability to usually obtain a larger sample or complete removal of a lesion versus percutaneous methods. Bleeding encountered during a surgical procedure is easier to control than with percutaneous methods.

Updated: August 15, 2007

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