Principles of Biopsy



1.  Provide representative sample

- to determine whether benign or malignant

- to determine cell line

- to grade lesion


2.  Not compromise definitive treatment




Last step in evaluation / after staging


Don't perform definitive procedure immediately after biopsy unless

- pre-operative & Xray information characteristic

- fresh frozen section unquestionably confirms diagnosis

- i.e. ABC, GCT


Usually biopsy, then definitive OT later


Open vs Closed


Overall, open preferred





- more tissue

- lower sampling error



- larger field to excise later

- higher local complications (i.e. infection, haematoma)


Needle Biopsy



- less expensive / less risky

- smaller field to excise later



- reduced accuracy 70-85% vs 95% with open



1.  Homogenous tissue expected - Myeloma

2.  Treatment unchanged by subtle differences - Soft Tissue Sarcoma

3.  Diagnosis relatively certain - Metastasis

4.  Access difficult - Spine, Pelvis

5.  Expert histologist available

6.  Patient not able to tolerate big surgery or GA


Complications biopsy tract

- wound contamination -> tumour recurrence

- wound dehiscence

- infection

- haematoma - always drain biopsies (haematoma spreads tumour)


Performed by treating surgeon at treatment centre




Mankin 1982 JBJS 

- complication rate x 5~12  when performed by other surgeon / other hospital

- 60% major error in diagnosis

- 20% treatment compromised by biopsy


Mankin and Simon 1996

- musculoskeletal tumour society

- follow-up study from 1982

- results no different from previous study

- 597 patients 21 institutions

- rate of diagnostic error 17.8%

- problems with biopsy causing change in treatment to more difficult or complex procedure 19.3%

- change in outcome attributed to biopsy 10.1%

- 18 patients had unnecessary amputation

- errors, complications and changes in course and outcome

- 2 - 12x more common than if biopsy done in referring institute instead of treatment centre

- 19.3% of biopsies planned poorly


Most common errors


Transverse incisions in soft tissue tumours

Needle biopsies only 60% accurate compared to 76% with open biopsy 




Not always possible to perform biopsy in treatment centre

- do so after review of case and imaging with tumour surgeon

- discuss optimum biopsy approach


Biopsy Technique




Tumour staging first / all imaging obtained

Images reviewed with experienced MSK radiologist

Treating surgeon does biopsy at treating hospital

- discussed with tumour centre if not possible

Ensure expert pathological facilities

- experienced MSK pathologist

- frozen section available

No pre-op antibiotics / infection always in DDx


- no exsanguination

- release before closure and obtain hemostasis




1.  Approach

- plan with future OT in mind

- all aspects of biopsy tract must be excised later

- incision must be incorporated in definitive surgery

- violate one compartment only / trans-muscular

- incision is longitudinal, no undermining skin edges

- don't expose NV structures

- meticulous haemostasis


2.  Biopsy

- round cortical windows / decreased stress-risers

- swab taken / tissue for M/C/S

- tissue for FFS / histology

- no closure until discussion with pathologist on phone

- ensure they have enough to make a definitive diagnosis / cell line / grade 


3.  Closure

- plug bone windows with PMMA / minimises tumour spread 

- achieve haemostasis

- closure in layers

- drain exit site in line with and through wound

- subcuticular suture to skin

- firm dressing

- immobilise 


Post operative


Very careful post op

- pathological fracture changes outcome


Team approach

- pathologist / radiologist / oncologists / radiation oncologist

- all results are reviewed to ensure correct diagnosis and management