We can’t tell someone they have cancer unless we’re sure. At the most, we can say there is a suspicion of cancer. It is not rare to hear patients or their family members say, “The doctors said it was cancer, but then it turned out to be nothing”. This happens when diagnostic suspicion is confused with diagnostic certainty; the biopsy generally provides this certainty.
Biopsy involves removing a small piece of tissue, usually from a suspect nodule or abnormal outgrowth, then analyzed under the microscope in order to see if it contains tumor cells.
A sample can be taken by means of a fine needle, a very large needle (tru-cut), a scalpel or, during endoscopy (of the lung, colon, rectum, bladder, etc.), special pincers.
Biopsy can be performed on any organ, including those most difficult to reach, such as the brain, bone and pancreas. Sometimes, even when there are clear danger signals, it is not sure which site should be biopsied; in such cases, it may be necessary to resort to so-called “exploratory surgery”, in order to find a representative lesion that can be biopsied, to reach a sure diagnosis. This means performing diagnostic laparoscopy or thoracoscopy. These procedures involve making a small incision in the abdomen / chest and inserting an instrument to look inside and take a sample of suspect tissue to be analyzed. Although the incision is small, this is still a surgical operation and requires hospitalization.
In other cases, the presence of liquid in the abdomen or chest can facilitate the diagnosis; this liquid can be drawn off fairly easily and analyzed to see if it contains malignant cells.
In short, taking a biopsy may be easy or difficult, depending on where the suspected tumor is and what technique is used. For instance, fine-needle aspiration of a subcutaneous or a breast nodule can be performed in the outpatient department and causes the patient little pain; by contrast, laparoscopy is a surgical operation and must be performed under general anesthesia while the patient is hospitalized.
When performing a biopsy, the general rule is: the sample should be taken from the most accessible site, by means of the least invasive technique possible and should give the greatest possibility of reaching a precise diagnosis.
The result of the biopsy may be:
- positive (indicating the presence of a tumor), thereby marking the beginning of the patient’s cancer disease;
- negative for the presence of a malignant tumor, thereby putting an end to the patient’s long-standing and justifiable anxiety;
- finally, it may be negative for cancer, in the sense that no malignant cells are found, but may still leave a doubt.
This can happen when, for example, the material collected is insufficient or is damaged during the biopsy procedure. Understandably, this causes a lot of frustration. The doctor must therefore decide whether to repeat the biopsy or to “make do” with the level of certainty obtained from the 4 clinical dimensions described in HAVING A SURE DIAGNOSIS.