To whom should I refer a patient for a biopsy?

Referring Patients for Biopsy: Guidelines for Appropriate Specialist Selection

Patients requiring a biopsy should be referred to a radiologist with sufficient expertise to perform the procedure safely and manage any complications that may arise. 1

General Principles for Biopsy Referrals

Radiologist-Led Biopsies

• Radiologically-guided biopsies should be performed by or under the close supervision of an experienced consultant radiologist 1
• The radiologist must have sufficient expertise to:
  • Perform the procedure safely
  • Deal with any complications that may arise
  • Ensure adequate staffing for patient monitoring during and after the procedure 1

Multidisciplinary Approach

• For suspected primary bone tumors, a multidisciplinary approach including the radiologist and orthopedic oncologic surgeon should be followed 1
• For liver biopsies, proper communication between the requesting clinician, the operator, and the pathologist is essential 2

Biopsy Type-Specific Referral Guidelines

Lung Biopsies

• Refer to an interventional radiologist with experience in lung biopsies
• Pneumothorax complications decrease with operator experience 1
• The radiologist should have immediate access to:
  • Resuscitation facilities
  • Chest drain equipment 1
• Staffing must be adequate to monitor the patient for signs of distress during and after the procedure 1

Bone Biopsies

• For suspected primary bone tumors, refer to a center that will provide definitive treatment 1
• Core-needle biopsy is preferred over open biopsy due to:
  • Lower complication rates
  • Lower cost
  • Reduced risk of tumor seeding 1
• Biopsy should be performed by a musculoskeletal or interventional radiologist in collaboration with the surgeon who will perform the definitive resection 1

Liver Biopsies

• Refer to a radiologist experienced in liver biopsies
• For patients with coagulopathy, significant ascites, or dilated biliary tree, refer specifically for transjugular approach 1, 2
• For focal liver lesions, an 18G needle should be used; for non-lesional biopsies, a 16G needle is recommended 2

Special Considerations

High-Risk Situations

• For uncooperative patients, consider sedation with midazolam or general anesthesia 1
• For patients with extrahepatic biliary obstruction or bacterial cholangitis, avoid percutaneous approach due to risk of biliary peritonitis and septic shock 1, 2
• For patients with significant ascites, transjugular approach is preferred 1

Outpatient vs. Inpatient Procedures

• Percutaneous lung biopsies can be performed safely on an outpatient basis for appropriate patients 1
• "High risk" patients should not have biopsies performed as day case procedures 1
• For outpatient biopsies, patients should:
  • Live within 30 minutes of a hospital
  • Have adequate home support
  • Have access to a telephone 1

Common Pitfalls to Avoid

• Inadequate planning: Ensure the radiologist has access to all relevant imaging studies before the procedure 1
• Inappropriate needle selection: Use the correct needle size for the specific biopsy type 2
• Poor communication: Ensure proper communication between the requesting clinician, the operator, and the pathologist 2
• Improper biopsy route: For bone tumors, the biopsy route must be planned with the surgeon to ensure it lies within the planned resection bed 1
• Inadequate specimen: For liver biopsies, specimen length should be at least 20mm 2
• Insufficient monitoring: Monitor patients for at least 3 hours after liver biopsy, checking the biopsy site every 30 minutes for signs of bleeding 2

By following these guidelines, you can ensure your patients receive appropriate, safe, and effective biopsy procedures that maximize diagnostic accuracy while minimizing complications.