When is a biopsy indicated and what are the appropriate technique, pre‑procedure coagulation requirements, and post‑procedure care?

Biopsy: Indications, Technique, Coagulation Requirements, and Post-Procedure Care

When Biopsy is Indicated

Biopsy should be performed when non-invasive imaging cannot establish a definitive diagnosis, when tissue is required for treatment planning, or when histological confirmation would change management—but can be omitted in early-stage lung cancer patients proceeding directly to surgery where preoperative tissue adds unnecessary risk without altering treatment decisions. 1

Hepatocellular Carcinoma (Liver Lesions)

• For nodules ≥1 cm in cirrhotic patients: Biopsy is indicated when classical imaging hallmarks (arterial phase hyperenhancement with washout) are absent on multiphasic CT or MRI 1
• For nodules <1 cm: Follow with ultrasound at 4-month intervals; biopsy only if growth or changing pattern occurs 1
• Repeat biopsy is mandatory when initial histology is inconclusive, when histological findings contradict imaging (e.g., cirrhosis reported in a well-demarcated hypervascular lesion), or when lesions grow during surveillance without diagnostic imaging features 1

Lung Lesions

• New or enlarging solitary nodule/mass not accessible by bronchoscopy or when CT suggests bronchoscopy will be unsuccessful 1
• Multiple nodules in patients without known malignancy, with prolonged remission, or with multiple primary malignancies 1
• Persistent focal infiltrates after negative sputum, blood cultures, serology, and bronchoscopy 1
• Hilar masses following negative bronchoscopy 1
• Peripheral lesions (outer one-third): Use navigational bronchoscopy, radial EBUS, or transthoracic needle aspiration 1
• Central lesions: Bronchoscopy with or without EBUS is preferred 1

When Biopsy Can Be Avoided

• Strong clinical suspicion of stage I or II lung cancer in surgical candidates—proceed directly to surgery with intraoperative diagnosis to avoid added time, cost, and procedural risk 1
• Lesions definitively characterized as benign by MRI (lipomas, ganglions, hemangiomas, popliteal cysts) 2

Pre-Procedure Coagulation Requirements

All patients require coagulation screening before biopsy, with specific thresholds that constitute relative contraindications requiring hematology consultation before proceeding. 1

Mandatory Pre-Procedure Testing

• Prothrombin time (PT) 1
• Activated partial thromboplastin time (APTT) 1
• Platelet count 1

Relative Contraindications (Require Hematology Consultation)

• Platelet count <100,000/mL 1
• APTT ratio or PT ratio >1.4 1

Anticoagulation Management

• Oral anticoagulants must be stopped before percutaneous lung biopsy according to published perioperative anticoagulation guidelines 1

Additional Pre-Procedure Requirements for Lung Biopsy

• Recent pulmonary function tests (spirometry) are mandatory 1
• FEV1 <35% predicted is a relative contraindication requiring multidisciplinary team assessment before proceeding 1
• Recent chest radiographs and CT scans must be reviewed to determine appropriateness and must be available during the procedure 1

Biopsy Technique Selection

Core needle biopsy (CNB) is the preferred initial approach as it provides sufficient tissue for histologic diagnosis and eliminates the need for confirmatory biopsy in most cases, with higher diagnostic accuracy than fine needle aspiration. 3, 4

Technique Hierarchy by Diagnostic Accuracy

1. Open incisional biopsy: Highest diagnostic accuracy 4
2. Core needle biopsy (CNB): Higher accuracy than FNA, preferred initial approach 3, 4
3. Fine needle aspiration (FNA): Lowest diagnostic accuracy 4

Core Needle Biopsy Technique

• Obtain 3-5 cores to ensure adequate sampling 3
• Use image guidance (ultrasound preferred when possible, or CT) 1
• Place radiopaque marker/clip at biopsy site for small lesions that may be completely removed during sampling 3

Melanoma-Specific Requirements

• Complete excisional biopsy with 2-5 mm margin of normal skin including subcutaneous fat is mandatory for suspected melanoma on the sole 5
• Punch biopsies are contraindicated for melanoma as they prevent accurate Breslow thickness assessment and risk understaging 5
• Full-thickness elliptical excision oriented parallel to skin tension lines when possible 5

Musculoskeletal Tumor Considerations

• Biopsy tract must be planned to allow complete resection with the definitive surgery 6, 7
• Use longitudinal incisions in the direction of the extremity 7
• Select the shortest path between skin and lesion that avoids contaminating other compartments 7
• Meticulous hemostasis is critical as hematoma can contaminate the entire extremity 7

Multidisciplinary Decision-Making

• All patients with lesions should be discussed in a multidisciplinary meeting with respiratory physician and radiologist at minimum (for lung lesions) 1
• Risk-benefit assessment must be performed by the multidisciplinary team, especially for relative contraindications 1

Post-Procedure Care

An erect chest radiograph at 1 hour post-biopsy is sufficient to detect the majority of pneumothoraces after lung biopsy, with patients remaining in a monitored area where staff can be alerted to new symptoms. 1

Immediate Post-Procedure (Lung Biopsy)

• Erect chest radiograph at 1 hour post-biopsy 1
• Patients remain in monitored area for the first hour where staff can be alerted if symptoms develop 1
• No specific vital sign monitoring required unless complications develop 1
• Chest radiograph must be reviewed by a suitably qualified member of staff 1

Patient Education

• Inform patients of delayed pneumothorax risk 1
• Patients should not fly within 6 weeks of the procedure 1

Management of Pneumothorax

• If pneumothorax develops: Consider patient's clinical condition and home circumstances before deciding on chest drain placement versus observation 1
• Resuscitation facilities and chest drain equipment must be immediately available 1

Monitoring for Complications (If Complications Occur)

• Monitor and record: Pulse, blood pressure, and oxygen saturations in severely unwell patients 1

Expected Complication Rates (Lung Biopsy Benchmarks)

• Pneumothorax: 20.5% of biopsies 1
• Pneumothorax requiring chest drain: 3.1% 1
• Haemoptysis: 5.3% 1
• Death: 0.15% 1
• Operators should audit their own practice and achieve rates similar to or better than these benchmarks 1

Musculoskeletal Tumor Post-Procedure Care

• Compressive dressing to prevent postoperative hematoma 7
• Prohibit weight-bearing after biopsy of load-bearing bones if fracture risk exists 7
• Drains should be located in continuity with the skin incision or in direct extension of the wound 7

Common Pitfalls to Avoid

• Inadequate hemostasis during musculoskeletal tumor biopsy can contaminate the entire extremity with tumor cells 7
• Biopsy tract not aligned with planned definitive resection approach compromises future surgery 6, 7
• Shallow biopsies of melanoma carry significant risk of underestimating true depth and missing microinvasion 8
• Failure to obtain adequate cores (fewer than 3-5) may result in non-diagnostic samples requiring repeat biopsy 3