Principles of Tumor Biopsy

By Nicole Ehrhart

Tumor biopsy ts the cornerstone of sound therapeubc decision making in oncology. Although there are multiple ways to obtain a btopsy from any given tumor, each indtwdual procedure requires careful planning to ensure that the optimal treatment course is not compromised. Knowledge of the princtples and techntques underlying biopsy is tmperative to ensure an accurate dtagnosis with minimal morbidtty. Thts article descnbes the prmctples of biopsy and commonly used sampling techniques and where these procedures are most applicable. Appropriate tissue handling, interpretation of results, and some special techniques are also described. Copyright 1998 by W.B. Saunders Company

T many disease states in animals are highly dependent on

he correct treatment and determination of prognosis for

the treatment will eventually involve surgical removal of the mass. There is no evidence that a properly performed biopsy negatively impacts on survival or causes widespread dissemination of neoplasia. 1,2 On the other hand, performing a biopsy without consideration of future treatments may cause significant changes in the optimal treatment plan for the patient. In one study looking at bone and soft tissue tumors in human beings, more than 20% of patients had the optlmum treatment pathway changed as a result of a poorly planned biopsy. 3 This resulted in many undergoing amputations that otherwise would not have been necessary and negatively influenced survival outcomes in apprommately 10% of those patients. Clearly, an understanding of the principles of tumor biopsy is imperative to ensure the best possible care of each patient.

knowing the type, severity, and extent of disease. No place is this prmciple more important than in the treatment of the cancer patient. Histologic interpretation of a lesion is one of the most important initial steps in the staging and treatment of neoplasia; yet it is often done improperly or not at all. Surgery as a single treatment modality cures more cancer than any other therapy, and it is widely recognized that the first surgery is more likely to be curative than any subsequent procedure. While one-stage therapeutic removal and diagnosis has its indications, if performed without regard to tumor type or behavior, the optimal treatment course may be significantly compromised. Therefore it is important for the clinician to be aware of the indications and principles underlying tumor biopsy techniques to ensure that the procedure yields an accurate diagnosis with minimal detriment to the patient or treatment plan. Several biopsy techniques can be used for any given lesion. The procedure chosen depends on the clinician's skill and preference, location of the lesion, overall health of the animal, and treatment goals of both the clinician and owner. In general, biopsy techniques tend to fall into two categories based on the timing of the biopsy procedure: those done before the initiation of therapy (pretreatment biopsy) and those done at the time of definitive removal of the lesion (post-treatment or excislonal blopsy). For the latter category, histologic information ~s obtained after the entire lesion is removed. Cytologic preparations obtained by fine-needle aspirate are often helpful in guiding the selection of the best biopsy technique for a particular lesion. In general, for most externally accessible masses, it is best to biopsy before initiating treatment even if

General Principles for Tumor Biopsy

Indications for Pretreatment Biopsy
The indications for pretreatment biopsy are numerous. Pretreatment biopsy is indicated if the type or extent of treatment would be altered by knowledge of the tumor type or histologic grade. For example, a mass on the distal limb of a dog may be a benign skin tumor for which simple surgical excision would be curative, or a high-grade mast cell tumor requirmg extensive surgical margins and reconstruction. The two masses may be grossly indistinguishable, yet in the case of a high-grade mast cell tumor, simple surgical excision without regard to the tumor type may result in tumor ceils being left in the incision and may compromise the ability to achieve tumor-free surgical margins. Pretreatment biopsy is indicated if the lesion is located in a difficult area for reconstruction such as the periocular or perineal areas, distal limb or tail, or if the defimtive treatment carries significant risk to the patient (e.g., maxillectomy or hemipelvectomy). Finally, pretreatment biopsy is warranted when knowledge of the tumor type would change the owner's willingness to treat the pet. 145 For example, some owners would accept having their animal undergo an initially dangerous or disfiguring surgery for a condition with an optimistic prognosis for cure or long-term remission, but would decline the same surgery for a condition with a poorer prognosis. There are at least two instances in which pretreatment biopsy is contraindicated. The first is when knowledge of the tumor type would not change the choice of therapy. For example, a solitary lung or splenic tumor would mandate surgical removal regardless of histologic diagnosis in most cases. The second is when the biopsy procedure is as difficult or dangerous as the definitive surgery, such as with brain or spinal cord biopsy.

From the The Universtty of Illinois, Department of Chnmal Medicine, Urbana, IL. Address reprmt requests to Ntcole Ehrhart, VMD, MS, Dipl. ACVS, Department of Chnical Medicine, UniversW of Ilhnois, 1008 West Hazelwood Dnve, Urbana, IL 61802. Copynght 1998 by W.B. Saunders Company 0882-0511/98/1301-000358.00/0
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Clinical Techmques znSmallAnimal Practice, Vol 13 No 1 (February), 1998 pp 10-16

Biopsy Acquisition
Before beginning the biopsy procedure, the clinician should carefully examine the area. The clinician should avoid acquiring samples from areas of mflammation or necrosis. The underlying neoplastic process can be masked by tissue changes secondary to inflammation. Radiographs and other imaging techniques such as ultrasound, computed tomography (CT), or magnetic resonance imaging can be helpful in determining the extent of the lesion and its proximity to neurovascular structures, thus guiding the clinician to the best area for sampling. Often the best area for sampling is at the junction of normal and abnormal tissue. This allows the pathologist to see the transition between normal and neoplastic tissue. Primary bone tumors are an important exception to this principle, as they often have an extensive reactive process surrounding the primary lesion, and a small biopsy taken at the periphery ~s unlikely to yield an accurate diagnosis. Biopsy incisions should be made with subsequent therapeutic options in mind, particularly if these options may include radiation therapy or surgery. For example, a biopsy incismn on the distal limb should be oriented parallel to the long axis of the limb, thus allowing for simple excision at the time of definitive surgery. Incisions should be no larger than what is necessary to allow for adequate tissue sampling. Uninvolved tissue planes should be left undisturbed. Care should be taken to ensure that aseptic technique and meticulous hemostasis are followed. Formation of a seroma or fluid pocket can allow neoplastic cells to invade previously uninvolved tissue planes. Drains are generally avoided, as they will allow fluid that has been contaminated with neoplastic cells to contact all tissues through which the drain is placed, thereby enlarging the area that wall need to be excised or irradiated. If at all possible, the surgeon who will be performing the definitive surgery should also perform the biopsy 5 Larger biopsy samples tend to yield more accurate diagnoses. 14,5 Because tumors are not homogenous and contain areas of inflammation, necrosis, and reactive tissue, small biopsy samples may not be representative of the entire lesion. Therefore, one should obtain the largest sample possible to enhance correct diagnosis without compromising subsequent excisional attempts. Multiple biopsy specimens from different areas of the tumor should be submitted (preferably collected through the same incision) when using a needle biopsy instrument or other technique that yields specimens of small size. It is important to take care to preserve the original architecture of the tissue. Cautery and crushing instruments should not be used during the biopsy procedure, as these wall deform and distort tissues, making accurate diagnosis more difficult. Cautery for hemostas~s may be used once the sample is removed.

ment, a 25-gauge hypodermic needle can be used to transfer the specimen from the instrument trough to the biopsy container. It is also helpful to first place very small specimens on a dry piece of surgical glove paper and then place the paper with tissue attached into the specimen container. The sample will usually remain on the glove paper as it fixes, thus enabling the pathologist to easily locate it. Small samples should not be placed on surgical gauze, as it becomes difficult for the pathologist to remove them following fixation. Floating tissues (fat or lung) should be completely submerged to allow for fixation. Wrapping these types of tissues in gauze with a weight or small stone will sink them and keep them submerged as will placing a wad of gauze or paper in the top portion of the container to hold the specimen below the surface. Certain tissues such as bram, nerve, eye, and muscle may require special handling techniques and special fixatives. One should choose a laboratory experienced in interpreting and processing special tissues. It is important to contact the pathology laboratory before submitting special tissues to obtain specific handling instructions. For more details on biopsy sample handling, please refer to Chapter 2 of this issue.

Surgical Margins
Histologic evaluation of surgical margins is extremely important when determining the completeness of excision. 7 This is particularly relevant in terms of excisional biopsies. Because certain tumor types such as mast cell tumors, soft tissue sarcomas, and others have microscopic finger-like projections into the tissues surrounding them, one cannot be certain of completeness of excision based on gross mspection of the tumor bed after removal. In fact, "shelling out" a mass or taking very small margins of normal tissue may remove the parent mass, but leave the biologically most aggressive portion of tumor behind. Even tumors that seem well encapsulated are often surrounded by what is known as a pseudocapsule, a capsule-like structure that is actually composed of compressed tumor cells. Therefore, because it is impossible to determine the completeness of excision grossly, it is the clinician's responsibility to request margin evaluation and to aid the pathologist in discerning surgical margins. In some cases, such as with small dermal masses, the surgical margin may be obvious. In many cases, however, once the specimen has been placed in a container, fixed, removed at the pathology laboratory, sectioned, and mounted on a glass slide, the surgmal margin is much less apparent. Methods of surgical margin marking are discussed in detail in Chapter 4 of this issue.

Submitting Tissue and InterpretingResults

A veterinary-trained pathologist may be preferable over a pathologist trained in human tissue interpretation. Although many similarities exist between species, there are enough differences to cause interpretive mistakes. The clinician and pathologist must work as a team, each fulfilling certain responsibilities to ensure the most accurate diagnosis. It is the pathologist's job to provide the following information in the results report: histologlc diagnosis, benign versus malignant, surgical margins (if appropriate), and histologic grade (if available). Histologic grade is becoming increasingly important, as many oncologists use this classification for prognostic and treatment planning purposes. It is important for the clinician to interpret the hlstologIc diagnosis with the clinical

Sample Handling
Proper biopsy specimen handling is essential to ensure an accurate diagnosis. 6 After the specimen is removed from the patient, it is gently blotted to remove excess blood and body flmds. The specimen can be rinsed in physiologic saline if necessary. Rinsing in water is not recommended, as it will rupture cells. Cytologic impression smears can be obtained at this time. The tissue should be handled gently before fixauon, and further crushing should be avoided. For very small samples, such as those obtained with a needle biopsy instruPRINCIPLES OF TUMOR BIOPSY

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picture in mind. If the diagnosis does not fit with the patient or if the veterinarian has questions, a phone call to the pathologist is warranted. If all efforts to obtain an accurate diagnosis from the submitted specimen fail, a second biopsy is indicated. For more details on tissue submission and interpretation of results, please refer to Chapter 2 of this issue.

Biopsy Methods
Before biopsy, accessible lesions should be aspirated with a hypodermic needle arid placed on a glass slide for cytologic interpretation. Cytologic interpretation can greatly aid the clinician in choosing the biopsy method most suited to the particular lesion. 8 Cytology alone is generally not used in the definitive diagnosis of neoplasia because information about histologic architecture and grade cannot usually be ascertained. The following represent brief overviews of the more common techniques used for biopsy. 4 5 Table 1 lists options for biopsy techniques based on tumor location.

The outer sleeve is then advanced, which severs the tissue sample and traps it inside the trough. The entire instrument is removed. The tissue sample is recovered by retracting the outer sleeve. Sutures are often unnecessary. This method yields a specimen approximately 1.5 m m wIde and 0.5 to 2.0 cm long. Several tissue samples from various regions in the mass should be obtained to ensure adequate representation. The skin incision and biopsy tract should be entirely removed at the time of surgical removal.

Punch Biopsy
This technique ]s done with a skin punch instrument (Fig 2). It is most commonly used for cutaneous lesions, as these instruments do not effectively sample tissues below the dermis. 4,5,9 Instrumentation includes punch biopsy instrument, 2% lidocaine, atraumatic thumb forceps, and scissors. The lesion is prepared as described for the needle biopsy instrument. The skin is anesthetized with 2% lidocalne. The punch biopsy instrument is applied to the skin and downward pressure is exerted. A twisting motion is used to penetrate the tissue, and the instrument is buried up to the plastic hub. The instrument is removed and the specimen is gently lifted and cut with scissors at its base. Care is taken not to deform the tissue as the base is severed. This procedure yields a cylindrical specimen 2 to 6 m m in diameter depending on the diameter of the punch instrument. One or two simple interrupted skin sutures are used to close the defect. The entire defect is removed at the time of excislonal surgery.

Needle Core Biopsy

The needle core instrument (Fig 1) is most commonly used alone for externally accessible masses or with ultrasound guidance for deeper tissues such as liver, prostate, or kidney. Subcutaneous and dermal masses can often be biopsied with the animal awake and lightly sedated provided the patient is cooperative. The instrumentation needed is as follows: a needle core biopsy instrument (Tru-Cut instrument or similar [Tru-cut biopsy needle, Travenol Laboratories, Inc, Dearfield, IL]), 2% lidocaine, and a number l l scalpel blade. 4,5,9 The lesion is clipped of hair and aseptically prepared. Using sterile technique, the lesion is immobilized with one hand, and the skin overlying the tumor is anesthetized with lidocame. Because tumor tissue is often poorly innervated, the mass itself may not require any anesthesia. A 1 to 2 m m stab incision is made in the skin to allow the instrument to pass through easily. The instrument is introduced into the mass. With the outer sleeve held in place, the needle is thrust forward into the mass

Incisional Biopsy
This method is used when a larger tissue sample is desired. It is preferred over the needle core or punch biopsy methods when the lesion is highly ulcerated or inflamed. The skin overlying the lesion is clipped of hair, aseptically prepared, and draped. In some cases, inclsional biopsy can be performed on a sedated animal using local anesthetics, especially if the skin overlying the lesion is highly ulcerated. For deeper lesions or lesions of the face, mouth, or genital area, general anesthesia is usually necessary. With the use of standard surgical equipment, a wedge of tissue is removed from the mass. It is important to ensure that the lesion itself is sampled and not just overlying skin or fat. Hemostasis can be achieved using electrocautery once the specimen is removed. The incision is oriented with subsequent surgical excision in mmd. Sutures are used to close the skin and eliminate dead space. 4,5

TABLE 1. Application of Individual Biopsy Techniques for Specific Tumor Locations Mass Location Skin Subcutaneous/ Intramuscular Oral Bone Technique Inclslonal Punch Excisional Needle core Open (wedge) Incisional Punch Exctsional Needle core (Jamshldi) Open (Trefine curette) Nasal Abdominal Core punch (Straw) Curette Needle core Endoscopic Exploratory (mclslonal, excisional) Needle core Thoracotomy (inclsionat, exclslonal) Comments Border of normal/abnormal Avoid ulcers/necrosis Only m select cases Accessible (palpable) masses Cystic/hemorrhagic masses Mucosa and bone Avoid lip margin Benign gingival lesions Center of radiographic lesion Fracture rtsk for lytlc lesions Measure from nares to medial canthus Ultrasound guidance Superficial samples Mediastinal masses

Excisional Biopsy
Excisional biopsy can be both diagnostic and therapeutic. It is best used for small cutaneous masses where reexclsion (with 2 to 3 cm margins in all directions) can be easily attained or when aspiration cytology clearly indicates a benign lesion (e.g., hpoma). Exclsional biopsy should be performed with adequate margins for all tumors. This involves removing a cuff of normal tissue around the lesion. It may be prudent to separate portions of the sample for culture and sensitivity or special stains in some cases. If this is done, it should be planned in such a way that surgical margins are not disturbed. As mentioned previously, marking surgical margins is important to determine the completeness of resection. 4,5
NICOLE EHRHART

Intrathoracic

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Lymph Node Biopsy

Biopsy of a lymph node is often necessary to diagnose or stage a neoplastic process. A fine needle aspirate can be performed before biopsy to aid in determining the cause of lymphadenopathy. Caution must be used when interpreting palpation of submandibular lymph nodes, as they are often enlarged in the normal animal and are closely associated with the salivary glands, which, when aspirated, may resemble neoplastic cells. 9 Perhaps the most common situation in which lymph node biopsy is necessary is in the differentiation between lymphoma and lymph node hyperplasia. 9 In this case, lymph node excision is often ideal because it affords the pathologist the opportunity to inspect the lymph node architecture. A superficial lymph node is chosen in an easily accessible area. General anesthesia is required. Hair is clipped and the area is aseptically prepared. After draping, the lymph node is palpated through the skin and isolated between the surgeon's fingers. An incision is made over the lymph node, and the loose connective tissue and fat surrounding the lymph node is bluntly dissected until the node can be visualized. Vessels leading into and away from the lymph node are ligated, and the node is removed in its entirety. The subcutaneous and skin layers are closed. Occasionally lymph nodes in a region proximal or distal to a tumor are enlarged, and biopsy may be required for staging purposes. If the tumor will be treated with radiation therapy or surgery, the lymph node biopsy must be planned with the definitive procedure in mind so as to not contaminate an otherwise clean field.
\

Bone Biopsy
Bone biopsy is often essential to differentiate between neoplasia and infectious etiologies. The two most common instruments used for bone biopsy are the Michelle trephine (Michelle trephine, Kirschner Co., Tlmbinum, MD) and the Jamshiditype bone marrow biopsy needle (Jamshidi bone marrow needle, American Pharmaseal, Valencia, CA) (Figs 3 and 4). When used properly, both methods provide suitable biopsy specimens. Although the trephine method has the advantage of yielding a large sample size, the Jamshidi method does not require a surgical approach thereby minimizing soft tissue disruption. In addition, it leaves a considerably smaller cortical defect, making the risk of biopsy-related fracture less likely than with a trephine.i Both techniques require general anesthesia and strict aseptic technique. Radiographs of the lesion should be available for reference during the biopsy procedure. Skin incisions are planned carefully so that their placement does not interfere with subsequent surgery. If a limb-sparing procedure is to be considered, it is important to contact the referral institution where the definitive surgery is planned before performing the biopsy. The Jamshidi method requires a 1 to 2 mm stab incision in the skin overlying the tumor. The center of the lesion is located using radiographic and anatomic landmarks. The needle is advanced through the soft tissues until it contacts bone. The styler is removed and the needle is advanced into the bone using a twisting motion. Once it is firmly embedded in the bone, a rocking motion is used to allow the sample to break off within the needle. The needle is withdrawn and the specimen is forced out through the base (not the tip) using a probe that is provided with the needle. The needle can be redirected through the same stab incision to collect four to five additional

"!t

'C_t

Fig 1. (A) Needle core biopsy instrument (Cook, Inc., Bloomington, IN). Technique for True-Cut biopsy. A small skin incision is first made over the mass. (B) With the instrument closed, the outer capsule is penetrated. (C) The outer cannula is fixed in place and the inner cannula with specimen notch is thrust into the tumor. Tissue then protrudes into the notch. (D) The inner cannula is now fixed while the outer cannula is moved forward to cut off the biopsy specimen. (E) The entire instrument is removed and closed with tissue within. (F) The inner cannula is pushed ahead to expose tissue in specimen notch. (Reprinted with permission from Withrow SJ, Lowes N: Biopsy techniques for use in small animal oncology. J Am Anim Hosp Assoc 17:889-902, 1981 .s)
PRINCIPLES OF TUMOR BIOPSY

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specimens. The biopsy specimens are placed in 10% formahn. One simple interrupted suture is used to close the skin. Due to their small size, Jamshidi specimens require little to no decalcification at the pathology laboratory. This allows for rapid processing and quicker turnaround time. The trephine method requires a small surgical approach to the involved bone. Hemorrhage should be carefully controlled and soft tissue disruption minimized as much as possible. The instrument is applied directly to the bone, and a twisting motion is used to advance the instrument into the lesion. The instrument is rocked to allow the specimen to break off. The specimen is then removed from the hollow core of the instrument and placed in 10% formalin. The skin and subcutaneous layers are closed. Unlike the Jamshidi biopsy, trephine specimens require decalcification at the pathology laboratory. An additional way to acquire a bone biopsy is to use a bone curette. This technique requires a surgical approach to the bone. The curette is used to scoop out bony pieces, which are then placed in 10% formalin and processed by the pathology laboratory.

Nasal Biopsy
Biopsy of tumors within the nasal cavity requires that the patient be anesthetized and intubated with the cuff of the endotracheal tube inflated to prevent aspiration of blood. A number of procedures have been used to procure nasal biopsies. In medium to large dogs, a technique using a rigid plastic tube such as the outer sleeve of a Sovereign intravenous catheter (Monoject, Division of Sherwood Medical, St. Louis, MO) or any large-gauge (14- or 16-gauge) over-the-needle intravenous catheter, n The actual catheter portion is discarded and the metal stylet is cut off at the hub using bandage scissors. The hub should be able to connect securely to the outer plastic sleeve. A 12 mL syringe is attached to the hub of the needle. Radiographs or a CT scan should be available for reference during the procedure. The plastic sleeve is measured from the medial canthus of the eye to the tip of the nose. The sleeve is cut off at this point so that its length does not exceed that distance. This is done to prevent inadvertent disruption of the cribriform plate and entrance into the brain. The plastic tube is introduced past the wing of the nostril using ventral and medial pressure. The tube is advanced within the nasal cavity to the location of the tumor and then repeatedly reamed in and out of the tumor while suction is applied to the 12 mL syringe. Hemorrhage is considerable but self-limiting and should not deter the chnician from being aggressive. The tube is removed from the nose, the 12 mL syringe is removed and filled with air, and the specimen is blown out of the sleeve onto a gauze sponge to allow excess blood to dram off. Tumor tissue is usually tan or gray with areas of hemorrhage and mucus. Specimens are placed in 10% formalin. For smaller animals such as cats, small dogs, and brachycephalic animals, a curette can be used to obtain a nasal biopsy. 11 The instrument must not be introduced farther than the distance from the tip of the nose to the medial canthus of the eye. Surgical sponges can be placed above the soft palate to prevent tissue from being flushed into the nasopharynx. The curette is introduced into the nasal cavity, and a scooping motion is used to dislodge tissue. Cool saline is then pulsed into the nose with a flexible red rubber tube to flush out the specimens. The surgical sponges are removed from above the
NICOLE EHRHART

[3

Fig 2. (A) Punch biopsy instrument (Baker CummonsmKey Pharmaceuticals Inc., Miami, FL). Mechanism of Keyes biopsy punches. (B) Punch is rotated back and forth over lesion to desired depth (preferably at junction of normal and abnormal tissue), (C) Punch is removed (or angled across base to cut deep attachments). (D) Specimen can be elevated with forceps and deep attachments cut, Reprinted with permission from Withrow SJ, Lowes N: Biopsy techniques for use in small animal oncology. J Am Anim Hosp Assoc 17: 889-902, 1981 .s)

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Fig 3. Trephine instrument for biopsy of bone (Sherwood Medical, St Louis, MO).

soft palate and inspected for tissue fragments. All tissue is submitted for hlstopathologic evaluation. Mild postoperative hemorrhage is noted for several hours after surgery. This can be aggravated by sneezing or a dysphoric recovery. Animals need to be recovered under supervision in a quiet, calm environment overnight or for several hours after the biopsy procedure. These techniques are safe, have minimal morbidity when compared to open biopsies, and yield excellent specimens. H

Endoscopic/LaparoscopicBiopsy
Endoscopic and laparoscopic techniques may be used for biopsy. They have several advantages and, when used properly, have greatly enhanced the ability to achieve a diagnosis without invaswe surgery. They are ideal for staging purposes when all diagnostics point to diffuse, nonresectable disease or when an open procedure is either particularly dangerous or not desired} ,4,5 These techniques are particularly useful for the diagnosis of diseases that involve hollow organs and airways. They also have some important limitations. Endoscopic techniques used for hollow organ (e.g., bladder, bowel) biopsy are limited in that the operator can Inspect and biopsy only the mucosal and submucosal layers. Sample sizes obtained using
PRINCIPLES OF TUMOR BIOPSY

Fig 4. (A) Technique for Jamshidi bone biopsy showing multiple cores taken from center of lesion. (Reprinted with permission from Powers BE, LaRue SM, Withrow SJ, et ah Jamshidi needle biopsy for diagnosis of bone lesions in small animals. J Am Vet Med Assoc 193:205-210, 1988.1) (B) Jamshiditype biopsy needle (American Pharmasea Valencia, CA).

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cases. Because the process requires specialized personnel and equipment, its application is currently limited to large referral institutions. If a frozen section is desired, the pathologist and laboratory need to be notified in advance. The fresh specimen is given directly to the laboratory within a few minutes of acquisition. The laboratory technician or pathologist trims, freezes, and stains the sample, which is then examined by a pathologist. Overall accuracy is 93%.12 Turnaround time can be as little as 20 minutes.

Conclusion
A properly planned, executed, and interpreted biopsy is the cornerstone of good oncologic practice. Veterinary oncology has experienced an explosion of growth in the last decade. 4 Veterinarians are faced with meeting the needs of a public who have access to unlimited information through the Internet and other information networks. Therefore, the demand for stateof-the-art care for the pet with cancer is on the rise, and It is the veterinarian's responsibility to help pet owners make an informed choice between the many available treatment options. Advances in areas such as specialized surgical oncology, new chemotherapeutic agents, biologic response modifiers, and radiation therapy have allowed the veterinary oncologist to make huge strides in improving the quality and quantity of life for the veterinary oncology patient. At the core of quality care is accurate diagnosis, and at the foundation of accurate oncologic diagnosis is the well-executed and properly timed biopsy.

Fig 5. The core punch technique of nasal biopsy. (A) A measurement is first made from the external nares to the medial canthus and this distance marked on the instrument. (B) The instrument is inserted into the nasal cavity to the level of the tumor. Aspiration (negative pressure) is applied to the attached syringe. (C) The instrument is withdrawn and the sample strained through gauze and placed in formalin. (Reprinted with permission from Withrow SJ, Susaneck SJ, Macy DW, et al: Aspiration and punch biopsy techniques for nasal tumors. J Am Anim Hosp Assoc 21:551-554, 1985.11)

References
1. Withrow SJ, MacEwan EG. Small Animal Clinical Oncology (ed 2) Philadelphia, PA, W.B Saunders, 1996 2. Withrow SJ: Risks associated wtth biopsies for cancer, in Kirk RW, Bonagura JD (eds): Kirk's Current Veterinary Therapy XII (Small Animal Practice). Philadelphia, PA, W.B. Saunders, 1995, pp 24-26 3. Meller I, Moses M: Tumor existence in biopsy m biopsy scar tissue as seen after definitive resection of soft tissue and bony tumors, in Brown KLB (ed): Comphcatlons of Limb Salvage, Prevention, Management and Outcome. International Symposium on Limb Salvage, 1991 pp 335 4. Wlthrow SJ: Three rules of good oncology: Biopsy, biopsy, blopsyl J Am Anlm Hosp Assoc 27 311-314, 1991 5, Wlthrow SJ, Lowes N: Biopsy techniques for use in small animal oncology. J Am Anim Hosp Assoc 17:889-902, 1981 6. Weisbrode SE: The pathology laboratory in the diagnosMsof neoplasla. Proc Kal Kan Symp 17-20, 1987 (abstr). 7. Abide JM, Nahai F, Bennett RG: The meaning of surgical margins. Plast Reconstr Surg 73:492-496, 1984. 8. Allen SW, Prasse KW: Cytologic diagnosis of neoplasia and perloperative implementation Compend Contin Educ Pract Vet 8"72-80, 1986. 9. Ogdvle GK, Moore AS: Managing the Veterinary Cancer Patient. Trenton, NJ, Veterinary Learning Systems, 1995 10. Powers BE, LaRue SM, Wlthrow SJ, et al: Jamshidi needle biopsy for diagnosis of bone lesions m small animals. J Am Vet Med Assoc 193:205-210, 1988 11. Withrow SJ, Susaneck SJ, Macy DW, et al: Aspiration and punch biopsy techniques for nasal tumors. J Am Anlm Hosp Assoc 21:551554, 1985 12. Whltehalr JG, Gnffey SM, Olander HJ, et al: The accuracy of intraoperatJve diagnosis based on examination of frozen section: A prospective companson with paraffin embedded sections. Vet Surg 22:255, 1993

these methods are small, requiring that several samples be submitted. The clinician must keep in mind that a diagnosis of inflammation does not rule out neoplasia if full-thickness biopsies cannot be obtained. Most endoscopic and laparoscopic biopsy procedures require general anesthesia. Operative time is highly variable depending on the experience of the operator and in some cases may not be any faster than an open procedure. When using laporoscopic techniques for biopsy of a mass within the thoracic or abdominal cavity, one must always consider that uncontrolled hemorrhage or leakage of fluid from the tumor may enhance tumor seeding if neoplastic cells are allowed to contact peritoneal or pleural surfaces. In addition, options for definitive resection through an endoscope or laporoscope are limited. Therefore, in cases of solitary masses in the abdominal or thoracic cavity, the patient may be best served by an open procedure that can allow for definitive treatment at the time of diagnosis.

Frozen Sections
The use of frozen sections is becoming more widespread in veterinary medicine. This technique allows for a rapid diagnosis while the patient is still in surgery. It can be used to differentiate between malignant and nonmalignant lesions, determine the completeness of surgical margins, and accurately and specifically identify the pathologic process in many

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NICOLE EHRHART