Biopsy Procedures Guideline

Pre-Procedural Considerations

• 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, as recommended by the British Thoracic Society 1
• Radiologically-guided biopsies should be performed by or under the close supervision of an experienced consultant radiologist, with sufficient expertise to perform the procedure safely, deal with any complications, and ensure adequate staffing for patient monitoring during and after the procedure 1
• For suspected primary bone tumors, a multidisciplinary approach including the radiologist and orthopedic oncologic surgeon should be followed, as recommended by the National Comprehensive Cancer Network 2

Procedure-Specific Considerations

• Pneumothorax complications decrease with operator experience, highlighting the importance of referring patients to experienced interventional radiologists for lung biopsies 1
• The radiologist should have immediate access to resuscitation facilities and chest drain equipment, and staffing must be adequate to monitor the patient for signs of distress during and after the procedure 1
• Core-needle biopsy is preferred over open biopsy for suspected primary bone tumors due to lower complication rates, lower cost, and reduced risk of tumor seeding, as recommended by the National Comprehensive Cancer Network 2
• Biopsy should be performed by a musculoskeletal or interventional radiologist in collaboration with the surgeon who will perform the definitive resection, for suspected primary bone tumors 2
• The following table summarizes the recommended biopsy techniques:

Patient Selection and Management

• For patients with coagulopathy, significant ascites, or dilated biliary tree, a transjugular approach is recommended for liver biopsies, as suggested by the European Association for the Study of the Liver 3
• For uncooperative patients, consider sedation with midazolam or general anesthesia, and for patients with extrahepatic biliary obstruction or bacterial cholangitis, avoid percutaneous approach due to risk of biliary peritonitis and septic shock 3
• Contraindications or precautions for liver biopsy include extrahepatic biliary obstruction, uncooperative patient, bacterial cholangitis, significant ascites, amyloidosis, and pregnancy, as stated by the European Association for the Study of the Liver 3
• Special considerations should be taken for patients with coagulopathy, significant ascites, or low platelet count and/or prolonged prothrombin time, as stated by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 4, 3

Post-Procedural Care

• Percutaneous lung biopsies can be performed safely on an outpatient basis for appropriate patients, but "high risk" patients should not have biopsies performed as day case procedures, as recommended by the British Thoracic Society 1
• For outpatient biopsies, patients should live within 30 minutes of a hospital, have adequate home support, and have access to a telephone 1
• Monitor patients for at least 3 hours after biopsy, check biopsy site every 30 minutes for signs of bleeding, and discharge only if patient is hemodynamically stable with no evidence of bleeding, as recommended by the European Association for the Study of the Liver 3
• Provide written discharge instructions including activity restrictions and warning signs, and advise against strenuous physical activities for 48 hours after biopsy, according to the European Association for the Study of the Liver 3

Indications and Contraindications

• Liver biopsy is recommended when clinically important information about diagnosis, prognosis, or management cannot be obtained by safer non-invasive means, as stated by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases 3, 4
• Establishing a definite diagnosis is necessary when multiple etiologies are suspected, such as in patients with alcohol use disorder and abnormal liver tests who have co-existing liver disease, according to the American Association for the Study of Liver Diseases 4
• Guiding treatment decisions is crucial in cases where histology would change management, as stated by the European Association for the Study of the Liver 3
• Evaluating disease severity is necessary when non-invasive tests provide conflicting information, as recommended by the European Association for the Study of the Liver 3
• Chronic hepatitis B patients should consider biopsy if ALT is elevated to assess for moderate-severe necroinflammation or significant fibrosis, according to the Asian Pacific Association for the Study of the Liver 5
• Alcoholic liver disease patients should undergo biopsy when non-invasive tests are inconclusive or when suspicion of competing liver disease exists, as stated by the American Association for the Study of Liver Diseases 4

Avoiding Common Pitfalls

• Ensure the radiologist has access to all relevant imaging studies before the procedure to avoid inadequate planning 1
• For bone tumors, the biopsy route must be planned with the surgeon to ensure it lies within the planned resection bed, to avoid improper biopsy route 2
• Ensure proper communication between the requesting clinician, the operator, and the pathologist, as recommended by the European Association for the Study of the Liver 3
• Tissue blocks and slides should be stored for at least 30 years, and pathologists should have access to second opinions for biopsies performed outside specialist centers, avoiding overreliance on biopsy, inadequate specimen size, failure to communicate clinical context, inappropriate needle selection, and performing biopsy in high-risk situations, as recommended by the European Association for the Study of the Liver 3
• The risks of liver biopsy should be carefully weighed against clinical benefits and therapeutic consequences, as stated by the American Association for the Study of Liver Diseases 4
• Liver biopsy is subject to sampling error, variability in intra- and inter-observer interpretation, and carries a risk of complications such as bleeding and infection, with associated high medical costs, as noted by the American Association for the Study of Liver Diseases 6