To Biopsy or Not to Biopsy

Dr. Weeks’ Comment: We were all taught in medical school “When a diagnosis it at issue, we need to take some tissue.”  Has your doctor recommended a biopsy to clarify the diagnosis? If so< i bet he or she told you it is a safe procedure. No real risks.   Is that true? Is it safe to have a breast biopsy?  How about a skin biopsy?

Years ago, we clarified that the needle biopsy of a tumor of the prostate does spread cancer. At the time, all urologists denied this scientifically proven fact which was published in their own professional peer-reviewed Journal of Urology , May 1991. 145;1003-1007  Dr. Sheldon Bastacky and Dr. Patrick Walsh and Dr. Jonathan Epstein published an article entitled   “Needle biopsy Associated Tumor Tracking of Adenocarcinoma of the Prostate” giving an example of the needle biopsy spreading cancer. Dr. Ron Wheeler was the most outspoken critic of needless biopsy at the time – he wrote this.  Another medical colleague Dr. Diaz further criticized the process in this well written caveat.    

The problem of making an accurate diagnosis is real given the ambivalence about the merits of  the Prostate Specific antigen (PSA) test which I believe is with doing to see the pattern over time – especially to be vigilant for what we term PSA acceleration:  level of 0.4 for years then it bumps up to 1.6 and the next month up to 3.0 etc. As is the case with most aspects of medicine the trend is more significant than the present finding.

Now we have more proof that biopsy can spread cancer. So be fully informed as you go forward and insist that your doctor be honest in describing the risks and benefits of the proposed biopsy or at least the she or he keep up with the literature.

Risk of tumor cell seeding through biopsy and aspiration cytology

J Int Soc Prev Community Dent. 2014 Jan-Apr; 4(1): 5–11.

doi:  10.4103/2231-0762.129446

Author ShyamalaH. C. Girish, and Sanjay Murgod


There are two common methods of obtaining tissue from a tumor or lesion for the microscopic examination and diagnosis. One is biopsy, which is the removal of living tissue by surgical means and the other is aspiration of cells from the tumor with the help of a fine-needle (fine needle aspiration cytology [FNAC]). These procedures are associated with the risk of seeding tumor cells either into the interstitial tissue fluid from where they are carried to lymph nodes, or into the veins draining the tissue from where they enter the vasculature and may travel to lodge into any organ or tissue. There is also a risk of dragging cells along the surgical incision or needle track leading to the possibility of increasing the spread of cancer through biopsy.[1]

Cancer cells, besides reproducing uncontrollably, lose cohesiveness and orderliness of normal tissue, invade and get detached from the primary tumor to travel and set up colonies elsewhere. Dislodging neoplastically altered cells from a tumor during biopsy or surgical intervention or during simple procedure like needle aspiration is a possibility because they lack cohesiveness, and they attain the capacity to migrate and colonize.[1]

Every tumor cell is bathed in interstitial tissue fluid which drains into the lymphatic system and has an individualized arterial blood supply and venous drainage just like any other normal cell in our body. Whenever a needle for FNAC or scalpel for biopsy is inserted, the risk of dislodging a cell is high. The dislodged tumor cells may metastasize either through the blood stream or through the interstitial fluid.[1] Tumor cells are easier to dislodge due to lower cell-to-cell adhesion.[1] This theory with the possibility of seeding of tumor cells is supported by several case studies that have shown that after diagnostic biopsy of a tumor, many patients developed cancer at multiple sites and/or blood stream showed the presence of cancer cells.[2]

This review includes a review of articles from English literature and data from internet sources published between 1983 and 2012. In this review, we evaluate the risk of exposure to seeding of tumor cells by biopsy and aspiration cytology and provide some suggested practices to prevent tumor cell seeding.


Tumor seeding, whereby malignant cells are deposited along the tract of a biopsy needle, can have fatal consequences. More than 90% of cancer-associated mortality may be attributed to metastasis. Once cancer cells in a tumor attain metastatic potential it is a great challenge to treatment as it is difficult for one to discern the extent of systemic involvement by the tumor cells even though the primary tumors can be removed by surgical resection, chemotherapy or radiotherapy. Once in the circulation these metastatic seeds or the circulating tumor cells (CTCs) bring about dissemination to anatomically distant organs from a primary tumor.[40] Fortunately, tumor seeding is a rare occurrence, yet the issue invariably receives a high profile and is often regarded as a major contraindication to certain biopsy procedures. Although its existence is in no doubt, realistic insight into its likelihood across the spectrum of biopsy procedures and multiple anatomical sites is required to permit accurate patient counseling and risk stratification.[41]

We analyzed the data from Table 1 and have drawn inference based on the compiled data and made an attempt to provide suggested practices to reduce the risk of tumor cell seeding.

Data in the table leads us to infer two key findings;

  1. Risks are specific to some tumors: [Figures ​[Figures11 and ​and2]2] Breast cancers followed by liver malignancies with seeding complication have been reported more in literature may be relating to more risk with these tumor. In our review, 94% of breast cancers and 4% liver malignancies showed risk of seeding of tumor cells following biopsy or FNAC.

Figure 1

Bar chart showing risk of tumor cell seeding specific to type of tumor

Figure 2

Piechart with percentage of risk of tumor cell seeding specific to type of tumor

  1. Risks are localized to procedures:
    • Excisional biopsy associated with less seeding risk than Incisional biopsy: a procedure in which a tumor mass is removed in toto should carry little risk of spread as in Excisional biopsy with wide margins. The main risks of serious spread will apply with incisional biopsies, where a small portion of the large tumor mass is incised to carry out investigation on the biopsy tissue to arrive at a proper diagnosis before carrying out a definitive treatment.[4,42]
    • Procedures in which cancer itself is penetrated.
    • Improper handling of the tissue while making biopsy
    • Core needle shows more seeding risk when compared to fine-needle (FNAC) use.[42]
    • Repeated penetrations during needle procedure associated with increased seeding risk: Many a times to obtain sufficient amount of sample during needle biopsy for diagnosis the tumor may need to be penetrated several times. This repeated puncturing and manipulation inside the tumor mass with needle may seed tumor cells into the needle track and also may spill the cancerous cells directly in to the circulation.[2]


This study is an attempt to establish seeding risk and bring awareness among patients as well as health care workers. Support from more number of articles and long term follow-up of patients in whom these procedures have been performed may substantiate the results with more authority.

There are very few published data which give us information on the total number of patients undergoing biopsy or the needle procedures in given period of time and among these how many are actually showing tumor cell seeding. Hospitals, health institutions and research workers should work toward providing this data, which in reality will let us know if ‘seeding of tumor cells’ is worth all the attention.

Biopsy and aspiration cytology are the gold standards for the diagnosis of any tumor. They are age old and time tested practices. Cultivating the suggested practices while performing these procedures may make them risk proof.

Go to this link for the complete article. 




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