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Biopsy

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Can you tell us the process of how a biopsy sample is tested? My doctor said my lab report was flawed and I don't understand how this could happen.

Dr. Eric

When a piece of tissue arrives in the lab, there are more than 50 tests that CAN be run on it. Which ones get run, and how we handle the tissue depend entirely on what information we get with the tissue. If the doc clearly explains what he/she is looking for, the tissue will get divided and preserved for each of the tests that are ordered. We routinely process even TINY kidney biopsies for as many as 15 tests in 4 different preservatives, but we have to know what we are looking for, or the patient will hear "the lab screwed up".

When I hear that I know there is poor communication between the lab and the doc. The tests for fluorescent (not fluoroscopic) exam must be run on FRESH tissue, and must be examined immediately to get reliable results. It is true that the results can be vital to a proper diagnosis for many autoimmune diseases. It is extremely important that the doc lets the lab know that the tissue needs a fluorescent exam BEFORE the tissue arrives and is processed.

One more plug for the lab: studies have shown that about 80% of the decisions a doctor makes about a patient's care are based on lab results, but the cost of laboratory work is only about 4% of the total cost of health care in the USA. If you, or any other PAN pals have any questions about the lab, lab results, why lab tests are run, or even which labs do a better job with certain tests, let me know. I've spent my career working to make the lab the BEST part of the medical team.

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"Punch biopsy" may be less accurate. Eric said once that a "triple biopsy" is better. I think that means they biopsy the middle of the lesion (most likely to show active vasculitis), the edge of the lesion, and outside the lesion (where skin appears normal).

Also, with a triple biopsy, I think a different technique is used to get the biopsy -- more thorough and probably more painful. But more accurate than a punch biopsy. A dermatologist should do it. Eric -- please correct me if necessary! Linda.

Dr. Eric

Linda,

You are correct. Most dermatologists and pathologists like to have a "triple biopsy" for most skin lesions, especially for vasculitis.

The triple biopsy takes the first portion from the center of the lesion. This may show active vasculitis, but it may just show necrosis. The second portion is taken from the edge of the lesion. This is usually where the most active inflammation can be found. The third portion is taken from skin that does not show a visible lesion. This is a reference for what the normal skin looks like (everyone varies a little bit), but sometimes early inflammation can be seen in this portion.

Either a punch biopsy or an excisional biopsy can be used. Dermatologists and patients prefer the punch biopsy, but pathologists like to get as much tissue as possible, so they like the excisional biopsy (greedy docs that they are!)

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Eric can explain what a triple biopsy is. I believe he also knows to what level the MD should biopsy. I know the top layer or 2 of skin isn't enough! I think it's basically 3 biopsies in the area of a lesion.

Dr. Eric

As usual, Linda is right about the triple biopsy. It is a way of taking SKIN biopsies. In a triple biopsy, the doctor will take a piece of skin from the center of the lesion, a piece from the edge of the lesion, and a piece from outside the lesion. This gives the pathologist more tissue to make comparisons, and makes the diagnosis easier. Sometimes the damage is so extensive in the center of the lesion that it is difficult to determine just what is causing the damage, so the biopsy from the edge is more useful in these cases. The biopsy of uninvolved skin may show the pathologist a "background" that he can use to compare to the lesion.

Whether a punch biopsy or excisional biopsy is used depends on the extent and depth of the lesions, and is largely a judgement call on the part of the doc who is doing the biopsy. Note that the above is addressing SKIN biopsies. Generally only a single biopsy site will be used for nerve, arterial or kidney biopsies.

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Question

My doc says he's not sure if this is iron defic., anemia of chronic disease, both of those, or something else (i.e. something awful). I have lymphoma risk (Sjogren's) and leukemia risk (radiation). He says bone marrow Bx will help him arrive at a diagnosis. What's your opinion? Do you think he'll find out enough from a bone marrow to justify my going through it?

Dr. Eric

I think he's trying to rule out the "something awfuls", which are certainly a concern with your history. He may also be trying to confirm iron deficiency before starting the more aggressive therapy to prevent putting you into iron overload (plus Procrit is very expensive). The bone marrow bx is actually a fairly simple procedure. I've had it done three times (I'm a bone marrow donor). All three were done using only local (lidocaine) anesthesia, and all I suffered was some soreness and bruising at the site for a day or two. Not much different from bumping my hip against the corner of the kitchen counter (something I do at least once a month).

I'm not sure why he's reluctant to give you some mild sedation in addition to the local, unless he's concerned about the recovery period.

Some facilities may not have a place and/or personnel to monitor you until the sedation has worn off I just hope he asks the lab to do every possible test on the Bx. I am NOT going through this again for another 10 or 20 years. I'm sure he knows what to request. But I wish I knew what he should be asking for!

Ask if they are going to do flow cytometry on the bx to rule out leukemia/lymphoma. This is a much better test than just having the hematopathologist look at the smears. They should also look at the smears, because they can pick up other things from the morphology, but flow cytometry is the definitive method for leukemia/lymphoma.Ask him what he is looking for specifically. Ask how a positive finding will change the therapy and/or prognosis. Ask how a negative finding will change the therapy and/or prognosis. If there's no difference in the answers to the positive and negative questions, there is probably a shaky (or no) reason for doing the test, but I suspect it's a "rule out" situation.

Ask him why he won't or can't give you a sedative. "I don't think you need it" isn't an acceptable answer.Good luck. The procedure itself isn't all that bad, and it might give the docs a better picture to guide your treatment. I'll be praying for you.

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