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Last Modified September 15, 2022
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What Is a Mesothelioma Biopsy?

A mesothelioma biopsy is a medical procedure used to remove a sample of tissue to examine for signs of mesothelioma cancer. It is performed in combination with imaging scans and blood tests to diagnose mesothelioma. A biopsy is the most accurate way to confirm the presence of cancerous cells.

There are two primary steps in a biopsy: Collection of tissue samples and testing of those samples. Once suspicious tissue is collected, a pathologist then views the sample under a microscope to determine if cancer is present.

Mesothelioma Biopsy Facts

  • Involves removing tissue that may be cancerous for microscope analysis
  • Necessary for accurate mesothelioma diagnosis
  • Video-assisted thoracoscopic surgery (VATS) is most common for pleural mesothelioma
  • Fine-needle aspiration is used for peritoneal mesothelioma

Can Mesothelioma Be Diagnosed Without a Biopsy?

No, mesothelioma cannot be diagnosed without a biopsy. A mesothelioma biopsy is necessary to confirm the specific cell type of mesothelioma a patient has. Doctors can easily mistake mesothelioma for common benign illnesses or other types of cancer with similar cell characteristics, which is why biopsy testing is essential to confirming the diagnosis. It can take several days to a week or more to receive biopsy results.

Patients considered at risk of peritoneal mesothelioma commonly undergo a fine-needle aspiration biopsy, while video-assisted thoracoscopic surgery is more effective for patients at risk of pleural mesothelioma.

Endoscopic Mesothelioma Biopsies

Endoscopic biopsies are noninvasive procedures that involve inserting a small tube with a camera into the body to visualize tissue to be collected for testing. An endoscope is a thin, tube-shaped instrument with a light and a camera on the end that is used to look inside the patient’s body without the need to make a major incision.

Endoscopic Biopsy Procedure

  1. General anesthesia is given to the patient.
  2. The surgeon inserts an endoscope into the chest or abdominal cavity. The camera is used to identify tissue that appears cancerous for collection.
  3. A built-in tool is used by the surgeon to extract tissue samples, and other thin surgical tools guided by the camera might be used. Once samples have been collected, the endoscope is removed (which may involve sealing an incision, depending upon the procedure).
  4. The patient then goes to a recovery room for monitoring while the anesthesia wears off.
  5. Tissue samples are sent to a pathology lab for analysis.

Types of Endoscopic Biopsies for Mesothelioma

Thoracoscopy

A surgeon inserts an endoscope between the ribs to remove excess fluid, examine the appearance of the inside of the chest and take tissue samples. This procedure is performed on patients suspected of having pleural mesothelioma.

Mediastinoscopy

A surgeon inserts an endoscope at the base of the neck to obtain tissue samples of the lymph nodes around the windpipe. This can help diagnose cases of pleural mesothelioma, and it can provide evidence to determine the stage of mesothelioma.

Laparoscopy

A surgeon makes an abdominal incision then inserts an endoscope to examine the abdominal cavity and collect samples of suspicious tissue. This procedure is performed on patients suspected of having peritoneal mesothelioma.

Video-Assisted Thoracoscopy (VATS)

Thoracoscopic biopsy has a remarkable track record of accurate pleural mesothelioma diagnoses because it allows doctors to see into the pleural space to evaluate cancer spread and retrieve multiple tissue samples.

In a 2008 study of 45 malignant mesothelioma patients, researchers compared the accuracy of several biopsy techniques. Thoracoscopy was associated with the highest diagnostic accuracy, confirming a diagnosis in 95% of patients with the disease.

A 2021 study published in Anticancer Research confirmed that a thoracoscopy remains the most accurate biopsy technique in diagnosing pleural mesothelioma.

Fine-Needle Biopsy for Mesothelioma

A fine-needle aspiration is a quick and safe biopsy procedure that uses a long, hollow needle attached to a syringe to remove up to 10,000 sample cells for analysis. Under local anesthesia, a small needle is inserted using imagery from a CT scan or ultrasound.

This biopsy technique can be performed for pleural or peritoneal mesothelioma, and it is the common biopsy technique for the latter. Needle biopsies are not as effective for diagnosing pleural mesothelioma as thoracoscopic surgery, with an overall diagnostic sensitivity around 80%. A risk associated with fine-needle aspiration includes hemothorax, which is when blood collects in the pleural space between the chest wall and the lung.

Percutaneous Needle Core Lung Biopsy: An illustration depicts a needle passing through layers of skin and muscle tissue to enter the lung and extract cellular fluid for a biopsy sample from a target mass.

Fine-Needle Biopsy Procedure

  1. The patient’s skin is cleaned and local anesthesia is applied to the area where the needle will be inserted. The patient will be positioned so that the doctor can easily perform the procedure.
  2. An ultrasound or CT scan may be used to determine where to insert the needle. The doctor will then insert the needle into the chest or abdominal cavity to extract tissue. The needle is attached to a syringe that contains a vacuum to collect tissue samples. The procedure is typically performed in less than 10 minutes.
  3. Once the needle is removed, the incision is cleaned and bandaged. No sutures are needed.
  4. Tissue samples are sent to a pathology lab for analysis. It could take several days to a week or longer to get results.
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Similar Procedures

While not considered true biopsy procedures, a thoracentesis and paracentesis are treatments for fluid buildup around the lungs and abdomen, respectively, that can provide fluid biopsy samples.

Thoracentesis

Performed under local anesthesia, this procedure drains fluid from around the lungs. A doctor uses an ultrasound probe to guide a small needle between the ribs in the back to remove pleural fluid buildup. It only collects fluid, not tissue, so it cannot provide an official mesothelioma diagnosis. It is used to determine the cause of pleural effusions.

Paracentesis

This procedure removes fluid buildup in the peritoneum. It is performed the same way as a thoracentesis, but in the abdomen. It can determine the cause of ascites, or fluid buildup in the peritoneum, but it cannot provide an accurate diagnosis for mesothelioma because it does not collect tissue samples.

A fine-needle aspiration procedure provides a tissue biopsy that can accurately diagnose mesothelioma cancer, while a thoracentesis and paracentesis provide fluid biopsies that can only determine the cause of fluid buildup (pleural cytology).

Surgical Mesothelioma Biopsies

Tissue samples collected during surgery are called surgical biopsies. These are not very common for peritoneal mesothelioma, and they are extremely uncommon for pleural mesothelioma.

Types of Surgical Biopsies for Mesothelioma
Laparotomy

Exploratory surgery of the abdomen involves a laparotomy, which opens the abdomen and allows surgeons to collect tissue samples and remove suspicious tissue. Exploratory surgery is safer to perform on the abdomen compared to the chest, which is why some cases of peritoneal mesothelioma are discovered through surgery and next to zero cases of pleural mesothelioma are discovered through surgery.

Thoracotomy

A thoracotomy allows surgeons to open the chest to collect tissue samples. This procedure is generally not performed on patients suspected of having cancer in their chest, including pleural mesothelioma patients.

When surgery is performed on patients with pleural mesothelioma, surgeons attempt to remove as much of the malignant mesothelioma cancer as possible. This procedure provides the most tissue for analysis, which can help to determine the cell type of a mesothelioma tumor.

In some instances, it is not possible to perform a thoracoscopic biopsy as there is no pleural space and tumors have grown all around the lung. If that happens, a percutaneous needle biopsy is possible but will provide a small sample. 

The alternative is to perform an open pleural biopsy through a limited incision (mini-thoracotomy / 2-4 cm). This is particularly important in young or good performance-status patients who may qualify for more aggressive therapy and where determination of the histologic subtype (epithelioid versus sarcomatoid) is key. 

This is usually performed under general anesthesia but can be performed under IV sedation and local anesthesia as a day procedure. Most of the time, the thoracic surgeon will mark the best incisional area, guided by preoperative CT or ultrasound, before making the short incision.


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