Open Biopsy – Description
In principle, the location of the biopsy should be chosen in anticipation of the definitive surgical management of the lesion, and therefore should be done by a surgeon experienced in musculoskeletal oncology who will ultimately be performing the surgical treatment.
There are a number of principles to adhere to. The incision should be made as small as possible and in a longitudinal fashion. The dissection should be carried directly to the tumour in a sharp fashion, through the involved soft tissue compartment. There should be no elevation of skin or subcutaneous flaps, and noninvolved compartments, routine intramuscular planes, and neurovascular structures should be avoided. Basically, the exposure should go through skin, deep fascia, and underlying involved muscle, directly to the tumour. Meticulous hemostasis should be achieved along the way. If a pseudocapsule or soft tissue component is encountered, it should be sharply taken off and sent as specimen. If not, a small round window should be made in the bone with a midas rex, and the specimen obtained. It should be sent for stat frozen section and gram stain. The pathologist should be warned ahead of time to be prepared for the arrival of the specimen. Four questions should be asked at this point:
– is the tissue adequate to make a provisional diagnosis?
– is the tissue representative of the lesion?
– does the diagnosis make sense?
– is there enough tissue to perform definitive histologic analysis?
Meticulous hemostasis should then be achieved. If a tourniquet is used, it should be deflated and hemostasis achieved. The wound should be closed in watertight layers to reduce hematoma and local contamination. If a drain is used it should be brought out in line with the incision.