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Tissue biopsy

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Abstract

Obtaining tissue to establish a pathological diagnosis is a valuable tool in the investigation of disease. However, it should be remembered that the first duty of the clinician is to minimise harm to the patient in the process of obtaining a diagnosis. This applies particularly when performing a biopsy on the central nervous and neuromuscular systems, as even minimal damage to these tissues can cause significant and irreversible loss of function. This chapter considers sample submission, muscle biopsy, peripheral nerve biopsy, brain biopsy.

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Figures

Image of 6.1
6.1 Open muscle biopsy procedure. Position of the leg prior to draping. The incision site is indicated. The leg following draping and skin incision. The vastus lateralis is exposed.
Image of 6.3
6.3 Mosaic appearance of normal muscle stained with ATPase (pH 9.8). The darker fibres are the ‘fast’ type II myofibrils. (Original magnification X80)
Image of 6.4
6.4 Normal muscle in transverse section is composed of groups of myofibrils with similar diameters, a smooth polygonal outline and peripherally located nuclei. Atrophy of specific myofibrils produces a characteristic angular cross-sectional outline. Normal muscle. (H&E stain; original magnification X60) Myopathy in a cat. Note the atrophied fibres scattered through the muscle. (H&E stain; original magnification X25)
Image of 6.6
6.6 Regenerating myofibrils are reduced in diameter and have a basophilic appearance on H&E staining. (Original magnification X100) With some myopathies there is central migration of the nuclei. (H&E stain; original magnification X100)
Image of 6.7
6.7 Inflammatory infiltrate in canine muscle affected by neosporosis. Note the increased density of nuclei (stained blue). (H&E stain; original magnification X25)
Image of 6.9
6.9 Common peroneal nerve biopsy. The use of self-retaining retractors is of great value. The nerve (arrowed) lies beneath the fascia of the biceps femoris muscle, which is incised to reveal the nerve. The nerve is divided longitudinally using fine sutures to support the extremities and reduce artefact.
Image of 6.10
6.10 Nerves of the pelvic limb showing incision site for biopsy (black box) and the common peroneal nerve (arrowed). The vastus lateralis which lies over the peroneal nerve has been removed for clarity. Illustration created by Allison L. Wright, MS, CMI, Athens, Georgia, USA.
Image of 6.11
6.11 Transverse sections of a normal peripheral nerve showing the effects of fixation techniques on the appearance of the myelin sheath. BNF fixation, paraffin embedding and H&E staining. (Original magnification x100) 2.5% glutaraldehyde fixation, resin embedding and azure blue staining. Note the distinct appearance of the myelin sheath as a dark staining outline to each axon in the resin-embedded section. (Original magnification X100)
Image of 6.12
6.12 Demyelinating peripheral neuropathy in a dog. Myelin loss (naked axons, NA) and possible remyelination (thin myelin sheaths, TS) are evident. Note the macrophage with foamy cytoplasm (M); these inclusions contain lipid from the breakdown of myelin. (Resin-embedding and azure blue staining; original magnification approximately X250) (Courtesy of I Griffiths)
Image of 6.13
6.13 Nerve root affected by . The nerve has become thickened and there is an increased density of nuclei, suggesting a cellular infiltrate. (H&E stain; original magnification X60)
Image of 6.15
6.15 Lesions unsuitable for biopsy. Granulomatous meningoencephalitis. Post-contrast CT image showing patchy, mild contrast medium uptake diffusely (arrowheads) with white matter oedema but no obvious focus to target. Intraparenchymal haemorrhage. Following contrast medium administration, this CT image appeared similar to pre-contrast images with minimal uptake of contrast medium but a poorly defined area of hyperintensity (arrowheads).
Image of 6.16
6.16 Leksell stereotactic frame. This is one of the most commonly used frames for image-guided needle biopsy in human patients. (Courtesy of Elekta UK)
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6.17 An MRI stereotactic biopsy system. During surgery, the head of the animal is held rigidly in place using a c-clamp and skull screws, which press against the animal’s skull. The c-clamp is attached to a standard operating table using a large adjustable arm. An articulated surgical arm is attached the c-clamp to guide tools to the target. In conjunction with the neuronavigation software and the position sensor, a path is set to target the brain of the animal. Brainsight software enables the 3D reconstruction of imaging data, which is then used to target a tumour with a biopsy needle. Reconstructions of the skin, skull and brain are generated from MR images. A lesion or tumour is identified as a target (red) in the right temporal region using MR images of the dog and the Brainsight software. The centre of the target is visualized in 3D and the most appropriate trajectory to the tumour (avoiding key structures such as the ventricular system (yellow)) is saved by the software. Co-registration of the animal to the MR images is performed by identifying homologous points between the images and the subject with the help of fiducial markers that are rigidly fixed to the animal’s head. Once registered, neuronavigation is performed in real-time with the aid of a position sensor in the operating suite to precisely target the tumour. (Courtesy of S Frey, Rogue Research Inc.)
Image of 6.19
6.19 CT image of a choroid plexus papilloma following the injection of contrast medium. Note that there is marked contrast medium uptake, resulting in the extremely hyperdense appearance of the lesion (arrowhead). This is consistent with a highly vascular lesion.
Image of 6.20
6.20 Smear cytology characteristics of intracranial tumours at low power. Meningioma. Note the cohesive nature of this tumour and the tumour cells adhering to branching capillaries. (Diff-Quik stain; original magnification X50) Metastatic carcinoma. Note the appearance of sheets of tumour cells and ‘moulding’ of cell nuclei to each other. (Diff-Quik stain; original magnification X50)
Image of 6.21
6.21 Biopsy sample taken at craniectomy showing marked perivascular cuffing with mononuclear inflammatory cells, predominately lymphocytes and plasma cells, in GME. (H&E stain; original magnification X50)

Supplements

Muscle and nerve biopsy

A video demonstrating the steps involved in taking a muscle and nerve biopsy. (See page 99 in the Manual)

Stereotactic needle biopsy

A brief video describing the steps involved in taking a biopsy with the Brainsight system. (AUDIO DESCRIPTION) (Courtesy Dr S Frey) (See page 102 in the Manual)

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