<b>A biopsy is the removal of some tissue from a body, for examination in order to diagnose a condition.</b>  Biopsies may be surgical removal of the tumor, in part or completely, or completely with wide margins.  Biopsies can also be done with needles, either a core needle biopsy or a fine needle aspiration [FNA].

Cells have to undergo several mutations before they become cancer cells.  Besides reproducing uncontrollably, they also must lose the 'stickiness' and orderliness of normal tissue, and be able to invade and get loose and travel and set up colonies outside the primary site.  Because of the loss of cohesion, and the willingness of these cells to emigrate and colonize, it is sometimes very easy to dislodge cancer cells from a tumor during biopsy or surgical procedures.  

Every cell in your body has a capillary, a very small blood vessel, near it.  The Capillary comes from the smaller and smaller branching of arteries, and joins with other capillaries to form veins...to take the blood back to the heart.

Every cell in your body is bathed in 'interstitial' fluid.  This is the fluid that surrounds all the cells, and drains into the lymphatic system, goes through the lymph channels and past the lymph nodes, up to the upper left chest, where the major lymphatic channel drains directly into a blood vessel.

Tumor cells also have capillaries nearby, and are also bathed in interstitial fluid that goes to the lymphatic system. 

If you stick a needle into a tumor, you run the risk of dislodging a tumor cell into either a blood vessel or into the interstitial fluid.

Different tissues will have different cell-to-cell stickiness.   Tumors that metastasize must have decreased cell-to-cell stickiness.  Tumor cells will be easier to dislodge and more likely to travel. Tumor cells that land in blood vessels will travel to distant sites. Tumor cells that are pushed into the interstitial fluid will go to local lymph nodes.  And then travel up the chain of lymph nodes.

Stick needles into LMS tumors at your own risk.  But KNOW the risk before you do it.  
Excision of the tumor with wide margins is the way to go, if it is possible.  If it is not possible, then fine needle or core biopsies might be necessary.  Think clearly and carefully about this, and ask questions.

So, in summary, during biopsies or other procedures, one can dislodge some cancer cells, either into the interstitial fluid where they are carried away to lymph nodes, or possibly into the veins draining the tissue where they enter the vascular tree and travel to the lungs.  It is also possible to drag some cells along the needle track or along the surgical incision.   So it is possible to increase the incidence of lymphatic and hematogenous spread of the cancer, as well as local implantation along the surgical route or needle tracks. [see reference 9, below]

Some cancers are more notorious for seeding by track implantation than others; some are more likely to metastasize if biopsied before complete removal.  LMS usually spreads hematogenously, but can also spread by lymph nodes, and has been noted to implant along an instrument tract.

Whether the larger needle of a core needle biopsy causes more disruption in the tumor and more likelihood of track implantation or metastasis than a fine bore needle, or whether an open biopsy is even more likely to cause metastatic travel.... Is simply not known at this time.  It is very likely that the 'interference' with an LMS tumor for a biopsy will increase the risk of metastasis, and possibly local recurrence as well.  Which biopsy technique is the least likely to cause metastatic/recurrent problems is simply not known.  The needle biopsy methods are more cost effective and less invasive than open biopsy.  Core needle biopsy, because of the larger needle diameter, requires fewer passes than does the fine needle, and provides more adequate information.  It is unknown whether there is a greater risk of tumor disruption and spread with the larger needle versus repeated passes with the smaller needle.


<b>Letter to the LMS List from Roger</b>
Sent: Tuesday, July 02, 2002 11:33 AM
Subject: Needles, biopsies and lymph nodes

I noticed some recent mentions of lymph nodes and lymphatic spread of LMS. As one of the few people with lymphatic mets I would like to put my experience in.

I was talking to my first surgeon, at his annual check on my scars a couple of months ago. He is convinced that the reason my first tumor metastasized to the regional lymph node was the fact that it had been interfered with during the investigative period before he was involved.
And he very privately agrees with my opinion that the FNA biopsy done on the second tumor, in the lymph glands, was the cause of the third one, especially as the second tumor was excised fully encapsulated.

He has now operated on four more sarcomas after me (he tends to get the difficult extremity ones because primarily he is a reconstructive surgeon). Two of these were head/neck, one of them LMS (I have met her - she is the only other LMS patient I have knowingly met!!). In both cases their tumors had already been interfered with, one for biopsy and the other as a suspected cyst. After consulting the regional sarcoma specialist unit he dissected regional lymph nodes for both patients as well as doing wide excision of tumor sites. As a reconstructive surgeon he does free flap as well as skin grafts. In both cases the patient is doing well - one is past the year, the other (LMS) about six months ago. 

I feel there is a warning message about interfering with tumours. I would be strongly against sticking needles into them, even though the doctors reassure anyone when they want to do a needle biopsy.

Roger 
Hi-grade LMS left leg dx Feb 99. Lymphatic mets dx'd Jan (surgery) and Apr 2000 
(inoperable). Ifosfamide - May to Sept 2000. Disease now stable for 21 months.


<b>ANOTHER LETTER:</b>
Date:    Tue, 2 Jul 2002 19:36:14 +0100
From:    sheila 
Subject: Needles and LMS

One of the reasons that we were given by the liver surgeon as to why RFA was inappropriate for treating John's multiple liver mets, was the risk of dragging cancer cells out of each met with the probe, causing seeding and further mets.  What was interesting was that he regarded this as an established possibility, which was in contrast to the reassurances we had been given by the oncologist when discussing biopsies!
<b>[NB usually RFA probes are heated on the way out, so that they cauterize the tract to avoid tumor cell implantation. doctordee]</b>

Sheila
Wife of John (England)     retroperitoneal LMS 10/2000    


<b>A THIRD LETTER:</b>
Date:    Fri, 5 Jul 2002 13:30:38 -0400
From: Lisa 
Subject: Re: LMS needles, probes, and biopsies

Kendra,
Get another surgeon.  Speak with the Sarc onc on that and insist.  Insist firmly without raising your voice.  Insist repeatedly.  Continue to insist until someone listens.

If you don't have time to find the research on seeding from needle biopsy, insist that the surgeon inform you of the research that says it is safe **for LMS**.

Meanwhile, here are a few references (they are all for different types of cancer, since I could find nothing on LMS [no surprise]):

http://www.karlloren.com/biopsy/p31.htm

http://www.ikp.unibe.ch/lab2/Seeding.html

http://www.irus.rri.on.ca/~ddowney/cases/Case1.htm

this one has an obscure sentence about seeding along biopsy line:
http://www.vh.org/Providers/Textbooks/LungTumors/ClinicalPresentation/Text/TissueDiagnosis.html

Grace and Peace, Strength and Courage,
Lisa  (Steve's wife)
