Home » other animals » Dog and cat biopsy: indications and recommendations [Lek wet Piotr Smentek

Dog and cat biopsy: indications and recommendations [Lek wet Piotr Smentek

Biopsy and histopathology samples taken is an example of modern diagnostic methods used in our animals. In this article, you will find practical information for caregivers of dogs and cats.

Biopsy

Probably no one now needs to be convinced that the days when a veterinarian diagnosed a sick animal in need of help only on the basis of the observed clinical symptoms and his own clinical experience are long gone. Such a method of diagnosing diseases for obvious and obvious reasons, unfortunately, carries a huge risk of making a mistake, which often reduces the chances of full recovery and sometimes even ends tragically for the animal.

Nowadays, the treatment of diseases should always be based on a previously made diagnosis, supported, of course, by skilfully selected additional tests. Although they do not replace a clinical trial, which we should never give up, they are its perfect complement. The vast majority of such diagnostic techniques are also available in routine veterinary practice, and their costs are lower and lower each year and therefore more accessible to every dog ​​or cat caretaker.

This trend, otherwise correct, is also an expression of modernity penetrating modern veterinary medicine and, consequently, results in smaller and smaller differences between human medicine and its "animal counterpart". Today, dog and cat keepers have at their disposal more and more perfect methods to fight diseases, thanks to which many diseases can be effectively controlled or even cured. It would not be possible without better and more perfect diagnostics.

Many methods have been adopted and transplanted, transferred directly from human medicine and adapted to diagnose specific canine diseases and conditions in cats.

A perfect example of this is, for example, exercise biopsy and  histological evaluation of tissues collected in this way, being the basis for accurate diagnosis and then targeted treatment.

There is no need to convince anyone that the best treatment is for diseases that are properly diagnosed at the very beginning of the therapeutic process and that well-diagnosed patients have a better chance of being fully cured. Perhaps, therefore, it is worthwhile to familiarize yourself with this area of ​​practical veterinary knowledge and its application in routine diagnostics. But from the beginning.

  • What is a biopsy?
    • Fine needle aspiration biopsy
    • Core needle biopsy
    • Surgical biopsy
    • Drill biopsy
    • Targeted biopsy
    • Endoscopic biopsy
  • Indications for a biopsy
  • How to prepare a dog and a cat for a biopsy?
  • Ultrasound-guided biopsy
  • Dog and cat skin biopsies
  • Handling the material after collection
  • Biopsies in oncology
    • How best to do a biopsy in the event of a malignant process?
  • Tissue biopsy on the example of the liver
  • Possible complications after the biopsy
  • Histopathology

What is a biopsy?

Biopsy is one of the simpler diagnostic techniques performed in living animals, which consists in taking a tissue material called a biopsy and then evaluating it in a microscopic examination (histopathological examination or cytological examination). Thus, a biopsy makes it possible to make a clinical diagnosis and identify disorders, pathological processes in a given organ or tissue.

As you can easily guess, you can get the material for analysis using different methods, hence different types of biopsy. And so, depending on the thickness of the needle used and the method of performing the biopsy itself, we can distinguish:

Fine needle aspiration biopsy

Fine-needle aspiration biopsy, thanks to its simplicity, speed and ease of execution as well as low invasiveness, is a very popular and frequently used diagnostic method.

The name biopsy is derived from the use of a fine needle, that is, a needle with a diameter less than or equal to 1 mm. With the help of fine needle biopsy, we can obtain material for examination from changes visible to the naked eye, palpable in the patient's palpation, and those deeper and visible using imaging techniques (ultrasound, computed tomography or X-ray examinations).

By assessing the collected material, we can describe the type and number of visible normal cells, inflamed cells, inflammatory infiltrates or visible pathogens (microorganisms - bacteria, fungi or sometimes parasites).

This technique is very often used in the diagnosis of neoplastic changes.

Core needle biopsy

Coarse-needle biopsy, also called oligobiopsy, is the collection of material with a thicker needle with a diameter greater than 1 mm. For this technique, Tru-Cut needles or Menghini needles are used.

As you can easily guess, the amount of tissue taken in this case will be greater, so also the possibility of assessing disturbances in the structure of the tissue taken is better, therefore we use this technique, for example. for the evaluation of parenchymal organs, e.g. kidney. This technique is also associated with greater tissue traumatization.

Surgical biopsy

Surgical or open biopsy is performed during an operation, during which the surgeon takes a section of an organ or pathologically changed tissue. Here, you can evaluate a fragment of the removed tissue, tumor, organ, then we call it a biopsy or remove the entire lesion and then we talk about a biopsy.

Drill biopsy

Drill biopsy called trepanobiopsy - which consists in taking a piece of tissue with the help of special trepans, i.e. tools rotating at different speeds by hand or with the help of an electric motor. The collected material remains in a trepane. This method is useful for the assessment of skin lesions and for bone marrow extraction.

Targeted biopsy

Targeted biopsy is a precise examination consisting in taking tissue or cells from pathology sites with the use of diagnostic tools that allow to accurately visualize and locate pathology, i.e. thanks to ultrasound, laparoscopy or computed tomography.

The needle is carefully inserted into the lesion, controlling its course in the imaging examination.

Endoscopic biopsy

Endoscopic biopsy involves collecting material for examination from the lesions imaged in the endoscopic examination. Thanks to it, we collect samples of the mucosa of the gastrointestinal tract, urinary, reproductive and respiratory systems with the use of special biopsy tools.

A common feature of all these types of biopsy is the collection of material for cytological or histopathological evaluation and thus making an accurate diagnosis, although the collection itself is performed using various tools.

This material will, of course, differ in the size of the tissue collected for testing, so it is always worth considering which specific method to choose.

Indications for a biopsy

Indications for a biopsy

Once we know what a biopsy is and what types of it are, it is worth answering the basic question, i.e. when should it be performed.

In general, any focal or diffuse lesion in the parenchymal organs may require a biopsy. Such a collection can be performed with the use of a commonly available ultrasound apparatus.

The great advantage of an ultrasound biopsy is also the possibility of emptying cystic lesions or those filled with some fluid or interstitial fluid from the contents. The material obtained in this way can be sent for cytological or microbiological tests.

Tissue biopsy can be extremely helpful in assessing solid lesions, i.e. well-defined tumors.

Many laymen associate biopsy with oncological processes, which is true because the assessment of neoplastic tissue is the basis for the subsequent selected causal treatment and the implementation of an appropriate treatment algorithm and treatment protocol. In this case, it is difficult to find effective treatment without histopathological evaluation.

In fact, we can perform a biopsy in many cases and disease states, and so, for example, the indications for a biopsy may be:

  • liver diseases:
    • causing its enlargement or hepatomegaly,
    • persistent high levels of liver enzymes,
    • chronic parenchyma disease,
    • toxic tissue damage during poisoning,
    • cirrhosis,
    • metabolic diseases,
    • storage diseases,
    • diseases with cholestasis,
    • liver cancer,
  • lung tissue diseases:
    • in particular, focal changes found during X-ray or CT imaging examinations of the chest:
      • pulmonary fibrosis,
      • lung cancer,
      • tuberculosis,
    • sarcoidosis,
    • severe inflammations that do not respond to treatment,
    • other changes in the lung parenchyma that cannot be treated.
  • prostate diseases:
    • especially enlargement of the prostate found on rectal examination or ultrasound examination, which may indicate neoplastic processes of the prostate,
    • differentiation of benign prostatic hyperplasia from malignant neoplasms.
  • urinary tract diseases:
    • proteinuria of unknown origin,
    • hematuria of unknown cause,
    • diagnosis and differentiation of glomerulonephritis,
    • acute renal failure of unknown cause,
    • interstitial nephritis of unknown cause,
    • kidney amyloidosis,
    • kidney dysplasia,
    • neoplastic processes,
  • skin diseases:
    • neoplastic changes,
    • dermatoses that do not respond to treatment,
    • long-lasting ulcers,
    • some diseases with blistering,
    • any severe condition or one for which treatment can be extremely costly or dangerous,
    • skin asthenia,
    • zinc-dependent dermatoses, etc.

The easiest way to biopsy changes visible to the naked eye, hence it is probably no surprise that biopsy is often used in skin diseases or tumors related to it.

In the case of a skin biopsy, there are no clear guidelines on when to absolutely perform it. Nevertheless, in general, we can assume that it should be considered in the event of treatment failure, after the implemented treatment for 3-4 weeks.

For obvious reasons, a well-established diagnosis is extremely important, because incorrectly selected treatment will not bring the expected results.  The collected material for histopathological and cytological evaluation can be extremely helpful here.

Of course, I do not encourage anyone to perform a biopsy for every dermatological disease because it is simply unnecessary. On the other hand, the implemented treatment may affect the histopathological picture of the collected material and thus make the diagnosis difficult. Therefore, at the outset, it is necessary to consider whether a biopsy will be useful in making a diagnosis or whether an effective therapy can be implemented on the basis of other, simple diagnostic tests.

Many owners come to the clinic with their pupils with various changes in the skin or subcutaneous tissue and want to know immediately what is wrong with their dog or cat. It is very difficult to make a certain diagnosis due to the similar clinical picture of many proliferative lesions or visible tumors.

Then a biopsy and taking a slice or cells from the lesion before the therapy is implemented and deciding whether to remove the lesion immediately may be very helpful.

Finally, it is difficult to imagine modern oncology without biopsy. The assessment of the collected material is crucial in this matter and allows the owner to answer the most intriguing questions about the type of cancer, effective therapy or survival period or the chances of full recovery. Often we do not know what a given change is and only a biopsy allows us to get the right answer.

Biopsy of lymph nodes, especially enlarged ones, allows for the assessment of the cells visible in them and thus the diagnosis.

In oncology, accurate diagnosis is the basis for implementing the most appropriate chemotherapy regimen based on multi-drug therapy.

How to prepare a dog and a cat for a biopsy?

How to prepare a dog and a cat for a biopsy?

Biopsy, although it is a simple and minimally invasive diagnostic method, requires compliance with certain fundamental principles to be safe.

As a diagnostic method, it cannot expose the animal to possible unnecessary complications, which in many cases can be easily avoided. Therefore, each time the injection site must be properly prepared by cutting the hair beforehand and disinfecting the skin. For this purpose, we can use commonly available disinfectants (e.g. based on alcohol). To puncture the lesions or perform an ultrasound-controlled biopsy, we must use sterile equipment (needles and syringes).

Such basic and seemingly obvious issues really allow us to avoid many possible complications, including infections, so we must remember about them.

Complete sterility is absolutely essential when performing tissue biopsies from lesions located in the abdominal cavity.

The very collection of material for testing requires sedation and sometimes even general anesthesia in the animal. However, many biopsies, especially of changes in the skin and subcutaneous tissue or superficial lymph nodes, are not associated with full anesthesia, but can be safely performed under local anesthesia, slight pharmacological sedation, or sometimes even without the need for these additional procedures.

In general, any test method used should be painless or mildly painful for the animal and safe. The necessity to undergo anesthesia will be associated with earlier routine additional examinations, including blood and heart tests.

General anesthesia also has its advantages, as it allows not only to immobilize the patient but also lowers blood pressure, which reduces bleeding.

A biopsy, which we perform using a thick needle, requires us to check the clotting factors first so that we do not have problems with stopping the bleeding later.

When the change of interest is surrounded by fluid, it is worth draining the fluid before collecting the cells for evaluation. For this purpose, an indispensable method may be to perform an ultrasound examination, which not only allows you to specifically locate the lesion, but also to plan the best and the shortest access to the one you want to change.

Biopsy is a minimally invasive diagnostic technique, but in order to be carried out safely, it is important to qualify the patient for it first. We should not perform it in every "random" patient and we should always remember about possible complications.

Before performing a biopsy, therefore, we should collect all data from the clinical history, conduct a thorough examination of the patient supported by laboratory tests (morphology and biochemistry and urinalysis), and in many cases perform imaging tests (ultrasound, tomography or endoscopy). The latter techniques are also used to collect a sample for testing.

In hematological examination, we should always assess the parameters of the blood coagulation system (bleeding time, clotting time, platelet count, prothrombin time), as pathologies in this area may result in difficulties in stopping bleeding and are a contraindication to biopsy.

After completing a complete set of tests, we can safely carry out the collection of material for histopathological and cytological examination, thus reducing the risk of complications to the necessary minimum.

Ultrasound-guided biopsy

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To perform this test, you need an ultrasound machine that allows you to perform the B-mode test. It is best to choose higher frequencies thanks to which it is possible to visualize the needle in the examination, similar to the choice of the linear probe. Sometimes it is possible to use special heads with biopsy guides to help guide the needle at a specific angle.

Most often, we perform this test using the so-called. from a free hand. It is performed by one person who at the same time applies the probe to the examined area and makes the change visible, and with the other hand performs the collection of the material with a needle.

Another method is indirect targeting, which consists in performing an ultrasound examination - a traditional method, thanks to which we determine the size of the lesion, its location, and the depth of its location. Then, knowing where the interesting change lies, from which we want to take a sample, we perform a standard puncture. This technique is most often used with large tumors or body cavities filled with a significant amount of fluid.

Each time after the biopsy is performed, after about 2 minutes, a control ultrasound examination of the place from which we collected the sample is performed in order to visualize possible bleeding and accumulation of liquid content in the area of ​​the collected lesion.

Dog and cat skin biopsies

Performing this type of biopsy is a simple research technique, but still requires adherence to certain rules.

Incorrectly performed biopsy is not only an unnecessary test that does not bring much to diagnosis, but also unnecessarily exposes the animal to potential complications.

  • The place of collection should be properly prepared in advance.
  • Taking into account the comfort of the recipient and the accuracy of the collection, the animal should be sedated and sedated. Sometimes (e.g. biopsies of the auricle, lip, nose), in the case of minor changes, when it is necessary to precisely collect the material, short-term general anesthesia is required.
  • Then you need to trim the hair in such a way that the razor blade does not touch the outer layer of the skin. Any washing of the skin or wiping with disinfectants is not recommended as they may affect the appearance of the outer layer of the skin (remove the keratin layer or inflammatory cells).
  • After drying, or disinfecting with 70% ethanol, anesthetize the site of the planned injection with a lidocaine solution. We do not perform anesthesia in the case of lesions located in the subcutaneous tissue, in fat.
  • For biopsy, we usually use biopsy punches with a diameter of 6-8 mm or smaller (4 mm) when tissue is collected from the area of ​​the nose, eye, ears or finger pads. Place the trepan against the skin and take the tissue for examination by rotating it to one side.
  • The collected sample can be fixed in a formalin solution and the resulting wound can be closed with one suture approaching the edges.
  • When we want to collect changes with fluid, blisters or pustules, we can cut these changes with a scalpel, of course, keeping an appropriate margin from the edge of the lesion.

It is important where the sample is taken for testing so that the sample is representative. So we take the fragment most typical for a given disease that we suspect. It is also good practice to collect several samples in accordance with the principle that the more samples, the greater the chance of making a correct diagnosis.

In dermatology, the following changes are mainly selected for biopsy:

  • bubbles,
  • blisters,
  • pustules,
  • lumps,
  • erosions,
  • and of course the lumps.

We avoid collecting skin from places that are licked by an animal, or with abrasions due to the low diagnostic value of the material obtained.

Handling the material after collection

It is extremely important to handle the material after collection so that the tissue obtained for evaluation is not damaged, which will destroy the possibility of its evaluation.

And so, immediately after taking the sample, place the sample in the fixing material.

The sample is transferred using anatomical forceps or vascular forceps that do not crush or crush the obtained tissue.

A sample heavily soiled with blood can be gently cleaned by tamponing.

Autolysis processes leading to the formation of artifacts that make it difficult to evaluate the sample develop immediately after taking the biopsy, hence improper handling of the sample may affect its low diagnostic value.

A very important activity, extremely helpful for the histopathologist assessing the sample, is a detailed description of the lesions, the place of the sample taken or the history of the disease. Including information about symptoms, medications used, medical history or our suspicions in the referral for examination definitely facilitates the work of the histopathologist.

Finally, one must remember about possible artifacts, i.e. distortions, which may affect the assessment of the collected material. This can happen in the case of an incorrect sampling site due to the use of topical medications, auto-damage or the presence of dead tissue, improper washing, shaving the hair, use of disinfectants, due to a poor collection technique (e.g. old blunt trepan that destroys the tissue taken) or bad fixation of the excerpts.

Biopsies in oncology

Biopsies in oncology

The basis for the treatment of any neoplastic disease is an earlier diagnosis, without which it is impossible to implement a specific, most effective therapy that gives the best chances for a cure or a maximum extension of life.

Many tumors or changes in the clinical picture give non-specific symptoms, hence it is not possible to make a diagnosis based on the physical appearance or the results of laboratory tests.

Cancer is a process of uncontrolled formation of diseased tissue. Therefore, it should come as no surprise that the assessment of cancer-building cells, and thus making a diagnosis, is the optimal method of diagnosing oncological diseases.

Biopsy is therefore a simple and the best method that provides the pathologist with material to assess cells and their features and answers an extremely important question, namely what is the boundary between healthy, normal and diseased tissue. The obtained result tells us what kind of cancer we are dealing with and what is the approximate survival estimated on the basis of statistically similar patients.

The assessment of the collected sample also provides information whether the lesion was removed with an appropriate margin of healthy tissues and the risk of recurrence at the operated site. Making a diagnosis allows the oncologist to plan the best treatments.

In oncology, we use fine needle biopsies, with the use of a tru-cut needle, trepanobiopsies, excision and cutting biopsies, and with the use of forceps during endoscopy.

Biopsies are not always recommended and should not be taken into account in all cases.

This is the case, for example, when the type of neoplastic process does not affect the surgical treatment used. An example of what I am writing about are spleen tumors or mammary gland tumors in which the most effective and logical therapeutic procedure is their entire surgical removal with the entire organ (these are not organs necessary for life, without which the body can function normally).

In the above-mentioned case, usually the neoplastic lesion is removed first and the tumor obtained during the procedure is sent for histopathological examination, hence the earlier biopsy does not seem necessary.

The collected sample does not always provide a lot of valuable information. This is the case with ulceration of neoplastic lesions or their significant necrosis.

How best to do a biopsy in the event of a malignant process?

First, it should be reasonably representative, so we should avoid ulcerated, necrotic or inflamed tissue. It is important that the collected biopsy is obtained from the appropriate tumor depth. And finally, there should be a tissue on the border of the healthy and the sick with it.

The collection itself should be safe for the patient, so:

  • we do our best not to spread cancer cells to the surrounding tissues and thus contribute to recurrence or metastasis; we achieve this by gentle tissue sourcing, so we avoid contact of surgical instruments with healthy tissue,
  • we limit damage to healthy and neoplastic tissue to the maximum,
  • we ensure minimal bleeding in the surgical field,
  • we try not to touch the neoplastic tissue.

When performing a biopsy, we should not hinder the future surgical procedure, so the collected material should rather be at the site of the future surgical incision.

These are, of course, general rules that should be followed by every biopsy doctor so that the biopsy is safe and brings a lot of valuable information important for prognosis and future treatment.

Tissue biopsy on the example of the liver

Dog biopsy

In the case of liver diseases, the final diagnosis is not always possible on the basis of routine laboratory diagnostics or ultrasound, but sometimes it requires the use of more invasive techniques with a higher risk of complications, including serious complications. Liver biopsy is an important part of a comprehensive diagnostic procedure.

Of course, the key to its implementation are the indications, as it should only be considered when absolutely necessary.

Although the mortality during its implementation is low, according to various sources, it is still from 1% to 3% depending on the technique. However, it is an invasive technique and it arouses a lot of emotions among many owners.

So when should we do it??

We should consider a biopsy in the case of:

  • persistent abnormal liver enzyme results,
  • when the applied treatment does not bring the expected results,
  • hepatomegaly,
  • when we cannot make an accurate diagnosis,
  • neoplastic process,
  • ascites when a hepatic background is suspected,
  • in storage diseases,
  • fatty liver in cats etc.

The absolute contraindications for the biopsy are:

  • liver abscesses,
  • unstable general condition of the patient,
  • severe coagulation disorders,
  • inability to undergo safe anesthesia,
  • extrahepatic cholestasis.

Conducting a biopsy requires performing the appropriate tests previously discussed and introducing the patient to the state of anesthesia or premedication.

We can perform a blind fine-needle biopsy, under ultrasound supervision, or during a diagnostic laparotomy procedure, puncture through the abdominal wall or chest.

Each of these techniques has its own advantages and disadvantages.

After the biopsy and tissue collection for examination, each patient's condition should be closely monitored. Therefore, it is recommended to observe the patient for at least a few hours and urgently react in the event of potential complications, e.g., in the form of a hemorrhage. Typically, if nothing bad happens within 3-6 hours after the biopsy is done, a serious life-threatening complication is unlikely.

After a biopsy, a few hours later and fully awake, the animal can be safely returned home and the owner himself informed about situations when he should react quickly.

Possible complications after the biopsy

Dog biopsy

Biopsy is a minimally invasive diagnostic technique, but nevertheless carries a certain risk of potential complications that are always worth knowing. Knowing the possible risks allows you to consciously make decisions and estimate the benefit-risk ratio, and thus answer the basic question whether to perform a biopsy in a given case.

The frequency and type of complications following a biopsy depend on several factors. Generally, it depends on the type of biopsy, the location of the lesion or organ from which the material for the examination is taken, as well as the experience of the person collecting the sample.

The thicker the needle used for the biopsy, and therefore the larger the sample taken, the greater the risk of potential complications (fine-needle biopsy is safer than coarse-needle biopsy).

The more frequent complications of biopsy include bleeding or hematomas arising under the capsule of the organ from which the biopsy was taken. Sometimes a haemorrhage may occur, although it is not life threatening. Typically, bleeding will stop within minutes after the biopsy needle is removed.

Another complication is soreness at the injection site or possible infection of the organs and tissues from which the material is taken. This is the case when asepsis is not followed.

The most dangerous and fortunately rare complication can even be fatal.

We must also remember about the possibility of spreading cancer cells, which may take place through hematogenicity (via blood vessels) or along the path of the biopsy needle insertion.

Serious complications occur when biopsy is taken from sites in the abdominal cavity, and not from superficial lesions.

A complication after a skin biopsy may be a disturbance in the healing of the skin at the collection site, which may also be affected by concurrent medications in the treatment of the underlying disease (e.g. glucocorticosteroids).

We should also be especially careful when using high doses of lignocaine, especially in young animals with low body weight, as this may be associated with side effects resulting from the action of this anesthetic.

In general, the possible complications do not exceed the benefits that can be obtained by assessing the biopsy material, so in most cases it is worth carrying out a biopsy.

Histopathology

Histopathological examination is a valuable diagnostic test consisting in the assessment of the collected material under a microscope in terms of the ongoing disease process.

Histopathological examination of the collected material may be of enormous importance in the already mentioned neoplastic processes, monitoring the progress of treatment, in inflammatory and degenerative diseases, or allows postmortem determination of the cause of death and assessment of all pathological processes that led to death.

Histopathological examination is therefore an assessment of the material collected during the biopsy, i.e. it is the next step in the diagnostic process after taking a biopsy. It is a much more valuable test compared to the cytological test because it allows to assess not only the cells themselves but also the spatial conditions prevailing in the sample. On its basis, we can obtain more reliable and accurate results.

Tissues for this examination are collected during a biopsy, during postmortem examination during an autopsy, or during the operation itself.

The collected material must be quickly placed in a fixative fluid, often formalin. The collected tissue, before its evaluation under the microscope, must be properly prepared, in other words, it is subjected to histopathological treatment.

In short, it consists in placing the material first in alcohol, which dehydrates the tissue, then in xylene or toluene and liquid paraffin. The sample preparation process itself usually takes several hours. The collected sample is placed in a paraffin pickle filling a block-shaped form. The material prepared in this way is then cut into thin strips or scraps.

The sections prepared in this way are then specially colored, thanks to which we can very carefully see the cell organelles or visualize the cell division.

Most often we choose staining with hematoxicillin or eosin (the former stains the nuclei blue and the latter the cytoplasm pink). The staining of the collected tissue also uses other dyes such as silver salts, congo red, Prussian blue or safranin.

The obtained preparations are assessed by a histopathologist.

We must remember that the result of the histopathological examination is usually obtained within 2 weeks of taking the sample, and the cost of the histopathological examination is in the range of several dozen - two hundred zlotys and depends on the laboratory performing it.

Summary

Modern veterinary medicine is a very vast field of science, covering many different, complementary fields.

It should be aimed at helping sick animals and serving their owners. Its standards should also be high and very similar to human ones.

A perfect example of this described in the article is the diagnostic technique of biopsy and subsequent assessment of the collected material by a pathologist. This process allows not only to make an accurate diagnosis, but also to implement effective therapy at the very beginning, which for obvious reasons is extremely beneficial for the health of the animal.

Financial considerations are also important, because effective diagnosis often means shorter treatment, better selected drugs, or fewer side effects associated with, for example, long-term ineffective therapy.

Therefore, it is worth using the available diagnostic methods, the more that many of them are simple to perform, not painful and how useful practically. A biopsy is a perfect example of this. So let's use it whenever it is absolutely needed, which I hope I was able to convince you of in the article.

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