Key points
- Tissue diagnosis plus staging comes before a treatment decision.
- Core biopsy gives architecture and receptor status; FNA gives cells only.
- Some lesions should not be biopsied first: testicular masses, suspected phaeochromocytoma, some sarcomas.
- Every cancer plan is made by the MDT and agreed with the patient.
The pathway
Red-flag symptom → urgent suspected-cancer referral → tissue diagnosis and staging → MDT discussion → options discussed with the patient → treatment. Delays at each step add up, which is why fast-track pathways exist.
Getting tissue
| Method | Gives | Used for |
|---|---|---|
| Fine-needle aspiration (FNA) | Cells only (cytology) | Thyroid nodules, lymph nodes, cysts |
| Core biopsy | A strip of tissue: architecture, grade, receptors | Breast lumps, liver lesions, soft-tissue masses |
| Endoscopic biopsy | Mucosal tissue | Oesophagus, stomach, colon, rectum |
| EUS-guided biopsy | Cells or cores from deep lesions | Pancreas, submucosal tumours, nodes |
| Excision or incision biopsy | The whole lesion, or part | Skin lesions (excision biopsy for suspected melanoma), lymphoma (whole node) |
When not to biopsy first
- Testicular mass: inguinal orchidectomy, never a scrotal biopsy (it seeds a different lymphatic field).
- Suspected phaeochromocytoma: biopsy can trigger a hypertensive crisis; check metanephrines.
- Retroperitoneal or limb sarcoma: plan the biopsy with the sarcoma centre so the track can be removed later.
- Resectable pancreatic head mass in a fit patient: surgery may proceed without a pre-operative biopsy, after MDT discussion.
Staging investigations
- CT chest, abdomen and pelvis: the workhorse for most solid cancers.
- MRI: rectal cancer (the mesorectal fascia), liver lesions, pelvis, brain.
- PET-CT: oesophageal and lung cancer, lymphoma, suspected recurrence.
- Endoscopic ultrasound: T and N staging of the oesophagus, stomach and pancreas.
- Staging laparoscopy: gastric and pancreatic cancer, to find small peritoneal deposits that CT misses.
The multidisciplinary team
Surgeons, medical and clinical oncologists, radiologists, pathologists, specialist nurses and palliative care meet to review the diagnosis, stage, performance status, other illnesses and the patient’s wishes, and recommend a plan. The final choice is the patient’s.
Breaking bad news: SPIKES
- Setting: privacy, sitting down, the right people present
- Perception: what does the patient already understand?
- Invitation: how much do they want to know?
- Knowledge: give a warning shot, then the news, in plain words
- Emotions: acknowledge and respond with empathy
- Strategy and summary: the plan and the next step
Frequently asked questions
What is the difference between FNA and core biopsy?
Fine-needle aspiration gives cells only (cytology). A core biopsy gives a strip of tissue showing architecture, grade and receptor status.
What is the SPIKES protocol?
A six-step way to break bad news: Setting, Perception, Invitation, Knowledge, Emotions, and Strategy and summary.
What is a cancer MDT?
A multidisciplinary team meeting of surgeons, oncologists, radiologists, pathologists, specialist nurses and palliative care that reviews each case and recommends a treatment plan.
Further reading
- Baile WF, et al. SPIKES: a six-step protocol for delivering bad news. Oncologist 2000;5:302–11.
- NICE NG12. Suspected cancer: recognition and referral. 2015 (updated).