Biopsy, Cervical


Biopsy, Cervical

Synonym/acronym: Cone biopsy, LEEP.

Common use

To assist in diagnosing and staging cervical cancer.

Specimen

Cervical tissue.

Normal findings

(Method: Microscopic examination of tissue cells) No abnormal cells or tissue.

Description

Biopsy is the excision of a sample of tissue that can be analyzed microscopically to determine cell morphology and the presence of tissue abnormalities. The cervical biopsy is used to assist in confirmation of cancer when screening tests are positive. Cervical biopsy is obtained using an instrument that punches into the tissue and retrieves a tissue sample. Schiller’s test entails applying an iodine solution to the cervix. Normal cells pick up the iodine and stain brown. Abnormal cells do not pick up any color. Punch biopsy results may indicate the need for a cone biopsy of the cervix. Cone biopsy involves removing a wedge of tissue from the cervix by using a surgical knife, a carbon dioxide laser, or a loop electrosurgical excision procedure (LEEP). LEEP can be performed by placing the patient under a general anesthetic; by a regional anesthesia, such as a spinal or epidural; or by a cervical block whereby a local anesthetic is injected into the cervix. The patient is given oral or IV pain medicine in conjunction with the local anesthetic when this method is used. Following colposcopy or cervical biopsy, LEEP can be used to treat abnormal tissue identified on biopsy.

This procedure is contraindicated for

  • high alertPatients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site) or acute pelvic inflammatory disease

Indications

  • Follow-up to abnormal Papanicolaou (Pap) smear, Schiller’s test, or colposcopy
  • Suspected cervical malignancy

Potential diagnosis

Positive findings in:

  • Carcinoma in situ
  • Cervical dysplasia
  • Cervical polyps

Critical findings

  • Assessment of clear margins after tissue excision
  • Classification or grading of tumor
  • Identification of malignancy

  • It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • This test should not be performed while the patient is menstruating.
  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in establishing a diagnosis of cervical disease.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex, iodine, or anesthetics.
  • Obtain a history of the patient’s reproductive system, especially any bleeding disorders and other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure.
  • Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Instruct the patient that prophylactic antibiotics may be administered before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered to promote relaxation and reduce discomfort prior to the percutaneous biopsy; general anesthesia will be administered prior to the open biopsy. Explain that no pain will be experienced during the test when general anesthesia is used but that any discomfort with a needle biopsy will be minimized with local anesthetics and systemic analgesics. Inform the patient the biopsy is performed under sterile conditions by an HCP specializing in this procedure. The biopsy can be performed in the HCP’s office and takes approximately 5 to 10 min to complete. The open biopsy is performed in a surgical suite, usually takes about 20 to 30 min to complete, and sutures may be necessary to close the site.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids, anesthetics, analgesics, or IV sedation.
  • Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners)

  • Ensure that the patient has complied with dietary restrictions.
  • Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Notify HCP if patient anticoagulant therapy has not been withheld. Ensure that patients on beta-blocker therapy have continued their medication regimen as ordered.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Have the patient void before the procedure.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen containers with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location.
  • Have the patient remove clothes below the waist. Assist the patient into a lithotomy position on a gynecological examination table (with feet in stirrups). Drape the patient’s legs. Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement during the local or general anesthetic and the procedure.

    • Punch Biopsy

  • Iodine solution is used to cleanse the cervix and distinguish normal from abnormal tissue. Local anesthesia, analgesics, or both, are administered to minimize discomfort.
  • A small, round punch is rotated into the skin to the desired depth. The cylinder of skin is pulled upward with forceps and separated at its base with a scalpel or scissors.

    • LEEP in the HCP’s Office

  • A speculum is inserted into the vagina and is opened to gently spread apart the vagina for inspection of the cervix.
  • Iodine solution is used to cleanse the cervix and distinguish normal from abnormal tissue. Local anesthesia, analgesics, or both, are administered to minimize discomfort.
  • The diseased tissue is removed along with a small amount of healthy tissue along the margins of the biopsy to ensure that no diseased tissue is left in the cervix after the procedure.

    • Open Biopsy

  • Adhere to Surgical Care Improvement Project (SCIP) quality measures. Administer ordered prophylactic antibiotics 1 hr before incision, use antibiotics that are consistent with current guidelines specific to the procedure, and use clippers to remove hair from the surgical site if appropriate.
  • After administration of general anesthesia and surgical preparation are completed, the procedure is carried out as noted above.

    • General

  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
  • Place tissue samples in properly labeled specimen container containing formalin solution, and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume preoperative diet, as directed by the HCP. Assess the surgical patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Discontinue prophylactic antibiotics within 24 hr after the conclusion of the procedure. Protocols may vary among facilities.
  • Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Advise the patient to expect a gray-green vaginal discharge for several days, that some vaginal bleeding may occur for up to 1 wk but should not be heavier than a normal menses, and that some pelvic pain may occur. Instruct the patient to wear a sanitary pad, and advise the patient that tampons should not be used for 1 to 3 wk. Patients who have undergone a simple cervical punch biopsy can usually resume normal activities immediately following the procedure. Instruct patients who have undergone LEEP or open biopsy to avoid strenuous activity for 8 to 24 hr; to avoid douching or intercourse for 2 to 4 wk or as instructed; and to report excessive bleeding, chills, fever, or any other unusual findings to the HCP.
  • Assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
  • Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
  • Recognize anxiety related to test results, and offer support. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Decisions regarding the need for and frequency of conventional or liquid-based Pap tests or other cancer screening procedures should be made after consultation between the patient and HCP. The American Cancer Society’s guidelines for preventing cervical cancer recommend cytological screening every 3 years for women age 20 to 29 years; co-testing for HPV and cytological screening every 5 years (or cytological screening alone every 3 years for women age 30 to 65 years; no screening is recommended for women who have had a hysterectomy). The most current guidelines for cervical cancer screening of the general population as well as of individuals with increased risk are available from the American Cancer Society (www.cancer.org) and the American College of Obstetricians and Gynecologists (ACOG) (www.acog.org). Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include Chlamydia group antibodies, colposcopy, culture anal/genital, culture viral, Pap smear, and syphilis serology.
  • See the Reproductive System table at the end of the book for related tests by body system.