Biopsy : Principles and techniques

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Biopsy : Principles and Techniques:

Biopsy : Principles and Techniques Presented by : Anubhuti Gupta IInd BDS

Steps in lesion exam:

Steps in lesion exam It is important to develop a systematic approach in evaluating a patient with a lesion in the oral and maxillofacial region. Steps: A detailed health history A history of the specific lesion A clinical examination A radiographic examination Laboratory investigations Surgical specimens for histopathologic evaluation

Health History:

Health History An accurate health history may disclose predisposing factors in the disease process or factors that affect the patients management. Up to 90% of systemic diseases can be discovered through history taking. The same can be true of oral lesions when one is familiar with the natural progression of the more common disease processes.

History of the Lesion:

History of the Lesion

Questions to Ask:

Questions to Ask Duration of the lesion Changes in size and rate of change Changes in the character of the lesion. Lump to ulcer, etc Associated systemic symptoms: fever nausea anorexia

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More Questions to Ask:

More Questions to Ask Pain Abnormal sensations Anesthesia A feeling of swelling Bad taste or smell Dysphagia Swelling or tenderness of adjacent lymph nodes Character of the pain if present

Clinical Examination:

Clinical Examination The clinical examination should always include when possible: Inspection Palpation Percussion Auscultation

Clinical Evaluation:

Clinical Evaluation The anatomic location of the lesion/mass The physical character of the lesion/mass The size and shape of the lesion/mass Single vs. multiple lesions The surface of the lesion The color of the lesion The sharpness of the boundaries of the lesion The consistency of the lesion to palpation Presence of pulsation Lymph node examination

Radiographic Examination:

Radiographic Examination The radiographic appearance may provide clues that will help determine the nature of the lesion. A radiolucency with sharp borders will often be a cyst A ragged radiolucency will often be a more aggressive lesion Radiopaque dyes and instruments can help differentiate normal anatomy


RADIOGRAPHS Ameloblastoma Description: Large multilocular radiolucent lesion of the posterior body and ramus of the mandible Location: Posterior body and ramus of the mandible, left side Radiograph of a molar that had an aberrant root canal which opened on the side of the root. Location: Lateral of periapical region

Further radiographic investigations:

Further radiographic investigations OPG showing mixed radiolucent and radioopaque lesion involving left body of mandible CT Scan showing bicortical expansile lesion and its 3D reconstruction

Laboratory Investigation:

Laboratory Investigation Oral lesions may be manifestations of systemic disease. If a systemic disease is suspected it should be pursued . Determination of serum calcium, phosphorus, and alkaline phosphatase and protein can be very useful in excluding certain pathological processes.

These include:

These include Tumour of parathyroid gland – Hyperparathyroidism Paget’s disease Multiple myeloma Paget’s Disease

Indications for Biopsy:

Indications for Biopsy Lesion persisting for >2 weeks with no apparent etiologic basis Any inflammatory lesion that does not respond to local treatment after 10 to 14 days. Persistent hyperkeratotic changes in surface tissues. Any persistent swelling, either visible or palpable beneath relatively normal tissue.

Indications for Biopsy:

Indications for Biopsy Inflammatory changes of unknown cause that persist for long periods Lesion that interfere with local function Bone lesions not specifically identified by clinical and radiographic findings Any lesion that has the characteristics of malignancy

Characteristics of lesions that raise the suspicion of malignancy:

Characteristics of lesions that raise the suspicion of malignancy Erythroplasia- lesion is totally red or has a speckled red appearance. Ulceration- lesion is ulcerated or presents as an ulcer. Duration- lesion has persisted for more than two weeks. Growth rate - lesion exhibits rapid growth Bleeding- lesion bleeds on gentle manipulation Induration- lesion and surrounding tissue is firm to the touch Fixation- lesion feels attached to adjacent structures

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Erythroplasia Induration

What is a biopsy?:

What is a biopsy? Greek origin : bio , meaning life; and opsia , meaning to see. Biopsy is the removal of tissue for the purpose of microscopic examination and diagnosis. Can serve as treatment option for smaller lesions by excising in toto.

Types of Biopsy:

Types of Biopsy Exfoliative cytology Aspiration biopsy Needle/Core biopsy Incisional biopsy Excisional biopsy

Exfoliative Cytology:

Exfoliative Cytology Study of cells which exfoliate or abrade from body surfaces


Features Not a substitute but an adjunct to surgical biopsy Quick, simple, painless, bloodless procedure Helps as a check against false negative biopsies Helpful in follow-up of recurrent carcinoma Useful for screening where gross appearance of lesion is such that biopsy is not warranted May be helpful with monitoring postradiation changes, herpes, pemphigus.


Uses Carcinoma Herpes simplex, zoster Pemphigus vulgaris Benign familial pemphigus Keratosis follicularis Hereditary benign intra epithelial dyskeratosis White sponge neavus Anemia – pernicious, sickle cell Research application eg tobacco users

Technique :


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Normal vs Abnormal Cytology Findings:

Normal vs Abnormal Cytology Findings


Advantages Quick, easy Local anesthetic not required Special techniques such as immunostaining can be applied Most useful for detection of virally damaged cells acantholytic cells of pemphigus candidal hyphae


Disadvantages Presence / extent of invasion cannot be assessed. Majority of benign lesions in oral cavity are not accessible. Not useful in leukoplakia – scarcity of viable surface cells Negative report does not rule out disease. Expertise in oral cytology is not widely available.

Needle biopsy:

Needle biopsy Also known as Fine Needle Aspiration Cytology Diagnostic procedure sometimes used to investigate superficial lumps or masses


indications Performed - On a lump or a tissue-mass when its nature is in question. For known tumors, to assess the effect of treatment or to obtain tissue for special studies.

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When the lump can be felt, the biopsy is usually performed by a cytopathologist or a surgeon. In this case, the procedure is usually short and simple. Otherwise, it may be performed by an interventional radiologist, under X-ray, ultrasound or CT guidance

Common sites :

Common sites Lymph node Breast Salivary gland Thyroid Soft tissue masses Kidney, liver, intra abdominal masses (guided)


procedure Patient examined, lump localized Overlying skin cleaned with alcohol Lump fixed with fingers of one hand Needle of 20 ml syringe (in holder) introduced Needle moved back & forth 1-3 mm to soften tissue Suction applied – minimal aspirate visible in needle hub – suction released Syringe withdrawn, puncture site sealed

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Syringe-needle separated, filled with air, reconnected, material blown out on slide Smears made using coverslip Fixation in methanol for 10 mins Stained with Giemsa stain If blood is aspirated – procedure to be stopped, restarted




advantages Quick and effective test for determining the status of suspect tissue In volves little possibility of scarring, infection or pain Significantly shorter recovery time. Useful in the diagnosis and treatment of cysts.

Disadvantages :

Disadvantages Possibility of cancer cells being trailed into unaffected tissue as the needle is removed – usually not a problem when performed by skilled practitioner. Risk that any abnormal cells may be missed and not detected – sample taken is small – high rate of false negatives Require some expertise to perform and interpret.

Aspiration Biopsy:

Aspiration Biopsy

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Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration of its contents. Indications : To determine the presence of fluid within a lesion To ascertain the type of fluid within a lesion When exploration of an intraosseous lesion is indicated



Incisional Biopsy:

Incisional Biopsy An incisional biopsy is a biopsy that samples only a particular portion or representative part of a lesion. If a lesion is large or has different characteristics in various locations more than one area may need to be sampled

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Technique & Features:

Technique & Features

Excisional Biopsy:

Excisional Biopsy An excisional biopsy implies the complete removal of the lesion.



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Technique: E ntire lesion with 2 to 3mm of normal appearing tissue surrounding the lesion is excised if benign.

General Principles of Surgery :

General Principles of Surgery


Anesthesia EMLA ( Prilocaine – Lidocaine eutectic) cream or patch used in most cases Block anesthesia is preferred to infiltration When blocks are not possible distant infiltration may be used Never inject directly into the lesion

Tissue Stabilization & hemostasis:

Tissue Stabilization & hemostasis Includes- Digital stabilization Specialized retractors/forceps Retraction sutures Towel Clips In case of bleeding Gauze compresses are usually adequate Suction devices should be avoided

Points to be considered during oral biopsy:

Points to be considered during oral biopsy Anesthesia to be used around periphery of lesion Sharp scalpel to be used to avoid tearing Removal of a border of normal tissue with specimen if possible Using forceps carefully so as not to mutilate specimen Immediately fixing specimen


Incisions Incisions should be made with a scalpel. be converging extend beyond the suspected depth of the lesion parallel important structures Margins should include 2 to 3mm of normal appearing tissue if the lesion is thought to be benign. 5mm or more with lesions that appear malignant, vascular, pigmented, or have diffuse borders.

Handling & Care of Tissue Specimen:

Handling & Care of Tissue Specimen Direct handling of the lesion will expose it to crush injury resulting in alteration the cellular architecture . The specimen should be immediately placed in 10% formalin solution, and be completely immersed.

Surgical Closure:

Surgical Closure Primary closure of the wound is usually possible Elliptical incision on the hard palate or attached gingiva may be left to heal by secondary intention.

Biopsy Data Sheet:

Biopsy Data Sheet A biopsy data sheet should be completed and the specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed.

Intraosseous and Hard Tissue Biopsy:

Intraosseous and Hard Tissue Biopsy Intraosseous lesions are most often the result of problems associated with the dentition. Indications – Any intraosseous lesion that fails to respond to routine treatment of the dentition. Any intraosseous lesion that appears unrelated to the dentition.

Principles of Surgery:

Principles of Surgery Incisions should be over sound bone Major neurovascular structures should be avoided Avoid roots and neurovascular structures The tissue consistency and nature of the lesion will determine the ease of removal

Biopsy Results: What If ?:

Biopsy Results: What If ? They don’t corroborate your clinical impression Repeat the biopsy Determine if the tissue was looked at by an Oral Pathologist The results might be atypical - malignancy

When To Refer For Biopsy:

When To Refer For Biopsy When the health of the patient requires special management that the dentist feel unprepared to handle The size and surgical difficulty is beyond the level of skill that the dentist feels he/she possesses If the dentist is concerned about the possibility of malignancy


bibliography Textbook of Oral Pathology by William G. Shafer Cawson's Essentials of Oral Pathology and Oral Medicine - Roderick A. Cawson & Edward W Odell Wikipedia Google

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