Biopsy

Principles and Techniques of Biopsy

Principles and Techniques of Biopsy It is important to develop a systematic approach in evaluating a patient with a lesion in the Oral and Maxillofacial region.

These steps include : A detailed health historyA history of the specific lesionA clinical examinationA radiographic examinationLaboratory investigationsSurgical specimens for histopathologic evaluation

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 deseases 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.

Medical conditions that warrant special care include: Congenital heart defectsCoagulopathiesHypertensionPoorly controlled diabeticsImmunocompromised patients

History of the Lesion

Questions to Ask Duration of the lesionChanges in size and rate of changeChanges in the character of the lesion.Lump to ulcer, etcAssociated systemic symptoms:fevernauseaanorexia

More Questions to Ask PainAbnormal sensationsAnesthesiaA feeling of swellingBad taste or smell DysphagiaSwelling or tenderness of adjacent lymph nodesCharacter of the pain if present

Historical Reasons for the Lesions: Trauma to the areaRecent toothacheHabits

Clinical Examination The clinical examination should always include when possible:InspectionPalpationPercussionAuscultation


Clinical Evaluation The anatomic location of the lesion/massThe physical character of the lesion/massThe size and shape of the lesion/massSingle vs. multiple lesionsThe surface of the lesionThe color of the lesionThe sharpness of the boundaries of the lesionThe consistency of the lesion to palpationPresence of pulsationLymph node 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 cystA ragged radiolucency will often be a more aggressive lesionRadiopaque dyes and instruments can help differentiate normal anatomy

Laboratory Investigation Oral lesions may be manifestations of systemic disease. If a systemic disease is suspected it should be pursued.

These include: Tumor of hyperparathyroidismPadgets diseaseMultiple myelomaDetermination of serum calcium, phosphorus, and alkaline phosphatase and protein can be very useful in excluding certain pathological processes.

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

Indications for Biopsy Inflammatory changes of unknown cause that persist for long periodsLesion that interfere with local functionBone lesions not specifically identified by clinical and radiographic findingsAny lesion that has the characteristics 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 growthBleeding- lesion bleeds on gentle manipulationInduration- lesion and surrounding tissue is firm to the touchFixation- lesion feels attached to adjacent structures

What is a Biopsy? Biopsy is the removal of tissue for the purpose of diagnostic examination.

Types of Biopsy Oral cytologyAspiration biopsyIncisional biopsy Excisional biopsyNeedle biopsy

Oral Cytology Developed as a diagnostic screening procedure to monitor large tissue areas for dysplastic changes.Most frequently used to screen for uterine cervix malignancyMay be helpful with monitoring postradiation changes, herpes, pemphigus.

The Disadvantage of oral cytological procedures include: Not very reliable with many false positives.Expertise in oral cytology is not widely availableThe lesion is repeatedly scraped with a moistened tongue depressor or spatula type instrument. The cells obtained are smeared on a glass slide and immediately fixed with a fixative spray or solution.


Aspiration Biopsy Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration if its contents.Indications:To determine the presents of fluid within a lesionTo a certain the type of fluid within a lesionWhen exploration of an intraosseous lesion is indicated

Aspiration An 18 gauge needle on a 5 or 10 ml syringe is inserted into the area under investigation after anesthesia is obtained.The syringe is aspirated and the needle redirected if necessary to find the fluid cavity.

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

Incisional Biopsy Indications:Size limitations Hazardous location of the lesionGreat suspicion of malignancyTechnique:Representative areas are biopsied in a wedge fashion.Margins should extend into normal tissue on the deep surface.Necrotic tissue should be avoided.A narrow deep specimen is better than a broad shallow one.

Excisional Biopsy An excisional biposy implies the complete removal of the lesion.Indications:Should be employed with small lesions. Less than 1cmThe lesion on clinical exam appears benign.When complete excision with a margin of normal tissue is possible without mutilation.

Excisional Biopsy Technique:The entire lesion with 2 to 3mm of normal appearing tissue surrounding the lesion is excised if benign.

Principles of Surgery

Anesthesia Block anesthesia is preferred to infiltrationWhen blocks are not possible distant infiltration may be usedNever inject directly into the lesion

Tissue Stabilization Digital stabilizationSpecialized retractors/forcepsRetraction suturesTowel Clips

Hemostasis Suction devices should be avoidedGauze compresses are usually adequateGauze wrapped low volume suction may be used if needed

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


Handling of the Tissue Specimen Direct handling of the lesion will expose it to crush injury resulting in alteration the cellular architecture.

Specimen Care The specimen should be immediately placed in 10% formalin solution, and be completely immersed.

Margins of the Biopsy Margins of the tissue should be identified to orient the pathologist. A silk suture is often adequate. Illustrations are also very helpful and should be included.

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

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 lesions are most often the result of problems associated with the dentition.

Indications for Intraosseous Biopsy Any intraosseous lesion that fails to respond to routine treatment of the dentition. Any intraosseous lesion that appears unrelated to the dentition.

Palpation of the area of the lesion with comparison to the opposite side.Any radiolucent lesion should have an aspiration biopsy performed prior to surgical exploration.Information from the aspiration will provide valuable information about the lesion. Solid Fluid FilledVascularWithout Contents Clinical Exam

Principles of Surgery Mucperiosteal flaps should be designed to allow adequate access for incisional/excisional biopsy.Incisions should be over sound boneCortical perforation must be considered when designing flapsFlaps should be full thicknessMajor neurovascular structures should be avoided

Principles of Surgery Osseous windows should be submitted with the specimenOsseous preformations can be enlarged to gain accessAvoid roots and neurovascular structuresThe tissue consistency and nature of the lesion will determine the ease of removal

Principles of Surgery Incisional biopsies only require removal of a section of tissueSoft tissue overlying the lesion should be reapproximated following thorough irrigation of the operative site.The specimen should be handled as previously described


Biopsy Results: What If ? They don’t corroborate your clinical impressionRepeat the biopsy!!!Determine if the tissue was looked at by an Oral PathologistThe results show malignancy

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