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 history A history of the specific lesion A clinical examination A radiographic examination Laboratory investigations Surgical 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 defects Coagulopathies Hypertension Poorly controlled diabetics Immunocompromised patients

History of the Lesion

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

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

Historical Reasons for the Lesions:

Trauma to the area Recent toothache Habits

Clinical Examination

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

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
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

Laboratory Investigation

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

These include:

Tumor of hyperparathyroidism Padgets disease Multiple myeloma Determination of serum calcium, phosphorus, and alkaline phosphatase and protein can be very useful in excluding certain pathological processes.

Biopsy and HistopathologicalExamination

Biopsy is the surgical removal of a tissue specimen from a living organism for microscopic examination and final diagnosis. A biopsy is a minor surgical procedure and, depending on whether the entire pathologic lesion or part of it is removed, is either an excisional biopsy or incisional biopsy. Furthermore, aspiration or needle biopsy uses a needle to withdraw a sample from the lesion for examination.

Principles for Successful Outcome of Biopsy

In clinically suspicious lesions, biopsy must be carried out as soon as possible. The choice of the biopsy technique to be employed is determined by the indications of each case. Direct injection of the local anesthetic solution inside the lesion is to be avoided, because there is a possibility of causing distortion to the tissues.

Principles for Successful Outcome of Biopsy

The use of the electrosurgical blade is to be avoided, due to the resulting high temperature, which causes coagulation and destruction of tissues. The tissue specimen must not be grasped with forceps. When their use is necessary, though, the normal part of the removed tissue should be grasped.

Principles for Successful Outcome of Biopsy

The tissue specimen taken should be representative. Immediately after its removal, the tissue specimen should be placed in a container with fixative. Keeping the tissue specimen outside of the container for a prolonged period dries the specimen, while there is a risk of it falling or being misplaced.

Principles for Successful Outcome of Biopsy

The fixative solution to be used is 10% formalin, and not water, alcohol, or other liquids that destroy the tissues. It is recommended that the container to be sent to the laboratory is plastic to avoid risk of breakage during its transfer and subsequent loss of the specimen.

Principles for Successful Outcome of Biopsy

The label with the name of the patient and date should be placed on the side of the container, and not on the lid. This way the possibility of mix-up at the laboratory after opening is avoided.

Indications for Biopsy

Any lesion that persists for more than 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 mass or tumor, either visible or palpable beneath relatively normal tissue.

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.
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

Types of Biopsy

Oral cytology(cell exfoliative cytology) Aspiration biopsy, Needle biopsy(FNAC) Incisional biopsy Excisional biopsy Punch biopsy Oral brush biopsy Optical coherence tomography

Oral Cytology

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

Exfoliative Cytology

The Disadvantage of oral cytological procedures include:
Not very reliable with many false positives. Expertise in oral cytology is not widely available The 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 lesion To a certain the type of fluid within a lesion When 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 lesion Great suspicion of malignancy Technique: 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 1cm The 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.

Note

Remember……..Many times what we see is only the Tip of the Iceberg .

Punch biopsy

The punch biopsy technique is an alternative to the traditional incisional biopsy, Essentially the punch comprises a circular blade attached to a plastic handle. This removes a core of tissue the base of which can be simply and atraumatically released using curved scissors.


Punch biopsy
The resultant wound may not require suturing if using the smaller diameter punches.

Punch biopsy

Punch biopsy may be difficult on freely movable oral tissues and probably offers no advantage compared with scalpel biopsy . The technique may be appropriate in the hard palate and other sites with better support and tissue that is bound down, and it is likely to produce a satisfactory specimen. The wound heals by secondary intention, and discomfort may persist longer than anticipated by the clinician and the patient.

Brush biopsy

Image used with permission from Dr. Jane Eisen, DDS, OralCDx, CDx Laboratories, 2004

Oral brush biopsy is a noninvasive method of evaluating oral mucosal lesions for cellular atypia. It is a three-layer transepithelial exfoliative cytology technique

Adjuvant techniques

Kit contents: Chemiluminescent device 30 ml acetic acid Light stick holder/retractor
Image used with permission from Dr. Mark Bride, DDS, ViziLite, Zila Pharmaceuticals, 2004

Steps: Patient rinses with 1% acetic acid for 1 minute Activate device by bending outer capsule to break inner vial Shake capsule to mix contents Insert capsule into retractor unit Dim room lighting Visually inspect oral cavity using device Discard materials


Normal epithelium absorbs the light and appears dark Abnormal tissue reflects light and appears bright white
Images used with permission from Dr. Mark Bride, DDS, ViziLite, Zila Pharmaceuticals, 2004


Tissue autofluorescence–based systems (VELscope) Tissue autofluorescence–based systems (VELscope) rely on the exposure of oral epithelium to specific wavelengths of light in order to produce an emission of energy in the form of fluorescence. The proposed mechanism of this fluorescence is related to reflective and absorptive patterns due to naturally occurring fluorophores in the oral mucosal tissue. This fluorescence is variable and it is affected by changes in tissue metabolism and structure. Further, the presence of hemoglobin, vessel dilation, and inflammation in the examined tissue can affect its appearance. Illuminating oral tissues with the VELscope device causes normal mucosa to emit a pale green light, whereas abnormal mucosa appears dark in presentation.

Tolouidine Blue Staining

Tolonium Chloride
Toluidine blue Metachromatic dye Stains nuclear DNA 1% aqueous solution followed by 1% acetic acid to decolorize lesion Abnormal tissue retains the blue dye

Principles of Surgery

Anesthesia
Block anesthesia is preferred to infiltration When blocks are not possible distant infiltration may be used Never inject directly into the lesion

Tissue Stabilization

Digital stabilization Specialized retractors/forceps Retraction sutures Towel Clips

Hemostasis

Suction devices should be avoided Gauze compresses are usually adequate Gauze wrapped low volume suction may be used if needed

Incisions

Incisions should be made with a scalpel. They should be converging Should extend beyond the suspected depth of the lesion They should parallel important structures Margins 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 Filled Vascular Without Contents
Clinical Exam

Principles of Surgery

Mucperiosteal flaps should be designed to allow adequate access for incisional/excisional biopsy. Incisions should be over sound bone Cortical perforation must be considered when designing flaps Flaps should be full thickness Major neurovascular structures should be avoided

Principles of Surgery

Osseous windows should be submitted with the specimen Osseous preformations can be enlarged to gain access Avoid roots and neurovascular structures The 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 tissue Soft 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 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

Thank you