This document provides information on biopsy and exfoliative cytology procedures. It defines biopsy as the removal of living tissue for examination to establish a diagnosis. Biopsies are categorized as excisional, incisional, or needle biopsies. Exfoliative cytology examines cells that exfoliate or abrade from body surfaces through microscopic analysis. It was pioneered by Dr. Papanicolaou in 1941 and provides a non-invasive method for examining superficial cells through smears. Both procedures provide important diagnostic information but biopsy is needed to confirm cytology findings.

1. BIOPSY AND EXFOLIATIVE CYTOLOGY
Dr Monika
MDS
ORAL PATHOLOGY ,MICROBIOLOGY
AND FORENSIC ODONTOLOGY

2. BIOPSY
 INTRODUCTION
 The word Biopsy was coined by the French
Dermatologist ERNEST HENRY BESNIER
in 1879.
 It originated from 2 Greek words,
 BIOS - meaning life and OPSIS -
meaning vision.
 It also serves as treatment options for
smaller lesions by excising in toto.

3. DEFINITION
 Biopsy is the removal of living tissue for
examination in order to establish a precise
diagnosis.
 According to Richard W. Tiecke
Biopsy in its broadest sense includes
removal of tissue for examination,
microscopic analysis, clinical analysis
and bacterial analysis or a combination of
all.

4. RATIONALE :-
 Biopsy should be performed for both moral and
legal reasons.
 All hard and soft tissue removed during surgical
procedures should be submitted for gross and
microscopic examination.
 Such a system,
 1. Safeguards against unnecessary surgical
procedures.
 2. Permits the establishment of a final
diagnosis and proper patient management.

5.  Reveals the nature of a disease process
that is completely unsuspected by the
clinician.
 In Medico-legal cases, the Biopsy report
provides an important legal document in
support of the clinician.

6. INDICATIONS OF BIOPSY :-
 1. Performed on lesions that cannot be definitively diagnosed
by other techniques such as clinical examination,Radiography,
Cytology and Clinical laboratory methods.
 2. Performed on all lesions that clinically fail to respond to
well established treatment modalities.
 If a lesion does not respond to usual treatment within a
reasonable period usually 10 days to two weeks the lesion
must be biopsied to confirm its clinical nature and rule out the
possibility that the clinician is dealing with a dangerous entity.
 3. For those lesions that clinically suggest a malignant
neoplastic process. This includes lesions that are rapidly
growing and which exhibit paresthesia or loss of function.

7.  4. Conditions that are potentially pre-
cancerous. e.g. leukoplakia, Erythroplakia.
 5. Biopsy is necessary for classification,
grading, staging of Tumors and as a
prognostic indicator for counselling of
patients.
 6. For evaluation of surgical margins in
order to determine whether a dangerous
lesion has been completely excised.

8. CONTRA-INDICATIONS OF BIOPSY:-
Anticoagulant therapy
Over-whelming sepsis
Severe impaired lung
function
Uncontrolled
bleeding.
Uncooperative
patient
Local infection near
the site CONTRA-
INDICATION

9. TYPES OF BIOPSIES [CLASSIFICATION]

 1. Excisional or Total Biopsy.

 2. Incisional Biopsy.
 a. Wedge Biopsy
 b. Modifications of Incision Biopsies
 i. Punch biopsy
 ii. Drill Biopsy
 iii. Curettage Biopsy

 3. Needle Biopsy
 a. Aspiration Needle Biopsy
 - FNAB
 - LNAB
 b. Core Needle Biopsy.

10. EXCISIONAL BIOPSY:-
 It is the total excision of the lesion and is
employed in smaller lesions usually less than 2
cms.
 When clinical examination reveals that the
lesion is benign it is better to employ this
technique as
 1. Whole of the lesion is made available for
examination.
 2. This is the only form of treatment
available for most of the conditions.

12. DRAWBACKS
 1. In case of malignant lesions, care should
be taken to involve the entire lesion for if the
tumor is not completely removed then it may
not be possible to visualize the primary tumor
making clinical staging of tumors difficult.
 2. Since it is not possible to delineate the
accurate tumor boundaries, there are chances
that one might resect excessive tissue and
the surrounding normal area may also be
exposed to unwanted radiotherapy.

13. INCISIONAL BIOPSY
 [WEDGE BIOPSY] :-
 It is the removal of a portion of a lesion and is
employed when the surface lesion exceeds 1
cm in all of its dimensions. Here the lesion is
widespread and total excision is not advisable.
 It is generally employed to establish a
diagnosis between benign and malignant
lesion so that definite therapy can be planned.
There are 2 opinions regarding the use of
incisional biopsy in malignancy.

16.  1. Should not be carried out because
seeding of viable tumor cells leads to
metastasis.
 2. Risk of spreading cells is secondary to
establishing a diagnosis which will help in
correct planning.

17. 3 MODIFICATIONS OF INCISIONAL BIOPSY ARE
 1 PUNCH BIOPSY
 2 DRILL BIOPSY
 3 CURETTAGE BIOPSY

 1. PUNCH BIOPSY - Any method in which
cylindroid piece of tissue is removed for
biopsy by means of a special instrument
that pierces the skin / m.m.
 Here a special surgical group or biopsy
punch is used which “bites' out small
fragments of tissue or cylindroid piece
of tissue from inaccessible lesion or
from a large lesion where excision is
contra-indicated.
 e.g. Palatal biopsy of minor salivary
glands in case of Sjogren's syndrome.

19. 
 ADVANTAGES :
 1. It operates quickly and effectively.
 2. It produces a clean and sharp incision.
 3. Little bleeding occurs following this type of biopsy and suture
is generally unnecessary.
 4. Pain is minimal and hence it may be carried out without
anaesthesia or only topical application.

 DISADVANTAGE :
 The tissue may be crushed or there may be distortion of
the tissue, hence the results of the histopathological study are
often uncertain and not dependable for a definite diagnosis

20. 2. DRILL BIOPSY -
 Specimens can be obtained by use of
Modified Ellis Biopsy Drill which has teeth
at the cutting end and is fitted in the straight
handpiece.
 Specimens of 1.2 cm long and 1.4 mm
width can be obtained by this method.

21.  USE :
 It is useful in obtaining specimens of central fibro-
osseous lesions of the jaws.

 DISADVANTAGE :
 1. Heat is generated which may distort the tissue.
 2. It is very easy to miss the lesion when inserting the drill,
hence negative drill biopsy should be confirmed by other
methods.
 Precautions should be taken prior to Drill Biopsy and vascular
lesions should be aspirated prior to surgical intervention to avoid
profuse heamorrhage. If haemorrhage is encountered it may be
controlled by gelatin sponge, oxidised cellulose or bone-wax.

22. CURETTAGE BIOPSY
 A small portion of the lesion is curetted for
histopathological study with the help of a curette.
 Used primarily for -
 1. Intra osseous lesion and for very
 2. friable cellular lesions where only small amount of
surface material is necessary for evaluation.
 Extremely small segments of tissue are centrifuged after
fixation. The sedimentary segments are then placed in a
media such as Agar and they are then sectioned as a Cell

23. ASPIRATION BIOPSY
 Is any method in which the specimen for biopsy is
removed by aspirating it through a hypodermic
needle or trocar (rod with sharp 3 cornered tip which
is fitted to a cannula & is used for withdrawing fluids
from a cavity) that is pierced through the skin or
through the external surface of an organ into the
underlying tissue to be examined.
 It is said to be a simple procedure and causes
minimal inconvenience to the patient.
 The aspirated material should be sent for
cytological and bacteriological examination.

24. TECHNIQUES OF ASPIRATION BIOPSY
 There are two techniques
 1. Fine needle aspiration biopsy (FNAB)

 2. Large needle aspiration biopsy (LNAB)

25. FINE NEEDLE ASPIRATION BIOPSY (FNAB)
 In the 1950s, Franzen et al and others at the Karolinska Institute
developed the fine needle aspiration biopsy using needle sized
20 guaze and smaller.
 ADVANTAGES
 1. It is a useful, safe (free of complications) and accurate
technique (accuracy never below 80%).
 2. Bleeding is easily controlled and usually stops with a few
seconds.
 3. This technique is performed safely in children without having
to restrain the child.
 4. Fine needles cause very little discomfort, hence L.A is
generally not used.

26.  5. FNAB diagnosis is usually more rapid
than surgical biopsy diagnosis.
 6. It is a simple and economical
technique.
 7. Can be performed safely in pregnant and
high risk patients (pt. is either in supine
or sitting position).
 8. FNAB leaves no scar

27. DISADVANATGES OF FNAB
 1. Since the needle is fine , there may be plugging
of the tissue in the needle.
 Equipment
 used while performing FNAB.
 22 - 25 gauze needle without stylet
 Length of needle -2.5 - 6 cms
 Drain of needle - 0.5 to 0.9 mm in case of soft
tissue
 - 1 to 2mm in case of sclerotic or
bony tissues.
 2. Syringe - this may be coated with silicone to
ensure tight fitting of the plunger

28. LARGE NEEDLE ASPIRATION BIOPSY - (LNAB)
 ADVANTAGES
 1. Since the needle is large, plugging of the tissue
in the needle does not occur.
 2. Since a nick is made on the skin, there is no
withdrawal of squamous cells from the surface of
the lesion.
 DISADVANTAGES
 1. There may be scar formation.
 2. L.A has to be given

29. CORE NEEDLE BIOPSY
 Here a cylindrical specimen (core) is
removed with the help of silverman
needle 14 gauge needle with stylet and
cutting trocar inserts or similar type of needle
for histological evaluation.

30. METHODS USED FOR OBTAINING BIOPSY
 Surgical excision using-Scalpel
 •Cautery
 •Laser
 •Biopsy forceps [punch biopsy]
 •Aspiration with needle

31. BIOPSY TECHNIQUE
 Do not paint surface of area to be biopsied
with iodine or highly coloured antiseptic.
 If using infiltration anaesthesia inject around
periphery
 Use sharp scalpel to avoid tearing lesions
 Remove border of normal tissue with
specimen if at all possible
 Use care, not to mutilate specimen
 Fix tissue immediately upon in
10%FORMALIN/70% alcohol
 If specimen is thin place it on a piece of glazed
paper and drop into the fixative to prevent curling of
tissue

32. ORAL EXFOLIATIVE CYTOLOGY

33. EXFOLIATIVE CYTOLOGY
 This is the study of cells which exfoliated or
abrade from body surface
 When epethelium becomes seat of any pathology,
cells lose their cohesiveness and cells in deeper
layers may shed along with superficial cells.
 Microscopic examination of shed cells from body
surfaces or cell harvested by rubbing or brushing
a lesional tissue surface .
 First introduced by Papanicolau in 1941 .
 It’s a simple , pain free ,non invasive and rapid
technique This technique is only used for study of
superficial cells and requires other cytological
analysis to confirm .

34. Dr. George N. Papanicolaou (1941).

35. BASIS OF EXFOLIATIVE CYTOLOGY.
 Physiology of the epithelium.
 Morphologic alteration of individual cells
indicative of malignancy.
 Loss of cohesion allowing exfoliation

36. INDICATIONS
1. A mucosal lesion that appears clinically
innocuous and otherwise would not be
biopsied.
2. Evaluation of an extensive mucosal lesion
when it is not possible to do a sufficient
number of incisional biopsies for adequate
sampling.
3. Follow-up for patients with a prior diagnosis
of either a premalignant or malignant
mucosal lesion.

37. 4. If the patient's medical status is too
fragile for a surgical biopsy or if the
patient refuses.
5. To assess potential oral candidiasis
and viral infections.

38. BASIC TECHNIQUE
The supplies needed for oral cytology are:
 Glass slides
 Cytobrush or a steel spatula or a wooden
spatula.
 Alcohol fixative or Spray fixative.
 A Request for Tissue Examination form

39. Steps-:
 Explain to the patient the purpose of the exam
and, in general, the steps of the technique.
 With a marking pencil write accession number
on the frosted end of a glass slide.

40.  Remove one Cytobrush from the package.
 With a gauze gently remove any excess
saliva in the area that will be smeared.

41.  Vigorously scrape and rotate the Cytobrush
over the entire lesion.
 Or scrape the lesion with a spatula.

42.  Take the Cytobrush and spread the harvested cells
onto the glass slide by starting at the frosted end and
rotating the Cytobrush until you reach the other end
of the slide.

43.  One should be able to see a white, filmy
debris on the glass slide.
 Spray the surface of the glass slide right
away with the Spray-cyte while holding the
can about 6 inches away from the slide.

45. SITES OF SMEAR
 Buccal mucosa
 Junction between hard and soft palate
 Dorsum of tongue
 Floor of mouth

46. MICROSCOPIC FINDINGS
 Smears, whether oral or uterine, are graded in
five categories (I, II, III, IV, and V).
 Class I smear
 Normal nuclear/cytoplasmic ratios.
 The blue/green staining indicates that those cells
were acquired from deeper layers (diagnostic).
 The red/orange cells were acquired from superficial
layers (not diagnostic).

47. Class I = "Normal, no atypical cells seen"

48.  Class II Smear –
 There may be slight atypia that is assumed to be the
result of inflammation.
 The nuclei are of normal size and shape. There are,
however, scattered inflammatory cells and some subtle
atypical changes in the upper left cell.
Class II = "A few
atypical cells;
probably
inflammatory."

49.  Class III Smear –
 The nuclei of these cells are abnormally large
(altered nuclear/cytoplasmic ratio) indicating that
they may be malignant.
 Changes occur in superficial cells (red/orange) is
worrisome.
Class III = "Atypical cells
seen; may be
malignant."

50.  Class IV Smear –
 Many nuclei almost fill the cells (altered N/C ratio).
 Cells are of different sizes and shapes
(pleomorphism).
 Biopsy is the required next step.
Class IV = "Many
atypical cells; probably
malignant."

51.  Class V Smear –
 Features of anaplasia are overwhelming.
There is altered N/C ratio, pleomorphism,
and enlarged/multiple nuclei. The lesion
is malignant.
Class V = "Most
cells are atypical;
definitely
malignant."

52. FEATURES
 Cytology is not a substitute but an adjunct to
surgical healing.
 It is a quick simple painless and bloodless
procedure.
 It is especially helpful in follow up detection
of recurrent carcinoma in previously treated
cases.
 It is valuable for screening lesions whose
gross appearance is such that biopsy is not
warranted.

53. CONTRAINDICATION
 An obvious cancer that would justify a
biopsy Sub mucosal lesions
 White lesion that do not rub off

54. ADVANTAGES OF ORAL EXFOLIATIVE CYTOLOGY
 It is a quick, simple, painless, bloodless, non-
invasive chair side procedure.
 Better patient compliance.
 Repeat procedure causes less inconvience.

55. DISADVANTAGES
 Relatively limited information provided by
exfoliated material when compared to a
histological preparation.
 Positive result gives definite value where as
negative result is of considerably less value.
 Exfoliative cytology is limited to tissues,
which exfoliate cells into reasonable
accessible sites.