I was in BDS 3rd year when done that

1. GOOD MORNING

2. Oral Pathology Seminar
Topic : Biopsy and Fine
Needle Aspiration Cytology
(FNAC)
Submitted By : Guided By :
1.P.V.S.Ankita DR.Kartikay
Roll no – 43 Saxena
3rd Year BDS

3. BIOPSY

4. What is a biopsy?
*Biopsy is derived from a Greek
word ( Bio – Opsis)
Bio – meaning life or tissue
Opsis – meaning vision or
microscopy
Biopsy means study of tissue using
microscopy.

5. Definition
*A biopsy is the examination of tissue
removed from a lesion and by
extension the term is also used to
convey the removal of the tissue.
(WHO 1966)
* Biopsy is a surgical procedure to
obtain tissue from a living organism
for its microscopical
examination,usually to perform a
diagnosis.

6. Objectives of biopsy
*To confirm a diagnosis made on
clinical findings.
*To determine the treatment plan.
*As a medical record.

7. Indications for biopsy
*Persistant hyperkeratotic changes in
surface tissue. (ex- lips or oral
mucosa)
*Lesions that interfere with local
function. ( ex-fibroma)
*Any inflammatory lesion that does not
respond to local treatment after 10 to
14 days ( after removing local irritant)

8. Indications of biopsy
*Bone lesions not specifically identified
by clinical and radiographical finding.
*Any lesion persists for more than 2
weeks with no apparent etiology
basis.
*Any lesion that has the characteristics
of a malignancy.

9. Contra-Indications of
biopsy
*Anticogulant Therapy
*Over-whelming Sepsis
*Severe impaired lung function
*Uncontrolled Bleeding
*Uncooperative Patient
*Local Infection near the site

10. Classification of Biopsy
1.Features of the lesion :
a.Direct biopsy- when the lesion is
located on the oral mucosa and can
be easily accessed with a scalpal
from the mucosal surface.
b.Indirect biopsy-when the lesion is
covered by an apparently normal
oral mucosa.

11. 2.By the timing of the biopsy/Clinical timing
of sampling :
a.Pre-operative
b.Intra-operative
c.Post-operative
3.Purpose of the biopsy :
a.Diagnostic Biopsy
b.Experimental Biopsy

12. Histopathological investigation
*Biopsy *Cytology
*Exfoliative
*Incisional *Excisional *Needle biopsy *Needle
biopsy biopsy biopsy *Brush biopsy
biopsy
*Core Needle biopsy *FNAC
*Punch *Wedge
biopsy biopsy *Vaccume *CT/Image USG guided
assiated biopsy biopsy
biopsy

13. Procedure of biopsy
1.Selection of the area of biopsy
2.Preparation of surgical field
3.Local Anasthesia
4.The incision
5.Tissue handling
6.Suturing of the resulting wound

14. Selection of the area of biopsy
*Biopsy is generally
avoided in an infected
site.
*Preferentially,the area
of advancing
inflammatory changes
of the lesion is
desirable for biopsy.
*Old lesions showing
secondary changes
like
crusts,fissures,erosion
,excoriations and
ulceration are avoided
since the characterstic
feature of disease may
not be clearly
distinguished.
*Lesions and their biopsy sites :
*Pathological *Selection of
lesion area for biosy
1.Vesicles Newest
vesicles
biopsied(48h)
intact with adj.
noraml app.skin
2.Bulla At the edge,
keeping the
blister roof
intact.
3.Non-bullous Maximal lesion
skin and min.
normal skin
4.Large lesion edge,the
thickest
portion or area
of abnormal
colouration

15. *In case of doubtful malignant character of the
lesion,the following aids can be used as an
adjunct to select respresentative ares.
*Toluidine Blue
*VEL scope
*Toluidine blue :
*Toluidine blue is a metachromic vital dye of
the thiiazide group that inc. Visual
detection of oral precancerous and cancer
lesions after negative clinical examination.
*It is effectively used as nuclear stain
because of its ability of DNA binding.

16. Procedure –
*The patient is asked to rinse with.
1. Water for 20 sec to remove debris
2. 1% acetic acid for 20 sec.
3. 1% Toluidine blue water solution for high
risk areas for 20 sec.
4. Mouth wash with 1% acetic acid should be
applied,to clear mechanically retained stain
and
5.A final rinse with water.
*The sample should include healthy tissue at
the margin of the lesion.

17. *Lugol’s Iodine :
*Lugol’s iodine staining based on the
principle of higher amount of glycogen in
the normal mucosa compared to abnormal
mucosa.
*VEL Scope(narrow
emission tissue fluorescence)
*The fluroscence imaging involves the
exposure of tissue to a specific wavelength
of light, which results in the
autofluroscence of cellular flurophores
after excitation.

18. *When there is morphological
alteration in the cells,the
concentration of the
fluorphores is altered which
affects the scattering and
absorption of light in the
tissue.This leads to change in
colour which is observed
visually.
*The unit emits intense blue
excitation (400-460nm) ,a pale
green autofluorscence is
emitted by the normal
mucosa,this is seen through
the selective filter
incorporated within the
instrument handpiece.
*The areas of abnormal or
suspected tissues are darker
than the adjacent normal
tissue due to decreased
amount of normal
autofluorescence.

19. Preparation of the surgical field
*Common skin antiseptics such as
isopropyl alcohol,povidine iodine or
chlorohexidine gluconate can be used
to prepare the biopsy site.
*Mark the intended lesion with a
surgical marker as it may be
temporary obliterated following
injection of the local anaesthetic
solution.

20. Local Anaesthesia
*An amide-type local anaesthesia with
vasoconstrictor is uesd.
*Infiltration should be given 1 cm away
from the area of the anaesthesia
solution.

21. The Incision
*A well defined,delicate
incision is made to remove
a portion of the tissue
during an incisional biopsy.
*Soft tissue incision are
elliptical in shape,thus a V-
wedge tissue comprising
both the lesion and the
healthy margin are
obtained.
*In case of more than one
lesion in the oral cavity ,
multiple biopsies are
necessary.

22. Tissue Handling
*The specimen should be meticulously
handled to avoid crushing of tissue and
placed in the fixing solution.
*Wash the specimen with copious running
saline to remove traces of blood.
*10% formalin is the widely used fixing
agent,it cause minimal histological
alterations in the samples. Other reagenta
such as isopropyl or methyl alcohol,saline
or distilled water should never be used as it
severely alters the microstructure.
*Surplus amount of fixing agent should be
used 10 to 20 fold the volume of the sample
is used.

23. *For immunofluorescence or
immunostaining,the specimen should not be
fixed and should be sent immediately to the
laboratory for freezing or placed in Michel’s
solution.
*The specimen is sent to the pathologist, it
should also carry a summary containing
identification of the patient,clinical
records,clinical signs,radiographic
feature(if applicable), a provisional
diagnosis and the orientation of the sample.

24. Suture
*The suture should achieve good
haemostasis,facilitate healing and should
be removed after 6-8 days.
*Contraindication to suturing include biopsies
in infected or poorly healing skin,these
wounds heal better by secondary intention.
*It is also contraindicated in susceptible
cancerous lesion to avoid cell seeding in
healthy tissue.

25. Biopsy Report
*The report of a biopsy is usually returned to
the operator by the pathologist within a few
days unless some special procedure,such as
decalcification of tooth,bone, or other
calcified substances or application of special
stains,are necessary
*A negative biopsy report or a
histopathological diagnosi not in conformity
with the expected diagnosis should never be
considered final. It means only that there are
no feature to suggest the expected diagnosis
in the particular piece of tissue which is
removed at that particular time.
*A repeat biopsy should always be performed
when there is any doubt about the adequacy
or representative nature of the original
specimen.

26. Incisional Biopsy
*The intent of an incisional
biopsy is to sample only a
representative portion of
the lesion.
*If the lesion is large or has
many differing
characteristics,more than
one area may require
sampling.
*Done on lesions larger
than 2 cm.

27. Types of Incisional biopsy
*Wedge biopsy
*Punch biopsy

28. 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 specimen.
*Sharp blade is used.

29. Wedge biopsy
*Grasp area to be removed with a
forecep.
*Make an elliptical incision from the
centre onto clinically normal tissue.
*Wound after removel of incised
tissue,suturing completed.

31. Indications
*Vascular or Bulbous lesions.
*Ulcerative lesion.

32. Punch biopsy
*A small cylindrical
punch is applied into
the lesion through full
thickness of the skin
and a plug of tissue is
removed.
*A small cylindrical
punch is removed
from the lesion, the
punch comprises of
the full thickness of
skin and the plug of
tissue.

34. Indications
*Method of choice for many
flat lesions.
*Interpretation of skin
cancer like Basal cell
carcinoma and Kaposi’s
Sarcoma.
*Diagnois of bulbous kind
of lesions like
Pamphigious Vulgaris.
*Diagnosis of inflammatory
skin disorders like Discoid
lupus erythromeatus.
*Removel of small
lesions,such as
intradermal nevus.

35. Indications
*Diagnosis of a typical
appearing lesion like
typical mycobacterial
infections.
*Evaluation of lesions
of uncertain origin.
*Used to conform or
exclude the presence
of the malignancy.

36. Advantages
*Simple procedure.
*Can be expertised by the physian.
*Time conserving.
*Low incidence of
inffection,bleeding,nonhealing.
*Scaring is insignificant,hence it is
cosmatic.
Disadvantages
*Punch biopsy less than 3mm heal by
secondary intention. Punch biopsy more
than 3mm need one or two sutures to
prevent unacceptible scaring.

37. Excisional Biopsy
*A excisional biopsy implies
to the complete removel of
the lesion for microscopic
study.
*Done on lesions less than 2
cm.
*Done for both diagnostic
and therapeutic purpose.

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

39. Indications
*Small minor lesions that are clinically benign.
*Lesions less than 2mm in greatest diameter.
Advantages
*An excisional biopsy allows for
histopathologic examination of whole lesion.
*Another advantage of excisional biopsy is the
amount of the tissue that can be removed
from one biopsy site,ensuring adequate
sample for various studies such as
culture,histopathology,immunofluroscence
and electron microscopy.

40. Disadvantages
*If the tumour is highly infiltrating the
margin of the excision cannot be
exactly elicated, further surgery will
be required.
*Cancerous cells actively multiply at
the tumour margins, debulking of the
mass may result in residual cancerous
cells left out.
*Excision needs greater precision and
skill of the surgeon.

41. Shave Biopsy
*A scalpel or razor blade is used
to shave off a thin layer of the
lesion parallel to the skin.
*Shave biopsies will normally
provide information only about
the epidermis and high dermis.
*Types :
1.Superficial shave biopsy
2.Deep shave biopsy

42. Difference between superficial
and deep shave biopsy
*Superficial shave
biopsy :
*Superficial shave
biopsies are done
across or nearly
parallel to the skin
surface and extend
into the epidermis
and superficial
dermis, e.g removel
of skin tags and
other small
exophytic structures
*Deep shave biopsy :
*The deep shave
biopsy ( also known
as ‘saucerisation
biopsy ) facilitates
sampling of dermis
and epidermis which
is important for
assessing
carcinomas, e.g
basal cell carcinoma
and squamous cell
carcinoma

43. Indications
*Indicated in plane warts and benign
pigmented lesions, skin tags.
*Seborrhoeic or actinic keratosis
*Superficial basal cell or squamous cell
carcinoma.
*Advantages
*Time conserving.
*Only need little experties.
*Heal without the need of sutures.

44. Disadvantages
*Shave biopsy should not used for
pigmented lesions; since if
unsuspected melanoma is partially
removed, it cannot be properly
staged.

45. Frozen Biopsy
*Frozen biopsy is done
whenever biopsy report is
needed at the earliest.
*It is usually done in a
pathology set up existing
adjacent to the operation
theatre.
*Technique :
An unfixed fresh tissue is
frozen (using Co2 ) in a
metal and sections are
made and stained.

46. Indications
*Carcinoma breast and follicular
carcinoma of thyroid when FNAC fails.
*During surgery after resection of the
tumour to look for (on table) the
clearance in the margin and depth and
also to study the lymph node for their
positivity.

47. Advantages
*Quick and Surgeon can decide the
further step of procedure in same
sitting like nodal clerance/ type of
resection to be done.
Disadvantages
*Technically difficult.
*Processing and staining is of inferior
quality.
*Often it is difficult to give accurate
results.

48. Needle Biopsy
*The removel of tissue or fluid with
a needle for examination under a
microscope.
*When a wide needle is used it is
called Core needle biopsy (Trucut
biopsy).
*When a thin needle is used it is
Called fine needle biopsy.
* Core needle biopsy
(Trucut biopsy)
*Core needle biopsy involve the
removel of a core of deep tissue
usually using a Trucut needle.

49. Advantages
*CNB allows for accurate diagnosis because
of the large quantity of tissue that can be
obtained.
*The type and grade of the tumour,the
invasiveness as well as hormone receptor
status can be assessed.
This is an advantage over FNAC, particularly
in case of patient with large masses
suggestive of cancer.

50. *Types
1.Image/ CT-guided biopsy :
*The procedure is comaparable to
core biopsy ; it is conducted
with a large needle with
assisted CT scan equipment.
*The simultaneous CT scan allow
identification and visualisation
of the exact site of the tumour
on the computer screen.
*This advanced technology
enable the operator to directly
guide the needle into the
tumour and obtain several
samples of tissue. The tissue
samples are later examined by
the pathologist.

51. 2.Vacuum-assisted biopsy
*It is a variant of the
core biopsy an
automated suction
device is attached to
the lateral side of
the needle .
*It increase the
amount of fluid and
cells aspirated
through the needle.
This ensures large
tissue sample and
reduces the need for
repuncture.

52. Bone marrow biopsy
*Bone marrow is a spongy
substance present in the
core of large bones where
blood cells are formed.
*Bone marrow biopsy is
indicated in patients with
abnormal blood counts,as in
case of unexplained anemia,
high white cell count , low
platelet count.
*Bone marrow is obtained
from the red marrow of
pelvic bone mainly posterior
superior iliac spine.