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Biopsy final.ppt

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Biopsy final.ppt

  1. 1. Biopsy Dr. Kush 1
  2. 2. “The best surgeon is a clinical pathologist who performs operations” 2
  3. 3. 3 Al-Zahrawi, an Arab physician, surgeon and pharmacist - perform a needle biopsy (of the thyroid). He used hollow needles to investigate abnormal growths of the thyroid gland. Around the year 1000 AD, he wrote his famous book 'Al Tasreef Liman 'Ajaz 'Aan Al-Taleef (or 'al-Tasreef') (''An Aid for Those Who Lack the Capacity to Read Big Books'). History
  4. 4. 4 In the early 16th century, Sir Marcello Malphigi termed it as, Bios- LIFE, Opsis- A sight In the modern era, a Russian, M.M. Rudnev – used diagnostic biopsy in 1875.
  5. 5. 5 Expert committee of WHO (1996) – “ Biopsy is examination of tissue removed from a lesion & by extension the term is also used to convey the removal of the lesion” The term 'biopsy' was introduced into medical terminology in 1879 by Ernest Besnier.
  6. 6. 6 • 100 years of biopsy can be easily divided into 3 major steps: 1. An occasional use of procedure - until the late 19th century - involving living organs and tissues for observation and study.
  7. 7. 7 2. Restricted application of biopsy- until the mid-20th century. 3. Present stage - widely adopted, not only in oncology but practically in all clinical specialties.
  8. 8. Histological characteristics  Differentiation  Extent or spread  Evoluative control of disease process  Healing or relapse  Irrefutable legal medical value. 8 The Technique Allows Us To Establish
  9. 9. Indications Primarily – To confirm the clinical impression of the lesion. Any persistent lesions >10-14days With no apparent etiologic basis. That does not respond to Rx even after removal of cause / irritant. 9
  10. 10. 10 Persistent swelling Bone lesions - Not specifically identified by clinical & radiographic findings. Lesions presenting the characteristics of malignancy
  11. 11. Conditions that are potentially precancerous Persistent hyperkeratotic change. e.g.: leukoplakia. Inflammatory changes of unknown causes. 11
  12. 12. Lesions interfering with normal functions. For: Classification, Grading / staging of tumor 12
  13. 13. 13 Evaluation of surgical margins To alleviate patient apprehensions Evaluate prognosis
  14. 14. Contraindications Compromised general health, h/o bleeding diathesis. Lesion close to vital anatomic, vascular or ductal structures. Intrabony lesions should not be biopsied or removed prior to investigational aspiration. 14
  15. 15. 15 Normal anatomic & racial variation – e.g. Physiologic pigmentation, linea alba, Fordyce's granules. Acute / sub acute inflammatory condition – bacterial, viral infection.
  16. 16. Absolute: Pulsative lesion, large hemangiomas – appear to be filled with blood. 16
  17. 17. Selection Of Specimen  Area representative of whole lesion.  Adequate amount of tissue must be present. 17
  18. 18. 18 In large lesions – Specimen is removed from most easily accessible & representative area. Deep sections of lesion along with normal tissue are needed. If several lesions - specimen taken from most representative area.
  19. 19.  Intra osseous lesions – Cortical plate of bone should be removed & curetted material must be evaluated.  Skin / mucosal biopsy – Epithelium + Connective tissue. 19
  20. 20. 20 Ulcer – Normal area + Deep part of ulcer Multiple ulcers – More than one biopsy & at the site of maximum clinical activity.
  21. 21. INSTRUMENTS AND MATERIALS 21
  22. 22. INSTRUMENTS AND MATERIALS 22
  23. 23. Procedure  Injecting local anesthesia.  Elliptical or wedge shaped incision including normal & abnormal tissue. 23
  24. 24. 24 Tissue is grasped with forceps & cut under tension.
  25. 25. 25 Place the sample in 10% formalin.
  26. 26. 26 10% Formalin Label the bottles
  27. 27. 27
  28. 28. 28
  29. 29. HANDLING OF TISSUE  Avoid liberal use of tissue forceps. Critical step 29
  30. 30. Ensure spill-proof packaging. Label “PATHOLOGIC SPECIMEN” TRANSPORTATION 30
  31. 31. Approach for lesion 31 Type of Biopsy
  32. 32. Types according to technique BONE INCISIONAL PUNCH CURETTAGE LASER SHAVE EXPLORATIVE BRUSH EXCISIONAL 32
  33. 33. INCISIONAL BIOPSY Indications: • Large lesions (> 1cms) • Hazardous location with uncertain nature. • Doubtful malignant lesions 33
  34. 34. 34
  35. 35. 35 Oral cavity – Commonest lesion for incisional biopsy – white hyperkeratotic lesions. Bleeding, ulcerated or indurated area must be taken.
  36. 36. EXCISIONAL BIOPSY Removal of lesion in - Toto – with adequate margins Accomplishes the goal of the biopsy (entire lesion is available for H/P examination)as well as Rx 36
  37. 37. 37 Indications Lesions <1cms Clinically benign lesions Easily accessible
  38. 38. PUNCH BIOPSY Convenient method for oral mucosal lesions Biopsy punch Make circular incisions (3-4mm in diameter) Surgically inaccessible regions e.g. palatal biopsy of minor salivary glands, lips. 38
  39. 39. 39
  40. 40. 40
  41. 41. Principle Punch – circular / twisting motion  a circular incision on lesion. Remove the punch. Grasp the margin – separate the base with scissors or scalpel. 41
  42. 42. 42
  43. 43. 43  Quick & effective  Produces a clean & sharp incision  Little bleeding  Minimal pain Advantages Disadvantages  Tissue distorted  Can’t be used in soft palate, floor of mouth
  44. 44. CURETTAGE Curette – Spoon like tip Designed for scraping out cavities for tissue (diagnostic/therapeutic purposes) eg: maxillary antrum, cystic lesions within the jaws 44
  45. 45. 45 Used primarily for intraosseous lesions (cystic/fibro-osseous), soft friable soft tissues (granulation tissue) Easy to perform
  46. 46. 46  Modified Ellis drill, fits into straight hand piece.  For central fibro -osseous lesions, osteolytic lesions of bone, lymph node masses.  Needle is introduced through small skin incision & rotated at slow speed until tumor is reached. Drill biopsy
  47. 47.  Entered into tumor mass.  Gentle negative pressure is applied to needle by means of small syringe on withdrawal.  Contained core expelled into fixative. 47
  48. 48. Disadvantages Heat May miss the lesion (< 2cms) Advantages Less trauma to healthy tissues. Less chances of metastasis. 48
  49. 49. Shave biopsy Easiest biopsy to take when lesion is raised above surface. Using scalpel blade or special disposable blade. Sawing / shaving action is used. 49
  50. 50. 50 Plastic blade mounted in rigid plastic handle
  51. 51. 51
  52. 52. Electro surgery/ Laser biopsy • Specimen is taken using electrode. • Minimum discomfort & bleeding. (cauterization) 52
  53. 53.  Electro-surgery refers to the cutting and coagulation of tissue using very high-frequency, low-voltage electrical currents.  Useful in producing a bloodless operative field.  Thermal coagulation is used. 53
  54. 54. Electro-surgical technique The lesion is grasped with forceps through the loop electrode. The electrode is activated going under the lesion, removing the growth. 54
  55. 55. • Currently not advised for oral biopsies Disadvantages: • In electro surgery – Thermal damage may result in charred appearance of tissue. • Laser – less extensive thermal damage. 55
  56. 56. Aspiration biopsy (FNAC / FNAB) • To obtain material from body cavity, cystic space or fluid containing lesion. • Introduced by Martin, Ellis & Stewart in 1950. • Obtained material can be smeared on a slide, fixed & stained. 56
  57. 57. 57 Indications: Differentiate neoplastic from non neoplastic tissues
  58. 58. Advantages : Quicker to perform Less painful Technically less demanding Inexpensive Repeatable 58
  59. 59. 59 Technique: Cleansing of skin , LA at periphery of mass. Sterile needle attached to syringe is guided inside abnormal area.
  60. 60. ASPIRATION CYTOLOGY GUN 60
  61. 61. Franzen’s handel with syringe & needle fitted on it for performing FNAC 61
  62. 62. 62
  63. 63. The proper lesion may get missed easily. Tissue relationships not known (as only few cells are studied) Most of the times needs a confirmatory biopsy Disadvantages 63
  64. 64. Stab incision To distinguish between reactive changes / recurrent malignancies/ cervical metastases. Symptom less H&N swellings Disadvantages •Tumor dissemination / seeding Core biopsy / True – cut biopsy 64
  65. 65. 65
  66. 66.  Study of superficial cells which have been either exfoliated or shed from mucous membrane.  Cells are collected by scraping or pulling off from tissue surface.  Can also be done with sputum or saliva. 66 Exfoliative cytology
  67. 67. Indications:  For suspected malignant and premalignant oral lesions.  Recurrent oral cancers after treatment.  Mass screening of oral cancer. 67
  68. 68. Contradictions:  Deep seated lesions (both soft and hard tissue).  Fibrous lesions.  Non-ulcerative lesions. 68
  69. 69. 69  The lesion is repeatedly scraped with a moistened tongue depressor or spatula or cytobrush type instrument.  The cells obtained are smeared on a glass slide and immediately fixed with a fixative spray or solution. Technique
  70. 70. 70
  71. 71. 71
  72. 72. 72 Special instrument called biopsy brush Trans-epithelial biopsy obtained Indications For precancerous / cancerous oral mucosal lesions Advantages Easy to perform; requires less time Well tolerated by the patient Oral brush biopsy
  73. 73. 73
  74. 74. 74
  75. 75. 75
  76. 76. 76
  77. 77. Dangers during biopsy… Spreading of tumor cells along lymphatics / vascular channels. Hemorrhage Infection 77
  78. 78. Specific tissue considerations Oral biopsies: methods and applications R. J. Oliver, P. Sloan and M. N. Pemberton BRITISH DENTAL JOURNAL VOLUME 196 NO. 6 MARCH 27 2004 78
  79. 79. For red & white lesions include both red & white area 79
  80. 80. Ulcers Include margin, deep part of ulcer and site of maximal clinical activity. AVOID Superficial ulcers & necrotic tissue 80
  81. 81. Vesiculo-bullous lesions Fluid is more representative. Intact vesicle or bulla should be biopsied. 81
  82. 82. For LICHEN PLANUS – representative area should be biopsied 82
  83. 83. For LEUKOPLAKIA – Most dysplastic area should be biopsied 83
  84. 84. Do not cut into pigmented and vascular lesions 84
  85. 85. 85 Oral biopsies: methods and applications R. J. Oliver, P. Sloan and M. N. Pemberton BRITISH DENTAL JOURNAL VOLUME 196 NO. 6 MARCH 27 2004
  86. 86. 86 Clinical diagnosis Type of biopsy Suitable for general dental practice Chronic ulcer or squamous cell carcinoma Incisional biopsy of margin of ulcer No, urgent referral to hospital Leukoplakia/ erythroplakia Incisional or punch biopsy of worst area consider multiple biopsies if extensive lesion No, referral to hospital Mucosal lichen planus Incisional biopsy of the area Only very experienced practitioners Bullous lesions (pemphigus pemphigoid etc.) Incisional or punch biopsy of unaffected mucosa close to bulla No, referral to hospital
  87. 87. 87 Clinical diagnosis Type of biopsy Suitable for general dental practice Granulomatous diseases (Crohn’s, Orofacial granulomatosis, ulcerative colitis, TB) Deep incisional biopsy plus fresh sample to microbiology if infective agent suspected No, referral to hospital Mucocele Careful excision biopsy Yes, with care Fibroepithelial polyp, pyogenic granuloma, epulis Excision biopsy Yes Minor salivary gland tumour Palate: deep incisional biopsy Upper lip: excisional biopsy No, urgent referral to hospital
  88. 88. Summary 88

Editor's Notes


  • Medium through which the doctor in clinical practice gets an opportunity to learn & relearn the important basic scientific facts is the “Biopsy”.

  • Since the nineteenth century, medical researchers and practitioners have developed many different kinds of instruments to perform biopsies on different body parts.
    Modern instruments such as intestinal biopsy tubes can extract samples from parts of the body which are not easily accessible.

  • When there is a lesion which is persistent from more than 10-14 days with etiology and does not respond to medicines
  • Tumescence = swelling due to vascular congestion
  • Alleviate – making less severe
    Prognosis – forecast of the outcome of a medical situation
  • bleeding diathesis. -unusual susceptibility to bleed 
  • From a pathologist’s point of view– whole lesion is most desirable specimen.
  • Formalin – disinfectant, germicide and antiseptic in nature
    Prevents decay by bacterial growth
  • Pigmented lesions (melanoma) may be removed with generous margin of normal surrounding tissue.
  • sinus, fistulae with in soft tissue.
  • Specimen is forcibly ejected over albumin coated slide & then spread.

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