2. Biopsy
– Bios = Living, Opsis = Visualizing (16th century, Sir Marcello Malphigi who
formulated microscopic technique)
– Biopsy is the removal of the tissue for examination. Microscopic analysis,
chemical analysis, and bacterial analysis or a combination of all four. The term is
used most frequently to indicate removal of tissue from living subject for
analysis.
– WHO definition: A biopsy is the examination of tissue removed from the lesion
and by extension the term is also used to convey the removal of the tissue.
3. Indications
– To confirm clinical impression of the lesion
– When an inflammatory lesion is not responding to conservative therapy after
10-14 days
– For the determination of the more definitive treatment of the lesion
– To determine the nature of any intraosseous lesion which cannot be identified
clinically and radiographically
– To determine the nature of all abnormal tissue removed from the during
surgery, including cysts and granulomas
– Suspicious skin or oral cavity lesions
4. – To diagnose the type of malignancy in the patient with metastatic lesions seen
radiologically for planning chemo/radiotherapy
5. Contraindications
– Pulsatile lesions
– Intra-bony radiolucent lesions should not be biopsied without initial aspiration
– Pigment lesions should not be biopsied incisionally because of risk of spread of
melanoma, transformation of premalignant lesions to malignant ones
– Lesion present at difficult location making lesion surgically difficult to access
e.g., posterior tongue and oropharynx offer severe problems to access.
7. Incisional Biopsy
– Removal of just a small part of the lesion for histopathological study
– An Incisional biopsy implies the acquisition and presentation of a representative
part of a lesion
– Indication:
Lesion larger than 2 cm
Dangerous location (nerve, vessels)
Great suspicion of malignancy
8.
9. – Technique:
Representative area is biopsied in a wedge fashion
Margins should extend into the normal tissue on the deep surface
Necrotic tissue should be avoided
A narrow deep specimen is better than a broad shallow one
Sharp blade
Do not inject L.A.
11. Excisional Biopsy
– An excisional biopsy implies to the complete removal of the lesion for
microscopic study
– Indications
Should be employed with small lesions. Less than 2 cm
The lesion on clinical exam appears benign
When complete excision with a margin of normal tissue is possible without
mutilation
12.
13. – Technique
The entire lesion with 2 to 3mm of normal appearing tissue surrounding
the lesion is excised if benign
– Advantage
Both diagnostic and therapeutic
Need not perform separate surgery
– Contraindications
Large lesion of more than 2 cm
14. Punch Biopsy
– Small part of the lesion obtained using punch.
– Indication
Mucosal lesion that cant be reached by conventional method
– Disadvantage
Crushing of tissue while taking biopsy
16. – Punch biopsies can remove entire depth of lesion, but they are difficult to use in
certain locations, such as where bone is close to the skin
– In this method the surgical instrument fills out small segment of tissue from
inaccessible lesion or from large lesion where excision is contraindicated
17. Fine needle aspiration biopsy
(FNAC)
– Aspiration biopsy is done by using needle and syringe to penetrate a lesion for
aspiration of the contents of the lesion
– 18 to 24 Gz needle is used
– Indications
To determine the presence of fluid within a lesion
To know the type of fluid
Exploration of intraosseous lesion
18.
19. – Advantage
Obtain cells from any site of the body
Less labour than biopsy
Fast
Permits early start of the treatment
Can Be done repeatedly on most masses/lesions
Enough material obtained for other studies as well
20. – Disadvantage
Can be painful
Requires great skills
Needle can damage vital structures
Internal bleeding possible
Dissemination of tumor cells into damaged vessels
It is not a diagnostic procedure
Adjunct to biopsy
21. Exfoliative Cytology
– Study of morphology of exfoliated cells under microscope using special stain
– Cannot be used as a diagnostic procedure
– Used as adjunct/aid to biopsy
– Most commonly used stain is PAP smear
22.
23. – Indications
Mucosal lesion that appears clinically innocuous and otherwise would not be
biopsied
Follow up of patient with prior diagnosis of premalignant and malignant mucosal
lesion
Individual who are debilitated
To assess the oral candidiasis and viral infection
To study and confirm the false, negative biopsy result
24. – Technique
Clean the surface of the lesion
Use moistened tongue blade or cement spatula to scrape surface of lesion many
times in one direction only
Material obtained is spread in a rotatory motion on a clean glass slide
Make thin uniform smear
Keep it in jar containing fixative for 15-30 mins
Staining the smear and examining the slide
25. – Advantage
Developed as a diagnostic screening procedure to monitor large tissue areas for
dysplastic changes
Maybe helpful with monitoring post-radiation changes, herpes, pemphigus
– Disadvantage
Not very reliable with many false positives
Expertise in oral cytology is not widely available
26. Shave Biopsy
– Best for raised lesions mostly confined to the epidermis
Benign nevi
Small nodular basal cell carcinoma
– Not for suspected melanoma
29. Electro-surgery biopsy
– Refers to the cutting and coagulation of tissue using very high-frequency, low-
voltage electrical currents
– A blended current combines cutting and coagulation and is useful in producing
a bloodless operative field
– Lesion excisions on the face are usually performed with only a cutting current to
limit scarring at the wound base, which can be produced by the effects thermal
coagulation
30.
31. – Technique
The lesion is rasped with forceps through the loop electrode is activated going under
the lesion removing the growth
32. Exploratory biopsy
– It is done for the investigation of an internal lesion
In this removal of all portion of tissue exposed is done
This is commonly employed for the intra osseous lesions of mandible and maxilla
33. Curettage biopsy
– Used primarily for intra osseous lesions and friable cellular lesions, where only
small amounts of surface material are necessary for evaluation
– Extremely small tissues are centrifuged and sedimentary segments are placed in
agar media and then sectioned as tissue blocks
– Used successfully on lesions like actinic keratosis, superficial squamous cell
carcinoma and basal cell carcinoma and warts
34. Imprint cytology
– In this technique, the biopsied tissue is cut into two halves and the cut surface
is touched to the slide
– Slide is stained later to see the exfoliated cells
– Imprint cytology of biopsied tissue could be used to provide a rapid preliminary
diagnosis
– Imprint cytology of a biopsy can be reported within an hour
35. Frozen Section Biopsy
– To get immediate report of lesion
1. Tissue kept in deep freeze
2. Sectioned
3. Stained
4. Examined
Commonly used in onco-surgery for intra-operative diagnosis to make decision if the
frozen section is positive for malignancy then radical surgery may be required.
36.
37. Points to consider prior to biopsy
Why is biopsy being taken? E.g. to confirm a mucosal disease such as lichen
planus or to exclude malignancy
What information is required from the pathologist? E.g. is the lesion completely
excised?
Is the biopsy to exclude malignancy? Therefore take the biopsy from the edge of
the lesion
38. – Is the biopsy incisional or excisional? E.g. for excisional biopsies a margin of
surrounding normal tissue will be required
– Is a fresh specimen required? For vesiculobullous lesions these are often
required for direct immunofluorescence. They are also used for a rapid
diagnosis
– Will the specimen be required to be oriented? This is important for excisional
biopsies so that if residual tumor is left or the excision is close to the margin,
the surgeon knows where to perform a re-excision if necessary
