definition and classification

1. BIOPSY
SEMINAR - 4
Presented by-.Dr.Jyoti Chand
Moderator-Dr. Sachit Anand Arora
Percepter-Dr. Rupali Kalsi Mathur

2. TABLE OF CONTENTS
1. INTRODUCTION
2. HISTORY
3. DEFINITIONS
4. OBJECTIVES
5. INDICATIONS AND CONTRAINDICATIONS
6. CLASSIFICATION
7. VARIOUS BIOPSY PROCEDURES
8. BIOPSY ARTIFACTS
9. HEALING OF A BIOPSY WOUND
10. COMPLICATIONS
11. CONCLUSIONS
12. REFERENCES

3. 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.
INTRODUCTION

4. Biopsy is the removal of tissue from the living
organism for the purposes of microscopic examination
and diagnosis. (Shafer’s textbook of oral pathology (5th edition pg-821)
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.
DEFINITION

5. Biopsy not only helps in the diagnosis but
also serves as a treatment option for
smaller lesions by exicising in toto
The technique allows us to establish the
histological characteristics of suspect lesions,
their differentiation, extent or spread, and to
adopt an adequate treatment strategy. 1,2
Shafer’s textbook of oral pathology (5th edition pg-821)

6. 1. Performed on lesions that cannot be definitively
diagnosed by other techniques such as clinical examination,
Radiography, Cytology and Clinical laboratory methods.3,4
2. Performed on all lesions that clinically fail to respond
to well established treatment modalities.
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
INDICATIONS 3,4

7. 4. Conditions that are potentially precancerous.
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.
INDICATIONS

8. 1. Anticoagulant therapy
2. Over-whelming sepsis
4. Uncontrolled bleeding.
5. Uncooperative patient
6. Local infection near the site
CONTRAI-INDICATIONS 1,5

9. OBJECTIVES6
• Define a lesion on the basis of its histopathological aspect
• To establish a prognosis in malignant or premalignant lesions
• Facilitate the prescription of specific treatment
• Contribute to the assessment of the efficacy of the treatment
• Act as a document with medical-legal value.

10. 1. Before the procedure is undertaken, the characteristics of the lesion
(size, shape, colour, texture, consistency, time of evolution,
associated signs and symptoms, regional nodes) should be
described in the patient’s clinical records together with a presumed
diagnosis and possible differential diagnosis.
2. The patient should receive information on the technique that will be
performed and the reasons why it is performed, avoiding terms that may
cause anxiety. Informed consent is required.
General principles of oral biopsy6

11. Regarding the surgical technique:
• Regional block local analgesia rather than infiltrative
techniques is preferred.
• elliptical incisions should be attempted in order to ease
suture.
• incisions parallel to nerves are preferred.

12. Armamentarium
The minimal requirements are as follows:
• blade handle and no. 15 blade
• fine tissue forceps (preferably Adson
forceps)
• syringe and local anesthetic
• retractor appropriate for the site
• sutures, if needed
• needle driver
• curved scissors
• hemostatic agents
(silver nitrate or absorbable
gelatin sponge)
• gauze sponges
• specimen bottle
containing 10% neutral
buffered formalin Avon LS ,Klieb H E J Can Dent Assoc 2012;78:c75

13. 1. SURGICAL BIOPSY (INCISIONAL OR
EXCISIONAL)
2. FINE NEEDLE ASPIRATION BIOPSY
3. THICK NEEDLE/CORE BIOPSY
CLASSIFICATION
SOURCE- Cawson’s essentials of oral pathology and oral medicine (8th edition) pg.9

14. METHODS BY WHICH MATERIAL MAY
BE OBTAINED FROM A LESION FOR
MICROSCOPIC STUDY
1. Surgical Excision by scalpel
2. Surgical removal by cautery or a high-
frequency cutting knife
3. Laser
4. Removal by biopsy forceps or biopsy punch
5. The exfoliative cytology technique
shaffer’s textbook of oral pathology (5th edition pg-822)

15. • Incisional biopsy: consists of the removal of a
representative sample of the lesion and normal adjacent
tissue.
• Excisional biopsy: is aimed at the complete surgical
removal of the lesion for diagnostic and therapeutic
purposes.

16. INCISIONAL BIOPSY7
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.
Source-
http://www.jcda.ca/article/c75

17. 1. Crush, splits and haemorrhage are the artefacts
most frequently found in incisional oral biopsies.
2. Theoretical seeding of cancer cells into the
adjoining tissues
3. Multiple biopsy samples may be required if the
lesion is extensive or shows a variety of clinical
presentation
DISADVANTAGES

18. An elliptical incision, with a length-to-width ratio of 3:1, is made with a size
15 scalpel blade. The inferior incision is made first, so that hemorrhage
does not obscure the surgical field. The anterior tip of the ellipse is gently
lifted with tissue forceps, and the base is severed.
Source- Avon LS ,Klieb H E J Can Dent Assoc 2012;78:c75

19. An excisional biopsy implies the
complete removal of the lesion.
Indications:
Should be employed with small lesions. Less than 1cm
(such as fibroma, pyogenic granuloma)
The lesion on clinical examination appears benign.
When complete excision with a margin of normal
Tissue is possible without mutilation.
EXCISIONAL
BIOPSY8
Small, pedunculated,
exophytic lesions in
accessible areas are
excellent candidates.

20. Technique:
The entire lesion with 2 to 3mm of normal
appearing tissue surrounding the lesion is
excised if benign.
Excisional
biopsy of
nodular region
of the palate
source
McAndrew PG. Oral cancer biopsy
in general practice. Br Dent J 1998;
185:428.

21. PUNCH BIOPSY10
• It is an alternative technique of tissue removal
• Applicable to both incisional and excisional biopsy.
Punch is placed on the tissue and a downward twisting
motion is applied.
Lateral tongue and buccal
mucosa are appropriate sites
as it is feasible for the device
to aproach the mucosal
surface perpendicularly

22. 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

23. Punch biopsy should be used with caution when the lesion
overlie significant submucosal structures such as mental
foramen or nasopalatine foramen and occurs in inaccessible
areas such as the maxillary posterior buccal alveolar ridge
and anterior lingual aspect of the mandible.9

24. After the biopsy site has been anesthetized, the site
is gently blotted with sterile gauze.
• The edge of the blade of the biopsy punch is placed
on the site and rotated back and forth using moderate
pressure to an appropriate depth until the external
bevel is not visible and creates a clearly defined
surgical margin.
TECHNIQUE

25. The tissue is then grasped with an a traumatic forceps and the
base of the tissue core is released using a scalpel blade or fine
curved scissors.
• Suture is rarely needed, as the hemorrhage is minimal.
• Local pressure with sterile gauze is sufficient to
induce haemostasis

26. Specimen obtained by punch
biopsy
Thin, homogenous leukoplakia
affecting the lateral and ventral areas of
the tongue is suitable for incisional punch
biopsy. The punch biopsy device is applied
with a downward and twisting motion.

27. ASPIRATION BIOPSY
Is any method in which the specimen for biopsy is
removed by aspirating it through a hypodermic
needle or trocar
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

28. 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.

29. SOURCE-Cawson’s essentials of oral pathology and oral medicine (8th edition) pg.10

30. DISADVANATGES OF FNAB
1. Since the needle is fine , there may be plugging
of the tissue in the needle.
Source -
http://medicaldevices.asmedigitalcollection.asme.org/article.aspx?articleid=1876525

31. LARGE NEEDLE ASPIRATION BIOPSY - (LNAB)
ADVANTAGES
1. Since the needle is large, plugging of the tissue
in the needle does not occur.
DISADVANTAGES
1. There may be scar formation.
2. L.A has to be given

32. CORE NEEDLE BIOPSY
Here a cylindrical specimen (core) is removed with
the help of silverman needle 14 gauge needle with stylet
and cutting trocar.
th

33. SOURCE- Cawson’s essentials of oral pathology and oral medicine (8th edition) pg.10
 Allow a stained slide to examined within 10 minutes of taking specimen
 Tissue is sent fresh to lab to be quickly frozen preferably to about -70
degree celcius
FROZEN SECTIONS

34. Electrosurgery and laser techniques produce
thermal artifacts that may hamper histologic interpretation;
accordingly, these methods should be used with caution for
diagnostic biopsy or when information from the margins is
required.
A laser produces a zone of thermal coagulation smaller
than that of electrosurgery, but still, a 0.5-mm margin
should be maintained between the cut and he representative
area to be sampled.
ADVANTAGE-Laser
minimizes hemorrhage
and discomfort in thick
and widespread lesions

35. BIOPSY TECHNIQUE10
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

36. Fix tissue immediately in 10%FORMALIN
If specimen is thin place it on a piece of glazed
paper and drop into the fixative to prevent curling of
tissue

37. It is a quick and simple procedure, is an important
alternative to biopsy in certain situations.
In exfoliative cytology, cells shed from body surfaces,
such as the inside of the mouth, are collected and examined.
This technique is useful only for the examination of surface
cells and often requires additional cytological analysis to
confirm the results.
Exfoliative Cytology6,8
First introduced by Papanicolau in 1941 .

38. 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.

39. 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.

40. With a gauze gently remove any excess
saliva in the area that will be smeared.
TECHNIQUE
Vigorously scrape and rotate the Cytobrush
over the entire lesion.
Or scrape the lesion with a spatula

41. 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.

42. Spray the surface of the glass slide right away with
the Spray-cyte while holding the can about 6 inches
away from the slide.

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

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

45. ADVANTAGES OF ORAL EXFOLIATIVE
CYTOLOGY
It is a quick, simple, painless, bloodless,
noninvasive chair side procedure.
Better patient compliance.
Repeat procedure causes less inconvience

46. 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.

47. Handling of the biopsy Specimen11
• The specimen must be gently grasped with forceps or
secured with a traction suture.
 Suction devices, if required, should be used with care to
prevent loss of the specimen and suction-induced
artifact.
.
 The specimen should be placed in 10% neutral buffered
formalin with at least 20 times the volume of the sample
to avoid improper fixation

48. ARTIFACT = Artificial (man made) product
Artifacts are alteration in the tissue morphology
that results from various forms of mechanical,
chemical, or thermal insult to the tissue specimens
removed for diagnostic purposes, anywhere from
fixation to processing to staining. Numerous types
of artefacts can affect the biopsy specimen.

49. • Crush artifact is common and is typically due to
inappropriate compression from forceps.
 Thermal artifact accompanying use of laser or
electrosurgery devices
 In colder climates, tissues may freeze during mailing
freezing severely distorts the histologic architecture

50. OTHER CAUSES OF TISSUE ARTIFACTS
• Clinical application of chemicals.
• Local injection of anaesthetics.
• Surgical sectioning.
• Excessive heat.
• Freezing.
• Surgical mishandling of the specimen.
• Inadequate fixation.
• Improper fixation medium.
• Faulty tissue processing.
• Improper staining.
Source- Avon LS ,Klieb H E J Can Dent Assoc 2012;78:c75

51. HEALING OF BIOPSY WOUNDS
• The healing of a biopsy wound of the oral cavity is
identical with the healing of a similar wound in any
other part of the body and thus may be classified as
either primary healing or secondary healing.
SOURCE- Shafer’s textbook of oral pathology (5th edition pg-822-24

52. • When the edges of the wound are brought into contact
and held in place by sutures, the blood clots, and in a
matter of hours numerous leukocytes are mobilized to
the area.
• Connective tissue cells in the immediate vicinity undergo
transformation into fibroblasts which in turn undergo
mitotic division, and the new fibroblasts begin to migrate
into and across the line of incision.

53. In time, these cells form thin, delicate collagen
fibrils which intertwine and coalesce in a general
direction parallel to the surface of the wound.
• At the same time, endothelial cells of the
capillaries begin to proliferate, and small capillary
buds grow out and across the wound and form new
capillaries which fill with blood, and a rich network
of young capillaries and capillary loops are formed.

54. • When there is a close apposition of the edges of the
wound, the surface epithelium proliferates rapidly
across the line of incision and reestablishes the integrity of
the surface.
• The delicate connective tissue fibrils eventually coalesce
into denser bundles and usually contract.
• Shows a small linear scar which may be depressed below
the surface.
• Wound heals rapidly.

55. Secondary healing:
• Healing by second intention, healing by granulation
or healing of an open wound occurs when there is
loss of tissue and the edges of wound cannot be
approximated.
• Removal of a lesion of the palate or a large lesion of
the alveolar ridge is usually followed by healing by
second intention, since the edges of the wound
cannot be coapted.

56. • It is basically identical with healing by primary
intention except that the fibroblast and capillaries
have a greater distance to migrate; more granulation
tissue must form, and the healing is slower.

57. 1. Heamorrahage
2. Infection
3. Poor wound healing
4. Spread of tumour cells
5. Injury to adjacent organs
6. Post operative pain.
7. Paraesthesia in the lips or the tongue,
8. Swelling and bruising - in the tongue, lips and buccal mucosa
9. Procedures in the floor of the mouth can lead to submandibular or
sublingual duct damage.
10. Removal of mucocoeles from the lip carries the risk of further
gland damage and ‘recurrence’.
COMPLICATIONS

58. • For entities of uncertain significance or etiology, a biopsy
provides the simplest and most speedy means of obtaining
the perfect diagnosis. In the concern of patient’s welfare,
correct diagnosis is of extreme importance.
• A carefully selected, performed and interpreted biopsy is
critical in rendering an accurate diagnosis.
• When considering biopsy, a little forward planning and
thought can greatly improve the diagnostic value obtained.
CONCLUSION

59. REFERENCES
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