Biopsy

By Dr Ajish M Saji
Deparment of Oral Pathology
Malabar Dental College
Edappal

 History
 What is a biopsy?
 Indications
 Characteristics of lesions that raise the
suspicion of malignancy.
 Contraindications of biopsy
 Types of Biopsy
 Methods by which material may be obtained
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 Oral cytology
 Aspiration biopsy
 Incisional biopsy
 Excisional biopsy
 Punch biopsy
 Handling of the tissue specimen
 Specimen care
 Intraosseous and Hard tissue biopsy
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 One of the earliest diagnostic biopsies was
developed by the Arab physician
Abulcasim(1013-1107).
 The term “Biopsy” was introduced into
medical terminology in 1879 by Ernest
Besnier.
 The first diagnostic biopsy was performed in
1875 by M M Rudnev.
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Biopsy is the removal of tissue
from a living individual for
diagnostic examination.
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 Any lesion that persists for more than 2
weeks with no apparent cause.
 Any inflammatory lesion that does not
respond to local treatment after 10 to 14
days.
 Persistent hyperkeratotic changes in surface
tissues.
 Any persistent tumescence, either visible or
palpable beneath relatively normal tissue.
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 Inflammatory changes of unknown cause
that persist for long periods.
 Lesion that interfere with local function.
 Bone lesions not specifically identified by
clinical and radiographic findings.
 Any lesion that has the characteristics of
malignancy.
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 Erythroplasia- lesion is totally red or has a
speckled red appearance.
 Ulceration- lesion is ulcerated or presents as
an ulcer.
 Duration- lesion has persisted for more than
two weeks.
 Growth rate- lesion exhibits rapid growth.
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 Bleeding- lesion bleeds on gentle
manipulation.
 Induration- lesion and surrounding tissue
is stoney hard to the touch.
 Fixation- lesion feels attached to
adjacent structures.
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 Relative contraindications.
a) Inflammatory lesions of allergic, viral, fungal or
bacterial aetiology.
b) Patients with a history of coagulopathy or bleeding
diathesis and patients on anticoagulant therapy.
c) Proximity of lesions to vital anatomic, vascular,
neural, or ductal structures and lesions in areas of
difficult surgical access.
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 Absolute contraindications
a) Pulsatile lesions or even those suggestive of a
vascular nature.
b) Intra bony radiolucent lesions should not be
biopsied or removed without prior investigational
aspiration.
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 Oral cytology
 Aspiration cytology
 Incisional biopsy
 Excisional biopsy
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 Methods by which material may be obtained
are,
a) Surgical excision by scalpel.
b) Surgical removal by cautery.
c) Laser
d) Punch biopsy
e) Aspiration through a needle.
f) Exfoliative ctology technique.
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 Dr George Papanicolaou-father
of cytology.
 Two main forms of oral cytology
can be used-differing in the
method of cellular collection
and in diagnosis.
 Exfoliative cytology.
 Oral brush cytology.
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 It is the study of cells which exfoliate or
abrade from the body surface.The rationale
for exfoliative cytology lies in epithelial
physiology (Desquamation of Cells).
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 Desquamation is the enzymatic process of
dissolving the desmosomes, the protein
connections between corneocytes, and the
eventual shedding of these cells.
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 Clean the surface of the oral lesion off debris
and mucin,and then vigorously scrape the
entire surface of the lesion several times with
a metal cement spatula or a moistened tongue
blade.
 The collected material is then quickly spread
evenly over a microscopic slide and fixed
immediately before the smear dries.
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 The fixative may be either a commercial
preparation such as spray–cyte ,95%
alcohol or equal parts of alcohol and
ether.
 After the slide is flooded with the
fixative,it should be allowed to stand for
30min to air-dry.slides are never flame
fixed as bacteriologic smears.
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The cytologic smear will usually be reported
into one of 5 classes.
 Class1(normal):indicates that only normal cells
were observed (fig A).
 Class2(atypical):indicates the presence of minor
atypia but no evidence of malignant changes
(fig B).
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 Class3(indeterminate):this is an inbetween
cytology that separates cancer from non cancer
diagnosis.the cells display wider atypia that
may be suggestive of cancer,but they are not
clear cut and may represent precancerous
lesions or carcinoma insitu.biopsy is
recommended
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 Class4(Suggestive of cancer):A few cells with
malignant characteristics or many cells with
borderline characteristics.Biopsy is mandatory.
 Class5(Positive for cancer):Cells that are obviously
malignant.Biopsy is mandatory.
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 It is a quick,simple,painless and bloodless
procedure;with no LA or suturing.
 It helps as a check against false-negative
biopsies.
 Helpful in follow-up detection of recurrent
carcinoma in previously treated cases.
 Valuable for screening lesions whose gross
appearance is such that biopsy is not warranted.
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 The presence or extent of invasion cannot be
assessed.
 The benign lesions that occur in the oral
cavity which does not lend themselves to
cytology smear.eg:fibroma.
 A negative cytology report does not rule out
cancer.
 False –ve and False +ve results can be
obtained.
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 A direct imprint is prepared by pressing a
glass slide gently on to the freshly cut
surface of the specimen.
 Avoiding a gliding movement, which will
distort the shape of the cells.
 The imprint slide is immediately fixed in 95%
ethyl alcohol for 5-6 seconds and then
stained (rapid haematoxylin and eosin).
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 It uses a special brush to collect the
epithelial cells.
 This technique is superior to exfoliate oral
cytology.
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 Indications
 Lesions that are large,multiple or varied.
 Mixed red and white lesions.
 Presenting difficult surgical access.
 Follow-up detection of recurrent lesions.
 Contraindications
 fibromas, mucoceles, hemangiomas, pigmented
lesions, amalgam tattoos, submucosal masses
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 Brush Biopsy Procedure (three-layer exfoliative
computer-assisted cytology) :
1. Wet brush with water or saliva.
2. Use mild (flat ulcerated) to firm (thick
keratinized) pressure for 5 (flat)-10 (thick)
rotations.
3. See pink micro-bleeding; bend brush handle and
bristles.
4. Spread immediately over entire glass slide.
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5.A fixation step follows immediately by
flooding the slide with fixative solution
(alcohol/propylene glycol) and allowing it to
air dry.
6.Upon completion of air-drying of the
fixative, the cellular sample on the slide is
stained.
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 Neural network-based image processing software
specifically tailored and designed for detection of
oral mucosal premalignant and malignant cells is
used to analyze the stained and scanned slides.
Any abnormality in cell morphology, including
altered cell size, degree of keratinization, nuclear
staining intensity, and size are characterized and
analyzed. Images produced by this software are
further analyzed and refined to the level in which
as few as 2 abnormal cells among thousands of
other keratinocytes, inflammatory cells,
erythrocytes, and debris can be detected within
the brush biopsy specimen, which they display on
a high-resolution video monitor.
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Specimen is classified into
 Negative:indicates that no epithelial abnormality was
detected.
 Positive:indicate that defenitve cellular evidence of
epithelial dysplacia or carcinoma is present.Refered for
scalpel biopsy.
 Atypical:indicates that abnormal epithelial changes are
present.
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 The clinician receives atypical or positive
results in a digitized color format.
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 An “atypical” OralCDx result showing epithelial
cells with an increase in the nuclear-to-cytoplasmic
ratio.
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 It is a chair side test.
 Does not require any topical or local
anesthesia.
 Minimal discomfort or bleeding.
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 The accuracy of the cytologic examination
from any body site depends greatly on the
quality of collection, preparation, staining
and interpretation of the material.
Inadequacy in any of these steps will
adversely affect the quality of diagnostic
cytology.
 Lesions with intact epithelium—such as
mucoceles, fibromas and hemangiomas—are
excluded.
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 First discovered by Kun in 1847 and
reintroduced in 1930 by Martin and Ellis.
 Aspiration biopsy is the use of a needle
and syringe to penetrate a lesion for
aspiration of its contents.
 Indications:
 To determine the presents of fluid within a
lesion.
 The type of fluid within a lesion.
 When exploration of an intraosseous lesion is
indicated. 11/15/2019 6:19:31 AM

1)Used only to determine whether or not a
lesion contains fluid or air.
2)Used to remove cellular material for
diagnostic examination. it is done by the
technique of fine needle aspiration…
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a) A radiolucent lesion in the jaw that yields straw-colored
fluid on aspiration is most likely a cystic lesion.
b) If pus is aspired,an inflammatory or infectious process
should be concidered(abcess).
c) Air on aspiration may indicate that a traumatic bone
cavity has been entered.
d) Blood on aspiration could represent a vascular
malformation in the jaw.
e) Aneurysmal bone cysts,central giant cell granulomas and
other lesions can produce a bloody aspirate.
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 The lesion is fixed between
the thumb and index finger
of the left hand, with the
skin stretched.
 An 18 gauge needle on a 5 or
10 ml syringe is inserted into
the area under investigation
after anesthesia is obtained.
 The syringe is aspirated and
the needle redirected if
necessary to find the fluid
cavity.
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 Try to avoid significant muscle mass eg.
sternocleidomastoid, while fixing the lesion
because it is not only painful, but also
muscle tends to plug the needle tip,
preventing further material from entering
the needle.
 For small lesions, aspiration of central
portion is indicated. For larger lesions that
may have necrosis, cystic change or
hemorrhage in the center, aspiration may be
done from the periphery.
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 Immediately after withdrawing, detach the
needle, draw air into the syringe, reattach
the needle and express the material in the
needle onto a slide. Needle tip is brought
into light contact with the slide and the
aspirate is carefully expressed without
spraying into the air, which can cause air-
drying and also can form aerosols, which are
potentially infectious.
 Fixing is done in 95% alcohol for 1hr for PAP
stain and a little prolonged for HE stain.
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 Simplicity of technique (it can be easily
performed on an outpatient basis using a local
anesthetic).
 Greater patient acceptance and less risk of
delayed wound healing and infection than with
incisional or excisional biopsy.
 Rapid diagnosis, and economy (it eliminates the
need for hospitalization and tissue processing
and saves operating room time).
 Different areas within a mass can easily be
sampled to ensure that representative material
has been obtained.
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 Bruising and soreness.
 Because the biopsy is very small (only a few
cells), that the problematic cells will be
missed, resulting in a false negative result.
 There is also a risk that the cells taken will
not enable a definitive diagnosis.
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 An incisional biopsy is a biopsy that samples
only a particular portion or representative
part of a lesion.
 If a lesion is large or has different
characteristics in various locations more than
one area may need to be sampled.
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 Indications:
 Extensive size.
 Hazardous location of the lesion.
 Great suspicion of malignancy.
 Principles:
 Material should be taken from the edge of the lesions to
include some normal tissue.
 Necrotic tissues should be avoided.
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 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.
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 Controversy exists as to the possibility that
incisional biopsies of malignant lesions may
increase the risk of metastasis, by disrupting
the barrier preventing migration of the
neoplastic cells and thus favoring invasion of
the bloodstream at the site of the surgical
wound.
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An excisional biposy implies the complete
removal of the lesion at the time when the
surgical procedure is performed.
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 Indications:
 Should be employed with small lesions. Less than 1cm
 The lesion on clinical examination appears benign.
 When complete excision with a margin of normal tissue
is possible without mutilation.
 Principles:
 Entire lesion, along with 2 to 3 mm of normal-appearing
surrounding tissue is excised.
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 An excisional biposy implies the complete removal
of the lesion.
 A perimeter of normal tissue (2-3 mm) surrounding
the lesion is included with the specimen.
 Excisional biopsy should be performed on smaller
lesions (less than 1 cm in diameter) that appear
clinically benign.
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 Rarely necessary in the oral cavity as most of
the oral lesions are easily available.
 The surgical defect that is produced is small
and does not require suturing.
 TECHNIQUE
 A sharpened hollow tube;several mm in diameter
is rotated until underlying bone or muscle is
reached.
 The tissue is then removed in the same manner
as in incisional or excisional biopsy.
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 Direct handling of the lesion will expose it to
crush injury resulting in alteration the cellular
architecture.
 The use of a traction suture through the specimen
is an excellent method for avoiding specimen
trauma.
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 The specimen should be immediately placed in
10% formalin (4% formaldehyde) solution that is
atleast 20 times the volume of the surgical
specimen.
 The tissue should not become lodged on the wall
of the container above the level of the formalin.
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 Any intraosseous lesion that fails to respond
to routine treatment of the dentition.
 Any intraosseous lesion that appears
unrelated to the dentition.
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 Mucperiosteal flaps should be designed to
allow adequate access for biopsy.
 Cortical perforation must be considered
when designing flaps.
 The tissue consistency and nature of the
lesion will determine the ease of removal
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 Any radiolucent lesion that requires biopsy
should undergo aspiration before surgical
exploration.
 This provides with valuable diagnostic
information regarding the nature of the
lesion.
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 It depends on the nature of the biopsy and the
consistency of the tissue encountered.
 Small lesions that have a connective tissue capsule
can be removed in their entirety.
 A dental curette is used to peel the connective
tissue wall of the specimen from surrounding
bone.
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 1)R Rajendran ,B Shivapadasundaram
,Shafer’s Textbook Of Oral Pathology
,Elsevier ,Fifth Edition ,821-825.
 2)Peterson ,Ellis ,Hupp ,Tucker
,Contemporary Oral And Maxillofacial Surgery
,Elsevier ,Fourth edition ,458-478.
 3)Anil Govindrao Ghom ,Textbook Of Oral
Medicine ,Jaypee ,75-79.
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 4) Jerry E. Bouquot, Patricia Suarez,
Nadarajah Vigneswaran ,The Journal of
Implant & Advanced Clinical Dentistry , Vol.
2, No. 3 , April 2010.
 5) David L. Hall, Journal of Dental Education
, Volume 70, Number 8, August 2006 .
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Thank
you
11/15/2019 6:19:31 AM

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