1. K.D. DENTAL COLLEGE & HOSPITAL,MATHURA
DEPARTMENT OF ORALAND MAXILLOFACIAL SURGERY
ORAL BIOPSY
WHAT,WHEN & HOW ???
Presented By-
Dr.Hasti Kankariya
Head Of Department,K.D.Dental College & Hospital,Mathura
MDS(Oral & Maxillofacial Surgery),GDC Trivandrum
Fellowship In Maxillofacial Surgery(CMC Vellore)
.
2.
3.
4. Biopsy was coined by the French Dermatologist ERNEST HENRY BESNIER in 1879.
BIOS - MEANING LIFE OPSIS - MEANING VISION.
DEFINITION
Biopsy is the removal of tissue from the living organism for the purpose of
microscopic examination and diagnosis. (Shafer’s textbook of oral pathology)
Biopsy in its broadest sense includes removal of tissue for examination mainly
MICROSCOPIC analysis but can also be CHEMICAL , MICROBIOLOGIC or a
combination of all. (Richard W. Tiecke)
.
5. *Biopsy not only helps in the diagnosis but also serves as a treatment
option for smaller lesions by excising in toto.
*Biopsy allows us to establish the histological characteristics of suspect
lesions, their differentiation, manner of spread, and helps us to adopt an
adequate treatment strategy
6. INDICATIONS FOR BIOPSY:
*Idiopathic lesion of more than 2 weeks duration
*Any inflammatory lesion that does not respond to treatment for 2 weeks.
*An persistent tumescence(swelling), either visible Or palpable beneath relatively normal tissue
without any clear diagnosis.
*Lesions that is suggestive of malignancy
*Bone lesions that cannot be exclusivelydiagnosed based on their radiographic appearance.
9. INCISIONAL BIOPSY
• It is the REMOVAL of a precise portion of the oral lesion for microscopic
examination.
• It is employed on large, diffuse lesions often above the size of 2 cm in its maximum
dimension.
• It is also employed on lesions with suspected malignant potential.
• The aim of the procedure will be to remove a portion of the lesional tissue in question
along with a sample of normal adjacent tissue for comparison.
It consists of 2 types:
WEDGE TYPE
PUNCH TYPE
10. 1.Wedge Biopsy:
• Elliptical skin incision is made using a
scalpel.
• Begins 2-3 mm from the normal tissue
and penetrates into the region
surrounding the abnormal tissue.
• It is always better to incise tissue
narrow and deep, than broad and
shallow.
Indications:
• Vesicular or bullous lesion
• Ulcerative lesions
11. 2.Punch Biopsy :
•A small cylindrical punch( of diameter 4/8/10 mm) is applied into the lesion through
the full thickness of the skin and a plug of tissue is removed.
• The plug of tissue comprises of cone shaped core of tissue with its widest diameter
at the skin surface and narrowest at the biopsy base.
• It is the widely accepted procedure for diagnostic biopsy or removing small lesions.
Usually done in mass screening programmes from representative areas.
12.
13. Indications:
• It is the method of choice for many flat lesions.
• Interpretation of skin tumours like basal cell carcinoma or Kaposi's sarcoma.
• Diagnosis of bullous skin' disorders like pemphigus vulgaris._
• Diagnosis of inflammatory skin disorders like discoid lupus erythematoses.
• Removal of small skin lesions such as intradermal nevi.
• Diagnosis of atypical appearing lesions like mycobacterial infections..
• Used to confirm or exclude the presence of malignancy.
Advantage:
• Simple, Time conserving.
• Low incidence of infection, bleeding or nonhealing.
• Scarring is insignificant, hence it is cosmetic.
Disadvantage:
• Punch biopsy <3mm heal by secondary intention.
• Biopsy>3mm need one or two sutures to prevent unacceptable
• scarring.
14. Best place for pathologic tissue is
in jar of formalin
EXCISIONAL BIOPSY
15. EXCISIONAL BIOPSY:
* Performed for lesions that require complete removal for diagnostic and therapeutic
purpose.
*Indicated for lesions diagnosed as benign, requiring complete removal and are mostly less
than 2cm.
16. Advantage:
*Allows for histopathologic examination of entire lesion
*Ensure adequate sample for various studies such as culture, histopathology,
immunofluorescence and electron microscopy.
Disadvantage:
* If the tumour is highly infiltrative the margin of excision cannot be exactly elicited, further
surgery will be needed.
* cancerous cells actively multiply at the tumour margins, debulking of the mass may result
in residual cancerous cells left behind.
*Excision needs greater precision and skill of the surgeon.
17.
18. ELECTRO-SURGERY BIOPSY
• Electro-surgery 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 of thermal coagulation
19. Electro-Surgical Technique:
The lesion is grasped with forceps through the loop electrode. The electrode is activated
going under the lesion, removing the growth.
23. NEEDLE BIOPSY
Needle biopsy may be of:
• Core needle biopsy.
• Aspiration biopsy
• Fine needle aspiration cytology.
1.CORE NEEDLE BIOPSY-TRUCUT BIOPSY
Core needle biopsy involves the
removal of a core of deep tissue
usually using a Trucut needle.
24. Advantages :
*Core Biopsy allows for accurate diagnosis because of the large quantity of tissue that can
be obtained.
• The type and grade of the tumour can be assessed. This is an advantage over FNAC,
particularly in case of patients with large masses suggestive of cancer.
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 increases the amount of fluid and cells aspirated through the needle. This
ensures larger tissue sample and reduces the need for re-puncture.
25. needle biopsy Indications:
*Initial method of diagnosis for almost all solid swelling of head and neck region.
• Part of initial diagnostic workup of lymphadenopathy, metastatic lesion or lymphomas.
• Indicated in distinguishing benign from malignant and cystic lesions from inflammatory
lesions.
• Part of initial evaluation of swelling of major salivary gland.
• Helps in distinguishing salivary gland neoplasm, soft tissue neoplasm, parotid lymph nodes,
lympho-epithelial cells, sialadenitis with sensitivity and specificity.
• can be Used for definitive diagnosis of odontogenic tumours like ameloblastoma, OKC, etc.
Advantages:
• Minimally invasive.
• Safe, fast and cost effective method, less time consuming
*Do not distrupt the tumours or distrupt the field for surgical dissection.
*Helps to differenciate benign and malignant lesions, thus helping in pre surgical planning.
28. 2. ASPIRATION BIOPSY:
• Needle aspiration biopsy refers to procedure of removing contents of a lesion, usually a
swelling for the purpose of analysis or quick observation by the clinician
• Aspiration biopsy is typically used to rule out the possibility of a vascular lesion.
• A 18-gauge needle and syringe injected into the exact area.
• The needle may be subsequently readjusted so that it is placed within the centre of the
lesion.
30. Image/CT-Guided/usg guided Biopsy:
• The procedure is comparable to core biopsy; it is conducted with a larger needle with
assisted CT scan equipment.
The simultaneous CT scan allows identification and visualisation of the exact site of the
tumour on the computer screen.
• This advanced technology enables 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.
31. ENDOSCOPIC BIOPSY:
*Endoscopy is defined as “the examination of the interior of a canal or hollow viscous by
means of an endoscope.”
*Lesions that are not clearly accessible for examination example on base of tongue
• tool for the internal examination of large jaw cysts that may contain regional neoplastic
processes within the cyst lining.
• Especially in areas that are difficult to inspect and sample through a standard “bony
window” technique.
32.
33. Endoscopic view showing areas of thickened lining containing
exophytic protrusions measuring up to 10 mm in diameter.
34. Advantage:
It is possible to visualise the lesion directly and to take tissue samples through the
scope for further analysis.
Disadvantages:
• Expensive.
• Difficult to master.
35. BRUSH BIOPSY
• Brush biopsy is an easy, affordable and non invasive technique of biopsy.
• it is to identify lesions that are clinically innocuous, though histologically may exhibit
as atypical cells, dysplasia or frank carcinoma.
• This is the latest diagnostic procedure that utilises a computer-assisted method of
analysis developed by Oral CDx (OralScan Laboratories).
*A brush biopsy kit contains a brush biopsy instrument (round stif nylon brush), a bar-
coded glass slide, alcohol-based fixative and a protective plastic case for mailing
and instruction sheet.
• brush is designed to collect cells from all layers of epithelium including basal cell
layer in contrast to traditional exfoliative cytology where only superficial epithelial cells
are usually collected and evaluated.
36. *The procedure include applying firm pressure on the lesion and rotating the brush 5-10
times.
• Pinpoint bleeding or exposure of pinkish-red mucosa usually signals that an adequate and
successful sample collection.
• Following cell extraction, the nylon brush is manipulated over the glass slide so that more
cells are distributed evenly across the slide. The slide is treated with the alcohol fixative in the
kit. The slide is dried, transferred to a plastic container and mailed. It is analysed by
computerised programmes specifically designed for pathological review.
37.
38. Results are given as negative, atypical or positive.
A biopsy returned with a result of atypical or positive requires an incisional or excisional
biopsy to microscopically review the histological architecture of the lesion for definitive
diagnosis.
40. Advantages of Brush Biopsy:
* Helps in case of diagnosis of recurrent tumour in previous cancer site.
• Non invasive procedure compared to surgical biopsy. Local anaesthesia is not
required.
• Reduced chair side time. Simple procedure which is easy to master.
• Can be used as a screening tool for oral cancer..
Indications :
*Precancerous lesions
• Oral squamous cell carcinoma
• Candidiasis
• Herpes simplex virus infection
• Human papilloma virus infection
•Pemphigus vulgaris
41. FROZEN SECTION:
• During resection of malignant and huge benign tumours, it is required that the surgical
margins are made free of tumour cells.
• Hence, during surgery, bits of tissues along the surgical margin are taken and sent for rapid
microscopic examination and opinion.
• The bits of tissue are processed in a special instrument called cryostat, which has a
microtome ,The tissue is loaded on a metallic cassette, it is stabilised and rapidly frozen to -
20 to -300°C.
42. • The specimen is blocked in gel like medium usually a mixture of poly ethylene glycol and
polyvinyl alcohol. Consecutively, it is cut frozen with the microtome. The sections are placed
on a glass slide, stained with haemotoxylin and eosin.
43. NEWER AIDS IN BIOPSY
In case of doubtful malignant character of the lesion, the following aids can be used as an
adjunct to select representatives areas:
1. Toluidine blue
2. light based detection system- VELscope/MICROLUX -DL (narrow emission tissue
fluorescence)
3. Oral CDx
.
44. *Toluidine blue is a metachromatic vital dye of the thiazine group that increases
visual detection of oral precancer and cancer lesion after negative clinical
examination. It is effectively used as a nuclear stain because of its ability of DNA
binding
*The dysplastic and malignant cells contain quantitatively abundant nucleic acid as
compared to normal cells. Since the toluidine blue stain is basically a nuclear dye, it
stains these abnormal cells specifically and thus helps in diagnosis.
*Actively growing tissues contains high level of sulphated mucopolysaccharides,
hence the dyes will bind to the actively growing tissues like tumours
*Toluidine blue also binds to negatively charged mitochondrial membranes, which
occurs more prominently in dysplastic and malignant cells.
45. CHEMILUMINESCENCE (REFLECTIVE TISSUE FLUORESCENCE :
• Chemiluminescence is usually used as an aid in the diagnosis of cervical mucosa for
aceto white premalignant and malignant lesions.
• Nowadays, the same technology is adapted for use in oral cavity and marketed as
ViziLite Plus and MicroLux DL.
• These systems aim for easy identification of oral mucosal abnormalities. Both the
systems are used similarly; patient should first rinse mouth with a 1% acetic acid
solution, and the oral cavity is directly visualised by a blue-white light source.
• A disposable chemiluminescent light packet is present in Vizilite Plus, while a reusable,
battery-powered light source is present in MicroLux DL.
46. • 1% Acetic acid wash removes surface debris, due to the mild cellular dehydration;
visibility of epithelial cell nuclei is increased.
• Normal epithelium appear lightly bluish while abnormal epithelium are distinctly white
under blue-white illumination.
• The tolunium chloride solution in the Vizilite Plus(Tblue) labels the acetowhite lesion
such that it is visible under normal light, thus, aids in further biopsy procedures.
• Various studies have suggested that chemiluminescence is a dependable oral cancer
screening aid.
47.
48. BIOPSY PROCEDURES
STEPS OF BIOPSY:
Selection of the area of biopsy
Preparation of the surgical field
Local anaesthesia
The incision
Tissue handling
suturing of the resulting wound
49. 1.Selection of the area of biopsy:
Biopsy is generally avoided in an infected site, how-ever, a biopsy is indicated to rule out
infection.
SPECIAL CONSIDERATION:
In large
lesions
• Accessible areas
• Characteristic areas
In
multiple
lesions
• Most representative areas
• Material curetted from
interior of the lesions
61. *Bp blade no 15 and Bp blade handle
*Fine tissue forceps (preferably Adson forceps)
*Syringe and local anaesthetic
*Retractor appropriate for the site
*Sutures, if needed
*Curved scissors
*Needle holder
*Haemostatic agents (silver nitrate or absorbable gelatin sponge)
*Gauze sponges
*Specimen bottle containing 10% neutral buffered formalin
*Biopsy data sheet
62. Preparation Of The Surgical Field:
• Common skin antiseptics such as isopropyl alcohol providone-iodine/or chlorhexidine
gluconate can be used to prepare the biopsy site.
• Mark the intended lesion with a surgical marker as it may be temporarily obliterated following
injection of the anaesthetic solution.
Local Anaesthesia:
An amide-type local anaesthetic with vasoconstrictors used.
Infiltration should be given 1 cm away from-the area to be biopsied.
63. The Incision:
• A well defined, delicate incision is made to remove a portion of the tissue during an
incisional biopsy.
Soft tissue incisions are elliptical in shape, thus a-wedged tissue comprising both the lesion
and the healthy margins are obtained.
• In case of more than one lesion in the oral cavity, multiple biopsies are necessary.
For exploratory biopsy – bone burs, chisel, periosteal elevator and curette are included.
• Electric cautery should not be used for removal of tissue because the surgical margins get
coagulated. Cautery can however be used on a postsurgical site in order to control
bleeding
64. TISSUE STABILIZATION
•Soft tissue biopsies in the oral cavity are frequently performed on movable structures, such
as the lips, soft palate, and tongue.
•Accurate surgical incisions are easiest to perform on tissues that are properly stabilized.
•Several methods are available to achieve tissue stabilization.
An assistant’s fingers pinching the lip on the both sides of the biopsy area can immobilize the
lips. This method also aids in haemostasis by compressing the labial arteries.
•Heavy retraction sutures or towel clips can be used to aid immobilization of the tongue or
soft palate. When used, the sutures should be placed deeply into the substance of the tissue,
away from the proposed biopsy site. They will be useful for secure stabilization without pulling
through the tissue.
65. • The chalazion clamp is a helpful tool for oral biopsies on the oral lips, anterior buccal
mucosa, or tongue. This clamp, with a solid metal back and ring like opening anteriorly, is
tightened in place around the lesion to be biopsied.
• It performs the two important functions of providing a firm surface to work and yields nearly
complete haemostasis.
• Sutures can be placed in the center of the ringed opening before the clamp is loosened.
66. Tissue Handling:
• The specimen should be meticulously handled to avoid crushing of tissues 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 causes minimal histological alterations in the
samples. Other reagents such as
isopropyl or methyl alcohol, saline or distilled water
should never be used as it severely alters the
microstructures leading to misdiagnosis.
• Surplus amount of fixing agent should be used, about
10 to 20 fold the volume of the samples used.
67. Orientation Of Specimens:
• The container should be large enough to accommodate the specimen and filled with enough
formalin to completely cover & surround the specimen. The specimen should be float freely in
the container for adequate fixation.
• Submitting Multiple Sites : Submit multiple specimen of same patient in multiple separate
appropriately labelled jar.
• If multiple specimens are submitted in a single container (which is less ideal) there needs to
be some method of tissue identification (i.e. suture) to denote respective anatomical sites and
a written description of the specimen in relation to suture.
• At least two adjoining margins must be clearly identified to ensure correct orientation, with the
help of short suture and a long suture.
68. Tagging denoting margins :
• Used to indicate margins or for orientation
• Use variable numbers and/or colours of suture - Provide a clear description on the
submission form denoting what the sutures indicate (i.e. one suture = cranial margin)
69. • For immunofluorescence or immunostaining, the specimens should not be fixed and should
be sent immediately to the laboratory for freezing or placed in/Michel's solution
• Michel's transport media is not a fixative, it is merely a solution that maintains isotonicity and
pH of a tissue (7.0-7.2). It effectively stabilises proteins for immunofluorescence. This
solution is made up of citric acid, ammonium sulphate, n-ethylmaleimide and magnesium
sulphate.
• However Fresh material is needed for the following purpose:
1. Frozen section
2. Immunocytochemistry
3. Cytological examination
4. Microbiological sampling before histopathology
5. Chromosome analysis
6. Research purpose
7. Museum display
70. Temperature of fixation:
• The fixation can be carried out at room temperature. Tissue should not be frozen once it
has been placed in the fixative solution, for a peculiar ice crystals distortion will result.
Speed of fixation:
• The speed of fixation of most fixative is almost 1 mm/hour. Therefore, a fixation time of
several hours is needed for most specimens.
Amount of fixative fluid:
• This should be approximately 10-20 times the volume of the specimen.
• Fixative should surround the specimen on all sides.
71. Labeling Of The Specimen:
• The patient’s name, the location of the specimen, clinical records, radiographic features(if
applicable), a provisional diagnosis, orientation of sample and the date of the surgical
procedure are all essential.
• If the specimen is to be mailed, it is better to place it in gauge within the specimen
container so that if a rupture with loss of fluid occurs, the gauze will maintain the tissue in a
moist fixed state.
72. Details Required In Pathology Form
• Patient data
• Clinical details of lesion
• Any medical history with details of medication
• Oral habits - all forms of tobacco and alcohol consumption
• Investigations done, if any
• Site and biopsy type
• Clinical diagnosis with differential diagnosis
• Previous biopsy done, if any, with details
73. Suture:
• The suture should achieve good haemostasis, facilitate healing and should be
after 6-8 days.
• Contraindications to suturing include if biopsies are infected or poorly healing
these wounds heal better by secondary intention.
*It is also contraindicated in susceptible cancerous lesion to avoid cell seeding in
healthy tissue
74. COMPLICATIONS OF BIOPSY:
*Haemorrhage
*Infection
* Poor wound healing
*Spread of tumour cells
* Injury to adjacent organs
*Post operative pain
*Paraesthesia in the lips or the tongue
*Swelling and bruising - in the tongue, lips and buccal mucosa
* Procedures in the floor of the mouth can lead to submandibular or sublingual duct damage.
*Removal of mucoceles from the lip carries the risk of further gland damage and
‘recurrence’.
