Biopsy in maxillofacial field
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Biopsy In Maxillofacial Field
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Biopsy in maxillofacial field
- 1. Biopsy In Maxillofacial Field
- 2. • Biopsy is the surgical removal of a tissue specimen from a living organism for microscopic examination and final diagnosis. • A biopsy is a minor surgical procedure and, depending on whether the entire pathologic lesion or part of it is removed, is either an excisional biopsy or incisional biopsy. Furthermore, aspiration or needle biopsy uses a needle to withdraw a sample from the lesion for examination.
- 3. Principles for Successful Outcome of Biopsy • In clinically suspicious lesions, biopsy must be carried out early. • The choice of the biopsy technique to be employed is determined by the indications of each case. • Direct injection of the local anesthetic solution inside the lesion is to be avoided, because there is a possibility of causing distortion to the tissues.
- 4. Principles for Successful Outcome of Biopsy • The use of the electrosurgical blade is to be avoided, due to the resulting high temperature, which causes coagulation and destruction of tissues. • The tissue specimen must not be grasped with forceps. When their use is necessary, though, the normal part of the removed tissue should be grasped. • The tissue specimen taken should be representative.
- 5. Principles for Successful Outcome of Biopsy • Immediately after its removal, the tissue specimen should be placed in a container with fixative. Keeping the tissue specimen outside of the container for a prolonged period dries the specimen, while there is a risk of it falling or being misplaced. • The fixative solution to be used is 10% formalin, and not water, alcohol, or other liquids that destroy the tissues.
- 6. Principles for Successful Outcome of Biopsy • It is recommended that the container to be sent to the laboratory is plastic to avoid risk of breakage during its transfer and subsequent loss of the specimen. • The label with the name of the patient and date should be placed on the side of the container, and not on the lid. This way the possibility of mix-up at the laboratory after opening is avoided.
- 7. Instruments and Materials • The instruments necessary for performing surgical biopsy of soft and hard tissues are the following: local anesthesia syringe. Scalpel handle and blade. Surgical–anatomic forceps. Hemostat. Needle holder. Curved scissors. Suction tip. Periosteal elevator. Periapical curette. Bone file. Rongeur.
- 9. • The materials considered necessary for biopsy are: local anesthetic cartridge and needle for anesthesia, sutures, surgical dressing, gauze, and vial containing 10% formalin solution for placement of specimen. • As for aspiration biopsy, the necessary instruments and materials include the following: trocar needle or a simple low- gauge needle, plastic disposable syringe, glass slides, and fixative material.
- 10. Excisional Biopsy • This technique entails removal of the entire lesion, along with a border of normal tissues surrounding the lesion. • The indications for employing incisional biopsy are the following: - Small lesions, whose size ranges from a few millimeters to one or two centimeters. - Specific clinical indications that the lesion is benign.
- 11. Generally, the procedure for performing the biopsy is as follows: • After administration of local anesthesia, which is performed at the periphery of the lesion and not directly inside the lesion.
- 12. Two elliptical incisions are made on normal tissue surrounding the lesion, which are joined at an acute angle.
- 13. The lesion is then removed, the mucosa is undermined using blunt scissors, the wound margins are re-approximated,
- 14. Suturing is performed, and healing is achieved by primary intention
- 15. • If the lesion is located at the gingiva or palate, suturing may be not possible. In such a case, a surgical dressing is applied and the wound heals by secondary intention. • It is recommended that the lesion be grasped at its base using forceps or a suture.
- 16. • If the lesion were to be grasped at the center and not at its base, the histological presentation could be altered and could cause problems in diagnosis.
- 17. Examples of lesions that may be removed with excisional biopsy
- 18. Traumatic Fibroma of Buccal Mucosa
- 19. Traumatic Fibroma of Buccal Mucosa
- 20. Traumatic Fibroma of Buccal Mucosa
- 21. Traumatic Fibroma of Buccal Mucosa
- 22. Traumatic Fibroma of Tongue
- 23. Traumatic Fibroma of Tongue
- 24. Traumatic Fibroma of Tongue
- 25. Peripheral Giant Cell Granuloma
- 26. Peripheral giant cell granuloma at the region of the maxillary central incisor Incision peripheral to the lesion Peripheral Giant Cell Granuloma
- 27. Reflection of lesion with broad end of periosteal elevator Surgical field after removal of lesion Peripheral Giant Cell Granuloma
- 28. Application of surgical dressing at area of removal of lesion Postoperative clinical photograph 15 days later Peripheral Giant Cell Granuloma
- 29. Hemangioma of Cheek Small hemangioma of buccal mucosaElliptical incision at normal tissue border surrounding lesion Excision of lesion with scalpel
- 30. Hemangioma of Cheek Surgical field after removal of hemangioma Undermining of mucosa of wound margins from underlying soft tissues with blunt scissors Suturing of wound with interrupted sutu
- 31. Hemangioma of lower lip Hemangioma of lower lip Demarcation of wedge-shaped incision Which includes the entire lesion
- 32. Hemangioma of lower lip Suturing begins at mucosa and ends on skinHemostats just inside of wound margins aid in hemostasis of surgical field before suturing
- 33. Peripheral Fibroma of Gingiva Peripheral fibroma of gingiva located in the region of the lateral and central incisor of the maxilla Incision on normal tissue peripheral to lesionReflection of lesion with broad end of periosteal elevator
- 34. Peripheral Fibroma of Gingiva Surgical field after removal of lesion. Application of surgical dressing at the region of removal of the lesion 3 months after the surgical procedure
- 35. Leukoplakia Leukoplakia of buccal mucosa posterior to commissure of lip Demarcation of incision for surgical excision of leukoplakia
- 36. Leukoplakia Gradual removal of lesion with scalpel and scissors
- 37. Incisional Biopsy • Incisional biopsy involves removal of only a portion of a relatively more extensive lesion, so that histo-pathological examination may be performed and a diagnosis made. • Indications of incisional biopsy: - Lesion is larger than 1 or 2 cm. - There is suspicion that the lesion is malignant.
- 38. The incisional biopsy technique involves the following • After local anesthesia, a wedge-shaped portion of the most representative part of the lesion is removed, usually from the periphery of the lesion, extending into normal tissue as well
- 40. Surgical field after removal of specimen
- 41. Operation site after suturing
- 42. Extensive palatal swelling which is an indication for incisional biopsy Administration of local anesthesia in normal tissues surrounding lesion
- 43. • Surgical field after wedge-shaped excision of tissue Wedge-shaped incision for removal of part of lesion Surgical field after wedge-shaped excision of tissue
- 44. Operation site after placement of sutures
- 45. Fine-Needle Aspiration • A useful method for evaluating subcutaneous or more deeply situated mass lesions, • FNA requires specialized training. This type of procedure is most widely used in determining the nature of salivary gland or neck masses.
- 46. Aspiration Biopsy • Aspiration biopsy is indicated in cases where lesions are not accessible for histopathological examination, e.g., tumors of the parotid gland, lymph nodes, cysts, etc. • It is performed using a trocar needle or fine needle (21-gauge to 23- gauge) adapted to a glass syringe or plastic disposable syringe . • The aspirated material is smeared on a glass slide.
- 47. Aspiration Biopsy • Then immersed in Hoffman solution (95% ethyl alcohol solution and 5% ether solution) in equal parts or it is fixed with hair spray. • Cytological examination is then performed. • A histological examination may be performed if a specimen is sucked into the needle tip, usually with a trocar needle, and expressed onto a glass slide.
- 48. Aspiration Biopsy Aspiration biopsy from a mandibular cyst Glass slide with material obtained by aspiration biopsy
- 49. Aspiration Biopsy Smearing of aspirate Glass slide after smearing and fixation of aspirate with hair spray
- 50. Frozen Section • Diagnosis may influence immediate surgical management. • Lesion is not accessible or the patient not amenable to preoperative biopsy • Preoperative biopsy attempted but was not successful • Staging of malignant neoplasms • Assessing the adequacy of excision
- 51. Attention to: • Surgical pathologist should confirm the following conditions are met: - No risk of compromising the tissue specimen. - High probability of rendering the correct diagnosis. - Little risk of conveying incorrect diagnostic information. Then and only then should the frozen section examination proceed
- 52. Specimen Care • The tissue specimen removed with biopsy is placed in a vial containing an aqueous solution of 10% formalin (4% formaldehyde) and sent to the laboratory, along with the biopsy data sheet containing all the necessary clinical information. The pathology laboratory will send the dentist the pathology report that includes a histological description and diagnosis.
- 53. Exfoliative Cytology • This method is to be used as an additional aid to, and not a substitute for, biopsy, mainly providing bacteriological information. • The reason for this is that it is considered unreliable due to lack of pathologist expertise in the field of exfoliative cytology. Individual cells are examined, rather than the lesion as a whole, which represents a drawback. • The lesion is scraped using a cement spatula or tongue depressor. The superficial cells scraped from the area are smeared evenly on a glass slide. The fixation procedure that follows is the same as that for aspiration biopsy, after which the cells are stained.
- 54. Tolouidine Blue Staining • This method is used most often to indicate the most appropriate biopsy location, even though it does not indicate tumors present under normal epithelium. • A 1% tolouidine blue staining solution is applied to the epithelial surface, whereupon rinsing with a 1% acetic acid solution leaves no stain on normal epithelial surfaces or benign erythematous lesions. • On the contrary, the stain remains on the surface of premalignant and malignant erythematous lesions. • Benign lesions usually have well-defined stain margins, whereas premalignant or malignant lesions have more diffuse margins.
Editor's Notes
- Excisional Biopsy Excisional biopsy is typically used to manage clinically benign lesions that are < 2 cm in diameter. An excisional biopsy is defined as a diagnostic surgical procedure in which all clinically abnormal tissue is removed for microscop- ic analysis. Excision of a small but poten- tially malignant lesion (eg, squamous cell carcinoma with a primary tumor [T], regional nodes [N], and metastasis [M] staging of T1N0M0) may be appropriate in settings in which the surgeon performing the biopsy is also responsible for final treat- ment. With rare exceptions, an excisional biopsy should not be performed on a suspected malignant lesion unless the per- forming clinician is involved in definitive treatment. Otherwise, the surface mucosa may be completely healed by the time the patient is referred to the oncologist, obscuring the extent of the original lesion and unnecessarily hindering definitive treatment planning. Specimen orientation is recommended whenever a clinician suspects that a neo- plastic process may have recurrent or malignant potential, including conditions such as epithelial dysplasia or pleomorphic adenoma. This can be accomplished by careful identification of the anatomic mar- gins of the biopsy specimen with suture(s), an accompanying sketch of the specimen, and its orientation to the surrounding tis- sues or both. Such anatomic orientation of the tissue sample allows the pathologist to properly subdivide and process the speci- men so that the adequacy of excision can be assessed at all surgical margins. The terms negative or clear margins are used when the surgical margins appear free from tumor involvement. When tumor is transected or lies immediately adjacent to the surgical margin without evidence of a capsule, proper specimen orientation per- mits the location of the positive margin(s) to be determined as precisely as possible. With this information the surgeon can then plan the most conservative surgical approach that will also accomplish the pri- mary goal of therapy: complete removal of residual neoplastic tissue.
- Incisional Biopsy Incisional biopsy is generally indicated for large lesions (> 2 cm) and those that could represent unencapsulated or potentially malignant neoplasms. By definition an incisional biopsy is a diagnostic surgical procedure in which a sample or portion of a lesion is removed for histopathologic review, leav- ing the remainder of the lesion at the biop- sy site. In cases of suspected malignancy, an incisional biopsy is usually the procedure of choice unless the clinician performing the biopsy will also be involved in defini- tive treatment of the cancer
- Fine-Needle Aspiration Fine-needle aspi- ration (FNA) is a useful method for evalu- ating subcutaneous or more deeply situated mass lesions, although obtaining a diagnos- tic sample and interpreting the results accu- rately requires specialized training. This type of procedure is most widely used in determining the nature of salivary gland or neck masses. Currently FNA is available in most large urban areas throughout the United States, usually in conjunction with tertiary care medical centers.
- Exfoliative Cytology Exfoliative cytol- ogy is a relatively inexpensive noninva- sive technique that may be used to pro- vide additional information related to lesions of surface origin. The utility of this technique in the diagnosis of condi- tions such as candidiasis, herpesvirus (herpes simplex virus, human her- pesviruses 1 and 2) infections, and pem- phigus vulgaris is well documented. More recently a modified form of cytologic sampling that employs an oral brush instrument to collect epithelial cells followed by automated histopathologic evaluation has been introduced to den- tistry. Suggested advantages include improved sampling of all epithelial layers and increased sensitivity and specificity in the detection of precancerous and cancer- ous lesions versus results with routine exfoliative cytology. This new technique does not provide a definitive diagnosis, however, and cannot be used as a substi- tute for scalpel biopsy and routine histopathologic examination (see below). Therefore, in a clinical setting where the index of suspicion for possible precancer- ous or cancerous change is high, such as the high-risk areas for oral cancer (ie, ven- trolateral tongue, floor of mouth, tonsillar pillars, soft palate), or in a patient with sig- nificant risk factors (ie, heavy smoking, heavy alcohol use, or both), use of brush cytology would not be recommended due to the inherent delay in definitive diagno- sis of the lesional tissue and any subse- quent treatment. In cases in which a per- sistent mucosal lesion is identified but the index of suspicion is low, the brush cytol- ogy technique may be useful in excluding the presence of precancerous or malignant epithelial changes. For such innocuous lesions, a finding of abnormal cells could trigger scalpel biopsy (and definitive diag- nosis) before the surgical procedure might otherwise have been deemed necessary.