BIOPSY Oral Surgery

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BIOPSYBIOPSY


Biopsy:Biopsy:

DefinitionDefinitionIndicationsIndicationsContraindicationsContraindicationsPoints must be considered to ensure obtaining proper specimenPoints must be considered to ensure obtaining proper specimen

Types of biopsyTypes of biopsy Excisional biopsyExcisional biopsy Incisional biopsyIncisional biopsy Punch biopsyPunch biopsy Cone BiopsyCone Biopsy Brush BiopsyBrush Biopsy Frozen section BiopsyFrozen section Biopsy Core Needle biopsyCore Needle biopsy Fine Needle Aspiration CytologyFine Needle Aspiration Cytology Exfoliative cytologyExfoliative cytology


Definition:Definition:Bios – life Opsis – visionBios – life Opsis – vision

Removal of tissue from living Removal of tissue from living beings for the purpose of microscopic beings for the purpose of microscopic examination and diagnosis.examination and diagnosis.


INDICATIONS:INDICATIONS:1.To determine the nature of lesion which does not 1.To determine the nature of lesion which does not

readily respond to conservative & simple therapy.readily respond to conservative & simple therapy.

2.To determine the nature of the lesion which is 2.To determine the nature of the lesion which is unknown.unknown.

3.To establish the diagnosis where there is 3.To establish the diagnosis where there is suspecion of neoplasm.suspecion of neoplasm.

4.To determine nature of any intraosseous lesion 4.To determine nature of any intraosseous lesion which can’t be identified radiographically.which can’t be identified radiographically.

5.To determine the nature of all abnormal tissue 5.To determine the nature of all abnormal tissue removed from the oral cavity including cysts & removed from the oral cavity including cysts & granulomas.granulomas.


Contraindications:Contraindications:A)A) Relative contraindications:Relative contraindications:1.In cases of inflammatory lesions may be 1.In cases of inflammatory lesions may be

due to allergy ,viral ,fungal, or bacterial due to allergy ,viral ,fungal, or bacterial lesion. e.g. candidiasis.lesion. e.g. candidiasis.

2.Compromised generalised health of 2.Compromised generalised health of patient. e.g. patient on anticoagulant patient. e.g. patient on anticoagulant therapy.therapy.

3.Proximity of lesions to vital , anatomic, 3.Proximity of lesions to vital , anatomic, physiologic, neural, vascular, or physiologic, neural, vascular, or glandular structures.glandular structures.


B) Absolute contraindications:B) Absolute contraindications:

1.Pulsatile vascular lesions. e.g. angiosarcoma.1.Pulsatile vascular lesions. e.g. angiosarcoma.2.Pigmented lesion should not be biopsied. e.g. 2.Pigmented lesion should not be biopsied. e.g.

Melanoma. Melanoma.3.Intrabony radiolucent lesions should not be 3.Intrabony radiolucent lesions should not be

biopsied or removed without prior investigational biopsied or removed without prior investigational aspiration.aspiration.


Points must be considered to Points must be considered to ensure obtaining proper specimen:ensure obtaining proper specimen:

1.Do not paint the surface of the area to be biopsied 1.Do not paint the surface of the area to be biopsied with iodine or other highly coloured antiseptic.with iodine or other highly coloured antiseptic.

2.Don’t inject LA into the lesion.2.Don’t inject LA into the lesion.3.Use sharp scalpel to avoid tearing of tissue.3.Use sharp scalpel to avoid tearing of tissue.4.Use care not to mutilate the specimen when 4.Use care not to mutilate the specimen when

grasping it with forceps.grasping it with forceps.5.Fix the tissue immediately upon removal in 10% 5.Fix the tissue immediately upon removal in 10%

formalin or 70% alcohol.formalin or 70% alcohol.6.If the specimen is thin, place it upon a piece of 6.If the specimen is thin, place it upon a piece of

glazed paper & drop into fixative which prevents glazed paper & drop into fixative which prevents curling of tissue.curling of tissue.


Repeated cutting of the tissue during Repeated cutting of the tissue during incision should be avoided.incision should be avoided.

Edge of the specimen should be vertical & Edge of the specimen should be vertical & not beveled.not beveled.

If the lesion is multifocal or large,it is ideal If the lesion is multifocal or large,it is ideal to obtain more than one sample from to obtain more than one sample from different sites for making more accurate different sites for making more accurate diagnosis.diagnosis.

The biopsy specimen should be of The biopsy specimen should be of sufficient thickness and depth (size- 1x0.6 sufficient thickness and depth (size- 1x0.6 cm, depth- 2mm)cm, depth- 2mm)


The wound should be sutured and The wound should be sutured and bleeding must be controlled.bleeding must be controlled.If the biopsy specimen is a calcified tissue If the biopsy specimen is a calcified tissue (e.g.bone and tooth) then decalcification (e.g.bone and tooth) then decalcification of the said specimen is to be done before of the said specimen is to be done before the standard processing and sectioning. the standard processing and sectioning. Decalcification is usually done by keeping Decalcification is usually done by keeping the specimen in EDTA or other acid the specimen in EDTA or other acid solutions.solutions.Biopsy should be repeated, if the diagnosis Biopsy should be repeated, if the diagnosis is not consistent with the clinical findings is not consistent with the clinical findings or the provisional diagnosis.or the provisional diagnosis.


TYPES OF BIOPSY:TYPES OF BIOPSY:1.Excisional biopsy1.Excisional biopsy2.Incisional biopsy2.Incisional biopsy3.Scalpel biopsy3.Scalpel biopsy4.Punch biopsy4.Punch biopsy5.Cone Biopsy5.Cone Biopsy6.Brush Biopsy6.Brush Biopsy7.Frozen section Biopsy7.Frozen section Biopsy8.Core Needle biopsy8.Core Needle biopsy9.Fine Needle Aspiration Cytology9.Fine Needle Aspiration Cytology10.Exfoliative cytology10.Exfoliative cytology


EXCISIONAL BIOPSY:EXCISIONAL BIOPSY:

*Definition: Total excision of a small *Definition: Total excision of a small lesion for microscopic study is called lesion for microscopic study is called

“ “excisional biopsy”.excisional biopsy”.

*Use : Lesions smaller than 1cm in *Use : Lesions smaller than 1cm in

meter. meter.


Method:Method:

Give LA which should not be closer Give LA which should not be closer than 2cm from the site.than 2cm from the site.

Stabilize the lesion via the suture.Stabilize the lesion via the suture.

Incise mucosa around the base of the Incise mucosa around the base of the lesion in an elliptical shape.lesion in an elliptical shape.

Place specimen immediately in a Place specimen immediately in a fixative.fixative.

Close the wound using suture.Close the wound using suture.



INCISIONAL BIOPSY:INCISIONAL BIOPSY:Definition: Some lesions are too large to Definition: Some lesions are too large to

excise initially without having excise initially without having established diagnosis or are of such a established diagnosis or are of such a nature that excision would be inadvisable nature that excision would be inadvisable in such instances a small section is in such instances a small section is removed for examination called incisional removed for examination called incisional or diagnostic biopsy.or diagnostic biopsy.

Use : For large lesions or there is a suspicion Use : For large lesions or there is a suspicion of malignancy.of malignancy.


Method:Method:Administer LA.Administer LA.Identify the apparent junction between normal Identify the apparent junction between normal tissue & the lesion select the specimen across tissue & the lesion select the specimen across region.region.Stabilize the specimen with a suture.Stabilize the specimen with a suture.Dissect the specimen from the edge of the lesion Dissect the specimen from the edge of the lesion & include a margin of apparently normal tissue.& include a margin of apparently normal tissue.The specimen should include representative area The specimen should include representative area of the lesion.of the lesion.Place the specimen immediately in a prescribed Place the specimen immediately in a prescribed specimen bottle containing 10% formalin.specimen bottle containing 10% formalin.Close surgical site by sutures.Close surgical site by sutures.



PUNCH BIOPSY:PUNCH BIOPSY:

A surgical instrument is used to A surgical instrument is used to punch out a representative portion of punch out a representative portion of tissue.tissue.

Since resulting specimen is often Since resulting specimen is often damaged damaged

by the procedure so biopsy by by the procedure so biopsy by scalpel is preffered.scalpel is preffered.


Cone BiopsyCone Biopsy

It is a surgical biopsy and it removes It is a surgical biopsy and it removes the tissue which is cylindrical or cone the tissue which is cylindrical or cone shaped. The advantage of this shaped. The advantage of this technique is that it provides a large technique is that it provides a large sample of tissue.sample of tissue.


Brush BiopsyBrush Biopsy

This technique is used to collect cells This technique is used to collect cells from the surface as well as from the surface as well as subsurface layers of a suspected subsurface layers of a suspected lesion for microscopic examination.lesion for microscopic examination.

A round stiff bristle brush is rotated A round stiff bristle brush is rotated vigorously at a particular site of the vigorously at a particular site of the lesion until bleeding starts, which lesion until bleeding starts, which ensures a sufficiently deep sample.ensures a sufficiently deep sample.


Frozen section biopsyFrozen section biopsyIt is performed in order to get an It is performed in order to get an immediate histological report of a lesion immediate histological report of a lesion (eg. To determine whether a lesion is (eg. To determine whether a lesion is malignant or not, or to evaluate the malignant or not, or to evaluate the margin of an excised cancer to ascertain margin of an excised cancer to ascertain that the entire lesion is removed at time of that the entire lesion is removed at time of surgery). The tissue is obtained from a surgery). The tissue is obtained from a lesion and a fresh tissue is quickly frozen lesion and a fresh tissue is quickly frozen at about -70 degrees in liquid nitrogen or at about -70 degrees in liquid nitrogen or dry ice. The frozen section is then dry ice. The frozen section is then sectioned in a refrigerated microtome and sectioned in a refrigerated microtome and then stained to get prompt diagnosisthen stained to get prompt diagnosis


Needle/trephine/drill biopsy:Needle/trephine/drill biopsy:

Use : to biopsied deep-seated fibro-Use : to biopsied deep-seated fibro-osseous lesions.osseous lesions.

The resulting specimen is smaller The resulting specimen is smaller may be non-representative & again may be non-representative & again often damaged by the procedures so often damaged by the procedures so they are not often used.they are not often used.


Fine Needle Aspiration biopsy:Fine Needle Aspiration biopsy:Use – Applicable to many cystic & Use – Applicable to many cystic &

fluctuant lesionsfluctuant lesionsMethod- Method- Clean the tissue over the proposed Clean the tissue over the proposed

aspiration site.aspiration site.-Inject LA solution over the lesion.-Inject LA solution over the lesion.-Select a wide bore needle & 10 ml syringe.-Select a wide bore needle & 10 ml syringe.-Penetrate tissue & aspirate fluid.-Penetrate tissue & aspirate fluid.-Transfer the aspirate into a screw top -Transfer the aspirate into a screw top

specimen bottle.specimen bottle.



CT Guided FNACCT Guided FNAC

The technique is same as The technique is same as conventional FNAC but the imaging conventional FNAC but the imaging facility attached with the instrument facility attached with the instrument helps in locating the wound to be helps in locating the wound to be biopsied.biopsied.


ORAL EXFOLIATIVE ORAL EXFOLIATIVE CYTOLOGY:CYTOLOGY:

Oral epithelium is the harbour for manyOral epithelium is the harbour for many pathology lesions of varied origin, where pathology lesions of varied origin, where the cells denude at the surface.Such cells the cells denude at the surface.Such cells can be used as ancan be used as an ADJUNCT to diagnose ADJUNCT to diagnose epithelial malignancies,viralepithelial malignancies,viral lesions & lesions & dermatologicdermatologic diseases with oral diseases with oral manifestations.The technicmanifestations.The technic by which we by which we study the exfoliatingstudy the exfoliating oral cells isoral cells is termed termed as”Oral exfoliative cytology”.as”Oral exfoliative cytology”.


Collection of smear:Collection of smear:-A clean cotton tip applicator or a wooden -A clean cotton tip applicator or a wooden

spatula is used for collecting the spatula is used for collecting the specimen.specimen.

-If the area to be scrapped is dry applicator -If the area to be scrapped is dry applicator or spatula should be moistened.or spatula should be moistened.

-The material to be collected is obtained -The material to be collected is obtained either by scrapping the surface of lesion or either by scrapping the surface of lesion or by rolling motion against the lesion.by rolling motion against the lesion.

-Scrapping obtained should be smeared in -Scrapping obtained should be smeared in the center of the previously marked slide. the center of the previously marked slide.


Fixation of smear:Fixation of smear:This is to maintain the almost same status as it was in the oral cavity.This is to maintain the almost same status as it was in the oral cavity. Fixatives used are :Fixatives used are :1)1) Equal parts of ether & 95% ethyl alcohol give superstaining Equal parts of ether & 95% ethyl alcohol give superstaining

qualities.qualities.2)2) Carbowax/Aquawax – This contains Carbowax/Aquawax – This contains -Polyethyl glycol-Polyethyl glycol -Distilled water-Distilled water -Glacial acetic acid-Glacial acetic acid The slide should be immersed into fixative before the smear The slide should be immersed into fixative before the smear

dries out and remain it in the fixative for 30 minutes.dries out and remain it in the fixative for 30 minutes. Small specimens are generally fixed overnight, and large Small specimens are generally fixed overnight, and large

specimen are fixed for 24 hrs, so that the fixative can penetrate specimen are fixed for 24 hrs, so that the fixative can penetrate and diffuse into the tissue specimen.and diffuse into the tissue specimen.

The volume of fixative should be atleast 10 times to that of the The volume of fixative should be atleast 10 times to that of the tissues.tissues.


Staining of the smear:Staining of the smear:

This is done by using “The Modified This is done by using “The Modified Papnicolaou technique”.-1946 Papnicolaou technique”.-1946 utilizing Mayer’s haematoxylin, utilizing Mayer’s haematoxylin, Orange G stain,combination of eosin Orange G stain,combination of eosin & light green stains.& light green stains.


Screening criteria:Screening criteria:-Normal cells: Parabasal & immature prickle cells.-Normal cells: Parabasal & immature prickle cells. Cells are spherical or cuboidal with centrally placed Cells are spherical or cuboidal with centrally placed

& EVEN CHROMATIN DISTRIBUTION.& EVEN CHROMATIN DISTRIBUTION.Cytoplasm stains green or bluish green.Cytoplasm stains green or bluish green.-Intermediate cells: irregularity of cytoplasmic -Intermediate cells: irregularity of cytoplasmic

morphology with some degree of contraction of morphology with some degree of contraction of nucleus.nucleus.

Cytoplasm stains red or pink.Cytoplasm stains red or pink.-Mature cells: Flattened with pyknotic nucleus, may -Mature cells: Flattened with pyknotic nucleus, may

be anucleatedbe anucleated cytoplasm stains, orange or yellow.cytoplasm stains, orange or yellow.


Criteria of malignant cells:Criteria of malignant cells:1.Irregular cell and nuclear borders.1.Irregular cell and nuclear borders.2.Basal & parabasal cells. i.e in superficial part.2.Basal & parabasal cells. i.e in superficial part.3.Cells with pyknotic nuclei or absence of nuclei in 3.Cells with pyknotic nuclei or absence of nuclei in

an abnormal location.an abnormal location.4.Altered cytoplasm to nucleus ratio.4.Altered cytoplasm to nucleus ratio.5.Epithelial giant cells.5.Epithelial giant cells.6.Poikilocarynosis.6.Poikilocarynosis.7.Abnormal miosis.7.Abnormal miosis.8.Hyperchromatism.8.Hyperchromatism.9.Abnormal chromatin pattern & distribution.9.Abnormal chromatin pattern & distribution.




Biopsy Results: What If ?Biopsy Results: What If ?

They don’t corroborate your clinical They don’t corroborate your clinical impressionimpression– Repeat the biopsy!!!Repeat the biopsy!!!– Determine if the tissue was looked at by Determine if the tissue was looked at by

an Oral Pathologistan Oral Pathologist– The results show malignancyThe results show malignancy


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BIOPSY Oral Surgery