Detailed Biopsy presentation

1. Biopsy
Dr. Kush
1

2. “The best surgeon is a
clinical pathologist who
performs operations”
2

3. 3
Al-Zahrawi, an Arab physician, surgeon and
pharmacist - perform a needle biopsy (of the thyroid).
He used hollow needles to investigate abnormal
growths of the thyroid gland.
Around the year 1000 AD, he wrote his famous book
'Al Tasreef Liman 'Ajaz 'Aan Al-Taleef (or 'al-Tasreef')
(''An Aid for Those Who Lack the Capacity to Read Big
Books').
History

4. 4
In the early 16th century, Sir Marcello Malphigi
termed it as,
Bios- LIFE, Opsis- A sight
In the modern era, a Russian, M.M. Rudnev –
used diagnostic biopsy in 1875.

5. 5
Expert committee of WHO (1996) – “
Biopsy is examination of tissue removed
from a lesion & by extension the term is also
used to convey the removal of the lesion”
The term 'biopsy' was introduced into medical
terminology in 1879 by Ernest Besnier.

6. 6
• 100 years of biopsy can be easily divided into 3 major
steps:
1. An occasional use of procedure - until the late 19th
century - involving living organs and tissues for
observation and study.

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2. Restricted application of biopsy- until the
mid-20th century.
3. Present stage - widely adopted, not only in
oncology but practically in all clinical specialties.

8. Histological characteristics
 Differentiation
 Extent or spread
 Evoluative control of disease process
 Healing or relapse
 Irrefutable legal medical value.
8
The Technique Allows Us To Establish

9. Indications
Primarily – To confirm the clinical
impression of the lesion.
Any persistent lesions >10-14days
With no apparent etiologic basis.
That does not respond to Rx even after
removal of cause / irritant.
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10. 10
Persistent swelling
Bone lesions - Not specifically identified by
clinical & radiographic findings.
Lesions presenting the characteristics of
malignancy

11. Conditions that are potentially precancerous
Persistent hyperkeratotic change. e.g.:
leukoplakia.
Inflammatory changes of unknown causes.
11

12. Lesions interfering with normal functions.
For:
Classification,
Grading / staging of tumor
12

13. 13
Evaluation of surgical margins
To alleviate patient apprehensions
Evaluate prognosis

14. Contraindications
Compromised general health, h/o bleeding
diathesis.
Lesion close to vital anatomic, vascular or ductal
structures.
Intrabony lesions should not be biopsied or
removed prior to investigational aspiration.
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15. 15
Normal anatomic & racial variation – e.g.
Physiologic pigmentation, linea alba,
Fordyce's granules.
Acute / sub acute inflammatory condition –
bacterial, viral infection.

16. Absolute:
Pulsative lesion, large hemangiomas –
appear to be filled with blood.
16

17. Selection Of Specimen
 Area representative of whole lesion.
 Adequate amount of tissue must be present.
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18. 18
In large lesions – Specimen is removed
from most easily accessible & representative
area.
Deep sections of lesion along with normal
tissue are needed.
If several lesions - specimen taken from
most representative area.

19.  Intra osseous lesions – Cortical plate of
bone should be removed & curetted material
must be evaluated.
 Skin / mucosal biopsy – Epithelium +
Connective tissue.
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Ulcer – Normal area + Deep part of ulcer
Multiple ulcers – More than one biopsy & at
the site of maximum clinical activity.

21. INSTRUMENTS AND MATERIALS
21

22. INSTRUMENTS AND MATERIALS
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23. Procedure
 Injecting local
anesthesia.
 Elliptical or wedge
shaped incision
including normal &
abnormal tissue.
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24. 24
Tissue is grasped with forceps & cut under
tension.

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Place the sample in 10% formalin.

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10% Formalin
Label the bottles

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29. HANDLING OF TISSUE
 Avoid liberal use of tissue
forceps.
Critical step
29

30. Ensure spill-proof packaging.
Label “PATHOLOGIC
SPECIMEN”
TRANSPORTATION
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31. Approach for lesion
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Type of Biopsy

32. Types according
to technique
BONE
INCISIONAL
PUNCH
CURETTAGE
LASER
SHAVE
EXPLORATIVE
BRUSH
EXCISIONAL 32

33. INCISIONAL BIOPSY
Indications:
• Large lesions (> 1cms)
• Hazardous location with uncertain
nature.
• Doubtful malignant lesions
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34. 34

35. 35
Oral cavity – Commonest lesion for incisional
biopsy – white hyperkeratotic lesions.
Bleeding, ulcerated or indurated area must be
taken.

36. EXCISIONAL BIOPSY
Removal of lesion in -
Toto – with adequate
margins
Accomplishes the goal of
the biopsy (entire lesion
is available for H/P
examination)as well as
Rx
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37. 37
Indications
Lesions <1cms
Clinically benign lesions
Easily accessible

38. PUNCH BIOPSY
Convenient method for oral
mucosal lesions
Biopsy punch Make
circular incisions (3-4mm in
diameter)
Surgically inaccessible
regions e.g. palatal biopsy of
minor salivary glands, lips.
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40. 40

41. Principle
Punch – circular / twisting motion  a
circular incision on lesion.
Remove the punch.
Grasp the margin – separate the base with
scissors or scalpel.
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 Quick & effective
 Produces a clean & sharp incision
 Little bleeding
 Minimal pain
Advantages
Disadvantages
 Tissue distorted
 Can’t be used in soft palate, floor of mouth

44. CURETTAGE
Curette – Spoon like tip
Designed for scraping
out cavities for tissue
(diagnostic/therapeutic
purposes)
eg: maxillary antrum,
cystic lesions within the
jaws
44

45. 45
Used primarily for intraosseous lesions
(cystic/fibro-osseous), soft friable soft
tissues (granulation tissue)
Easy to perform

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 Modified Ellis drill, fits into straight
hand piece.
 For central fibro -osseous lesions,
osteolytic lesions of bone, lymph
node masses.
 Needle is introduced through small
skin incision & rotated at slow
speed until tumor is reached.
Drill biopsy

47.  Entered into tumor mass.
 Gentle negative pressure is applied to needle
by means of small syringe on withdrawal.
 Contained core expelled into fixative.
47

48. Disadvantages
Heat
May miss the lesion (< 2cms)
Advantages
Less trauma to healthy tissues.
Less chances of metastasis.
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49. Shave biopsy
Easiest biopsy to take when lesion is raised above
surface.
Using scalpel blade or special disposable blade.
Sawing / shaving action is used.
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Plastic blade mounted in rigid plastic handle

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52. Electro surgery/ Laser biopsy
• Specimen is taken using electrode.
• Minimum discomfort & bleeding. (cauterization)
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53.  Electro-surgery refers to the cutting and coagulation of
tissue using very high-frequency, low-voltage electrical
currents.
 Useful in producing a bloodless operative field.
 Thermal coagulation is used.
53

54. Electro-surgical
technique
The lesion is grasped
with forceps through
the loop electrode.
The electrode is
activated going
under the lesion,
removing the growth.
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55. • Currently not advised for
oral biopsies
Disadvantages:
• In electro surgery – Thermal
damage may result in charred
appearance of tissue.
• Laser – less extensive thermal
damage.
55

56. Aspiration biopsy
(FNAC / FNAB)
• To obtain material from body cavity, cystic
space or fluid containing lesion.
• Introduced by Martin, Ellis & Stewart in 1950.
• Obtained material can be smeared on a slide,
fixed & stained.
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Indications:
Differentiate neoplastic from non neoplastic
tissues

58. Advantages :
Quicker to perform
Less painful
Technically less demanding
Inexpensive
Repeatable
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Technique:
Cleansing of skin , LA at periphery of mass.
Sterile needle attached to syringe is guided
inside abnormal area.

60. ASPIRATION CYTOLOGY
GUN 60

61. Franzen’s handel with syringe & needle fitted on it for
performing FNAC
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63. The proper lesion may get missed easily.
Tissue relationships not known (as only few cells
are studied)
Most of the times needs a confirmatory biopsy
Disadvantages 63

64. Stab incision
To distinguish between reactive
changes / recurrent malignancies/
cervical metastases.
Symptom less H&N swellings
Disadvantages
•Tumor dissemination / seeding
Core biopsy / True – cut biopsy
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65. 65

66.  Study of superficial cells which have been either
exfoliated or shed from mucous membrane.
 Cells are collected by scraping or pulling off from
tissue surface.
 Can also be done with sputum or saliva.
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Exfoliative cytology

67. Indications:
 For suspected malignant and premalignant oral
lesions.
 Recurrent oral cancers after treatment.
 Mass screening of oral cancer.
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68. Contradictions:
 Deep seated lesions (both soft and hard tissue).
 Fibrous lesions.
 Non-ulcerative lesions.
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 The lesion is repeatedly scraped with a moistened
tongue depressor or spatula or cytobrush type
instrument.
 The cells obtained are smeared on a glass slide and
immediately fixed with a fixative spray or solution.
Technique

70. 70

71. 71

72. 72
Special instrument called biopsy brush
Trans-epithelial biopsy obtained
Indications
For precancerous / cancerous oral
mucosal lesions
Advantages
Easy to perform; requires less time
Well tolerated by the patient
Oral brush biopsy

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77. Dangers during biopsy…
Spreading of tumor cells along lymphatics /
vascular channels.
Hemorrhage
Infection
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78. Specific tissue considerations
Oral biopsies: methods and applications
R. J. Oliver, P. Sloan and M. N. Pemberton BRITISH DENTAL JOURNAL
VOLUME 196 NO. 6 MARCH 27 2004
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79. For red & white lesions include both red & white
area
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80. Ulcers
Include margin,
deep part of
ulcer and site of
maximal clinical
activity.
AVOID
Superficial
ulcers &
necrotic tissue
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81. Vesiculo-bullous lesions
Fluid is more representative. Intact vesicle or bulla
should be biopsied.
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82. For LICHEN PLANUS – representative area should be
biopsied
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83. For LEUKOPLAKIA – Most dysplastic area should be
biopsied
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84. Do not cut into pigmented and vascular lesions
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85. 85
Oral biopsies: methods and applications
R. J. Oliver, P. Sloan and M. N. Pemberton BRITISH DENTAL JOURNAL
VOLUME 196 NO. 6 MARCH 27 2004

86. 86
Clinical diagnosis Type of biopsy Suitable for general dental
practice
Chronic ulcer or
squamous cell
carcinoma
Incisional biopsy of
margin of ulcer
No, urgent referral
to hospital
Leukoplakia/
erythroplakia
Incisional or punch
biopsy of worst area
consider multiple
biopsies if extensive
lesion
No, referral to
hospital
Mucosal lichen
planus
Incisional biopsy of
the area
Only very
experienced
practitioners
Bullous lesions
(pemphigus
pemphigoid etc.)
Incisional or punch
biopsy of unaffected
mucosa close to bulla
No, referral to
hospital

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Clinical diagnosis Type of biopsy Suitable for general
dental practice
Granulomatous diseases
(Crohn’s,
Orofacial granulomatosis,
ulcerative colitis, TB)
Deep incisional biopsy
plus fresh sample to
microbiology if
infective agent
suspected
No, referral to
hospital
Mucocele Careful excision biopsy Yes, with care
Fibroepithelial polyp,
pyogenic granuloma, epulis
Excision biopsy Yes
Minor salivary gland
tumour
Palate: deep incisional
biopsy
Upper lip: excisional
biopsy
No, urgent referral
to
hospital

88. Summary
88