PRINCIPLES of DIFFERENTIAL DIAGNOSIS AND BIOPSY

EXAMINATION AND DIAGNOSTIC METHODS

HEALTH HISTORY HISTORY OF LESION CLINICAL EXAMINATION RADIOGRAPHIC EXAMINATION LABORATORY EXAMINATION

INDICATIONS FOR BIOPSY

Any lesion that persists for more than 2 weeks with no apparent etiology Any inflammatory lesion that does not respond to local treatment (or just allow it to heal) after 1014 days Persistent hyperkeratotic changes in surface tissues

INDICATIONS FOR BIOPSY

Any persistent tumescence, either visible or palpable beneath relatively normal tissue Inflammatory changes of unknown cause that persist for long periods Lesions that interfere with local function (e.g.fibroma) Bone lesions not specifically identified by clinical and radiographic findings Any lesion that has the characteristics of malignancy

PRINCIPLES OF BIOPSY

INCISIONAL BIOPSY EXCISIONAL BIOPSY ASPIRATION (FINE NEEDLE ASPIRATE FNA) CYTOLOGY (e.g. brush biopsy)

Diagnostic Imperative

If one of the choices in the differential diagnosis is a malignancy, you MUST rule that possibility out Corollary: If one of the choices REQUIRES histological exam for extensive therapy, you MUST rule that possibility out

SURGICAL PRINCIPLES

ANESTHESIA TISSUE STABILIZATION HEMOSTASIS INCISION HANDLING OF TISSUE IDENTIFICATION OF MARGINS SPECIMEN CARE SURGICAL CLOSURE PAPERWORK!

BIOPSY TECHNIQUES

Anesthetize around lesion, not in it Use an assistant and the Adams forceps Pick a representative spot to R/O worst disease

BIOPSY TECHNIQUES

Make sure to include lesion margins and some normal Get deep enough to include suspected lesion Only sin is not getting enough

BIOPSY TECHNIQUES

Use fingers, tissue forceps and scissors or scalpel Blotting usually better than suction Gauze and finger pressure stops most bleeding! Close with 4/0 chromic

BIOPSY TECHNIQUES

Get specimen in formalin ASAP Watch for crushing If only mucosa, consider sewing to suture backing and labeling margins

Pigmented and leukoplakia lesions

Oral Brush Biopsy

ADVANTAGES

DISADVANTAGES

good for lesions otherwise watched fast no great skill required good instructions good for cancer and needle phobics covered by insurance

may still require biopsy false negatives? Must get representative sample

Oral Brush Biopsy

To be used only on leukoplakic, ulcerous or erythematous lesions Not to be used on submucosal or deep masses or bony lesions

Excisional Biopsy
Lesions 1 cm or smaller

Incisional Biopsy lesions larger than 1 cm

Mucoceles

HARD TISSUE BIOPSY

ASPIRATION FLAP EXPOSURE OSSEOUS WINDOW REMOVAL OF SPECIMEN SPECIMEN CARE

Bone Lesions

In general, opaque lesions less serious, lucent lesions more serious

Hard tissue biopsy

CHARACTERISTICS OF LESIONS THAT RAISE THE SUSPICION OF MALIGNANCY

Erythroplasia - lesion is totally red or has a speckled red and white appearance Ulceration - lesion is ulcerated or presents as an ulcer Duration - lesion has persisted more than 2 weeks

CHARACTERISTICS OF LESIONS THAT RAISE THE SUSPICION OF MALIGNANCY

Growth rate - lesion exhibits rapid growth Bleeding - lesion bleeds on gentle manipulation Induration - lesion and surrounding tissue is firm to the touch Fixation - lesion feels attached to adjacent structures

Suspicion of malignancy

Almost all can wait 2 weeks

Remove irritants

Bad things dont go away Try conservative therapy in meantime

Fine needle aspiration (FNA)

Used for palpable but occult masses in areas otherwise difficult to biopsy

When to Refer?

Patient health Surgical difficulty Access to pathologist? Suspicion of Malignancy

Thank you !