BIOPSY Oral Surgery

BIOPSY
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Biopsy:
Definition Indications Contraindications Points must be considered to ensure obtaining proper specimen
Types of biopsy
Excisional biopsy Incisional biopsy Punch biopsy Cone Biopsy Brush Biopsy Frozen section Biopsy Core Needle biopsy Fine Needle Aspiration Cytology Exfoliative cytology
Definition:
Bios life Opsis vision Removal of tissue from living beings for the purpose of microscopic examination and diagnosis.
INDICATIONS:
1.To determine the nature of lesion which does not readily respond to conservative & simple therapy. 2.To determine the nature of the lesion which is unknown. 3.To establish the diagnosis where there is suspecion of neoplasm. 4.To determine nature of any intraosseous lesion which cant be identified radiographically. 5.To determine the nature of all abnormal tissue removed from the oral cavity including cysts & granulomas.
Contraindications:
A) Relative contraindications: 1.In cases of inflammatory lesions may be due to allergy ,viral ,fungal, or bacterial lesion. e.g. candidiasis. 2.Compromised generalised health of patient. e.g. patient on anticoagulant therapy. 3.Proximity of lesions to vital , anatomic, physiologic, neural, vascular, or glandular structures.
B) Absolute contraindications: 1.Pulsatile vascular lesions. e.g. angiosarcoma. 2.Pigmented lesion should not be biopsied. e.g. Melanoma. 3.Intrabony radiolucent lesions should not be biopsied or removed without prior investigational aspiration.
Points must be considered to ensure obtaining proper specimen:

1.Do not paint the surface of the area to be biopsied with iodine or other highly coloured antiseptic. 2.Dont inject LA into the lesion. 3.Use sharp scalpel to avoid tearing of tissue. 4.Use care not to mutilate the specimen when grasping it with forceps. 5.Fix the tissue immediately upon removal in 10% formalin or 70% alcohol. 6.If the specimen is thin, place it upon a piece of glazed paper & drop into fixative which prevents curling of tissue.
Repeated cutting of the tissue during incision should be avoided. Edge of the specimen should be vertical & not beveled. If the lesion is multifocal or large,it is ideal to obtain more than one sample from different sites for making more accurate diagnosis. The biopsy specimen should be of sufficient thickness and depth (size- 1x0.6 cm, depth- 2mm)
The wound should be sutured and bleeding must be controlled. If the biopsy specimen is a calcified tissue (e.g.bone and tooth) then decalcification of the said specimen is to be done before the standard processing and sectioning. Decalcification is usually done by keeping the specimen in EDTA or other acid solutions. Biopsy should be repeated, if the diagnosis is not consistent with the clinical findings or the provisional diagnosis.
TYPES OF BIOPSY:
1.Excisional biopsy 2.Incisional biopsy 3.Scalpel biopsy 4.Punch biopsy 5.Cone Biopsy 6.Brush Biopsy 7.Frozen section Biopsy 8.Core Needle biopsy 9.Fine Needle Aspiration Cytology 10.Exfoliative cytology
EXCISIONAL BIOPSY:
*Definition: Total excision of a small lesion for microscopic study is called excisional biopsy. *Use : Lesions smaller than 1cm in meter.
Method:
Give LA which should not be closer than 2cm from the site. Stabilize the lesion via the suture. Incise mucosa around the base of the lesion in an elliptical shape. Place specimen immediately in a fixative. Close the wound using suture.
INCISIONAL BIOPSY:
Definition: Some lesions are too large to excise initially without having established diagnosis or are of such a nature that excision would be inadvisable in such instances a small section is removed for examination called incisional or diagnostic biopsy. Use : For large lesions or there is a suspicion of malignancy.
Method:
Administer LA. Identify the apparent junction between normal tissue & the lesion select the specimen across region. Stabilize the specimen with a suture. Dissect the specimen from the edge of the lesion & include a margin of apparently normal tissue. The specimen should include representative area of the lesion. Place the specimen immediately in a prescribed specimen bottle containing 10% formalin. Close surgical site by sutures.
PUNCH BIOPSY:
A surgical instrument is used to punch out a representative portion of tissue. Since resulting specimen is often damaged by the procedure so biopsy by scalpel is preffered.
Cone Biopsy
It is a surgical biopsy and it removes the tissue which is cylindrical or cone shaped. The advantage of this technique is that it provides a large sample of tissue.
Brush Biopsy
This technique is used to collect cells from the surface as well as subsurface layers of a suspected lesion for microscopic examination. A round stiff bristle brush is rotated vigorously at a particular site of the lesion until bleeding starts, which ensures a sufficiently deep sample.
Frozen section biopsy

It is performed in order to get an immediate histological report of a lesion (eg. To determine whether a lesion is malignant or not, or to evaluate the margin of an excised cancer to ascertain that the entire lesion is removed at time of surgery). The tissue is obtained from a lesion and a fresh tissue is quickly frozen at about -70 degrees in liquid nitrogen or dry ice. The frozen section is then sectioned in a refrigerated microtome and then stained to get prompt diagnosis
Needle/trephine/drill biopsy:
Use : to biopsied deep-seated fibroosseous lesions. The resulting specimen is smaller may be non-representative & again often damaged by the procedures so they are not often used.
Fine Needle Aspiration biopsy:

Use Applicable to many cystic & fluctuant lesions MethodClean the tissue over the proposed aspiration site. -Inject LA solution over the lesion. -Select a wide bore needle & 10 ml syringe. -Penetrate tissue & aspirate fluid. -Transfer the aspirate into a screw top specimen bottle.
CT Guided FNAC
The technique is same as conventional FNAC but the imaging facility attached with the instrument helps in locating the wound to be biopsied.
ORAL EXFOLIATIVE CYTOLOGY:

Oral epithelium is the harbour for many pathology lesions of varied origin, where the cells denude at the surface.Such cells can be used as an ADJUNCT to diagnose epithelial malignancies,viral lesions & dermatologic diseases with oral manifestations.The technic by which we study the exfoliating oral cells is termed asOral exfoliative cytology.
Collection of smear:
-A clean cotton tip applicator or a wooden spatula is used for collecting the specimen. -If the area to be scrapped is dry applicator or spatula should be moistened. -The material to be collected is obtained either by scrapping the surface of lesion or by rolling motion against the lesion. -Scrapping obtained should be smeared in the center of the previously marked slide.
Fixation of smear:
This is to maintain the almost same status as it was in the oral cavity. Fixatives used are : 1) Equal parts of ether & 95% ethyl alcohol give superstaining qualities. 2) Carbowax/Aquawax This contains -Polyethyl glycol -Distilled water -Glacial acetic acid The slide should be immersed into fixative before the smear dries out and remain it in the fixative for 30 minutes. Small specimens are generally fixed overnight, and large specimen are fixed for 24 hrs, so that the fixative can penetrate and diffuse into the tissue specimen. The volume of fixative should be atleast 10 times to that of the tissues.
Staining of the smear:

This is done by using The Modified Papnicolaou technique.-1946 utilizing Mayers haematoxylin, Orange G stain,combination of eosin & light green stains.
Screening criteria:
-Normal cells: Parabasal & immature prickle cells. Cells are spherical or cuboidal with centrally placed & EVEN CHROMATIN DISTRIBUTION. Cytoplasm stains green or bluish green. -Intermediate cells: irregularity of cytoplasmic morphology with some degree of contraction of nucleus. Cytoplasm stains red or pink. -Mature cells: Flattened with pyknotic nucleus, may be anucleated cytoplasm stains, orange or yellow.
Criteria of malignant cells:

1.Irregular cell and nuclear borders. 2.Basal & parabasal cells. i.e in superficial part. 3.Cells with pyknotic nuclei or absence of nuclei in an abnormal location. 4.Altered cytoplasm to nucleus ratio. 5.Epithelial giant cells. 6.Poikilocarynosis. 7.Abnormal miosis. 8.Hyperchromatism. 9.Abnormal chromatin pattern & distribution.
Biopsy Results: What If ?

They dont corroborate your clinical impression
Repeat the biopsy!!! Determine if the tissue was looked at by an Oral Pathologist The results show malignancy
THANK YOU

BIOPSY Oral Surgery

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BIOPSY

Points must be considered to ensure obtaining proper specimen:

Frozen section biopsy

Fine Needle Aspiration biopsy:

ORAL EXFOLIATIVE CYTOLOGY:

Staining of the smear:

Criteria of malignant cells:

Biopsy Results: What If ?

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