Biopsy in Oral and Maxillofacial Surgery

Question 1

Principles of Tissue Biopsy in Oral and Maxillofacial Surgery
* Biopsies are an important diagnostic tool for the diagnosis of lesions ranging from

Answer 1

peri-apical lesions to malignancies in the oral cavity.

Question 2

Indications for Biopsy
(5)

Answer 2

Any persistent swelling, either
visible or palpable beneath
relatively normal tissue
Persistent hyperkeratosis
changes in tissue
Lesion that interfere with
local function (ex: fibroma)
Bone lesions identified by
radiographic finding.
Any lesion that has the characteristics
of malignancy.

Question 3

Erythroplakia -

Answer 3

lesion is totally red or has
speckled red appearance

Question 4

Ulceration -

Answer 4

lesion is ulcerated or presents
as an ulcer and the lesion has persisted more
than 2 weeks

Question 5

Characteristics of lesions that raise the suspicion of malignancy
(4)

Answer 5

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

Question 6

ndications for Biopsy
* Any suspicious lesion persists for more than — with no apparent etiology basis.

Answer 6

2 weeks

Question 7

Principles of Tissue Biopsy in Oral and Maxillofacial Surgery
* It is important to develop a systematic approach in evaluating a patient with a
lesion/pathology in the Oral and Maxillofacial region before performing a biopsy
procedure.
* — prior to performing a biopsy is essential.

Answer 7

Careful planning

Question 8

Patient Evaluation, Examination & Other Investigations
(6)

Answer 8

• Health history
• History of the lesion
• Clinical examination
• Imaging Studies
• Laboratory investigation
• Biopsy (Histo-pathological exam)

Question 9

Health History

Answer 9

• Determine the health status of the patient to rule out any systemic disease that can
  cause a pathological condition in the head and neck region.

Question 10

History of the Lesion - Questions to Ask
(8)

Answer 10

• Duration.
• Changes in size and rate of change.
• Changes in the character of the lesion.
  – Lump to ulcer, etc
• Changes in color
• Pain
• Anesthesia
• Swelling or tenderness of adjacent lymph nodes
• Associated systemic symptoms:
  – Fever
  – Dysphagia

Question 11

Determine the Etiology of the Lesion
(2)

Answer 11

• Trauma to the area (with an ill fitting denture, traumatic cheek bite etc.,)
• Habits (Tobacco use, Smoking, Alcohol)

Question 12

Clinical Examination
* The clinical examination should include when possible:
(2)

Answer 12

– Inspection
– Palpation

Question 13

Clinical Examination
(9)

Answer 13

• The anatomic location of the lesion/mass
• The size and shape of the lesion/mass
• Single vs. multiple lesions
• The surface of the lesion
• The color of the lesion
• The sharpness of the boundaries of the lesion
• The consistency of the lesion to palpation
• Presence of pulsation
• Lymph node examination

Question 14

Radiographic Examination

Answer 14

• The radiographic appearance may provide clues that will help determine the nature of
  the lesion

Question 15

Imaging studies
(5)

Answer 15

• Apart from regular X-rays, whenever necessary it is important use more advanced
  imaging modalities:
• Cone Beam Computerized Tomography (CBCT Scan)
• Conventional C.T. Scan (Medical Grade)
• M.R.I (Magnetic Resonance Imaging)
• Ultrasound

Question 16

Imaging studies
* Apart from regular X-rays, whenever necessary it is important use more advanced imaging
modalities:
(2)

Answer 16

Conventional C.T. Scan
(Medical Grade) Cone Beam Computerized Tomography (CBCT Scan)

Question 17

Laboratory Investigation
* Oral lesions may be manifestations of systemic disease.
* If a systemic disease is suspected, the appropriate lab investigations should be pursued before
performing a biopsy procedure.
* Hyperparathyroidism

Answer 17

causes significant elevation of the serum calcium level (10.5 to 11.6 mg/dl).
- A normal serum calcium level is 8-10 mg/dL
- Hypercalcemia is defined as a serum calcium level greater than 10.5 mg/dL

Question 18

Commonly Performed Biopsy Procedures
(5)

Answer 18

Excisional biopsy
Incisional biopsy
Bone Biopsy
Punch biopsy
Fine Needle Aspiration biopsy

Question 19

Excisional Biopsy
Definition:

Answer 19

Total excision of a lesion for microscopic study is called “Excisional
biopsy”.

Question 20

“Excisional
biopsy”.
(4)

Answer 20

• Slow growing lesions that appear benign on clinical examination.
• Removal of the entire lesion
• A perimeter of normal tissue surround the lesion is also excised to ensure total removal
• Constitute definitive treatment

Question 21

Principle of Excisional Biopsy
The entire lesion, along with –mm of normal appearing surrounding tissue, is
excised.

Answer 21

2 to 3

Question 22

Incisional Biopsy
(3)

Answer 22

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 when there is a suspicion of malignancy.

Question 23

Principles of Incisional Biopsy
(5)

Answer 23

• Representative areas of lesion should be incised in wedge fashion.
• Selected in an area that shows complete tissue changes (the lesion extends into normal tissue at
  the base and/or margin of the lesion).
• Necrotic tissue should be avoided
• Taken from the edge of the lesion to include some normal tissue
• A deep, narrow biopsy rather than a broad, shallow one

Question 24

Aspiration
(3)

Answer 24

• Aspiration is the use of a needle and syringe to penetrate a lesion for aspiration of its content.
• A 18-gauge needle is connected to a 5 or 10 ml syringe
• The tip of needle may have to be repeatedly repositioned to locate a fluid center

Question 25

Indication of Aspiration
(3)

Answer 25

• Aspiration should be carried out on all lesions thought to contain fluid or any intra-
  osseous lesion before surgical exploration
• A fluctuant mass in the soft tissues should also be aspirated to determine its contents
• Any radiolucency in the bone of the jaw should be aspirated to rule out a vascular
  lesion that can cause life threatening hemorrhage.

Question 26

Intraosseous and Hard Tissue Biopsy
(2)

Answer 26

• Any intraosseous lesion like tumors, cyst, infections(osteomyelitis) diseases like
  fibro-osseous lesions require a bone biopsy procedure.
• Bone and other hard tissues that contain calcium takes extra time for processing in the
  histopathological lab.

Question 27

Punch Biopsy

Answer 27

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

Question 28

Punch Biopsy
(3)

Answer 28

• The punch comprises a circular blade attached to a plastic handle. Diameters of two to
  ten millimetres are available.
• The punch removes a core of tissue the base of which can be simply and
  atraumatically released using curved scissors.
• The resultant wound may not require suturing if using the smaller diameter punches.

Question 29

Fine Needle Aspiration Biopsy
Use:

Answer 29

to biopsy deep-seated lesions

Question 30

Fine Needle Aspiration Biopsy
* Technique:

Answer 30

Uses very thin needle and a syringe to take out a small amount of fluid and
very small pieces of tissue from tumor/mass.
* In cases where the tumor is deep seated, then you can use C.T.Scan guided or
ultrasound guided Fine Needle Aspiration.

Question 31

Fine Needle Aspiration Biopsy
* Advantages:
(2)
* Disadvantages:
(1)

Answer 31

• Does not require incision on skin.
• Biopsy results available the same day
• Needle cannot remove enough tissue for diagnosis

Question 32

Anesthesia
(3)

Answer 32

• Block local anesthesia techniques are employed when possible
• The anesthetic solution should not be injected within the tissue to be removed, because
  it can cause artificial distortion of the specimen.
• If necessary, infiltration of local anesthesia may be used locally, but the solution should
  be injected at least 1 cm away from the lesion.

Question 33

Tissue Stabilization
(2)

Answer 33

• Tongue or soft palate
  -Heavy retraction sutures
• Lip
  -Assistant’s finger pinching the lip on both sides of the biopsy area.

Question 34

Hemostasis
(3)

Answer 34

• Avoid suction device.
• Gauze wrapped over the tip of the low volume suction device.
• Simple gauze compression.

Question 35

Specimen Care
(4)

Answer 35

• For diagnosis, the excised specimen needs to be fixed to stop tissue autolysis
  prior to the sample reaching the pathology laboratory.
• The solution of choice to do this is 10% Formalin fixative (Neutral, Phosphate
  buffered)
• Specimen must be totally immersed in the solution.
• Care should be taken to be sure that the tissue has not become lodged on the
  wall of the container above the level of the formalin. (In order to prevent
  specimen from becoming dry and unfixed).

Question 36

Biopsy Procedure and Specimen (3)

Answer 36

Care for Mucocutaneous lesions
Biopsies are commonly taken to confirm the clinical diagnosis of lichen planus, lichenoid reactions
or other similar muco cutaneous conditions
To aid in the histo-pathological diagnosis of such lesions, an area of non-erosive lesional tissue
should be chosen. Adjacent normal tissue is not generally required for such lesions,
Sampling of an erosive area will often show non-specific inflammatory changes associated with
ulceration and will not aid in the diagnosis.

Question 37

Biopsy Procedure and Specimen Care for Mucocutaneous lesions
For suspected vesiculo-bullous disorders, the site of the biopsy should be adjacent to bulla where
the epithelium is still intact.
For these lesions it is desirable also for the laboratory to receive a fresh specimen of tissue in
— medium for direct immunofluorescence.

Answer 37

Michel’s transport

Question 38

Biopsy Data Sheet
(4)

Answer 38

• Label the specimen container with the patient’s name date of birth.
• A biopsy data sheet should be completed and the specimen immediately labeled.
• All pertinent history and descriptions of the lesion must be conveyed.
• Send the copy of clinical photographs and radiographs, detailed history along with the
  biopsy sheet to the pathologist whenever necessary.

Question 39

Average Time Taken To Obtain Biopsy Results
* In case of Soft tissue biopsies, the result is usually available in

Answer 39

1 week period.
* A mineralized sample, such as bone or tooth may require decalcification before it can be
processed. The time for the decalcification will vary according to the size and consistency
of the specimen as well as the methods employed by a particular lab. It can take a matter
of weeks (2 to 3 weeks) before the report for hard tissue biopsy is available.

Question 40

Final Diagnosis
* The final diagnosis should be made only after the biopsy report is available.
* A negative pathology report for cancer should not lull the dentist into a false sense of
security when the clinical characteristics of the lesion still indicate malignant potential.
* If the pathology report does not corroborate the

Answer 40

clinical impression of the lesion, the
biopsy procedure should be repeated