principles of biopsy Flashcards
Biopsy Definition
Biopsy is an examination of tissue removed from a living person to discover the presence, cause, or extent of a disease.
biopsy of vascular lesions
NEVER, use diascopy or aspiration to determine this
Indications for Biopsy:
* Any persistent?
* Persistent?
* Lesion that interfere with?
* Bone lesions identified by?
* Any lesion that has the characteristics
* of?
- 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.
Characteristics of lesions that raise the suspicion of malignancy
- Erythroplakia - lesion is totally red or has speckled red appearance
- Ulceration - lesion is ulcerated or presents as an ulcer and the lesion has persisted more than 2 weeks.
Characteristics of lesions that raise the suspicion of malignancy
* Growth rate?
* Bleeding ?
* Induration?
* Fixation?
- 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 structures
Indications for Biopsy
* Any suspicious lesion persists for more than?
- Any suspicious lesion persists for more than 2 weeks with no apparent etiology basis
systemic approach and planing with biopsies
- 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. - Careful planning prior to performing a biopsy is essential.
pt health hx and biopsies
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.
Browns Tumor of Hyperparathyoidism
Hairy Leukoplakia –HIV Patient
History of the Lesion - Questions to Ask
- Duration.
- Changes in size and rate of change.
- Changes in the character of the lesion.– Lump to ulcer, etc
- Changes in color
- Pain- infection
- Anesthesia- tumor encroachment on nerves
- Swelling or tenderness of adjacent lymph nodes
- Associated systemic symptoms:
– Fever
– Dysphagia
common etiologies of lesions
- Trauma to the area (with an ill fitting denture, traumatic cheek bite etc.,)
- Habits (Tobacco use, Smoking, Alcohol)
The clinical examination should include when possible:
– Inspection
– Palpation
Clinical Examination desciptors
* The anatomic location?
* The size and shape?
* Single vs. multiple?
* The surface?
* The color?
* The sharpness of?
* The consistency of the lesion to?
* Presence of?
* Lymph nodes?
Always document these and take pictures
* 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- vascular
* Presence of pulsation
* Lymph node examination
Radiographic Examination
- The radiographic appearance may provide clues that will help determine the nature of the lesion.
lesions with well defiend radiogrpahic borders
radiolucent
A radiolucency with defined
borders is often a cyst
ragged or indistinct radiolucencies
A ragged (indistinct) radiolucency will often be a more aggressive lesion.
advanced imaging options
- CBCT Scan
- Conventional C.T. Scan (Medical Grade)
- M.R.I
- Ultrasound
deep seated lesion biopsies
often done in hosptial with pathologists using CT or MRI
what imaging is good for soft tissues
MRI
Laboratory Investigation
* Oral lesions may be manifestations of?
* If a systemic disease is suspected, what should be pursued before
performing a biopsy procedure?
- 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.
hyperPTH
Hyperparathyroidism 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
CAn cause browns tumor
Commonly Performed Biopsy Procedures
Excisional biopsy
Incisional biopsy
Bone Biopsy
Punch biopsy
Fine Needle Aspiration biopsy
Excisional Biopsy
Definition:
Total excision of a lesion for microscopic study is called “Excisional
biopsy”.
excisional biopsy uses:
* growth of lesion/app?
* Removal of?
* what is also excised to ensure total removal?
* Constitute?
common lesions ?
- 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
often used with firbomas/papillomas
send to lab for definitive diagnosis and keep copy for pt
Principle of Excisional Biopsy
The entire lesion, along with 2 to 3 mm of normal appearing surrounding tissue, is excised.
Incisional Biopsy
- 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
Principles of Incisional Biopsy
* Representative areas of lesion should be incised in?
* Selected in an area that shows?
* Necrotic tissue?
* Taken from?
* deep or broad?
- 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
Aspiration
* done when?
* Aspiration is the use of? in order to?
* needle gauge/syringe?
* The tip of needle may have to be?
- done when hard to access lesion surgically
- 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
Indication of Aspiration
* Aspiration should be carried out on all lesions thought to contain?
* soft tisses?
* Any radiolucency in the bone of the jaw should be aspirated to rule out a?
- 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.
Intraosseous and Hard Tissue Biopsy
* Any intraosseous lesion like tumors, cyst, infections(osteomyelitis) diseases like fibro-osseous lesions require?
* time for processing in the histopathological lab?
- 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.
Punch Biopsy
- A surgical instrument is used to punch out a representative portion of tissue.
Punch Biopsy
* The punch comprises a? Diameters available?
* The punch removes?
* The resultant wound may not require?
- 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
Fine Needle Aspiration Biopsy Use:
to biopsy deep-seated lesions
Fine Needle Aspiration Biopsy
* Technique:
* In cases where the tumor is deep seated, then you can use?
- Technique: 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.
decreasaes risk to other structures
Fine Needle Aspiration Biopsy
* Advantages:
- Does not require?
- Biopsy results available?
* Disadvantages:
- Needle cannot?
- Advantages:
- Does not require incision on skin.
- Biopsy results available the same day
- Disadvantages:
- Needle cannot remove enough tissue for diagnosis
Anesthesia for biopsies
* Block or local?
* The anesthetic solution should not be injected within?
* If necessary, infiltration of local anesthesia may be used locally, but the solution should be injected where?
- 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.
Tissue Stabilization
* Tongue or soft palate
* Lip
- Tongue or soft palate
-Heavy retraction sutures - Lip
-Assistant’s finger pinching the lip on both sides of the biopsy area.
Hemostasis for biopsies
* Avoid?
* tool?
* Simple gauze?.
- Avoid suction device.
- Gauze wrapped over the tip of the low volume suction device.
- Simple gauze compression.
prevention of sample autolysis
- 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)
Biopsy Procedure and Specimen 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.
Biopsy Procedure and Specimen Care for Mucocutaneous lesions:
For suspected vesiculo-bullous disorders
- 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 Michel’s transport medium for direct immunofluorescence
Direct immunofluorescence stain: pemphigus
Direct immunofluorescence stain
Immunoglobulin G deposited in the
intercellular regions of the keratinocytes
of the epithelium - Intra-oral Pemphigus
Biopsy Data Sheet
* Label the specimen container with?
* A biopsy data ? labeling?
* All pertinent history and descriptions of the lesion must be?
* Send what along with the biopsy sheet to the pathologist whenever necessary?
- 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
average Time Taken To Obtain Biopsy Results
- In case of Soft tissue biopsies, the result is usually available in 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
Final Diagnosis
* The final diagnosis should be made only after?
* A negative pathology report for cancer should not? when the clinical characteristics of the lesion still indicate?
* If the pathology report does not corroborate the clinical impression of the lesion?
- 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 clinical impression of the lesion, the
biopsy procedure should be repeated
