Soft Tissue Lesions and Biopsy Flashcards
What is a biopsy?
Sample for histopathological analysis
- Helps confirm or establish diagnosis (not necessarily of malignancy)
- Determines prognosis and treatment required
When would you consider referral for biopsy?
If lesion prone to bleeding
If suspected cancer
Lumps in upper lip (always presumed cancer until proven different- common site for minor gland lesions)
When may a patient choose to not biopsy a growth?
If it is a traumatic polyp
Why do we biopsy lesions?
- To remove it- ending disease process
- To identify lesion
Why are aspirates from abscesses preferred over swab?
- Avoids contamination
- Protection of anaerobic species
- If keratocyst- white cheesy material
- Radicular/dentigerous cyst- straw coloured fluid
- Determines whether solid or fluid filled
- If blood- may be haemangioma
What other aspirates may be taken?
Blood sample
* Venous blood
* eg. FBC, U&E, haematinics, glucose etc
What is a fine needle aspirate and its uses?
Aspirate cells from solid lesions, sent to cytology
- Neck swellings
- Breast lesions
- Salivary gland
What is done in an excision biopsy?
- Remove all of clinically abnormal tissue
- You must be fairly confident of provisional diagnosis
What are the indications for excisional biopsy?
Usually benign lesions-fibrous overgrowths, denture hyperplasia, mucoceles (well-known clinical appearance)
Must be discrete lesion
What is an incisional biopsy?
Don’t remove lesion but take representiitve sample of it
What are the instances may an incisional biopsy be opted for?
Larger lesions that may be spread
Uncertain diagnosis- leukoplakia, LP, SCC (sometimes a discrete lesion- but leave some evidence to help guide surgeons)
What are the features of a punch biopsy?
Type of incisional biopsy
- Uses Hollow trephine- 4, 6, 8mm diameter
- Removes core of tissue- would be difficult to remove with scalpel
- Minimal damage
- May not require suture or minimal suturing
How is an area for incisional biopsy selected?
- Must be large enough
- Must be representative (may need to take more than one)
- If an ulcer- take peri-lesional biopsy (tissue next to ulcer)
How is a sample sent to pathology lab?
- Put into 10% formalin (be careful with handling as it is carcinogenic)
- Don’t place on damp swab- distorts
- Suture to help pathologist orientate (if that is important)
- Include relevant clinical info (description, include diagrams or pictures)
What can a specimen be put onto if gauze is not allowed?
Filter paper
What damage can occur to specimens if handled incorrectly?
Crushing can occur when taking biopsy
-> Distorts flat samples
Tear- surface of epithelium is ripped off from underlying tissue (can look like different disease)
What information is provided on pathology form?
- All information possible about patient- name, DoB, gender, address, who to contact-number, where the report is to go to, hospital number, department (ensure this is filled out properly)
- Tick histopathology
- When you collected- time and date
- What sample is (nature)- basic description
- Clinical details- MH, provisional diagnosis
- Risk of infection- specify
How does cytopathology specimen differ from histopathology? (rare in dentistry)
- Goes on slide
- Is fresh sample not fixed
What information may we want to include when describing a lesion?
- Location
- Colour- white, red, mixed etc
- Pattern/texture- striated, ulceration
- Size
What should be done when putting specimen in the pathology pot?
- label as fully as possible
- correct usage should ensure no leaks
- do not confuse with the tooth collection pots
-> Package and send to pathology at QE, by courier (may not be possible in GDP)
What should we avoid when choosing area to sample with biopsy?
Try to avoid:
salivary gland duct orifices
tip of tongue
areas close to nerves
larger blood vessels
** Not required to take normal tissue margin
What are fordyce spots?
Fordyce spots- ectopic sebaceous glands
-> Does not require biopsy
What is a fibrous epulis?
Swelling arising from the gingivae caused by hyperplastic response to irritation
-> Overhanging restorations
-> Subgingival calculus
How does a fibrous epulis appear clincially?
Smooth surface
Rounded swelling
Pink
Pedunculated
How is a fibrous epulis treated?
- Excisional biopsy
- Coe pack dressing
- Removal of source of irritation (prevent recurrence)
What causes fibrous overgrowth or polyp?
Frictional irritation
Trauma
How does a fibrous overgrowth appear clinically?
Can be semi-pendunculated or sessile
Pink
Smooth surface
Commonly seen on inner surface of lower lip or buccal mucosa
How is fibrous polyp treated?
Surgical excision- no need for deep excision or normal margin
- Stabilise lesion with suture
- Cut around with scalpel
What is a giant cell epulis?
Peripheral giant cell granuloma
-> Multi nucleated giant cells in vascular stroma
How do giant cell epulides present?
In Teenagers
Anterior regions of mouth
Deep red or purple lesion with broad base
Why do we need a radiograph when we see a giant cell epulis?
To check it is not a central epulis arising from bone
How is a giant cell epulis treated?
Surgical excision with curettage of base (may bleed)
-> Coe pack dressing
What is a haemangioma?
Developmental overgrowth of BVs
-> form of hamartoma
How does a haemangioma present clincially?
Bunch of grape apeearance
Exophytic
Blue in colour
Pressing on it causes blanching
How is a haemangioma treated?
Cryotherapy/freezing- 3 cycles for a minute each (leave to thaw- this causes damage)
-> no confirmed diagnosis required as appearance is classic
Surgical removal
What is a lipoma?
Benign neoplasm of fat
How does a lipoma appear?
Soft swelling
Pale yellow
Sessile
How is a lipoma treated?
Excision
What lesion is a pregnancy epulis histologically identical to?
Pyogenic granuloma
What causes a pregnancy epulis?
Hormonal changes enhance response to irritation
-> calculus
How are pregnancy epulides treated?
Small lesions- may not require removal, and can regress after baby is born
Larger lesions- excise
*** source of irritation must be removed
What is a pyogenic granuloma?
Arises from failure of normal healing- Overgrowth of granulation tissue
-> May be related to extraction sockets or traumatic soft tissue injuries
How is a pyogenic granuloma treated?
Surgical excision
Curettage of base
What is a squamous cell papilloma?
Being neoplasms that commonly occurs on palate, buccal mucosa, lips, uvula
How does a squamous cell papilloma appear?
Pendunculated
White surface
Cauliflower appearance
Similar to viral warts
How is squamous cell papilloma treated?
Excision at base
Test for HPV
What is denture hyperplasia?
Hyperplastic reaction to poorly fitting dentures
How does denture hyperplasia present?
Roll of excess tissue on outer aspect of denture flange or between flange and alveolar ridge
-> most common in lower labial sulcus
How is denture hyperplasia treated?
Trim flange of denture (make new denture)
Remove excess tissue
-> If very large area Coe pack dressing to ensure sulcus depth maintained
What is a leaf fibroma
- Polyp caused by chronic irritation by denture
- Squashed by denture so looks flat like a leaf (pedunculated)
How is leaf fibroma treated?
Excision
What is a mucocele?
Mucous extravasation cyst
- Damage to minor salivary gland duct causes leaking into submucosal layer
- Disappear on trauma then recur
How do mucoceles present?
Soft bluish swelling fluid filled
-> recurrent
What happens if the mucocele as ruptured when you plan to remove it?
You must wait until it returns
Why do we remove any other minor glands we see on dissection of a mucocele?
- Removing mucocele often damages another salivary gland
What is a ranula?
Big blue swelling in floor of mouth
- Dissecting is problematic due to salivary gland ducts and lingual nerve
- Associated with sublingual gland
- Can plunge off the back of mylohyoid
How is a mucocele excised?
- LA
- Incise around- elliptical opening (vertical not horizontal- reduces risk of nerve damage)
- Blunt dissection to remove it
- Ensure tissue bed is clear
- Suture
How does squamous cell carcinoma present?
- Non-healing ulcer with raised rolled margins which is indurated
- Bleed easily
- Red and white patches
- Fixed to surrounding tissue- Difficulty moving tissue around it
- Painful
How is SSC managed?
Need histological diagnosis before treatment plan
Refer via rapid access pathway- via scigateway on urgent suspicion of cancer pathway (consider following up with a phone call)
Patients need to be seen within 2 weeks
Treatment must be started in 62 days
