soft tissue lesions and biopsy techniques

Question 1

• why is aspiration from lesion good?
• what is reticular cyst?

Answer 1

• Aspiration avoids contamination by oral commensals
  Protection of anaerobic species
  May also aspirate cystic lesions
  > Keratocysts-keratin
  Aspiration will determine whether a lesion is solid or
  fluid filled
  Occasionally aspiration may yield blood e.g.
  haemangioma
• stall coloured fluid

Question 2

• when do you do excisional biopsy?

Answer 2

• Usually fairly confident of provisional diagnosis
  Usually benign lesions e.g. fibrous overgrowths, denture
  hyperplasia, mucocoeles

Discrete lesions

Question 3

• when do you do incisional biopsy?

Answer 3

• Representative tissue sample

Larger lesions

Uncertain diagnosis

E.g. Leukoplakia, lichen planus, squamous cell
carcinoma

Question 4

what is a punch biopsy?

Answer 4

• Type of incisional biopsy

Hollow trephine 4, 6 or 8mm diameter

Removes core of tissue

Minimal damage

May not require suture or only minimal number of sutures

Question 5

• how do you send samples to lab?
• why not place in gauze?
• what is best thing to put sample on and why?

Answer 5

• Sample should be placed immediately into 10% formalin, don’t place on gauze swab

Suture may help the pathologist to orientate the sample

Include relevant clinical information on the pathology form to aid in diagnosis. Diagrams are helpful

Pathology form- in GDH now electronic (Trakcare)

• gauze can distort it
• filter paper to reduce sample distortion

Question 6

what is this an example of?

Answer 6

crushed specimen

Question 7

what is this an example of?

Answer 7

tear in specimen

Question 8

how would you describe this?

Answer 8

mixed red and white lesion with striated areas and has some areas of ulceration on buccal mucosa of edentulous patient. Size - extensive whole buccal mucosa

Question 9

what area should you avoid biopsying?

Answer 9

Try to avoid salivary gland duct orifices, tip of tongue, areas close to nerves and larger blood vessels

Question 10

what is this?

Answer 10

fordyce’s spots

Question 11

what is fibrous epulis?

Answer 11

• Swelling arising from the gingivae
• Hyperplastic response to irritation
  > Overhanging restoration
  > Subgingival calculus
• Smooth surface, rounded swelling
• Pink and pedunculated
• Excisional biopsy
• Coe pack dressing
• Removal of source of irritation

Question 12

what is this and describe it?

Answer 12

fibrous overgrowth

Fibroepithelial polyp
Frictional irritation or trauma
Semi pedunculated or sessile
Pink
Smooth surface
Most common buccal mucosa and inner surface of lip
Surgical excision
No need for deep excision or normal margin

Question 13

why do you use suture for excising polyp?

Answer 13

to stabilise lesion

Question 14

what is giant cell epulis?

Answer 14

Peripheral giant cell granuloma
Multi nucleated giant cells in vascular stroma
Teenagers, anterior regions of mouth
Deep red or purple, broad base
Need x-ray to ensure not centrally originating (would
appear as radiolucency)
Surgical excision with curettage of base
Coe pack dressing

Question 15

what is this and describe it?

Answer 15

heamangioma

Hamartomata
Developmental overgrowths
Exophytic
Blue in colour
Pressure will cause loss of colour
Surgical removal or more commonly cryotherapy
Only drawback of cryotherapy is no histological diagnosis

Question 16

what is lipoma?

Answer 16

Benign neoplasm of fat
Soft swelling
Pale yellow
Sessile
Excision

Question 17

what is this and describe it?

Answer 17

Pregnancy epulis

Histologically same as pyogenic granuloma
May be related to calculus often bleed easily
Hormonal changes enhance response to tissue irritation
Small lesions may not require excision and may regress after birth of baby
Larger lesions should be excised

Question 18

what is pyogenic granuloma?

Answer 18

Arises from failure of normal healing
Overgrowth of granulation tissue
May be related to extraction sockets or traumatic soft
tissue injuries
Red in colour
Surgical excision
Curettage of base

Question 19

what is this and describe it?

Answer 19

squamous cell papilloma

Most common palate, buccal mucosa or lips
Benign neoplasm
Usually pedunculated
White surface
Cauliflower appearance
Excision at base
Similar to viral warts

Question 20

what is this and describe it?

Answer 20

denture hyperplasia

Poorly fitting denture
> hyperplastic reaction
Roll of excess tissue on outer aspect of denture flange or between flange and alveolar ridge
Most common lower labial sulcus
Trim flange of denture
Remove excess tissue
If very large area Coe pack dressing to ensure sulcus
depth maintained

Question 21

what is this and describe it?

Answer 21

leaf fibroma

Chronic irritation from denture
Would be round if not covered by denture but
becomes flattened
Pedunculated
Excision

Question 22

what is this and describe it?

Answer 22

mucocoele

Mucus extravasation cyst
Most common minor salivary gland problem
Damage to minor gland duct
Saliva leaks into submucosal layer
Soft bluish swelling fluid filled
Recurrent - if bite and burst it can come back
Floor of mouth ranula

Question 23

how to diagnose a mucocoele?

Answer 23

Diagnosis usually from history
Surgical excision
Blunt dissection
Often rupture
Patients should be warned about recurrence
Remember swellings in upper lip are usually neoplastic rather than simple mucocoeles

Question 24

what is this? what must you be careful from?

Answer 24

ranula

• need to treat with care because of close relation to sub lingual gland

Question 25

what is this and describe it?

Answer 25

squamous cell carcinoma

May present as a lump, red or white patch, nonhealing ulcer
Classical description
Ulcer
Rolled margin
Induration
Lesion may bleed easily and may be ‘fixed’ to surrounding tissue

Question 26

what must you do with a squamous cell carcinoma?

Answer 26

Need a histological diagnosis
Incisional biopsy
Should be referred urgently via the rapid access pathway
By phone followed up by a faxed referral