BIOPSY in oral pathoogy

1. DR.ASIF IQBAL
2ND YEAR P.G
BIOPSY

2. WHAT IS A BIOPSY?
 Biopsy is derived from a Greek word
(By-op-see) = Bio – meaning LIFE and
Opsy – TO LOOK(Vision)
Biopsy is the removal of tissue from a
living organism for the purpose of
microscopic examination and
diagnosis.

3.  1870, Ruge and Joham Vert in Berlin
introduced surgical biopsy as an essential
tool for diagnosis.
 1889, Emarch put forward an argument that
confirmations should be made before
surgeries for malignancies.
 Williams halsted 1st introduced this principle
in United States.
 1941, study of exfoliated cells from female
genital tract is done by Papanicolaou.
HISTORICAL PERSPECTIVE

4. BIOPSY : WHEN, WHY, WHERE?

6. CHARACTERISTICS OF LESIONS THAT RAISE THE
SUSPICION OF MALIGNANCY
 Growth rate– lesion exhibits rapid growth
 Bleeding— lesion bleeds on gentle
manipulation
 Induration– lesion and surrounding tissue is
firm to the touch
 Fixation– lesion feels attached to adjacent
structures

7. 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
 Duration— lesion has persisted for more
than 2 weeks

9. INDICATION FOR BIOPSY
 Persistent hyperkeratosis changes in surface
tissue (ex: lips or oral mucosa)
 Lesion that interfere with local function
(ex :fibroma)
 Any inflammatory lesion that does not
respond to local treatment after 10 to 14
days (that is after removing local irritant)

10. INDICATION FOR BIOPSY
 Bone lesions not specifically identified by
clinical and radiographic finding.
 Any lesion persists for more than 2 weeks
with no apparent etiology basis.
 Any lesion that has the characteristics of
malignancy .

11. WHEN IS ORAL BIOPSY NOT
NEEDED?
 There is no need to biopsy normal structures.
 There is no need to biopsy for inflammatory or infectious
lesions that respond to specific local treatments, as
pericoronitis, gingivitis or periodontal abscesses.
 No incisional biopsies should be performed on suspected
angiomatous lesions.

12.  Anticoagulant therapy
 Over-whelming sepsis
 Severe impaired lung function
 Uncontrolled bleeding.
 Uncooperative patient
 Local infection near the site
CONTRA-INDICATIONS

13. To confirm a diagnosis made on clinical
findings.
To determine the treatment plan
Valuable self teaching diagnostic aid.
As a medical record
OBJECTIVES OF BIOPSY

14. CLASSIFICATION OF BIOPSY
According to the procedures applied, oral biopsies can be
classified by:
a) Features of the lesion:
• Direct biopsy: when the lesion is located on the oral
mucosa and can be easily accessed with a scalpel from
the mucosal surface.
• Indirect biopsy: when the lesion is covered by an
apparently normal oral mucosa.

15. b) Area of surgical removal:
• Incisional biopsy: consists of the removal of a
representative sample of the lesion and normal adjacent
tissue in order to make a definitive diagnosis before
treatment.
• Excisional biopsy: is aimed at the complete surgical
removal of the lesion for diagnostic and therapeutic
purposes. This procedure is elective when the size and
location of the lesion allows for a complete removal of
the lesion and a wide margin of surrounding healthy
tissue.

16. c) By the timing of the biopsy/ Clinical timing of
sampling:
• Pre-operative
• Intra-operative
• Post-operative
d) Purpose of the biopsy.
Diagnostic Biopsy
Experimental Biopsy

17. TYPES OF BIOPSY
 Surgical biopsy- Incisional Biopsy ,Excisional
Biopsy and Punch Biopsy.
 Fine Needle Aspiration Cytology(FNAC) and CT
guided FNAC.
 Exfoliative Cytology.
 Brush Biopsy.
 Frozen Section Biopsy.
 Cone Biopsy.
 Core Needle Biopsy.
 Suction Assisted Core Needle Biopsy.
 Laser Biopsy.

18. STEPS OF BIOPSY
 1.SELECTION OF AREA OF BIOPSY
 2.PREPARATION OF SURGICAL FIELD
 3.LOCAL ANASTHESIA
 4.INCISION
 5.HANDLING OF SPECIMEN
 6.SUTURING OF THE RESULTING WOUND

19. If a lesion is large or has
different characteristics in
various locations more than one
area may need to be sampled
INCISIONAL BIOPSY

20. Incision should extend from the ulceration out onto clinically normal
tissue
Grasp area to be removed with forceps and make an elliptical incision from the
centre out onto clinically normal tissue: wound after removal of incised tissue:
suturing completed

21. INCISIONAL BIOPSY
 Indications:
 Size limitations
 Hazardous location of the lesion
 Great suspicion of malignancy
 Technique:
 Representative areas are biopsied in a wedge fashion.
 Margins should extend into normal tissue on the deep
surface.
 Necrotic tissue should be avoided.
 A narrow deep specimen is better than a broad shallow
one.

22. DISADVANTAGES:
1. Crush, splits and haemorrhage are the
artefacts most frequently found in
incisional oral biopsies.
2. Theoretical seeding of cancer cells into
the adjoining tissues.

23. Excisional Biopsy
The entire lesion with 2 to
3mm of normal appearing
tissue surrounding the
lesion is excised if
benign.

24. EXCISIONAL BIOPSY
An excisional biposy implies the complete removal
of the lesion.
 Indications:
 Should be employed with small lesions. Less than 1cm
 The lesion on clinical exam appears benign.
 When complete excision with a margin of normal tissue
is possible without mutilation.

25. EXCISIONAL BIOPSY
 Technique:
 The entire lesion with 2 to 3mm of normal
appearing tissue surrounding the lesion is
excised if benign.

26. FOR MUCOCELE LESIONS – CAREFUL EXCISIONAL BIOPSY

27. PUNCH BIOPSY

28. Advantages :
 Ease of technique
 Sutures may not be required if small diameter
punch
 May produce a more satisfactory specimen in
bound down tissues (e.g. hard palate)
Drawbacks:
 May not be adequate for biopsy of deeper
pathology
 May be difficult to biopsy freely movable tissues
(e.g. soft palate, floor of mouth)

29. CORE BIOPSY
 Fine needle biopsy has been established
as a safe procedure and is routinely
performed under local anaesthesia. Many
pathologists believe that for histologic
study, core tissue is more useful than
cytologic material

30. Core needle biopsy (CNB) has emerged as an important
sampling method in the diagnosis of musculoskeletal
tumours

31. FINE NEEDLE ASPIRATION CYTOLOGY
 It is the “Technique of aspiration of cells/
fluid/ tissue fragments using a fine needle for
examination under a microscope”

32.  ADVANTAGES
1. The technique is relatively painless,
produces speedy results.
2. It is an inexpensive technique.
3. It requires little equipment.
4. The technique can be done as an out
patient or a bed side procedure.
5. There is no problem with wound healing.
6. The technique is readily repeatable

33.  INDICATIONS
 1. Non palpable lesions, or area difficult to biopsy
but can be localized by CT, MRI, Ultrasound.
 2. To rule out vascular lesions prior to open
surgery.
 3. In cases where Biopsy is contraindicated on
medical background.
 4. Used as a diagnostic screening test at
community level for head and neck masses.
 5. Indicated for known tumors to assess effect of
treatment.
 6. Used to obtain tissue for specific studies.

34. FINE NEEDLE WITH
ASPIRATION

35. FOR MAJOR SALIVARY GLAND/LYMPH GLAND LESIONS FNAC MAY BE
USEFUL

36. BRUSH BIOPSY
 Diagnosis of oral epithelial dysplasia has
traditionally been based upon histopathological
evaluation of a full thickness biopsy specimen
from lesional tissue.
 It has recently been proposed that cytological
examination of “brush biopsy” samples is a non-
invasive method of determining the presence of
cellular atypia, and hence the likelihood of oral
epithelial dysplasia.

38.  Exfoliative Cytology
It is a quick and simple procedure, is an
important alternative to biopsy in certain
situations. In exfoliative cytology, cells
shed from body surfaces, such as the
inside of the mouth, are collected and
examined. This technique is useful only for
the examination of surface cells and often
requires additional cytological analysis to
confirm the results.

39. DANGERS OF BIOPSY
 Spreading of infection
 Haemorrhage
 Infection
 Operative trauma

40. INJECTION

41. For red & white lesions include both red &
white area

42. For Vesiculobullous lesions
Fluid is more representative. Intact vesicle or bulla
should be biopsied.

43. ULCERS
Include
margin,deep part of
ulcer and site of
maximal clinical
activity.
AVOID Superficial
ulcers & necrotic tissue

44. BIOPSY DATA SHEET
 PATIENT DATA
 HISTORY
 CLINICAL DESCRIPTION
 NATURE OF BIOPSY
 RADIOGRAPHS & PHOTOGRAPHS
 DISCRIPTION OF BIOPSY SPECIMEN

45. BIOPSY REPORT
 IT SHOULD INCLUDE DIAGNOSIS AS
WELL AS A COMPLETE MICROSCOPIC
DESCRIPTION

46. ARTIFACT = Artificial (man made) product
 Artifacts are alteration in the tissue morphology
that results from various forms of mechanical,
chemical, or thermal insult to the tissue specimens
removed for diagnostic purposes, anywhere from
fixation to processing to staining. Numerous types
of artefacts can affect the biopsy specimen.

47. CLASSIFICATION
PRE BIOPSY ARTIFACTS:
They are introduced prior to the collection of the tissue
BIOPSY ARTIFACTS
Injection of L.A. into the lesion.
Injection Artifacts
Improper handling of the tissue
Errors during manipulation of tissue
Forceps/ Squeeze Artifact
Problems in orienting excised tissue
Heat Artefact(Fulguration Artifact)
Foreign Bodies or Starch Artifact.

48. INJECTION ARTIFACT
IMPROPER REMOVAL

49. HEAT ARTEFACT

50. FORCEPS ARTIFACT
CRUSH ARTIFACT
SPLIT ARTIFACT

51. It is not easy to procure a good biopsy
specimen, nor is it very difficult, but the
procedure must be carefully planned and
carried out.

52. THANK YOU