BIOPSY

1. BIOPSY

2. DEFINITION “Biopsy is the removal of tissue from living organism for the purpose of microscopic examination and diagnosis” Oral pathology- Shafer 4th edition

3. TYPES OF BIOPSY • EXFOLATIVE CYTOLOGY • ORAL BRUSH BIOPSY • EXCISIONAL BIOPSY • INCISIONAL BIOPSY • PUNCH BIOPSY • CORE BIOPSY • BONE BIOPSY

4. ARMAMENTARIUM FOR BIOPSY INSTRUMENTS FOR SOFT TISSUE BIOPSY: • Local anesthetic equipment • Scalpel (No. 15 blade) • Scissors • Needle holder, suture etc. • Biopsy bottle; 10% formalin • Biopsy data sheet • Fine tissue forceps • Small hemostat • Gauze sponges (suction if necessary)

5. Additional instruments for hard tissue biopsy or biopsy of soft tissue within bone: • Periosteal elevator • Rongeur • Bur and rotary handpiece • Sterile saline solution • Curettes

6. INSTRUMENTS FOR ASPIRATION BIOPSY: • 5 or 10 ml syringes • 18-gauge needle for fine needle aspiration biopsy • 23-guage needle for fine needle aspiration cytology

7. INDICATIONS • Any inflammatory lesion that does not respond to local treatment after 10 to 14 days (i.e., after removing local irritant) • Persistent hyperkeratotic tissues • Lesions that interfere with local function (eg. Fibroma). • Bone lesions not specifically identified by clinical and radiographic findings. • Any lesions that has the characteristic of malignancy (eg. Erythroplakia)

8. RELATIVE CONTRAINDICATION • This should include inflammatory lesions of allergic, viral, fungal or bacteria etiology. • Normal and racial variations such as those seen physiologic pigmentation, leukedema, linea alba, tori, exostoses etc.

9. ABSOLUTE CONTRAINDICATION • Pulsatile lesions or those suggestive of a vascular nature • Intrabony radiolucent lesions • Lesions that are clinically, obviously malignant should be biopsied . • Biopsy irritative/traumatic lesions

10. OBJECTIVES The aim of the biopsy is to: • Define a lesion on the basis of its Histopathological aspect • To establish a prognosis in malignant or premalignant lesions; • Facilitate Specific treatment • Act as a document with medical-legal value

11. EXFOLATIVE CYTOLOGY • Exfoliative cytology is the histopathologic examination of cells that have been obtained by their physical removal, followed by their placement on a glass slide. • Term pap smear is used. • The first modern use of cytology for head and neck cancers was in 1949

12. Technique • The supplies needed for oral cytology are: • 2 glass slides • 1 Cytobrush (if there is more than one lesion, then 1 Cytobrush per lesion) or a wooden or a metal spatula • Any cytology fixative - commonly used is 95% Ethanol; Commercial spray fixatives are also used .

13. Technique • Tongue blade is placed under tongue • Lesion is stroked gently but firmly with its tip of wooden blade • The exfoliated cells collected is harvested • You should be able to see a white filmy debris on the glass slide • Fixative spray • Repeat the procedure for the second smear on the same lesion.

14. Cytologicdiagnosis • A cytologic diagnosis is different with a surgical biopsy • Categorize lesions as normal, atypical intermediate ,suggestive or positive • Any lesions with either a suspicious or malignant cytologic diagnosis need to be followed with a biopsy of the site. • In the case of candidiasis, indicate fungal infection

15. ORAL BRUSH BIOPSY • A simple, rapid, and highly accurate method is currently available for the assessment of oral epithelial abnormalities, • which may include precancerous and cancerous lesions • Unlike cytology instruments, which collect only exfoliated superficial cells the biopsy brush penetrates to the basement membrane, removing tissue from all three epithelial layers . • Does not require topical or local anesthetic and causes minimal or no bleeding or pain.

16. Indications • Oral and oropharyngeal mucosal abnormalities • leukoplakia erythroplakia • Mixed red and white lesions • Speckled leukoplakia • Cancer or pre cancer • identifying unsuspected oral cancers at early and curable stages.

17. Procedure • In brush biopsy technique the use of a specially designed circular brush is used. • which is used to sample the epithelial lesion in question. • The brush may be moistened with water or the patient's saliva and applied to the surface of the lesion. • Contact between the brush and the mucosal surface may be along either the flat end or the rounded surface, • Moderate pressure applied

18. Procedure • The brush is then rotated until pinpoint bleeding is noted and enters into the lamina propria and, thus, obtaining epithelial cells through the full-thickness of the epithelium • Removed cells are transferred to a glass slide. • A fixation step follows immediately by flooding the slide with fixative solution (alcohol/propylene glycol) and allowing it to air dry.

19. Interpretation • classified as • negative -(ie, no epithelial abnormality) • Atypical -(i.e., abnormal epithelial cells, but of uncertain diagnostic significance), • Positive -(i.e., unequivocal).).

20. FINE NEEDLE ASPIRATION CYTOLOGY • “An aspiration cytology is the removal of contents of amass for the purpose of analysis” • This technique is usually used to rule out and or differentiate fluid filled lesions.

21. Removal a very small core of cells from a deep seated-lesions • Used for deep lesions which are not accessible indications • Suspected tumor of parotid gland • Enlarged lymhnodes in sub mandibular ,and submental region.

22. Advantages • Case performance • Cost • Effectiveness • Convenience • Accuracy

23. Indications • Cysts ,Abscess, Vascular lesions, Hematomas, Sialoceles, or Empty cavities (Traumatic bone cyst). • The aspiration cytology is applicable to both intraosseous as well as soft tissue masses. • All radiolucencies in the jaws

24. Procedure • Under local anesthesia, • 23-guage needle attached to a 10-cc disposable syringe • Negative pressure • The aspirate is expressed onto the glass slide. • A second slide is placed on the first and used to spread the aspirant. • One in 95% ethanol fixative other is air dried • Alcohol fixed- Papanicolaou’s stain • Air dried-wrights stain ( quick evaluation)

25. EXCISIONAL BIOPSY • “Excisional biopsy is removal of a lesion in total, plus a layer of surrounding normal tissue” • It is the combination of a diagnostic and definitive therapy

26. Indications • For lesions less than 2-2.5cms in diameter • clinically benign • That are small, well defined bony lesions Contraindication • Vascular & pigmented

27. ADVANTAGES • Entire lesion is available • Biopsy may be treatment for many cases

28. INCISIONAL BIOPSY • “Incisional Biopsy is the removal of a small portion of the lesion for microscopic examination”

29. Indications 1)Large Intrabony or soft tissue lesions 2)Diffuse lesions 3)Suspected malignancies • Hyperkeratotic lesions

30. Contraindications • Pigmented and vascular lesions • Ulcerations

31. PUNCH BIOPSY • This is a form of biopsy that in is best suited for the diagnosis of mucosal abnormalities that may require multiple biopsies • Biopsy punches • Size from 1.0 to 12.0 mm, increasing in increments of 0.5mm.

32. Procedure • The biopsy is done by placing the punch at the intended biopsy site • Rotating the punch back and forth • Until the level of the head of the punch is no longer visible • The punch is removed • Curved iris scissors. • Multiple plugs of tissues can be taken.

33. CORE BIOPSY • Core needle biopsy was introduced to over come the limitations of FNA • The core needles are larger caliber than fine needles • Mounted onto a spring-loaded device that allows small cylinders of tissue to be cut and collected within the notch of the needle ,14-gauge needles

34. BONE BIOPSY • A bone biopsy or bone marrow biopsy is a test in which a piece of bone or marrow taken for biopsy • A special drill needle is usually used. • A local anesthetic is given • A small (about 1/8 inch) incision is made in the skin • Biopsy needle is pushed and twisted into the bone. Bone marrow is removed for examination

35. Indications • Anemia • Hemochromatosis • Thrombocytopenia • Polycythemia Vera • Infectious diseases • Osteoid osteoma • Osteoblastoma • Bone cyst

36. HEALING • Healing of Biopsy wound is identical to healing of similar wound • By primary or secondary healing • Primary healing -healing which occurs after excision of a piece of tissue with close apposition of the edges. • This wound heals rapidly.

37. HEALING • Secondary healing- Healing by granulation or healing of an open wound occurs • When there is loss of tissue and edges of wound cannot be approximated • It is similar to healing by primary intention • Except that the fibroblasts and capillaries have a greater distance to migrate • More granulation tissue must form and healing is slower.

38. TOLUIDINE BLUE • Toluidine blue is a cationic metachromatic dye that binds sulphates, phosphates and carboxylates • This dye is used as an adjunct diagnostic test for the early detection of epithelial dysplasia and SCC of the oral cavity

39. Early detection of malignant changes in premalignant lesions. • As a method of follow-up.

40. Composition 100 c.c of the 1% TB solution:- 1gm of TB powder, • 10 ml of 1% acetic acid • 4.19 ml of absolute alcohol • 86ml of distilled water to make up 100 ml of a 1% solution of TB.

41. Procedure • Rinse his mouth twice with water for 20 seconds • 1% acetic acid is given for 20 seconds to remove any ropey saliva. • 1% TB solution is then applied for 20 seconds either with cotton swab or given as a rinse • A second rinse with 1% acetic acid will be given to reduce the extent of mechanically retained stain • Finally the mouth is rinsed with water

42. FIXATIVES • They undergo a process of self-destruction or autolysis • Which is initiated soon after cell death by the action of intracellular enzymes • Causing the breakdown of protein and eventually liquefaction of the cell. • Autolysis is independent of any bacterial action • Retarded by cold • Greatly accelerated at temperatures of about 30°C .

43. Autolysis is more severe in tissues which are rich in enzymes ,less in elastic fiber and collagen • `washed-out' appearance with swelling of cytoplasm • Objectives is to preserve cells and tissue constituents- life-like state, without change • Fixation arrests autolysis and bacterial decomposition

44. Formaldehyde solutions10% neutral buffer formalin (4% formaldehyde)REAGENTS REQUIRED1] 40% formaldehyde 100 ml2] Distilled water 900 ml3] Sodium dihydrogen orthophosphate 4 g4] Disodium hydrogen orthophosphate (anhydrous) 6.5 g

45. Interpretation • A dark blue (royal or navy)- positive • Light blue staining is considered doubtful. • If there is no colour absorbed-negative Positive

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