DR.ASIF IQBAL

2ND YEAR P.G

BIOPSY

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.

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

BIOPSY : WHEN, WHY, WHERE?

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

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

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)

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 .

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.

Anticoagulant therapy

Over-whelming sepsis

Severe impaired lung function

Uncontrolled bleeding.

Uncooperative patient

Local infection near the site

CONTRA-INDICATIONS

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

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.

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.

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

TYPES OF BIOPSY

Surgical biopsy- Incisional Biopsy ,ExcisionalBiopsy 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.

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

If a lesion is large or has

different characteristics in

various locations more than one

area may need to be sampled

INCISIONAL BIOPSY

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

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.

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.

Excisional Biopsy

The entire lesion with 2 to

3mm of normal appearing

tissue surrounding the

lesion is excised if

benign.

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.

EXCISIONAL BIOPSY

Technique:

The entire lesion with 2 to 3mm of normal

appearing tissue surrounding the lesion is

excised if benign.

FOR MUCOCELE LESIONS – CAREFUL EXCISIONAL BIOPSY

PUNCH BIOPSY

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)

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

Core needle biopsy (CNB) has emerged as an important

sampling method in the diagnosis of musculoskeletal

tumours

FINE NEEDLE ASPIRATION CYTOLOGY

It is the “Technique of aspiration of cells/

fluid/ tissue fragments using a fine needle for

examination under a microscope”

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

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.

FINE NEEDLE WITH

ASPIRATION

FOR MAJOR SALIVARY GLAND/LYMPH GLAND LESIONS FNAC MAY BE

USEFUL

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.

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.

DANGERS OF BIOPSY

Spreading of infection

Haemorrhage

Infection

Operative trauma

INJECTION

For red & white lesions include both red &

white area

For Vesiculobullous lesions

Fluid is more representative. Intact vesicle or bulla

should be biopsied.

ULCERS

Include

margin,deep part of

ulcer and site of

maximal clinical

activity.

AVOID Superficial

ulcers & necrotic tissue

BIOPSY DATA SHEET

PATIENT DATA

HISTORY

CLINICAL DESCRIPTION

NATURE OF BIOPSY

RADIOGRAPHS & PHOTOGRAPHS

DISCRIPTION OF BIOPSY SPECIMEN

BIOPSY REPORT

IT SHOULD INCLUDE DIAGNOSIS AS

WELL AS A COMPLETE MICROSCOPIC

DESCRIPTION

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.

CLASSIFICATION

PRE BIOPSY ARTIFACTS:

They are introduced prior to the collection of the tissue

BIOPSY ARTIFACTSInjection 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.

INJECTION ARTIFACT

IMPROPER REMOVAL

HEAT ARTEFACT

FORCEPS ARTIFACT

CRUSH ARTIFACT

SPLIT ARTIFACT

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.

THANK YOU