BIOPSY (2)

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BIOPSY 

P.PARAMESWARII ND M.D.SDEPARTMENT OF ORAL

PATHOLOGY 

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OVER VIEW OFCONTENTS

TION

TION

NAL BIOPSY

L BIOPSY 

PSY 

L BIOPSY 

CTION

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Biopsy [BIO =LIFEOPSIS=VISION]

Biopsy is the removal of thetissue from the living organismfor the purpose of mirosopie!amination an" "iagnosisAccord!" #o #$% r%&or# o' (! %)&%r#co**#% o' WHO +,-/0A 1o&23 2#$% %)(*!(#o! o' #224% r%*o5%d'ro* ( 6%2o! (!d 13 %)#%!#o! #$%#%r* 2 (62o 42%d #o co!5%3 #$%

r%*o5(6 o' #$% #224%.

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 I!#rod4c#o! 7

Biopsy is "erive" from a #ree$ %or" & By&op&see

Bio ' (IFE an" Opsy ' VISION or TO (OO) 

*+,- & Frenh "ermatologist Ernest Besnier intro"ue" the %or"

81o&239

Ruge an" /oham Vert intro"ue" surgial 0iopsy as an essentialtool for "iagnosis1

*++- & Emarh put for%ar" an argument that on2rmations shoul"0e ma"e 0efore surgeries for malignanies1

*-3*& Stu"y of e!foliate" ells from female genital trat 0y4apaniolaous 5 this %as a"apte" to stu"y ells from other 0o"ysystems

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*& N%cro&23 6 7utopsy81

9& Bo&23 1

M e t h o d s o f s t u d y i n g

m o r p h o l o g i c c h a n g e s

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•  The stu"y of organs an" tissues remove" fromthe d%(d 1od3 for veri2ation of the linial"iagnosis an" treatment of the "isease 1

• Inlu"es: gross 5 mirosopi e!amination1

N e c r o p s y

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• 4athologial stu"y of surgially remove" tissuesor organs d4r!" 6'% for "iagnosis 5 therapy1

• Inlu"es: gross 5 mirosopi e!amination1

B i o p s y

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C6(22:c(#o! 7

D%&%!d!" o! #$% c$(r(c#%r2#c2 o' #$% #(r"%# 6%2o!7

•

;iret '  (oate" super2ially< %ith easy aess

• In"iret '

  When the lesion lies in "epth an" is overe" 0y normally

appearing muosa or tissue

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D%&%!d!" o! #$% *(#%r(6 42%d7

• Conventional salpel

• 7 punh

•  Eletrosurgial

• (aser

D%&%!d!" o! #$% c6!c(6 #*!" o' #$% 1o&23

• Intraoperative & Sample" material is proesse" %ithout

2!ation< fro=en %ith "ry ie• E!traoperative & Re>uires 2!ation 5 longer proessing

time of tissue1

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D%&%!d!" o! #$% #%c$!;4% %*&6o3%d 7

• Inisional '

Removal of a representative portion of thetarget lesion an" of a part of healthy tissue

• E!isional '

 Total removal of the lesion< %ith slightperipheral an" in&"epth safety margins

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 To on2rm a presumptive "iagnosis ma"e onlinial an" R?# 2n"ings1 To "etermine the treatment plan

Valua0le self teahing "iagnosti ai"1 To remove the aneropho0ia7s a me"iolegal reor"

OB

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SURGICAL

NON0SURGICAL

SOFT TISSUE

BONE

;I7#NOSTIC

C@R7TIVE

•PUNCH•ELECTROCAU•SOFT TISSUE

CURETTAGE•

FROZEN SEC•EXCISIONAL

B     I     

 O     P      S     

 Y     

;I7#NOSTIC

C@R7TIVE

•CURETTAGE

•TREPHINE•ASPIRATION

•FROZEN

•ENUCLEATION

•RESECTION

•CURETTAGE

7S4IR7TION CYTOLOGY 

•SCALPEL•CAUTERY 

•EXFOLIATIVE

•FNAC

•INCISIONAL

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biopsy

surgical Non surgical

Soft tissue Bone

Diagnostic

curative

IncitionalPunchElecto

curretage

Excessional

Diagnostic

curative

CurretageTrephenationaspiration

enucliation

aspiration cytology

Exfolative cytolo

fnac

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INDICATIONS FOR BIOPSY 

• 7ny progressive ulerate" lesion %hih has 0eenpresent for three %ee$s or one %hih fails to respon"toA therapy in three %ee$s shoul" 0e 0iopsie"1

• 7ny mass %hih has 0een present for three %ee$s or

more shoul" 0e 0iopsie"1• White pathes in muous mem0rane espeially

those having a %harty appearane1

• 7reas %hih are intra&osseous an" pro"ue

rarifation an" e!pansion of the ortial plates1• Complete e!ision of small lesions as a metho" of

"iagnosis may also serve as treatment in someinstanes1

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USES OF BIOPSY 

• ;iagnosti&verifying or esta0lishing a "iagnosis ofa linially suspiious lesion1

• 4lanning proper treatment&loal orAra"ial<surgery or irra"iation1

• Che$ing progress of treatment&as toeetiveness1

• Che$ing e!tension of "isease&%hether invasive1

• Evaluation en" result&%hether free of reurrene1

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C7R7CTERISTICS OF (ESIONS T7T

R7ISE TE S@S4ICION OF D7(I#N7NC 

• ERTRO4(7SI7 : (esion is totally re" or has a

spe$le" re" an" %hite

appearane 1• @(CER7TIONS : (esion is ulerate" or

present as an uler 1

•

;@R7TION : (esion has persiste" morethan 9 %ee$s 1

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• #ROWT R7TE : (esion e!hi0its rapi" gro%th 1

• B(EE;IN# : (esion 0lee"s on gentle

manipulation 1

• IN;@R7TION : (esion an" surroun"ing

tissue is 2rm to the touh 1

• FI7TION : (esion feels attahe" to

a"Gaent strutures1

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  7RD7DENT7RI@D FOR BIO4S

INSTRUMENTS FOR SOFT TISSUE

BIOPSY7

(oal anestheti e>uipment

Salpel 6no *H 0la"e8

Sissor %ith pointe" tips

Fine tissue foreps

Small hemostat

#au=e sponges 6sution if neessary8

Nee"le hol"er

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INSTRUMENTS FOR HARD TISSUEBIOPSY 

• 4eriosteal elevator

• Rongeur

• Bur an" rotary han"piee

• Sterile saline irrigation

• Curettes

INSTRUMENTS FOR ASPIRATIONBIOPSY 

•

H or * ml syringe < *+ gauge nee"le

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C6!c(6 d("!o22 T3&% o' 1o&23 S4#(16% 'or"%!%r(6 d%!#(6

&r(c#c%

Chroni uler ors>uamous ellarinoma

Inisional 0iopsy ofmargin of uler

No< urgent referral tohospital

(eu$opla$ia?erythropla$

ia

Inisional or punh

0iopsy of %orst area1Consi"er multiple0iopsies if e!tensivelesion

No< referral to

hospital

Duosal lihen planus Inisional 0iopsy of arepresentative area

Only verye!periene"

pratitioners

Bullous lesions64emphigus<4emphigoi"8

Inisional or punh0iopsy of unaete"muosa lose to 0ullaor erosion 5 fresh

tissue speimen

No< referral tohospital

#ranulomatous ;eep inisional 0iopsy No< referral to

G4d%6!%2 'or (&&ro&r(#% 1o&23

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C6!c(6 d("!o22 T3&% o' 1o&23 S4#(16% 'or"%!%r(6 d%!#(6&r(c#c%

Duooele Careful e!ision 0iopsy es< %ith are

Fi0roepithelial polyp<pyogenigranuloma< epulis

E!ision 0iopsy es

Dinor Salivary glan"

tumor

4alate& ;eep inisional

0iopsy@pper lip& E!isional0iopsy

No< urgent referral

to hospital

DaGor salivary glan"tumor

FN7C No< urgent referralto hospital

 G4d%6!%2 'or (&&ro&r(#% 1o&23 + co!#../

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 The four maGor types of 0iopsy routinely use" in an" aroun" theoral avity are :

• Cytology

• 7spiration 0iopsy

• Inisional 0iopsy

• E!isional 0iopsy

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Or(6 c3#o6o"3 7

•  I!#rod4c#o! 7

• *+K Beale & Cytologial "iagnosis of Caner of the pharyn! 0y meansof an oral smear

• Dorrison an" o&%or$ers & 2rst to a"voate strongly the appliation ofytology for the "iagnosis of nasopharyngeal an" oral lesions1

• *-H* Dontgomery an" Von aam stu"ie" the ytology in patients %ith

arinoma of the oral muosa

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Or(6 c3#o6o"3+co!#../7

• Oral ytology is typially use" as an a"Gunt to< not a su0stitute forInisional or E!isional 0iopsy proe"ures

• Cytology allo%s e!amination of in"ivi"ual ells< 0ut annot provi"e thehistologi features ruial for an aurate an" "e2nitive "iagnosis

• It is a "iagnosti sreening proe"ure to monitor large tissue areas for"ysplasti hanges1

L%2o!2 'or c3#o6o"c %)(*!(#o! *(3 !c64d%

• 4ost&ra"iation hanges

• erpes

• Fungal infetions an"

• 4emphigus1

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  T%c$!;4% 7

• In a ytologi e!amination< the lesion is srape" repeate"ly an" 2rmly%ith a moistene" tongue "epressor or ytology 0rush1

•  The ells are then transferre" to an" smeare" evenly on a glass sli"e1

•  The sli"e is imme"iately immerse" in a 2!ing solution or spraye" %ith a2!ative

•  The ells an then 0e staine" an" e!amine" un"er the mirosope1

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Ad5(!#("%2

• Cytology may 0e helpful %hen large areas of muosalhange are note"< or in areas %ith "iLult surgial aess

D2(d5(!#("%2

• Not very relia0le %ith many false positives1

• E!pertise in oral ytology is not %i"ely availa0le

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 R%246#2

Class I Normal

Class II 7typial4resene of minor atypia< No Dalignany

Class III Interme"iateWi"e atypia< preanerous?arinoma in situ< 0iopsysuggeste"

Class IV Fe% ells %ith malignant hange ? many ells %ith

0or"erline hangesBiopsy man"atory

Class V O0viously malignantBiopsy man"atory

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 F!% !%%d6% (2&r(#o! 1o&23 7

• 7spiration 0iopsy is the use of a nee"le an" syringe to remove asample of ells or ontents of a lesion1

•  The ina0ility to %ith"ra% Mui" or air in"iates that the lesion ispro0a0ly soli"

I!dc(#o!27

 To "etermine the presene of Mui" %ithin a lesion

 To a ertain the type of Mui" %ithin a lesion

When e!ploration of an intraosseous lesion is in"iate"

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T%c$!;4% 7

• 7n *+&gauge nee"le is onnete" to a H or * ml syringe an" isinserte" into the enter of the mass via a small hole in the lesion1

•  The tip of the nee"le may nee" to 0e positione" in multiple"iretions to loate a potential Mui" enter1

• Release the sution an" %ith"ra% nee"le one ellular aspirate isseen

•  The material %ith"ra%n "uring aspiration 0iopsy an 0e su0mitte"

for pathologi e!amination an"?or ulturing1

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•  The ina0ility to %ith"ra% Mui" or air & lesion is pro0a0ly soli"1

• 7 ra"ioluent lesion in the Ga%<

  Stra%&olore" Mui" on aspiration & a ysti lesion1

• If purulent e!u"ate 6pus8 & InMammatory or infetious proess

•  The aspiration of 0loo" & vasular malformation1

• 7ny intra0ony ra"ioluent lesion<

& aspirate" 0efore surgial intervention to rule out a vasular

lesion1

• If the lesion & vasular in nature< the Mo% rate "etermine" 0eauseunontrolla0le hemorrhage an our if inise"

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  R%246#2

InsuLient Sample ta$en %as not a"e>uate to e!lu"e or on2rm a"iagnosis

Benign There are no anerous ells present(ump or gro%th is un"er ontrol 5 has no sprea" to otherareas of the 0o"y

7typial Suspiious of malignany : Results unlear

Surgial 0iopsy may 0e re>uire" to a"e>uately sample theells

Dalignant Cells are anerous< unontrolle"ave the potential to have sprea" to other areas of the 0o"y

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Ad5(!#("%2 7

• ui$ an" eetive test for "etermining the status of suspettissue

• Involves little possi0ility of sarring< infetion or pain1

•  Signi2antly shorter reovery time

•  @seful in the "iagnosis an" treatment of ysts1

 D2(d5(!#("%2 7

• 4ossi0ility of aner ells 0eing traile" into unaete" tissue asthe nee"le is remove" 1

• Ris$ that any a0normal ells may 0e misse" an" not "etete"as sample ta$en is small

•  Re>uires some e!pertise to perform an" interpret

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FOR D7/OR S7(IV7R #(7N;?(D4 #(7N; (ESIONS

FNAC D7 BE @SEF@(

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Brush 0iopsy

• Firm pressure %ith airular 0rush isapplie"< rotate" 2ve

to ten times< ausinglight a0rasion1

 The ellular material

pi$e" up 0y the 0rushis transferre" to aglass sli"e< preserve"<an" "rie"1

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• I!c2o!(6 1o&23

•  The intent of an inisional 0iopsy is to sample only a representativeportion of the lesion1

• If the lesion is large or has many "iering harateristis< morethan one area may re>uire sampling1

I!dc(#o!2 7

• (esion is "iLult to e!ise 0eause of its e!tensive si=e

• @lerate" lesion

• a=ar"ous loation of the lesion• #reat suspiion of malignany

• E!isional surgial management re>uires hospitali=ation orompliate" %oun" management1

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T%c$!;4% 7

Representative areas are 0iopsie" in a %e"ge fashion

Dargins shoul" e!ten" into normal tissue on the "eep surfae1

Neroti tissue shoul" 0e avoi"e"1

 The sample shoul" 0e ta$en from the e"ge of the lesion to inlu"e

surroun"ing normal tissue It shoul" 0e "eep enough to inlu"e un"erlying hanges of the

surfae lesion1

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E)c2o!(6 1o&23 7

In"iations:

Shoul" 0e employe" %ith small lesions & less than *m

 The lesion on linial e!am appears 0enign1

When omplete e!ision %ith a margin of normal tissue is possi0le%ithout mutilation1

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T%c$!;4% 7

7n e!isional 0iposy implies the omplete removal of the lesion1

 The entire lesion %ith 9 to mm of normal appearing tissue surroun"ing

the lesion is e!ise" if 0enign1

9 ' m if malignant1

E!isional 0iopsy shoul" 0e performe" on smaller lesions 6less than *m in "iameter8 that appear linially 0enign1

 4igmente" an" vasular lesions shoul" 0e remove"< if possi0le< in their

entirety1  This avoi"s see"ing of the melanin pro"uing tumor ells into the

%oun" site or in the ase of a hemangioma< allo%s the liniian toa""ress the fee"er vessels1

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FOR D@COCE(E (ESIONS ' C7REF@( ECISION7( BIO4S

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P4!c$ 1o&23 7

7nother tool that an 0e use" for inisional or e!isional purposes1

Biopsy is espeially %ell suite" for "iagnosis '

Oral manifestations of muoutaneous

Vesiuloulerative "iseases  lihen planus< pemphigus

 P(r#2 o' &4!c$ 1o&23 !2#r4*%!#

$(!d6%

$41

16(d%

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V(ro42 d(*%#%r2 o' 1o&23 &4!c$%2  

Biopsy punhes shoul" range in si=e from 9&* mm in "iameter

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T%c$!;4% 7

•

 The smaller "iameters shoul" 0e avoi"e" "ue to the ris$ of over&manipulating an" rushing the tissue 1

•  The tehni>ue is easily performe" %ith a lo% ini"ene of postsurgialmor0i"ity1

• Suturing in regar"s to a punh 0iopsy proe"ure is usually not re>uire"as the surgial %oun"s heal 0y seon"ary intention1

D2(d5(!#("%2 7

• It is "iLult to o0tain a"e>uate< representative tissue "eeper than thesuper2ial lamina propria1

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  Fro>%! 2%c#o! 1o&23 7

•  ;one %henever report is nee"e" at the earliest time1

•  ere an un2!e" fresh tissue is fro=en 6using CO98 in a metal an"setions are ma"e 5 staine"1

  I!dc(#o!2 7

•  Folliular Carinoma of thyroi" %hen FN7C fails

•  For aessing on&ta0le learane margin an" "epth1

•  Stu"y of lymph no"es an" their positivity for malignany1

CRO ST7T

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Ad5(!#("%27 

• Its >ui$ an" surgeons an "ei"e the further steps to follo%

D2(d5(!#("%27

•  Tehnially "iLult

• ;iLult to get aurate result

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Dr66 1o&23

• It is a high spee" "rill tehni>ue "esri0e" 0y

"eelay6*-+8• Ellis 0iopsy "rill

• @seful for entral&20ro osseous lesion

•   7"vantage

*8 (ess trauma an" "amage

98 Sprea" of lesion is avoi"e"

  ;isa"vantage

8 Not use" in lesions less than 9 ms38 ;rill lesion an 0e misse"

i" i i i2 l i

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Consi"eration in spei2 lesion

  Some lesions have a""itional onsi"eration in0iopsy tehni>ue

*1 4reanerous lesion

•. Seletion of the area

•. In spe$le" re" an" %hite•. Dore severe "ysplasia

91 Salivary glan"

•. In ase of maGor salivary glan"s

•. 0reah in apsule lea"s to potential ellspillage

•. Release of muoi" material ontaining via0letumor ells1

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(ymph no"e

• It is "iLult tissues to 2! 0eause of their "ense

apsule an" their ellularity1• Sagital plane

• Ni""le aspiration

Cysti lesions

• Every attempt shoul" 0e ma"e to remove the lesion%ithout rupture1

• Duoepi"ermoi" tumors

• Boney ysts6"entigerous ysts8

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 Tooth

• ;rill the ro%n or apial thir" of the root to allo%

for pulpal 2!ationVesile or 0ullae

Biopsy is performe" on a fresh< intat 0lister

4empigus vulgaris

(onger 0or"er shallo% 0iopsy as this is a surfaephenomenon

Intra osseous lesion

E! ' perapial granuloma

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ealing of 0iopsy %oun"

•  The healing of a 0iopsy %oun" of the oral avity is

either 0y primary healing or seon"ary healing 1• ;epen"s %hether e"ges are 0rought into lose

apposition 0y suturing 1

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Biopsy "ata sheet

*8 4atientPs name< a"ress< age< se!<

91 4ertainent history

1 Clinial "esription

31 Nature of 0iopsy

H1 Ra"iograph< photograph

K1 Coments on 0iopsy speimen

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REFERENCES

• Neville