Principle of oral biopsy

Principles of oral biopsy

By

Dr. Abdusalam Alrmali

The key to reduction of death due to oral cancer is early detection,

and dentist can play an important role

How ?

Thorough history , oral examinations, and detection of the early

lesions

Biopsy and histological evaluation of the lesion

From the history will know the following Risk Factors:

Tobacco use

Alcohol use

Exposure to sunlight

Age

Gender

Race

Physical Exam:

Be systematic and thorough so as not to miss things

For the same reason, go to the area of interest last

Inspection and palpation

Location: Be descriptive, diagrams can be very helpful

Try and ascertain what tissues are involved, eg epithelial or

submucosal

Certain locations correspond to certain diseases – e.g. oral cancer

and lateral border of the tongue vs. the dorsum of the tongue

Size and shape of the lesion

Accurate measurements allow to follow the changes in the

size of the lesion

Measurement of the lesion is used in the T staging of oral

squamous cell carcinoma and salivary gland malignancies

Surface of the lesion

Verruciform

Smooth

Ulcerated

Associated with hematoma

Filled with with granulation tissue or necrotic debris

Expresses purulence

Relation of the lesion to the surrounding tissues

fixed vs. freely mobile

A fixed lesion is often a finding indicating infiltration of

adjacent tissues

Consistency of the lesion

– Soft = lipoma

– Firm = fibroma

– Hard = torus

– Indurated = firm-hard

Consistency of a lesion will give you a clue as to its component tissues

Fluctuation

Fluctuation is a term describing a wave like motion felt on palpation of

a lesion

Describes a fluid component

Pulsations

o Thrills = palpable murmur

o Bruit = audible murmur

o These are descriptors of vascular lesions and malformations. Their

presence should prompt referral to a specialist for management.

Lymph node examination

o Must be performed as part of any examination.

o Lymph nodes should always be examined before any surgery so as

to not confuse reactive adenopathy with their pathologic

involvement

Lymph Node Exam must include these descriptors:

1. Size - less than 1 cm usually not pathologic

2. Tenderness - painful vs. painless

3. Degree of fixation

4. Texture - soft, firm, fluctuant, hard

Radiographs - PA’s, Panoramic radiographs, computed tomography,

magnetic resonance imaging, bone scanning, chest X rays, …

1. Benign versus aggressive features

5. Laboratory Investigations

1. Based on your findings and differential diagnosis

Features that arise the suspicion of malignancy:

Warning Signs:

Leukoplakia

Erythroplakia

Lump or thickening of oral soft tissue

Soreness or “lump” in throat

Difficulty chewing or swallowing

Ear pain

Difficulty moving jaw or tongue

Hoarseness

Numbness of tongue or mouth

Swelling of the jaw

Clinical features of squamous cell carcinoma:

Leukoplakia

Erythroplakia

Non-healing ulcer

Exophytic

Verrucous

Indurated

Oral biopsy

Is the removal of tissue from a living individual for diagnostic

examination.

The aim of biopsy is to :

• Define a lesion on the basis of its histopathological aspect;

• To establish a prognosis in malignant and premalignant lesions;

• Facilitate the prescription of specific treatment;

• Contribute to the assessment of the efficacy of the treatment;

• Act as a document with medical-legal value.

Indications for biopsy :

1. A lesion that persists for more than 2 weeks with no apparent

etiologic basis.

2. An inflammatory lesion that doesn't respond to local treatment after

14 days (i.e, after removing local irritant ).

3. Lesions that interfere with local function e.g fibroma

4. Persistent hyperkeratotic changes in surface tissues.

5. A persistent lesion, either visible or palpable beneath a relatively

normal tissue.

6. A persistent traumatic ulcer doesn't resolve after removing the

cause .

7. Bone lesions not specifically identified by clinical and radiographic

findings.

8. Any lesion that has the characteristic of malignancy

Contraindications of biopsy:

1. In case of acute infection near the site of biopsy

2. Uncontrolled compromised patient e.g bleeding disorder,

anticoagulant .

3. When its sure from malignancy

4. Incisional biopsy absolute contraindication in vascular and

pigmented lesions.

5. Incisional biopsy is also contraindicated in major salivary gland

lesions.

When is oral biopsy not needed?

There is no need to biopsy normal structures;

There is no need to biopsy irritative or traumatic lesions that

respond to the removal of a presumed local irritant;

There is no need to biopsy inflammatory or infections lesions that

respond to specific local treatments, as pericoronitis, gingivitis or

periodontal abscesses;

Types of oral biopsy :

According to the procedures applied, oral biopsy can be classified into:

Oral cytology

Aspiration biopsy

Fine needle aspiration cytology

Incisional biopsy

Excisional biopsy

Punch biopsy

Drill biopsy

Frozen section biopsy

Timing of the biopsy:

• Pre-operative

• Intra-operative

• Post-operative when aimed at checking the efficiency of a

treatment

Pre-biopsy Screening test:

Toluidine Blue test :

• A vital stain technique

• Displays affinity for areas of dysplasia, malignancy and high cell

turn over

Toluidine Blue- Instructions for use:

Swish for 1 minute then spit, each in order:

1. 0.25% Acetic acid

2. Water

3. Toluidine blue

4. 0.25% Acetic acid

5. Water

Oral Brush Biopsy

The brush is sterile

One Oral brush test kit per oral lesion

The brush was designed to penetrate to the basement membrane

and thus achieve a complete trans-epithelial specimen

Unlike cytology instruments which collect only superficial cells,

the brush biopsy obtains cells from all three epithelial layers of the

oral mucosa: superficial, intermediate and basal

Indications:

For herpetic infection

Candidal infection

Dysplastic changes

Think of this technique as a screening tool

This kit helps you decide which lesions need to undergo

conventional biopsy

If a lesion is highly suspicious, skip this option and go right to the

incisional/ excisional biopsy

Exfoliative cytology

Oral exfoliative cytology should not be used as a substitute

for a conventional biopsy because of the false-negative

results

The technique consists of scrapping the lesion with a tongue

blade or spatula and spreading the scrapping over a glass

slide, which is fixed immediately in 95% ethyl alcohol, then

allow to dry in air and examined

Aspiration biopsy

This is the use of needle and syringe to penetrate a lesion for aspiration

of it's contents.

Indications :

1. To determine the presence of fluid within a lesion.

2. To a certain the type of fluid within a intraosseous lesion as cyst

3. To rule out a vascular lesion that can cause life threatening

hemorrhage.

Technique :

1. An 18- gauge neelde is connected to a 5 or 10 ml syringe

2. The area is anesthesized and the needle is inserated into the depth

of the mass during aspiration

3. For bony lesion either forcing the needle to perforate the cortex or

opening of small flap to facilitate the aspiration.

Fine Needle Aspiration cytology

Technique consists of repeatedly passing a needle, under negative

pressure, through a lesion to collect cells

Generally requires analysis by a cytopathologist

Indications:

Major Salivary gland swelling

Neck masses

Lymph node masses

Incisional biopsy

Technique simple, only a portion of the lesion is removed

Selects a representive portion of the lesion, especially select areas

most likely to demonstrate most advanced disease

Indications:

Large lesions with more than 1cm in diameter

Hazardous location

Malignancy suspected

Technique :

Biopsy of a wedge of representative tissue

Several regions may be sampled

Avoid necrotic tissue

Areas of tissue transition can be useful, such as the margin of the

lesion

Wedge should be deep enough to sample the full depth of the

lesion and its transition to normal tissue

Excisional Biopsy

Removes the entire lesion at the time of tissue sampling

A margin of normal tissue is generally included

Offers the advantage of definitive treatment at the time of

diagnosis

Indications:

– Smaller lesions, < 1cm

– Pigmented and small vascular lesions

– Benign lesions

Principle: lesion and 2-3mm margin of normal tissue is excised

Drill biopsy

This type of biopsy is used mainly for intra-osseous lesions

A drill in a dental engine to remove a core from the centre of the

tumour is done

Frozen sections

This is quick method of diagnosis that can be used during surgery

to make sure that the margin of the lesion is clear

Frozen sections for tumour diagnosis usually provide a rapid and

highly reliable answer and the only problem may be that of

conveying the specimen from theatre to laboratory rapidly and

without deterioration

Armamentarium for biopsy

Set of instruments necessary for soft tissue specimen sampling by

biopsy.

Steps :

Local anesthesia :infiltration or field block.

– Careful not to distort your margins 1 cm away

Haemostasis

– Sponge > suction

Incision

– Scalpel/punch > electrocautery

– 2-3mm of normal tissue

Tissue Handling

– Gentle, do not crush your specimen

– Identification of margins

– Sutures for orientation

– Specimen care

– Gentle handling with forceps

– Closure

– Undermining as needed

– Pathology Sheet

– Be descriptive

N.B: The use of CO2 laser is compromised by thermal cytological

artifacts. The same is also applied to electrosurgical units.

Errors to be avoided when taking oral biopsies:

Taking insufficient amount of tissue in extension and depth

Pressing the sample with tweezers, producing tissue tears

Infiltrating anaesthetic solution within the lesion

Using an insufficient volume of fixing solution

Inclusion of undesired material in the sample; glove powder,

calculus, restorative materials, etc.

Stabilization of the lower lip before biopsy, using assistant's finger's.

Stabilization of tissue with mechanical device. C, Stabilizaticn of tissue

with traction sutures. Two silk sutures are used to stabilize tongue before

excisional biopsy. They are placed through substance of tongue (both

mucosa and muscle) to prevent pulling through tissue. H, Lesion is

removed after elliptic incision was made around it. i, Resorbable sutures

are placed to approximate muscle. J, Mucosa is closed.

Marking the biopsy with sutures

Sample of biopsy sheet:

Patient details: name, gender, race, age, address,

medical and social history

Clinical details

History: symptoms, previous biopsy and treatment

Examination: signs, size, shape, position, texture, color

Investigations: microbiology, hematology, radiology

Biopsy type

Previous biopsy number/s

Orientation: use a diagram

Clinical diagnosis

Biopsy data sheet :

Date ……………………. Case number…………………..

Patient name :……………….. gender…………….. age ………………..

Race …………………. Address……………………………………..

Home phone ……………………………work phone……………………..

Occupation…………………………

submitting doctor's name………………………… phone ………………

email…………………………………………………………….

History:

asymptomatic white plaque of unknown duration but first noticed by

patient about 2 months ago, left lateral border of tongue, patient denies (

tobacco usage, alcohol usage), the lesion is not painful , no local trauma

noticed, past medical history is unremarkable.

Type of biopsy: incisional

Clinical description /location: 3*5 cm white , rough surface plaque on

lateral surface of the tongue, non-ulcerated, with uniform thickness.

Clinical margin:

Anterior border tagged with single suture, superior border tagged with 2

sutures.

Provisional clinical diagnosis: leukoplakia, verrucous carcinoma, SCC.

Additional comments / radiographic attachment if present .

This table illustrate oral cavity structures and their drainage

LN

Area Draining lymph nodes Cheek Submandibular

Upper lip Submandibular

Lower lip lateral part

Submandibular

Lower lip middle part Submental

Mandibular gingiva Submandibular

Anterior Mandibular teeth Submental

Posterior mandibular teeth Submandibular

Maxillary teeth Deep cervical

Maxillary gingiva Deep cervical

Tongue tip Submental

Lateral border of tongue

anterior two third

Submandibular

Posterior one third Deep cervical

Floor of mouth Submandibular

Hard Palate Deep cervical

Soft palate Retropharyngeal & Deep

cervical

Tonsil & uvula Jugulodigastric