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Biopsy

Dr. Kush
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“The best surgeon is a clinical

pathologist who performs
operations”
 History 3

Al-Zahrawi, an Arab physician, surgeon and

pharmacist - perform a needle biopsy (of the thyroid).

He used hollow needles to investigate abnormal

growths of the thyroid gland.

Around the year 1000 AD, he wrote his famous book

'Al Tasreef Liman 'Ajaz 'Aan Al-Taleef (or 'al-Tasreef')
(''An Aid for Those Who Lack the Capacity to Read Big
Books').
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In the early 16th century, Sir Marcello Malphigi

termed it as,

Bios- LIFE, Opsis- A sight

In the modern era, a Russian, M.M. Rudnev –

used diagnostic biopsy in 1875.
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The term 'biopsy' was introduced into medical

terminology in 1879 by Ernest Besnier.

Expert committee of WHO (1996) – “

Biopsy is examination of tissue removed
from a lesion & by extension the term is
also used to convey the removal of the
lesion”
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• 100 years of biopsy can be easily divided into 3 major

steps:

1. An occasional use of procedure - until the late 19th

century - involving living organs and tissues for
observation and study.
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2. Restricted application of biopsy- until the

mid-20th century.

3. Present stage - widely adopted, not only in

oncology but practically in all clinical specialties.
 The Technique Allows Us To Establish 8

 Histological characteristics

 Differentiation

 Extent or spread

 Evoluative control of disease process

 Healing or relapse

 Irrefutable legal medical value.

 Indications 9

Primarily – To confirm the clinical

impression of the lesion.

Any persistent lesions >10-14days

With no apparent etiologic basis.
That does not respond to Rx even after
removal of cause / irritant.
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Persistent swelling

Bone lesions - Not specifically identified by

clinical & radiographic findings.

Lesions presenting the characteristics of

malignancy
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Conditions that are potentially precancerous

Persistent hyperkeratotic change. e.g.:

leukoplakia.

Inflammatory changes of unknown causes.

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Lesions interfering with normal functions.

For:

Classification,

Grading / staging of tumor

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Evaluation of surgical margins

To alleviate patient apprehensions
Evaluate prognosis
 Contraindications 14

Compromised general health, h/o bleeding

diathesis.
Lesion close to vital anatomic, vascular or ductal
structures.
Intrabony lesions should not be biopsied or
removed prior to investigational aspiration.
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Normal anatomic & racial variation – e.g.

Physiologic pigmentation, linea alba,
Fordyce's granules.

Acute / sub acute inflammatory condition –

bacterial, viral infection.
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Absolute:
Pulsative lesion, large hemangiomas –
appear to be filled with blood.
 Selection Of Specimen 17

 Area representative of whole lesion.

 Adequate amount of tissue must be present.

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In large lesions – Specimen is removed

from most easily accessible & representative
area.

Deep sections of lesion along with normal

tissue are needed.

If several lesions - specimen taken from

most representative area.
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 Intra osseous lesions – Cortical plate of bone

should be removed & curetted material must
be evaluated.

 Skin / mucosal biopsy – Epithelium +

Connective tissue.
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Ulcer – Normal area + Deep part of ulcer

Multiple ulcers – More than one biopsy & at

the site of maximum clinical activity.
INSTRUMENTS AND MATERIALS
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INSTRUMENTS AND MATERIALS
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 Procedure
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 Injecting local
anesthesia.

 Elliptical or wedge
shaped incision
including normal &
abnormal tissue.
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Tissue is grasped with forceps & cut under

tension.
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Place the sample in 10% formalin.

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10% Formalin

Label the bottles

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 HANDLING OF TISSUE
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Critical step

 Avoid liberal use of tissue

forceps.
 TRANSPORTATION
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Ensure spill-proof packaging.

Label “PATHOLOGIC
SPECIMEN”
Type of Biopsy
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 INCISIONAL EXCISIONAL 32

BONE PUNCH

Types
according to
BRUSH
technique CURETTAGE

EXPLORATIVE SHAVE

LASER
 INCISIONAL BIOPSY
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Indications:

• Large lesions (> 1cms)

•Hazardous location with uncertain

nature.

•Doubtful malignant lesions

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Oral cavity – Commonest lesion for

incisional biopsy – white hyperkeratotic
lesions.

Bleeding, ulcerated or indurated area must

be taken.
 EXCISIONAL BIOPSY
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Removal of lesion in -
Toto – with adequate
margins

Accomplishes the goal of

the biopsy (entire lesion
is available for H/P
examination)as well as
Rx
Indications 37

Lesions <1cms

Clinically benign lesions

Easily accessible
 PUNCH BIOPSY
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Convenient method for oral
mucosal lesions

Biopsy punch Make

circular incisions (3-4mm
in diameter)

Surgically inaccessible
regions e.g. palatal biopsy of
minor salivary glands, lips.
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Principle

Punch – circular / twisting motion  a

circular incision on lesion.
Remove the punch.
Grasp the margin – separate the base with
scissors or scalpel.
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Advantages 43

 Quick & effective

 Produces a clean & sharp incision
 Little bleeding
 Minimal pain

Disadvantages

 Tissue distorted
 Can’t be used in soft palate, floor of mouth
 CURETTAGE
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Curette – Spoon like tip

Designed for scraping

out cavities for tissue
(diagnostic/therapeutic
purposes)

eg: maxillary antrum,

cystic lesions within the
jaws
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Used primarily for intraosseous lesions

(cystic/fibro-osseous), soft friable soft tissues
(granulation tissue)

Easy to perform
 Drill biopsy
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 Modified Ellis drill, fits into straight hand piece.

 For
central fibro -osseous lesions, osteolytic lesions of
bone, lymph node masses.

 Needle is introduced through small skin incision &

rotated at slow speed until tumor is reached.
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 Entered into tumor mass.

 Gentlenegative pressure is applied to needle by means of

small syringe on withdrawal.

 Contained core expelled into fixative.

Advantages 48

Less trauma to healthy tissues.

Less chances of metastasis.

Disadvantages

Heat

May miss the lesion (< 2cms)

 Shave biopsy
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Easiest biopsy to take when lesion is raised above

surface.

Using scalpel blade or special disposable blade.

Sawing / shaving action is used.

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Plastic blade mounted in rigid plastic handle

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 Electro surgery/ Laser biopsy 52

• Specimen is taken using electrode.

• Minimum discomfort & bleeding. (cauterization)
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 Electro-surgery refers to the cutting and coagulation of

tissue using very high-frequency, low-voltage
electrical currents.

 Useful in producing a bloodless operative field.

 Thermal coagulation is used.

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Electro-surgical
technique
The lesion is grasped
with forceps through
the loop electrode. The
electrode is activated
going under the lesion,
removing the growth.
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• Currently not advised for
oral biopsies

Disadvantages:
• In electro surgery – Thermal
damage may result in
charred appearance of tissue.

• Laser – less extensive thermal

damage.
 Aspiration biopsy
(FNAC / FNAB) 56

• To obtain material from body cavity, cystic

space or fluid containing lesion.

• Introduced by Martin, Ellis & Stewart in 1950.

• Obtained material can be smeared on a slide,

fixed & stained.
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Indications:

Differentiate neoplastic from non neoplastic

tissues
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Advantages :
 Quicker to perform
 Less painful
 Technically less demanding
 Inexpensive
 Repeatable
Technique: 59

 Cleansing of skin , LA at periphery of mass.

 Sterile needle attached to syringe is guided

inside abnormal area.
ASPIRATION CYTOLOGY GUN
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Franzen’s handel with syringe & needle fitted on it for performing
FNAC
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Disadvantages 63

The proper lesion may get missed easily.

Tissue relationships not known (as only few cells

are studied)

Most of the times needs a confirmatory biopsy

 Core biopsy / True – cut biopsy
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Stab incision

To distinguish between reactive

changes / recurrent malignancies/
cervical metastases.

Symptom less H&N swellings

Disadvantages
•Tumor dissemination / seeding
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 Exfoliative cytology 66

 Study of superficial cells which have been either

exfoliated or shed from mucous membrane.

 Cells are collected by scraping or pulling off from

tissue surface.

 Can also be done with sputum or saliva.

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Indications:
For suspected malignant and premalignant oral
lesions.

 Recurrent oral cancers after treatment.

Mass screening of oral cancer.

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Contradictions:
Deep seated lesions (both soft and hard tissue).

Fibrous lesions.

Non-ulcerative lesions.
 Technique 69

 The lesion is repeatedly scraped with a moistened

tongue depressor or spatula or cytobrush type
instrument.

 The
cells obtained are smeared on a glass slide and
immediately fixed with a fixative spray or solution.
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 Oral brush biopsy
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Special instrument called biopsy brush

Trans-epithelial biopsy obtained

Indications

For precancerous / cancerous oral

mucosal lesions

Advantages

Easy to perform; requires less time

Well tolerated by the patient

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Dangers during biopsy…
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Spreading of tumor cells along lymphatics /

vascular channels.

Hemorrhage

Infection
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Specific tissue
considerations

Oral biopsies: methods and applications

R. J. Oliver, P. Sloan and M. N. Pemberton BRITISH DENTAL JOURNAL
VOLUME 196 NO. 6 MARCH 27 2004
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For red & white lesions include both red & white area
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Ulcers

Include margin,
deep part of
ulcer and site of
maximal clinical
activity.
AVOID
Superficial
ulcers &
necrotic tissue
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Vesiculo-bullous lesions
Fluid is more representative. Intact vesicle or bulla
should be biopsied.
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For LICHEN PLANUS – representative area should be
biopsied
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For LEUKOPLAKIA – Most dysplastic area should be
biopsied
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Do not cut into pigmented and vascular lesions

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Oral biopsies: methods and applications

R. J. Oliver, P. Sloan and M. N. Pemberton BRITISH DENTAL JOURNAL
VOLUME 196 NO. 6 MARCH 27 2004
 Clinical diagnosis Type of biopsy Suitable for general dental
practice

Chronic ulcer or Incisional biopsy of No, urgent 86

referral
squamous cell margin of ulcer to hospital
carcinoma
Leukoplakia/ Incisional or punch No, referral to
erythroplakia biopsy of worst area hospital
consider multiple
biopsies if extensive
lesion

Mucosal lichen Incisional biopsy of the Only very

planus area experienced
practitioners

Bullous lesions Incisional or punch No, referral to

(pemphigus biopsy of unaffected hospital
pemphigoid etc.) mucosa close to bulla
 Clinical diagnosis
Granulomatous diseases
(Crohn’s,
Orofacial granulomatosis,
ulcerative colitis, TB)
Mucocele
Fibroepithelial polyp,
pyogenic granuloma, epulis
Minor salivary gland
tumour
Type of biopsy Suitable for general
dental practice
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Deep incisional biopsy No, referral to
plus fresh sample to hospital
microbiology if
infective agent
suspected
Careful excision Yes, with care
biopsy
Excision biopsy Yes
Palate: deep incisional No, urgent referral to
biopsy hospital
Upper lip: excisional
biopsy
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Summary