BIOPSY

P.PARAMESWAR
II ND M.D.S
DEPARTMENT OF ORAL
PATHOLOGY

OVER VIEW OF
CONTENTS

CTION

ATION

ONAL BIOPSY

L BIOPSY

OPSY

AL BIOPSY

ECTION

Biopsy [BIO =LIFE

OPSIS=VISION]
Biopsy is the removal of the
tissue from the living organism
for the purpose of microscopic
examination and diagnosis

According to the report of an expert

commitie of WHO (1966)-A biopsy is
the examination of tissue removed
from a lesion and by extention the
term is also used to convey the
removal of the tissue.

 Introduction :

Biopsy is derived from a Greek word - By-op-see

Bio LIFE and Opsy VISION or TO LOOK

1879 - French dermatologistErnest Besnier introduced the word

biopsy
Ruge and Joham Vert introduced surgical biopsy as an essential
tool for diagnosis.
1889 - Emarch put forward an argument that confirmations should
be made before surgeries for malignancies.
1941- Study of exfoliated cells from female genital tract by
Papanicolaous & this was adapted to study cells from other body
systems

Methods of studying
morphologic changes

1- Necropsy ( Autopsy).
2- Biopsy .

Necropsy
The study of organs and tissues removed from
the dead body for verification of the clinical
diagnosis and treatment of the disease .
Includes: gross & microscopic examination.

Biopsy
Pathological study of surgically removed tissues
or organs during life for diagnosis & therapy.
Includes: gross & microscopic examination.

 Classification :

Depending on the characteristics of the target lesion:

Direct
Located superficially, with easy access

Indirect
When the lesion lies in depth and is covered by normally
appearing mucosa or tissue

 Depending on the material used:

Conventional scalpel
A punch
Electrosurgical
Laser
Depending on the clinical timing of the biopsy

Intraoperative - Sampled material is processed without

fixation, frozen with dry ice
Extraoperative - Requires fixation & longer processing
time of tissue.

 Depending on the technique employed :

Incisional
Removal of a representative portion of the
target lesion and of a part of healthy tissue
Excisional
Total removal of the lesion, with slight
peripheral and in-depth safety margins

OBJECTIVES OF BIOPSY
To confirm a presumptive diagnosis made on
clinical and R/G findings.
To determine the treatment plan
Valuable self teaching diagnostic aid.
To remove the cancerophobia
As a medicolegal record

DIAGNOSTIC
SOFT TISSUE
CURATIVE

PUNCH
ELECTROCAUT
INCISIONAL SOFT TISSUE
CURETTAGE
FROZEN SECT
SCALPEL
EXCISIONAL
CAUTERY

BIOPSY

SURGICAL
CURETTAGE

DIAGNOSTIC TREPHINE
ASPIRATION
FROZEN

BONE
CURATIVE

RESECTION
CURETTAGE

NON-SURGICAL
ASPIRATION

ENUCLEATION

CYTOLOGY

EXFOLIATIVE
FNAC

biopsy
surgical
Soft tissue

Non surgical
Bone

Diagnostic
Incitional
Punch
Electo
curretage
curative
Excessional

aspiration

Diagnostic
Curretage
Trephenation
aspiration
curative
enucliation

cytology

Exfolative cytolog
fnac

INDICATIONS FOR BIOPSY

Any progressive ulcerated lesion which has been
present for three weeks or one which fails to respond
to' therapy in three weeks should be biopsied.
Any mass which has been present for three weeks or
more should be biopsied.
White patches in mucous membrane especially
those having a wharty appearance.
Areas which are intra-osseous and produce
rarifaction and expansion of the cortical plates.
Complete excision of small lesions as a method of
diagnosis may also serve as treatment in some
instances.

USES OF BIOPSY
Diagnostic-verifying or establishing a diagnosis of
a clinically suspicious lesion.
Planning proper treatment-local or'radical,
surgery or irradiation.
Checking progress of treatment-as to
effectiveness.
Checking extension of disease-whether invasive.
Evaluation end result-whether free of recurrence.

CHARACTERISTICS OF LESIONS THAT

RAISE THE SUSPICION OF MALIGNANCY
ERYTHROPLASIA : Lesion is totally red or has a
speckled red and white
appearance .
ULCERATIONS

: Lesion is ulcerated or
present as an ulcer .

DURATION

: Lesion has persisted more

than 2 weeks .

 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.

ARMAMENTARIUM FOR BIOPSY

INSTRUMENTS FOR SOFT TISSUE
BIOPSY:
Local anesthetic equipment
Scalpel (no 15 blade)
Scissor with pointed tips
Fine tissue forceps
Small hemostat
Gauze sponges (suction if necessary)
Needle holder ,needle ,& suture
Biopsy bottle containing 10 %
formalin

 INSTRUMENTS FOR HARD TISSUE

BIOPSY
Periosteal elevator
Rongeur
Bur and rotary handpiece
Sterile saline irrigation
Curettes

INSTRUMENTS FOR ASPIRATION

BIOPSY
5 or 10 ml syringe , 18 gauge needle

Guidelines for appropriate biopsy

Clinical diagnosis

Type of biopsy

Suitable for
general dental
practice

Chronic ulcer or
squamous cell
carcinoma

Incisional biopsy of
margin of ulcer

No, urgent referral to

hospital

Leukoplakia/erythroplak Incisional or punch

ia
biopsy of worst area.
Consider multiple
biopsies if extensive
lesion

No, referral to
hospital

Mucosal lichen planus

Incisional biopsy of a
representative area

Only very
experienced
practitioners

Bullous lesions
(Pemphigus,
Pemphigoid)

Incisional or punch
biopsy of unaffected
mucosa close to bulla
or erosion & fresh
tissue specimen

No, referral to
hospital

Granulomatous

Deep incisional biopsy

No, referral to

 Guidelines for appropriate biopsy ( cont..)

Clinical diagnosis

Type of biopsy

Suitable for
general dental
practice

Mucocoele

Careful excision biopsy

Yes, with care

Fibroepithelial polyp, Excision biopsy

pyogenic
granuloma, epulis

Yes

Minor Salivary gland

tumor

Palate- Deep incisional

biopsy
Upper lip- Excisional
biopsy

No, urgent referral

to hospital

Major salivary gland

tumor

FNAC

No, urgent referral

to hospital

 The four major types of biopsy routinely used in and around the
oral cavity are :
Cytology
Aspiration biopsy
Incisional biopsy
Excisional biopsy

Oral cytology :

Introduction :

1860 Beale - Cytological diagnosis of Cancer of the pharynx by means

of an oral smear

Morrison and co-workers - first to advocate strongly the application of

cytology for the diagnosis of nasopharyngeal and oral lesions.

1951 Montgomery and Von Haam studied the cytology in patients with
carcinoma of the oral mucosa

Oral cytology(cont..):
Oral cytology is typically used as an adjunct to, not a substitute for
Incisional or Excisional biopsy procedures
Cytology allows examination of individual cells, but cannot provide the
histologic features crucial for an accurate and definitive diagnosis
It is a diagnostic screening procedure to monitor large tissue areas for
dysplastic changes.

Lesions for cytologic examination may include

Post-radiation changes
Herpes
Fungal infections and
Pemphigus.

Technique :

In a cytologic examination, the lesion is scraped repeatedly and firmly

with a moistened tongue depressor or cytology brush.

The cells are then transferred to and smeared evenly on a glass slide.

The slide is immediately immersed in a fixing solution or sprayed with a

fixative

The cells can then be stained and examined under the microscope.

 Advantages

Cytology may be helpful when large areas of mucosal

change are noted, or in areas with difficult surgical access

Disadvantages

Not very reliable with many false positives.

Expertise in oral cytology is not widely available

Results
Class I

Normal

Class II

Atypical
Presence of minor atypia, No Malignancy

Class III

Intermediate
Wide atypia, precancerous/carcinoma in situ, biopsy
suggested

Class IV

Few cells with malignant change / many cells with

borderline changes
Biopsy mandatory

Class V

Obviously malignant
Biopsy mandatory

Fine needle aspiration biopsy :

Aspiration biopsy is the use of a needle and syringe to remove a

sample of cells or contents of a lesion.

The inability to withdraw fluid or air indicates that the lesion is

probably solid

Indications:
To determine the presence of fluid within a lesion
To a certain the type of fluid within a lesion
When exploration of an intraosseous lesion is indicated

 Technique :
An 18-gauge needle is connected to a 5 or 10 ml syringe and is
inserted into the center of the mass via a small hole in the lesion.
The tip of the needle may need to be positioned in multiple
directions to locate a potential fluid center.
Release the suction and withdraw needle once cellular aspirate is
seen
The material withdrawn during aspiration biopsy can be submitted
for pathologic examination and/or culturing.

The inability to withdraw fluid or air - lesion is probably solid.

A radiolucent lesion in the jaw,

Straw-colored fluid on aspiration - a cystic lesion.

If purulent exudate (pus) - Inflammatory or infectious process

The aspiration of blood - vascular malformation.

Any intrabony radiolucent lesion,

- aspirated before surgical intervention to rule out a vascular
lesion.

If the lesion - vascular in nature, the flow rate determined because

uncontrollable hemorrhage can occur if incised

Results
Insufficient

Sample taken was not adequate to exclude or confirm a

diagnosis

Benign

There are no cancerous cells present

Lump or growth is under control & has no spread to other
areas of the body

Atypical

Suspicious of malignancy : Results unclear

Surgical biopsy may be required to adequately sample the
cells

Malignant

Cells are cancerous, uncontrolled

Have the potential to have spread to other areas of the body

Advantages :

Quick and effective test for determining the status of suspect

tissue
Involves little possibility of scarring, infection or pain.
Significantly shorter recovery time
Useful in the diagnosis and treatment of cysts.

Disadvantages :
Possibility of cancer cells being trailed into unaffected tissue as
the needle is removed .
Risk that any abnormal cells may be missed and not detected
as sample taken is small
Requires some expertise to perform and interpret

FOR MAJOR SALIVARY GLAND/LYMPH GLAND LESIONS

FNAC MAY BE USEFUL

Brush biopsy
Firm pressure with a
circular brush is
applied, rotated five
to ten times, causing
light abrasion.
The cellular material
picked up by the brush
is transferred to a
glass slide, preserved,
and dried.

Incisional biopsy

The intent of an incisional biopsy is to sample only a representative

portion of the lesion.
If the lesion is large or has many differing characteristics, more
than one area may require sampling.

Indications :

Lesion is difficult to excise because of its extensive size

Ulcerated lesion
Hazardous location of the lesion
Great suspicion of malignancy
Excisional surgical management requires hospitalization or
complicated wound management.

 Technique :
Representative areas are biopsied in a wedge fashion
Margins should extend into normal tissue on the deep surface.
Necrotic tissue should be avoided.
The sample should be taken from the edge of the lesion to include
surrounding normal tissue
It should be deep enough to include underlying changes of the
surface lesion.

 Excisional biopsy :
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.

 Technique :
An excisional biposy implies the complete removal of the lesion.
The entire lesion with 2 to 3mm of normal appearing tissue surrounding
the lesion is excised if benign.
2 3cm if malignant.
Excisional biopsy should be performed on smaller lesions (less than 1
cm in diameter) that appear clinically benign.
Pigmented and vascular lesions should be removed, if possible, in their
entirety.
This avoids seeding of the melanin producing tumor cells into the
wound site or in the case of a hemangioma, allows the clinician to
address the feeder vessels.

FOR MUCOCELE LESIONS CAREFUL EXCISIONAL BIOPSY

Punch biopsy :

Another tool that can be used for incisional or excisional purposes.

Biopsy is especially well suited for diagnosis

Oral manifestations of mucocutaneous
Vesiculoulcerative diseases
lichen planus, pemphigus

Parts of punch biopsy instrument

handle

blade
hu
b

Various diameters of biopsy punches

Biopsy punches should range in size from 2-10 mm in diameter

Technique :

The smaller diameters should be avoided due to the risk of overmanipulating and crushing the tissue .
The technique is easily performed with a low incidence of postsurgical
morbidity.
Suturing in regards to a punch biopsy procedure is usually not required
as the surgical wounds heal by secondary intention.

Disadvantages :

It is difficult to obtain adequate, representative tissue deeper than the

superficial lamina propria.

Frozen section biopsy :

Done whenever report is needed at the earliest time.

Here an unfixed fresh tissue is frozen (using CO2) in a metal and

sections are made &
stained.

Indications :

Follicular Carcinoma of thyroid when FNAC fails

For accessing on-table clearance margin and depth.

Study of lymph nodes and their positivity for malignancy.

CRYO STAT

Advantages:

Its quick and surgeons can decide the further steps to follow

Disadvantages:

Technically difficult
Difficult to get accurate result

Drill biopsy

1)
2)
3)
4)

It is a high speed drill technique described by

deelay(1980)
Ellis biopsy drill
Useful for central-fibro osseous lesion
Advantage
Less trauma and damage
Spread of lesion is avoided
Disadvantage
Not used in lesions less than 2 cms
Drill lesion can be missed

Consideration in specific lesion

1.
.
.
.
2.
.
.
.

Some lesions have additional consideration in

biopsy technique
Precancerous lesion
Selection of the area
In speckled red and white
More severe dysplasia
Salivary gland
In case of major salivary glands
breach in capsule leads to potential cell
spillage
Release of mucoid material containing viable
tumor cells.

Lymph node
It is difficult tissues to fix because of their dense
capsule and their cellularity.
Sagital plane
Niddle aspiration
Cystic lesions
Every attempt should be made to remove the lesion
without rupture.
Mucoepidermoid tumors
Boney cysts(dentigerous cysts)

Tooth
Drill the crown or apical third of the root to allow
for pulpal fixation
Vesicle or bullae
Biopsy is performed on a fresh, intact blister
Pempigus vulgaris
Longer border shallow biopsy as this is a surface
phenomenon
Intra osseous lesion
Ex perapical granuloma,cysts of jaw,

Healing of biopsy wound

The healing of a biopsy wound of the oral cavity is

either by primary healing or secondary healing .
Depends whether edges are brought into close
apposition by suturing .

Biopsy data sheet

1)
2.
3.
4.
5.
6.

Patients name, adress, age, sex,

Pertainent history
Clinical description
Nature of biopsy
Radiograph, photograph
Coments on biopsy specimen

REFERENCES
Neville,Damm,Allen,Bouquot, Oral
Maxillofacial Pathology 3rd Edition.
Shafers seventh edition.