BIOPSY.pptx

Biopsy

1. BIOPSY 1

2. Contents Definition History Aim and objectives Indications Contra indications Uses Complications Examination and diagnostic methods General Principles 2

3. CONTENTS Types of biopsy - Excisional - Incisional - Curettage - Punch - FNAB - Brush - Exfoliative - Bone marrow - Frozen section - Bite - 3

4. CONTENTS - Core - Irrigation - Tangential Principle of surgery After biopsy Bibliography 4

5. DEFINITION Biopsy (in Greek: bios = life and opsis = vision/look/appearance) According to S tedman’s medical dictionary- Process of removing tissue from patients for diagnostic examination. 5

6. DEFINITION A biopsy is the controlled and deliberate removal of tissue from a living organism for the purpose of microscopic examination. An Autopsy is removal of tissue from a dead organism (a post mortem examination performed) to confirm or determine cause of death. 6

7. HISTORY The term "biopsy" was introduced into medical terminology in 1879 by Ernest Besnier. The first diagnostic biopsy in Russia was performed in 1875 by M. M. Rudnev. One of the earliest diagnostic biopsies was developed by the Arab physician Abulcasim (1013-1107 AD). 7

8. Aim The aim is to provide a suitably representative sample for the pathologist to interpret, while minimizing postoperative discomfort for the patient. 8

9. OBJECTIVES The objectives of the biopsy are: • Define a lesion on the basis of its histopathological aspect; • To establish a prognosis in malignant or 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. 9

10. INDICATIONS Diagnostic confirmation of suspected malignant or precancerous lesions and chronic ulcerations of unknown cause. Inflammatory lesions that do not improve within two weeks of removal of local irritants. 10 Indications

11. Lesions that interfere with oral and local function. Lesions of unclear aetiology, particularly when associated with pain, paraesthesia or anaesthesia. Radiolucent or radio-opaque osseous lesions. Any inflammatory lesion that does not respond to local treatment after 10 to 14 days. Persistent hyperkeratotic changes in surface tissues. 11

12. Inflammatory changes of unknown cause that persist for long periods Bone lesions not specifically identified by clinical and radiographic findings Any lesion that has the characteristics of malignancy 12

13. Biopsy should not be delayed when following features are present: Rapid increase in the size of the lesion Absence of any recognized irritant Presence of firm regional lymph nodes Destruction of tooth roots and loosening of teeth with evidence of rapid expansion of the jaw History of cancer elsewhere in the body, previous history of oral cancer and radiation therapy. 13

14. Characteristics of lesions that raise the suspicion of malignancy Erythroplasia - lesion is totally red or has a speckled red appearance. Ulceration - lesion is ulcerated or presents as an ulcer. Duration - lesion has persisted for more than two 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 14

15. CONTRAINDICATIONS Benign lesion Irritation lesion Inflammatory lesion Site near the vital structure Angiomatous lesion 15

16. USES Diagnosis of pathological lesions. Grading of tumor for diagnosis. Determining Neoplastic and non-neoplastic lesions. Diagnosis of metastatic lesions. Evaluation of recurrence. Therapeutic assessment, differentiation between benign and malignant lesion. 16

17. COMPLICATIONS Hemorrhage, infection, poor wound healing. Spread to adjacent organs and reaction to local anesthesia. Lung biopsies are frequently complicated by pneumothorax . Biopsies of the liver, bile leakages may occur. Pancreatitis may occur after biopsies in the area around the pancreas. Deaths have been reported from needle aspiration biopsies. 17

18. EXAMINATION AND DIAGNOSTIC METHODS 18

19. EXAMINATION AND DIAGNOSTIC METHODS These steps include the Health history, History of the specific lesion, Clinical examination, Radiographic examination, Laboratory investigation, And, if indication, surgical procedures to obtain a specimen for pathologic examination. 19

20. HEALTH HISTORY The overall medical status of the patient is of paramount importance when investigating a lesion. 20

21. HISTORY OF THE SPECIFIC LESION How long has the lesion been present? Has the lesion changed in size? Has the lesion changed in character? What symptoms are associated with the lesion ? If painful, what is the character of the pain? Are there any associated constitutional symptoms ? Is there any historic reason for the lesion? 21

22. CLINICAL EXAMINATION   The anatomic location of the mass. The overall physical character of the lesion. The size and shape of the lesion. The surface of the lesion. The surface of the lesion. The color of the lesion. The sharpness of the boundaries of the lesion. The consistency of the lesion to palpation. Presence of fluctuation. Presence of pulsation. Lymph node examination. 22

23. LOCATION OF THE LESIONS 23

24. RADIOGRAPHIC EXAMINATION   Radiographs are useful as diagnostic adjuncts to the clinical examination and history of lesions within or adjacent to bone. 24

25. LABORATORY INVESTIGATION In most instances laboratory investigations are unnecessary in evaluation of oral lesions, because they generally are low yields a tissue diagnosis of a tumor, such as central giant cell granulomas. 25

26. GENERAL PRINCIPLES Update patient’s clinical record. Patient education and consent. Surgical technique. Tissue handling, fixation & transport. 26

27. GENERAL PRINCIPLES A. Update patient’s clinical record Before the procedure is undertaken, the characteristics of the lesion (size, shape, colour, texture, consistency, time of evolution, associated signs and symptoms, & regional nodes) should be described in the patient’s clinical records together with a presumed diagnosis and possible differential diagnosis. 27

28. GENERAL PRINCIPLES A. Update patient’s clinical record B. Patient education and consent The patient should receive information on the technique that will be performed and the reasons why it is performed, avoiding terms that may cause anxiety. Informed consent is required 28

29. GENERAL PRINCIPLES A. Update patient’s clinical record. B. Patient education and consent. C. Regarding the surgical technique: Regional or block local anesthesia preferred, but never into the lesion. Choose most suspicious area Avoid necrotic areas or ulcer sloughs Include normal tissue margin Elliptical incisions should be attempted in order to ease suture; Incisions parallel to nerves and vessels are preferred; 29

30. GENERAL PRINCIPLES A. Update patient’s clinical record B. Patient education and consent C. Regarding the surgical technique : Size & Type of lesion determines the technique. -if the lesion is smaller than 1 cm, excisional biopsy should be performed. -If larger, an incisional technique including representative areas of the lesion with healthy margins should be chosen; -Size of biopsy taken-Specimen should preferably be at least 1x 0.6 cm by 2mm deep 30

31. GENERAL PRINCIPLES A. Update patient’s clinical record. B. Patient education and consent. C. Regarding the surgical technique : The number and location of the biopsies will be decided on the basis of the clinical appearance of the lesion. If a lesion is large or shows several areas where biopsy would be indicated, more than one sample should be taken In these cases with precancerous or suspicious lesions, toluidine blue staining could be useful to choose the areas most relevant to biopsy 31

32. GENERAL PRINCIPLES A. Update patient’s clinical record. B. Patient education and consent . C. Regarding the surgical technique: Pass a suture through the specimen to control it & prevent it being swallowed or aspirated by the suction. It also helps to orient the tissue after biopsy Include every fragment for histological examination Suture & control any bleeding Warn patient of possible soreness afterwards. Give an analgesic 32

33. GENERAL PRINCIPLES A. Update patient’s clinical record. B. Patient education and consent. C. Regarding the surgical technique . D. Tissue handling, fixation & transport The specimen is handled gently to avoid crush artefacts and introduced in the fixing solution [10% formalin]. The role of the fixing agent is to preserve the cellular architecture of the tissues. 33

34. GENERAL PRINCIPLES A. Update patient’s clinical record. B. Patient education and consent. C. Regarding the surgical technique . Tissue handling, fixation & transport There are authors who suggest the placement of the specimen on a sterile paper with the mucous surface facing upwards to avoid distortion and curling of the sample margins. Label specimen bottle with patient’s name & clinical details 34

35. TYPES OF ORAL BIOPSY COMMONLY USED ONES Excisional biopsy Incisional biopsy Curettage biopsy Punch biopsy Fine Needle Aspiration biopsy Brush biopsy G. Bone marrow or intra osseous biopsy 35

36. TYPES OF BIOPSY LESS COMMONLY USED ONES Bite Cone Core Endoscopic Shave Sponge Tangential   36

37. GENERAL PRINCIPLES OF ORAL MUCOSAL BIOPSIES Most will be incisional biopsies rather than excisional biopsies. Select the worst looking area for biopsy. Always be aware of regional anatomy (nerves, blood vessels, etc.) Anaesthetize around the lesion rather than into the lesion. Avoid biopsying the centre of an ulcer or necrotic area. Avoid crushing the specimen with forceps. 37

38. ARAMENTERIUM Blade handle with a No. 15 blade Fine tissue forceps with teeth Local anesthetic solution and syringe 38

39. ARMAMENTERIUM Retractor appropriate for the site Suture for traction, if needed Needle holder Suture for closure, if indicated 39

40. ARMAMENTERIUM Fine-tipped scissors Laser or electrocautery device for fulguration, if indicated Specimen bottle containing formalin and biopsy data sheet Gauze sponges 40

41. Excisional biopsy 41

42. Excisional Biopsy An excisional biopsy implies the complete removal of the lesion. Indications: Should be employed with small lesions of Less than 1cm The lesion on clinical examination appears benign. When complete excision with a margin of normal tissue is possible without mutilation. 42

43. Principle of Excisional Biopsy 43

44. Excisional Biopsy Technique: The entire lesion with 2 to 3mm of normal appearing tissue surrounding the lesion is excised if benign. 44

45. Excisional biopsy 45 Oral lesion of approx 5mm x 3mm Infiltration of 1 ml of lignocaine 2% Lesion transfixed by suture

46. Lesion severed at base with a scalpel Lesion is removed Specimen is dispatched for histopathological examination Elliptical defect before suture 46

47. 47 Closure Traction suture Follow up

48. EXCISIONAL BIOPSY OF A NODULAR LESION OF THE PALATE 48

49. EXCISIONAL BIOPSY OF THE LIP 49

50. Incisional biopsy 50

51. Incisional Biopsy An incisional biopsy is a biopsy that samples only a particular portion or representative part of a lesion. If a lesion is large or has different characteristics in various locations, more than one area may need to be sampled. 51

52. Incisional Biopsy Indications: Size limitations 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. 52

53. Principles of Incisional Biopsy 53

54. Incisional biopsy For lichen planus the Incisional biopsy should be wide and for OSMF and leukoplakia it should be deep 54

55. 55

56. Punch biopsy 56

57. PUNCH BIOPSY Punch biopsy is a biopsy performed using a punch, an instrument for cutting and removing a disk of tissue. For example, a punch biopsy of the skin may be done to make the diagnosis of a malignancy. 57

58. PUNCH BIOPSY Specialized biopsy technique. Biopsy punch is the instrument used. Used in cases where depth is required. 58 The biopsy punch

59. TISSUE PUNCH BIOPSY 59

60. PUNCH BIOPSY 60

61. PUNCH BIOPSY 61 1. Oral mucosa 2. Adjacent minor salivary gland

62. Lesions suitable for punch biopsy 62

63. Not suitable for punch biopsy 63

64. FNAB 64

65. Aspiration Biopsy Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration of its contents. Indications: To determine the presence of fluid within a lesion To ascertain the type of fluid within a lesion When exploration of an Intraosseous lesion is indicated 65

66. Aspiration An 18 gauge needle (wide bore) on a 5 or 10 ml syringe is inserted into the area under investigation after anesthesia is obtained. The syringe is aspirated and the needle redirected if necessary to find the fluid cavity. 66

67. 67 Fine needle aspiration biopsy The syringe is aspirated and the needle redirected if necessary to gather the aspirate. Inability to aspirate fluid or air indicates that the mass is solid.

68. Fine needle aspiration biopsy Aspiration of air from the molar region of maxilla suggests that the needle is in the maxillary sinus. Aspiration of air from a cystic mandibular lesion suggests a solitary (haemorrhagic) bone cyst. Aspiration of blood suggest a hemangioma, haematoma, or blood vessel. 68

69. Fine needle aspiration biopsy Aspiration of pus indicates an abscess or infected cyst. Aspiration of keratin that looks like pus but has no unpleasant smell, indicates an odontogenic keratocyst. Aspiration of straw colored fluid containing crystals (of cholesterol) indicates a periodontal or dentigerous cyst. 69

70. Fine needle aspiration biopsy Ideally aspirate should have a high cell & low fluid content. 70

71. Fine needle aspiration biopsy-failures Failures may be due to : Needle missing a lesion & picking up inflammatory cells Lack of cells in central area of necrosis or cystic change Small malignant tumour being masked by larger benign tumour Lack of cells in dense fibroscerotic tissue 71

72. Fine needle aspiration biopsy-drawbacks An inadequate sample with few or no cells; A false negative result (lesion diagnosed as benign when it is malignant); A false positive result; Difficulty in reaching bony hard lesions 72

73. Aspiration biopsy Vs Aspiration cytology If an aspirate of cells is obtained using fine needles [21-25G] the technique should be called ‘fine needle aspiration cytology (FNAC)’ OR ‘fine needle aspiration (FNA)’. Whereas, if a core of tissue is produced using larger bore needles [14-18G], the procedure is best referred as ‘fine needle cutting biopsy (FNCB)’ 73

74. Fine needle aspiration biopsy Contents aspirated are placed on a slide and viewed under microscope. 74

75. Exfoliative biopsy 75

76. 76

77. Von haam concluded : Cytology is not a substitute for, but an adjunct to the surgical biopsy. It is quick, simple, painless and bloodless procedure. It helps to check against false negative biopies . It is helpful in follow up detection of recurrent carcinoma in previously treated cases. It is valuable for screening lesions whose gross appearance is such that biopsy is warranted. 77

78. Procedure Cleaning of oral lesion of debris and mucin Vigorous scraping of entire surface with metal cement spatula. Collected material quickly spread on slide Fixed immediately Allowed to air dry for at least 30 mins 78

79. Cytological Smear Grading Class 1 : Normal indicates only normal cells Class 2 : Atypical indicates the presence of minor atypia but no malignant change Class 3 : Indeterminate; the cells display wider atypia that may be suggestive of cancer, precancerous lesions or carcinoma in situ. (Biopsy recommended) Class 4 : Suggestive of cancer. A few cells with malignant characteristics or many cells with borderline changes Class 5 : positive for cancer obviously malignant cells (Biopsy mandatory) 79

80. Brush biopsy 80

81. BRUSH BIOPSY Brush biopsy/cytology was introduced in 1999 as an alternative to exfoliative cytology Investigation of persistent epithelial lesions not considered suspicious for carcinomas. Special circular brush is used. Used for mucosal biopsy. Less invasive than Incisional biopsy. 81

82. 82

83. Brush biopsy Brush is moistened and placed in contact with the mucosa. Brush rotated under firm pressure till pin point bleeding [indicating penetration of basement membrane] is noted to collect transepithelial specimen. Instrument then unloaded by rotating brush against the slide to disperse the cells. Removed cells spread onto glass slide. Immediate fixation done by flooding the slide with fixative and allowing to air dry. 83

84. Brush biopsy 84

85. THE ORAL Cdx KIT Oral brush biopsy instrument Precoded glass slide and matching coded test requisition form Alcohol fixative pouch Preaddressed container for submitting the contents 85

86. TECHNIQUE Brush suspicious lesion Smear on slide Pour on alcohol fixative and let it dry 86

87. Brush Biopsy classification Inadequate : Incomplete transepithelial specimen Negative : No epithelial abnormality Atypical : Abnormal epithelial changes of uncertain diagnostic significance Positive : Definitive cellular evidence of epithelial dysplasia or carcinoma 87

88. Suitable for brush biopsy 88

89. Not suitable for brush biopsy 89

90. BONE MARROW BIOPSY Bone marrow examination refers to the pathologic analysis of samples of bone marrow obtained by bone marrow biopsy (often called a trephine biopsy) and bone marrow aspiration. While much information can be gleaned by testing the blood itself (drawn from a vein by phlebotomy), it is sometimes necessary to examine the source of the blood cells in the bone marrow to obtain more information on hematopoiesis ; this is the role of bone marrow aspiration and biopsy. 90

91. On examination, If bone feels smooth & firm to palpate – indicates lesion has not expanded. If bone feels spongy on compression – indicates erosion & thinning of the bone. On aspiration, Brisk pulsating blood indicates vascular lesion. Straw colored fluid indicates cystic lesion. Air indicates traumatic bone cavity 91

92. INDICATIONS Done in the cases of peri apical granulomas and cysts 92

93. Trephination It is creation of surgical passage in the cortical plate in the region of root apex, usually by a bur to provide a channel for escape of pus and blood to relieve the accumulated pressure in the jaw bone around the root apex. It is advocated in the cases of acute alveolar abcess. 93

94. Technique Site is anesthetized Incision is made to expose and penetrate bone Direct line path of penetration is made 94

95. A bone marrow biopsy may be done in a health care provider's office or in a hospital. Informed consent for the procedure is typically required. The patient is asked to lie on his or her abdomen or on his/her side The skin is cleansed, and a local anaesthetic such as lidocaine is injected to numb the area.   Patients may also be pretreated with analgesics and/or anti-anxiety medications, although this is not a routine practice.   95

96. Typically, the aspirate is performed first. An aspirate needle is inserted through the skin until it abuts the bone. Then, with a twisting motion, the needle is advanced through the bony cortex (the hard outer layer of the bone) and into the marrow cavity. Once the needle is in the marrow cavity, a syringe is attached and used to aspirate ("suck out") liquid bone marrow. 96

97. 97

98. CURETTAGE BIOPSY This can be done on the surface of tumors or on small epidermal lesions with minimal to no topical anesthetic using a round curette blade. Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted. The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells. 98

99. CURETTAGE BIOPSY Liquid nitrogen or cryotherapy can be used as a topical anesthetic, however, freezing artifact can severely hamper the diagnosis of malignant skin cancers. 99

100. FROZEN SECTION BIOPSY performed to get an immediate histological report done to determine whether lesion is malignant or not TECHNIQUE tissue is obtained from lesion kept in deep freezer frozen tissue is sectioned and stained to get a prompt diagnosis. 100

101. DRAWBACKS In this type of biopsy, the slides cannot be preserved for future reference. The quality of the tissue sections is not as good as those of the permanent section.  A skilled pathologist and a knowledgeable surgeon can work together to use the frozen section's rapid availability to the patient's great benefit.     101

102. SMEARS The specimen is a liquid, or small solid chunks suspended in liquid. This material is smeared on a microscope slide and is either allowed to dry in air or is "fixed" by spraying or immersion in a liquid. The fixed smears are then stained, and examined under the microscope.   102

103. BITE BIOPSY A biopsy needle that is based upon an opening at the tip of the needle, not the side, that permits the entire sample to be cut from the patient yet has smooth sides to reduce injury to the patient when the needle is inserted. The needle of the invention has a coaxial inner needle or tube that allows the opening at the tip to be completely closed and the sample or specimen to be cut off at its point of attachment after insertion of the needle. The needle of the invention samples tissue in front of the needle as it is pushed forward, rather than scraping tissue from the edges of the needle track. 103

104. BITE BIOPSY In accordance with the invention, the coaxial inner needle can be withdrawn and the sample obtained without moving the outer needle or tube. Several samples can thus be obtained with minimal need for repositioning the needle avoiding pain, tissue damage and risks associated with such repositioning 104

105. CORE BIOPSY A core biopsy is a procedure where a needle is passed through the skin to take a sample of tissue from a mass or lump. Core biopsy may be performed when a suspicious lump is found. Core biopsy is a more invasive procedure than fine needle aspiration biopsy, as it involves a local anaesthetic. 105

106. HOW CORE BIOPSY IS PERFORMED Core biopsy is performed with the use of local anaesthetic A small incision (cut) is made in the skin over the lump, and a needle is inserted through the incision. When the tip of the needle is in the area to be examined, the specially-designed hollow needle is used to collect a sample of the cells that are present. The needle is then withdrawn, and the sample extracted. This may be repeated up to 5 times, until an adequate sample has been collected. 106

107. CORE BIOPSY Once the test is completed, a small dressing or some tape will be placed over the biopsy site. This can be removed the next day. COMPLICATIONS - Tenderness - Bruising - Swelling - Fever - Pain 107

108. RESULTS OF A CORE BIOPSY Inadequate/insufficient. Benign: There are no cancerous cells present. Atypical/indeterminate, or suspicious of malignancy: The results are unclear. Some cells appear abnormal but are not definitely cancerous. Malignant: The cells are cancerous, uncontrolled and have the potential or have spread to other areas of the body. 108

109. CORE BIOPSY OR FNAB? Fine needle aspiration biopsy is slightly quicker and less invasive than core biopsy. Fine needle aspiration biopsy does not require local anaesthetic as the needle is much finer. As with core biopsy, ultrasound or mammographic guidance may be needed to locate the lump or area to be sampled if it cannot be easily felt. Fine needle aspiration biopsy is more difficult to interpret than core biopsy. 109

110. CONE BIOPSY A cone biopsy is surgery to remove a cone-shaped piece of tissue from the cervix and cervical canal. Cone biopsy may be used to diagnose or treat a cervical condition. It is also called conization. A cone biopsy is done if a pap smear indicated moderate to severe cell changes. It can also be used to diagnose cervical cancer and to see how extensive the disease is.   110

111. RISK WITH CONE BIOPSY Risk with a cone biopsy are minimal.   After a cone biopsy, you can expect bleeding for up to a week and spotting and discharge for up to 3 weeks. 111

112. ENDOSCOPIC BIOPSY This is probably the most commonly performed type of biopsy.  It is done with the help of a fiber-optic endoscope (light, flexible tube) the doctor inserts into the gastrointestinal tract (alimentary tract endoscopy), urinary bladder (cystoscopy), abdominal cavity (laparoscopy), joint cavity (arthroscopy), mid-portion of the chest (mediastinoscopy), or trachea and bronchial system (laryngoscopy and bronchoscopy) - either through a natural body orifice or a small surgical incision.  112

113. ENDOSCOPIC BIOPSY 113

114. ENDOSCOPIC BIOPSY If you have Barrett's oesophagus, periodic endoscopic biopsy surveillance is the ONLY way to know for sure whether you are at increased risk for developing cancer. Periodic endoscopic biopsy surveillance has been shown to be safe and there is evidence that it is successful in the detection of oesophageal adenocarcinoma when the cancer is early and curable with surgery. 114

115. SHAVE BIOPSY INDICATIONS Non-pigmented Nevus Keratocanthoma Dermatofibroma Seborrheic Keratosis Cutaneous horn Possible small localized low-risk cancer CONTRAINDICATIONS 1.Do not shave biopsy possible Melanomas! 2. Do not shave biopsy pigmented lesions 3. Avoid shave biopsy of subcutaneous lesions 115

116. SHAVE BIOPSY Prep lesion with povidone-iodine (Betadine) Local Anesthesia with intradermal Local Lidocaine Shave tangential to skin with #15 blade Consider using Radiofrequency to smooth edges Effective at reducing scarring risk on face Use small electrosurgical loop electrode Set unit to 1.5 or 2.0 Stabilize hand against skin with pinky finger Use shallow short strokes to smooth lesion edges Hemostasis Aluminium chloride for face and mild bleeding   116

117. TANGENTIAL BIOPSY If a benign-looking, protruding mole needs to be removed due to irritation or to enhance cosmetic appearance, a technique called tangential incisional biopsy may be performed. This procedure consists of "shaving" the mole with a sharp scalpel parallel to the surface of the skin, followed by a light sanding. This biopsy removes the raised portion of the mole, leaving some mole cells in the skin. 117

118. TANGENTIAL BIOPSY A tangential-incisional-biopsy wound generally heal within two to three weeks as a flat scar approximately the same size as the original mole. It is important to provide good wound care to the area for the best cosmetic result. The healing tendency following tangential biopsies is unpredictable, depending greatly on the individual patient. If a raised scar does form, local steroid injections and firm deep massage are usually effective treatment.   118

119. EXPLORATORY BIOPSY Exploratory Biopsy is a diagnostic method used by doctors when trying to find a diagnosis for an ailment. It can be performed in both humans and animals, but it is far more common in animals. It is used most commonly to diagnose or locate cancer in humans, but it can be used for other ailments as well. Sometimes, cancer is located in a place where standard tests can't detect it. If a tumor is found, a biopsy is performed and tests are run to see what type of cancer was found. 119

120. UNPLANNED BIOPSY In the current report, the term unplanned excision is used synonymously with the term unplanned resection, to include patients who have had an excisional biopsy or an unplanned resection without preoperative imaging and without regard for the necessity to resect the tumor with a margin of normal tissue. SABRENA NORIA, , AILEEN DAVIS, M.SC., B.SC., P.T., RITA KANDEL et al Residual Disease following Unplanned Excision of a Soft-Tissue Sarcoma of an Extremity* 120

121. LYMPH NODE BIOPSY Lymph node biopsy is a test in which a lymph node or a piece of a lymph node is removed for examination under a microscope. The test is done in an operating room in a hospital, or at an outpatient surgical facility. There are two ways by which the sample may be obtained: -Needle biopsy - Open (excisional) biopsy 121

122. LYMPH NODE BIOPSY Needle biopsy A needle biopsy involves inserting a needle into a node to obtain the sample. Open biopsy An open biopsy consists of surgically removing all or part of a node. 122

123. TONGUE BIOPSY A tongue biopsy is surgery to remove a piece of the tongue for examination under a microscope. It can be done using a needle. After numbing the area, the health care provider gently sticks the needle into the tongue and removes a tiny piece of tissue. A needle biopsy is often somewhat uncomfortable even with use of an anesthetic, because the tongue is quite sensitive. The test is done to determine the cause of abnormal growths, lesions, or suspicious-appearing areas of the tongue. 123

124. TONGUE BIOPSY Abnormal Results Mean Amyloidosis Tongue (oral) cancer Risks Bleeding Infection Swelling of the tongue (can obstruct the airway and cause breathing difficulty 124

125. SKIN BIOPSY Skin biopsy is a biopsy technique in which a skin lesion is removed and sent to the pathologist to render a microscopic diagnosis. There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy. 125

126. SKIN BIOPSY SHAVE BIOPSY This is done with either a small scalpel blade, a curved razor blade, or a broken piece of "safety" razor. PUNCH BIOPSY This is done with a round shaped knife ranging in size from 1mm to 8 mm. 126

127. SKIN BIOPSY INCISIONAL BIOPSY When a cut is made through the entire dermis down to the subcutanous fat. Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutanous tissue can be obtained than a punch biopsy. EXCISIONAL BIOPSY This is essentially the same as incisional biopsy, except the entire lesion or tumor is included. 127

128. SKIN BIOPSY CURETTAGE BIOPSY This can be done on the surface of tumors or on small epidermal lesions with minimal to no topical anesthetic using a round curette blade. FNAB It is a method used to diagnose tumor deep in the skin or lymphnodes under the skin. 128

129. Principles of Surgery 129

130. Anesthesia Block anesthesia is preferred to infiltration. When blocks are not possible distant infiltration may be used. Never inject directly into the lesion 130

131. Tissue Stabilization Digital stabilization Specialized retractors/forceps Retraction sutures Towel Clips 131

132. Hemostasis Suction devices should be avoided Gauze compresses are usually adequate Gauze wrapped low volume suction may be used if needed 132

133. Incisions Incisions should be made with a scalpel. They should be converging Should extend beyond the suspected depth of the lesion They should parallel important structures Margins should include 2 to 3mm of normal appearing tissue if the lesion is thought to be benign. 5mm or more may be necessary with lesions that appear malignant, vascular, pigmented, or have diffuse borders. 133

134. Handling of the Tissue Specimen Direct handling of the lesion will expose it to crush injury resulting in alteration the cellular architecture. 134

135. Specimen Care The specimen should be immediately placed in 10% formalin solution, and be completely immersed. 135

136. Margins of the Biopsy Margins of the tissue should be identified to orient the pathologist. A silk suture is often adequate. Illustrations are also very helpful and should be included. 136

137. Surgical Closure Primary closure of the wound is usually possible Mucosal undermining may be necessary Elliptical incision on the hard palate or attached gingiva may be left to heal by secondary intention. 137

138. Biopsy Data Sheet A biopsy data sheet should be completed and the specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed. 138

139. BIOPSY DATA SHEET 139

140. AFTER THE BIOPSY The specimen should be delivered to the laboratory fresh in a sterile universal container. Ensure- Documentation Packing Labeling Safe Transportation 140

141. AFTER THE BIOPSY -FIXATION Ensure the specimen is placed in an adequate volume of fixative, this should be at least ten times the volume of the specimen. Avoid the use of gauze to place the specimen onto as it merely absorbs the fixative and can make separation of the specimen from the gauze difficult. The fixative should be 10% neutral buffered formalin which has a pungent and distinct odour. Occasionally, formalin is further diluted with water by ancillary staff or specimens are placed in alternative solutions such as saline or water which results in poor fixation and artefactual change. 141

142. AFTER THE BIOPSY - FIXATION Formalin fixes specimens by forming intermolecular bridges between proteins and cross-links between protein end-groups. If this process does not occur, soon after removal from the body the specimen will undergo autolysis. 142

143. When not to fix a biopsy material A disadvantage of the protein cross-linking produced by formalin is that the specimen is rendered unsuitable for immunofluorescent antibody staining. The diagnosis of vesiculobullous autoimmune disorders is aided by direct immunofluorescence of perilesional tissue which requires fresh material that can be immediately frozen. 143

144. When not to fix a biopsy material The other main situation where fresh tissue is processed is when frozen sections are used to examine surgical margins perioperatively. For Microbiological culture specimen should be sent fresh to the laboratory 144

145. AFTER THE BIOPSY -Packing & trasportation Both the tissue and the formalin in which it is placed are potentially harmful to those handling the specimen. The primary container in which the specimen is placed with the formalin should be tightly sealed and wrapped in sufficient absorbent material to absorb the fixative if leakage occurs. Paper towels or cotton wool are suitable for this purpose. The wrapped container should then be placed in a sealed plastic bag which should then be placed in a rigid outer container which is capable of being secured by adhesive tape. 145

146. AFTER THE BIOPSY -Packing & trasportation Specific cardboard boxes with full-depth lids or grooved polystyrene containers are available for this purpose. A further outer padded bag is recommended which should be labelled ‘PATHOLOGICAL SPECIMEN — FRAGILE WITH CARE’ and the name and address of the sender should be clearly displayed. 146

147. AFTER THE BIOPSY -- Tissue processing The fixed tissue is dehydrated by immersion in a series of the solvents, & impregnated with paraffin wax. The wax block is mounted on a microtome & usually 4 µm thick, are cut & mounted on glass microscope slides for staining. It takes 24-48 hours to fix, process, section & stain a specimen before the pathologist can report on it. 147

148. ARTEFACTS IN HISTOPATHOLOGY Artifacts are structures or features in tissue that interfere with normal histological examination. Artifacts interfere with histology by changing the tissues appearance and hiding structures. These can be divided into two categories: Pre-histology Post-histology 148

149. ARTEFACTS Defects or abnormalities in tissue sections may result from the faulty processing of the tissue specimens. These are referred to as artefacts. Artefacts may occur at different stages in the routine collection of tissues, fixation, processing, cutting and staining of tissues. The presence of a fine black precipitate on the slides, often with no relationship to the tissue (i.e., the precipitate appears adjacent to tissues or within interstices or vessels) suggests formalin-heme pigment has formed. 149

150. ARTEFACTS Tissues that are insufficiently dehydrated prior to clearing and infiltration with paraffin wax will be hard to section on the microtome, with tearing artefacts and holes in the sections. Though alcohols such as ethanol make excellent fixatives for cytologic smears, they tend to make tissue sections brittle, resulting in microtome sectioning artefacts with chattering and a "venetian blind" appearance. 150

151. ARTEFACTS Bubbles under the coverslip may form when the mounting media is too thin, and as it dries air is sucked in under the coverslip. Contamination of clearing agents or coverslipping media may also produce a bubbled appearance under the microscope. 151

152. RECENT ADVANCES Advances in the early detection of oral cancer are unfolding and analogous to those made in the advances for cervical cancer. Brush cytology has the potential to assist the diagnostic portion of the "screening gap" which currently challenges the early detection of many epithelial cancers, including oral cancer. Brush cytology can be a noninvasive means of diagnosing dysplasia and early carcinoma in those patients who are either asymptomatic or in those with minor symptoms who do not warrant immediate biopsy . 152

153. RECENT ADVANCES Examples of well-known applications of brush biopsies include fiberoptic bronchoscopy (bronchial), ureteral retrograde brush biopsy (renal or ureter tissue), cholangiography (bile duct stricture), pancreatic ductal brush biopsies and others, including endometrial, nasopharynx, and GI tract applications (rectal, gastric, esophageal, colon). Their use in the oral cavity was introduced by a commercial company OralCDx in 2000. 153

154. Bibliography Oral and maxillofacial surgery by Peterson Ellis Hupp Tucker (4 th edition) Minor oral surgery by Geoffrey L Howe (3 rd edition) An atlas of minor oral surgery by David A McGowan (2 nd edition) Oral and maxillofacial pathology by Robert E Marx, Diane Marx. Textbook of oral pathology by Shafer Hine Levy (4 th edition) Endodontic Practices by Louis Grossman (11 th edition) Internet 154