BIOPSY

Definition:
• Biopsy is a surgical procedure to obtain tissue from a living organism for its microscopical examination, usually to perform a
diagnosis.
Why Are Biopsies Done?
• A mammogram shows a lump or mass, indicating the possibility of breast cancer.
• A mole on the skin has changed shape recently and melanoma is possible.
• A person has chronic hepatitis and it's important to know if cirrhosis is present.
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
How to prepare for a biopsy
• Ask your doctor or nurse whether you can eat or drink anything before the biopsy.
• Also ask if you should take your regular medications that day. For certain biopsies, your doctor will want to know if you are
taking blood thinners or aspirin. Tell your doctor about all medications and supplements you are taking.
• Tell your doctor about any drug allergies or other medical conditions you may have.
• A member of your health care team will explain the procedure to you.
• You will be asked to sign a consent form that states you understand the benefits and risks of the biopsy and agree to have the
test done.
• Talk with your doctor about any concerns you have.
Prerequisites for a biopsy
• CBC, platelets, coagulation studies
• cross-sectional imaging - to evaluate local anatomy
• treatment center performing biopsy must be capable of proper diagnosis and treatment
Indications for Biopsy
• Inflammatory changes of unknown cause that persist for long periods
• Lesion that interfere with local function
• Bone lesions not specifically identified by clinical and radiographic findings
• Any lesion that has the characteristics of malignancy
 • aggressive bone or soft tissue lesions
• soft tissue lesions larger than 5cm, deep to fascia, or overlying bone/neurovascular structures
• unclear diagnosis in a symptomatic patient
• solitary bone lesions in a patient with history of carcinoma
When a biopsy is not indicated?
• asymptomatic latent bone lesions or a symptomatic active bone lesions which appear entirely benign on imaging don't
necessarily need a biopsy
• soft tissue lesion which are completely benign on MRI don't necessarily need a biopsy (e.g. lipoma, hemangioma)
TYPES OF BIOPSIES

 Image-guided biopsy.
 Fluoroscopy
 X-ray
 Magnetic resonance imaging (MRI) scan
 Image-guided biopsy
 CT-guided biopsy.
 Ultrasound-guided biopsy.
Other types of Biopsies
• Aspiration biopsy.
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 presents of fluid within a lesion

 To a certain the type of fluid within a lesion
 When exploration of an intraosseous lesion is indicated
Procedures:
 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.

 The material withdrawn during aspiration biopsy can be submitted for pathologic examination and/or culturing.

•  The inability to withdraw fluid or air indicates that the lesion is probably solid.
• A radiolucent lesion in the jaw that yields straw-colored fluid on aspiration is most likely a cystic lesion.
• If purulent exudate (pus) is withdrawn, then an inflammatory or infectious process should be considered..
• The aspiration of blood might indicate a vascular malformation within the bone.
• Any intra-bony radiolucent lesion should be aspirated before surgical intervention to rule out a vascular lesion.
• If the lesion is determined to be vascular in nature, the flow rate (high versus low) should be determined because
uncontrollable hemorrhage can occur if incised
Other types of Biopsies
• Surgical biopsy.
• Needle biopsy.
• Fine needle aspiration biopsy.
• provides cytologic (cellular) specimen
• frequently used for carcinoma
• not typically used for sarcoma
• Vacuum-assisted biopsy.
• Shave biopsy.
• Core needle biopsy.
• allow for tumor structural examination
• can evaluate both the cytologic and stromal elements of the tumor
• frequently used for soft tissue sarcoma
• 85-95% accuracy in diagnosis
• Excisional biopsy.
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 biopsy implies the complete removal of the lesion.

 A perimeter of normal tissue (2-3 mm) surrounding the lesion is included with the
specimen.
 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.

• 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.
• whenever the lesion is difficult to excise because of its extensive size
• in cases where appropriate excisional surgical management requires hospitalization or complicated wound management.
Technique of Incisional Biopsy
 • 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.
Principles of the open incisional biopsy
• Incision
• use longitudinal incision in the extremities
• allows for extension of the incision for definitive management
• Approach
• do not expose neurovascular structures
• all tissue exposed during the biopsy is considered contaminated with tumor
• maintain meticulous hemostasis
• post-operative hematomas are considered contaminated with tumor
• release tourniquet prior to wound closure
• Biopsy
• perform through the involved compartment of the tumor
• for bone lesions with a soft tissue mass, it is ok to perform the biopsy using the soft tissue mass
• Closure
• if using a drain, bring drain out of the skin in line with surgical incision
• allows drain site to be removed with definitive surgical extensile incision
• Endoscopic biopsy.
• Laparoscopic biopsy.
• Liquid biopsy.
Punch biopsy. Another tool that can be used for incisional or excisional purposes. biopsy is especially
well suited for diagnosis of oral manifestations of mucocutaneous and vesiculoulcerative diseases
Technique of punch biopsy
• biopsy punches should range in size from 2-10 mm in diameter
• the smaller diameters should be avoided due to the risk of over-manipulating 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
• One disadvantage of using the biopsy punch is that it is difficult to obtain adequate, representative tissue.
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.
Location of Biopsies
• Bone marrow biopsy.
• Bone marrow aspiration and biopsy
• Liver biopsy.
• Kidney biopsy.
• Capsule biopsy
• Prostate biopsy.
• Skin biopsy.
• Bone biopsy.
Who does a biopsy and who analyzes the sample?
• A surgeon
• A radiologist,
• An oncologist,
• A gastroenterologist,
• A pathologist,
• A cytologist,
• A dermatologist,
• A gynecologist,
• A family practice doctor
• Other specialists
During the procedure
• Local anesthesia is injected.
• Conscious sedation or monitored anesthesia is administered.
• General anesthesia
Principles of Surgery
Anesthesia-
• Block anesthesia is preferred to infiltration
• When blocks are not possible distant infiltration may be used
• Never inject directly into the lesion
TISSUE STABILIZATION
• Digital stabilization
• Specialized retractors/forceps
• Retraction sutures
• Towel Clips
• Hemostasis Suction devices should be avoided
• Gauze compresses are usually adequate
• Gauze wrapped low volume suction may be used if needed
Hemostasis
• Suction devices should be avoided
• Gauze compresses are usually adequate
• Gauze wrapped low volume suction may be used if needed
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.
Handling of the Tissue Specimen
special care should be undertaken to hold the specimen gently at the periphery of the sample.
• Injection of large amounts of anesthetic solution in the biopsy area, while providing hemostasis, can produce hemorrhage,
which masks the normal cellular architecture.
• Infiltration of local anesthetic around the lesion is acceptable if the field is wide enough in relation to the lesion;
• injection directly into the lesion should be avoided.
 • Use of electrocautery to excise the specimen remains a common complicating factor in determining an accurate microscopic
diagnosis.
• Heat produced by these units alters both the epithelium and the underlying connective.
• Small tissue biopsies to rule out malignancy are usually nondiagnostic if excised by electrocautery, as the presence of
epithelial atypia is typically obscured
• If electrocautery is to be used, the incision margin should be far enough away from the interface of the lesion to prevent
thermal changes at that interface
Specimen Care
• The specimen should be immediately placed in 10% formalin solution, and be completely immersed.
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.
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.
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.
The biopsy report
It should include
• the name of the clinician,
• date the specimen was obtained
• pertinent characteristics of the specimen.
• The location/site, size, color, number, borders or margins, consistency, and relative radiodensity of the lesion are all important
findings that should be included in the description of the specimen.
• If the lesion is evident on radiographs, it is very important to submit good quality radiographs with the specimen to aid in
pathologic correlation and diagnosis.
Intr avlaosseous and Hard Tissue Biopsy
• Intraosseous lesions are most often the result of problems associated with the dentition.
Indications for Intraosseous Biopsy
Surgical incision should be designed to allow adequate access for incisional/excisional biopsy.
• Incisions should be over sound bone
• Cortical perforation must be considered when designing flaps
• Flaps should be full thickness
• Osseous windows should be submitted with the specimen
• Osseous preformations can be enlarged to gain access
• Avoid roots and neurovascular structures
• The tissue consistency and nature of the lesion will determine the ease of removal
• PRINCE SURGER
• Incisional biopsies only require removal of a section of tissue
• Soft tissue overlying the lesion should be reapproximated following thorough irrigation of the operative site.
• The specimen should be handled as previously described
•
• Osseous windows should be submitted with the specimen
• Osseous preformations can be enlarged to gain access
• Avoid roots and neurovascular structures
• The tissue consistency and nature of the lesion will determine the ease of removal
After the procedure
The risks of a biopsy
• Infection
• Bleeding
• Severe pain
• Fever OS BALAK ULOKAN
Following up after a biopsy
• Growing ap upotho
When To Refer For Biopsy
• When the health of the patient requires special management that the dentist feel unprepared to handle
• The size and surgical difficulty is beyond the level of skill that the dentist feels he/she possesses
• If the dentist is concerned about the possibility of malignancy
Questions to ask your health care team