principles of tissue biopsy in oral and maxillofacial surgery speaker: 黃傳貴 大夫 speaker:...

Principles of Tissue Biopsy Principles of Tissue Biopsy in Oral and Maxillofacial in Oral and Maxillofacial

SurgerySurgery

Speaker: Speaker: 黃傳貴 大夫黃傳貴 大夫Moderator:Moderator: 雷文天 大夫雷文天 大夫

Examination Examination && Diagnostic Methods Diagnostic Methods

Health historyHealth history History of the lesionHistory of the lesion Clinical examinationClinical examination Radiographic examinationRadiographic examination Laboratory investigationLaboratory investigation BiopsyBiopsy

Definition of BiopsyDefinition of Biopsy

Removal of tissue from a living individual fRemoval of tissue from a living individual for diagnostic examinationor diagnostic examination

Indication for BiopsyIndication for Biopsy

Any lesion persists for more than 2 weeks Any lesion persists for more than 2 weeks with no apparent etiology basiswith no apparent etiology basis

Any inflammatory lesion that does not respAny inflammatory lesion that does not respond to local treatment after 10 to 14 days ond to local treatment after 10 to 14 days (that is,after removing local irritant) (that is,after removing local irritant)

Indication for BiopsyIndication for Biopsy

Persistent hyperkeratosis changes in surfaPersistent hyperkeratosis changes in surface tissue (ex:lips or oral mucosa)ce tissue (ex:lips or oral mucosa)

Any persistent tumescence,either visible oAny persistent tumescence,either visible or palpable beneath relatively normal tissuer palpable beneath relatively normal tissue

Lesion that interfere with local function (ex:Lesion that interfere with local function (ex:fibroma)fibroma)

Indication for BiopsyIndication for Biopsy

Bone lesions not specifically identified by Bone lesions not specifically identified by clinical and radiographic findingclinical and radiographic finding

Any lesion that has the characteristics of Any lesion that has the characteristics of malignancy malignancy

Characteristics of lesions that raise Characteristics of lesions that raise the suspicion of malignancythe suspicion of malignancy

Erythroplasia—lesion is totally red or has Erythroplasia—lesion is totally red or has speckled red appearancespeckled red appearance

Ulceration—lesion is ulcerated or presents Ulceration—lesion is ulcerated or presents as an ulceras an ulcer

Duration— lesion has persisted more than Duration— lesion has persisted more than 2 weeks2 weeks

Characteristics of lesions that raise Characteristics of lesions that raise the suspicion of malignancythe suspicion of malignancy

Growth rate– lesion exhibits rapid growthGrowth rate– lesion exhibits rapid growth Bleeding— lesion bleeds on gentle manipuBleeding— lesion bleeds on gentle manipu

lation lation Induration– lesion and surrounding tissue iInduration– lesion and surrounding tissue i

s firm to the touchs firm to the touch Fixation– lesion feels attached to adjacent Fixation– lesion feels attached to adjacent

structuresstructures

Aspiration BiopsyAspiration Biopsy

Aspiration biopsy is the use of a needle anAspiration biopsy is the use of a needle and syringe to penertrate a lesion for aspiratid syringe to penertrate a lesion for aspiration of its contenton of its content

Indication of Aspiration Biopsy Indication of Aspiration Biopsy

Aspiration should be carried out on all lesions thAspiration should be carried out on all lesions thought to contain fluid or any intraosseous lesion ought to contain fluid or any intraosseous lesion before surgical explorationbefore surgical exploration

a fluctuant mass in the soft tissues should also a fluctuant mass in the soft tissues should also be aspirated to determine its contentsbe aspirated to determine its contents

Any radiolucency in the bone of the jaw should bAny radiolucency in the bone of the jaw should be aspirated to rule out a vascular lesion that can e aspirated to rule out a vascular lesion that can cause life threatening hemorrhagecause life threatening hemorrhage

Technique of Aspiration BiopsyTechnique of Aspiration Biopsy

A 18-gauge needle is connected to a 5 or A 18-gauge needle is connected to a 5 or 10 ml syringe10 ml syringe

The tip of needle may have to be The tip of needle may have to be repeatedly repositioned to locate a fluid repeatedly repositioned to locate a fluid centercenter

Excisional BiopsyExcisional Biopsy

Removal of the entire lesionRemoval of the entire lesion A perimeter of normal tissue surround the A perimeter of normal tissue surround the

lesion is also excised to ensure total lesion is also excised to ensure total removal removal

Constitute definitive treatmentConstitute definitive treatment

Indication of Excisional BiopsyIndication of Excisional Biopsy

Smaller lesions(Smaller lesions(<1cm, in diameter) that,on <1cm, in diameter) that,on clinical examination, appear to be benignclinical examination, appear to be benign

Principle of Excisional BiopsyPrinciple of Excisional Biopsy

The entire lesion, along with 2 to 3 mm of The entire lesion, along with 2 to 3 mm of normal appearing surrounding tissue, is normal appearing surrounding tissue, is excisedexcised

Principle of Excisional BiopsyPrinciple of Excisional Biopsy

Incisional BiopsyIncisional Biopsy

Samples only a particular or Samples only a particular or representative part of the lesionrepresentative part of the lesion

Lesion is largeLesion is large Lesion has different characteristics at Lesion has different characteristics at

different locationdifferent location

Indication of Incisional BiopsyIndication of Incisional Biopsy

Extensive size (Extensive size (>1 cm in diameter)>1 cm in diameter) Hazardous locationHazardous location A great suspicious of malignancyA great suspicious of malignancy

Principles of Incisional BiopsyPrinciples of Incisional Biopsy

Representative areas of lesion should be iRepresentative areas of lesion should be incised in wedge fasionncised in wedge fasion

Selected in an area that shows complete tiSelected in an area that shows complete tissue changes(the lesion extends into norssue changes(the lesion extends into normal tissue at the base and/or margin of thmal tissue at the base and/or margin of the lesion)e lesion)

Principles of Incisional BiopsyPrinciples of Incisional Biopsy

Necrotic tissue should be avoided Necrotic tissue should be avoided Taken from the edge of the lesion to includTaken from the edge of the lesion to includ

e some normal tissuee some normal tissue A deep, narrow biopsy rather than a broad,A deep, narrow biopsy rather than a broad,

shallow oneshallow one

Principles of Incisional BiopsyPrinciples of Incisional Biopsy

AnesthesiaAnesthesia

Block local anesthesia techniques are empBlock local anesthesia techniques are employed when possibleloyed when possible

The anesthesic solution should not be injeThe anesthesic solution should not be injected within the tissue to be removed, becacted within the tissue to be removed, because it can cause artificial distortion of the suse it can cause artificial distortion of the specimen pecimen

AnesthesiaAnesthesia

When blocks are not possible, infilitration oWhen blocks are not possible, infilitration of local anesthesia may be used locally,but f local anesthesia may be used locally,but the solution should be injected at least 1 cthe solution should be injected at least 1 cm away from the lesion m away from the lesion

Tissue StabilizationTissue Stabilization

Tongue or soft palate Tongue or soft palate

--Heavy retractive sutures--Heavy retractive sutures

--Towel clips--Towel clips LipLip

-- assistant’s finger pinching the lip on both-- assistant’s finger pinching the lip on both

sides of the biopsy areasides of the biopsy area

Tissue StabilizationTissue Stabilization

Identification of Surgical MarginsIdentification of Surgical Margins

Marked with a silk suture to orient the Marked with a silk suture to orient the specimen for the pathologistspecimen for the pathologist

If the lesion is diagnosed as requiring If the lesion is diagnosed as requiring additional treatment, the pathologist can additional treatment, the pathologist can determine which margin, if any had determine which margin, if any had residualresidual

Identification of Surgical MarginsIdentification of Surgical Margins

One must be certain to illustrate the One must be certain to illustrate the orientation of the lesion and the method orientation of the lesion and the method with which the specimen was marked in with which the specimen was marked in the pathology data sheetthe pathology data sheet

HemostasisHemostasis

Avoid suction deviceAvoid suction device Gauze wrapped over the tip of the low Gauze wrapped over the tip of the low

volume suction devicevolume suction device Simple gauze compressionSimple gauze compression

Specimen CareSpecimen Care

Immediately placed in 10Immediately placed in 10% formalin % formalin solution that is at least 20 times the solution that is at least 20 times the volume of surgical specimenvolume of surgical specimen

Totally immersed in the solutionTotally immersed in the solution

Specimen CareSpecimen Care

Care should be taken to be sure that the Care should be taken to be sure that the tissue has not become lodged on the wall tissue has not become lodged on the wall of the container above the level of the of the container above the level of the formalinformalin

Surgical Closure Surgical Closure

Primary closure of the elliptic wound is Primary closure of the elliptic wound is usually possible usually possible

Palatal biopsy: best managed Palatal biopsy: best managed postoperatively with the use of an acrylic postoperatively with the use of an acrylic splintsplint

Surgical ClosureSurgical Closure

Dorsum or lateral border of the tongue: Dorsum or lateral border of the tongue: sutures to be placed deeply and at sutures to be placed deeply and at frequent intervals into the substance of the frequent intervals into the substance of the tongue to retain closuretongue to retain closure

Final DiagnosisFinal Diagnosis

The final diagnosis should correspond to The final diagnosis should correspond to the clinical course before and after biopsythe clinical course before and after biopsy

A negative pathology report for cancer A negative pathology report for cancer should not lull the dentist into a false should not lull the dentist into a false sense of security when the clinical sense of security when the clinical characteristics of the lesion still indicate characteristics of the lesion still indicate malignant potentialmalignant potential

Final DiagnosisFinal Diagnosis

If the pathology report does not If the pathology report does not corroborate the clinical impression of the corroborate the clinical impression of the lesion, the biopsy procedure should be lesion, the biopsy procedure should be repeatedrepeated

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