PRINCIPLES of DIFFERENTIAL PRINCIPLES of DIFFERENTIAL DIAGNOSIS AND DIAGNOSIS AND BIOPSYBIOPSY

EXAMINATION AND DIAGNOSTIC METHODS HEALTH HISTORY HISTORY OF LESION CLINICAL EXAMINATION RADIOGRAPHIC EXAMINATION LABORATORY EXAMINATION

INDICATIONS FOR BIOPSY

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

Any inflammatory lesion that does not respond to local treatment (or just allow it to heal) after 10-14 days

Persistent hyperkeratotic changes in surface tissues

INDICATIONS FOR BIOPSY Any persistent tumescence, either visible or

palpable beneath relatively normal tissue Inflammatory changes of unknown cause that

persist for long periods Lesions that interfere with local function

(e.g.fibroma) Bone lesions not specifically identified by

clinical and radiographic findings Any lesion that has the characteristics of

malignancy

PRINCIPLES OF BIOPSY

INCISIONAL BIOPSY EXCISIONAL BIOPSY ASPIRATION (FINE NEEDLE

ASPIRATE “FNA”) CYTOLOGY (e.g. brush biopsy)

“Diagnostic Imperative” If one of the choices in

the differential diagnosis is a malignancy, you MUST rule that possibility out

Corollary: If one of the choices REQUIRES histological exam for extensive therapy, you MUST rule that possibility out

SURGICAL PRINCIPLES ANESTHESIA TISSUE STABILIZATION HEMOSTASIS INCISION HANDLING OF TISSUE IDENTIFICATION OF

MARGINS SPECIMEN CARE SURGICAL CLOSURE PAPERWORK!

BIOPSY TECHNIQUES Anesthetize around

lesion, not in it Use an assistant

and the “Adams forceps”

Pick a representative spot to R/O worst disease

BIOPSY TECHNIQUES Make sure to

include lesion margins and some normal

Get deep enough to include suspected lesion

“Only sin is not getting enough”

BIOPSY TECHNIQUES Use fingers, tissue

forceps and scissors or scalpel

“Blotting” usually better than suction

Gauze and finger pressure stops most bleeding!

Close with 4/0 chromic

BIOPSY TECHNIQUES Get specimen in

formalin ASAP Watch for

crushing If only mucosa,

consider sewing to suture backing and labeling margins

Pigmented and leukoplakia lesions

Oral Brush Biopsy

ADVANTAGES good for lesions

otherwise “watched” fast no great skill required good instructions good for cancer and

needle phobics covered by insurance

DISADVANTAGES may still require

biopsy false negatives? Must get

representative sample

Oral Brush Biopsy To be used only

on leukoplakic, ulcerous or erythematous lesions

Not to be used on submucosal or deep masses or bony lesions

Excisional BiopsyLesions 1 cm or smaller

Incisional Biopsylesions larger than 1 cm

Mucoceles

HARD TISSUE BIOPSY ASPIRATION FLAP EXPOSURE OSSEOUS WINDOW REMOVAL OF SPECIMEN SPECIMEN CARE

Bone Lesions In general, opaque lesions less serious,

lucent lesions more serious

Hard tissue biopsy

CHARACTERISTICS OF LESIONS THAT RAISE THE SUSPICION OF MALIGNANCY Erythroplasia - lesion is totally red or

has a speckled red and white appearance

Ulceration - lesion is ulcerated or presents as an ulcer

Duration - lesion has persisted more than 2 weeks

CHARACTERISTICS OF LESIONS THAT RAISE THE SUSPICION OF MALIGNANCY 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

Suspicion of malignancy Almost all can wait 2 weeks

Remove irritants “Bad things don’t go away” Try conservative therapy in meantime

Fine needle aspiration (FNA)

Used for palpable but occult masses in areas otherwise difficult to biopsy

When to Refer?

Patient health Surgical

difficulty Access to

pathologist? Suspicion of

Malignancy

Thank you !