CHAPTER 22: PRINCIPLES OF DIFFERENTIAL DX AND BIOPSY

ppt / book

biopsy

the removal of tissue from a living individual for diagnostic examination

the primary purpose is to determine the diagnosis precisely so that proper treatment can be provided

biopsy = malignancy

clinical examination

anatomic location of the lesion

overall physical characteristics of the lesion

single versus multiple lesions

size, shape, and growth presentation

surface appearance of the lesion

lesion coloration

sharpness of lesion borders and mobility

consistency of the lesion to palpation

presence of pulsation

examination of regional lymph nodes

most fatal locations in the oral cavity

floor of the mouth

posterolateral border of the tongue

dorsum of tongue

this location could originate from epithelial, connective, vascular, neural, muscular, glandular, lymphatic tissues

inner lower lip

this location could consider a minor salivary gland origin, among other possibilities.

herpes zoster

this location of lesions may follow a linear pattern along a nerve pathway.

viral, bacterial, vesiculobullous diseases

commonly produce multiple lesions

small metric ruler

used to measure the lesion.

• describe whether the lesion is:

  • flat → not elevated

  • slightly elevated

  • endophytic → grows inward

  • exophytic → grows outward

  • sessile → broad-based

  • pedunculated → attached by a stalk

macule (<10mm)

flat, non-palpable lesion, circumscribed non-elevated area of color change that is distinct from adjacent tissues

examples:

• freckle

• petechiae

patch (>10mm)

a flat, discolored area on the skin

examples:

• café-au-lait spot

• vitiligo

• port-wine stain

• leukoplakia

• melasma

papules (<10mm)

circumscribed, small, elevated, solid palpable mass of the skin or mucosa

examples:

• mole

• lichen planus → most common oral lesion 

plaques (>10mm)

flat, slightly elevated superficial lesion

example:

• psoriasis

• eczema

nodules

dome-shaped lesion → another description

firm lesions that extend into the dermis or subcutaneous tissue

a large, elevated, circumscribed and solid palpable mass of the skin or mucosa

examples:

• cysts

• lipomas

• fibromas

vesicles (<10mm)

clear, fluid-filled blisters, a small blister, circumscribed elevation of skin or mucosa containing serous fluid

example:

• herpes simplex

• chickenpox

bullae (>10mm)

a blister, an elevated, circumscribed, fluid-containing lesion of skin or mucosa

example:

• burns

• bullous pemphigoid

pustules

small, cloudy, elevated, circumscribed pus-containing vesicle on skin or mucosa

example:

• acne

• impetigo

• pustular psoriasis

flat lesions

macule

patch

elevated lesions

papule

plaque

nodule

fluid-filled lesions

vesicle

bulla

pustule

clinical discovery of unilateral lesions

herpes zoster (shingles) trigeminal neuralgia (aka: tic douloureu)

managed by tegretol → common brand name carbamazepine

clinical discovery of bilateral lesions

lichen planus

malignant

aggressive, enlarging lesion

cyst with irregular borders might indicate a more aggressive lesion

benign

slower-growing lesion

endophytic

growing inward

exophytic

growing outward

sessile

broad-based

pedunculated

on a stalk

margins of an ulcer

flat

rolled

raised

everted

base of an ulcer

smooth

granulated

fungating appearance

hemorrhagic crust (scab)

covered by fibrin membrane/slough

vascular lesion

dark bluish + blanches on pressure

mucus-retaining cyst

lighter bluish + does not blanch

pigmented lesion

could be a traumatic tattoo or melanotic tumor

white / keratinized lesion

may result from repeated trauma or potentially premalignant changes

red / red-and-white lesion

may indicate more concerning dysplastic changes

has poor prognosis than a white lesion

fluctuant

used to describe the wave-like motion felt during bidigital palpation of a lesion with nonrigid walls that contains fluid

pulsation can be accompanied by:

thrill → palpable vibration

bruit → audible murmur

clinical importance: risk of fatal hemorrhage !

pulsation → rhythmic movement felt during palpation

examination of regional lymph nodes

should be accomplished before any biopsy procedure

bc biopsy can cause reactive lymphadenitis, which may make later diagnosis difficult.

• after biopsy, enlarged nodes could be due to:

  • reaction to the biopsy

  • infection/inflammation

  • metastatic tumor

• record:

  1. location

  2. size – preferably in centimeters

  3. pain/tenderness

  4. fixation

     • fixed, matted, movable

  5. texture

     • soft, firm, hardened

• should be systematic:

  • occipital

  • preauricular and postauricular

  • mandibular, submandibular, and submental

  • deep anterior cervical chain

  • superficial cervical nodes

    • along the sternocleidomastoid muscle

  • deep posterior cervical chain

  • supraclavicular nodes

  • buccal lymph nodes may or may not be routinely palpable.

shotty nodes

multiple slightly enlarged

barely palpable lymph nodes

feel like bird shot under the fingers

characteristics of lesions raise suspicion of malignancy

bleeding → bleeds on gentle manipulation

induration → surrounding tissues are firm to touch

growth rate → rapid growth

fixation → feels attached to adjacent structures

erythroplasia → totally red or speckled red-white appearance

ulceration → presents as an ulcer

duration → persisted > 2 weeks

mnemonic: BIGFEUD

indications of biopsy

refractory (poor prognosis)

to confirm a clinical diagnosis

persistent inflammatory signs

unexplained red, white, or pigmented lesions

intrabony lesions that appear to be enlarging

lesions suspected to be malignant or premalignant

lesions that grow rapidly without an obvious reason

persistent lesions that cannot be clinically diagnosed

lesions causing extreme patient concern (cancerphobia)

submucosal swelling beneath apparently normal mucosa

lesions that are firmly attached/fixed to nearby structures

lesions with no identifiable cause that remain for more than 10–14 days despite local treatment

lesions that do not respond to routine treatment or removal of a local irritant within 10–14 days

• unknown lesions in high-risk cancer areas, such as:

  • floor of the mouth, tongue

soft tissue biopsy techniques

• nerve block anesthesia

  • solution be injected at least 1cm away from the lesion → if local infiltration is needed

  • if within the tissues → artifactual distortion of the specimen

• tissue stabilization

  • tractional sutures & towel clips → can be used to aid immobilization of the tongue or soft palate

• hemostasis

  • the use of a suction device for keeping the surgical field free of blood during the procedure should be minimized as much as possible

  • use gauze instead

• incision

  • 2 football/elliptical-shaped incisions can be made, should converge toward the base

  • a periphery of normal-appearing tissue should be included in excisional biopsy specimens

  • this:

    • produces a good specimen, makes the wound easier to close

      • if it appears benign → 2-3mm of peripheral tissue

      • if it appears malignant → 5mm of peripheral tissue

  • carbon dioxide laser

    • used when necessary, but can still produce a narrow zone of tissue necrosis.

• removal of specimen

  • a dental curette is used

    • concave surface → in contact with the bone

    • convex surface → separates the specimen from surrounding bone

• specimen care

  • be placed in 10% formalin solution (4% formaldehyde)

  • at least 20 times the volume of the specimen

• wound closure

  • if possible, must be closed through primary closure

  • use black silk resorbable sutures for deeper layers

    • polyglycolic acid (Dexon)

    • polyglactin 910 (Vicryl)

    • chromic gut

  • undermined movable soft tissues, distance should be at least the width of the defect

    • allows tension-free closure of the wound edges.

• referral

  • be placed in 10% formalin solution (4% formaldehyde)

  • at least 20 times the volume of the specimen

hemostasis techniques

types of biopsy

cytology

aspirational

incisional

excisional

punch biopsy

exfoliative cytologic examination

diagnostic procedure for detection of uterine cervical malignancy or pre-cancer screening method

in the oral cavity, used as an adjunct and not substitute for incisional nor excisional biopsy

oral brush cytology

uses a special brush to collect the epithelial cells

may be a good tool for "monitoring" patients with chronic mucosal changes, such as:

• leukoplakia

• lichen planus

• history of oral cancer

aspiration biopsy

is performed on fluid-filled lesions except a mucocele

the use of a needle and syringe to penetrate a lesion for aspiration of its contents (16-18 gauge needle)

• 2 main purposes:

  • determine what is inside the lesion

    • is it fluid-filled? is it solid?

  • obtain cells for diagnosis

    • called Fine-Needle Aspiration (FNA)

      • used to obtain cells for pathologic examination, especially useful for:

        • soft tissue masses, neck masses

        • lesions where surgical biopsy may cause a scar or damage nearby structures

  • routinely performed on intraosseous radiolucent lesions before entering the bone.

    • this helps determine:

      • whether the lesion is vascular or cystic or solid

  • ⚠ This is important because entering a vascular lesion surgically can cause serious bleeding.

clinical discovery of pus

infectious process

clinical discovery of mucus

mucocele, ranula

clinical discovery of air or golden yellow fluid

traumatic bone cyst

clinical discovery of cheese-like, keratin

odontogenic keratocyst

clinical discovery of negative (nothing obtained)

solid lesion

clinical discovery of clear pale, straw-colored

dentigerous cyst

clinical discovery of straw-colored (beer-colored)

cystic (ameloblastoma)

clinical discovery of blood

vascular lesion (aneurysmal bone cyst)

incisional biopsy

a biopsy that samples only a particular or representative part of the lesion

• indications:

  • hazardous location

  • if there is a suspicion of malignancy

  • large lesions ( >1cm in diameter)

• procedure:

  • usually a wedge-shaped piece is removed

  • a narrow and deep specimen is better than a broad and shallow specimen.

  • the biopsy site should be selected in an area that shows complete tissue changes

  • the material should be taken from the edge of the lesion to include some normal tissue

[a negative report of a highly suspicious oral lesion suggests that another biopsy specimen is necessary in view of the clinical impressions]

excisional biopsy

removal of the entire lesion along with 2-3mm of normal appearing surrounding tissue is excised

• indications:

  • smaller lesions that on clinical examination appear to be benign (<1 cm)

  • any lesion that can be removed completely without mutilating the patient

  
  

punch biopsy

removal of a small piece of tissue using a punch (a small, hollow cylindrical tube-like bladed instrument)

crusts (crusted)

dried or clotted serum on the surface of the skin or mucosa

dysplasia (dysplastic)

any abnormal development of cellular size, shape, or organization in tissue

erosion

a shallow, superficial ulceration

hyperkeratosis

an overgrowth of the cornified layer of epithelium

hyperplasia (hyperplastic)

an increased number of normal cells

hypertrophy (hypertrophic)

an increase in size caused by an increase in the size of cells, not in the number of cells

keratosis (keratotic)

an overgrowth and thickening of cornified (horned layer) epithelium

leukoplakia

a slowly developing change in mucosa characterized by firmly attached thickened white patches

malignant

anaplastic, a cancer that is potentially invasive and metastatic

scale

a thin, compressed, superficial flake of cornified (keratinized) epithelium

stomatitis

any generalized inflammatory condition of the oral mucosa

ulcer

a crater-like circumscribed surface lesion resulting from necrosis of the epithelium

pathology report and follow-up

• patient is generally seen around 1 week after biopsy:

  • remove sutures, discuss results if available

• typical splint duration → 7-10 days

• pathology report → 7-14 days

sturge-weber syndrome

the syndrome that would manifest as port wine stain (aka: nevus flammeus)

lucas curette

type: double-ended surgical/bone curette

shape: spoon-shaped, rounded ends

uses: removes granulation tissue, debris, and cystic tissue from extraction sockets

sizes: #84–#88