Biopsy

Biopsy
Tissue biopsy is the gold standard for definitive diagnosis of soft and hard tissue lesions. An incisional biopsy evaluates a small representative sample, whereas an excisional biopsy involves removal and evaluation of the entire lesion. Biopsies may be submitted in formalin for routine histopathology or in saline or Michels medium for direct immunofluorescence and other advanced studies (including tissue culture) that require nonfixed tissue. Immunohistochemical studies can be performed in many cases on both formalin fixed and fresh tissue samples and may be useful for determining or refining the diagnosis. The pathology laboratory should be consulted in advance when there are any questions as to how a specimen should be submitted.

 In areas where the tissue is closely attached to underlying bone, as seen on the hard palate and gingiva, a simple wedge biopsy with a scalpel is generally easier than using a skin punch. Small, well-defined lesions may be excised fully. Placement of simple interrupted resorbable sutures or application of silver nitrate will effectively control bleeding following most incisional biopsies. Pain following biopsy is typically mild, requiring only acetaminophen or ibuprofen in most cases; occasionally opiates are needed.

 There are several important points to consider when performing a biopsy. If the lesion is nonhomogeneous, more than one area within the lesion should be sampled because early malignancies can present only focally in a field of dysplastic changes. If the differential diagnosis includes a vesiculobullous disorder, the biopsy site should be perilesional, specifically avoiding any area of ulceration.

Ulcerated lesions lack epithelial layers and as such, direct immunofluorescence testing cannot be adequately performed on specimens taken from such areas. All specimens should be carefully mapped and oriented. Regardless of the presumed clinical diagnosis, any tissue that is excised should be submitted for histopathological analysis. It is generally preferable to send specimens to a pathology laboratory with a board certified oral pathologist on staff or general pathologist with special training in oral pathology.

Fine needle aspiration of an enlarged cervical lymph node. Photograph courtesy of Sook-Bin Woo, DMD, MMSc, Boston, MA

Oral punch biopsy armamentarium that includes a 4.0-mm disposable punch, tissue forceps, and surgical scissors

Punch biopsy of an area of leukoplakia on the hard palate. (a) After rotation of the punch down to periosteum, prior to excision with forceps and scissors. (b) Excised surgical specimen placed in formalin

(a) Excisional biopsy of a recurrent benign tongue neoplasm (spindle cell tumor). (b) Outline of excision marked with surgical pen to ensure adequate margins. (c) Gross pathology of excised specimen. (d) Postoperative sutured excision site

Use of silver nitrate following a punch biopsy. (a) Silver nitrate sticks. (b) Prior to application. (c) The stick is quickly rotated and removed. (d) Biopsy site following application. The gray discoloration will gradually fade

Selection of multiple biopsy sites in a patient with a large area of erythroleukoplakia to ensure adequate sampling.

Perilesional biopsy in a patient with an ulcerative lesion undergoing evaluation for autoimmune vesiculobullous disease. The biopsy specimen was divided into equal fragments and submitted for both routine histopathology and direct immunofluorescence.

Adjuvant Tests
Brush cytology (OralCDx Brush Biopsy, CDx
Laboratories,Suffren, NY),

Toluidine blue vital tissue staining, Tissue reflectance (ViziLite Plus, Zila
Pharmaceuticals,Phoenix, AZ, and MicroLux DL, AdDent, Danbury, CT)

Tissue fluorescence (VELscope, LED Dental Inc,

Vancouver, Canada).

Exfoliative cytology kit including glass slides, alcohol packet, wood spatula, and brush

Oral cytology specimen of a suspected fungal infection demonstrating Candida hyphae (linear organisms; solid arrow) and conidiae (ovoid budding organisms; broken arrow).

Oral cytology specimen of a suspected herpes simplex virus infection demonstrating classic viral cytopathic changes in the cell above the normal keratinocyte.

Digital SLR camera equipped for intraoral photography with macro lens and ring flash

Oral hairy leukoplakia of the right lateral tongue with focal linear white plaques

Severe smokers palate showing heavy keratinization and intensely inflamed duct orifices.