SOFT TISSUE BIOPSY TECHNIQUE AND SURGICAL PRINCIPLES Medical Assignment Help

SOFT TISSUE BIOPSY TECHNIQUE AND SURGICAL PRINCIPLES

Oral soft tissue biopsy is a.technique that every dentist should be competent to perform. Performed properly, it is a simple and painless procedure that can be done quickiy in the dental office with common, simple instrumentfttion
(8()11( 21-1). The entire oral mUCUSJi~ amenable to biopsy, and the technique only diff~r~ ;lL(“~rdJng W 1(1(“;)\ anatomy and the size and type of ksion.
The surgical principles presented ill (:hdptt>r 3 apply’to biopsy technique, as well as tn an: (.rhu,>lIlgical procedure within the oral cavity. rhe~1.:.’rjnllple~ are briefly outlined in the following sections.

BOX 21-1

Armamentarium for Biopsy
Instruments for Soft Tissue Biopsy
• Local anesthetic equipment
• Scalpel (no. 15 blade)
• Scissors with pointed tips
• Fine tissue forceps
• Small hemostat
• Gauze sponges (suction, if necessary)
Needle holder, needle, and suture
• Biopsy bottle containing 10% formalin
• Biopsy data sheet’
Additional Instruments for Hard TISsue Biopsy
or Biopsy of Soft TIssue within Bone
• Periosteal elevator
• Rongeur
• Bur and rotary handpiece
• Sterile saline irrigation
• Curettes ~
Instruments for Aspiration of Intraosseous Lesion
• Syringe (5 or 10 ml) .
• Needle (18 gauge) .

Anesthesia
Block local anesthetic techniques are used when possible. The anesthetic solution-should not be injected within the tissues to be removed, because it can cause artifactual distortion of the specimen. When blocks are not possible, infiltration of local anesthetic may be used, but the solution
should be injected at least 1 cm away from the lesion (i.e., field block).

TIssue Stabilization 

Soft tissue biopsies in the oral cavity are frequently performed on movable structures, such as the lips, soft palate, and tongue. Accurate surgical incisions are easiest to perform on tissues that are properly stabilized. Several methods are available in the dental office to achieve tissuestabilization. An assistant’s fingers pinching the lip on both sides of the biopsy area can immobilize the lips (Fig. 21-6, A). This method also aids in hemostasis by compressing the labial arteries. Instruments are available
to perform this same function (Fig. 21-6, B). Heavy retraction sutures or towel clips can be used to aid immobilization of the tongue or soft palate (Fig. 21-6, C). When used, the sutures should be placed deeply into the substance of the tissue, away from the proposed biopsy site.
In this \vay they will be useful for secure stabilization, without pulling through. the tissues.

Hemostasis
The use o.f a suction device for aspiration of surgical hemorrhage
dUrIng bIOP)Y should be avoided. This is especially true’ lIt the high-volume evacuators available in The use o.f a suction device for aspiration of surgical hemorrhage dUrIng bIOP)Y should be avoided. This is especially true’ lIt the high-volume evacuators available in most dental offices. Small surgical specimens can he easily aspirated into these devices and lost. Gauze wrapped over the tip of a low-volume suction device or simple gauze compresses are adequate in most cases, unless
severe hemorrhage is encountered.

Incision
A sharp scalpel should be used to incise tissues for biopsy. The use of electrosurgical equipment is much less desirable. This equipment causes destruction of tissue adjacent to the incision line and may distort the histologic architecture of the specimen. The use of a carbon dioxide laser in the’ super-pulsed mode with a small, wellfocused beam can be used, but the clinician must realize that there will be a thin zone of necrosis from the laser. The advantage of using a laser is that hemostasis is immediately
achieved. Two incisions forming an ellipse at the surface and converging to form a V at the base of the lesion provide a good specimen and leave a wound that is easy to close (Fig. 21-7).

Handling of Tissue
Any tissue specimen removed must be in a condition that readily lends to histopathologic examination. Crushed specimens may be nondiagnostic and only delay definitive diagnosis and therapy because of the necessity of performing a repeat biopsy. Extreme care must be exercised
when removing the surgical specimens. Liberal use of tissue forceps on the specimen will severely damage the cellular architecture, especially in small biopsies. Once a tissue forceps is applied to the specimen, repeated releasing and replacing of the instrument should be avoided. The
use of a traction suture through the specimen is an excellent method for avoiding specimen trauma (fig. 21- J()).

Identification of Surgical Margins
when anytfting but a benign process is suspected. the clinician should mark the margins of the biopsv spcci-

23-6

23-6

FIG. 21-6-cont'd F, Stilbilization of tissue with I1leChaniclildevice. G, Stabilization of tissue with tr.action sutures. "T:wosilk sutures are used t;stabilize.i~gue.before excisional biopsy. They are placed through substance of tongue. (both mucosa and muscle) to prevent pulHng through tissue, H, LesioQ is removed after elliptic incision was made around it. I, Resorbable sutures are placed to approximate muscle. J, M.ucosa is closed.

FIG. 21-6-cont’d F, Stilbilization of tissue with I1leChaniclildevice. G, Stabilization of tissue with
tr.action sutures. “T:wosilk sutures are used t;stabilize.i~gue.before excisional biopsy. They are placed
through substance of tongue. (both mucosa and muscle) to prevent pulHng through tissue, H, LesioQ
is removed after elliptic incision was made around it. I, Resorbable sutures are placed to approximate
muscle. J, M.ucosa is closed.

FIG. 21-7 Illustration of excis~aI biopsy of soft tissue lesion. A, SurfaGe~. Elliptic incision ismade _- around lesion, at teast 3 mITtaway frill"! Jesien. ,I, Side view. tncision is made deep enough to remove lesion completely. C, End view. Incisior;lsare made convergent to depth of wound. If excision is made in this W;)y,closure wIll be facilitated.

FIG. 21-7 Illustration of excis~aI biopsy of soft tissue lesion. A, SurfaGe~. Elliptic incision ismade _-
around lesion, at teast 3 mITtaway frill”! Jesien. ,I, Side view. tncision is made deep enough to remove
lesion completely. C, End view. Incisior;lsare made convergent to depth of wound. If excision is made
in this W;)y,closure wIll be facilitated.

FIG. 21-8 A, illustration .showinq desirability of obtaining deep specimen rather than broad and shallow specimen when incisional biopsy is performed. If malignant cells are present only at base of lesion, broad and shallow biopsy might not obtain these diagnostic cells. B, Illustration showing desirability of obtaining incisional biopsy at margin of soft tissue lesion. Junction of lesion with normal tissue frequently provides pathologist with more diagnostic information than if biopsy were taken only from

FIG. 21-8 A, illustration .showinq desirability of obtaining deep specimen rather than broad and shallow
specimen when incisional biopsy is performed. If malignant cells are present only at base of lesion,
broad and shallow biopsy might not obtain these diagnostic cells. B, Illustration showing desirability
of obtaining incisional biopsy at margin of soft tissue lesion. Junction of lesion with normal tissue frequently
provides pathologist with more diagnostic information than if biopsy were taken only from

FIG 21-9 AND FLG 21-10

FIG 21-9 AND FLG 21-10

 

FIG. 21-11 Illustration showing principles used in closing en eliptic biopsy wound. Mucosa should be undermined pluntly with scissors to widr1!r'<of at/ginal ellipse in each direction. 'This allows appr~iOfl of-wound margins without tension.

FIG. 21-11 Illustration showing principles used in closing en eliptic biopsy wound.
Mucosa should be undermined pluntly with scissors to widr1!r’direction. ‘This allows appr~iOfl of-wound margins without tension.

Specimen Care
After removal the tissue should be immediately placed in 10% formalin solution (4% formaldehyde) that is at least 20 times the volume of the surgical specimen. The tissue must. be immersed in the solution, and care should be taken tobe sure that the tissue has not become lodged on
the wall of the container above the l.

Surgical Closure
Once the specimen is removed, primary closure of the elliptic wound is usually possible. The mucosa is undermined first by placing the closed tips of pointed scissors well into the submucosal area and spreading the tissues
by opening the stissor tips (Fig. 21-11). The submucosa is loose tissue that allows the mucosa to be easily undermined. The extent to which the margins should be undermined depends on the anatomic location and size
of the wound. In the lip, cheek, floor of mouth, and softpalate, undermining of the wound margins by at least the width of the ellipse in each direction is easily performed and allows approximation of the tissues with little tension on the suture line, The incision is then dosed with j~st eno gh sutures to obtain primary closure. Elliptic incisions on attached mucosal surfaces, such as gingiva. and palate, are not closed but rather allowed to heal by secondary intention. Periodontal dressings can be applied
Once the specimen is removed, primary closure of the elliptic wound is usually possible. The mucosa is undermined first by placing the closed tips of pointed scissors well into the submucosal area and spreading the tissues
by opening the stissor tips (Fig. 21-11). The submucosa is loose tissue that allows the mucosa to be easily undermined. The extent to which the margins should be undermined depends on the anatomic location and size
of the wound. In th  lip, cheek, floor of mouth, and soft
palate, undermining of the wound margins by at least the  idth of the ellipse in each direction is easily performed and allows approximation of the tissues with little tension on the suture line, The incision is then dosed with
j~st enough sutures to ob ain primary closure. Elliptic incisions on attached muc sal surfaces, such as gingiva and palate, are not closed but rather allowed to heal bysecondary intention. Periodontal dressings can be applied

FIG, 21-12 A. Biopsy data sheet. Such sheets vary .from one laboratory to the next; the one. listed here represents several. Information provided on this data. sheet descnbeslesion shown in Figure 21-13.

FIG, 21-12 A. Biopsy data sheet. Such sheets vary .from one laboratory to the next; the one. listed
here represents several. Information provided on this data. sheet descnbeslesion shown in Figure
21-13.

Biopsy Data Sheet
All specimens must be carefully labeled and identified
with demographic data of both the patient and the dentist’s
office on a biopsy data sheet (Fig. i1·12). The pathology
laboratory will supply the dentist with specimen bottles
and the biopsy data sheet. All pertinent history and a
clinical description of the lesion must be conveyed t9the
pathologist on this. form. Because radrograpns tof the’
lesion are useful to the pathologist when deahng with

,FIG.. 21-12-cont'd 8, Drawingo.f lesion,which is'to be sent . 'with data sheet.

,FIG.. 21-12-cont’d 8, Drawingo.f lesion,which is’to be sent
. ‘with data sheet.

and behaves clinically as if it were malignant, the dentist should search for further information. ~ negative pathol- .ogy report for cancer should not lull the dentist into a false sense ‘of security when the clinical charact~ristics of  the lesion still indicate malignant potential. If the pathol- , oS}’ report dOes not corroborate the clinical impression of the
l sion, the biopsy’ procedure should’ be. repeated. The area
bopsied may have been nondiagnostic or nonrepresentative of the.entire lesion, or the pathologist may have been. unfamiliar with the appearance of oral lesions. Clinicians, should always keep in mind that a ‘pathologist’s report can be in error. General pathologists unfamiliar,with oral
tissues mayread several types ‘of benign oral pathologic conditions as malignant, which is why many head and neck surgeons repeat the biopsy procedure of oral lesions before.performing ablative surgery. The second specimen is sent to a,pathologist who. has expertise.in oral pathology.
It is important that the dentist completely understand the terminology in the pathology report. If unsure or unfamiliar with .any terminology, the dentist should . contactthe pathologist to discuss the findings traught with the bad news and thrown into a state ofdepression. Thus each dentist must carefully handle theseinstances in his or her own way and never forget t9 keepthe patient’s best interests in mind.

 

 

 

 

 

 

 

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