2024 UWA Dental Student Lecture <!--PLACEHOLDER CAPTION: Lecture Title Slide for Surgery in Oral Medicine: Biopsy of Oral Lesions--> **SURGERY IN ORAL MEDICINE** **BIOPSY OF ORAL LESIONS** Dr Frank Chang Oral and Maxillofacial Surgeon BDS(Otago), MBChB(Auckland), FRACDS(OMS) Frank.chang@uwa.edu.au The University of Western Australia Government of Western Australia South Metropolitan Health Service Fiona Stanley Hospital Government of Western Australia East Metropolitan Health Service Royal Perth Hospital 2024 UWA Dental Student Lecture #### Presenter Information **Dr Frank Chang** Oral and Maxillofacial Surgeon BDS (Otago), MBChB (Auckland), FRACDS (OMS) Email: Frank.chang@uwa.edu.au #### Affiliations - The University of Western Australia - Government of Western Australia - South Metropolitan Health Service - Fiona Stanley Hospital - East Metropolitan Health Service - Royal Perth Hospital WHAT IS A BIOPSY? * Biopsy is a procedure that involves the removal of cells or tissues from a living body for the purpose of microscopic examination by a pathologist to achieve a diagnosis * Diagnose a condition and to measure how severe it is or at what stage of the condition it is in * Facilitate treatment required A biopsy is a procedure that involves the removal of cells or tissues from a living body for the purpose of microscopic examination by a pathologist to achieve a diagnosis. #### Purpose of Biopsy - Diagnose a condition and measure its severity or stage. - Facilitate the required treatment. # INDICATIONS FOR BIOPSY OF ORAL TISSUE - Assessment of any unexplained oral mucosal abnormality that persists despite treatment or removal of irritants - **Lesion persistent for >2 weeks with no obvious etiology** - Suspicion of malignancy when persistent oral mucosal lesions are red and white or ulcerated, indurated or fixated to deep tissue - Persistent lesion that bleeds easily or rapidly growing - Unexplained pigmented oral mucosal lesion that are new or changing - Unless the pigmented lesion been present for >5 years - Lesion interfering with local function - Lesion causing trismus, sudden loosening of teeth e.g. Langerhans cell histiocytosis - Persistent visible or palpable swelling with normal overlying tissue e.g. Lymphoma - Bone lesions that can not be diagnosed by clinical and radiological findings #### Clinical Indications - Assessment of any unexplained oral mucosal abnormality that persists despite treatment or removal of irritants. - **Lesion persistent for >2 weeks with no obvious etiology.** - Suspicion of malignancy when persistent oral mucosal lesions are red and white, ulcerated, indurated, or fixated to deep tissue. - Persistent lesion that bleeds easily or is rapidly growing. - Unexplained pigmented oral mucosal lesions that are new or changing (unless the pigmented lesion has been present for >5 years). - Lesion interfering with local function. - Lesion causing trismus or sudden loosening of teeth (e.g., Langerhans cell histiocytosis). - Persistent visible or palpable swelling with normal overlying tissue (e.g., Lymphoma). - Bone lesions that cannot be diagnosed by clinical and radiological findings. # CONTRAINDICATIONS ?? * **No absolute contraindications** * Whether you would proceed with biopsy depends on: * **Dental clinician’s** training, level of skill, interest, participation * **Patient’s** medical condition that has increased surgical risks * **Anticoagulation therapy** * **Immunocompromised** * **Multiple system disease** * **Multiple medications** * **Physically frail or unwell** * **Surgical** difficulty – access, surgical equipment, surgical skill * **Malignant potential** – refer to specialist for management to avoid delay * **Suspected** vascular lesions * Or if unsure, consider referring to Oral and Maxillofacial surgeon There are **no absolute contraindications** for a biopsy. However, the decision to proceed depends on several factors: #### Clinician and Surgical Factors - **Dental clinician’s** training, level of skill, interest, and participation. - **Surgical difficulty**: access, available equipment, and surgical skill. - **Malignant potential**: refer to a specialist for management to avoid delay. - **Suspected vascular lesions**. - If unsure, consider referring to an Oral and Maxillofacial surgeon. #### Patient Factors - Medical conditions that increase surgical risks: - Anticoagulation therapy - Immunocompromised status - Multiple system disease - Multiple medications - Physically frail or unwell Leeson; Line Diagram for Manuja Smoking Lesions **Lesion detection** **Health and lesion histories**, **clinical and radiograph examinations**, **laboratory testing** **Differential diagnosis** 2. **Observation or nonsurgical treatment for 10-14 days** 3. **Observation or nonsurgical treatment not indicated; high suspicion of malignancy** **Improvement** **No improvement** **Decision to biopsy** **Perform biopsy** **Refer to specialist** **No further treatment required** **Diagnosis indicates need for further treatment/surgery** **Care is within capabilities of a general dentist** **Need for referral to specialist** **Patient monitoring/follow-up/support** **FIGURE III-2. Decision tree diagram for managing suspicious lesions.** Reprinted with permission from Hupp.  #### Decision Tree for Managing Suspicious Lesions 1. **Initial Assessment**: Lesion detection through health and lesion histories, clinical and radiographic examinations, and laboratory testing. 2. **Differential Diagnosis**. 3. **Management Path A**: Observation or nonsurgical treatment for 10-14 days. - **Improvement**: No further treatment required; patient monitoring/follow-up. - **No improvement**: Decision to biopsy. 4. **Management Path B**: Observation or nonsurgical treatment not indicated; high suspicion of malignancy. - **Decision to biopsy**. 5. **Biopsy Execution**: - Perform biopsy (if care is within capabilities of a general dentist). - Refer to specialist (if needed). 6. **Post-Diagnosis**: Diagnosis indicates need for further treatment/surgery; provide patient monitoring, follow-up, and support. Flowchart diagram titled 'FIGURE III-2. Decision tree diagram for managing suspicious lesions.' The flow begins at 'Lesion detection' and proceeds through diagnostic steps including 'Differential diagnosis'. It branches into two paths: one for 'Observation or nonsurgical treatment for 10-14 days' (with outcomes of Improvement/No improvement) and another for cases where observation is not indicated due to high suspicion of malignancy, leading to a biopsy decision. Further nodes detail biopsy results ('No further treatment required', 'Need for referral to specialist') and subsequent monitoring. # PATIENT MANAGEMENT * History of presenting complaints * How long has the lesion been present * New lesion vs lesion been there for several years (likely to be benign) * Patient awareness of the lesion * Has the lesion changed in size * Enlarged in a short period of time ➔ aggressive lesion and possible malignancy * Slow growth ➔ possibly benign but not always * Has the lesion changed in character or features * Mass starts to ulcer; vesicle turning into an ulcer * Were there any symptoms * Pain, altered sensation, taste, odor, dysphagia, trismus * Anatomical location * Certain lesions have a predilection for certain anatomic areas; keratinized or non keratinized tissue * Any systemic symptoms * Fever, malaise, nausea * Viral conditions – measles, mumps, mononucleosis, herpes, AIDS, * Autoimmune condition – pemphigus, lichen planus, erythema multiforme, STI * Surrounding event associated with onset of the lesion * Trauma, recent treatment, new medications, exposures to toxins, travels  #### History of Presenting Complaints - **Duration and Awareness**: How long has the lesion been present? Is it a new lesion or has it been there for several years (likely benign)? Is the patient aware of it? - **Growth and Character**: - Has the lesion changed in size? Enlargement in a short period suggests an aggressive lesion or possible malignancy, while slow growth is often benign. - Has the character changed (e.g., mass starting to ulcerate, vesicle turning into an ulcer)? - **Symptoms**: Pain, altered sensation, taste, odor, dysphagia, or trismus. - **Anatomical Location**: Predilection for certain areas; involvement of keratinized vs. non-keratinized tissue. - **Systemic Symptoms**: Fever, malaise, or nausea. - Consider viral conditions (measles, mumps, mononucleosis, herpes, AIDS). - Consider autoimmune conditions (pemphigus, lichen planus, erythema multiforme, STI). - **Associated Events**: Trauma, recent treatment, new medications, exposure to toxins, or recent travel. A photograph of an hourglass with sand in the lower chamber, placed on a surface. In the context of 'Patient Management' and 'History of presenting complaints,' this visual metaphor represents the duration or timeline of a lesion's presence. # PATIENT MANAGEMENT * **Medical History** * Systemic illnesses can have oral manifestations * Different tests required instead of biopsy * **Medication History** * Medication induced conditions * Steven Johnsons syndrome * Aspirin burn * Petechiae * **Allergy History** * Antibiotics * NSAID's * Iodine * Others #### Medical and Medication History - **Medical History**: Systemic illnesses can have oral manifestations; some may require different tests instead of a biopsy. - **Medication History**: Identify medication-induced conditions such as: - Stevens-Johnson syndrome - Aspirin burn - Petechiae - **Allergy History**: Check for allergies to antibiotics, NSAIDs, iodine, or other substances. **# CLINICAL EXAMINATION** * Inspection and palpation of the lesion * **Anatomical location:** differential diagnosis can be obtained based on the location * Different pathologies can arise from the following types of tissues: Epithelium/mucosa, submucosal connective tissue, muscle, tendon, nerve, bone, blood vessels, lymphatic or salivary gland * **Physical Characteristics** * Bullae * Crusts * Dysplasia * Erosion * Hyperkeratosis * Hypertrophic * Hyperplastic * Keratotic * Leukoplakia * Malignant * Macule * Nodule * Papule * Plaque * Pustule * Scale * Stomatitis * Ulcer * Vesicle #### Inspection and Palpation - **Anatomical Location**: Differential diagnosis is often based on location. Pathologies can arise from: - Epithelium/mucosa - Submucosal connective tissue - Muscle, tendon, or nerve - Bone - Blood vessels, lymphatic, or salivary glands #### Physical Characteristics - Bullae - Crusts - Dysplasia - Erosion - Hyperkeratosis - Hypertrophic / Hyperplastic - Keratotic / Leukoplakia - Malignant - Macule - Nodule - Papule - Plaque - Pustule - Scale - Stomatitis - Ulcer - Vesicle ## CLINICAL EXAMINATION * **Single vs Multiple lesions** * E.g. Single ulcer vs multiple ulcers, infections (viral/bacterial/fungal), trauma, autoimmune * **Size, Shape and growth** * Regular margin vs irregular margin, exophytic vs endophytic, sessile vs pedunculated * **Surface appearance** * Smooth, verruciform, irregular, ulcer margin – rolled, flat, raised or everted * Base of ulcer can be smooth, granulated, fibrin membrane, slough, haemorrhagic scab * **Colour** * Dark blue can suggest vascular lesion, blue may resemble mucous retention cyst * Pigmented lesion can range from metallic tattoo to melanotic tumor * Erythematous lesion can represent severe dysplastic changes than a white lesion #### Lesion Distribution and Morphology - **Single vs. Multiple Lesions**: Single ulcers vs. multiple ulcers; consider infections (viral/bacterial/fungal), trauma, or autoimmune causes. - **Size, Shape, and Growth**: - Regular vs. irregular margins. - Exophytic vs. endophytic. - Sessile vs. pedunculated. - **Surface Appearance**: - Texture: Smooth, verruciform, or irregular. - Ulcer margins: Rolled, flat, raised, or everted. - Ulcer base: Smooth, granulated, fibrin membrane, slough, or hemorrhagic scab. - **Colour**: - Dark blue: Suggests vascular lesions. - Blue: May resemble a mucous retention cyst. - Pigmented: Ranges from metallic tattoo to melanotic tumor. - Erythematous: May represent more severe dysplastic changes than white lesions. # CLINICAL EXAMINATION ## Mobility * **Fixted** to surrounding deep tissues or freely mobile * Determine if this is coming from the underlying surrounding structure or infiltration ## Consistency * **Soft compressible** (lipoma, abscess, mucous retention cyst) * **Firm/Indurated** (fibroma or cancer) * **Hard** (bony exostosis) * **Fluctuant** (abscess, fluid filled cavity, mucous retention cyst) ## Pulsation * **Vascular lesion** ## Lymph nodes * **Lymphadenopathy** and location can indicate spread of disease #### Mobility and Consistency - **Mobility**: Determine if the lesion is fixed to surrounding deep tissues or freely mobile (indicates infiltration vs. localized structure). - **Consistency**: - **Soft/Compressible**: Lipoma, abscess, mucous retention cyst. - **Firm/Indurated**: Fibroma or cancer. - **Hard**: Bony exostosis. - **Fluctuant**: Abscess, fluid-filled cavity, mucous retention cyst. #### Pulsation and Lymphatics - **Pulsation**: Indicates a vascular lesion. - **Lymph Nodes**: Presence of lymphadenopathy and its location can indicate the spread of disease. <masterclass course main " " - Careful documentation of the lesion - Drawing or graphic schematic of the lesion, location, orientation, shape, dimension - **Digital photographic record**  - Careful documentation of the lesion. - Drawing or graphic schematic of the lesion, including location, orientation, shape, and dimensions. - **Digital photographic record**. Clinical photo showing a dental or medical professional wearing protective gear (mask, face shield) taking a digital photograph of a patient's mouth. The patient is seated in a chair with their mouth open and holding a retractor device to expose the oral cavity for documentation. # FEATURES SUSPICION OF MALIGNANCY * **Bleeding** – on gentle manipulation * **Duration** – persisted for more than 2 weeks * **Erythroplasia** – red lesion or speckled red and white lesion * **Fixation** – attached to adjacent structures * **Growth rate** – rapid growth in size * **Induration** – lesion and surrounding tissues are firm to touch * **Ulceration** – lesion is ulcerated or persistent ulcer - **Bleeding**: Occurs on gentle manipulation. - **Duration**: Persisted for more than 2 weeks. - **Erythroplasia**: Red lesion or speckled red and white lesion. - **Fixation**: Attached to adjacent structures. - **Growth rate**: Rapid growth in size. - **Induration**: Lesion and surrounding tissues are firm to touch. - **Ulceration**: Lesion is ulcerated or presents as a persistent ulcer. # **GENERAL PRINCIPLES OF BIOPSY** * Removal of tissue from living body for microscopic diagnostic examination * It is the most precise and accurate of all diagnostic tissue procedures * Performed whenever a definitive diagnosis cannot be obtained using less invasive procedures e.g. cytology, brush cytology, FNA * Primary purpose of biopsy is to determine the diagnosis precisely so that proper treatment can be provided #### Definition and Purpose - Removal of tissue from a living body for microscopic diagnostic examination. - It is the most precise and accurate of all diagnostic tissue procedures. - Performed whenever a definitive diagnosis cannot be obtained using less invasive procedures (e.g., cytology, brush cytology, FNA). - The primary purpose is to determine the diagnosis precisely so that proper treatment can be provided. **Surgical Biopsy** * **Punch Biopsy** * **Incisional** * **Excisional** Main focus for dentist in general practice * Fine Needle Aspiration Cytology (FNAC) * Core Biopsy * Cytology * Brush Biopsy * Frozen section Biopsy #### Surgical Biopsy Types (General Practice Focus) - Punch Biopsy - Incisional Biopsy - Excisional Biopsy #### Other Biopsy and Diagnostic Methods - Fine Needle Aspiration Cytology (FNAC) - Core Biopsy - Cytology - Brush Biopsy - Frozen section Biopsy **BIOPSY PROCEDURE** • Identify and mark the area for biopsy • Preparation of surgical field • Local anesthesia • Collect sample • Handling of specimen • Management of wound  1. Identify and mark the area for biopsy. 2. Preparation of the surgical field. 3. Administration of local anesthesia. 4. Collection of the sample. 5. Handling of the specimen. 6. Management of the wound. Clinical photo showing the inside of a mouth with purple surgical markings on the buccal mucosa, illustrating the 'Identify and mark the area for biopsy' step from the BIOPSY PROCEDURE list. **BIOPSY TECHNIQUES** • Punch Biopsy • Incisional • Excisional Common techniques include: - Punch Biopsy - Incisional Biopsy - Excisional Biopsy # PUNCH BIOPSY   PUNCH BIOPSY Clinical photo showing three disposable biopsy punch instruments in their clear plastic packaging. The devices feature a green textured handle and a metallic tip. Labels on the packaging indicate 'BIOPSY PUNCH', 'STERILE R', and 'SINGLE USE'. One of the packages includes a visible red marker or indicator near the bottom. Clinical photo displaying three different sizes of disposable biopsy punches ('BIOPSY PUNCH') arranged side-by-side. From left to right, the labels clearly identify the instrument sizes as '3mm', '4mm', and '6mm'. Packaging details include reference codes (e.g., BPP-30F, BPP-40F, BP-60F), lot numbers, expiration dates (2026-05), and manufacturer information for Kai Medical. # PUNCH BIOPSY  Medical procedure diagram illustrating a punch biopsy. The image is divided into three parts: on the left, a gloved hand holds a blue-handled punch tool positioned over a skin lesion; in the center top panel, a cross-section shows the tool penetrating the epidermis and dermis layers; in the center bottom panel, the tool rotates to extract a cylindrical core of tissue, indicated by an arrow pointing to the removed specimen. Fig. 3. (A) Ulcerative lesion of the right lower lip with final diagnosis of squamous cell carcinoma. (B) Use of 3 mm punch biopsy with firm twisting action to cut through lesion and deeper layers. (C) Use of scissors to amputate tissue specimen. (D) Reapproximation of tissue edges with use of 3-0 Vicryl (polyglactin 910) suture manufactured by Ethicon, Somerville, NJ, USA. - Shanti RM, tanaka T, stanton DC. Oral biopsy techniques. Dermatologic clinics. 2020 oct 1;38(4):421-7.  #### Clinical Procedure Example - **A**: Ulcerative lesion of the right lower lip (final diagnosis: squamous cell carcinoma). - **B**: Use of a 3 mm punch biopsy with a firm twisting action to cut through the lesion and deeper layers. - **C**: Use of scissors to amputate the tissue specimen. - **D**: Reapproximation of tissue edges using a 3-0 Vicryl (polyglactin 910) suture. A composite medical figure (Fig. 3) illustrating a biopsy procedure on the lower lip for squamous cell carcinoma diagnosis. It contains four panels: (A) shows an ulcerative lesion; (B) demonstrates a 3 mm punch biopsy tool in use; (C) depicts scissors amputating the tissue specimen; and (D) displays sutured tissue edges using 3-0 Vicryl suture. **PUNCH BIOPSY** * Easy technique * Suture may not be required if a small diameter punch were used * If sutures are required, often one suture is sufficient * Easy to use against soft tissue that are bound down like gingiva, alveolar soft tissue, hard palate * More tedious on mobile soft tissue #### Advantages and Considerations - Easy technique. - Sutures may not be required if a small diameter punch is used; if required, one suture is often sufficient. - Easy to use against bound-down soft tissue (e.g., gingiva, alveolar soft tissue, hard palate). - More tedious to perform on mobile soft tissue. **SURGICAL BIOPSY** **INCISIONAL AND EXCISIONAL BIOPSY** * Instrument setup for surgical biopsy * **Incisional biopsy** * Large lesion * Multiple different characteristics in different areas * Malignant lesion * **Excisional biopsy** * Small lesion that can be completely removed with a surrounding normal tissue  #### Indications for Incisional Biopsy - Large lesions. - Lesions with multiple different characteristics in different areas. - Suspected malignant lesions. #### Indications for Excisional Biopsy - Small lesions that can be completely removed along with surrounding normal tissue. Clinical photograph of a surgical instrument setup for biopsy laid out on a sterile blue drape. Visible items include various metal forceps, scissors, scalpels, and packaged medical supplies such as gauze sponges (labeled 'Sage' and 'AAXIS'), bottles of solution, and syringes. The image serves as a visual demonstration of the tools required for incisional or excisional biopsies. SURGICAL BIOPSY INCISIONAL AND EXCISIONAL BIOPSY  SURGICAL BIOPSY: INCISIONAL AND EXCISIONAL BIOPSY Clinical photograph showing a sterile surgical tray setup for an incisional or excisional biopsy. The image displays various medical instruments and supplies arranged on a blue and white sterile drape. Visible items include: a metal spatula (likely for tissue retraction), forceps, scissors, scalpels, probes, syringes, gauze swabs in packaging labeled 'AAXIS Sage', a bottle of Sodium Chloride Solution for Irrigation, a packaged specimen container, and other small surgical tools. A watermark in the bottom right corner reads 'Dr Frank Cheng ORAL & MAXILLOFACIAL SURGEON'. This visual demonstrates the equipment used during the procedure mentioned in the OCR context. INCISIONAL BIOPSY - Suspicion of malignancy - Location restriction – vessels, nerves, ducts - Large area of lesion - Taken in a wedge in an area that can represent the lesion - Often the worst looking area - Multiple samples - Normal margins are included within the biopsy and deep margins  #### Technique and Selection - Used for suspicion of malignancy, large areas, or when location is restricted by vessels, nerves, or ducts. - Taken as a wedge in an area representative of the lesion. - Target the "worst-looking" area. - Multiple samples may be necessary. - Normal margins and deep margins should be included within the biopsy. Text-based procedure outline for 'INCISIONAL BIOPSY'. Lists key indications including suspicion of malignancy and location restrictions near vessels/nerves. Describes the technique as a wedge biopsy taken from the worst-looking area with multiple samples to ensure normal margins are included. INCISIONAL BIOPSY - Disadvantages - Due to small sampling, handling of tissue can cause crushing and hemorrhage of the sample resulting in artefacts - Seeding of malignant cells into surrounding normal tissue #### Disadvantages - Small sampling size: handling can cause crushing and hemorrhage, resulting in artifacts. - Risk of seeding malignant cells into surrounding normal tissue. **INCISIONAL BIOPSY** **A** **Undesirable**: broad, shallow **Desirable**: narrow **Lesion** **Normal tissue** **B** --- **FIGURE III-12**. *A, Desirability of obtaining a deep specimen, rather than a broad and shallow specimen, when incisional biopsy is performed. If malignant cells are present only at the base of the lesion, then a broad and shallow biopsy might not obtain these diagnostic cells. B, Desirability of obtaining incisional biopsy at the margin of the soft tissue lesion. The junction of the lesion with normal tissue frequently provides the pathologist with more diagnostic information than a biopsy specimen taken only from the center of the lesion. This is particularly important when a biopsy of an ulcer is performed. Reprinted with permission from Hupp.* • Hupp JR, ellis III E, tucker MR: contemporary oral and maxillofacial surgery (ed 6). St. Louis, MO, elsevier, 2014  #### Specimen Depth and Location - **Depth**: It is desirable to obtain a deep specimen rather than a broad, shallow one. If malignant cells are only at the base, a shallow biopsy may miss them. - **Margin**: It is desirable to obtain the biopsy at the margin of the soft tissue lesion. The junction of the lesion with normal tissue frequently provides more diagnostic information than the center, especially in ulcers. Figure III-12 showing two panels (A and B) of incisional biopsy techniques. Panel A illustrates a cross-section of tissue with labels 'Lesion', 'Normal tissue', and two biopsy approaches: an undesirable broad/shallow biopsy versus a desirable narrow/deep biopsy reaching the base. Panel B shows a soft tissue lesion being biopsied at its margin to include normal tissue junction, compared to a center-only specimen. Caption explains that deep specimens capture malignant cells at the lesion base, while margins provide better diagnostic info than centers. **EXCISIONAL BIOPSY** • Complete removal of the lesion • Indicated for smaller lesions that can be completely excised with a normal margin without distortion of the wound • Clinically benign lesion • Removal of entire lesion with 2-5mm of normal appearing tissue surrounding the lesion • Mark biopsy sample to orientate specimen • If there are infiltrative lesion it will be easier to remove further soft tissue #### Indications and Procedure - Complete removal of the lesion. - Indicated for smaller, clinically benign lesions that can be excised with a normal margin without wound distortion. - Removal includes the entire lesion plus 2-5mm of surrounding normal-appearing tissue. - Mark the biopsy sample to orient the specimen. - If the lesion is infiltrative, it allows for easier removal of further soft tissue if necessary. # **EXCISIONAL BIOPSY** • Hupp JR, ellis III E, tucker MR: contemporary oral and maxillofacial surgery (ed 6). St. Louis, MO, elsevier, 2014  Medical diagram labeled 'FIGURE III-14. Excisional biopsy of soft tissue lesion.' It contains three panels: A (Surface view) showing an elliptical incision around a lesion at least 3 mm away; B (Side view) illustrating the incision depth to remove the lesion completely; and C (End view) demonstrating convergent incisions to facilitate closure. Labels include 'Lesion' and 'Incision' with arrows pointing to respective anatomical features. FINE NEEDLE ASPIRATE - Aspiration of fluid, cells, tissue products using a fine needle and examined under microscope - Used for biopsy of fluctuant lesions, collect cellular samples from lymph nodes - Easy technique with minimal pain - Cheap technique - Minimal wound - Rule out vascular lesions - Can be used for deep lesions found incidentally on CT scans - Ultra-sound guided FNAC  #### Overview - Aspiration of fluid, cells, or tissue products using a fine needle for microscopic examination. - Used for fluctuant lesions and collecting cellular samples from lymph nodes. - **Advantages**: Easy technique, minimal pain, inexpensive, and results in a minimal wound. - **Applications**: - Rule out vascular lesions. - Used for deep lesions found incidentally on CT scans (often Ultrasound-guided FNAC). Educational slide detailing the Fine Needle Aspirate (FNA) procedure. The content includes a title and bullet points describing the aspiration of fluid/cells for microscopic examination, its use in biopsying lesions/lymph nodes, benefits like minimal pain/wound, cost-effectiveness, contraindications (vascular lesions), and applications for deep lesions via CT or ultrasound guidance. PATHOLOGY REQUEST **Accurate patient details** **Test required** * Histopathology * Cytology **Detailed clinical notes to assist pathologists achieve accurate diagnosis** * Where is the lesion * How long has the lesion been present * Size of the lesion and any changes * Characteristics and features of the lesion and changes * Associated symptoms * Differential diagnosis  #### Request Requirements - **Accurate patient details**. - **Test required**: Histopathology or Cytology. - **Detailed clinical notes** to assist the pathologist: - Location of the lesion. - Duration and any changes in size. - Characteristics, features, and symptoms. - Differential diagnosis. A 'PATHOLOGY REQUEST' form from PathWest Laboratories. The table contains structured fields for patient details (Unit no., Surname, Date of Birth), test specifics (Tests Requested: Histopathology/Cytology), and clinical notes required for diagnosis. It includes sections for the requesting doctor's signature, collection date/time, copy report recipients (CLOT, SST, CIT, etc.), and collector's signature verification. TRANSPORT OF SPECIMEN - Haematoxylin and eosin (H&E) light microscopy is the routine test for most biopisies and should usually be transported in 10% buffered formalin solution - Tissue for DIF can be submitted in a sterile pot with saline-soaked gauze. Delays in specimen collection and processing can result in reduced diagnostic accuracy - Tissue for DIF can also be submitted in a transport medium such as Michel’s medium when there is less urgency in processing the specimen - Tissue for microbiological culture can be submitted fresh in a sterile container. If unsure, consult your pathology provider - The sample pot(s) should be labelled with patient identification details, the precise anatomical body site of the biopsy, time and date of biopsy, and all information checked against the request form for consistency  #### Transport Media and Labeling - **Routine (H&E)**: Transport in 10% buffered formalin solution. - **Direct Immunofluorescence (DIF)**: - Submit in a sterile pot with saline-soaked gauze (requires rapid processing). - Alternatively, use Michel’s medium if processing is less urgent. - **Microbiological Culture**: Submit fresh in a sterile container. - **Labeling**: Sample pots must include patient ID, precise anatomical site, time, and date. Check all information against the request form. Clinical photo showing two specimen transport containers used for biopsy. On the left is a PathWest Biopsy Jar with a blue lid containing 10% buffered neutral formalin (4% Formaldehyde), intended for H&E light microscopy. On the right is a sterile container with a yellow lid from Sarstedt Australia, suitable for microbiological culture or other fresh submissions. # INCISIONAL BIOPSY    Clinical photo showing an intraoral view of the floor of the mouth with a white lesion outlined by purple surgical marking ink. The title 'INCISIONAL BIOPSY' applies to this step as it demonstrates pre-operative site delineation. Clinical photo showing the incision made on the same lesion area. A metal retractor holds the cheek/lip open, and the tissue is cut, revealing the underlying surface. This represents the second step of the procedure. Clinical photo displaying the excised tissue specimen placed on a blue sterile drape next to a metric ruler for scale. The specimen appears as a small, fleshy mass attached to a thin strand of tissue. The ruler provides size reference (approx. 1-2 cm). # EXCISIONAL BIOPSY   Clinical photo showing a patient's face with an excision line marked on the chin using purple surgical ink. The title 'EXCISIONAL BIOPSY' is displayed above. Photo of excised tissue specimens placed on a white gauze pad in a blue tray, likely from the procedure shown in the left image. EXCISIONAL BIOPSY     Heading text 'EXCISIONAL BIOPSY' identifying the subject of the visual content. Clinical photo showing an excisional biopsy site on oral mucosa with a circular incision marked by purple ink and a surgical instrument present; includes watermark for Dr. Frank Chang. Intraoperative procedure image showing gloved hands using forceps to manipulate tissue during an excisional biopsy; includes signature watermark for Dr. Frank Chang, Oral & Maxillofacial Surgeon. Photo of excised specimen placed next to a ruler for scale, showing a small reddish-brown mass with attached suture material; includes watermark for Dr. Frank Chang.    Clinical intraoral photo showing a reddish lesion on the left side of the hard palate, circled in red for emphasis. The surrounding teeth and gums are visible, with a metal dental retractor at the bottom. Photo of an excised tissue specimen on a blue surgical drape, next to a ruler. Handwritten labels indicate orientation: 'Anterior', 'Medial', and 'Posterior'. A watermark for Dr. Frank Chang is present. Photo of two smaller pieces of the same excised tissue specimen on a blue surgical drape, next to a ruler. Handwritten notes include 'Fresh', '1mm-2mm', 'floride', and 'Histo' (histology). Watermark for Dr. Frank Chang is visible.     Clinical photo showing a patient's mouth with the tongue extended. A purple surgical marking outlines an area on the lateral aspect of the tongue, indicating a planned resection site. A labeled figure displaying a removed tissue specimen (orange/yellowish mass) placed on a sterile blue drape. Handwritten annotations identify it as 'Right lateral tongue' and label anatomical directions: 'Ant' (anterior), 'Post' (posterior), 'Ling' (lingual), and 'Lab' (labial). Procedure image depicting an intraoperative view where gloved hands are manipulating oral tissues. The surgical field is exposed to show the excision site on the tongue, surrounded by retractors and instruments. A labeled diagrammatic representation or photograph of a pathology specimen on a white background. Handwritten text identifies the source as 'Ant left lat tongue' and includes directional markers: 'Ant', 'Dorsal', 'Post', and 'Forn' (likely fornix). # **EXCISIONAL BIOPSY** IMG: Sequence of five clinical photos illustrating the excisional biopsy procedure, including intraoral examination, measurement and marking of a mass, dissection, resulting defect, and the extracted specimen displayed on a blue drape with a ruler.      #### Excisional Biopsy Clinical Sequence Sequence of five clinical photos illustrating the excisional biopsy procedure, including: 1. Intraoral examination. 2. Measurement and marking of a mass. 3. Dissection. 4. Resulting defect. 5. Extracted specimen displayed with a ruler. Clinical photo of an intraoral examination showing the oral cavity retracted to reveal soft tissue structures. Clinical photo illustrating the measurement and marking phase, where a ruler is placed next to a mass with a purple surgical outline drawn on the tissue. Clinical photo demonstrating the dissection step, showing surgical instruments cutting into the marked area of the tissue. Clinical photo displaying the resulting defect after excision, showing the open wound site within the oral cavity. Clinical photo of the extracted specimen displayed on a blue surgical drape alongside a ruler for size reference.   Clinical intraoral photograph showing a close-up view of the posterior oral cavity. A metal dental mirror is visible on the left side reflecting light. In the center, there are molar teeth with significant dark discoloration and decay on the occlusal surface, indicating advanced dental caries or a large restoration. Clinical intraoral photograph depicting an oral surgery procedure. The image shows the use of a metal surgical retractor to hold back soft tissue. A probe with measurement markings is positioned near the gingival tissue, likely measuring a periodontal pocket depth. Visible adjacent teeth include a molar with healthy occlusal anatomy.     Clinical photo showing the inner surface of a patient's lower lip with visible mucosal lesions and surrounding tissue. The image includes a gloved hand holding the lip open for examination. Clinical photo showing the same area as the first image but with purple surgical markings (dots) drawn on the mucosa, indicating planned incision or biopsy sites. A small amount of blood is visible near one of the marked areas. Procedure image showing an excised tissue specimen placed on a blue surgical drape next to a metric ruler for scale. The specimen appears reddish-brown with irregular borders, likely representing the removed lesion from the lip shown in the top images. Procedure image showing another view of the excised tissue specimen on a blue surgical drape with a metric ruler for scale. This specimen appears lighter in color compared to the first, possibly representing a different section or post-processing state of the removed tissue. Clinipath Pathology Dr Frank Chang Referrer 099862 Address DR ALBERGHINI & DR LEWIS 76A SOUTH TERRACE SOUTH PERTH WA 6151 Phone 0894742133 Your ref. 1 EINSTEIN WAY TAPPING WA 6065 Phone 0400771211 Copy to SOUTH PERTH HOSPITAL:MEDICAL RECORDS (0893670222) Requested 01/12/2021 Collected 01/12/2021 00:00 AWST Received 01/12/2021 19:37 AWST Specimen No: 162071-21CL **Histopathology Report** **Clinical Details:** 70M. Right lateral tongue raised lesion with rough surface and healing ulcer posteriorly. (photos available on request). **Macroscopic Description:** Right side tongue lateral: An orientated irregular mucosal fragment 14 x 9 x 3mm. A marking suture is present at the anterior pole designated at 12 o'clock. The 3 o'clock margin is inked green, the 9 o'clock margin is inked black. Transversely sectioned into five pieces and processed in two blocks. 5-2A TPM **Microscopic Description:** 1A. and 1B. Six levels of each examined. These sections show mature fibrous connective tissue covered by parakeratinised stratified squamous epithelium with a papillary surface configuration. Ulceration is not seen at these levels. Features of epithelial dysplasia including nuclear pleomorphism and hyperchromatism and irregular stratification are seen. These features are confined to the lower half of the epithelium. An eosinophilic coagulum is seen in the basement membrane zone. A moderately intense chronic inflammatory cell infiltrate composed predominantly of lymphocytes and macrophages can be seen in the connective tissue and disrupts the epithelium. No PAS-D positive fungal elements are seen. **Conclusion:** Right lateral tongue: Parakeratosis with moderate epithelial dysplasia possibly on a background of oral mucosal lichen planus. Mild dysplasia extends to peripheral margins. Clinical correlation is required. Case reviewed with Dr Norman Firth using remote digital microscopy. **Pathologist:** Dr Jason Lau, [jlau@clinipath.net](mailto:jlau@clinipath.net) , 08 9371 4519 Clinipath Specialist Oral Pathology Service. Clinipath Pathology NATA No: 2619-2612 Page 1 of 1  #### Histopathology Report Example - **Patient**: 70M - **Clinical Details**: Right lateral tongue raised lesion with rough surface and healing ulcer posteriorly. - **Macroscopic Description**: Irregular mucosal fragment 14 x 9 x 3mm. Marking suture at anterior pole (12 o'clock). Margins inked green (3 o'clock) and black (9 o'clock). - **Microscopic Description**: Mature fibrous connective tissue with parakeratinised stratified squamous epithelium. Features of epithelial dysplasia (nuclear pleomorphism, hyperchromatism, irregular stratification) confined to the lower half. Chronic inflammatory cell infiltrate present. - **Conclusion**: Right lateral tongue: Parakeratosis with moderate epithelial dysplasia possibly on a background of oral mucosal lichen planus. Mild dysplasia extends to peripheral margins. Clinical correlation required. Clinical histopathology micrograph showing a section of the right lateral tongue lesion. The image displays tissue stained with H&E (hematoxylin and eosin), revealing stratified squamous epithelium overlying connective tissue. The epithelial layer shows features consistent with dysplasia, including nuclear pleomorphism and hyperchromatism. The underlying stroma contains a moderate chronic inflammatory infiltrate.  Clinical histology photo: H&E stained tissue section showing epidermis and dermis with dense lymphocytic infiltrate. # THANK YOU # QUESTIONS Frank.chang@uwa.edu.au #### Thank You / Questions Contact: Frank.chang@uwa.edu.au [^1]: Original PDF page 1: [[L2 Surgery in Oral medicine.pdf#page=1|L2 Surgery in Oral medicine, p.1]] [^2]: Original PDF page 2: [[L2 Surgery in Oral medicine.pdf#page=2|L2 Surgery in Oral medicine, p.2]] [^3]: Original PDF page 3: [[L2 Surgery in Oral medicine.pdf#page=3|L2 Surgery in Oral medicine, p.3]] [^4]: Original PDF page 4: [[L2 Surgery in Oral medicine.pdf#page=4|L2 Surgery in Oral medicine, p.4]] [^5]: Original PDF page 5: [[L2 Surgery in Oral medicine.pdf#page=5|L2 Surgery in Oral medicine, p.5]] [^6]: Original PDF page 6: [[L2 Surgery in Oral medicine.pdf#page=6|L2 Surgery in Oral medicine, p.6]] [^7]: Original PDF page 7: [[L2 Surgery in Oral medicine.pdf#page=7|L2 Surgery in Oral medicine, p.7]] [^8]: Original PDF page 8: [[L2 Surgery in Oral medicine.pdf#page=8|L2 Surgery in Oral medicine, p.8]] [^9]: Original PDF page 9: [[L2 Surgery in Oral medicine.pdf#page=9|L2 Surgery in Oral medicine, p.9]] [^10]: Original PDF page 10: [[L2 Surgery in Oral medicine.pdf#page=10|L2 Surgery in Oral medicine, p.10]] [^11]: Original PDF page 11: [[L2 Surgery in Oral medicine.pdf#page=11|L2 Surgery in Oral medicine, p.11]] [^12]: Original PDF page 12: [[L2 Surgery in Oral medicine.pdf#page=12|L2 Surgery in Oral medicine, p.12]] [^13]: Original PDF page 13: [[L2 Surgery in Oral medicine.pdf#page=13|L2 Surgery in Oral medicine, p.13]] [^14]: Original PDF page 14: [[L2 Surgery in Oral medicine.pdf#page=14|L2 Surgery in Oral medicine, p.14]] [^15]: Original PDF page 15: [[L2 Surgery in Oral medicine.pdf#page=15|L2 Surgery in Oral medicine, p.15]] [^16]: Original PDF page 16: [[L2 Surgery in Oral medicine.pdf#page=16|L2 Surgery in Oral medicine, p.16]] [^17]: Original PDF page 17: [[L2 Surgery in Oral medicine.pdf#page=17|L2 Surgery in Oral medicine, p.17]] [^18]: Original PDF page 18: [[L2 Surgery in Oral medicine.pdf#page=18|L2 Surgery in Oral medicine, p.18]] [^19]: Original PDF page 19: [[L2 Surgery in Oral medicine.pdf#page=19|L2 Surgery in Oral medicine, p.19]] [^20]: Original PDF page 20: [[L2 Surgery in Oral medicine.pdf#page=20|L2 Surgery in Oral medicine, p.20]] [^21]: Original PDF page 21: [[L2 Surgery in Oral medicine.pdf#page=21|L2 Surgery in Oral medicine, p.21]] [^22]: Original PDF page 22: [[L2 Surgery in Oral medicine.pdf#page=22|L2 Surgery in Oral medicine, p.22]] [^23]: Original PDF page 23: [[L2 Surgery in Oral medicine.pdf#page=23|L2 Surgery in Oral medicine, p.23]] [^24]: Original PDF page 24: [[L2 Surgery in Oral medicine.pdf#page=24|L2 Surgery in Oral medicine, p.24]] [^25]: Original PDF page 25: [[L2 Surgery in Oral medicine.pdf#page=25|L2 Surgery in Oral medicine, p.25]] [^26]: Original PDF page 26: [[L2 Surgery in Oral medicine.pdf#page=26|L2 Surgery in Oral medicine, p.26]] [^27]: Original PDF page 27: [[L2 Surgery in Oral medicine.pdf#page=27|L2 Surgery in Oral medicine, p.27]] [^28]: Original PDF page 28: [[L2 Surgery in Oral medicine.pdf#page=28|L2 Surgery in Oral medicine, p.28]] [^29]: Original PDF page 29: [[L2 Surgery in Oral medicine.pdf#page=29|L2 Surgery in Oral medicine, p.29]] [^30]: Original PDF page 30: [[L2 Surgery in Oral medicine.pdf#page=30|L2 Surgery in Oral medicine, p.30]] [^31]: Original PDF page 31: [[L2 Surgery in Oral medicine.pdf#page=31|L2 Surgery in Oral medicine, p.31]] [^32]: Original PDF page 32: [[L2 Surgery in Oral medicine.pdf#page=32|L2 Surgery in Oral medicine, p.32]] [^33]: Original PDF page 33: [[L2 Surgery in Oral medicine.pdf#page=33|L2 Surgery in Oral medicine, p.33]] [^34]: Original PDF page 34: [[L2 Surgery in Oral medicine.pdf#page=34|L2 Surgery in Oral medicine, p.34]] [^35]: Original PDF page 35: [[L2 Surgery in Oral medicine.pdf#page=35|L2 Surgery in Oral medicine, p.35]] [^36]: Original PDF page 36: [[L2 Surgery in Oral medicine.pdf#page=36|L2 Surgery in Oral medicine, p.36]] [^37]: Original PDF page 37: [[L2 Surgery in Oral medicine.pdf#page=37|L2 Surgery in Oral medicine, p.37]] [^38]: Original PDF page 38: [[L2 Surgery in Oral medicine.pdf#page=38|L2 Surgery in Oral medicine, p.38]] [^39]: Original PDF page 39: [[L2 Surgery in Oral medicine.pdf#page=39|L2 Surgery in Oral medicine, p.39]] [^40]: Original PDF page 40: [[L2 Surgery in Oral medicine.pdf#page=40|L2 Surgery in Oral medicine, p.40]] [^41]: Original PDF page 41: [[L2 Surgery in Oral medicine.pdf#page=41|L2 Surgery in Oral medicine, p.41]]