 hello everyone welcome back to another session in dentistry and more today we have a small topic in surgery the biopsy biopsy is nothing but a surgical procedure where a part of the lesion will be surgically taken out and it will be sent for further examination so when we have very inconclusive diagnosis or we are not sure about a lesion we always opt for biopsy so biopsy will in most of the cases it will reveal the true nature of the lesion so let's learn biopsy and its procedures so definition of biopsy it is a surgical procedure to obtain tissue from a living organism for its microscopic examination usually to perform a diagnosis so when we should go for biopsy when we have a suspicion about a lesion whether it is a malignant or it has some malignant potential we should go for biopsy on red and white lesions so certain red and white lesions have the potential to become malignant lesion so such cases we should think of biopsy then ulceration when there is ulceration on the lesion when there is a duration that is if the lesion is persisting without healing more than two weeks or if the lesion which exhibits very rapid growth rate or if it has bleeding on gentle palpation and if the lesion and surrounding tissue is firm to the touch or if the lesion is attached to the adjacent structures so all these cases we should go for biopsy for its final confirmation and on what conditions we should not think of biopsy if the patient is on anticoagulant therapy or if there is overwhelming sepsis and if the patient has some impaired lung function in case of uncontrolled bleeding and if the patient is non-cooperative and if a local infection is present at the lesion site we should not go for biopsy so what are the objectives of biopsy it is mainly to confirm a diagnosis which was made on the clinical findings to determine the treatment plan and to keep as a medical record so these are the objectives of biopsy now let's move on to the classification of biopsy so basic types are surgical biopsy, finadial aspiration cytology, exfoliative cytology, brush biopsy, in surgical biopsy we have incisional biopsy, excisional biopsy and punch biopsy okay and there are many other types of biopsy such as frozen section biopsy, cone biopsy, core needle biopsy, laser biopsy so we are focusing only on this four and three categories of surgical biopsy so what are the steps of biopsy the first one is selection of the area of biopsy then preparing this surgical field then applying local anesthesia doing giving the incision then handling of specimen finally after the specimen taken out we need to suture the resulting wound the first one is incisional biopsy so incisional biopsy are indicated when there is size limitations and if there is hazardous location when the lesion is very close to vital structures and we have great suspicion of malignancy so if this red color is the lesion we take a part of it and a part of normal tissue okay so all this blank area is normal tissue you assume it as normal tissue so we take a part of the lesion and a part of normal tissue okay just like this these are all normal tissue and only this part is a lesion. So we take a part of the lesion and a part of normal tissue. That is incisional biopsy. When we have a great suspicion of malignant changes, we should never go for excisional biopsy. We should take just a part of the lesion and adjacent lesion. So the technique is it is like a witch fashion. We need to cut the lesion and margins should extend into the normal tissues and we should avoid the necrotic tissues. So a narrow and deep specimen. Okay so a narrow and deep specimen rather than a broad and flattened broad shallow one is not preferred. A narrow deeper one is preferred rather than a broad and shallow one. Okay so this is always preferred rather than broad and shallow one. So that is incisional biopsy. So incisional biopsy it should extend from the ulceration out on to clinically normal tissues. So clinically normal tissue also should be included in the specimen. So if it is excisional biopsy, before that we need to learn the disadvantages of incisional biopsy. For incisional biopsy, there could be crush, splits and hemorrhages are the problems which are more frequently found in this type of biopsies. There will be severe hemorrhage, there will be splits and there will be crush of the tissues and theoretically it will result in seeding of cancer cells into the adjoining tissues. So seeding of cancer cells to the adjoining tissues. When we do a procedure it might result in spreading the cancer on a theoretical ground. So that was about incisional biopsy. Exisional biopsy it implies a complete removal of the lesion. If this green is lesion we take a specimen with surrounding normal tissue and the complete lesion. So it is a biopsy which involves a complete removal of lesion. So it is always employed with smaller lesion when there is lesions which is less than 1 centimeter. So the lesion on clinical examination appears benign. So mostly we go for excisional biopsy on benign lesions. So when complete excision with a margin of normal tissue is possible without mutilation of the tissues. So in that case only we should go for excisional. That is benign lesions, smaller lesions we should go for excisional malignant lesions, suspected malignant lesions and bigger lesions we should think of incisional biopsy. So excisional biopsy technique is the entire lesion with 2 to 3 mm of normal adjacent tissue is excised. It is most commonly used in mucosil. Mucosil is excisional biopsy. Now we have punch biopsy. So punch biopsy it is like we know punched out lesions it will be like this punched out lesions. So it is a procedure in which small round piece of tissue about a size of pencil is removed using a sharp whole of circular instrument. So a circular scalpel it will be a circular scalpel. Usually the scalpel will be like this. So we use a circular scalpel used to cut into a lesion on the skin and the instrument is turned clockwise and anticlockwise and to cut down about 4 mm to the layer of fatty tissue below the dermis. So a small sample of tissue is removed to be checked under further histological examination. So it is punch biopsy. So instead of a normal scalpel we use a circular scalpel that is punch biopsy. So these are the surgical biopsy surgical procedures. Okay now let's go to FNAC the fine needle aspiration cytology. So before that we need to learn the advantage of punch biopsy it is very easy technique sutures may not be required if it is a very small diameter and it may produce more satisfactory specimen and it is commonly used in hard palate. Hard palate drawbacks it might not give adequate tissue for biopsy and it may be difficult to biopsy a freely mobile tissues such as soft palate and floor of the mouth. We need a very hard structures such as ginger or hard palate to take a circular scalpel because the tissues to be very firm. If it is movable we may not be able to taking a proper punch biopsy. So now we have fine needle aspiration cytology. So fine needle aspiration cytology is a technique of aspirating cells or fluids or tissue fragments using a fine needle for examination under microscope. So the fine needle aspiration that is aspirational biopsy indicated to determine the presence of fluid within elution or to determine the type of fluid within elution and to explore the intra-ocious lesion. So the procedure is 18 gauge needle is connected to F5 or 10 ml syringe and is inserted into the center of the mass using a small hole in the lesion. So if it is a lesion we create a small hole here and then we put our needle into it. So the tip of the needle may not be positioned properly so we need to keep at multiple directions to locate a potential fluid center. Then the material withdrawn using aspiration biopsy and it will be submitted for examination. And if we are unable to withdraw fluid or we are getting air which indicates that the lesion is probably solid and if we have a radio-lucid lesion in the jaw that gives a straw colored fluid. Straw colored fluid means it is a cyst and if we get pus then there will be an inflammatory or infectious process and if we are getting blood that is the aspiration is giving blood it indicates a vascular malformation within the bone. So any intra-boni radio-lucid lesion should be aspirated before surgical intervention to rule out a vascular lesion. So if the lesion is determined to be vascular in nature the flow rate should be determined because when we go for a surgical procedure this flow rate is very much important because if we don't know the flow rate there will be uncontrollable hemorrhage. So if you are going for a intra-auspicious surgical procedure FNAC would be very much helpful to make out or rule out the vascular malformation within the bone. So advantages are it is painless it produces speedy results in expensive technique with use of very little equipment is required which can be done as an outpatient or a bedside. There is no problem with wound healing and it is readily repeatable and it is commonly indicated in non palpable lesions or area difficult to be biopsied to roll out any vascular lesions prior to open surgery in case where biopsies contraindicated on medical background used as a diagnostic screening test for head and neck various masses indicated for non tumors to assess the effect of treatment. So these are the indications for FNAC and now we have exfoliative cytology. So exfoliative cytology is not actually a biopsy method it is an adjunct it cannot be used as a substitute for any surgical biopsy incisional or excisional it can be used as an adjunct along with this incisional and excisional biopsy. Okay so in exfoliative cytology so it is as I mentioned it is used as an adjunct not as a substitute. So it is examination of individual cells okay so the problem is it cannot provide the histological feature which is very vital for a definitive diagnosis. It developed as a diagnostic screening procedure it is mainly for screening procedure to monitor large tissue areas of displastic changes. So lesions that lend themselves to cytological examination includes basically herpes infection, fungal infection, pemphigus or post-radiation changes of tissues. So all this can be done under exfoliative cytology. So procedure is the lesion is scraped repeatedly and firmly with a moistened tongue depressor or cytology brush. So the cells are then transferred to ancemeated evenly on a glass slide. The slide is immediately immersed in a fixing solution and the cells later can be stained and studied. So the advantage is it may be helpful when large areas of mucosal changes are noted or in areas with difficult surgical access but the disadvantage is not very reliable because it gives so many false positive false positives. False positive is nothing but giving a false diagnosis and we don't have many expertise in oral cytology that is another problem. So that is fine needle aspiration cytology and the last one is brush biopsy. Brush biopsies usually when we diagnose oral epithelial dysplasia traditionally what we do is we take full thickness lesion. So the specimen will be full thickness. It includes most of the layers of tissue but the recent concept is that is brush biopsy. These samples is a non-invasive method to determine the presence of cellular atypia which will not take the complete full thickness biopsy specimen. So it is like firm pressure with a circular brush is applied which will be rotated five to ten times causing light abrasion. Abrasion is removing a superficial cells over the tissue or the lesion. So these cellular materials will be picked up by the brushes and then the same procedure it will be transferred to glass light then preserved dried and stained and studied. So that is a brush biopsy. It is again it can't be used as a substitute. It can be used as an agent. Okay so these are the basic types of biopsy surgical biopsy which are incisional excisional and punch biopsy then FNAC exfoliated cytology and brush biopsy. So what are the problems of biopsy? So there are lots of danger associated with biopsy such as spreading of infection. Hemorrhage is a big problem and chances of infection and there will be operative trauma. So that's all about biopsy. So I've discussed about surgical biopsy FNAC exfoliated and brush biopsy. Only thing is little bit confusion about incisional and excisional. This is a part of the lesion. This is complete lesion and this is punch biopsy. A circular blade will be used to take the lesion. So biopsy is very much important in diagnosing a lesion where we suspect malignancy. And on an exam point of view this will be asked as a short essay or short note like incisional, excisional, punch biopsy and exfoliated cytology is a commonly asked short note. So I'll come up with a new topic in surgery. Thank you.