04: Diagnostic Procedures

Transcribed by Nicole Farber 7/7/2014

[DOD] [Lecture #5/6] – [Diagnostic Procedures for Oral Lesions and Biopsy] by [Dr. Shah]

[1] – [Diagnostic Techniques for Oral Lesions][Dr. Shah] – Good afternoon, hello. Good afternoon, how are you guys? I can see you’re really excited about oral pathology. I can feel the excitement in the room. Ok. While I will not disappoint, todays lecture I think, of course I believe they’re all good, but todays lecture I think is really a special one cause I’m talking about, um, biopsy technique and different ways of uh, diagnosing oral lesions. Ok so let me begin. So there are two parts to this lecture today, this first part is entitled diagnostic technique for oral lesions and then the second part will be called, um, uh, surgical biopsy technique. Ok yea, alright, so let us begin. Ok so diagnostic techniques for oral lesions, this is one of the basic, basic rules.

[2] – The technique used for diagnosis must be appropriate...[Dr. Shah] – The technique used for diagnoses must be appropriate for the mucosal disease lesion. OK now I’m going to go over the various techniques, and you kind of have to know when you have a finding in the oral cavity which of these techniques you should be using to make the diagnosis, that is the point of this lecture. Okay, these are the techniques we will be discussing used for the diagnosis of oral mucosal disease and lesions

[3] – Specific techniques used for diagnosis of oral mucosal diseases/lesions[Dr. Shah] – Mucosal smear, the brush biopsy aka oral cdx, cause that is the name of the company that kind of holds the rights for this test, and then there’s incisional and excisional biopsies, and I’ve put scalpel/punch— because these are actually surgical biopsies. We can use the scalpel or you can actually use an instrument called a punch—okay, has anyone actually ever heard of a punch before? Does anyone know what a punch is? Okay, couple people. Perhaps you know if you’re related to a dermatologist, or you spent a lot of time at a dermatologist office, they love using punch biopsies. And this is something new that I picked up when I came to NYU, when I trained...um... did my training, you know this wasn’t even mentioned. But since I learned to do this, I love to do it. It’s so much easier. But I’ll go over that shortly. Okay, so let’s talk about the mucosal smear first.

[4] – 1. The mucosal smear[Dr. Shah] – Ok, so mucosal smear. The purpose of the smear is to examine the cells that can be collected by scraping the surface of a lesion. Ok so the smear is very superficial. You’re basically just getting the keratin layer and the top of the epithelium. So the smear is really indicated for only two things, okay. Candidiasis because the fungal organisms like to stay on the surface keratin, and herpes because the tzanck cells, which are the herpetic infected cells, are also superficial... So those are the only two indications that you should be doing a mucosal smear, but for nothing else. Okay? So as I just said to you, it’s used for the diagnosis of candidiasis and herpetic lesions. So candidiasis is a superficial proliferator of an organism.

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[5] – Indications for the mucosal smear[Dr. Shah] – Please note that a lot of us have candidiasis in our mouths. The older you get, the more likely you are to have the candida fungus in your mouth. The thing is, most of us have normal, competent, immune systems- so we don’t get an opportunistic infection from it. Herpetic lesions are ulcers that are located on fixed keratinous mucosa, such as the gingiva and palate, and is caused by herpes simplex virus. These are the only two indications to do a smear.

[6] – Broom sweep limited to superficial cells[Dr. Shah] – Ok, so this is a diagram to show you what kind of cells you are actually getting in a mucosal smear. So normally we use kind of a cotton tip applicator, or some type of wooden spatula instrument to collect the cells and do the scraping. So pretend that this is the epithelium, these are the basal cells which are deeper in the epithelium, this is the connective tissue, so the smear is just getting the top layer. So your specimen is just going to be superficial cells. You’re not going to be getting intermediate or basal cells of the epithelium, okay. [speaking about next slide before changing slides] So this is what a smear kit looks like. You know you guys are just starting clinic, so you haven’t seen any of these things, but you will.

[7] – Cytologic Smear Kit[Dr. Shah] – So a smear kit is freely available in the clinics and the school, and also when you go into private practice and hopefully associate yourself with an oral pathology lab and um, labs will always supply these with biopsy bottles, okay? So what’s in a smear kit? So you have an alcohol fixative, 2 glass slides, and the instruments for taking the scraping. This is really the favorite instrument, and maybe you’ve seen it. Well maybe some of you have seen something like this. They use it for pap smears as well. Okay. So kind of the same kind of the similar kit to what’s done with pap smears as well okay and then a lot of times now you don’t find these so we wind up using the cotton tip applicator or qtip but of course use this side, not the cottony side, but this side. Okay. Alright. Smear technique.

[8] – Smear Technique[Dr. Shah] – So if you see something that you think is candidiasis or herpetic and you want to do a smear, you take your wooden instrument and rub it along um, you know, the lesion, with a little bit of pressure okay. Cause you don’t want the fungal organisms of candidiasis- they tend to be really adherent to the epithelium - so in order to scrape it off and see it under the microscope you have to use a little bit of force. Okay, you don’t want to, you know, have the patient crying or injure them, but you do want to use a little bit of force okay? , once you get your sample, this is the glass slide.

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[9] – Smear Technique [Dr. Shah] – You want to make sure you’re on the right side of the glass slide, and that takes a little bit of knowledge. Basically you look at the labelled side and the rough surface is up, and the smooth surface is down, then you know your glass slide is correct. You take your wooden instrument and spread it along the slide, and it’s really important, especially from a pathology point of view, slides we don’t get clumps of cells. There needs to be a spreading out, so you take your instrument and you go something in a zig zag pattern like this, you don’t just clump it here or something like that okay? Then once you spread it you know, we don’t take time to chit chat or have a coffee break right away. You have to pour the alcohol fixative on your slide okay? I want to point out in this fixative packet there is a gauze in there that’s soaked with this alcohol, this is 95% ethanol okay. So you just want to open it and squeeze the ethanol to fix the slide. You don’t want to take the gauze out then wipe the slide off, then take off all your cells and hard work, and then throw it in the garbage okay? So please make sure you’re just opening and squeezing the packet, okay. And you only need enough to cover the slide. Keep in mind the next step is going to let the slide air dry, so you know the more of this alcohol you pour on the longer it’ll take to air dry, then the longer it’ll take for you to, um, move on and submit this. So you just want to do just enough to cover the slide when you’re doing this smear, okay. Then once it has air dried, and it can take any amount of time depending on how much alcohol fixative, the air temperature, things like that, okay.

[10] – Smear Technique[Dr. Shah] – So then you have a slide holder that you put the slides in and sometimes if you’ve done more than one side, with pencil, you label the sides and write the name on this label part of the slide. You can do up to 2-3 smears, you can put it in this holder which has slots and you want to make sure the slides aren’t touching.

[11] – Smear Technique[Dr. Shah] – So in the holder there’s compartments okay, so now I just want to spend a little bit- that was the smear technique- and once it air dries and you put It in here you submit it to a lab with a form. Then we look at it, but now I want to go over candidiasis a little bit more.

[12] – Oral Candidiasis[Dr. Shah] – I’m actually going to go more into detail about this on my lecture Monday when I talk about mucous membrane diseases and oral mucosa disease, but just a little bit of overview since this is one of the indications.

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[13] – Oral Candidiasis[Dr. Shah] – Okay so candidiasis can be either red or white and there’s a form of candida called pseudomembranous that wipes off with gauze. Okay then there’s denture related candidiasis, which is what this is. You guys remember this from the lecture I gave? Denture stomatitis. Okay this is a white type of candidiasis that wipes off, pseudomembranous. So who remembers this from my lecture on Monday, what is this? Does anyone remember what this is? Median rhomboid glossitis. Remember when I was talking about findings on the dorsal surface of the tongue? I talked about this and in the middle of the tongue, a red patch, it could be flat or slightly raised. And it’s said to be a developmental issue or possibly superimposed with candidiasis. Okay. Alright so let’s say a biopsy is done, you really should never have to do a scalpel biopsy for candidiasis. Except there’s one variant called hyperplastic, which are white patches that don’t wipe off, but otherwise you know if you’re in doubt you do a smear…

[14] – The fungal organisms that cause oral candidiasis…[Dr. Shah] – but if a biopsy is done then this is what the tissue looks like under the microscope. This is the epithelium, and this is the keratin, and what you notice here- these black cells- these black dots, are all neutrophils okay. So when you have a bunch of neutrophils in the top of the epithelium and the epithelium has these white spaces and the keratin is shaggy and not smooth, that’s really suspicious findings for candidiasis. Alright but many times what we do is if were trying to rule out candidiasis, it’s hard to actually see it here, we see the shaggy keratin and the neutrophils. But we’ll do a special stain called PAS- periodic acid schiff- and then it stains the fungal hyphe.

[15] – Candidiasis on surgical biopsy[Dr. Shah] – So they look like this- linear structures like this. So then I know that this is positive for candida, okay. But what are you going to see on the smear? This is what positive smear looks like. You’re going to see scattered epithelium cells that look like this alright. The blue ones are kind of deeper and the pink ones are more superficial and then you’ll see the fungal hyphe.

[16] – A positive mucosal smear[Dr. Shah] – Of course the smear is stained with PAS as well so you get this kind of nice magenta purple color for the fungal hyphe, so you see this is abnormal here. The important point in calling a smear positive is that these hyphe have to be infecting the epithelium cells. If you see hyphe, there’s actually round spores too just floating around in the background here. That could be a smear from any one of us that has candida in our mouths, it has to actually be invading an epithelial cell to be called positive for candidiasis, and many times when this happens the cells clump together because the hyphe goes over several epithelium cells. So you’ll see a clump of cells like this, this is positive for candida- very easy diagnosis here. Okay then I move to herpetic lesions, I just wanted to show you some examples again. I’m going to go into more detail next Monday for candida and herpes but I want to point out to

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you guys herpetic lesions in the mouth occur on fixed keratinous mucosa, usually the palate and the gingiva.

[17] – Oral Herpetic Lesions[Dr. Shah] – Okay so here’s an example- this is a mirror showing you the lesion that’s on the palate behind the tuberosity area, and many times with herpes you’ll get these punctate tiny ulcers that can fuse together or form these big irregular shapes. So that’s kind of what’s happening here. Look on the palatal area here- same thing. Tiny punctate ulcers that have fused together and these tiny punctate ulcers, or a crop, as I use that word for a group of small ulcers on the gingiva here. Okay so if an actual biopsy was done, which again should not need to be done, but if it was what you see is these large multinucleated cells. These are called tzank cells, t z a n c k, this is the characteristic finding of herpetic lesions and smears, which I will show you shortly.

[18] – Surgical biopsy of oral herpetic lesion[Dr. Shah] – So this is described as the multinucleated or molded glassy or glossy nuclei appearance. You have these nuclei fused together, have kind of this shiny look to them, and in the back are inflammatory cells- this is what scalpel biopsy would look like. This is what a smear would look like, of course in a smear the cells are going to be scattered and you’re not going to see the relationship of the tissues like you do here. And you’re looking for those same big multinucleated cells with molded nuclei. Here’s an example of a tzanck cell, herpes, here’s an example of tzanck cells and here’s some more examples.

[19] – mucosal smears positive for herpes[Dr. Shah] – The different colors are just due to the level that you’re at, and the lab that stained them okay? So that’s why it can look a little bit different. Okay. Are there any questions about the smear or the indications for them before I move to the next topic? Does anyone have a question? Speak now or forever hold your peace. Does anyone have a question? Okay moving on.

[20] – 2. The brush biopsy[Dr. Shah] – The brush biopsy is my next topic, and I have to say this is one of the hardest topics for students to understand every year, so I try my best to make it as clear as possible. Please let me know if there’s any, you know, misconceptions or misunderstandings. So the brush biopsy is very similar to the mucosal smear in technique, however, the instrument used is different. You’re not using a q tip or a wooden type of a spatula, you’re using this pretty scary looking brush that comes from the oral cdx company that has these pretty sharp bristles on it. What that does is it allows you to get more epithelium cells, and we are trying to get the entire thickness of the epithelium down to the basal cells when you do a brush biopsy. Okay so perhaps you’ve seen an ad like this, there was a time when oral cdx was really marketing this and it was on buses and you know the bus stands and things like that, but now some dental offices have pamphlets like this. “It’s a harmless spot

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for now, don’t let it grow up to be oral cancer”… “There’s a little spot on the tongue here. Ask your dentist about the brush test.”

[21] – It’s a harmless spot now[Dr. Shah] – And I won’t read it now, but this is a great disclaimer to read here from the ADA. I say this every year and you know I will say it again, I’m not a big believer of this test. You should be familiar with this type of test, but to me this test is a waste of time because if you think something is suspicious, scalpel biopsies and punch biopsies are so easy. If you’re a DDS, a doctor of dental surgery, and you can pull a tooth, you can do a soft tissue biopsy. So if it’s not suspicious watch it, if it’s suspicious just do a biopsy- a real biopsy- instead of doing this type of procedure okay, but still I want you guys to know about it so we will cover it. So in the brush biopsy you’re getting a complete trans epithelium tissue sample, the brush is going to look something like this. I’ll show you the uh picture coming up, and here this sample that you end up with is superficial, intermediate, and basal cells so you’re getting the whole thickness of the epithelium here instead of just the very superficial layer.

[22] – Brush biopsy complete transepithelial tissue sample[Dr. Shah] – And this helps because if you’re trying to determine whether a lesion is precancerous or dysplastic or not, the dysplasia starts from the bottom- the basal cells- and so you need a procedure or instrument that’s going to collect deeper cells and that’s what this does. Okay so the brush biopsy technique will collect cells from all the layers of the epithelium. Okay there you go.

[23] Oral CDx in Suffern, NY[Dr. Shah] – Okay this is what the kit looks like, it comes in a box like this postage paid where you can mail it back to them and the company is in upstate NY- Suffern, NY. And you have the paperwork here. This has a consent on it. Keep in mind when you do a mucosal smear or a brush biopsy you need consent, you’re removing tissue from a patient’s mouth so you do have to get a consent and a signature, and you also have to put insurance info on here. So there is a code, a billing code, for doing brush biopsies and smears as well. Then the rest of them, here’s the invasive looking brush that I’m going to show you pretty soon, this the slides, the holder, and the fixative. They are very similar to what you see in a mucosal smear, okay. Alright so this is what the brush looks like, you can see it has these really sharp kind of bristles. You can use the side of this or the top of this when you’re doing a brush biopsy. So here’s an example where they’re using the end of the brush on a sub labial mucosal lesion, and here’s an example using the side of the brush on the lateral border of the tongue.

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[24] – A special brush is used..[Dr. Shah] – The tricky thing about this is once you start doing it, and you have to turn the bristle a couple of times to get a good sample, and it’s hard kind of maintaining a position, and if you don’t have a good hold and you’re twirling that thing it goes all around the lip. It can hurt and the patients really don’t like this and find it unpleasant so you have to be, you know, have a really good hold and retraction of where you’re using this and um, this is technique sensitive too. And that’s another reason I don’t like brush biopsy, cause if you don’t get enough cells the lab is going to send you a diagnosis “insufficient for diagnosis” and everybody’s time and effort was wasted, okay, so let’s see. So then once you have your sample you’re doing the same thing like you did with the mucosal smear- you’re spreading the cells on the slide, the labelled slide, and then you’re going to get the alcohol fixative, place the sample, fix, air dry, and then you put it in the holder, fill out the form, and send the whole thing in the box to the oral cdx company in Suffern, NY.

[25] – Steps[Dr. Shah] – Two weeks later they will send the report in the mail that has some microscopic pics and that has the results, now a little bit about brush biopsy. What’s really being done once you send it away to the lab? There it’s a computer assisted type of test, a computer is scanning the cells and looking at the size of the nuclei and as you all may or may not know a feature of malignant cells is a larger nuclei and increased nuclei to cytoplasmic ratio, so it’s really sort of scanning and measuring the size of the nuclei and the cells you’re submitting and the computer is doing that, and so there’s this big lab with lots of computers and then they have these people who are cytopathologists, these people are different from me in that they just look at scattered cells.

[26] – The technology behind the brush test[Dr. Shah] – They’re not looking at actual tissues samples and biopsies, scalpel biopsies. When you get a report like this that has some pictures that the computer took, and that has the results up here. I’m going to show you what the results can be and here’s a setup again here of what the computer assisted technique is, so the results when you get back... your result, it’s going to be one of these four things: it’s either going to be negative, which is the best case scenario, it’s going to be atypical cells warranting further investigation, it’s going to be positive, and then the worst thing is “insufficient for diagnosis.”

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[27] – Brush biopsy results[Dr. Shah] – And this comes often, quite a bit of “insufficient for diagnosis,” and in my experience the reason I don’t like this test is cause you see this often and this- oops I’m sorry, atypical cells warranting further investing- what does that mean? Who knows what that means? That means that you have to do a scalpel biopsy, okay, so again why did you do this intermediate step alright? So I will say one positive thing about brush biopsy, there is one positive thing. Sometimes you have patients that are like, you know, a lot of patients think unless something hurts, nothing can be wrong. Or that it’s nothing, it doesn’t hurt, but that’s not really true okay? And in some patients who don’t have money, or are scared when they see the blade and won’t let you do anything, maybe if you do a brush biopsy of a suspicious lesion and it comes back positive or atypical cells, then you can sort of scare the patient and say, “look you know this is something I think we really need to do a scalpel biopsy on now,” that’s really the only use that I see with this to be very honest with you all, okay? So again, these are the 4 possible results: negative, atypical, positive, and insufficient for diagnosis. Okay so what are the indications for brush biopsy? I think this really is the hardest part for students to understand, when do you use a brush biopsy? Let me point out to you that you can use it any time you want, the police aren’t going to come and arrest you for using a brush biopsy on anything okay? So you can use it on anything you want, but there’s certain lesions you should use it on and there’s certain lesions you should not use it on.

[28] – Indications for Brush Biopsy[Dr. Shah] – Okay so the real indications are for flat white leukoplakias. Flat white leukoplakias. Leukoplakias, a flat white patch that doesn’t wipe off, and generally they should be in a non-high risk area, so lesions that have a very low index of suspicion such as you think a sharp and broken tooth, and you think it’s probably a traumatic or frictional hyperkeratosis or the patient admits to chewing their tongue or lip or cheek, those are low risk white lesions that you might use a brush biopsy on. Or maybe if you have an edentulous patient with a ridge keratosis when you have edentulous areas, and patients try to eat, the food rubs up against the ridge and causes a hyperkeratosis reaction. So these are all low risk sites that you might do a brush biopsy on if the patient is worried, or if the patient is a smoker, and you have any doubt at all. Okay so those are the kinds of indications, it should not be used for things that are high-risk sites, or that are very suspicious for cancers, but that doesn’t mean you can’t use it and if your patient won’t let you do a scalpel biopsy and you’re very suspicious, they might let you do a brush biopsy. Then you might do that, but that’s not the best indication okay?

[29] – Examples of Uses for Brush Biopsy[Dr. Shah] – So here’s some examples, here’s a patient that you know they bite their lip, and they have these lesions here- chronic lip biting, chronic cheek biting over here, cheek biting keratosis, these are good examples of things that you might do a brush biopsy on.

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[30] – (3 Images)[Dr. Shah] – Okay, here’s some more examples. Here’s some cheek biting keratosis, here’s an edentulous ridge that’s being prepared for implants that has some hyperkeratosis, here’s a patient that has this leukoplakia on the gingiva, and this patient perhaps they told you they brush really hard in that area or something like that... so you’re not that suspicious, or might need a scalpel biopsy, but could do a brush biopsy on that.

[31] – Contraindications for Brush Biopsy[Dr. Shah] – Okay so these are some indications. What are some contraindications? You should never do a brush biopsy on an exophytic nodular lesion, like a soft tissue or a salivary gland tumor. For example, if you have a fibroma or a salivary gland tumor that’s not an indicator. Remember, brush biopsy is only for epithelium— it’s not for any connective tissue lesion, you should not do a brush biopsy on ulcerated areas. Okay, tell me why you should not do a brush biopsy on ulcerated areas, who knows? Students mumbling. Someone said pain, not quite because you’re going to cause pain when you do a brush biopsy. Student speaking. That’s not the answer either, keep going. Student speaking. There’s no epithelium! Ulcer is an area that’s missing epithelium, and in a brush biopsy the whole point of it is to get an epithelium sample right, so if you do a brush biopsy on an ulcer what you’re going to see on the microspore is a bunch of necrotic crap and red blood cells everywhere, okay? And then you’re definitely going to get back insufficient for diagnosis, okay? So you don’t want to biopsy an ulcer, then you don’t do a brush biopsy of pigmented or vascular lesions and you don’t, you should not, do a brush biopsy for red lesions in high risk areas. Why not? Why should you not do a brush biopsy for red lesions in high risk areas? No one knows? Because that’s a very suspicious lesion. It requires a scalpel biopsy, you don’t want to waste time and effort going through this brush biopsy step when the lesion is very, very, suspicious okay? And remember, I told you guys that red is more suspicious than white, okay? And actually I’ll go more into that when I talk about biopsy technique in the next lecture here. Okay so that was brush biopsy, so again to repeat they should be... flat white lesions in non-high risk sites where you just have this 1% doubt that, okay, maybe this is something. Let me do this, or the patient requests it, okay? Do you guys have any questions on brush biopsy? Every year there some confusion about this, so I really want to make sure everything is clear. Yes? Okay. Let’s move on.

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[32] – 3. Incisional and Excisional Biopsy[Dr. Shah] – Incisional and excisional biopsy, these are scalpel or punch biopsy. This actually involves cutting of tissue, okay? So what’s an incisional biopsy? It’s where taking a piece of tissue a represent sample of the lesion is taken and submitted for microscope exam what do you think is the most important word in this definition? What’s the most imp word in this definition? Representative okay, and that’s why the next lecture comes into play. It’s very important when you do one of these scalpel biopsies, especially if it’s incisional, that you biopsy the right side. If you biopsy the wrong side, I can only, myself and other oral pathologists can only, diagnose what we see on the microscope and you completely miss the lesion, so biopsy selection site is very, very, important. Okay. So representative is an important word. Excisional biopsy: the entire lesion is removed and submitted for microscopic examination. Okay so the purpose of these incisional and excisional biopsies is to obtain a sample that allows the pathologist to see the relationship between the cells and tissues of the lesion. So what this really means is we get to see the big picture when we actually have a chunk of tissue, rather than the scattered cells when you get that from the brush biopsy or the mucosal smear.

[33] – The purpose of the incisional and excisional biopsy…[Dr. Shah] – Okay so what’s the basic criteria to determine whether to perform incisional or excisional biopsy? Let’s say you have a lesion, how do you know whether you should take a piece of it, or whether you should take the whole thing? Well, I have to tell you there’s a lot of clinical judgment that goes into that, okay, but you guys are starting students. I want to give you some basic guidelines, but please understand that these rules are not really written in stone, okay. So there is a size guideline of one cm so, um, you know, many people say that if a lesion is smaller than 1 cm you should take the whole thing out. If it’s bigger than 1 cm you should just take a piece of it out, but I want you to know there are so many exceptions to that rule. So, do not ignore the rest of this and go by 1 cm okay.

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[34] – Basic criteria used to determine whether to perform incisional or… [Dr. Shah] – The location of the lesion is very important. Surgical access and proximity to vital structures, okay, if you have poor access to a lesion, then you might want to do incisional and you might want to leave some of it. Let’s say you’re really close to vital structures, such as in the floor of the mouth, near the opening of the glands, near the lingual nerve, things like that. You might want to take just a piece of the lesion, rather than the whole lesion, if you have good access you’re nowhere near vital structures. Even if it’s bigger than 1 cm, you might take out the whole lesion. Degree of suspicion, I think this is one that a lot of people have a hard time understanding. If you have a very suspicious lesion, you should do an incisional biopsy, okay. Why does that make sense? Why would you do an incisional biopsy if you saw something that was very suspicious? Why wouldn’t you take the whole thing out? Can anyone think what that would be? Student speaking. Not quite. I want you guys to think through this. I’m a believer of critical thinking and not just memorizing. Think through this. Let’s say you have a lesion that’s possibly cancerous, that’s 1 cm big on the tongue, for what reason would I not want to take out the whole thing? Because if it winds up being cancer, what’s the next step? Student speaking. No. Not quite. How about you sir? Use what multiple times? Student speaking. Ok let me help you out here. You’re sort of on track, the answer to this is if you wind up having a patient that has a cancer, and it has to go to an oral surgeon for a larger excision okay. So if you have something suspicious and you take a piece of it, the surgeon can have the margins and find where the cancer is and take out a much bigger chunk of tissue, okay. Does that make sense? So it’s really about that, because ultimately someone such as myself or an oral medicine expert can do these biopsies. But if a patient is diagnosed with cancer, it goes to an oral surgeon or a head and neck surgeon for a much larger excision than I have the skills for, okay, so that’s one of the reasons why you really should do an incisional biopsy of something very suspicious, okay, and then vice versa. I mean let’s say you have something, you’re pretty confident that it’s suspicious, then you might want to remove the whole thing even if it’s bigger than a cm or whatever. Okay. Then there’s clinical judgment for exophytic lesions, um many fibromas you should if you’re pretty confident it’s a fibroma, why take a piece of it? You should remove the whole thing, right? And so, um, you use your judgment for fibromas and pedunculated lesions. You all remember what pedunculated means? What does pedunculated mean? Stalk like, mushroom like, like narrower at the bottom. So if you have something pedunculated, even if it’s like 2 cm on the top and the bottom is half a cm, you should remove the whole thing right? So there is, you know, some...um... judgment and other things that go into this when you decide whether something is incisional or excisional, ok.

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[35] – Incisional Biopsy of a Palatal Lesion[Dr. Shah] – So here’s an example of a palatal lesion. This was a patient with a salivary gland tumor, okay, you see this large exophytic mass here. So the best thing to do for this is to do an incisional biopsy for diagnosis, you know, no surgeon or no one is going to go in and just take this whole thing out without knowing what it is because it’s different. If it’s benign, you can do a conservative removal. If malignant, you need a margin around it, you might need radiation, things like that. So you need an incisional biopsy. An incisional biopsy is done in the middle of this lesion, and deep, you want to deep sample, okay? So that’s what this elliptical cut is here, okay, so that’s a great example of an incisional biopsy.

[36] – Incisional Biopsy of Tongue Leukoplakia[Dr. Shah] – Okay, so here’s some more examples. Here’s a tongue leukoplakia. Ok you see this, um, white patch? Using technique, it doesn’t wipe off on the lateral border of the tongue, which is a high risk site okay. So this could easily be a precancerous or early cancer lesion, so an incisional biopsy… we’re going to take a piece of it and I’m going to go over in the next lecture how you decide where you go here, okay. But for now just know that a piece of this was taken where the circle is, mainly you look for the worst area or areas that are rough, or areas that are red. This is a rough surfaced area, that’s why I chose to do the incisional punch biopsy here okay. Then this is what the sample looked like from this biopsy, and this was dysplastic, this was a precancerous lesion, this was a moderate epithelium dysplasia. We over grading next year, so you guys don’t have to worry about that right now. But we look for the dark, dark, cells. And they go um pretty high here, so I would call this a moderate epithelial dysplasia. Again, don’t concern yourselves with the grading of dysplasia yet, perhaps Dr. Kerr, when he does the oral cancer lecture, might go over this.

[37] – Excisional Biopsy 1[Dr. Shah] – Okay, some examples of excisional biopsy. So I showed you two incisional, excisional. This is an old picture, but this is what do. You think this is, I want you guys to think back to, what is one of the most common oral lesions on the buccal mucosa or one of the most common oral lesions in the entire mouth? Student: squamous cell carcinoma? No, if squamous cell carcinoma was most common, surgeons and pathologists would be rich, but no, not quite. Student: fibroma? Fibroma is the answer! Fibroma is the most common oral lesion, and especially on areas where you can bite, okay. So this is a fibroma, and if you feel this it would feel firm. Does it look sessile or pedunculated to you? Sessile. It looks like it spread out this way right? Okay. But if you feel pretty confident this is a fibroma, which you really should, then why would you take a piece of it?

[38] – Excisional Biopsy 2[Dr. Shah] – You should take out the whole lesion, excision biopsy, okay.

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[39] – Excisional Biopsy 3[Dr. Shah] – So this is after biopsy, the entire lesion was taken out, okay. And then this isn’t a biopsy I did, this was before my time. I would never put this many sutures, this person went crazy. I don’t know whether they were practicing suturing or you know, I don’t know what to say, but I just want to clarify that that was not me, ok?

[40] – Surgical Artifact[Dr. Shah] – Okay so as you can see, this was sutured multiple times, okay, then um... one other point I want to make out is when you do a biopsy, handling the tissue well is important. So there’s this thing called a retraction clamp. If you’re squeezing the crap outta the tissue, this is what I end up with under the microscope. These big holes, this is a retraction clamp artifact, and this is the fibroma. It’s not that big of a deal, but sometimes it obscures the diagnosis of the tissue. Okay.

[41] – Excisional Biopsy[Dr. Shah] – Alright. Here’s another example of excision biopsy. This was a patient with a swelling of the upper lip, okay, and when I felt it, it was a firm, freely moveable, well defined kind of a mass. So we’re favoring a benign soft tissue or a benign salivary gland tumor. Painless locally. So, this entire thing should be removed because it’s so well defined that the entire thing just pops out, okay. So if you feel pretty confident about the diagnosis of this, which you know a clinician with some knowledge would, then you can remove the whole lesion. You make an incision on top and just basically separate the fascia, and pop this entire nodule out as an excisional biopsy. And this ended up being a salivary gland tumor, a benign salivary gland tumor, it was well and kept isolated. Alright, does anyone have any questions on excisional or incisional biopsy? Any questions at all? Yes sir. Student: Um so you said that when we diagnose a fibroma, is it still sent to the lab after you remove it? Absolutely. It threatens the standard of care. You should never remove tissue and just throw it in the garbage, so absolutely. 100% yes. You should. The truth is, that any tissue removed from a patient’s mouth, even when a tooth is taken out and there’s periapical pathology or cyst, those endodontists are supposed to submit that tissue, okay. But that’s not always what happens due to insurance reasons, due to the patient getting a bill that they don’t want to pay, due to medical malpractice, all these other reasons. But it’s supposed to be done. But definitely for periapical pathology, any other soft tissue lesions should be submitted even though we’re pretty confident that this is a fibroma. 95% it is. It could be another soft tissue lesion, there’s some other ones that you don’t know about yet, but they’re all lesions and things like that so it does need to be diagnosed under the microscope, okay? Yes? Student: Um, do you always diagnosis things as a fibroma or is there ever a time you… they could be benign. Ok so that’s a good question. Um, it’s kind of interesting cause I have two answers for you. As a pathologist I would say anything abnormal should be removed and not left there. As a clinician, cause I spend a lot of time in the clinic and I have a lot of patients, there’s other factors. Cause sometimes you can do more harm to a patient than good, especially if you have a patient that

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has a complex medical history. I don’t want to go chasing a fibroma if the patient has a bleeding disorder and can bleed to death, okay. So um, there’s a lot of judgment that goes into this. The truth is again, I told you that pathology should be removed, but you do have to take other circumstances into consideration. But realistically, if you have a normal healthy patient that can afford the biopsy, the lesion should be removed, okay. A fibroma isn’t going to transform into something malignant, however, it will continue to get bigger. Okay. And it’s not going to go away or get smaller or disappear so, any other questions? Okay.

[42] – What do I need to know from this lecture? A summary![Dr. Shah] – So this is my summary slide for this part, what do I need to know from this lecture, a summary. Well the truth is, you have to know all of it, but this is a little bit of a summary here. So in order to make an accurate diagnosis, you have to use the appropriate diagnostic technique. You don’t want to use a brush biopsy on a candidiasis or herpes, you don’t want to do a smear on a soft tissue lesion. You have to know what technique to use for what lesion, okay, so the smear you’re just getting cells from the surface. Okay. And what are the two indications for a smear? Herpes and candidiasis, right. Brush biopsy – you want to get a full thickness of the epithelium, mostly from a flat white lesion in a non-high risk area, just to remove that last bit of doubt. Okay. And incisional and excisional scalpel biopsies… Incisional is a piece, excision is the whole thing. And um, most importantly, if you’re going to do incisional, you need to get a representative area, okay? And we’re going to go over representative areas in the next part of this lecture, okay? Any questions again? So I’m just going to move on to um... do you guys want to take a small break or should I just move on to the next part of the lecture? If I move on well be done in half an hour. Students: Move on. I thought you’d see it that way. Alright…

45:23

“Ready for part two” called at ~45:45, lecture continues on until 1:31:30. There was a clear divide in first and second half of lecture without the break period, and each half was practically equal.

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04: Diagnostic Procedures

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