BIOPSY , CYTOLOGY & TUMOUR METASTASIS 2

8/7/2019 BIOPSY , CYTOLOGY & TUMOUR METASTASIS 2

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1) Principles and technique of biopsy andcytological sampling

2) Benign and malignant neoplasm and

mechanisms of metastases

By Dr Subash Nair

SupervisedProf Mutum Samarendra

Pathology


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BIOPSY Definition : involves the removal of a

piece of tissue for the examination of thehistological architecture and cellulardetails .

Indications:

o Definitive treatment small lesions

o Diagnosis and Prognosis

o Staging work-up define the extent ofinvolvement & to document recurrence ormetastatic spread.


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Pre biopsy requirements

The accurate recording of lesions- site,

size , shape , colour , consistency , &

mobility

Inform pathologist whenever required.

Types of anesthesia.GA, Local

anaesthesia injections or topical sprays

Consent

Prepare patient for appopriate procedures


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Types of Biopsy

Open Excisional , incisional

Closed percutaneous

Endoscopic punch , snare


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Excisional biopsy Complete removal of

the lesion for ahistological diagnosis

May be curative

If benign-no furtherprocedure

If malignant if themargin of N tissueremoved is adequate no further treatmente.g SCC -1cm , BCC 5mm, malignantmelanoma 5cm


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Incisional biopsy Where the possible diagnoses include chr. inflammation,

dysplasia and cancer .

Is the removal of part of a large lesion for histological

examination and leaving the remainder to be controlled

by subsequent therapy .

Care should be taken obtain a sample from the edge of

the lesion & a section of N tissue adjacent to the tumour

should be included .

Disadvantages:o disturbed by necrotic and inflammatory tissue.

o multiple biopsy required when sampling is small in

relation to the whole lesion (central, deeper and edge).


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Percutaneous closed biopsy Very satisfactory method of biopsy for deeper lesions . Involves the targeted removal of a needle core of tissue

from the suspected site .

Good material for tissue diagnosis.

It can be performed blind for superficial lesions (breast

lumps) or imaging guided (lung or liver lesions) .

Type of needle varies with the nature of the tissues involved

Abrams needle- lung ,

Menghini needle- liver

Tru-cut needle breast mass, liver

spring-loaded modification of tru-cut needle- BPH withTRUS guidance .

Manual trephines and high speed rotating drills - obtaincores in tissues of greater density


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Percutaneous needlesTru-cut needle : A nick made with a

scalpel .

Insert the closed needlewith one hand, the otherfix the lump.

The needle is held stillwhile the stylette isadvanced.

The stylette is held stilland the needle isadvanced thru it.

The needle is held stilland the stylette isadvanced, cutting off athin core of tissue.

The needle is keptclosed and withdrawn.


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Endoscopic

The use of fibreoptic endoscope has enormouslyenlarged the scope of biopsy by illuminatingmore and more body tubes and cavities .

Examples : Colon, stomach, oesophagus ,bladder, lungs & uterus

Tiny fragments taken by small crocodile forcepspunchbiopsy forcep

Polypoid lesions can be snared .

Preparation of such small samples must bemeticulous & their correct identification andorientation are vital for documentation ofdiagnosis.


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CytologyExamination of cells without the

architecture of tissues:

the cellular characteristics (nuclear

size, chromatin architecture , nucleoli)The degree of cohesion of the cells

decreased in cancer aspirates

Immunocytochemistry- can be used todetect the presence of specificproducts or markers which help indiagnosis of malignancy


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Types

Exfoliative

Brush

Imprint

Fine needle aspirations


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Exfoliative cytology

o from secretion or excretion.

o The cells shed from epithelium lining of

hollow viscera.

o It is readily applied to disease of upper

GIT, respiratory and genitourinary tracts.

o Pap smear , bronchial lavage , peritonealtap.


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CytologyBrush cytology :

Employed in endoscopic

work

Brushings are obtained

from the entire surface of

the lesion

The superficial cells

caught amongst the

bristles are transferred toa glass slide .

Imprint Cytology :

The application of a

sterile glass microscope

slide to the cut surface of

tissue, e.g. lymph node,bone marrow.

When combined with

labelled monoclonal

antibody to tumoursurface antigens very

sensitive to detect

secondary deposits in LN


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Fine Needle Aspiration Cytology Employing needles to obtain cells and tissue

fragments

The most commonly used tumour diagnosismethod.

Screening

For :

localized and clearly defined tumour by clinicalexamination or by any radiological imagingtechnique .

Superficial growth of the skin, subcutis, softtissues & organs s/a thyroid , breast , salivaryglands & superficial LN


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FNACAdvantages

Technique: relatively

painless

Accuracy : can approach

that of HPE

May provide rapid

microscopic diagnosis

Save hospital cost low

risk : can be done as outpatient procedure .

Readily repeatable

Disadvantages

Negative cytology cannot

rule out malignancy

Certain tumours

(lymphoma, sarcoma)cannot be reliably

diagnosed by this

technique

Tumour transplantationalong the needle tract

Material sometimes

inadequate for diagnosis


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Fine Needle Aspiration Cytology:

Gadgets


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MethodThe syringe holder (Franzen , Cameco) permits the

aspiration to be performed w one hand while the other , fix

the lump.

Needle inserted into tissue to be sampled.

Suction is applied.

Needle advanced several times into the tissue, so that

cellular material is drawn into its shaft.

Negative pressure must be released prior to withdrawal of

the needle to prevent the cell from entering the barrel of

the syringe and loss.

Content of needle are squirted onto a slide then smeared.

If the sample is fluid, centrifuged and smear.


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Method


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Benign and malignant neoplasm and

mechanisms of metastases


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Neoplasm-new growth.

Willis(1948)- an abnormal mass of tissue,

the growth of which exceeds and is

uncoordinated with that of the normaltissues and persists in the same excessive

manner after the cessation of the stimuli

which evoked the change.

Fundamental- loss of responsiveness to

normal growth controls.


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BENIGN MALIGNANT

Rate of growth Slow rapid

encapsulated No capsule , invasive

Smooth surface Irregular

Histological features Highly differentiated, resemble

cell of origin

Range- well to poorly differentiated

DNA and karyotype normal Nuclear and cellular pleomorhism

Hyperchromatism, increase nuclear/

cytoplasmic ratio

Architecture Well formed Disarray

No stromal necrosis Haemorrhage and necrosis

Local invasion Nil infiltrative

Metastasis None Present


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Tumour metastasis

Invasion and metastasis are biologichallmarks of malignancy.

The spread of tumours complex processinvolving a series of sequential steps .

The sequence may be interrupted at any

stage by host or tumour related factors


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How do tumours spread ? Tumour cells detach

from each other becauseof reduced adhesivenessand loosening ofintercellular junctions.

Cells attached tobasement membrane viathe laminin receptorand secrete proteolyticenzymes

Degradation ofbasement membraneoccur

Tumour cell migration

will follow


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Direct spread

Tumour size isimportant larger

tend to cause

troublesome local

spread

Ca of cervix ,

perineurial invasion

of facial nerve in

Adenoid cystic ca ,

oesophageal SCC.

Via fluid filled space

Peritoneum, pleural

cavities , pericardium ,

joints & CSF

Small fragments of

tumours are shed into

these cavities depositspotentially forming

wherever the fluid

extends .

Ovarian ca peritoneal

seedlings & ascites -

pseudomyxoma peritonei


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Blood vessel invasion Tumours can invade any

blood vessels

Veins may be invaded

by carcinomas &

especially sarcomas(arteries less commonly

affected )

Sarcoma lungs

GIT tumours liver

Prostatic vertebral

column


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Lymphatic invasion Commonest mode of spread Carcinomas often spread and produce

metastatic disease by invasion of lymphatics

Group of cells form emboli afferent

lymphatic channels appear in cortical sinus reach the medulla grow into efferentchannel metastasize to other nodes.

Invaded nodes are enlarged (useful clinical

signs of metastasis) , firm and white. Oedema in the region not drained by the

enlarged nodes.


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Spread of tumour


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BIOPSY , CYTOLOGY & TUMOUR METASTASIS 2

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