Transcribed by Nicole Farber 7/7/2014

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[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
youre 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 theyre all good,
but todays lecture I think is really a special one cause Im 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 Im 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 theres incisional
and excisional biopsies, and Ive put scalpel/punch because these are actually
surgical biopsies. We can use the scalpel or you can actually use an instrument
called a punchokay, has anyone actually ever heard of a punch before? Does
anyone know what a punch is? Okay, couple people. Perhaps you know if youre
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 wasnt even mentioned.
But since I learned to do this, I love to do it. Its so much easier. But Ill go over that
shortly. Okay, so lets 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. Youre 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, its used for the diagnosis of candidiasis
and herpetic lesions. So candidiasis is a superficial proliferator of an organism.

Transcribed by Nicole Farber 7/7/2014

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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 dont 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. Youre 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 havent 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
whats 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 youve 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
whats done with pap smears as well okay and then a lot of times now you dont 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 dont 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 dont 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 youre 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 its
really important, especially from a pathology point of view, slides we dont 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 dont just clump it here or
something like that okay? Then once you spread it you know, we dont 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
thats 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 dont 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 youre 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 itll take to air dry, then the longer itll take for you to, um, move on and
submit this. So you just want to do just enough to cover the slide when youre 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 youve 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 arent touching.

[11] Smear Technique
[Dr. Shah] So in the holder theres 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] Im 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 theres a form of
candida called pseudomembranous that wipes off with gauze. Okay then theres
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 its said to be a developmental issue or possibly superimposed
with candidiasis. Okay. Alright so lets say a biopsy is done, you really should never
have to do a scalpel biopsy for candidiasis. Except theres one variant called
hyperplastic, which are white patches that dont wipe off, but otherwise you know if
youre 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, thats really suspicious
findings for candidiasis. Alright but many times what we do is if were trying to rule
out candidiasis, its hard to actually see it here, we see the shaggy keratin and the
neutrophils. But well 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. Youre 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 youll 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, theres 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 youll 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. Im 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 heres an example- this is a mirror showing you the lesion thats
on the palate behind the tuberosity area, and many times with herpes youll get
these punctate tiny ulcers that can fuse together or form these big irregular shapes.
So thats kind of whats 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 youre not going to see the relationship of the tissues like
you do here. And youre looking for those same big multinucleated cells with molded
nuclei. Heres an example of a tzanck cell, herpes, heres an example of tzanck cells
and heres some more examples.

[19] mucosal smears positive for herpes
[Dr. Shah] The different colors are just due to the level that youre at, and the lab
that stained them okay? So thats 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 theres 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. Youre not using a q tip or a
wooden type of a spatula, youre 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 youve 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. Its a harmless spot
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for now, dont let it grow up to be oral cancer Theres a little spot on the tongue
here. Ask your dentist about the brush test.

[21] Its a harmless spot now
[Dr. Shah] And I wont 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, Im 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 youre a DDS, a doctor of dental surgery, and you can pull a
tooth, you can do a soft tissue biopsy. So if its not suspicious watch it, if its
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 youre getting a complete trans epithelium tissue sample, the brush is going
to look something like this. Ill show you the uh picture coming up, and here this
sample that you end up with is superficial, intermediate, and basal cells so youre
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 youre 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 thats going to collect deeper cells
and thats 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, youre removing tissue
from a patients 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, heres the invasive looking brush
that Im 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 youre doing a brush biopsy. So heres
an example where theyre using the end of the brush on a sub labial mucosal lesion,
and heres 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 its hard kind of
maintaining a position, and if you dont have a good hold and youre twirling that
thing it goes all around the lip. It can hurt and the patients really dont like this and
find it unpleasant so you have to be, you know, have a really good hold and
retraction of where youre using this and um, this is technique sensitive too. And
thats another reason I dont like brush biopsy, cause if you dont get enough cells
the lab is going to send you a diagnosis insufficient for diagnosis and everybodys
time and effort was wasted, okay, so lets see. So then once you have your sample
youre doing the same thing like you did with the mucosal smear- youre spreading
the cells on the slide, the labelled slide, and then youre 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. Whats
really being done once you send it away to the lab? There its 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 its really sort of scanning and measuring
the size of the nuclei and the cells youre submitting and the computer is doing that,
and so theres 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] Theyre 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. Im going to show you what the results can be
and heres a setup again here of what the computer assisted technique is, so the
results when you get back... your result, its going to be one of these four things: its
either going to be negative, which is the best case scenario, its going to be atypical
cells warranting further investigation, its 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 dont like this test is cause you see this often and this-
oops Im 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 its nothing, it doesnt hurt, but thats not really true
okay? And in some patients who dont have money, or are scared when they see the
blade and wont 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, thats 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 arent going to come and arrest you for using a brush biopsy on
anything okay? So you can use it on anything you want, but theres certain lesions
you should use it on and theres 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 doesnt 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 its 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
doesnt mean you cant use it and if your patient wont let you do a scalpel biopsy
and youre very suspicious, they might let you do a brush biopsy. Then you might do
that, but thats not the best indication okay?

[29] Examples of Uses for Brush Biopsy
[Dr. Shah] So heres some examples, heres 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, heres some more examples. Heres some cheek biting keratosis,
heres an edentulous ridge thats being prepared for implants that has some
hyperkeratosis, heres 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 youre 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 thats not an indicator. Remember, brush biopsy is only for epithelium its
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 youre going to
cause pain when you do a brush biopsy. Student speaking. Thats not the answer
either, keep going. Student speaking. Theres no epithelium! Ulcer is an area thats
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 youre going to
see on the microspore is a bunch of necrotic crap and red blood cells everywhere,
okay? And then youre definitely going to get back insufficient for diagnosis, okay?
So you dont want to biopsy an ulcer, then you dont do a brush biopsy of pigmented
or vascular lesions and you dont, 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 thats a very suspicious lesion. It requires
a scalpel biopsy, you dont 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 Ill 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. Lets 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 whats an incisional biopsy? Its 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?
Whats the most imp word in this definition? Representative okay, and thats why
the next lecture comes into play. Its very important when you do one of these
scalpel biopsies, especially if its 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 whats the basic criteria to determine whether to perform
incisional or excisional biopsy? Lets 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 theres 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 its 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. Lets say youre
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 youre
nowhere near vital structures. Even if its 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 wouldnt 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. Im a believer of critical thinking
and not just memorizing. Think through this. Lets say you have a lesion thats
possibly cancerous, thats 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, whats 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. Youre 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 its 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 thats one of the reasons why you really should do an incisional biopsy
of something very suspicious, okay, and then vice versa. I mean lets say you have
something, youre pretty confident that its suspicious, then you might want to
remove the whole thing even if its bigger than a cm or whatever. Okay. Then
theres clinical judgment for exophytic lesions, um many fibromas you should if
youre pretty confident its 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 its 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 heres 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 its different. If its 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 thats what this elliptical cut is here, okay,
so thats a great example of an incisional biopsy.

[36] Incisional Biopsy of Tongue Leukoplakia
[Dr. Shah] Okay, so heres some more examples. Heres a tongue leukoplakia. Ok
you see this, um, white patch? Using technique, it doesnt 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 were going to take a
piece of it and Im 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, thats 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 dont 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, dont 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.



Transcribed by Nicole Farber 7/7/2014

13
[39] Excisional Biopsy 3
[Dr. Shah] So this is after biopsy, the entire lesion was taken out, okay. And then
this isnt a biopsy I did, this was before my time. I would never put this many
sutures, this person went crazy. I dont know whether they were practicing suturing
or you know, I dont 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 theres this thing called a retraction clamp. If youre 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. Its not that big of a
deal, but sometimes it obscures the diagnosis of the tissue. Okay.


[41] Excisional Biopsy
[Dr. Shah] Alright. Heres 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 were favoring a benign soft tissue or a
benign salivary gland tumor. Painless locally. So, this entire thing should be
removed because its 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 patients mouth, even when a tooth is taken
out and theres periapical pathology or cyst, those endodontists are supposed to
submit that tissue, okay. But thats not always what happens due to insurance
reasons, due to the patient getting a bill that they dont want to pay, due to medical
malpractice, all these other reasons. But its supposed to be done. But definitely for
periapical pathology, any other soft tissue lesions should be submitted even though
were pretty confident that this is a fibroma. 95% it is. It could be another soft
tissue lesion, theres some other ones that you dont know about yet, but theyre 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 thats a good question. Um, its 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, theres other factors. Cause sometimes
you can do more harm to a patient than good, especially if you have a patient that
Transcribed by Nicole Farber 7/7/2014

14
has a complex medical history. I dont want to go chasing a fibroma if the patient
has a bleeding disorder and can bleed to death, okay. So um, theres 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 isnt going to transform into something
malignant, however, it will continue to get bigger. Okay. And its 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 dont want to use a brush biopsy on a
candidiasis or herpes, you dont 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 youre 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 youre
going to do incisional, you need to get a representative area, okay? And were going
to go over representative areas in the next part of this lecture, okay? Any questions
again? So Im 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 youd 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.