Special Techniques in the Diagnosis of Oral Cancer* Biopsy: Definitive Diagnosis of Oral Cancer HarveyW. Baker, M.D. Oral Exfoliative Cytology: An Adjunct to Biopsy N. H. Rickles, D.D.S., M.S. Staining Techniques: Screening Tests for Oral Cancer Jamesl. Helsper. M.D.
Biopsy: Definitive Diagnosis of Oral Cancer HarveyW. Baker, M.D. Does the patient have oral cancer? While the appearance and location of a lesion offer many clues, biopsy is essen tial for a definitive diagnosis. Thus, the removal of a representative portion of tissue and histologic examination is in dicated to rule out cancer in any mucosal ulceration which has persisted for three weeks or longer, to confirm the diag nosis of a submucosal soft tissue mass which may be neoplastic, or to positively identify a lesion which appears malignant. Some authorities maintain that biopsy is best performed by the specialist who will ultimately be responsible for ther apy. While this may be advantageous in certain specific situations, most feel that biopsy can generally be safely per formed by any physician who has ade quate facilities and is familiar with the proper technique. Certainly, the dentist who is particularly accustomed to work ing with delicate instruments in the mouth is capable of obtaining a repre sentative portion of an accessible lesion. Biopsy of a surface lesion is generally a simple and safe procedure; a deeper submucosal mass, vascular lesion or lesion of bone may present more prob lems. A more dangerous lesion, in an in accessible location, may require biopsy by a surgeon, in an operating room, with the patient under general anesthesia. Biopsy Technique Biopsy may be either excisional or incisional. If a lesion is small, super ficial, accessible and probably benign, an excisional biopsyâ removing the en tire lesion as well as a small surrounding rim of normal tissueâ may be per formed. In most circumstances, how ever, an incisional biopsyâ removing only a small portion of the tissue for microscopic identificationâ is preferred since it allows for a more rational deci sion regarding management of the entire lesion. Although a representative portion of a lesion must be obtained for pathologic interpretation, the specimen need not be large. Therefore, perform the biopsy gently, causing as little disturbance of normal tissue planes and relationships as possible. Nothing is more disconcert ing or hampering to the therapist than finding the extent of a tumor obscured by edema, ecchymosis and deep sutures as the result of an extensive and trau matic biopsy procedure. Dr. Baker isclinical Professorof Surgery. Univer sity of Oregon MedicalSchool, Portland, Oregon. 159
Biopsy of a Surface Lesion Fig. 2. Incision should extend from the ulceration out onto clinically normal tissue. Fig. 3. Grasp area to be removed with forceps and make an elliptical incision from the center out onto clini. cally normal tissue: wound after removal of incised tissue: suturing completed. 160
Fig. 4. Use of biopsy punch. This instrument may be helpful in obtaining a core of tissue from a mass covered by normal mucosa. Fig. 5. Use of biopsy forceps. Many ulcerated lesions are insensitive and biopsy may be per formed without anesthesia. 161
Ulcerated neoplasms, particularly exophytic ones, are often insensitive and biopsy may be performed without anes thesia. If anesthesia is required, how ever, infiltrate one or two percent pro caine or xylocaine into the normal ap pearing tissues at the periphery of a lesion; do not inject the anesthetic into the lesion itself. Since diagnosis may be difficult if the superficial portions of an ulcerating lesion are infected and ne crotic, obtain tissue from the periphery, using a sharp cup-type biopsy forceps. At times, a scalpel and fine tissue forceps can be used to obtain a small elliptical wedge-shaped specimen. Bleeding is usually slight, and can generally be quickly controlled with gentle pressure. Occasionally, a few sutures of fine cat gut on a small curved needle are re quired for hemostasis. Handle the removed tissue as little as possible and place it immediately in a solution of 10 percent fonmalin. Identify the tissue submitted to the pathologist by the patient's name and the site of re moval. A report of the patient's history and a clinical description of the lesion are often invaluable to the pathologist in making a prompt diagnosis. Biopsy of a mass lying beneath intact mucous membrane requires infiltration anesthesia and incision of the mucosa. Excise a representative wedge of the lesion with a scalpel; a biopsy punch may be used to free a small plug of tissue. Close the mucosa with one or two fine sutures. Biopsy of bone is best carried out by a surgeon who is familiar with the techniques of exposure and re moval of portions of the jaw. A mass in the neck requires the most careful consideration. If a cervical mass is malignant, open biopsy may spread tumor cells throughout the incision. This â œ seedingâ of the surgical wound and the scarring resulting from biopsy may make definitive treatment most difficult and jeopardize the patient's chance for cure. Therefore, if an oral cancer is present, a cervical mass is assumed to be a metastasis and biopsy is generally not indicated. When biopsy of a cervical mass is required, it is recommended that this be done with an aspirating needle. This is a very simple procedure and may be done in the office in only a few minutes. Although there is a theoretical possibility of spreading cancer cells by aspiration biopsy, certainly this possi bility is much less than with an open biopsy. Many clinicians experienced in the use of aspiration biopsy have never seen â œ seedingâ as a result of this procedure. If the aspiration biopsy is nondiagnostic, then a formal biopsy is indicated. On those occasions, the pro cedure is best carried out by a trained surgeon. Correction: In the article, â œ Benign Oral Tumors and Tumor-Like Conditions, â œ (Caâ A Cancer Journal for Clinicians, March/April, 1972), Figure) and Figure 3 are reversed: Figure lisa fibroma of the buccal mucosa and Figure 3 is a mucocele of the lower lip. Figure 8and Figure 9are also reversed: Figure 8 isa giant cell reparative granuloma and Figure 9 is a hemangioma of the tongue. The illustration for Figure 15, a panorex film of the mandible, was cropped incorrectly. 162