Introduction
Before surgical resection or treatment of oral or maxillofacial pathologies, the dental, maxillofacial, or head and neck oncology surgeon should have a thorough understanding of soft and hard tissue biopsies in the affected regions, including biopsy techniques that determine the specific cell types diagnostic of head and neck lesions or pathologies.
What Are the Considerations for Biopsy?
Biopsy gives primarily an insight into the nature of the lesion while also allowing for considerations to be taken into view, by the operator which can ensure a thoughtful and detailed treatment or surgical planning for the patient. Pre-operative biopsy in short is to basically ensure the rationale of a predictably safe as well as optimal treatment. In the case of oral cancers or in maxillofacial lesions, fibrosis or bony lesions, and infections of the head and neck, there can be significant trauma to the local tissues and the extent of spread to the surrounding tissues also needs to be studied. Though many oral or head and neck lesions may be often benign processes as well that may require long-term observation and follow-up, in the cases of certain high-grade cancers or malignant tumors, the lesions in contrast to the benign tumors (a mass of cells that does not invade neighboring tissue) would be requiring the operator to intervene in a significant fashion be it in terms of medical or surgical intervention. The initial evaluation and biopsy hence are always representative of determining the diagnosis and establishing the prognosis, before even adopting a treatment strategy for any lesion.
The practitioner or operator further needs to understand and be considerate of the rationale behind a biopsy, which requires taking into account the patient's current systemic status, medical history, predisposing risk factors, patient age, presenting clinical signs and symptoms, as well as the correlatable radiographic features, to decide the location and the proper technique or type of biopsy to be performed.
What Are the Armamentarium Used?
Biopsy of most soft tissue lesions in the head and neck or the oral and maxillofacial regions can be performed with the following equipment:
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A local anesthetic is the primary requirement with a vasoconstriction agent (agents constricting the blood vessels) incorporated into it.
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15-blade or a similar incisional device like 12-blade.
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Small dissecting scissors.
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Toothed forceps.
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Suction with a tip to prevent blood from obstructing the operator's visual field.
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Gauze material.
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Suture material for wound closure and even for specimen marking.
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Electrocautery device (a device using heat from an electric current to destroy the tumors) as required by the operator for the doubtful lesion.
In the case of biopsy needed for bony lesions, the operators need to be aware of the extensive preoperative planning, and the decision between an incisional or excisional biopsy is then typically made during the procedure. For instance, when a bony lesion is opened up, the presence of yellow or clear fluid would usually suggest to the operator only a mild or moderate cystic pathology. In such cases, a simple excisional biopsy is performed as described earlier. After eliminating the lesion, the possibility of bone grafting or reconstruction of the bone or soft tissue should be considered by the dental or the maxillofacial surgeon along with the stabilization of the mandible or maxilla with the necessary hardware material, depending on the bone density and the remaining bone structure left in the patient's jaw. In case of a lack of fluid aspirate from the bony lesion in question, and if the operator observes a solid tissue upon exposing the lesion, an incisional biopsy is recommended to eliminate a sample of the lesion.
In addition to the instrumentation that is listed above, the operator would be further requiring the burrs needed for drilling into the bone, and a needle as well as a syringe to aspirate the bony lesion. Hemostatic agents are also required when trying to biopsy a hard tissue lesion in the patient.
What Is Excisional and Incisional Biopsy?
In order to ensure optimal patient outcomes, the dentist or the maxillofacial surgeon would require interdisciplinary coordination with the core clinical team members, the office-based clinical staff, the operating room staff, the general or oral pathologists, as well as the pharmaceutical members or staff. This requires the use of specialized equipment in each of these interdisciplinary departments or the use of specialized equipment rather for the exclusive purpose of biopsy.
Malignancies or high-grade cancers that would frequently require interdisciplinary care that is based on the medical inputs or instructions to be followed according to the local institutional tumor board (of the region or country the patient is located in). While soft tissue biopsies can be easily performed by the operator in an outpatient clinical setting, usually under local anesthesia there would be two types of biopsies that the operator would consider.
An excisional biopsy indicates that the operator needs to completely remove or eliminate the lesion for thorough assessment and subsequent histopathologic examination. An incisional biopsy is warranted when there's a suspected cancer or the lesion in question has extensive or destructive involvement in the local tissues or has a systemic route of spread.
How Is the Specimen Evaluated and Transported?
The specimens after being obtained would then require a routine procedure or a formal histopathological evaluation, which is why these are placed in formalin. If the dentist or maxillofacial surgeon suspects an underlying immunological lesion, such as oral lichen planus (painful, lacy white mouth lesions), pemphigus (autoimmune disease causing skin blisters), mucous membrane-related pemphigoid (a disorder characterized by blistering primarily affecting mucous membranes) then a separate tissue sample would be obtained further for direct immunofluorescence tests that would be placed in Michel solution. Biopsies that would require an immunological evaluation should be also further discussed in detail with the oral or maxillofacial pathologist before performing the procedure. It is ideal for the dentist or the maxillofacial surgeon to perform a biopsy with an onsite pathologist, for the quick evaluation of a frozen section, so that it may be possible to rule out high-grade suspected cancers intraoperatively. Usually, it would take a few hours for the complete evaluation and assessment of the cells present in the lesion that be analyzed by the oral or maxillofacial pathologist before planning any specific treatment or surgical protocol further.
Conclusion
Successfully performing a biopsy of a lesion within a patient's oral cavity would indeed require interdisciplinary care and strategic planning, especially when it comes to extensive or aggressive oral or head and neck lesions. The maxillofacial surgeon should communicate or instruct well in advance or clearly with the interdisciplinary team members, the need for a frozen section that would be obtained from the patient which would be transported to the lab for microscopic examination. Patients with advanced diseases, with final diagnoses who may require further complicated treatment strategies, need further pre-operative planning or joint or coordinating care between these interdisciplinary teams.
