Salivary Gland Disorders & Biopsy Lecture 2024 PDF

Dr Terence Alexander Oral Maxillofacial Surgeon OVERVIEW OF SALIVARY GLAND DISORDERS DR ALEXANDER 2024 MANY CONDITIONS AFFECT THE SALIVARY GLANDS DR ALEXANDER 2024 ANATOMY MINOR SALIVARY GLANDS MAJOR SALIVARY GLANDS 3 PAIRED GLANDS PAROTID SEROUS SUBMANDIBULAR MIXED SUBLINGUAL MUCOUS DR ALEXANDER 20...

Dr Terence Alexander Oral Maxillofacial Surgeon OVERVIEW OF SALIVARY GLAND DISORDERS DR ALEXANDER 2024 MANY CONDITIONS AFFECT THE SALIVARY GLANDS DR ALEXANDER 2024 ANATOMY MINOR SALIVARY GLANDS MAJOR SALIVARY GLANDS 3 PAIRED GLANDS PAROTID SEROUS SUBMANDIBULAR MIXED SUBLINGUAL MUCOUS DR ALEXANDER 2024 ANATOMY DR ALEXANDER 2024 HISTOLOGY Proximal (near to gland) Distal (near to duct opening) DR ALEXANDER 2024 HISTOLOGY EXCRETORY DUCT STRIATED DUCT INTERCALATED DUCT ACINUS DR ALEXANDER 2024 SALIVA AND ITS PRODUCTION 24Hour period 70% Submandibular; 25% Parotid and 5% from the minor glands Least produced during sleep Average production 0.75-1.5 Litres per day SALIVA ◦ 90% Water ◦ Electrolytes ◦ pH of saliva falls between 6 and 7.4. ◦ Organic matter e.g. Amylase, albumin, immunoglobulins & Lysozyme etc. ◦ Digestion, Lubrication, wound healing and protection DR ALEXANDER 2024 Flow Rates Flow Rates of Whole Saliva Whole Saliva Flow Rates (ml/min) Unstimulated (Resting) Whole Saliva* Stimulated Whole Saliva* Normal Flow Rates Abnormal Flow Rates 0.3 - 0.4 ml/min < 0.1 ml/min 1 - 2 ml/min < 0.5 ml/min *Whole saliva is the total output from the major (parotid + submandibular + sublingual) and minor salivary glands. DR ALEXANDER 2024 HISTORY and EXAMINATION Swelling Acute /chronic Unilateral / bilateral Intermittent / persistent Mass Size Site Other Saliva flow Eyes Joints Pain Eating Correlation with medical Hx Consistency Colour Lymph nodes Facial nerve Overlying skin / mucosa DR ALEXANDER 2024 WORKING CLASSIFICATION OF DISORDERS OF THE SALIVARY GLANDS ABNORMAL FUNCTION OBSTRUCTION INFECTIVE CONDITIONS NON NEOPLASTIC CONDITIONS NEOPLASMS Lets look at each of these categories DR ALEXANDER 2024 ABNORMAL FUNCTION Abnormal function of the salivary glands affects saliva secretion Salivary secretion may be reduced Salivary secretion may be increased Composition of the saliva may be changed at a reduced, increased or normal flow rate Outflow of saliva may be abnormal DR ALEXANDER 2024 TERMINOLOGY “SIALORRHEA”/PTYALISM An apparent excessive flow of saliva. Also known as Hypersalivation Called Drooling “XEROSTOMIA” A dry mouth or sensation of a dry mouth as a result of altered saliva flow or production. DR ALEXANDER 2024 Causes of Sialorrhea False teeth/dentures Pain Jaw fracture/dislocation Difficulty in swallowing Oral ulcers Psychosis/anxiety Mental retardation Neurological disease Morning sickness/pregnancy Rabies Mercury poisoning DR ALEXANDER 2024 Causes of Xerostomia Look at this site https://oralcancerfoundation.org/complications/xerostomia/ Iatrogenic Medications, radiotherapy, chemotherapy, surgical Chronic inflammatory Chronic sialadenitis Autoimmune diseases Sjögren’s syndrome Endocrine disorders Diabetes mellitus, hyper- and hypothyroidism Neurological disorders Depression, anxiety states, Parkinson’s disease Genetic disorders/congenital abnormalities Cystic fibrosis Malnutrition Anorexia, bulimia, anaemia, alcohol abuse Infections HIV/AIDS, mumps, Epstein–Barr virus, tuberculosis Other Hypertension, chronic fatigue syndrome, burning mouth syndrome, sarcoid DR ALEXANDER 2024 WORKING CLASSIFICATION OF DISORDERS OF THE SALIVARY GLANDS ABNORMAL FUNCTION OBSTRUCTION INFECTIVE CONDITIONS NON NEOPLASTIC CONDITIONS NEOPLASMS Lets look at each of these categories DR ALEXANDER 2024 OBSTRUCTIVE DISORDERS Mucoceles(minor glands) ◦ Mucus extravasation type ◦ Mucus retention type Ranulas (Major salivary gland/sublingual) ◦ Oral ◦ Cervical/plunging Sialolithiasis Strictures DR ALEXANDER 2024 MUCOCELES MUCUS EXTRAVASATION TYPE Trauma MUCUS RETENTION TYPE Obstruction DR ALEXANDER 2024 MUCOCELES https://www.ncbi.nlm.nih.gov/books/NBK560855/ MUCUS EXTRAVASATION TYPE MUCUS RETENTION TYPE Traumatic severance of salivary gland duct Obstruction to salivary flow due to sialolith, scar or tumour Mucus escapes into surrounding tissue Central mucin pool surrounded by granulation tissue and neutrophil and macrophage inflammatory reaction. Mucus surrounded by ductal epithelium Central mucin surrounded by compressed epithelial cells Gland becomes inflamed and scarred Sialolith may be present Lower lip, buccal mucosa and anteroventral surface of tongue Upper lip, palate, cheek and floor of mouth, & more mobile Varied size, painless, “bluish” in colour Mucosa normal colour, non tender Rupture and recur Rx- Excision of the gland and cyst, removal of the sialolith, marsupialisation Rx- Excision with the minor salivary gland DR ALEXANDER 2024 MUCOCELE **Presentation of a mucocele of the lower lip DR ALEXANDER 2024 Treatment Excision is preferred (look up technique You Tube link below) Local anaesthetic Can recur- remove associated minor salivary gland tissue Submit for histology Warn about pain, swelling, possible lip numbness in the area (temporary?) https://www.youtube.com/watch?v=dHIryuUnxcQ DR ALEXANDER 2024 Treatment DR ALEXANDER 2024 Excision of a mucocele Sutured Before After DR ALEXANDER 2024 RANULA A form of mucocele/mucus retention cyst of the floor of the mouth “RANA” latin for Frog 1-3rd decade of life SIMPLE and PLUNGING SIMPLE(Oral) True retention cyst of the sublingual gland, floor of mouth above the mylohyoid muscle Bluish, displaces the tongue, cross the midline, can rupture thick fluid and recur PLUNGING(Cervical) Extends through a hiatus in the mylohyoid muscle into the neck DR ALEXANDER 2024 PLEASE LOOK AT THIS Ranulas and Plunging Ranulas Treatment & Management Author: Brent Golden, DDS, MD; Chief Editor: Arlen D Meyers, MD, MBA http://emedicine.medscape.com/article/847589-overview#showall Mucocele And Ranula Author: Muhammad Huzaifa; Abhinandan Soni. https://www.ncbi.nlm.nih.gov/books/NBK560855/ DR ALEXANDER 2024 Management of Ranulas Needle aspiration Scan (MRI or CT) Ultrasound May or not have a epithelial lining Medical Rx: orally administered Nickel Gluconate-Mercurius Heel-Potentised Swine Organ Preparations D10/D30/D200, a homotoxicological agent. Causes cyst reabsorbtion/gland repair and improved function of the gland. Surgical Rx: Marsupialisation/Micro marsupialisation/sclerosing agents/Co2 laser/Gland excision with or without Marsupialisation. Can be via Intraoral or extra oral approach DR ALEXANDER 2024 Magnetic resonance Images of a Plunging Ranula (MRI) DR ALEXANDER 2024 RANULA- Plunging DR ALEXANDER 2024 RANULA 1. Surgical excision 2. Marsupialisation Pack with Gauze or in this case a drain for 7-10 days Re-epithelialization Seals off leaking site Atrophy of leaking acini 3. Other (Smaller lesions) Laser Ablation, Cryosurgery Electrocautery: Intralesional Injection of a Sclerosing agent DR ALEXANDER 2024 RANULA-Simple DR ALEXANDER 2024 RANULA- Simple DR ALEXANDER 2024 RANULA- Simple Rx: Marsupialisation better for smaller cysts 7mm Mesial to the 7’s No sialogram- can displace stone back ◦ Surgical exposure of duct, incision and removal of stone, no stent if no stricture. ◦ Sialogogues- encourage saliva flow and patency DR ALEXANDER 2024 Submandibular sialolith- anteriorly Sialolithectomy DR ALEXANDER 2024 SIALOLITHECTOMY DR ALEXANDER 2024 Treatment of submandibular sialolithiasis POSTERIOR PORTION ◦ Often asymptomatic and become fairly large ◦ If there is ongoing chronic infection the gland may not recover ◦ Radiographs and Sialograms may visualise stone ◦ Poor filling and irregular cavitation in the gland = poorer prognosis ◦ Intraglandular stone generally = submandibulectomy DR ALEXANDER 2024 Submandibular Stone and submandibulectomy DR ALEXANDER 2024 SIALOLITHIASIS Submandibular stone DR ALEXANDER 2024 Submandibulectomy DR ALEXANDER 2024 STRICTURES Caused by: Rx: Resolution of ulcers in the duct lining caused by stones Dilatation with every 2 weeks probes Papillotomy incising the stricture and suturing it into an open position Transverse incisions instead of longitudinal incisions to release stones Sialodochoplasty Retransplanting the duct Papillary stricture Sialendoscopy Other lesions DR ALEXANDER 2024 OBSTRUCTION (Continued) Lesion of Parotid Papilla DR ALEXANDER 2024 Stent and healed duct DR ALEXANDER 2024 WORKING CLASSIFICATION OF DISORDERS OF THE SALIVARY GLANDS ABNORMAL FUNCTION OBSTRUCTION INFECTIVE CONDITIONS NON NEOPLASTIC CONDITIONS NEOPLASMS Lets look at each of these categories DR ALEXANDER 2024 INFECTIVE DISORDERS NON SPECIFIC INFLAMMATION Acute suppurative sialadenitis Chronic recurrent sialadenitis SPECIFIC INFLAMMATION Viral sialadenitis The suffix “itis” comes from Latin and Greek and means inflammation or a disease characterised by inflammation DR ALEXANDER 2024 Submandibular Sialadenitis 1. Infectious Causes 3. Inflammatory causes Bacterial: Often, polymicrobial. Post radiation sialadenitis Staphylococcal aureus: the most common organism Contrast-induced sialadenitis Hemophilus influenza Radioiodine treatment (131-I) Gram-negative aerobes (e.g., Enterobacteriaceae) 4.Drug-induced sialadenitis Anaerobes: Prevotella, Fusobacterium, Peptostreptococcus Clozapine Virus: I-asparaginase Mumps Phenylbutazone HIV 5. Autoimmune sialadenitis Others: Sjögren syndrome Actinomyces IgG4-related disease Tuberculosis 6. Granulomatous sialadenitis 2.Obstructive causes Sarcoidosis Sialolithiasis Xanthogranulomatous sialadenitis Ductal stricture Ductal foreign body eg.fish bone, hair, grass blade External compression of duct: e.g., denture flanges DR ALEXANDER 2024 Classification of sialadenitis by cause Acute bacterial sialadenitis Immune sialadenitis Acute purulent/suppurative parotitis/sialadenitis Acute immune complex type Acute postoperative parotitis/sialadenitis Epitheloid cell sialadenitis Chronic recurrent Sialadenitis Autoimmune myoepithelial sialadenitis Chronic sclerosing sialadenitis of submandibular gland (Kuttner’stumour) Radiation sialadenitis Other granulomatous types of sialadenitis Giant cell sialadenitis Tuberculosis Viral sialadenitis Sialadenitis of minor salivary glands Parotitis epidemica (mumps) Cytomegalovirus infections (salivary gland viral disease) Look at this article on classification and treatment Other types (coxsackie virus, infectious mononucleosis, of sialadenitis measles, echovirus) https://www.ncbi.nlm.nih.gov/books/NBK562211/ HIV-associated lesions DR ALEXANDER 2024 Acute suppurative sialadenitis “Overwhelming microbial overgrowth in a gland with reduced salivary flow” DR ALEXANDER 2024 Acute suppurative sialadenitis Commonly in the Parotid gland – “acute suppurative parotitis” Elderly, malnourished dehydrated and often post surgical (3-5dys) Calculi, poor hygiene and duct strictures 5% post dental treatment DR ALEXANDER 2024 Acute suppurative sialadenitis Clinically: Coagulase +ve Staph.Aureus often present Penicillin resistant Acute ,painful enlargement of gland Fever, malaise, leucocytosis (20 000 wbc/mm³) Purulent discharge from the duct 20% bilateral Trismus DR ALEXANDER 2024 Acute suppurative sialadenitis Treatment: Culture and sensitivity testing of purulent discharge Rehydration Try improve saliva flow Empirical intravenous penicillinase , antistaphylococcal antibiotic ( Flucloxacillin 12g 6hrly ) Improvement 24-48 hours CT or ultrasound to investigate Incision and drainage if fluctuation occurs DR ALEXANDER 2024 Chronic recurrent sialadenitis Can occur in the parotid or submandibular gland PAROTID Reduced saliva flow Ongoing acute parotitis, Sjögrens syndrome, idiopathic, or part of progressive juvenile parotitis (3-6 yr olds, strep.viridans, resolves at puberty?) Uni or bilateral Females common SUBMANDIBULAR Duct obstruction due to stones Recurrent episodes if infection Swelling and pain on eating Be aware of chronic infections mimicking malignancy- “Kuttners Tumour” DR ALEXANDER 2024 Chronic recurrent sialadenitis Treatment: Sialography during remissions- ectasia, pooling of contrast media Acute phase Culture and sensitivity testing of discharge Rehydration Salicylates/analgesia Antibiotic therapy Sialendoscopy to remove stone or mucus plugs Gland removal? DR ALEXANDER 2024 SIALOGRAMS/ SIALOGRAPHY DR ALEXANDER 2024 Sialography INDICATIONS Sialolithiasis Acute obstruction Chronic enlargement Xerostomia Suspected tumour Salivary fistulas CONTRAINDICATIONS Acute infections- disrupted ductal epithelium allows leakage of contrast Sensitivity to contrast/iodine etc May influence thyroid function tests Therapeutic Other DR ALEXANDER 2024 Sialography IDEAL CONTRAST MEDIA Similar to saliva Non toxic Inert Radiopaque Low viscosity and surface tension- flow easy Easy elimination Water or fat soluble DR ALEXANDER 2024 Sialography Abnormal sialogram DR ALEXANDER 2024 Sialogram CT DR ALEXANDER 2024 Viral Sialadenitis Commonly mumps Other viruses can mimic mumps e.g. Coxsackie A; Influenza A and Cytomegalovirus DR ALEXANDER 2024 VIRAL - Mumps M:F Young adults and children Seasonal Parotid often affected 70% bilateral Max Swelling 2-3 days after onset Improves in 10 days Uncommon in developed countries- Vaccinations DR ALEXANDER 2024 Pathogenesis of Mumps Respiratory droplet spread Paramyxovirus proliferates in nasopharynx and lymphnodes Incubation 2-3 weeks, viraemia Multiple glandular and organ involvement (Testes, ovaries, liver, spleen, pancreas, kidneys and nervous system) DR ALEXANDER 2024 The result ! DR ALEXANDER 2024 Complications Orchitis and oophoritis Viral encephalitis Myocarditis Nephritis Fatality Nerve deafness DR ALEXANDER 2024 Treatment of mumps Symptomatic Bedrest Analgesics DR ALEXANDER 2024 Prevention of Mumps Live attenuated Vaccine Non communicable sub clinical infection Ab conversion 90% Lifelong immunity DR ALEXANDER 2024 WORKING CLASSIFICATION OF DISORDERS OF THE SALIVARY GLANDS ABNORMAL FUNCTION OBSTRUCTION INFECTIVE CONDITIONS NON NEOPLASTIC CONDITIONS NEOPLASMS Lets look at each of these categories DR ALEXANDER 2024 NON NEOPLASTIC CONDITIONS SARCOIDOSIS SIALADENOSIS SJÖGRENS SYNDROME* SALIVARY LYMPHOEPITHELIAL LESION NECROTISING SIALOMETAPLASIA* CYSTIC LESIONS DR ALEXANDER 2024 SARCOIDOSIS (Self Study) Granulomatous disease Non Caseating granulomas on biopsy 20- 40 year olds Female African-Americans Self limiting often Parotid uni/bilaterally enlarged Involves lungs, skin, eyes, liver, oral cavity, nasal cavity DR ALEXANDER 2024 SARCOIDOSIS (Self Study) DIAGNOSIS Assay for angiotensin I- converting enzyme: Raised levels +ve Chest X-ray (nodes, pulmonary fibrosis) Histology TREATMENT Corticosteroids, other drugs DR ALEXANDER 2024 SIALADENOSIS (Self Study) Term for a group of conditions that cause salivary gland enlargement Absence of an inflammatory component Examples Chronic alcoholism Diabetes mellitus Type I Hyperlipoproteinaemia Acromegally Pancreatitis DR ALEXANDER 2024 SJÖGRENS SYNDROME Dry Mouth Dry eyes Other autoimmune condition e.g. Rheumatoid arthritis DR ALEXANDER 2024 SJÖGRENS SYNDROME Schirmer’s test Primary Sjögrens Dry mouth and dry eyes (Keratoconjunctivitis sicca) ↑ Risk of lymphoma Secondary Sjögrens Dry eyes, dry mouth and a connective tissue disease (15% Rheumatoid arthritis and 20% Lupus erythematosis) DR ALEXANDER 2024 The Schirmer's test is used determine whether your tear glands produce enough tears to keep your eyes adequately moist. Calibrated strips of a non-toxic filter paper are used.... Wetting of less than 5 mm in 5 minutes is indicative of deficient tear production, but is not necessarily diagnostic of Sjogren's syndrome. SJÖGRENS SYNDROME Features 90% females 50 years + Xerostomia and its effects Parotid swellings Occular defects DR ALEXANDER 2024 SJÖGRENS SYNDROME Xerostomia Difficulty eating and swallowing Altered taste Altered speech Painful dry/parched red tongue Increased infections e.g. Candida Prone to dental caries Prone to suppurative parotitis DR ALEXANDER 2024 SJÖGRENS SYNDROME Diagnosis Sialochemical studies Salivary flow rate < 0.5 ml /hr Lower lip biopsy ** Antibody screen e.g. Rheumatoid factor, antinuclear Ab’s or antiSjögrens A (SS-A) and antiSjögrens B (SS-B) Sialography – sialectasia “Snowstorm / cherry blossom appearance” Other DR ALEXANDER 2024 SJÖGRENS SYNDROME Lower lip biopsy DR ALEXANDER 2024 SJÖGRENS SYNDROME Histology Peri-ductal plasma cell and lymphocyte infiltrate Spread of infiltrate with destruction of acini DR ALEXANDER 2024 SJÖGRENS SYNDROME Management Diagnosis Salivary gland damage is irreversible Symptomatic Artificial tears and saliva Oral hygiene Dietary modification Topical flourides Sialogogues ??? DR ALEXANDER 2024 Rheumatologist General practitioner Dentist Ophthalmologist SALIVARY LYMPHOEPITHELIAL LESION Uncommon Major salivary gland enlargement Histology similar to Sjögrens so not to be confused with it DR ALEXANDER 2024 NECROTISING SIALOMETAPLASIA Tumour like Minor glands palate Middle aged males Cigarette smokers Painless ulcer 15-20 mm Cause? DR ALEXANDER 2024 WORKING CLASSIFICATION OF DISORDERS OF THE SALIVARY GLANDS ABNORMAL FUNCTION OBSTRUCTION INFECTIVE CONDITIONS NON NEOPLASTIC CONDITIONS NEOPLASMS Lets look at each of these categories DR ALEXANDER 2024 NEOPLASMS WHO classification of salivary neoplasms (1992) We will look at * Benign Other tumours Adenomas Non-epithelial tumours Pleomorphic adenoma* Angioma Myoepithelioma Lipoma Basal cell adenoma Neural tumours Warthin’s tumour (adenolymphoma) Other benign tumours Oncocytoma Sarcomas Canalicular adenoma* Malignant lymphomas Sebacous adenoma Secondary tumours Ductal papilloma Unclassified tumours Cystadenoma Tumour-like lesions DR ALEXANDER 2024 NEOPLASMS WHO classification of malignant salivary neoplasms (1992) We will look at * Malignant Malignant Carcinoma Mucinous adenocarcinoma Acinic cell carcinoma Oncocytic carcinoma Mucoepidermoid carcinoma* Adenocarcinoma Adenoid cystic carcinoma* Malignant myoepithelioma Polymorphous low-grade adenocarcinoma Carcinoma in pleomorphic adenoma* Epithelial-myoepithelial carcinoma Squamous cell carcinoma Basal cell adenocarcinoma Small-cell carcinoma Sebaceous carcinoma Papillary cystadenocarcinoma Undifferentiated carcinoma Other carcinomas DR ALEXANDER 2024 Changes in Classification of Benign epithelial salivary gland tumours DR ALEXANDER 2024 Changes in Classification of salivary gland Malignancies DR ALEXANDER 2024 Salivary gland neoplasms MINOR NB!! PAROTID 10% of all Salivary gland neoplasms 75% of all salivary gland neoplasms 45% are malignant 15% malignant SUBLINGUAL 0.3 % of all SUBMANDIBULAR Salivary gland 12% of all Salivary gland tumours neoplasms 30% Malignant 86% malignant DR ALEXANDER 2024 Benign salivary gland neoplasms DR ALEXANDER 2024 Pleomorphic adenoma 75% of Parotid tumours, 50% of minor gland tumours Females 30-60 yrs of age May undergo malignant change (Carcinoma ex Pleomorphic adenoma) Can metastasize as a pleomorphic adenoma to the lung DR ALEXANDER 2024 Pleomorphic adenoma “Mixed Tumour” Slow growing, rubbery, lobulated swellings Palate is most common intra oral site DR ALEXANDER 2024 Pleomorphic adenoma HISTOLOGY(Self study) Mixed tumour Pseudo encapsulated Pseudopod outgrowths result in recurrence Epithelial component in ducts, tubules, ribbons or sheets Mesenchymal part is hyalinised or myxoid, often see fat , cartilage or bone DR ALEXANDER 2024 Pleomorphic adenoma APPROACH Full history and examination Fine needle aspirate (22 Gauge needle) CT or MRI May have a peripheral CN VII Palsy which differs from a patient who may have suffered a cerebrovascular incident Surgery DR ALEXANDER 2024 Pleomorphic adenoma TREATMENT Surgical excision good margin Recurrence 5%- 30% Parotid Superficial parotidectomy or Parotidectomy Facial nerve preservation Submandibular Submandibulectomy Palate Excision ,mucosa and bone ostectomy DR ALEXANDER 2024 Parotidectomy DR ALEXANDER 2024 Parotidectomy COMPLICATIONS Facial nerve injury Frey’s Syndrome (Parasymp.parotid and symp.sweat fibres) Haemorrhage and haematoma Salivary fistula/sialocele DR ALEXANDER 2024 Parotidectomy COMPLICATIONS Frey’s Syndrome (Parasymp.parotid and symp.sweat fibres) Auriculotemporal nerve Sympathetic fibres to sweat glands of scalp switch with parasympathetic fibres to parotid Sweating on the cheek after eatinglemon test DR ALEXANDER 2024 Auriculotemporal nerve syndrome Flushing and sweating of the face resulting from eating spicy or acidic foods, due to damage of the parasympathetic fibers in the auriculotemporal nerve. Synonym(s): Dupay syndrome, Frey syndrome, gustatory sweating syndrome, gustatory-sudorific reflex DR ALEXANDER 2024 Cannalicular adenoma Only in the oral cavity Often the upper lip Women > 50 yrs Rx- Wide excision DR ALEXANDER 2024 NEOPLASMS WHO classification of malignant salivary neoplasms (1992) Malignant Malignant Carcinoma Mucinous adenocarcinoma Acinic cell carcinoma Oncocytic carcinoma Mucoepidermoid carcinoma* Adenocarcinoma Adenoid cystic carcinoma* Malignant myoepithelioma Polymorphous low-grade adenocarcinoma Carcinoma in/ex pleomorphic adenoma* Epithelial-myoepithelial carcinoma Squamous cell carcinoma Basal cell adenocarcinoma Small-cell carcinoma Sebaceous carcinoma Papillary cystadenocarcinoma Undifferentiated carcinoma Other carcinomas* DR ALEXANDER 2024 Malignant salivary gland neoplasms Symptoms Lump on face, neck, or mouth (can be painless) May have numbness in the face Inability to move some facial muscles, (progressive facial muscle paralysis) Difference between the size and/or shape of the left and right sides of the face or neck DR ALEXANDER 2024 Malignant salivary gland neoplasms Diagnosis Many tests to diagnose and determine if it has metastasized. Biopsy. Incisional biopsy not favoured in salivary gland tumours. Fine needle aspiration (cytology).* Endoscopy. Computed tomography (CT or CAT) scan. Magnetic resonance imaging (MRI). Ultrasound. Positron emission tomography (PET) scan. DR ALEXANDER 2024 Malignant salivary gland neoplasms Diagnosis Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumours. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body, especially images of soft tissue. A contrast medium may be injected into a patient’s vein to create a clearer picture. Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images. DR ALEXANDER 2024 Malignant salivary gland neoplasms Staging Is a way of describing cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Knowing the stage helps to decide what kind of treatment is best and can help predict a patient’s prognosis (chance of recovery). There are different stage descriptions for different types of cancer. DR ALEXANDER 2024 Malignant salivary gland neoplasms TNM /TMN This system uses three criteria to judge the stage of the cancer: the tumour itself, the lymph nodes around the tumour, and if the tumour has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. DR ALEXANDER 2024 Malignant salivary gland neoplasms TMN TNM is an abbreviation for tumour (T), node (N), and metastasis (M). How large is the primary tumour and where is it located? (Tumour, T) Has the tumour spread to the lymph nodes? (Node, N) Has the cancer metastasized to other parts of the body? (Metastasis, M) DR ALEXANDER 2024 Malignant salivary gland neoplasms Treatment Neck dissection Depends on the staging and TMN, A multidisciplinary team Can be cured, especially if found early. Goal : cure with preservation / restoration of function. DR ALEXANDER 2024 Malignant salivary gland neoplasms Surgery Hemi-maxillectomy The goal of surgery is to remove as much of the tumour as possible and leave negative margins Parotidectomy/submandibulectomy/other. Neck dissection. A neck dissection (lymph nodes in the neck are removed). A neck dissection may cause numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. Multiple surgeries/reconstructions Tracheostomy? DR ALEXANDER 2024 Malignant salivary gland neoplasms Radiation therapy of the head and neck It is most often used in combination with surgery, given either before or after the operation. It may also be given along with chemotherapy. A thorough examination from an oncologic dentist DR ALEXANDER 2024 Malignant salivary gland neoplasms Radiation therapy of the head and neck Side effects: Redness or skin irritation to the treated area Xerostomia or thickened saliva, from damage to salivary glands Bone pain Nausea; fatigue Mouth sores and/or sore throat-Mucositis Dental problems (usually preventable) Painful or difficulty swallowing Loss of appetite, often due to a change in sense of taste Hearing loss Risk of osteo-radionecrosis DR ALEXANDER 2024 Malignant salivary gland neoplasms Chemotherapy Chemotherapy is given by a medical oncologist. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time. Chemotherapy is seldom used in the initial treatment of salivary gland cancer. DR ALEXANDER 2024 Mucoepidermoid carcinoma Most common malignancy of salivary glands* Adults Most common childhood salivary gland malignancy Palate most common oral site Can arise centrally in bone DR ALEXANDER 2024 Mucoepidermoid carcinoma Low-intermediate-high grade Low grade- more mucus component and less epidermoid cells : Better prognosis High grade- Less mucus and more epidermoid cells: poorer prognosis DR ALEXANDER 2024 Mucoepidermoid carcinoma Prognosis and Treatment Based on grade High grade: 60% chance of local or distant spread in 5 years. 40% 5 year survival and only 25% cure after 15 years. Poorer prognosis Low grade: 95% 5year survival DR ALEXANDER 2024 Mucoepidermoid carcinoma Prognosis and Treatment High grade: Surgery (Including neck dissection) plus radiation therapy Low grade: May involve surgery only with/out neck dissection DR ALEXANDER 2024 Adenoid cystic carcinoma 23% of all salivary gland tumours 50-70% occur in minor glands Often ulcerate overlying mucosa** 40-70 yr olds M:F DR ALEXANDER 2024 Adenoid cystic carcinoma Aggressive, can metastasise many years later (lung) Perineural and perivascular spread 70% 5 yr survival only 10 % 15 yr survival Histology, margins and size(>4cm) affects outcome DR ALEXANDER 2024 Adenoid cystic carcinoma Histology (self study) 3 Patterns Tubular, cribriform & solid Look for perineural invasion Solid – poorer prognosis DR ALEXANDER 2024 Adenoid cystic carcinoma Treatment Superficial parotidectomy with/out deep lobectomy. Facial nerve resection? Intraorally- wide/radical resection with bone Radiation therapy – wide field Chemotherapy ? DR ALEXANDER 2024 Polymorphous low grade adenocarcinoma (self study) 40-80 yrs M:F Almost exclusively in minor salivary glandspalate 45% Low grade – good prognosis Wide excision- 10% recurrence DR ALEXANDER 2024 Carcinoma in Pleomorphic adenoma Pleomorphic adenoma can undergo malignant change Late phenomenon Sudden growth in a longstanding lesion** 68% parotid Excision/ neck dissection if nodes 30% may have metastasised-lung and bone 20-30% 5 yr survival DR ALEXANDER 2024 Salivary duct carcinoma High grade malignancy Poor prognosis 80% parotid duct M-80% 60-70 yrs Excision 50% mortality 5months – 5yrs DR ALEXANDER 2024 Conclusion Vast ,complex array of disorders affect the salivary glands. Challenge us in diagnosis and treatment Overview useful ? DR ALEXANDER 2024 Thank you “A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment” DR ALEXANDER 2024 References MUCOCELE AND RANULA Author: Catherine M Flaitz, DDS, MS, Professor of Oral and Maxillofacial Pathology and Pediatric Dentistry, Department of Diagnostic Sciences, University of Texas Health Sciences Center at Houston, Dental Branch Coauthor(s): M John Hicks, DDS, MS, PhD, MD, Professor, Department of Pathology, Baylor College of Medicine; Medical Director of Ultrastructural Pathology, Medical Director of Cytogenetics and Molecular Cytogenetics, Department of Pathology, Texas Children's Hospital Contributor Information and Disclosures NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE INTERVENTIONAL PROCEDURES PROGRAMME Interventional procedure overview of therapeutic sialendoscopy http://www.nice.org.uk/nicemedia/live/11289/31714/31714.pdf SIALENDOSCOPY A new approach to salivary gland obstructive pathology Michael D. Turner Oded Nahlieli, Liat Hecht Nakar, Yaron Nazarian J Am Dent Assoc 2006;137;1394-1400 MODERN MANAGEMENT OF OBSTRUCTIVE SALIVARY DISEASES P Capaccio, S Torretta, F Ottaviani,1 G Sambataro, and L Pignataro Department of Otorhinolaryngological and Ophthalmological Sciences, University of Milan, Acta Otorhinolaryngol Ital. 2007 August; 27(4): 161–172. SUBMANDIBULAR SIALADENITIS/SIALADENOSIS Author: Adi Yoskovitch, MD, MSc, Chief, Department of Otolaryngology - Head and Neck Surgery, Fleury Hospital, Canada Contributor Information and Disclosures Updated: Nov 18, 2009 Salivary Gland Neoplasia: A Review for the Practicing Pathologist Mod Pathol 2002;15(3):298–323 Richard J Zarbo M.D., D.M.D. 11Henry Ford Hospital, Detroit, Michigan Correspondence: Richard J. Zarbo, M.D., Department of Pathology, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, Michigan 48202. www.nature.com/modpathol/journal/v15 DR ALEXANDER 2024 DR ALEXANDER 2024 Extra information. PLEASE READ THIS TOO ! THIS IS EXAMINABLE DR ALEXANDER 2024 Malignant salivary gland neoplasms Tumour (T) TX: Indicates the primary tumour cannot be evaluated. T0: No evidence of a tumour is found. T1: Describes a small, non-invasive (has not spread) tumour that is 2 cm at its greatest dimension. T2: Describes a larger, non-invasive tumour, between 2 cm to 4 cm. T3: Describes a tumour that is larger than 4 cm, but not larger than 6 cm, that has spread beyond the salivary glands, but does not affect the seventh nerve, the facial nerve that controls expression such as smiles or frowns. T4a: The tumour invades the skin, jawbone, ear canal, and/or facial nerve. T4b: The tumour invades the skull base and/or the nearby bones and/or encases the arteries. DR ALEXANDER 2024 Malignant salivary gland neoplasms Metastasis(M) Distant metastasis. The "M" in the TNM system describes cancer that has spread to other parts of the body. MX: Indicates distant metastasis cannot be evaluated. M0: Indicates the cancer has not spread to other parts of the body. M1: Describes cancer that has spread to other parts of the body. DR ALEXANDER 2024 Malignant salivary gland neoplasms Node (N) Lymph nodes near the head and neck are called regional lymph nodes. L Lymph nodes in other parts of the body are called distant lymph nodes. NX: Indicates the regional lymph nodes cannot be evaluated. N0: There is no evidence of cancer in the regional nodes. N1: Indicates that cancer has spread to a single node on the same side as the primary tumour, and the cancer found in the node is 3 cm or smaller. N2: Describes any of these conditions: N2a: Cancer has spread to a single lymph node on the same side as the primary tumour, and is larger than 3 cm, but not larger than 6 cm. N2b: Cancer has spread to more than one lymph node on the same side as the primary tumour, and none measure larger than 6 cm. N2c: Cancer has spread to more than one lymph node on either side of the body, and none measure larger than 6 cm. N3: Cancer found in lymph nodes is larger than 6 cm. DR ALEXANDER 2024 Malignant salivary gland neoplasms Staging and TNM system. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments. DR ALEXANDER 2024 Malignant salivary gland neoplasms Stage I: Describes non invasive tumors (T1, T2), with no spread to lymph nodes (N0) and no distant metastasis (M0). DR ALEXANDER 2024 Malignant salivary gland neoplasms Stage II: Describes an invasive tumor (T3), with no spread to lymph nodes (N0), or distant metastasis (M0). DR ALEXANDER 2024 Malignant salivary gland neoplasms Stage III: Describes smaller tumors (T1, T2) that have spread to regional lymph nodes (N1), but have no sign of metastasis (M0). DR ALEXANDER 2024 Malignant salivary gland neoplasms Stage IVA: Describes any invasive tumor (T4a), with either no lymph node involvement (N0) or spread to only a single same-sided lymph node (N1), but no metastasis (M0). It is also used for a T3 tumor with onesided nodal involvement (N1), but no metastasis (M0), or any tumor (T) with extensive nodal involvement (N2). DR ALEXANDER 2024 Malignant salivary gland neoplasms Stage IVB: Describes any cancer (T), with more extensive spread to lymph nodes (N2, N3), but no metastasis (M0). DR ALEXANDER 2024 Malignant salivary gland neoplasms Stage IVC: Describes any cancer with distant metastasis (M1). DR ALEXANDER 2024 Malignant salivary gland neoplasms Radiation therapy Radiation therapy is the use of high-energy A new method of external radiation x-rays or other particles to kill cancer cells. therapy, known as intensity modulated radiation therapy (IMRT), allows for more effective doses of radiation therapy to be delivered while reducing the damage to External-beam radiation therapy, which is nearby healthy cells and causing fewer side radiation given from a machine outside the effects. body. Internal radiation therapy or brachytherapy. Internal radiation therapy involves tiny pellets or rods containing radioactive materials that are surgically implanted in or near the cancer site. The implant is left in place for several days while the person stays in the hospital. DR ALEXANDER 2024 PRINCIPLES OF TISSUE BIOPSY IN ORAL AND MAXILLOFACIAL SURGERY DR TERENCE ALEXANDER MAXILLOFACIAL AND ORAL SURGEON Dr Alexander 2024 LEARNING OBJECTIVES Approach to oral lesions Examine a lesion correctly Distinguish between benign and sinister conditions Use appropriate terminology Types of investigation techniques Know when to refer Dr Alexander 2024 APPROACH TO ORAL LESIONS Main Complaint Medical / Dental History History of the lesion Clinical examination Differential diagnosis Radiographic examination Laboratory investigation Biopsy / histopathological evaluation Definitive diagnosis Treat Refer Follow up Dr Alexander 2024 HISTORY OF THE LESION Questions to ASK ! I. Duration of the lesion II. Changes in size and rate of change III. Changes in character of the lesion- lump becomes an ulcer IV. Associated systemic symptoms- weight loss, productive cough, fever V. Pain / type of pain VI. Bad taste or smell VII. Dysphagia VIII. Lymph nodes IX. Habits X. Any cause Dr Alexander 2024 Dr Alexander 2024 EXAMINATION SHOULD ALWAYS INCLUDE: I. Inspection II. Palpation III. Percussion IV. Auscultation Dr Alexander 2024 EXAMINATION I. Anatomical location II. Physical character of the lesion/mass III. Size and shape IV. Single vs multiple V. Surface of the lesion VI. Colour of the lesion VII. Sharpness/ boundaries of the lesion VIII. Consistency to palpation IX. Pulsation? X. Lymph node palpation Dr Alexander 2024 EXAMINATION OF THE MOUTH(8 SITES) Dr Alexander 2024 DEFINITION OF BIOPSY Removal of tissue from a living individual for diagnostic examination The word biopsy originates from the Greek terms bios (life) and opsis (vision): vision of life. A biopsy consists of the obtainment of tissue from a living organism with the purpose of examining it under the microscope in order to establish a diagnosis based on the sample Dr Alexander 2024 IS IT THAT IMPORTANT The technique allows us to establish the histological characteristics of suspect lesions, their differentiation, extent or spread, and to adopt an adequate treatment strategy. Biopsies establish any change in the disease processes, and are able to document healing or relapse. Biopsy findings are of irrefutable medico-legal value Dr Alexander 2024 INDICATIONS FOR BIOPSY Any lesion persists for more than 2 weeks with no apparent etiology basis Any inflammatory lesion that does not respond to local treatment after 10-14 days (after removing local irritant) Persistent Hyperkeratotic changes in surface tissues Trauma from newly erupted teeth Dr Alexander 2024 Asprin burn INDICATIONS FOR BIOPSY Persistent hyperkeratosis, erythro or leukoplakia Persistent changes in the surface of tissue Any persistent lump, either visible or palpable beneath relatively normal tissue Lesions that interfere with local function e.g. fibroma Bony lesions especially if painful, expanding or change in growth. Premalignant conditions e.g Lichen planus Cysts Systemic diseases e.g. SjÖgrens Certain infections e.g. Syphilis and tuberculosis Vessiculo-bullous lesions Dr Alexander 2024 INDICATIONS FOR BIOPSY Bone lesions not specifically identified by clinical and radiographic finding Any lesion that has the characteristics of malignancy Dr Alexander 2024 CHARACTERISTICS OF LESIONS THAT RAISE THE SUSPICION OF MALIGNANCY Erythroplakia / erythroplasia —lesion is totally red or has speckled red appearance Ulceration—lesion is ulcerated or presents as an ulcer Duration— lesion has persisted more than 2 weeks Dr Alexander 2024 CHARACTERISTICS OF LESIONS THAT RAISE THE SUSPICION OF MALIGNANCY Growth rate– lesion exhibits rapid growth Bleeding— lesion bleeds on gentle manipulation Induration– lesion and surrounding tissue is firm to the touch Fixation– lesion feels attached to adjacent structures Dr Alexander 2024 CONTRAINDICATIONS TO SIMPLE BIOPSY TECHNIQUES I. Certain vascular lesions II. Difficult access, risk to adjacent structures III. Multiple neurofibromas- risk of sarcomatous change IV. Major salivary gland tumours V. Obvious clinical conditions Linea alba Geographic tongue Lingual /Palatal tori VI. Severe systemic disease Dr Alexander 2024 CLASSIFICATION Biopsies classified According to: A. ACCESS Direct or Indirect A. TECHNIQUE EMPLOYED Incisional or Excisional B. METHOD USED Laser, Punch , Scalpel, needle C. TIMING OF SAMPLING Intra or Extra-operative Dr Alexander 2024 TYPES OF BIOPSY Depending on the characteristics of the target lesion, the biopsy is defined as direct (located superficially, with easy access) or indirect (when the lesion lies in depth and is covered by normally appearing mucosa or tissue Dr Alexander 2024 METHODS USED i. Oral cytology ii. Aspiration biopsy iii. Incisional biopsy iv. Excisional biopsy v. Needle biopsy vi. Punch biopsy Candida albicans “Oral mucosa exhibits a rapid turnover of cells and these exfoliated cells have a valuable role in diagnosis of certain local and systemic diseases.” Dr Alexander 2024 ORAL CYTOLOGY Developed as a diagnostic screen, allows monitoring of large tissue areas for dysplastic changes Not reliable, False positives, Expertise required Dr Alexander 2024 ORAL CYTOLOGY Dr Alexander 2024 DISCLAIMER I HAVE NO VESTED INTEREST IN THIS PRODUCT AND I HAVE NEVER USED IT Dr Alexander 2024 METHODS USED i. Oral cytology ii. Aspiration biopsy iii. Incisional biopsy iv. Excisional biopsy v. Needle biopsy vi. Punch biopsy Dr Alexander 2024 ASPIRATION BIOPSY Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration of its content Cyst fluid Pus aspirate Dr Alexander 2024 INDICATION OF ASPIRATION BIOPSY I. Aspiration should be carried out on all lesions thought to contain fluid or any intraosseous lesion before surgical exploration II. A fluctuant mass in the soft tissues should also be aspirated to determine its contents III. Any radiolucency in the bone of the jaw should be aspirated to rule out a vascular lesion that can cause life threatening hemorrhage IV. Ascertain the type of fluid contained within a lesion Dr Alexander 2024 TECHNIQUE OF ASPIRATION BIOPSY A 18-gauge needle is connected to a 5 or 10 ml syringe The tip of needle may have to be repeatedly repositioned to locate a fluid center after local has been administered. Quick , easy and cheap. Dr Alexander 2024 METHODS USED Oral cytology Aspiration biopsy Incisional biopsy Excisional biopsy Needle biopsy Punch biopsy Dr Alexander 2024 EXCISIONAL BIOPSY Removal of the entire lesion if possible, without mutilation A perimeter of normal tissue surround the lesion is also excised to ensure total removal Constitute definitive treatment Dr Alexander 2024 INDICATION OF EXCISIONAL BIOPSY Smaller lesions(1 cm in diameter) II. Hazardous location III. Suspect malignancy IV. Lesion has multiple characteristics, more than one area needs sampling V. Try choose representative sample in area of easiest access Controversy as whether it increases risk of spread of malignancy Dr Alexander 2024 PRINCIPLES OF INCISIONAL BIOPSY Representative areas of lesion should be incised in wedge fashion Selected in an area that shows complete tissue changes(the lesion extends into normal tissue at the base and/or margin of the lesion) Remember your local anatomy !!!!! Dr Alexander 2024 PRINCIPLES OF INCISIONAL BIOPSY Necrotic tissue should be avoided. Clean deep cuts avoid tearing Taken from the edge of the lesion to include some normal tissue A deep, narrow biopsy rather than a broad, shallow one Place individual samples in separately marked bottles Dr Alexander 2024 ANESTHESIA Block local anesthesia techniques are employed when possible The anesthetic solution should not be injected within the tissue to be removed, because it can cause artificial distortion of the specimen Dr Alexander 2024 ANESTHESIA When blocks are not possible, infiltration of local anesthesia may be used locally, but the solution should be injected at least 5mm away from the lesion NOT into the lesion Top ,bottom, left and right = Cardinal points Dr Alexander 2024 MARK IT BEFORE YOU INJECT! Dr Alexander 2024 TISSUE STABILIZATION Retraction sutures- orientation too Towel clips Digitally Specialised retractors Do Not macerate the sample Allis tissue forceps Towel clip Dr Alexander 2024 HEMOSTASIS Avoid suction device Gauze wrapped over the tip of the low volume suction device Simple gauze compression works fine Suture or allow to granulate - Surgicell or gauze soaked in Tranexamic acid ? YOU DO NOT WANT TO SUCK UP THE SPECIMEN Dr Alexander 2024 SPECIMEN CARE Immediately placed in 10% formalin solution that is at least 20 times the volume of surgical specimen Totally immersed in the solution Complete form and label on specimen bottle Dr Alexander 2024 SPECIMEN CARE Care should be taken to be sure that the tissue has not become lodged on the wall of the container above the level of the formalin Dr Alexander 2024 SURGICAL CLOSURE Primary closure of the elliptic wound is usually possible Palatal biopsy: best managed postoperatively with the use of an acrylic splint Dorsum or lateral border of the tongue: sutures to be placed deeply and at frequent intervals into the substance of the tongue to retain closure Dr Alexander 2024 METHODS USED Oral cytology Aspiration biopsy Excisional biopsy Incisional biopsy Needle biopsy Punch biopsy Dr Alexander 2024 FNA for cytologic evaluation of a neck mass was first reported by Kun in 1847. NEEDLE BIOPSY Quick in office, non invasive False negatives/ sampling error- missed it!! False positives Can be ultrasound/ CT guided best results Discrete well defined masses offer best results Salivary gland lesions Sample must be processed fairly quickly 94 % accuracy [Knappe et al] Dr Alexander 2024 WHY THE ERROR ? Dr Alexander 2024 NEEDLE BIOPSY Dr Alexander 2024 NEEDLE BIOPSY METHODS USED Oral cytology Aspiration biopsy Excisional biopsy Incisional biopsy Needle biopsy Punch biopsy Dr Alexander 2024 PUNCH BIOPSY Rapid, Simple, Safe Caution is moreover required when using the punch to sample lesions located over important submucosal structures such as the mental or nasopalatine foramen. Inexpensive The instrument consists of a sterile and discardable punch with a plastic handpiece and cylindrical cutting blade. The latter may be 2, 3, 4, 5, or 6 to 8 mm in diameter Suture often not necessary Dr Alexander 2024 On the other hand, the instrument is difficult to use in the region of the soft palate, maxillary tuberosity or floor of the mouth, due to the lack of firm tissue fixation or support, and the mobility of the target zone INTRA OPERATIVE FROZEN SECTION Intraoperative Suspect a malignancy Sample processed without fixation it is frozen with dry ice Temp. -40˚C to -60 ˚C Sectioned with microtome Check surgical margins: Positive negative or doubtful Not always reliable Not for bone / tissues needing fixation No not the FOOD Section Dr Alexander 2024 EXTRA OPERATIVE PROCESSING Takes longer Better quality Can be embedded in Paraffin (LM)or methacrylate(EM) Can be looked at fresh under light microscope Can be prepared for electron microscopy Apply specialised stains Hemotoxylin and eosin is most common stain for LM Dr Alexander 2024 POINTS TO CONSIDER PRIOR TO MUCOSAL BIOPSY 1. Why is biopsy being taken? E.g. to confirm a mucosal disease such as lichen planus or to exclude malignancy. 2. What information is required from the pathologist? E.g. is the lesion completely excised. 3. Is the biopsy to exclude malignancy? Therefore take the biopsy from the edge of the lesion 4. Is the biopsy incisional or excisional? E.g. For excisional biopsies a margin of surrounding normal tissue will be required. 5. Will the specimen be required to be orientated? This is important for excisional biopsies so that if residual tumour is left or the excision is close to the margin, the surgeon knows where to perform a re-excision if necessary. 6. Is a fresh specimen required? For vesiculobullous lesions these are often required for direct immunofluorescence. They are also used if a rapid diagnosis is required Dr Alexander 2024 Dr Alexander 2024 FINAL DIAGNOSIS The final diagnosis should correspond to the clinical course before and after biopsy A negative pathology report for cancer should not lull the dentist into a false sense of security when the clinical characteristics of the lesion still indicate malignant potential Dr Alexander 2024 FINAL DIAGNOSIS If the pathology report does not corroborate the clinical impression of the lesion, the biopsy procedure should be repeated Dr Alexander 2024 REFERENCES 1)Med Oral Patol Oral Cir Bucal. 2007 Nov 1;12(7):E504-10. Oral biopsy Oral biopsy in dental practice Amparo Mota-Ramírez ¹, Francisco Javier Silvestre ², Juan Manuel Simó 3 2)British Dental Journal volume 196 No. 6 March 27 2004 Oral biopsies: methods and applications R. J. Oliver1 P. Sloan2 and M. N. Pemberton 3)Fine-Needle Aspiration of Neck Masses: Overview... emedicine.medscape.com/article/1819862-overview Jan 30, 2014 - FNA for cytologic evaluation of a neck mass was first reported by Kun in 1847. However, the procedure did not gain wide acceptance in... 4)Oral Tissue Biopsy: Overview, Periprocedural Care... emedicine.medscape.com/article/1079770-overview Aug 4, 2014 - Oral mucosal biopsy has few contraindications. The standard biopsy techniques may require modification in some patients, including those with... Dr Alexander 2024