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Artefacts in Oral incisional biopsies in general dental practice: a pathological audit

J Seoane, PI Varela-Centelles, JR Ramirez, J Cameselle-Teijeiro, MA Romero

Journal of Oral Diseases (2004) 10, 113–117

Presenter- Sumit BahlMDS 1st yr ORAL & MAXILLOFACIAL PATHOLOGY

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INTRODUCTIONApplication of biopsy in management of oral lesions has protocol

Adequate data collection

Proper surgical management

Evaluation and interpretation of

the reportPatient follow up

Competent diagnostic skills

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Artefact refers to an artificial structure or tissue alteration on a prepared microscopic slide.

They can be from-1.Crush ( by forceps)2. Fragmentation3. injection4. improper fixation 5. freezing

What is a artifact?

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How to avoid artefacts ?

Co2 lasers are used

for diagnostic

biopsyTHERMAL

CYTOLOGICAL

ARTEFACTS

Electrocautery

Punch biopsy has been suggested to reduce the artefacts , although , it could not be confirmed under controlled experimental conditions.

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Artefacts related to an incorrect handling of the specimens seem to be common in oral mucosal biopsy material.

• No information is available on the performance of General dental practioners.

Biopsy obtained from oral & maxillofacial surgeons.

• No comparisons between the two groups have been described in the literature so far.

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AIM

Investigate the artefacts produced in oral biopsy by

GDP & O & MFs

Identify the concordance of clinical & pathological diagnosis in both groups

The accomplishments of these objectives may contribute to define dos and donts when oral mucosal biopsies are performed by GDPs.

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MATERIALS & METHODS

• The incisional biopsies were carried out using a standard technique; a conventional elliptical biopsy was performed by scalpel.

• Specimens were immediately introduced into a widemouthed container and fixed in a copious amount of 10% formol-buffered solution for 24 h.

• All specimens were cut with a new disposable knife for every section and orientated before embedding in paraffin.

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MATERIAL & METHODS CONT..• Samples were cut in 4-µm sections and stained with

haematoxylin & eosin. All specimens were processed under the same protocol.

• All 354 samples were studied by the same pathologist.

• Clinical and pathological diagnoses were considered for each specimen.

• Histological examination assessed both prevalence and location of surgical handling artefacts (squeeze artefacts): crush, splits, haemorrhage and Fragmentation.

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RESULTS• Oral mucosa was the most

frequently biopsied area both by GDPs (75.1%) and O&MSs (62.7%).

• The biopsies by the GDPs were diagnosed as inflammatory disorders and oral precancer in up to 67.2% of the pathologist’s.

• Most biopsies (65%) performed by O& MSs were diagnosed as benign or malignant tumoral disorders.

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RESULTS CONT..• The most frequently identified

artefact in GDPs’ (27.1%) and O&MSs’ (10.2%) biopsies was the crush. This artefact was more commonly found on inflammatory lesions.

• The artefacts identified in GDPs’ biopsies were by frequency: crush 27.1%; haemorrhage 19.8%; splits 11.3%; and fragmentation 6.2%. No statistically significant differences in the proportion of artefacts were observed when the location of the original lesion was considered (P > 0.05).

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RESULTS CONT..General dental practioners Oral & maxillo facial surgeons

CRUSH- 27.1 % CRUSH-10.2 %

HAEMORRHAGE- 19.8 % HAEMORRHAGE- 8.5%

SPLITS – 11.3% SPLITS- 13%

FRAGMENTATION- 6.2% FRAGMENTATION- 2.3%

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RESULTS CONT..

No autolysis or phenomena associated with inadequate tissue fixation were observed. Pathological diagnosis was not impaired in any of the cases by theimproper surgical handling of the specimens.

EXCELLENT ( K > 0.75) , MODERATE ( 0.40 ≤ K ≤ 0.75), AND POOR ( K< O.40)

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DISCUSSION

Causes of artifacts :

• Artefacts incurred during handling of tissue are a major source of diagnostic problems.

• Squeeze artefacts are a form of tissue distortion resulting from even the most minimal compression of tissue that groups crush, haemorrhage, splits, fragmentation and pseudocysts, and are usually caused by forceps, by using a stitch for traction or by a dull scalpel blade .

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1. The results suggest that crush, splits and haemorrhage are the artefacts most frequently found in incisional oral biopsies. Crush and haemorrhage are significantly more common in biopsies performed by GDPs.

2. This could be explained by thefact that inflammatory tissue is more prone to suffer crush when biopsied and these disorders are predominant amongst GDPs’ specimens.

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1. Preparation of the area of biopsy with iodine tincture or other coloured solutions should be avoided as it can interfere with tissue processing and staining.

2. Intralesional injection of anaesthetic solution should also be avoided as it can produce haemorrhage with extravasation and separation of connective tissue bands with vacuolization.

3. The ability of the oral pathologist to interpret a biopsy correctly is directly proportional not only to the quality, but also to the quantity of the specimen.

4. Curling artefacts are common in samples that are too small, making the correct orientation difficult during the embedding procedure.

5. This problem can be prevented if, after the biopsy, it is placed with the mucosal surface up on a piece of the sterile paper that held the suture material.The specimen is allowed to remain unfixed for a short time while the incision is being sutured .

GUIDELINES TO PREVENT ARTEFACTS

selecting the best area for biopsy

Submit sufficient tissue or the whole

specimen

Handle tissue with care without pulling, or crushing. Minute specimen has to be kept on cardboard , prior fixation

In cautery, margins has to be resected

away from the lesion.

Do not contaminate the tissue with foreign material.

Giuseppe Ficarra, Bonnie McClintock, Louis S. Hansen, Artefacts Created DuringOral Biopsy Procedures, J. Cranio-Max.-Fac. Surg. 15 (1987) 34-37

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Critical evaluation

• Presence of sutures

• Starch contamination

• Necrosis due to monsels solution

• Cellulose contamination

• Gelfoam artefacts

• Heat damage

Prefixation artefacts

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Presence of sutures

Suture material is an occasional inclusion in histological specimens.It may consist of isolated fragments or complete fibre bundles cut in transverse , oblique or longitudinal planes. Silk sutures show strong birefringes under polarised light.

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Starch contamination

Starch is used as a powder in surgical gloves and can therefore be deposited within or upon the surface of surgically – acquired tissues. On occasions it may be present within granulomas removed surgically . Starch contamination can also occur in the labortary if new gloves are not washed before handling specimen. Starch stains very strongly with PAS stain and shows a characteristic “ Maltase birefringence” with polarised light.

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Necrosis due to monsels solution

Monsel solution is a topical hemostatic agent used to control bleeding following skin or mucosal biopsy . It can cause necrosis to a maximum depth of 0.6mm . On occasion monsels solution is mistakenly applied before the biopsy is taken. This can result in a general basophilia , partial desquamation and cracking of the epithelium and signs of early necrosis.

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Cellulose contamination

Cellulose can be encountered as a contaminant arising from paper, cotton gauze used during specimen preparation.

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Gelfoam artefacts

Gelfilm and gelfoam are used from absorbable gelatin and , in the form of a thin film or sponge , are used to control bleeding in various surgical procedures. They may be encountered in sections usually adhering to a specimen surface.

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HEAT DAMAGE

Heat damage is seen along the margins of surgical biopsy. It takes the form of strong acidophilic staining in the local area with loss of nuclear & cytoplasmic detail. Connective tissue fibres become cougulated due to effects of heat and, if glandular tissue is present, it may become vacuolated. This artefact is caused by laser generated heat fixation of tissues.

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JOURNAL CLUB - Critical appraisalS.NO APPRAISAL YES NO CONCLUSION

1. Article source-Journal of Oral Diseases (2004) 10, 113–117

2. Title of the study Meaningful & complete

3. Reviewing of the abstract Summarizes clearly

4. Introduction Meaningful & concise

5. Are the research objectives precisely identified

√

6. Methodology Study design appropriate to objectives

7. Results Completeness

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References• JOSEPH E.et al, Artifacts in Oral Biopsy Specimens, J Oral Maxillofac Surg

43:163-172. 1985

• Giuseppe Ficarra, Bonnie McClintock, Louis S. Hansen , Artefacts Created During Oral Biopsy Procedures, J. Cranio-Max.-Fac. Surg. 15 (1987) 34-37

• Artifacts in histological and cytological preparation, Geoffery O rolls, Neville J farmer and john B hall.

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