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    Head and neck small biopsies and teeth

    Background

    Malignancies of the oral mucosa and are most commonly squamous cell carcinomas but adenocarcinomas, salivary gland neoplasms and neuroendocrine epithelial neoplasms can also occur.1 Specimens from the nasopharynx and sinuses may also be received. Small biopsies are commonly undertaken to diagnose lesions to determine appropriate treatment.

    This protocol is applicable to small biopsy specimens. See oral resection protocol for larger specimens.


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    LP Lichen planus
    MMP Mucous membrane pemphigoid
    SCC Squamous cell carcinoma
    CHC Chronic hyperplastic candidosis
    MRG Median rhomboid glossitis
    FEP Fibroepithelial polyp

    Courtesy of Prof Michael Aldred

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.

    Follow best practice procedures to minimise cross-over contamination of small fragments to other specimens.2

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen.

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Describe the following features of the specimen:

    Procedure

    Record as stated by the clinician.

    • Incisional biopsy
    • Excisional biopsy
    • Other, describe

    Specimen size (mm)

    • Total specimen in three dimensions, length x width x thickness1,3,4

    Specimen site

    Record the specimen site as stated by the clinician.

    RBM Right buccal mucosa
    LBM Left buccal mucosa
    R comm Right commissure
    L comm Left commissure
    R tongue Right side of tongue
    L tongue Left side of tongue
    FOM Floor of mouth
    Q_| Right maxilla
    |_Q Left maxilla
    Q¯| Right mandible
    |¯Q Left mandible

    Courtesy of Prof Michael Aldred

    Specimen description

    • Identifiable lesion
      • Absent
      • Present, describe
        • Ulceration
        • Scar
        • Thickening
        • Nodule
        • Polyp
    • Bone, if present

    If received, record the following:

    • Number, if more than one, designate and describe each separately
    • Fédération Dentaire Internationale (FDI) designation4
    • Mobility
    • Periodontal ligament involvement
    • Root resorption
    • Note the presence of any fillings
    • Note the presence of soft tissue attached and record location
    • Root apex
    • Side of root
    • Around crown
    • Attached at amelo-cemental junction

    Permanent teeth are recorded as 1-8 in four quadrants with a two digit numbering system. The first number designates the quadrant and the second number designates the tooth. Quadrants are read clockwise (1. right maxilla, 2. left maxilla, 3. left mandible and 4. right mandible).

    e.g. the mandibular left third molar may be recorded as tooth 38 or |¯8.

    See also the illustration in general information on anatomical terms.


    Dissection

    • Mucosal biopsies usually do not require dissection.
    • Excisional biopsies are usually best sectioned transversely (across the short axis) to demonstrate the closest margins.
    • Incisional biopsies are usually bisected through the long axis. Note that many biopsies of lichen planus are incisional and should not be sliced transversely. Instructions for tissue to be embedded on edge should be communicated to embedding staff.
    • Hard tissue, bone and teeth should be decalcified before dissection.4,6
    • Cysts =<10mm, bisect and submit all tissue for processing.
    • Cysts >10mm, section transversely at 4-5mm intervals.

    Bisect or section transversely across the specimen to the closest margins at 3-4mm intervals.

    A photo or diagram is required.

    • Larger excision biopsies (>10mm) should be dissected to demonstrate representative margins according to the diagram provided.
    • Note the position of any orientating sutures.
    • Fragments <5mm, submit whole for processing after decalcification.
    • Fragments >5mm, section transversely at 3-4mm intervals after decalcification.
    • Note the position of any orientating sutures.
    • Slice off outer surfaces to obtain a section through the middle of the tooth.

    Internal Inspection

    If applicable, describe the cut surface appearance including the following items:

    Tumour/lesion

    • Absent
    • Present
      • Number; if more than one, designate and describe each separately

    Tumour size (mm)

    • In three dimensions, length x width x thickness1
    • Macroscopic depth of invasion (mm)*

    *This is the depth of invasion below luminal surface not thickness of tumour. Ulcerated tumours should be measured from an estimate of the reconstructed surface.1

    Photograph the dissected specimen, if required.

    Note photographs taken, diagrams recorded and markings used for identification


    Processing

    • Submit whole for processing. Instructions for tissue to be embedded on edge should be communicated to embedding staff.
    • If <10mm, submit whole for processing.
    • If >10mm, submit all sections for processing.
    • If <10mm, submit all sections for processing.
    • If >10mm, submit representative sections demonstrating the relationship of lesion to margins.
    • <5mm, submit whole for processing (after decalcification).
    • >5mm, submit all sections (after decalcification).
    • Submit representative sections through the middle of the tooth for processing (after decalcification) if microscopic examination is required.

    Record details of each cassette.

    An illustrated block key similar to the one provided may be useful.

    Block allocation key

    Specimens <10mm

    Cassette id
    Site
    No. of pieces
    A+
    All tissue, whole or all sections
     
     

    Specimens >10mm

    Cassette id
    Site
    No. of pieces
    A+
    Representative sections demonstrating relationship of lesion to margins

     

     

    Acknowledgements

    Prof Richard Logan for his contribution in reviewing and editing this protocol.


    References

    1. Helliwell T and Woolgar J. Dataset for histopathology reporting of mucosal malignancies of the oral cavity, The Royal College of Pathologists, London, 2013.
    2. Lester SC. Extraneous Tissue. In: Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010;33-34.
    3. Dahlstrom J, Coleman H, Johnson N, Salisbury E, Veness M and Morgan G. Oral structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2012.
    4. Speight P, Jones A, Napier S, Helliwell T. Tissue pathways for head and neck pathology. London: The Royal College of Pathologists; 2014.
    5. International Organization for Standardization (ISO). Dentistry -- Designation system for teeth and areas of the oral cavity. 2009. (Accessed 14 May 2014).
    6. Dimenstein IB. Bone grossing techniques: helpful hints and procedures. Ann Diagn Pathol 2008;12(3):191-198.

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      26-Mar-2019
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