The aim of this pilot study was to evaluate the effectiveness of cutting
needle biopsy in the diagnosis of solid oral lesions.
Material and Methods
The biopsies were carried out on seven patients who presented with solid oral
lesions with sizes ranging from 2 to 6 cm. Specimens were obtained from each
lesion before conventional biopsies using a cutting needle with 18-gauge x 9
cm (MD TECH, Gainesville, FL, USA). A total of 64 specimens processed by
hematoxylin-eosin staining method, were obtained. Afterwards, the analysis
was performed by an oral pathologist, in two different stages, with and
without the clinical history of each lesion. Then, these answers were
compared with the final histological diagnosis.
Results
Results presented by the descriptive analysis showed that the correct
diagnosis using cutting needle biopsy without the clinical history of
lesions was registered in 37.5% of cases, while with the clinical history in
76.6%.
Conclusions
Despite the promising results as a potential technique for biopsies and
histological diagnosis of oral lesions, the cutting needle biopsy should be
analyzed carefully in those cases.
Cutting needle was firstly described in 1931, when Hoffman [1] presented this instrument as a new method for biopsy. The
methods used at that time, like conventional biopsy, cautery, suction or
"punches" were satisfactory, however, they presented some disadvantages
like greater trauma and sometimes, insufficient material for microscopic analysis.
In contrast, the new cutting needle biopsy (CNB) method was a faster, safely and
less morbid technique and it could be performed under local anaesthesia, providing a
tissue specimen for a reliable histological diagnosis [2-4]. Consequently, this
technique has been used for many years in lung [5], liver [3], breast [4], lymph nodes [6] and kidney [7] biopsies.
However, there are only a few studies related to the use of CNB in head and neck
regions [8].
Yamashita et al. [9] were one of the first
authors who have investigated the use of CBN in intraoral lesions whose results
showed that this method was safe and effective for the diagnosis of head and neck
lesions including intraoral ones. In addition, Southam et al. [10] and Yuan and Li [6]
have developed a study that described the use of an 18-gauge needle to obtain
specimens of head and neck nodes, concluding that this method is valuable for the
pathologists' interpretation. Besides, there are some studies which have been
compared CNB with other biopsy methods like fine-needle aspiration, cytology and
conventional biopsy [4,11-13].
Recently, some authors have reported high success rates concerning the use of CNB
taking into account that this method provides adequate biopsy samples for an
accurate histological diagnosis [8,13]. Therefore, this pilot study aimed to
evaluate the effectiveness of cutting needle biopsy in the diagnosis of solid oral
lesions.
MATERIAL AND METHODS
This study was approved by the Ethical Committee of the School of Dentistry at
Pontifical Catholic University of Paraná (PUCPR), and by the National Council
of Ethics in Research, Brazil.
Three male and four female patients (aged 32 to 81 years, mean age = 56.5 ± 15.7
years) from Stomatology Clinic at Pontifical Catholic University of Paraná,
who presented with solid oral lesions with more than two centimetre of size were
selected for the study. The lesions had not vascular origin, and needed conventional
biopsy, partial or total, for their final diagnosis. The sequence to carry out the
present study was done firstly using the cutting-needle biopsy (18-gauge x 9 cm
needle, MD TECH, Gainesville, FL, USA) in each patient after local anaesthesia.
Thus, the needle was calibrated to obtain the specimens of one centimetre and then
was carefully inserted inside the lesion until the end of the cannula. At this
moment, the patient was warned about the noise coming from the shooting procedure.
After that, the needle was removed from the lesion and calibrated again, showing the
entire cutting section and allowing the specimen removal, which was done carefully
(Figure 1A and B). At least three shots
were done in each lesion, according to the studies of Lane [14], Kissin et al. [15]
and Scope et al. [16] and the final number of
sixty four specimens were obtained. Soon after the cutting needle biopsy procedure,
conventional biopsy, partial or total, was performed in each lesion. All specimens
were processed by the hematoxylin-eosin staining method. For this, each specimen was
fixed in 10% buffered formalin and further embedded in paraffin. Sixty four paraffin
blocks were prepared from the 65 specimens, and one histological slide with 4 µm
thick section was obtained from each block.
Photograph showing the tissue specimen: A = in the cutting needle; B = being
removed from the needle cutting section.
Afterwards, the slides were showed randomly to a specialist in oral pathology and the
analysis was carried out in two stages, according to the following question: what is
the histological diagnosis of each slide? In the first stage, the slides were
analyzed without the clinical history of each lesion and in the second stage they
were analyzed with the clinical history of each lesion. Finally, the
pathologists' answers were compared with the "gold standard" result
obtained from the histological diagnosis of the conventional biopsies (Figure 2 and Figure 3). A dichotomous scale of values (0-diagnosis coincident and
1-diagnosis non coincident) in relation to diagnosis obtained before and after the
knowledge of the clinical history of each lesion was established.
The histological specimen showing the histological view of fibrous
inflammatory hyperplasia: a = epithelium; b = conjunctive tissue.
A = hematoxylin and eosin stain, original magnification x40; B = hematoxylin
and eosin stain, original magnification x100.
Histological diagnosis of fibrous inflammatory hyperplasia showed in the
piece of the conventional biopsy: a = epithelium; b = conjunctive
tissue.
Hematoxylin and eosin stain, original magnification x40.
RESULTS
Seven cases were included in this study and the final histological diagnosis after
conventional biopsy, size and location of lesions are presented in Table 1. There are five cases with the final
diagnosis of fibrous inflammatory hyperplasia, one with the central giant cell
granuloma and one with the peripheral giant cell granuloma. All solid lesions were
located in the oral cavity and their sizes ranged from 2 to 6 cm.
Final histological diagnosis of conventional biopsy, size and location of
the lesions
Case#
Final histologicaldiagnosis
Size(cm)
Location
1
FIH1
5
Maxillary alveolar ridge
2
FIH 2
4
Lower buccal vestibule
3
FIH 3
6
Maxillary alveolar and buccal mucosa
4
FIH 4
2
Hard palate
5
FIH 5
2
Lower buccal vestibule
6
CGCG
3
Mandibular alveolar ridge
7
PGCG
2
Maxillary alveolar ridge
FIH = fibrous inflammatory hyperplasia; CGCG = central giant cell
granuloma; PGCG = peripheral giant cell granuloma.
Sixty four specimens were obtained prior to conventional biopsy using cutting needle
biopsy method from the same lesions and analyzed microscopically. Results presented
by descriptive analysis showed that the correct diagnosis using cutting needle
biopsy without the clinical history of the lesions was registered in 37.5% of cases,
while with clinical history in 76.6% (Table
2).
Final histological diagnosis, number of specimens/slices obtained for
each lesion and number of correct cutting needle biopsy (CNB) diagnosis
without and with clinical history
Final histologicaldiagnosis
Number of specimens/slides for each lesion
Correct CNB diagnosiswithout clinical history
Correct CNB diagnosiswith clinical history
FIH 1
6
5
6
FIH 2
12
6
9
FIH 3
21
1
15
FIH 4
8
3
8
FIH 5
8
4
6
CGCG
3
0
0
PGCG
6
5
5
Total
64
24 (37.5%)
49 (76.6%)
FIH = fibrous inflammatory hyperplasia; CGCG = central giant cell
granuloma; PGCG = peripheral giant cell granuloma.
DISCUSSION
The present pilot study showed (Table 2) that,
even without the knowledge of the clinical history, the number of cases with correct
diagnosis was considerable (37.5%). It is important to point out that the reason to
have presented the slides to the pathologist without any kind of clinical
information was just because we wanted to check the potentiality of the specimens
collected with the current cutting needle in order to provide the correct
histological diagnosis. However, when the pathologist has known the clinical
information, the number of coincident diagnosis was twice higher (76.6%) than those
ones obtained without clinical information. Indeed, this was an expected result
considering that it is much more difficult and not recommended to carry out
histological diagnosis analyzing only the slides, without the clinical history.
Furthermore, quality and quantity of the specimens obtained with a cutting needle
with 18-gauge x 9 cm were satisfactory to carry out the microscopic analysis in the
majority of cases. Nevertheless, in some cases, even with the knowledge of clinical
history, the histological diagnosis of specimens was not coincident with the final
diagnosis (23.4%). Probably, in those cases, the quantity and quality of the
specimens were not satisfactory to carry out the correct histological diagnosis.
This is a very important aspect and shows that the conventional biopsy technique
cannot be fully substituted by the cutting needle biopsy one, concerning the
histological diagnosis of oral lesions. The latter still has important limitations
with regard quantity and quality of the specimens.
These results are also directly related to the following question: how many shots are
necessary to obtain the specimens with a good quality for cutting needle biopsy? In
the literature, some authors such as Lane [14], Kissin et al. [15] and Scope et
al. [16] argued that three shots are
sufficient to cover the entire lesion, while Southam et al. [10] stated that only two shots are needed. Jennings et al.
[17] and Christopher et al. [18] obtained good results with three to six
shots, but Bearcroft et al. [19], Abreu-Lima
et al. [20], Farias et al. [21] and Lieberman et al. [22] repeated the procedure only when the specimen was
insufficient clinically. As we can see, there is not a consensus regarding that
question. For the moment, we may suggest the number of shootings depends on the
lesion size and anatomical location. In addition, considering that the biggest
height of the cutting section of the needle we have used for the current research is
2 cm, it is not recommend to use that needle in lesions smaller than this size,
otherwise it would be very difficult to insert the needle in such lesions.
Furthermore, if it is possible to shot the lesions more than once, this procedure
should be done in different places of the lesion. In our study, there was not a
standardization of the number of the specimens obtained. However, we have
established a criteria to obtain at least there specimens from each lesion.
As far as the literature could be consulted, the cutting needle biopsy is an
efficient, fast and safe method, which provides sufficient material for an accurate
histological diagnosis [23] and it is widely
used in the medicine as stated by Farias et al. [21], Lieberman et al. [22], Yu et
al. [24] and Guimarães et al. [25]. However, in dentistry it is necessary to
develop more studies to evaluate the effectiveness of this technique [9]. Additionally, Akan et al. [26] compared cutting needles of 14-, 16- and
18-gauge in rabbit's experimental studies, to verify the possible
intraoperative complications caused by those needles; however, they did not find
relevant results. In contrast, Yu et al. [24]
found that hematoma occurred in patients who were submitted to cutting biopsy with
needle with 18- and 20-gauge.
Two main limitations for the present study are related to the few samples analyzed
and to the types of oral lesions which were biopsied, for instance, five fibrous
inflammatory hyperplasia and two giant cells granulomas, one central and another one
peripheral. Hence, we cannot affirm that the cutting needle biopsy technique could
be used successfully in other types of lesions, considering that the majority of the
current cases were only inflammatory reactions. In addition, Table 2 shows that the histological diagnosis of a central giant
cell granuloma (CGCG) through the specimens obtained by the cutting needle biopsy
has failed in both stages, before and after the knowledge of clinical history. Once
again, this particular result confirms that there is an important limitation of this
technique depending of the type of the oral lesion. In the same context, for some
rare histological diagnosis the use of this technique could be also evaluated [27]. Moreover, in this study, only one
examiner, specialist in oral pathology, has analyzed all slices. Thus, it is
important to point out that the results of cutting needle biopsy in the histological
diagnosis of oral lesions should be more robust with more examiners.
CONCLUSIONS
Considering the preliminary results of this pilot study, the use of cutting needle
biopsy in the histological diagnosis of oral lesions should be analyzed carefully.
Despite the promising results obtained with the knowledge of clinical history and
the recommendation to take at least three shots in oral lesions, further studies
including a large variability of these lesions in order to investigate the real
potentiality of this technique in their histological diagnosis should be done.
ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS
The author reports no conflicts of interest related to this study.