ARTÍCULOS ORIGINALES
Efficacy of core needle biopsy technique for jawbone diseases
Federico Stolbizer1,2, Romulo L. Cabrini3, Alicia Keszler3
1 Emergency Department.
2 Department of Oral-maxillofacial Surgery.
3 Oral Pathology Department, School of Dentistry University of Buenos Aires. Argentina.
CORRESPONDENCE Dr. Federico Stolbizer. Servicio de Urgencias Facultad Odontologia. Universidad de Buenos Aires M.T. de Alvear 2146. C1122AAH C.A.B.A. Argentina e- mail: fstolbizer@hotmail.com
ABSTRACT
Core needle biopsy (CNB) has been proven useful for diagnosing bone lesions, although it is not often used for jawbone lesions. The aim of this study was to evaluate the efficacy of the CNB method in a series of cases of intramaxillary lesions. CNB was performed on 85 patients with intraosseous lesions which were grouped according to radiographic appearance as: radiopaque lesions (RO, n=13), radiolucent lesions (RL, n=39) and mixed lesions with both radiolucent and radiopaque areas (RL-RO, n=33). The technique enabled us to obtain several tissue cylinders from each lesion (average 2.5 cylinders), which were processed following routine histopathological technique and H&E stain, plus special techniques when necessary. The histopathological analysis together with clinical data enabled accurate diagnosis (AD) in 81% of the cases and descriptive diagnosis (DD) in 14%. The material obtained in 5% of the cases was not appropriate for study (ND). The difference between successful (AD) and unsuccessful (DD+ND) CNB cases is statistically significant. The highest percentage of successful CBNs was for RO and RLRO lesions (85% and 100% respectively). RL lesions were more difficult because most of them were cystic lesions with fluid content.
Key words: Core needle biopsy; Jaw diseases.
RESUMEN
Eficacia de la técnica de punción ósea para biopsia de lesiones de maxilares
La biopsia-puncion osea ( Core needle biopsy, CNB) es un procedimiento de probada utilidad en el diagnostico de lesiones oseas. Sin embargo, no es una tecnica de uso frecuente en las lesiones de los maxilares. La finalidad de este trabajo fue evaluar la eficacia del metodo de CNB en una serie de casos de lesiones intramaxilares. Se realizaron CNB en 85 pacientes con lesiones intraoseas, las cuales fueron agrupadas segun su aspecto radiografico en lesiones radiopacas ( RO, n=13), lesiones radiolucidas (RL, n=39) y lesiones mixtas con sectores radiolucidos y radiopacos (RL-RO, n=33). La tecnica permitio obtener varios cilindros de tejido de cada lesion ( promedio: 2.5 cilindros) los cuales fueron procesados segun tecnica histopatologica de rutina con tincion de H&E y tecnicas especiales en los casos en que fueron necesarias. El analisis de los cuadros histopatologicos conjuntamente con los datos clinicos, permitio realizar un un diagnostico de certeza (AD) en el 81% de los casos y un diagnostico descriptivo (DD) en el 14 % . En el 5% de los casos el material obtenido no fue adecuado para su estudio (ND) La diferencia entre los casos de CNB exitosa y no exitosa ( DD+ND) es estadisticamente significativa. El mayor porcentaje de CBN exitosas correspondio a las lesiones RO y RL-RO ( 85% y 100% respectivamente) Las lesiones RL presentaron mayor dificultad debido a que, en su mayoria, eran lesiones quisticas con contenido liquido.
Palabras clave: Biopsia puncion osea; Lesiones de los maxilares.
INTRODUCTION
Biopsy sampling is a surgical procedure for obtaining
material from a lesion on which to perform
histopathological studies for use together with all
the clinical data to reach a diagnosis and provide
appropriate treatment. The choice of technique and
instruments for taking the biopsy depends on the
nature and location of the lesion. For intraosseous
lesions, a tissue sample can be obtained by
performing either surgical biopsy (open biopsy) or
puncture biopsy (closed biopsy).
Since 1901, when the first instrument for
performing puncture biopsy was registered 1 great
efforts have been made to develop techniques and
instruments to avoid the complications that can
arise with an open biopsy, particularly when the
lesions are located deep inside the tissue or are in
contact with vital structures 1-11. Progress in these
devices has generated great interest among
physicians. A number of case series published have
shown the efficacy and advantages of using core
needle biopsy (CNB), reporting success rates ranging from 20 to 95% 1,6,12-19. The published data
demonstrate how the technique has developed and
improved over the years.
In contrast to the widespread use of CNB in the field
of medicine, and in spite of the frequency and
variety of lesions that affect the jaws, the procedure
has not had significant application in the field
of dentistry. The aim of this study was to assess
the efficacy of the CNB method in a series of
intramaxillary lesion cases.
MATERIALS AND METHODS
Core needle biopsies were performed on eighty-five
patients, 45 female and 40 male, age range 6 to 80
years, with intramaxillary lesions and indication for
biopsy. All patients provided informed consent. The
project was approved by the Ethics Committee of
the School of Dentistry, University of Buenos Aires.
The radiographic appearance of biopsied lesions
was radiolucent (RL) in 39 cases, mixed radiolucentradiopaque
(RL-RO) in 33 cases, and radiopaque
(RO) in 13 cases.
The CNB technique was performed on outpa -
tients under local anesthesia with 4% Carticaine
Chlorhydrate with L-Adrenaline 1:1000,000
(Bernabo Laboratory, Buenos Aires, Argentina),
using 11 gauge/10cm-long needles, originally
designed for taking bone marrow samples from the
iliac crest, (Gallini medical devices, BM 11G-
10cm, Italy). A transmucosal puncture was
performed without prior incision. Several samples
were taken using the same puncture site and
positioning the needle in different directions. The
number of samples taken depended in each case on
the size of the lesion and the degree of homogeneity
in the X-ray image. The operation does not require
subsequent suture. The tissue cylinders obtained
were fixed in 10% formalin and demineralized in
7% nitric acid for 12-24 h, depending on their
degree of mineralization. Following routine
embedding in paraffin, sections were obtained and
stained with H-E. When special techniques were
needed as a diagnostic aid, histochemical and
immunohistochemical stains were also performed
on adjacent sections. The following techniques
were used: Periodic acid Schiff, Gomori’s Trichrome
stain, and immunohistochemical reactions for the
expression of the antigens CK7/20, CD3, CD20,
CD1a, S100, Vimentin and kappa and lambda
light chains.
After correlating histopathological findings
with the individual patients´ histories, clinical and
image data, final diagnoses were grouped in three
categories as follows: 1- Accurate diagnosis (AD),
when it was possible to arrive at the diagnosis
of a defined pathological entity, 2- Descriptive
diagnosis (DD), when the histopathological
diagnosis was descriptive but not conclusive, and
together with clinical and radiographic data enabled
a defined pathology to be suggested, though not
identified; 3- No diagnosis (ND), when the quantity
or quality of the material obtained from the biopsy
was not sufficient to establish a diagnosis.
Final AD diagnoses of biopsy samples obtained by
CNB were then confirmed with the study and
diagnosis of the surgical specimen, when the
treatment of the biopsied lesion was surgery. In cases
not requiring surgery, (e.g. fibrous dysplasia) the
diagnosis was confirmed through clinical and
radiographic follow-up of the patient for at least two
years.
For the purpose of this study, we did not change
the final DD and ND of the CNBs, even if subsequent
studies enabled improvement in the diagnosis.
To evaluate the efficacy of the CNB method, the
percentage of AD (successful CNBs) was compared
to the percentage of DD+ND (unsuccessful CNBs)
using the One-Sample Proportion Test.
We also evaluated the percentage of AD, DD and
ND with relation to the radiographic appearance of
the lesions to determine whether lesion type
conditions the success of the CNB. Pearson´s Chisquared
test was used for this purpose.
RESULTS
The technique enabled material to be obtained in all cases (100%), with an average of 2.5 tissue cylinders per patient. CNB diagnosis of a defined entity or accurate diagnosis (AD), subsequently confirmed by the study of the surgically removed tissue or patient follow-up, was achieved in 81% of the cases. Descriptive diagnoses (DD) were made for 14% of the cases and no adequate material for diagnosis (ND) was obtained in 5%. The percentage of successful CNBs (AD) differed statistically from DD + ND (One-Sample Proportion Test, p= 0.005 ). Fig. 1 shows an example of the material studied in one case in which accurate diagnosis of ossifying fibroma was made. Table 1 shows final diagnoses of all the study cases.
Fig. 1: Lesion in the upper jawbone in which core needle biopsy led to the diagnosis of ossifying fibroma. A) CT image, B)
Puncture technique C) Tissue cylinders obtained from the lesion, C) Lesion in the mucosa after puncture, - D-F) Microscopic
features . HE. Original magnification X 5 and X 40.
Table 1: Lesions under study and diagnoses of core needle biopsies.
Table 2 shows the distribution of percentages of CNB final diagnoses with relation to the different radiographic appearances. The CNB was effective for all radiologic types of the biopsied lesions. However, radiolucent lesions were more difficult. The percentage of successful cases is significantly higher in RO and RL-RO lesions (85% and 100% respectively) than in the group of RO lesions
Table 2: Distribution of percentages of CNB final
diagnoses for different radiographic
appearances.
(Pearson´s Chi-squared test, p=0.002). In RO lesions group diagnosis was conclusive in cases of periostitis, condensing focal osteitis, odontoma, Paget’s disease, and in 5 out of the 7 cases of osteomyelitis. The group of RL-RO lesions included a wide range of pathologies of very different nature. The group of RL lesions, in which 64% of CNBs were successful, included several cystic lesions (Table 2).
DISCUSSION
Core needle biopsy has several advantages over
open biopsies. It allows tissue to be obtained from
the depth of the lesion, whereas surgical open
biopsy is often limited to the periphery of the lesion.
This is relevant for large lesions. For smaller
lesions, it may be possible to obtain a tissue
cylinder for the entire diameter of the lesion. By
placing the needle at different angles through a
single puncture site, several representative cylinders
can be obtained from different zones of the lesion.
This is particularly important when the lesion is
large and/or has a heterogeneous radiographic
appearance. CNB does not require incisions or
sutures, thus shortening the surgical times and being
less traumatic, less invasive, and better tolerated by
the patient. Moreover, it usually causes less
hemorrhage and less contamination of the surgical
site and often reduces the cost of surgery.
However, the use of puncture biopsies in the field
of maxillofacial surgery is not yet widespread. This
may be due partly to the fact that there is easy access
to the oral cavity for conventional surgical biopsies.
However, once minimal necessary training has been
acquired, a specialist surgeon has all the advantages
described above.
Some authors have evaluated the use of fine needle
aspiration biopsy in intramaxillary lesions, and have
found it to have significant diagnostic value 20-22 in
spite of the fact that by using this technique,
material is only obtained for the study of isolated
cells. The few papers that refer to the application of
CNB in jaw pathologies describe the methodology
and report single clinical cases 23-26, but we have not
found any reports of series of cases evaluating the
usefulness of the method. The CNB technique proved
effective in radiopaque lesions and radiologically
inhomogeneous lesions. The lower efficacy of CNB
in radiolucent lesions was due to the fact that this
group included six cystic lesions containing fluid,
and three keratocystic odontogenic tumors for
which a conclusive diagnosis was only achieved in
one case, in which a sample of the cystic membrane
was obtained.
Assessing the efficacy of CNB according to the
radiographic appearance of a lesion is clinically
relevant, and would serve in clinical practice as a
basis to determine the fastest, simplest, and most
suitable biopsy technique in each specific case.
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