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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
  Table of Contents    
CASE REPORT  
Year : 2023  |  Volume : 27  |  Issue : 5  |  Page : 85-90
 

Tru-cut needle biopsy: A novel approach in the diagnosis of solid oral pathologies


1 Department of Oral and Maxillofacial Pathology and Microbiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
2 Oral and Maxillofacial Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission16-May-2022
Date of Acceptance03-Jun-2022
Date of Web Publication04-Feb-2023

Correspondence Address:
Thamizhchelvan Harikrishnan
HOD Department of Oral Pathology, Sri Ramachandra Institute of Higher Education and Research, 1, Mount Poonamallee Rd., Sri Ramachandra Nagar, Ramachandra Nager, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomfp.jomfp_212_22

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   Abstract 


Nowadays, new biopsy techniques such as fine and wide needles are now employed instead of invasive biopsy techniques. Compared to open biopsy, true-cut needle biopsy has a number of advantages. It's quick and simple to do, can be done in an outpatient department, avoids incisions into previously irradiated skin, and has few risks. In order to examine malignant and benign tumours, there had been a debate in the past century on the utilisation and efficiency of tru-cut biopsy over Fine needle aspiration cytology (FNAC) and surgical biopsy in solid tumours. A non-odontogenic tumour that occurs in jaws, also classified as a fibro-osseous lesion of the jaw, is Cemento-Ossifying Fibroma. Clinically, these lesions occur as gradually growing, reaching an enormous size if not treated. In this article, a case of cemento-ossifying fibroma noticed in the maxilla with facial swelling is discussed and the diagnosis was done using a tru-cut needle biopsy.


Keywords: Newer biopsy techniques, solid tumour biopsy, tru-cut biopsy


How to cite this article:
Lalita S, Harikrishnan T, Azariah ED, Chandrasekaran D. Tru-cut needle biopsy: A novel approach in the diagnosis of solid oral pathologies. J Oral Maxillofac Pathol 2023;27, Suppl S1:85-90

How to cite this URL:
Lalita S, Harikrishnan T, Azariah ED, Chandrasekaran D. Tru-cut needle biopsy: A novel approach in the diagnosis of solid oral pathologies. J Oral Maxillofac Pathol [serial online] 2023 [cited 2023 Mar 24];27, Suppl S1:85-90. Available from: https://www.jomfp.in/text.asp?2023/27/5/85/369168





   Introduction Top


The tru-cut biopsy is a procedure that involves removing the core of tissue of about 2 mm thickness from a mass or tissue using a specific needle. Hoffman was to report a tru-cut needle biopsy in 1931.[1] Traditional biopsy, cautery, suction, or “punches” were satisfactory at the time, but they had significant drawbacks, such as increased trauma and occasionally insufficient material for microscopic study. The tru-cut needle biopsy procedure is a novel minimally invasive technique, on the other hand, was a faster, safer, and less morbid technique that could be done under local anaesthetic and provided a tissue sample for a good histological diagnosis.[2] As a result, this method has been adopted in lung,[3] liver,[4] breast,[5] lymph node,[6] and kidney biopsies for many years. There are, however, only a few studies on the use of tru-cut biopsy in the head and neck areas.[7]

The first to study the use of tru-cut biopsy in intraoral lesions was by Yamashita et al.,[8] with findings indicating that this procedure was less invasive and efficacious which can play a major role in diagnosis. An 18-gauge needle was found to show better results in obtaining specimens from the head and neck lymph nodes according to a study done by Southam et al.[9] and Yuan and Li.[5] In addition, some studies have compared true-cut biopsy to other biopsy methods such as fine-needle aspiration, cytology, and conventional biopsy.[10] Using transverse cut biopsy, several writers have lately reported high success rates, stating that this approach provides enough biopsy samples for a satisfactory histological diagnosis.[11] As a result, the goal of this case was to see how efficient transverse cut biopsy was at diagnosing solid oral lesions.

Cemento-ossifying fibroma is an odontogenic tumour under the category of fibro-ossifying lesions which are characterized by replacing normal health fibrous architecture with collagen and fibroblast-containing calcified tissue. Cemento-ossifying fibroma was initially classified as a fibro-osseous neoplasm according to World Health Organization (WHO),[1],[2] whereas later in 1972, ossifying fibroma (OF) and cementifying fibroma was considered to be a tumour of the bone origin and odontogenic origin, respectively.[3] But WHO in the year 1992 classified these for the final time under the same category of the common denomination as cements-ossifying fibroma and its histological variants. These lesions have a similarity to OF and cemento-osseous dysplasias. There has been a debate among certain authors stating that these lesions are of mesenchymal cells of the periodontal ligament. These cells have a tendency to form fibrous tissue, cementum and bone or a combination of these tissues. While it is also believed that it is formed from the remnants of cementum after extraction of a tooth. Hence, there still exists a controversy about the origin based on the criteria of diagnosis and also the extent for classifying and terming the lesion as “Cemento-ossifying fibroma.” Hence, this case report gives us an insight into the process of data using a tru-cut biopsy for the diagnosis of Cemento-ossifying fibroma based on the clinical, histological-pathological basis.


   Case History Top


A 44-year-old female reported to the Department of Oral Medicine and Radiology with a chief complaint of swelling in the right side of the face in relation to the upper front tooth region for the past 3 months. On taking a note of the history of the patient, she revealed that the swelling had gradually increased in size over the past term of 3 months and the associated pain of the swelling has also increased with swelling through this period.

The extra-oral examination revealed that the swelling was found on the right side of the face on the maxillary region, with an extra-oral diffuse swelling of size 4 × 4 cm approximately with the border extending superiorly from the right zygomatic arch and inferiorly 3 cm above the inferior border of the mandible, mesially 1 cm away from the right side ala of the nose and distally approximately 3 cm away from the right preauricular region. The overlying skin of the swelling appeared normal and intact, and no paresthesia was found. On palpation, the swelling is non-tender and firm in consistency [Figure 1]. No evidence of any secondary changes was found. Intra-oral examination revealed a localized swelling seen on the right side of the maxilla, the size was approximately 3 × 5 cm in the first quadrant extending anteriorly from the lateral incisor and posteriorly to the first molar and soft tissue extension is from the mesial aspect marginal gingiva of the canine to the buccal sulcus distally, with buccal cortical plate expansion obliterating the buccal vestibule [Figure 2] and [Figure 2]b. Clinically, the surface mucosa was found to be normal on inspection, and on palpation, it was bony hard in consistency. Fibro osseous lesion on the right side of the maxilla was considered a provisional diagnosis based on the clinical examination.
Figure 1: Extraoral presentation

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Figure 2: (a) Intraoral presentation. (b) Intraoral presentation

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On radiographic examination of Intra oral periapical radiograph, orthopantomograph, and 3D computed tomography [Figure 3]a and [Figure 3]b and [Figure 4] were performed. A well-defined radiopaque lesion with mixed radiolucencies resembling a cyst was evident on the right side of the maxilla extending from the nasal border of the maxillary bone to zygomaticomaxillary suture anteroposteriorly and superoinferiorly from the lower border of the inferior border of the orbit to the alveolus of the maxilla canines with tooth displacement and without root resorption. The computed tomography revealed a heterogenous, expansile, dense calcifying lesion, also a heterogeneous hypointense lesion with specs of radio-opacity, the lesion has displaced the lateral wall of the right nasal cavity. The periphery of the lesion shows cortical destruction of the anterior and the medial wall of the maxillary sinus.
Figure 3: (a) CT Frontal. (b) CT Lateral

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Figure 4: CT Axial

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Blood investigations were done and the results were found to be within normal range (ALP- 20 to 140 IU/L; ACP- 0.13-0.63 U/L). As a final diagnostic procedure, a tru-cut needle biopsy was performed as it is less invasive for histopathological diagnosis. The procedure is performed using a specially designed needle [Figure 5]. Tru-cut needle biopsy reported a single bit of tissue, whitish in colour, cylindrical in shape, soft in consistency, and measuring 1.5 × 0.3 × 0.3 cm in dimension [Figure 6]. Histopathological examination of the tru-cut needle biopsy sample showed in H & E lower power showed a richly cellular matrix [Figure 7]. H & E high power showed proliferating fibroblasts in the connective tissue stroma, areas of osteoid formation and areas of basophilic calcifications with numerous fibroblasts found scattered in the trabeculae of the lamellar bone and cementoid masses [Figure 8]a and [Figure 8]b. Numerous spindle-shaped cells in the connective tissue stroma were evident. Based on the clinical finding and tru-cut needle biopsy histological examination, a diagnosis of cemento-ossifying fibroma was concluded. The lesion was surgically removed as per the traditional approach and the patient was kept under follow-up. The sample of the lesion was sent for histopathological examination which was concurrent with our diagnosis.
Figure 5: Tru cut needle biopsy needle

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Figure 6: Tru cut needle biopsy sample

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Figure 7: H & E section at 4x

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Figure 8: (a) H & E section at 40 x. (b) H & E section at 40 x

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   Discussion Top


This study used Tru-cut needle biopsy as the primary diagnostic tool because of its benefits, which include high diagnostic accuracy (total accuracy of 98.2%), less traumatic than open biopsy, high accuracy in distinguishing benign from malignant lesions, better quality specimens obtained through this biopsy technique, short recovery time, and patients.[12] The tru-cut needle biopsy process entails passing the gap near the needle's tip into the lesion, then passing the surrounding sheath with a cutting tip below the needle.[13],[14] The sheath then slices the specimen in the gap created by the needle, after which the needle with the cutting tip is inserted into the lesion and a tru-cut biopsy is done. The needle was inserted into the core of the tissue and aspirated backward and filled the needle trough.[15] In addition, the biopsy needle is usually several inches long, with a barrel roughly the size of a large paper clip. The needle is hollow to allow the tissue samples to be captured.

A tru-cut needle core biopsy provides an intermediate step between FNAC and open surgical biopsy. The histologic specimen obtained at core biopsy is also of sufficient size to permit extensive immunohistochemical staining. The use of image guidance and the larger size of the core biopsy sample also reduce sampling error, increasing sensitivity and negative predictive value. All of these advantages of core biopsy are particularly relevant to the diagnosis of salivary gland pathologies, lymph node pathologies and so on.[16] The possibility of sampling error does persist, however, and, if histopathology remains as inconclusive after a negative biopsy result, we recommend a repeat core or open biopsy.

According to the literature, cutting needle biopsy is an efficient, rapid, and safe approach that offers sufficient biological tissue for the histopathological diagnosis and is used in the field of medicine which has to be further implemented in dentistry too.[17],[18],[19],[20],[21] A rabbit model study by Akan et al. suggested that 14-, 16-, and 18- gauge cutting needles did not show any significant results whereas 18- and 20-gauge needles showed good results on hematoma by Yu et al.[20],[22]

A variant of the OF was first described in 1872 by Menzel in a 35-year-old female presenting with a large tumour of the mandible.[23] In 1927, Montgomery was the first author to coin the term ossifying fibroma, by which the lesion is currently known. Before 1948, it was thought that fibrous dysplasia and OF were variants of the same lesion. Sherman and Sternberg et al. (1948) were the first authors to present a detailed report on the clinical, radiological and histological features of OF, and subsequently, most researchers concur that fibrous dysplasia and OF are two different clinical entities (Gondivkar et al. 2011).[23],[24] In 1968, Hamner et al.[25] grouped all cementum-containing tumours into one category known as fibro-osseous lesions; however, the term “Ossifying Fibroma” has been in use since 1927. This lesion has been known by numerous names including non-osteogenic fibroma, cemento-ossifying fibroma, osteofibrous dysplasia, osteofibroma and fibro-osteoma. It was previously also identified as osteofibrous dysplasia which was first reported by Campanacci et al.[24] (1976), where the lesion presented in the fibula and tibia.[25] Jaffe and Lichtenstein (1942) described the same lesion above as a non-osteogenic fibroma, also commonly known as ' Jaffe-Campanacci syndrome More Details'. In the latest WHO classification of 2005, the term 'Cementifying Ossifying Fibroma' was replaced with 'Ossifying Fibroma'.[26] Brannon and Fowler in 2001 appear to have started the trend to use OF instead of cementifying ossifying fibroma.

OF is an osteogenic tumour with membranous ossification. It hence involves solely the maxillofacial bones.[27] It is thought to originate from the periodontal ligament which contains multi-potential cells capable of forming fibrous tissues, cementum and lamellar bone. This thought is supported by the fact that some lesions contain cementum-like calcifications while others only contain bony material; however, a mixture of the two types of calcifications is frequently present in a single lesion which is concurrent with our study.[28],[29] It is well-documented that the lesion occurs most frequently in patients below the age of 40 years which is similar to our study's age-group.[30]

OF in Asian populations was seen to present with considerably more swellings, while in Africans, the lesion does not present with as much swelling in the affected jaw which presents with a large swelling and surgical biopsy was considered as a diagnostic technique other than radiography.[30]

Very few studies in the literature have reported on the utilisation of tru-cut biopsy in diagnosing the lesions of jaws. Kansagara et al.[31] evaluated 25 patients with maxillofacial pathologies using 14 gauge tru-cut biopsy with incisional and excisional biopsy and found a sensitivity of 68.42%; specificity of 83.33% for tru-cut biopsy.

The tru-cut biopsy method was found to be a very useful method for rapid identification of maxillofacial pathology since it is simple to use, provides less tissue stress, reduces the danger of malignant lesions metastasizing during the process, and is largely free of complications. Large studies comparing the various solid tumours using different biopsy techniques like FNAC, tru-cut biopsy of various gauges and open biopsy needs to be done.

Key messages

The tru-cut biopsy allows access to the deeper sections of a tumour and is a novel technique for the examination of deeper structures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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28.
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31.
Kansagara PR, Shrinivas, Kumar HRS, Rai KK, Chatura KR, Bera HA. Comparison of tru-cut biopsy and incisional biopsy in achieving prompt diagnosis of maxillofacial pathology. J Maxillofac Oral Surg 2021;20:479-85.  Back to cited text no. 31
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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