SA3 - What Are the Cases That Would Necessitate Multiple Incisional Biopsies? A Case Series and Suggested Algorithm

Abstract:

Purpose: A high-quality biopsy is essential for the diagnosis of oral squamous cell carcinoma (OSCC). Accurate histopathological analysis depends on sampling representative tissue. Sampling errors occur when the tissue sample does not accurately represent the lesion, leading to inaccurate diagnoses. Despite advancements in medicine, the 5-years survival rate for OSCC continues to be 50%. Early diagnosis and treatment are essential to improve the survival rate. The purpose of this study was to present a series of cases that had false negative initial results with a confirmed OSCC on subsequent biopsies. Moreover, we are presenting our institutional treatment algorithm for suspicious lesions of the oral cavity.
Materials and

Methods: This was a retrospective case series study. The study cohort was derived from patients who presented to the Oral and Maxillofacial Surgery (OMS) outpatient clinic at the University of Rochester Medical Center (URMC), Rochester, NY, between October 15, 2023, and February 15, 2025, for evaluation and treatment of a suspected OSCC lesion. The study inclusion criteria were subjects who underwent more than one biopsy procedure, had a false negative result following initial biopsy, and had a final histopathology result confirming OSCC. For the study, a false negative result is defined as a discrepancy between the initial and final histopathological analysis, with the final result confirming OSCC. We excluded subjects who had a single incisional biopsy procedure confirming OSCC, diagnoses that were non-malignant, and malignant diagnoses that were not OSCC.

The study team collected patient demographics, past medical history, tobacco use history, initial biopsy provider, lesion descriptors (location, dimension, clinical presentation), total number of biopsies, results of initial biopsies, and histopathological analysis results. Descriptive statistics were determined.

Results: During the study period, 4 patients with a mean age of 48 years (range 11 to 86) were included in the study. All patients (n = 4, 100%) were Caucasian. Patient medical history was hypertension (n = 1, 25%), Cerebrovascular Accident (n = 1, 25%), Chronic Kidney Disease (n = 1, 25%), and Gastroesophageal Reflux Disease (n = 1, 25%). Most of our patients had never smoked (n = 3, 75%), and 1 patient was a former smoker. The initial biopsies were performed by the following providers: community oral and maxillofacial surgeon (n = 2, 50%), periodontist (n = 1, 25%), and URMC oral and maxillofacial surgery clinic (n = 1, 25%). The average number of performed biopsies was 3 (range 2 to 5). Most of the OSCC lesions were in the gingiva (n = 3, 75%), and one case was in the lateral tongue (n = 1, 25%). Fifty percent of cases measured less than 3 cm in their greatest dimension. Clinical presentation was as the following: exophytic lesions (n = 4, 100%), papillary surface mucosa (n = 3, 75%), ulceration (n= 2, 50%), leukoplakia (n = 2, 50%), erythroleukoplakia (n = 1, 25%), tenderness or pain (n = 1, 25%). The histopathology analysis results of the initial biopsy were cellular atypia (n = 2, 50%), squamous papilloma (n=1, 25%), and verrucous hyperkeratosis (n = 1, 25%)

Conclusions: Our data highlight the importance of incorporating more than one biopsy for lesions with high-risk features or lesions located in high risk areas. The majority of patients in our cohort presented clinically with exophytic lesions with papillary mucosal appearance and cellular atypia in their initial histopathology analysis. Our study had certain limitations, as it was a retrospective case series with a small number of cases. Our team is continuing to collect data on cases that presented with false negative histopathological analysis.

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2. Chi AC, Day TA, Neville BW. Oral cavity and oropharyngeal squamous cell carcinoma--an update. CA Cancer J Clin. 2015;65(5):401-421.
Figure 1: Institutional Treatment Algorithm for determining the need for initial biopsy and the approach to a suspected false negative result Table 1: Patient Demographics associated with Case Series Figure 2: One of the gingival lesions, initially diagnosed as squamous papilloma on initial biopsy