Ultrasonography and ultrasound-guided fine-needle aspiration biopsy of head and neck lesions: A surgical perspective

A head and neck ultrasound-guided fine-needle aspiration clinic was set up to determine the role of ultrasound and ultrasound-guided fine-needle aspiration in the evaluation of patients with lesions in this region. One hundred ninety-five lesions were biopsied by ultrasound-guided fine-needle aspiration in 203 patients. Ultrasound detected 2 or more lesions in 14 (48%) of 29 patients with a clinically solitary thyroid nodule. Three (8.8%) of 34 lesions thought to be within the parotid gland were determined to be external. A pronounced learning curve was evident in the technique of ultrasound-guided fine-needle aspiration, particularly for nonpalpable disease. Adequacy of sampling for each 3-month period was 71%, 89%, and 94%, respectively. Seventy-four percent of central aspirations were satisfactory compared to 54% of peripheral aspirations. Ultrasound-guided fine-needle aspiration did not alter the clinical staging of metastatic neck disease in 8 patients having 10 neck dissections but proved useful in detecting nodal recurrence in 3 irradiated necks that did not proceed to surgery. The smallest node to harbor malignancy had 4-mm maximal axial diameter. We conclude that ultrasound and ultrasound-guided fine-needle aspiration are valuable adjuncts to the clinical examination.     

Ultrasound-guided core-needle biopsy in the diagnosis of head and neck lesions

This article describes the technique of ultrasound-guided core-needle biopsy in the head and neck, and also warns of its risks. In contrast to fine-needle aspiration, this minimally invasive procedure has the advantage of supplying a histological specimen rather than a cytological smear. Therefore, it could be used as an additional diagnostic tool in the investigation of head and neck lesions, and can be carried out within the out-patients clinic.     

Ultrasound-guided cutting-needle biopsy of the parotid gland

We describe the technique of ultrasound-guided 18 gauge (1.2 mm) needle biopsy in 16 patients with parotid gland lesions. This provides material suitable for histological analysis and can be performed quickly and safely under local anaesthesia. Thirteen of the patients had non-diagnostic blind fine-needle aspiration cytology (FNAC) with a 21 gauge (0.8 mm) needle prior to biopsy. Initial ultrasound was found to be superior to clinical examination in 31 per cent of cases. The ultrasound-guided technique provided a diagnostic specimen in 100 per cent of patients and was helpful where FNAC had been inconclusive. There was a diagnostic accuracy of 100 per cent in the patients who underwent subsequent surgery. This method should be considered when FNAC is non-diagnostic and surgical treatment is being considered. It is particularly useful in patients with diffuse enlargement of the gland and does provide a core of material for accurate assessment of tissue architecture. In this series, nine patients avoided unnecessary surgery.     

Automatic core needle biopsy: a diagnostic option for head and neck masses

OBJECTIVE: To examine the role of core needle biopsy in the diagnosis of head and neck masses. DESIGN: Prospective observational study. SETTING: The otolaryngology-head and neck surgery department outpatient clinic of a large managed care organization. PATIENTS: The study population comprised 40 consecutive patients referred for core needle biopsy of a cervicofacial lesion for which previous fine-needle aspiration biopsy had not provided the diagnosis. INTERVENTION: Manually guided Delta Cut (Boston Scientific, Natick, Massachusetts) core needle biopsy was performed on neck masses larger than 1.5 cm. MAIN OUTCOME MEASURE: Diagnosis was indicated by core needle biopsy results without excisional biopsy. RESULTS: A core needle biopsy specimen sufficient for diagnosis and treatment was obtained from 36 of the 40 patients (90%). In 22 patients, subsequent excisional biopsy or curative surgery was performed after core needle biopsy, and pathologic examination confirmed the diagnosis for 19 of these 22 patients (86%). For 12 of the remaining 14 patients (86%), core needle biopsy was successfully used to diagnose lymphoma. No complications resulted from the core needle biopsy. CONCLUSIONS: For lesions that require immunohistochemical staining or that remain undiagnosed after fine-needle aspiration, use of core needle biopsy should be considered before excisional biopsy. Core needle biopsy is a safe, effective, time-efficient, inexpensive procedure that can be an important tool for diagnosing head and neck masses, especially when lymphoma is suspected.     

Image-guided needle biopsy of inaccessible head and neck lesions

Fine-needle biopsy and large-needle core biopsy of inaccessible and deep-space lesions of the head and neck are difficult and sometimes hazardous to perform. Patients subsequently may have to undergo a major surgical procedure with exploration of the neck and open biopsy. We describe our experience with computed tomography and ultrasound-guided fine-needle and core-needle biopsy for 11 patients with inaccessible lesions in the head and neck. Carcinoma was diagnosed in three patients and nonmalignant pathologic findings in eight patients. Three of the needle biopsy findings were confirmed by surgical excision. The initial diagnoses made from the cytopathologic findings have remained unchanged in all patients. Compared with the alternative of open biopsy, we have found this method to be technically easy, diagnostically expeditious, and safe. Head and neck surgical oncologists should be familiar with image-guided biopsy techniques, since many of their patients may benefit from these diagnostic procedures.     

超声引导下针吸细胞学检查在头颈肿瘤围手术期的临床应用价值评估

目的 通过超声引导下针吸细胞学检查研究,进一步提高头颈肿瘤在围手术期的确诊率。方法 随机对30例头颈肿瘤患者的区域性颈部包块或淋巴结行针吸细胞学检查,尤其是前哨淋巴结的检测分析,确定头颈肿瘤的组织细胞学类型,为头颈肿瘤患者围手术期的手术术式、切除范围及预后评估提供理论依据。结果 本组30例患者中,1次性取材成功率为93.33%(28/30),组织学确诊率为93.33%(28/30)。活检过程顺利,仅1例因穿刺部位出现局部血肿需要加压包扎,其他患者均无特殊处理。结论 超声引导下针吸细胞学检查改变了以往术中直视下凭经验判断头颈肿瘤良恶性及术中冰冻确定肿瘤组织学类型的传统方法,间接减少了切缘阳性率、切端残留癌,最大限度地实现了功能性外科,值得临床推广。     

Metastatic neck disease. Palpation vs ultrasound examination

Nodal disease is a diagnostic problem in head and neck oncology. Current methods for investigation of the neck are not satisfactory as far as differentiation between necks with positive nodes and those with negative nodes is concerned. In the present study, the results of palpation and ultrasound examination were compared with histopathologic examination results of 120 neck dissection specimens. Furthermore, the value of ultrasound examination, combined with cytologic examination, of neck nodes was evaluated. Ultrasound examination was characterized by high sensitivity, ie, 96.8%; specificity was 32.0%. When the results of ultrasound-guided fine-needle aspiration biopsy were added to the ultrasound findings, specificity was as high as 92.9%. From these results, it was concluded that ultrasound examination with fine-needle aspiration biopsy is an accurate method for assessment of the neck in head and neck oncology.     

Fine-needle aspiration biopsy: application to pediatric head and neck masses

Fine-needle aspiration biopsy cytology is widely used to screen masses in adults. The authors present a series of 89 fine-needle aspiration biopsies performed between January 1973 and December 1988 on 86 pediatric patients with clinically significant head and neck masses. All fine-needle aspiration diagnoses were confirmed by subsequent surgical biopsy, autopsy, or clinical follow-up for a minimum of 18 months. Of 21 tumors identified, 19 were malignant. Of the 89 aspirations performed, 67 required no subsequent surgical biopsy. In 11 of these cases, metastatic or recurrent tumor was diagnosed and appropriate therapy instituted. Fifteen of the 89 aspirates revealed previously undiagnosed tumors requiring surgical intervention. One false-negative and two false-positive results were obtained. No radical treatment resulted from the false-positive diagnoses, and no patient delay in treatment occurred because of the false-negative result. The sensitivity was 94.4%, and the specificity was 97.1%. The usefulness and cost-effectiveness of fine-needle aspiration is stressed.     

Critical clinical appraisal of the role of ultrasound guided fine needle aspiration cytology in the management of parotid tumours

OBJECTIVE: Fine needle aspiration cytology is a well established tool for investigating many head and neck conditions. Its application in parotid tumours is, however, controversial. This article is aimed at defining the role of ultrasound guided fine needle aspiration cytology (FNAC) in the diagnostic work up of parotid tumours. The accuracy and utility of FNAC of parotid tumours was also assessed. DESIGN: Retrospective case note review. SETTING: District general hospital. PARTICIPANTS: Review of 69 patient records who had parotid surgery under one surgeon's care (JS). Clinical opinion, FNAC results and final pathology findings were examined. MAIN OUTCOME MEASURES: The results of the FNAC were compared to the histopathological diagnosis obtained from the surgical specimen. RESULTS: Histological evaluation revealed 13 malignant tumours and 56 benign lesions. The overall sensitivity of FNAC was 84.6 per cent and specificity was 96.4 per cent. We noted 11 true positive, 54 true negative, two false negative and two false positive results. Positive predictive value for diagnosing malignancy was 84.6 per cent and negative predictive value for malignancy was 96.4 per cent. The overall accuracy of FNAC of parotids in this study was 94.2 per cent. CONCLUSIONS: FNAC results provide useful preoperative information. FNAC enables more reliable patient counselling and reduces pathological surprises. Pre-operative recognition of malignant tumours may help prepare both the surgeon and patient for an appropriate surgical procedure. Its enhancement of the pre-operative recognition of malignant parotid tumours may alert more stringent attention to the operative margin and hence better tumour clearance. Ultrasound guided FNAC was found to be highly specific for malignancy and its sensitivity for malignancy was good.     

Laryngeal chondrosarcoma diagnosed by core-needle biopsy

We report a case of chondrosarcoma of the larynx, diagnosed by a percutaneous core-needle biopsy (CNB). Cartilaginous tumors of the larynx are usually diagnosed by biopsy with direct laryngomicroscopy under general anesthesia. However, patients find it difficult to undergo a biopsy under general anesthesia, for physical, economic, and social reasons. Instead, we can readily detect and sample tumors of the larynx using ultrasound under local anesthesia with reduced stress. Concerning needle-puncture biopsies, including fine-needle aspiration cytology (FNAC) and CNB, some studies have reported needle track dissemination, a possible complication in patients with malignant tumors. Thus, in the head and neck region, we generally use FNAC for biopsies, not CNB. However, it can be difficult to diagnose bone tumors by cytology alone. Regarding primary bone tumors, only one study has reported needle track dissemination by CNB, in osteosarcoma of the femur. Additionally, this complication has not been reported before with chondrosarcoma anywhere in the body. To our knowledge, this is the first report concerning chondrosarcoma of the larynx diagnosed by percutaneous CNB. We recommend CNB as a useful and safe diagnostic technique for primary bone tumors in the head and neck region.     

Percutaneous Magnetic Resonance Image–Guided Biopsy and Aspiration in the Head and Neck

Objective/Hypothesis To test the hypotheses that 1) magnetic resonance imaging (MRI)–guided biopsy and aspiration with an open 0.2‐T system (Magnetom Open, Siemens, Erlangen, Germany) in the head and neck is feasible and successful and 2) procedure times can be sufficiently short to be well tolerated by the patient. Methods Sixty‐one MRI‐guided procedures were performed in 47 patients (ages, 6 mo–88 y) in the head and neck, including the mucosal sites and masticator and parapharyngeal spaces (n = 23), parotid space (n = 6), submandibular space (n = 2), cervical vertebral column/paraspinal tissues (n = 8), skull base (n = 3), larynx or hypopharynx (n = 3), and infrahyoid nodal chains and surrounding tissues (n = 16). A clinical C‐arm imaging system was used, supplemented by an in‐room radiofrequency–shielded liquid crystal monitor, rapid gradient echo sequences for needle guidance, and MRI‐compatible anesthesia, monitoring, and surgical lighting equipment. Tissue sampling included fine‐needle aspiration (n = 58) and cutting‐needle core biopsy (n = 27), with 24 patients undergoing both procedures. Procedures were evaluated for success of needle placement, procedure time, and complications. Results Successful needle placement was accomplished in all cases without complication, with tissue sufficient for pathological diagnosis obtained for all but five patients with an average of 2.1 passes per patient. For fine‐needle aspiration, average instrument time was 7.8 minutes per pass, and average cutting‐needle core biopsy time was 9.2 minutes. Conclusions Interactive MRI guidance for needle biopsy and aspiration of deep head and neck lesions is feasible, successful, and safe. Procedure times are sufficiently short to be well tolerated by the patient.     

Ultrasonography guided fine needle aspiration cytology in patients with laryngo-hypopharyngeal lesions

IntroductionLaryngeal lesions are usually evaluated by microlaryngoscopy/direct laryngoscopy under anaesthesia for disease mapping and tissue diagnosis. However patients with anticipated airway compromise due to laryngeal mass may require either a protective tracheotomy or emergency tracheotomy to secure the airway. To minimise risk of unplanned tracheotomy and expedite the diagnosis we performed ultrasound-guided transcutaneous fine needle aspiration cytology.ObjectiveTo evaluate the feasibility and performance of ultrasound-guided transcutaneous fine needle aspiration cytology of suspicious/recurrent laryngo-hypopharyngeal masses.MethodsFine needle aspiration cytology was performed under ultrasound guidance. Twenty- four patients were recruited, of which 17 had a pure laryngeal lesion; 6 patients had laryngo-pharyngeal, and one patient had a base tongue lesion with supra-glottis extension.ResultsOut of 24 patients, 21 had positive cytology for squamous cell carcinoma, 2 patients had non-diagnostic cytology (atypical cells) and the other had inadequate tissue for definitive diagnosis. Patients with negative and inconclusive cytology underwent direct laryngoscopy biopsy, which was positive for squamous malignancy. All patients tolerated the procedure well and no adverse events were noted.ConclusionAlthough direct laryngoscopy remains the standard of care in evaluation of laryngo-hypopharyngeal lesions, this pilot study has shown that ultrasound-guided transcutaneous fine needle aspiration cytology was feasible as an out-patient procedure, employing safe and sensitive technique enabling rapid diagnosis and avoiding the need for direct laryngoscopy under GA for tissue diagnosis.     

Cholangiocarcinoma metastatic to the neck: first report of a case

We describe a unique case of a cholangiocarcinoma that metastasized to a cervical lymph node--to our knowledge the only such case ever reported. The diagnosis was based on fine-needle aspiration cytology and confirmed by excision biopsy. This case illustrates the importance of keeping all possible options in mind when diagnosing head and neck masses.     

The role of ultrasound-guided fine-needle aspiration biopsy in the previously treated patient with thyroid cancer

The aim of the present study was to evaluate the effectiveness of ultrasound-guided fine-needle aspiration in detecting locoregional recurrence in previously treated patients with thyroid cancer. A retrospective analysis of ultrasound-guided fine-needle aspiration (FNA) biopsy was carried out for suspected recurrence of thyroid cancer over a 5-year period at a single institution. There were 37 biopsies in 37 patients. Each patient's ultrasound report, cytology report and medical notes were examined to determine the result of the biopsy and the patient's outcome. There were 29 true-positives, 6 true-negatives, 1 false-negative and 1 inadequate biopsy. Ultrasound-guided FNA, therefore, had a sensitivity of 96.7%, specificity of 100% and overall accuracy of 97.2% in detecting recurrence. Ultrasound-guided FNA is an accurate method of identifying suspected recurrence.     

Parotid gland tumours in 255 consecutive patients: Mount Sinai Hospital's quality assurance review

Parotid neoplasms represent a diverse group of tumours found in the head and neck. Complications following parotidectomy, including Frey's syndrome, facial nerve paralysis, sialoceles, and parotid fistulae, have been well documented. A retrospective review of 255 patients treated surgically for parotid masses over an 8-year period at Mount Sinai Hospital in Toronto was reviewed as part of a quality assurance program. The sensitivity, specificity, and predictive values for fine-needle aspiration cytology were analyzed. The incidence of benign and malignant lesions is presented. The complications following parotidectomy are reviewed and in our series are consistent with the figures published in the literature.     

The clinical value of image cytometry DNA analysis in distinguishing branchial cleft cysts from cystic metastases of head and neck cancer

OBJECTIVES/HYPOTHESIS: A branchial cleft cyst presents as a lump in the neck that, generally, is easily cured by surgical excision. The preoperative diagnosis is based on clinical examination and, especially in the Scandinavian countries, fine-needle aspiration cytology. However, at times, the histopathological analysis of the excised cyst reveals a cystic metastasis of squamous cell carcinoma of the head and neck. If adequate diagnosis could be obtained preoperatively, patients would most likely fare better. The study was performed to investigate whether the diagnostic accuracy for these lesions could be improved preoperatively by image cytometry DNA analysis of the fine-needle aspiration cytology specimen. STUDY DESIGN: Image cytometry DNA analysis was performed on the preoperative fine-needle aspiration cytology specimen and the surgical specimens from 51 patients with solitary cysts in the lateral region of the neck. Thirty-six patients were selected because there was a discrepancy between findings on fine-needle aspiration cytology and the final histopathological diagnosis or an uncertain cytological diagnosis. There were 25 metastatic squamous cell carcinomas and 3 thyroid cancers, there was 1 lymphoma and 1 sialoadenitis, and there were 21 branchial cleft cysts. METHODS: The cytodiagnostic Giemsa-stained slides were destained in Methanol and then stained with Schiff's reagent. The paraffin-embedded material from excised cysts were cut and deparaffinized and then stained with Schiff's reagent. Ahrens image analysis was used for DNA analysis and lymphocytes were used as control cells. DNA valves exceeding 5c was regarded as aneuploid. RESULTS: Image cytometry DNA analysis of the preoperative cytological specimen was possible in 41 of 51 patients. We found that in 53% of the cases with cystic metastasis, image cytometry DNA analysis, when possible, revealed aneuploidy, thus indicating malignancy. DNA analysis showed diploidy in all benign cases. CONCLUSIONS: Aneuploidy is highly specific for malignancy. Image cytometry DNA analysis increases the diagnostic sensitivity for malignant cystic metastasis and therefore is a valuable supplement to conventional cytological study for these lesions.     

Fine-needle aspiration biopsy of the thyroid gland: results of a five-year experience and discussion of its clinical limitations

The results of a five-year experience with fine-needle thyroid aspiration cytology are reported to assess the value, accuracy and limitations of this biopsy procedure. The cytologic diagnoses on 1,465 thyroid aspirates are listed, and correlation of cytology with histology on 207 cases undergoing surgery is reported. The incidence of malignancy among the atypical and malignant cytology aspirates with histologic confirmed diagnosis was 65% (28/43) while a false negative rate of 11.5% (15/131) was found. Fine-needle aspiration biopsy is a safe and useful procedure with an acceptable accuracy rate that complements other investigations in the screening of patients for thyroid surgery.     

Management of cervical lymph nodes in patients with head and neck cancer

Summary The status of the cervical lymph nodes is the single most important prognostic factor in head and neck cancer. Unfortunately, clinical assessment of the neck is not very accurate, although newer imaging techniques such as CT, MRI and ultrasound-guided fine needle aspiration cytology can be used to improve upon the results of clinical palpation alone. While diagnostic techniques remain less than 100% accurate, the risk of occult disease in the neck will remain. If this occurrence is judged to be greater than 15–20%, elective treatment to the neck may then be justified. When the neck is treated surgically, histological information can be gained which has both prognostic and therapeutic implications. Indications for the use of surgery and radiotherapy for the elective and therapeutic management of the neck and the results of such treatment are discussed.     

Magnetic resonance navigation for head and neck lesions.

OBJECTIVE: Review applications of interventional magnetic resonance imaging and describe methods, procedures, and additional instrumentation for the magnetic resonance "operating theater." Describe advantages of magnetic resonance navigation for biopsies of head and neck tumors. STUDY DESIGN: Patients with palpable and nonpalpable head and neck and cranial base tumors were recruited into the study. Patients underwent magnetic resonance-guided biopsy. Retrospective analysis of 21 patients was conducted. METHODS: 0.5 Tesla superconducting open magnetic resonance imaging was used for navigation of the biopsy needle. Patient records and magnetic resonance images were reviewed. The type, size, and location of the lesions were tabulated. Type of anesthesia and monitoring method were analyzed. The histopathologic correlation was conducted in patients who required further surgeries or open surgical biopsies. RESULTS: Twenty-two biopsies were carried out in the magnetic resonance suite. One patient required general anesthesia and the other biopsies were conducted under intravenous sedation. There was only one case of nonconcurrence in a patient with Wegener's granulomatosis of the posterior orbit. Overall, a 92% concurrence rate between image-directed fine-needle aspiration, open biopsy, and surgical therapy was encountered. No complications occurred. CONCLUSIONS: The use of interventional magnetic resonance imaging to assist with fine-needle aspiration core biopsy has made the biopsy procedure safer and more accurate. Potentially morbid and disfiguring surgeries have been avoided in some patients. Deeper lesions have been more easily approached, as the needle for biopsy is under constant magnetic resonance guidance. Improved visualization for critical structures allows safer performance of biopsies. The primary difficulties of open magnetic resonance imaging relate to the need for nonferromagnetic instrumentation and equipment and their high costs. An inverse relationship exists between the imaging quality and the "dead time" required to acquire images.     

Interobserver variability in the interpretation of fine-needle aspiration biopsy of head and neck masses

Fine-needle aspiration biopsy is gaining acceptance as a clinically useful tool. We set out to evaluate the accuracy of fine-needle aspiration biopsy at our institution by measuring the interobserver variability in cytopathologic interpretation, and by measuring the agreement between cytopathologic and histologic diagnosis. In a prospective study, 253 aspirations were performed on head and neck masses by the otolaryngology service. Specimens were interpreted independently by two cytopathologists (V.J.S. and P.Z.), and interpretations were compared with the surgical histopathologic diagnosis when available. The interobserver variability between cytopathologists was 8% with a specificity of 96% and a sensitivity of 97%. We conclude that fine-needle aspiration biopsy is a safe and useful tool in the diagnosis of head and neck masses. In the diagnosis of epithelial cysts and squamous epithelial malignancies, fine-needle aspiration biopsy is as accurate as open biopsy.