Image-guided fine-needle aspiration of the head and neck: five years' experience

Paramaxillary CT-guided fine needle aspiration of head and neck lesions: technique, diagnostic yield, and safety profile

Computed tomography (CT)-guided percutaneous biopsy of deep-seated head and neck lesions can be a less invasive and equally effective alternative to surgical techniques. There are multiple approaches for needle biopsy that target varying spaces within the head and neck while successfully avoiding critical anatomy. In the paramaxillary approach, the needle is advanced through the infrazygomatic buccal space, in between the maxilla and mandible. In this study, we examine the safety and diagnostic yield of FNA without core needle biopsy performed via the paramaxillary approach in 19 patients yielding 20 fine needle aspirates between 2014 and 2022. Of the fine needle aspirates, 85.0% (17/20) were diagnostic. Concordant histopathologic diagnosis was obtained in 100% (17/17) diagnostic fine needle aspirates. There were no postprocedural complications.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

Percutaneous CT-Guided Core Needle Biopsies of Head and Neck Masses: Technique, Histopathologic Yield, and Safety at a Single Academic Institution

BACKGROUND AND PURPOSE

CT-guided head and neck biopsies can be challenging due to the anatomy and adjacent critical structures but can often obviate the need for open biopsy. A few studies and review articles have described approaches to biopsy in the head and neck. This retrospective study evaluated technical considerations, histopathologic yield, and safety in CT-guided head and neck core needle biopsies.

MATERIALS AND METHODS

A retrospective review of head and neck biopsies performed from January 2013 through December 2019 was conducted. Clinical diagnosis and indication, patient demographics, mass location and size, biopsy needle type, technical approach, dose-length product, sedation details, complications, diagnostic histopathologic yield, and the use of iodinated contrast were recorded for each case.

RESULTS

A total of 27 CT-guided head and neck core needle biopsies were performed in 26 patients. The diagnostic sample rate was 100% (27/27). A concordant histopathologic diagnosis was obtained in 93% (25/27) of cases. There was a single complication of core needle biopsy, a small asymptomatic superficial hematoma.

CONCLUSIONS

Percutaneous CT-guided biopsy of deep masses in the head and neck is safe and effective with careful biopsy planning and has a high diagnostic yield that can obviate the need for open biopsy.

Techniques and Approaches for Safe, High-Yield CT-Guided Suprahyoid Head and Neck Biopsies

OBJECTIVE

The purpose of this article is to present imaging approaches and key technical, safety, and patient care best practices critical for safe, successful image-guided biopsy of head and neck masses.

CONCLUSION

Image-guided sampling is an important adjunct to the diagnosis and management of head and neck masses and may be particularly useful when lesions are not accessible via an endoscope or by palpation-guided sampling. Appropriate workup is mandatory before the patient is scheduled for such a procedure. Once the procedure has been initiated, needle selection and technique are critical for increasing the diagnostic yield. Knowledge of the various head and neck biopsy approaches and their associated complications is important for optimal tissue sampling and minimization of morbidity.

Verification bias in diagnostic accuracy studies for fine- and core needle biopsy of salivary gland lesions in otolaryngology journals: a systematic review and analysis

BACKGROUND

Diagnostic test accuracy (DTA) studies for needle biopsy are frequently published in otolaryngology journals, but this body of literature has not been assessed for verification bias.

METHODS

We conducted a systematic review of DTA studies on needle biopsy of salivary gland lesions appearing in otolaryngology journals. Studies were assessed by 2 reviewers for verification bias.

RESULTS

We identified 95 DTA studies for needle biopsy of salivary gland lesions. Eighty-one studies (84%) had verification bias. Five of the biased studies provided sufficient data to estimate the extent of bias. Verification bias was associated with an overestimate of sensitivity and an underestimate of specificity. Studies on core needle biopsy (CNB) had a lower rate of verification bias than fine-needle aspiration (FNA) studies.

CONCLUSION

Verification bias is common in DTA studies of needle biopsy for salivary gland lesions published in ear, nose, and throat (ENT) journals. Such studies overestimated sensitivity and underestimated specificity.

Retropharyngeal and prevertebral spaces: anatomic imaging and diagnosis

Cross-sectional imaging plays an important role in the evaluation of the retropharyngeal space (RPS) and the prevertebral space (PVS). Because of their deep location within the neck, lesions arising within these spaces are difficult, if not impossible, to evaluate on clinical examination. This article details the cross-sectional anatomy and imaging appearances of primary and secondary diseases involving the RPS and PVS, including metastasis and spread from adjacent spaces. The role of image-guided biopsy is also discussed.

Early recurrence or submucosal residual of laryngeal squamous cell carcinoma: diagnosis by CT-guided endolaryngeal core biopsy on a transcutaneous approach

BACKGROUND

Ultrasound and CT-guided biopsy is a common procedure for histologic diagnosis of recurrence of head and neck squamous cell carcinoma. The present study describes a novel CT-guided endolaryngeal puncture site.

METHODS AND RESULTS

A 59-year-old man was treated for a T2N0M0 supraglottic laryngeal tumor by laser resection and bilateral lymph node dissection; exeresis was judged complete. Six-month follow-up found persistent dysphonia. Endoscopic examination and iterative biopsy gave reassuring results, but (18) fluorodeoxyglucose positron emission tomography-CT ((18) FDG PET-CT) found highly suspicious increased right hemilaryngeal metabolic activity. Diagnosis of residual tumor was confirmed on CT-guided endolaryngeal biopsy.

CONCLUSIONS

Image-guided biopsy is the technique of choice in head and neck lesions that are deep or difficult to palpate and inaccessible to endoscopy. It is especially useful when recurrence is suspected after radiation therapy or cancer surgery. Many puncture sites have been reported in the literature; the present novel laryngeal approach extends the range of image-guided biopsy, although further studies will be needed to assess possible morbidity.

MRI-guided biopsy and aspiration in the head and neck: evaluation of 77 patients

OBJECTIVES

To evaluate the efficacy and safety of MRI-guided percutaneous biopsy procedures of head and neck lesions using 0.23T open MRI with optical tracking.

METHODS

A retrospective analysis of 77 patients (51 male, 26 female; mean age, 43 years; range, 11-88 years) who underwent MRI-guided percutaneous biopsy of a head and neck lesion was performed. Mean lesion diameter was 3 cm (range, 1-7.8 cm). Rapid gradient echo sequences were used for image guidance. 23/77 lesions were biopsied after intravenous gadolinium. Tissue sampling techniques included needle aspiration (n = 19) and core needle biopsy (n = 58). Outcome variables included technical success, diagnostic accuracy, procedure time and complications.

RESULTS

In all patients, a sufficient amount of tissue for pathological analysis was obtained. Pathological analysis diagnosed 41 malignant lesions and 36 benign lesions. In 42 cases, surgical correlation was available. In 35 cases, the final diagnosis was confirmed by imaging and clinical follow-up. MR-guided biopsy had a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 93.2%, 100%, 100%, 91.7%, and 96%, respectively. Procedure time was 29 min (range, 15-47 min). No major complications occurred.

CONCLUSIONS

MRI-guided biopsy of head and neck lesions has a high diagnostic performance and is safe in clinical practice.

KEY POINTS

• MRI-guided biopsy helps clinicians to assess patients with head&neck masses. • Differention of malignant and benign lesions is possible with 96% accuracy. • The safety profile of MRI-guided biopsy of head&neck lesions is favorable. • MRI guidance enables accurate biopsy without the use of ionizing radiation.

Dynamic susceptibility contrast perfusion MR imaging in distinguishing malignant from benign head and neck tumors: a pilot study

PURPOSE

To preliminarily investigate the utility of dynamic susceptibility contrast perfusion MR imaging in distinguishing malignant from benign head and neck tumors.

MATERIAL AND METHODS

Seventy eight patients with head and neck masses underwent single shot dynamic susceptibility contrast T2*-weighted perfusion weighted MR imaging after bolus infusion of gadolinium-DTPA was administrated. The signal intensity time curve of the lesion was created. Dynamic susceptibility contrast percentage (DSC%) was calculated and correlated with pathological findings.

RESULTS

The mean DSC% of malignant tumor (n=40) was 39.3±9.6% and of benign lesions (n=38) was 24.3±10.3%. There was a statistically significant difference of the DSC% between benign and malignant tumors (P=0.001) and within benign tumors (P=0.001). When DSC% of 30.7% was used as a threshold for differentiating malignant from benign tumors, the best results were obtained: accuracy of 84.6%, sensitivity of 80% and specificity of 89.2%.

CONCLUSION

Dynamic susceptibility contrast perfusion weighted MR imaging is a non-invasive imaging technique that can play a role in differentiation between malignant and benign head and neck tumors.

Approaches for percutaneous needle placement for various head and neck procedures

Use of image-guidance allows safe and precise percutaneous placement of needles for various diagnostic and therapeutic procedures in the head and neck region. This review describes the anatomy relevant to safe-access route planning and the techniques, advantages, and limitations associated with various approaches used for percutaneous needle placement in different head and neck regions. Subzygomatic, retromandibular, paramaxillary, submastoid, transoral, and posterior approaches can be used for percutaneous access in the suprahyoid head and neck region, including skull base and upper cervical vertebrae. In the infrahyoid portion of the neck and for lower cervical vertebrae, access can be achieved via the anterolateral (between the airways and the carotid sheath), posterolateral (posterior to the carotid sheath), and direct posterior approaches.

Perk Station--Percutaneous surgery training and performance measurement platform

MOTIVATION

Image-guided percutaneous (through the skin) needle-based surgery has become part of routine clinical practice in performing procedures such as biopsies, injections and therapeutic implants. A novice physician typically performs needle interventions under the supervision of a senior physician; a slow and inherently subjective training process that lacks objective, quantitative assessment of the surgical skill and performance. Shortening the learning curve and increasing procedural consistency are important factors in assuring high-quality medical care.

METHODS

This paper describes a laboratory validation system, called Perk Station, for standardized training and performance measurement under different assistance techniques for needle-based surgical guidance systems. The initial goal of the Perk Station is to assess and compare different techniques: 2D image overlay, biplane laser guide, laser protractor and conventional freehand. The main focus of this manuscript is the planning and guidance software system developed on the 3D Slicer platform, a free, open source software package designed for visualization and analysis of medical image data.

RESULTS

The prototype Perk Station has been successfully developed, the associated needle insertion phantoms were built, and the graphical user interface was fully implemented. The system was inaugurated in undergraduate teaching and a wide array of outreach activities. Initial results, experiences, ongoing activities and future plans are reported.

Neck masses: evaluation and diagnostic approach

Oral and maxillofacial surgeons frequently deal with patients who present with an unknown neck mass. Formulation of a differential diagnosis is essential and requires that the surgeon bring to bear a host of skills to systematically arrive at a definitive diagnosis and ensure that the correct treatment is rendered. This article highlights some of the skills needed in the workup of neck masses and reviews some of the available techniques that aid in achieving the correct diagnosis.

[Parapharyngeal tumors: diagnosis and treatment]

OBJECTIVES

Parapharyngeal space tumors are rare and usually benign. Their treatment is surgical and many approaches have been described. We report our experience in managing these neoplasms. Two points are developed more fully: the correlation between imaging and surgical observation and the reliability of the cervical approach.

MATERIAL AND METHODS

A retrospective review of primary parapharyngeal space tumors treated at the Rennes University Hospital between 1992 and 2004 is presented. Nine patients were included, all treated surgically with a cervical approach without parotidectomy.

RESULTS

Eight MR imaging and seven CT scans were done. Two retrostyloid tumors and six prestyloid tumors, all independent of the deep lobe of the parotid gland, were found. They were benign in all cases (five salivary tumors and four schwannomas). Two patients treated for a pleomorphic adenoma presented recurrence and were reoperated successfully. The average follow-up was 66 months. None of the patients died. Definitive postoperative complications occurred only for neurogenic tumors.

CONCLUSION

The cervical approach is safe and allows the surgical excision of retrostyloid and prestyloid tumors, independent of the deep lobe of the parotid gland. Large tumor (8cm in our study) excision can be done with few complications. An attentive study of preoperative imaging is necessary to choose the best surgical approach.

18-FDG PET in the diagnosis of laterocervical metastases from occult carcinoma

The management of patients with cervical node metastasis (CNM) from carcinoma of unknown primary (CUP) often includes several radiographic studies and invasive procedures that are only successful in detecting an occult primary tumour in less than 25% of the cases. In this prospective study we have assessed the role of total body positron emission tomography (PET) using an 18-F-fluorodesoxyglucose (FDG) in the detection of primary tumours in patients with metastases from CUP. Thirteen patients with lymph node metastases from cytologically verified CUP have undergone total body FDG PET which confirmed the possibility of lymph nodal lesion; all patients have also undergone conventional imaging with CT and/or MRI. The data obtained with the FDG-PET method have subsequently been confirmed both by the histopathological examination and by the clinical course of the disease. The current work aims at assessing and defining the effectiveness of the FDG-PET method during the diagnostic work-up of laterocervical metastasis from CUP conventionally examined with CT and/or MRI; based on our results, we recommend a flow-chart for the clinical-diagnostic management of the patient affected by laterocervical metastasis in the absence of known primary.

Clinical utility of fine-needle aspiration for diagnosis of head and neck lymphoma

BACKGROUND

Although fine-needle aspiration (FNA) is currently used for the diagnosis of lymphoma, its diagnostic utility in patients with head and neck (HN) lymphoma is unclear. We therefore assessed the utility of initial clinical and FNA diagnoses for HN lymphoma in a clinician's perspective.

METHODS

We conducted a retrospective study of total 109 patients with HN lymphoma underwent both FNA and tissue diagnoses from January 2000 through December 2005. The diagnostic sensitivity of FNA was compared with that of histopathology. FNA diagnosis was based on cytomorphology alone in 69 patients and on immunophenotyping plus morphology in 40.

RESULTS

On clinical diagnosis, lymphoma was suspected in 54 patients, nonlymphoma/metastatic malignancy in 31, and benign disease in 24. FNA diagnosed lymphoma in 41 patients; suspicious of lymphoma in 23; atypical lymphoma in 20; benign disease in 19; and was nondiagnostic in 6 patients. Diagnostic accuracy of FNA was not significantly improved by repeat core needle biopsy and immunophenotyping. Delay from FNA to tissue diagnosis was significant in the benign FNA-diagnostic group, with a mean 49 days.

CONCLUSIONS

The clinical and FNA diagnoses of HN lymphoma may be incomplete and include the potential pitfall of significant diagnostic delay.

Percutaneous Biopsy of Head and Neck Lesions with CT Guidance: Various Approaches and Relevant Anatomic and Technical Considerations

Deep-seated head and neck lesions, which traditionally were evaluated by surgical means, are now accessible with less invasive computed tomography-guided percutaneous needle biopsy techniques. Major vessels, the trachea, and osseous structures like the maxilla, mandible, and vertebrae often preclude direct access to these lesions. It is important to understand the anatomy relevant to safe access route planning and the techniques, advantages, and limitations associated with various approaches used for percutaneous biopsy of head and neck lesions. For biopsy of suprahyoid head and neck lesions, including those of the skull base and upper cervical vertebrae, various approaches such as the subzygomatic, retromandibular, paramaxillary, submastoid, transoral, and posterior approaches can be used. Lesions in the infrahyoid portion of the neck and lower cervical vertebrae can be accessed with the anterolateral approach (between the airways and the carotid sheath), posterolateral approach (posterior to the carotid sheath), and direct posterior approach. The location and extent of the lesions and their relationship to adjacent structures influence the choice of the trajectory to use. Careful planning of the procedure and considerable familiarity with head and neck anatomy are necessary for a biopsy that is both precise and safe.

Cystic metastasis from head and neck squamous cell cancer: a distinct disease variant?

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) commonly spreads to regional deep cervical nodes. In most cases, these metastases present as firm, solid masses in the designated lymph node chains. A distinct subset of metastatic nodes present as cystic masses, with most of the volume made up of a liquid center surrounded by a thin solid rim. It has been observed that certain squamous cell carcinoma (SCC) subsites are more likely to produce metastases that are cystic. These sites predominantly include primary tumors of tonsil tissue from Waldeyer's ring. In the past, these cystic cancers often have been erroneously diagnosed as branchiogenic carcinomas, that is, a branchial cleft cyst that has undergone malignant degeneration. Today, most authors have concluded that so-called branchiogenic carcinomas are actually cystic metastases in the neck probably arising from an oropharyngeal primary SCC. The purpose of this work is to consider the phenomenon of cystic lymph node metastasis in head and neck cancer in depth.

METHODS

A review of the relevant English-language literature linking cystic metastasis and head and neck cancer was performed.

RESULTS

These studies indicate that lateral cystic masses in adults often represent an occult primary cancer originating in the epithelium within Waldeyer's ring.

CONCLUSIONS

Adult patients who are initially seen with a lateral cystic neck mass must be presumed to have a cancer until proven otherwise. The mass should be biopsied by fine-needle aspiration (FNA). However, negative FNA findings may be misleading; therefore, an excisional biopsy and examination under anesthesia with directed biopsies of Waldeyer's ring and bilateral tonsillectomy should be considered a part of the diagnostic workup.

Fine needle aspiration: a novel application in laryngology

Fine needle aspiration (FNA) has had an early start in medicine and has been heavily used in the United States since the 1980s. It is regarded as a highly effective means to sample mass lesions, serving as the first diagnostic procedure in many instances. FNA is safe, less invasive than biopsy, and reduces the risk of scar formation. Its main limitations can be overcome through effective training and practiced technique. In laryngology, the development of new and diversified therapeutic and diagnostic strategies depends on the development of equally appropriate diagnostic tools. FNA has the potential to be a relatively easy procedure that can be performed under local anesthesia, increasing the otolaryngologist's armamentarium. Combining the FNA procedure with technology now available, secondary to advances in genomic science, rather than cytology and H&E stains, provides the means of obtaining clinically useful information about benign and malignant disease for clinicians and researchers. This paper provides a review of the traditional FNA procedure. It offers an introduction to the future applicability of FNA to office-based laryngology. Lastly, this paper familiarizes the reader with the genomic principles being used for this procedure.

Preoperative cytology in the management of parotid neoplasms

BACKGROUND

This study evaluates the diagnostic role of preoperative cytology of parotid neoplasms. The method is particularly useful in the evaluation of the parotid diseases in which the same clinical features may be treated variously. Fine-needle aspiration biopsy is a simple and well-tolerated diagnostic tool, which provides accurate information for diagnosis and follow-up of the disease. The accuracy of the method partly depends on the operator skill.

MATERIALS AND METHODS

From a series of 452 subjects who underwent parotidectomy, preoperative cytological evaluation was available in 310 and compared with histological diagnosis in a retrospective review.

RESULTS

The agreement between histotype determination using fine-needle aspiration biopsy and final histological diagnosis was 79%, specificity was 100%, sensitivity was 83%, and diagnostic accuracy was 97%.

CONCLUSION

These findings demonstrated that, given the low complication rate, preoperative cytology is particularly useful in diagnosing parotid disease and in planning the surgical strategy and approach.

Validation of ultrasonography to evaluate murine orthotopic oral cavity tumors

BACKGROUND

The murine orthotopic oral cavity tumor model allows evaluation of tumor growth and invasion. Currently, serial measurements of tissue growth are difficult to obtain since invasive procedures or animal sacrifice is necessary to evaluate tumor size. High-resolution ultrasound was evaluated as a noninvasive method to monitor tumor size in vivo.

METHODS

Sixteen immunodeficient mice, age 9 weeks, were injected transcervically with a human squamous cell carcinoma cell line into the tongue, and tumor volume was assessed by high-frequency ultrasound at 11 days. The animals were subsequently sacrificed and the tumors processed for histology. Tumor size was then calculated by caliper measurement in two dimensions.

RESULTS

Tumor dimensions obtained using ultrasound were found to significantly correlate with the histologic measurements (Spearman coefficient 0.90, p < 0.0001). Tumor dimensions were on average larger using ultrasound versus histologic measurements, although this was not significantly different than zero (95% confidence interval -13.96 to 62.37 mm2).

CONCLUSIONS

High-resolution ultrasound accurately measures tumor volume in the murine orthotopic oral cavity tumor model without sacrifice.

Fine-needle aspiration cytology in the diagnosis of superficial lymphadenopathy: a 5-year Brazilian experience

To determine the accuracy of fine-needle aspiration (FNA) in the diagnostic assessment of lymphadenopathies, a retrospective study was conducted on 627 cases of FNA of the lymph nodes performed at Department of Pathology, UNIFESP (Federal University of São Paulo), between 1997 and 2001. Cytology results were compared to the results of biopsies if available. The cytological diagnosis was unsatisfactory in 14.7% of cases, positive in 46%, and negative in 39.3%. Among the positive cases, 79.4% were classified as metastases, 14.2% as lymphoma, and 6.4% as indeterminate. Anatomopathological exams for the determination of cytohistological correlation were available in 218 of the 627 cases. There were three (1.88%) false-negative and two (1.25%) false-positive cases. Accuracy tests revealed 97.41% sensitivity, 95.45% specificity, and 96.88% efficacy, with cytohistological agreement being almost perfect (kappa = 0.92). The high accuracy of this study based only on cytomorphological criteria associated to the variety of malignant neoplasias diagnosed by the procedure demonstrates its relevance on patient care, especially in areas of limited financial resources.

Cytopathologic analysis of paraspinal masses: a study of 59 cases with clinicoradiologic correlation

Paraspinal masses (PSM) are uncommon and present a wide spectrum of differential diagnoses on fine-needle aspiration (FNA). We analyzed 59 cases of PSM on FNA in a 15-yr period, in the context of clinicoradiologic correlation. Radiologic findings, clinical data, and tissue biopsies were reviewed. Patients were 14-83 yr of age (mean 54.7) with a M:F ratio of 1.36:1. Of the 59 cases, 39 (66%) were deemed diagnostic. Of these, 8 (21%) revealed nonneoplastic lesions and 31 (79%) yielded neoplasms: 2 (6%) benign and 29 (94%) malignant. Of the malignant cases, 22 (76%) were metastatic tumors from various sites, while 7 (24%) were cancers from local spread, which included non-Hodgkin's lymphoma (NHL, 5) and myeloma (2). Benign neoplasms were nerve sheath tumors. Metastatic tumors consisted of adenocarcinoma, 9; squamous-cell carcinoma, 3; renal-cell carcinoma, 1; and non-small-cell carcinoma/not otherwise specified (NOS), 9. Twenty-four (41%) cases received further studies: immunoperoxidase (IPOX) alone, 17 (71%); special stains for microorganisms, 2 (8%); IPOX/other special stains, 4 (17%); and flow cytometry analysis, 1 (4%). Eight (14%) cases received follow-up biopsies. Half of these biopsies added information to previously "nondiagnostic" FNAs. Of the previously "diagnostic" FNAs, tissue biopsy yielded no additional information. Cytopathologic diagnoses were consistent with the pre-FNA radiology analyses in 13 (39%) cases. In instances of radiologic and cytopathologic discrepancy (4 cases, 12%), diagnoses made by FNA reversed the initial radiologic impression of neoplasm to infection, and vice versa. PSMs are rare lesions (0.26% of total FNAs done in 15 yr at our institution). The most common lesion encountered is metastatic adenocarcinoma, followed by NHL. Ancillary studies are helpful in difficult cases. In cases of radiologic/cytopathologic discrepancy, FNA diagnoses are more accurate and decisive for patient management. The sensitivity and specificity of a PSM FNA are 88% and 75% respectively.

Percutaneous Biopsy from Blinded to MR Guided: An Update on Current Techniques and Applications

The advent of interventional MR imaging techniques as well as their adoption to guide percutaneous biopsies and aspirations has served as a further step along a series of technical refinements that commenced with the implementation of image-guided approaches for tissue sampling. Nowadays, the practice of and the expectations from these procedures are quite different from those of the blind percutaneous thrusts performed in the late nineteenth and early twentieth centuries. As the field of interventional MR imaging continues to flourish and to attract more radiologists who realize the many opportunities that this technology can offer to their patients, there is a need for a full comprehension of the concepts, techniques, limitations, and cost-effectiveness of MR imaging guidance to present this service to clinical partners in the appropriate setting. Radiologists should also recognize the need for their significant involvement in the technical aspects of MR-guided procedures, because several user-defined parameters and trajectory decisions can alter device visualization in the MR imaging environment and hence affect procedure safety.

Diagnostic Accuracy of Palpation-Guided and Image-Guided Fine-Needle Aspiration Biopsy of the Thyroid

We conducted a retrospective study to compare the sensitivity and specificity of traditional palpation-guided fine-needle aspiration biopsy (FNAB) performed by clinicians and pathologists with that of image-guided FNAB performed by radiologists for the evaluation of thyroid nodules. We reviewed the medical records of 89 patients who had undergone thyroid FNAB and subsequent surgical excision and pathology. Of this group, 58 patients had undergone palpation-guided FNAB performed by a clinician, 20 had undergone palpation-guided FNAB performed by a pathologist, and 11 had undergone image-guided FNAB performed by a radiologist. The sensitivity of the three techniques was 86, 100, and 100%, respectively, and the specificity was 78, 94, and 44%; there were no statistically significant differences in sensitivity or specificity among the three groups. Our data indicate that FNAB of the thyroid can be performed with equal reliability by clinicians, pathologists, and radiologists.

Interventional neuroradiology of the head and neck

Vascular interventions are important and helpful for treatment of various pathologies of the head and neck. Interventional neuroradiology of the head and neck includes image-guided biopsies, vessel occlusion, and local chemotherapy. Knowledge of anatomy, functional relationships between intra- and extracranial vessels, and pathology are the basis for therapeutic success. The interventional neuroradiologist is responsible for appropriate selection of patients based on clinical information, indications, and risk assessment. Neuroradiologic imaging, especially CT and MR imaging, and appropriate analysis of angiographic findings help ensure indication for treatment and plan an intervention. Technical equipment, including an angiographic unit, catheters, needles, embolizing materials, and so forth, are important. Knowledge of hemodynamics is relevant to avoid complications and to find the optimal technique for solving the clinical problem. Indications for image-guided biopsies are preverterbal fluid-collections, spinal and paraspinal inflammations and abscesses, deep cervical malignancies, vertebral body, and skull base tumors. Special care should be taken to preserve critical structures in this region, including spinal nerve roots, cervical plexus, main peripheral nerves, and vessels. Indications for vessel occlusion are emergency situations to stop bleeding in vascular lesions (traumatic, malformation, or tumors) by reduction of pressure, preoperative reduction of blood flow to minimize the surgical risk, palliative occlusion of feeding vessels to produce tumor necrosis, or potential curative (or presurgical) occlusion of vascular malformations. Pressure reduction to support normal coagulation, such as epistaxis, in hereditary hemorrhagic telangiectasia can be achieved by proximal vessel occlusion with large particles or platinum coils. Prevention of intraoperative bleeding requires occlusion of the microvascular bed with small particles. Examples of these interventions are: a hemangioma of the hard palate, a juvenile angiofibroma, a hemangiopericytoma, a malignant meningioma, a malignant fibrous histiocytoma, and a glomus tumor. Effective treatment of vascular malformations, such as AV fistulas or angiomas, needs exact occlusion of the fistula or the angiomatous nidus, which is demonstrated in the case of an AV angioma of the base of the tongue. Chemotherapy with local intra-arterial cisplatin combined with intravenous administration of sodium thiosulfate as antidote is indicated as an adjuvant modality in a multimodal regimen of oropharyngeal squamous cell carcinoma or as palliative treatment of recurrent and otherwise untreatable malignant tumors of the head and neck. Examples are a carcinoma of the alveolar ridge, a squamous cell carcinoma of the floor of the mouth, and a nasopharyngeal lymphoepithelioma. Palliative treatment of a bleeding oropharyngeal cancer is another example of interventional treatment. Selective treatment, either occluding or pharmacologic, may be preoperative, palliative, or curative. The objective is reduction of surgical risk, improvement of quality of life, or curative therapy of a lesion. Thus, the interventional treatment should not be associated with morbidity or mortality. Major complications, such as cerebral stroke, blindness, or cranial nerve palsies, can result from application of inappropriate techniques or poor evaluation of angiographic findings and should be avoided in the majority of cases. Sometimes collateral lesions are unavoidable. These include inflammation, necrosis, and nerve damage. Based on neuroradiologic experience, most of those risks are predictable. The benefits, risks, and expected damages of neuroradiologic interventions must be balanced during the informed consent procedure with the patient. Avoiding complications, handling unavoidable problems, and dealing with complications is a skill founded on knowledge and experience. Continuing education is a firm basis to push the limits of interventions and expand benefits without increasing risk for the patient. Nevertheless, state-of-the-art external carotid intervention should, in skilled hands, have a permanent morbidity far below 1% and no mortality.

The rate of false-positive results with EUS-guided fine-needle aspiration

BACKGROUND

The aims of this study were to determine the rate of false-positive diagnosis with EUS-guided fine-needle aspiration and to identify factors contributing to this type of error.

METHODS

The records of 577 patients undergoing EUS-guided fine-needle aspiration were reviewed and a subset of 188 patients with malignant cytology who underwent surgery was identified. Operative histopathology was compared with EUS-guided fine-needle aspiration cytopathology and false-positive cases were identified. An experienced cytopathologist, who was not involved with the original interpretation of the specimens, reviewed these cases to identify any factor(s) contributing to the errors.

RESULTS

Three cases of false-positive diagnosis were identified (1.6%; 95% CI [0.3%, 4.6%]). By aspiration site, the false-positive rates were as follows: pancreas 2/39 (5.1%), 95% CI [0.6%, 17.3%]; lymph nodes 1/136 (0.7%), 95% CI [0.02%, 4.0%]; and other sites 0/13, 95% CI [0.0%, 24.7%]. In both instances of a false-positive diagnosis for a pancreatic aspiration cytologic specimen, interpretative errors were identified. The false-positive interpretation of cytologic material aspirated from a lymph node occurred in a patient without any evidence for malignancy at surgery. In 111 patients with confirmed esophageal, gastric, or rectal malignancy undergoing EUS-guided fine-needle aspiration of nonperitumoral lymph nodes, there was no false-positive diagnosis, suggesting that specimen contamination by luminal tumor is rare.

CONCLUSION

The overall rate of false-positive diagnosis for EUS-guided fine-needle aspiration is similar to that reported for other modalities. Most false-positive diagnoses are caused by interpretation errors.

Management and outcome of cervical lymph node metastases of unknown primary sites: a retrospective study

Analysis of the case records of 114 patients with cervical lymph node metastases from unknown primary sites showed that management should be adapted according to the site of nodal disease and the histopathology. Poorly differentiated carcinoma was best treated with radiotherapy, squamous cell carcinoma with radiotherapy and excision, and non-papillary adenocarcinoma by radical thyroidectomy and neck dissection. The 5-year survival for each regimen alone, was 15/40 (38%), 7/13 (54%) and 5/8 (63%), respectively. For metastatic masses in the supraclavicular region, chemotherapy was the preferred treatment. The overall survival for the 107 patients who completed the follow up was 36%.

Utility of cytomorphologic criteria and p53 immunolocalization in distinguishing benign from malignant cystic squamous-lined lesions of the neck on fine-needle aspiration

Fine-needle aspiration can effectively distinguish between benign and malignant cystic lesions of the head and neck. However, in some instances it may be difficult to arrive at a definite diagnosis due to limited cellularity, reactive changes, and cellular degeneration. In this study we examined the usefulness of six cytomorphologic features including the presence or prevalence of nuclear atypia, anucleated cells, tissue fragments, necrosis, and background inflammation in distinguishing between benign and malignant cystic lesions of the head and neck. The case cohort comprised 14 benign and 22 malignant cases. P53 immunostain was performed in 19 cases. These features were semiquantitatively measured on a sliding scale of 0-4 in both air-dried Diff-Quik-stained, alcohol-fixed Papanicolaou-stained smears and Millipore filter preparations. Mean and standard errors were calculated and statistical significance was evaluated by unpaired t-test (StatView). Increased number of tissue fragments (P < 0.001), greater degree of nuclear atypia (P < 0.001), and background necrosis (P < 0.001) were more frequent in cystically degenerating squamous carcinoma as compared to benign squamous cystic lesions. No significant differences were noted in the number of single cells, anucleated cells, or in the amount of background inflammation found in aspirates of benign vs. malignant cystic squamous lesions. A higher percentage of the malignant cystic squamous lesions FNA cases demonstrated p53 immunolocalization but this difference was not statistically significant. Application of the above-mentioned cytomorphologic criteria and the use of p53 immunostain could effectively distinguish between benign and malignant cystic lesions of the head and neck.

Magnetic resonance imaging--guided fine-needle aspiration biopsies of retropharyngeal lesions

OBJECTIVE

The retropharyngeal space is a deep neck space susceptible to a host of disease processes. Surgical access to this space is technically difficult and associated with potential morbidity. An image-guided fine-needle aspiration (FNA) biopsy, if proven accurate and safe, would be of great benefit as an alternative diagnostic approach to this space. This study reports on the use of magnetic resonance imaging (MRI)--guided FNA for diagnostic evaluation of retropharyngeal lesions. Technical details of needle systems, approach to this space, and reliability of this method are described.

STUDY DESIGN

This is a prospective study of 14 patients with retropharyngeal lesions who underwent MRI-guided FNA biopsy at the University of California at Los Angeles Center for the Health Sciences between October 1989 and October 1998.

METHODS

A 0.2-tesla open magnet was used to obtain magnetic resonance images of each retropharyngeal lesion. After standard skin preparation a coaxial needle system was used to reach and sample the lesion. In most instances, the specimen was immediately stained and examined by a cytopathologist for adequacy before removing the patient from the scanner.

RESULTS

Eleven of 14 (78%) patients had diagnostic aspirations; only 2 of these 11 patients required additional surgical biopsy for more specific histological characterization of their lesions before definitive treatment recommendations were given. All aspiration procedures were well tolerated and without any complications.

CONCLUSION

We have demonstrated that MRI-guided approach to the retropharynx is feasible, safe, and sensitive enough to obviate the need for open biopsies in a large percentage of patients.

Fabrication and characterization of controlled release poly(D,L-lactide-co-glycolide) millirods

A compression-heat molding procedure was developed to fabricate poly(D,L-lactide-co-glycolide) (PLGA) controlled release drug delivery devices for the local treatment of tumors. The drug delivery devices were designed in the shape of a cylindrical millirod (1.6-mm diameter, 10-mm length), which allows them to be implanted by a modified 14-gauge tissue biopsy needle into tumor tissues via image-guided interventional procedures. In this study, the prototype trypan blue-containing PLGA millirods were fabricated under a compression pressure of 4.6 x 10(6) Pa and different fabrication temperatures for 2 h. The scanning electron microscopy results showed complete polymer annealing for millirods fabricated at 80 and 90 degrees C, while the cross sections of the 60 and 70 degrees C millirods showed incompletely annealed PLGA microspheres and trypan blue powders. The density, flexural modulus, and release properties of the PLGA millirods were also characterized and compared. The average values of the density and flexural modulus of the millirods increased with an increase in fabrication temperature. The flexural modulus values of most PLGA millirods were above 1 x 10(8) Pa, which provides sufficient stiffness for implantation within the tumor tissue. In addition, a Delta c(p) method was developed to determine the loading density of trypan blue in the PLGA millirods by differential scanning calorimetry. Results from the Delta c(p) measurement showed that trypan blue was homogeneously distributed in the millirod. Release studies in phosphate-buffered saline showed that the release rate decreased for the millirods fabricated at higher temperatures. The times for the release of 50% trypan blue were 5, 25, 25, and 25 h for millirods fabricated at 60, 70, 80, and 90 degrees C, respectively. Millirods fabricated at 90 degrees C had the most reproducible release profiles. The results from this study established compression--heat molding as an effective method to fabricate controlled release PLGA millirods with sufficient mechanical strength and reproducible release profiles for local cancer therapy.

Management of a lump in the neck

This article reviews the management of adults who present with a neck lump, and discusses the potential causes and relevant investigations. The review emphasizes the avoidance of open biopsy and need for early referral to the appropriate specialist.

Major salivary gland imaging

The algorithm for imaging the salivary glands depends on the clinical scenario with which the patient presents to the clinician. Because of the importance of identifying small calculi in the gland or salivary duct as the cause of the symptom complex, nonenhanced computed tomography is often the best initial study for the evaluation of the painful gland. If an infiltrative neoplasm is highly suspected, nonenhanced and enhanced magnetic resonance (MR) imaging may be superior in demonstrating perineural, meningeal, and skull base invasion. Sialography is reserved for the evaluation of chronic sialadenitides unrelated to sialolithiasis. Thin-section MR techniques for MR sialography may soon replace conventional sialography.

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.

The false-positive parathyroid sestamibi: a real or perceived problem and a case for radioguided parathyroidectomy

OBJECTIVE

To demonstrate that the positive parathyroid sestamibi scan, if correctly interpreted and applied, truly represents a parathyroid adenoma, never a "false-positive" scan.

SUMMARY BACKGROUND DATA

Although the sestamibi scan is widely ordered preoperatively to locate parathyroid adenomas, concern about a false-positive scan often causes surgeons to distrust the results. Tissues such as thyroid adenomas and lymph nodes have been blamed for false-positive studies, but the radioactivity of these presumed false-positive tissues has never been measured.

METHODS

Over an 1 8-month period, 17 patients were referred for persistent primary hyperparathyroidism after undergoing at least one neck exploration. All patients had a sestamibi scan prior to their initial operation that was interpreted as clearly positive and then, during or after an unsuccessful operation, deemed false-positive by the surgeon. At the authors' institution, all patients underwent repeat sestamibi scintigraphy and were taken to the operating room while radioactive for a minimally invasive radioguided parathyroidectomy (MIRP).

RESULTS

The authors' sestamibi scans demonstrated the same single focus of radioactivity displayed on the outside scans, clearly positive. During MIRP, an adenoma was successfully located and removed in all patients, with confirmation of the diagnosis by quantitative differential radioactivity and subsequent histologic examination. Removal of the radioactive tissue cured all patients.

CONCLUSION

Intraoperative nuclear mapping permitted identification and removal of parathyroid adenomas in all patients with positive sestamibi scans that had previously been labelled false-positive, indicating that each patient would have been cured during their previous operation if radioguided techniques were used. Surgeons should be extremely cautious in deciding intraoperatively that a positive sestamibi scan is a false-positive scan.