Comparison of ultrasound-guided core-needle biopsy and fine-needle aspiration in the assessment of head and neck lesions

Feasibility of Using Needle Rinse Fluid for Cobas Human Papillomavirus (HPV) Assay in Diagnosing HPV+ Oropharyngeal Cancer with Neck Lymph Node Aspiration

BACKGROUND

Human papillomavirus (HPV) is a crucial prognostic factor in oropharyngeal cancer (OPC). p16 is a surrogate marker for diagnosing HPV+ OPC, however it is not direct evidence of HPV existence.

OBJECTIVE

The purpose of our study was to evaluate an HPV DNA test-Cobas HPV assay-in diagnosing HPV+ OPC through neck lymph node aspiration.

METHODS

Patients with suspected neck mass who received fine needle aspiration (FNA) or core needle biopsy (CNB) at the National Taiwan University Hospital between January 2018 and December 2022 were reviewed. Besides routine cytology and pathology study, needle rinse fluid was collected for the Cobas HPV assay to detect high-risk HPV.

RESULTS

We analyzed 137 patients with suspected lymph nodes, 32 (23.4%) of whom were HPV+ OPC patients and 105 (76.6%) of whom had non-HPV-related disease. FNA was performed in 31 patients and CNB was performed in 106 patients, according to the size and necrosis status of the lymph nodes. For diagnosing HPV+ OPC, CNB combined with p16 immunohistochemistry staining showed sensitivity of 93.3%, specificity of 97.8%, positive predictive value (PPV) of 87.5%, negative predictive value (NPV) of 98.9%, and accuracy of 97.2%. On the other hand, for the needle rinse Roche Cobas HPV assay, the test showed sensitivity of 96.9%, specificity of 100%, PPV of 100%, NPV of 99.1%, and accuracy of 99.3%. Compared with p16 IHC staining, the Cobas HPV test showed better PPV with statistical significance (p = 0.04).

CONCLUSION

The Cobas HPV assay is a US FDA-approved, highly automated, and readily used technique to directly detect the presence of high-risk HPV. We recommend utilizing the Cobas HPV assay in combination with routine cytology or histopathology examination in the work-up of neck lymphadenopathy.

Accuracy of ultrasound-guided fine-needle aspiration for small cervical lymph nodes: A retrospective review of 505 cases

Purpose

The overall diagnostic value of fine-needle aspiration (FNA) is not as excellent as that of core needle biopsy (CNB). Limited research has investigated small cervical lymph nodes inaccessible to ultrasound-guided CNB due to technical challenges associated with their small size. Therefore, this study aimed to evaluate the accuracy of ultrasound-guided FNA in determining the etiology of small cervical lymph nodes.

Methods

A retrospective analysis was conducted on patients who underwent FNA between May 2018 and May 2021 at our hospital. Cytological, histopathological, and clinical follow-up data were analyzed. The diagnostic yield of FNA was assessed based on sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy calculations.

Results

This study included 505 patients, each with a small cervical lymph node under evaluation (total number of lymph nodes: 505). The average maximal diameter of the lymph nodes was 14.6 ± 6.2 mm. According to the Sydney system, the cytology results were as follows: Category I in 26 lymph nodes (5.1 %); Category II in 269 (53.3 %); Category III in 35 (6.9 %); Category IV in 17 (3.4 %); and Category V in 158 (31.3 %). We identified 212 malignant cases (203 metastases and 9 lymphomas) and 293 benign lymph nodes. FNA achieved high sensitivity (88.8 %), specificity (99.6 %), PPV (99.4 %), NPV (91.8 %), and overall accuracy (94.8 %) in determining the etiology of small cervical lymph nodes.

Conclusion

FNA cytology is suitable for small lesions inaccessible by CNB and provides a diagnostic basis for implementing clinically appropriate treatment measures.

Ultrasonography-guided core-needle biopsy of lymphadenopathies suspected of lymphoma: Analysis on diagnostic efficacy and safety of 1000 front-line biopsies in a multicenter Italian study

The reliability and safety of front-line ultrasonography guided core needle biopsy (UG-CNB) performed with specific uniform approach have never been evaluated in a large series of patients with lymphadenopathies suspected of lymphoma. The aim of this study was to assess the overall accuracy of UG-CNB in the lymph node histological diagnosis, using a standard reference based on pathologist consensus, molecular biology, and/or surgery. We retrospectively checked the findings concerning the application of lymph node UG-CNB from four Italian clinical units that routinely utilized 16-gauge diameter modified Menghini needle under power-Doppler ultrasonographic guidance. A data schedule was sent to all centers to investigate the information regarding techniques, results, and complications of lymph node UG-CNB in untreated patients over a 12-year period. Overall, 1000 (superficial target, n = 750; deep-seated target, n = 250) biopsies have been evaluated in 1000 patients; other 48 biopsies (4.5%), screened in the same period, were excluded because inadequate for a confident histological diagnosis. Most patients were suffering from lymphomas (aggressive B-cell non-Hodgkin lymphoma [aBc-NHL], 309 cases; indolent B-cell [iBc]-NHL, 279 cases; Hodgkin lymphoma [HL], 212 cases; and nodal peripheral T-cell [NPTC]-NHL, 30 cases) and 100 cases from metastatic carcinoma; 70 patients had non-malignant disorders. The majority of CNB results met at least one criterion of the composite reference standard. The overall accuracy of the micro-histological sampling was 97% (95% confidence interval: 95%-98%) for the series. The sensitivity of UG-CNB for the detection of aBc-NHL was 100%, for iBc-NHL 95%, for HL 93%, and for NPTC-NHL 90%, with an overall false negative rate of 3.3%. The complication rate was low (6% for all complications); no patient suffered from biopsy-related complications of grade >2 according to the Common Terminology Criteria for Adverse Events. Lymph node UG-CNB as mini-invasive diagnostic procedure is effective with minimal risk for the patient.

Efficacy and safety of ultrasound-guided core needle biopsies (US-CNBs) in cervical lymphadenopathy in patients with suspected head and neck cancer during the COVID-19 pandemic

BACKGROUND

Cervical lymphadenopathy can be benign or malignant. Its accurate diagnosis is necessary to determine appropriate treatment. Ultrasound-guided core needle biopsies (US-CNBs) are frequently used as a percutaneous sampling approach.

OBJECTIVES

Our aim was to identify the efficacy and safety of US-CNBs in 125 patients with cervical lymphadenopathy and clinically suspected head and neck cancer during the COVID-19 pandemic with limited surgical resources.

METHODS

US-CNBs of pathological lymph nodes were performed in 146 lymph nodes on 125 patients. Biopsies were performed ultrasound-guided with a reusable gun core biopsy system and a 10-cm-long 16-G needle. Standard of reference for the histological findings were panendoscopy, clinical and sonographic follow-up, surgical biopsy or a repeat US-CNB.

RESULTS

Adequate material for histologic diagnosis was obtained in 111 patients (89%), of these 83 patients (75%) were diagnosed as malignant, whereas benign lymphadenopathy accounted for 28 patients (25%). Therefore, US-CNB was able to identify malignant or benign lymphadenopathy with an overall accuracy of 88% and 90%, respectively.

CONCLUSIONS

Percutaneous US-CNB is a safe and effective alternative to surgical biopsy in the management of cervical lymphadenopathy in patients with clinically suspected head and neck cancer in a setting with limited resources.

The Applications and Potential Developments of Ultrasound in Oral Cancer Management

Oral cancer is endemic and causes a great burden in Southern Asia. It is preferably treated by surgery with/without adjuvant radiotherapy (RT) or chemoradiation therapy, depending on the stage of the disease. Close or positive resection margin and cervical lymph node (LN) metastasis are important prognostic factors that have been presented to be related to undesirable locoregional recurrence and poor survival. Ultrasound (US) is a simple, noninvasive, time-saving, and inexpensive diagnostic modality. It can depict soft tissues very clearly without the risk of radiation exposure. Additionally, it is real-time and continuous image is demonstrated during the exam. Furthermore, the clinician can perform US-guided fine needle aspiration (FNA) or core needle biopsy (CNB) at the same time. US with/without US-guided FNA/CNB is reported to be of value in determining tumor thickness (TT), depth of invasion (DOI), and cervical LN metastasis, and in aiding the staging of oral cancer. DOI has a relevant prognostic value as reported in the eighth edition of the American Joint Committee on Cancer staging of oral cancer. In the present review, we describe the clinical applications of US in oral cancer management in different phases and potential applications in the future. In the pretreatment and surgical phase, US can be used to evaluate TT/DOI and surgical margins of oral cancer in vivo and ex vivo. The prediction of a malignant cervical LN (nodal metastasis) by the US-based prediction model can guide the necessity of FNA/CNB and elective neck dissection in clinical early-stage oral cancer. In the posttreatment surveillance phase, US with/without US-guided FNA or CNB is helpful in the detection of nodal persistence or LN recurrence, and can assess the possibility and extent of carotid artery stenosis after irradiation therapy. Both US elastography and US swallowing assessment are potentially helpful to the management of oral cancer.

Tumour Seeding Following Core Biopsy of a Mucoepidermoid Carcinoma of the Parotid: Radiological Evidence and a Surgical Approach to En-Bloc Dissection of the Mass and Tract

Tumour seeding along the needle tract following core needle biopsy of the parotid is a recognised complication. We present a unique case of mucoepidermoid carcinoma of the parotid in an 18-year-old patient with associated tumour seeding within the core needle biopsy tract. Tumour seeding was confirmed both histologically and radiologically on magnetic resonance imaging as early as 35 days post-biopsy. The patient was treated successfully with a combination of surgery and adjuvant proton beam therapy. This case also visually demonstrates a surgical approach to en-block excision of the mass and tract.

Computed tomography-guided percutaneous biopsy of head and neck masses: techniques, outcomes, and complications

Objective

To assess the technique, efficacy, and safety of computed tomography (CT)-guided percutaneous biopsies of head and neck masses.

Materials and Methods

This was a retrospective, single-center study of CT-guided percutaneous core-needle biopsies of head and neck masses. For the analysis of diagnostic accuracy, biopsy results were compared with the final diagnosis, which was determined by histological examination and clinical follow-up.

Results

We evaluated 74 biopsies performed in 68 patients. The mean age of the patients was 55.6 years. Most of the lesions (79.7%) were located in the suprahyoid region, and the maximum diameter ranged from 11 mm to 128 mm. The most common approaches were paramaxillary (in 32.4%), retromandibular (in 21.6%), and periorbital (in 14.9%). Five patients (6.8%) developed minor complications. The presence of a complication did not show a statistically significant association with any clinical, radiological, or procedure-related factor. Sufficient material for histological analysis was obtained in all procedures. Thirty-eight biopsies (51.4%) yielded a histological diagnosis of malignancy. There was a false-negative result in three cases (8.3%), and there were no false-positive results. The procedure had a sensitivity of 92.7%, a specificity of 100%, and an accuracy of 96.0%.

Conclusion

Our results demonstrate that CT-guided percutaneous core-needle biopsy of head and neck lesions is a safe, effective procedure for obtaining biological material for histological analysis.

Diagnostic use of fine-needle aspiration cytology and core-needle biopsy in head and neck sarcomas

The diagnostic role of fine-needle aspiration cytology (FNAC) and core-needle biopsy (CNB) has not been comprehensively assessed in head and neck sarcomas. A systematic review of published cases (1990-2020) was conducted. Diagnostic performance of both FNAC/CNB to determine tumor dignity and histopathological diagnosis was calculated. One hundred and sixty-eight cases were included for which FNAC (n = 156), CNB (n = 8), or both (n = 4) were used. Predominant histologies were skeletal muscle, chondrogenic and vascular sarcomas. FNAC correctly assessed dignity in 76.3% and histology in 45% of cases. Dignity was significantly better for vascular tumors, metastatic and recurrent specimens, and worse for chondrogenic sarcomas. CNB showed a 92% accuracy to identify dignity and 83% for histopathology. FNAC and CNB are useful methods for the diagnosis of head and neck sarcomas, particularly well-suited in the context of recurrent or metastatic disease. The role of CNB remains largely unexplored for this indication.

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.

Navigation-guided core needle biopsy for skull base and parapharyngeal lesions: a five-year experience

The aim of this study was to evaluate the diagnostic accuracy of navigation-guided core needle biopsy for skull base and parapharyngeal lesions. Twenty patients with skull base and parapharyngeal lesions were included in this study. The preoperative design and intraoperative real-time image guiding was done using an optical navigation system. A spring-loaded semi-automatic biopsy gun and biopsy needle were used for specimen harvesting. Accuracy was established on the basis of the postoperative pathology. All patients underwent needle biopsy successfully without any immediate or delayed complications. The subzygomatic approach was adopted in all cases. The number of passes ranged from three to five. The diagnostic accuracy was 90% (18/20). Navigation-guided core needle biopsy offers an easy approach for the diagnosis of skull base and parapharyngeal lesions, with a high yield of specimens and good patient tolerance.

Diagnostic value of navigation-guided core needle biopsy in deep regions of the head and neck with focal FDG uptake on 18F-FDG PET/CT

PURPOSE

The aim of this study was to evaluate the feasibility and diagnostic accuracy of core needle biopsy (CNB) in patients with focal fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) in deep regions of the head and neck, with the guidance of infrared navigation integrated with PET.

MATERIALS AND METHODS

Patients with suspected primary or recurrent malignancies of the head and neck on PET/CT, from June 2016 to December 2018, were included. Before CNB, the region of interest was delineated and the ideal needle entry points, target sites, and a number of trajectories were designed on iPlan CMF 3.0. CNB was performed with the guidance of infrared navigation integrated with PET, according to the pre-plan. Sensitivity and diagnostic accuracy were analyzed by comparing the biopsy results with the final diagnosis.

RESULTS

Thirty-one consecutive patients were included. Among the 31 lesions, 18 were skull base, six were infratemporal fossa, and seven were maxillary region. The median values for SUVmax, SUVmean, and MTV were 6.09 (range: 1.43-24.67), 3.41 (range: 0.38-20.96), and 25.83 (range: 3.54-361.94) for the 31 lesions, respectively. Combined needle approaches were employed, including temporal (nine), subzygomatic (19), paramaxillary (11), and retromandibular (16) approaches. The depths of the 31 deep-region lesions, measured from the needle entry site on the skin to the target point, ranged from 1.33 cm to 7.82 cm (median 4.25 cm). There were three non-diagnostic lesions resulting from CNB, and these were all skull base. The diagnostic accuracy was 90.3%, while the sensitivity was 88%. According to the binary logistic regression for the final diagnosis, the only significant parameter was SUVmax.

CONCLUSION

With the guidance of navigation integrated with PET, CNB is a feasible and accurate diagnostic modality, which is also an alternative to open biopsy in patients with suspected primary or recurrent malignancies in deep regions of the head and neck on PET/CT.

Ultrasound Imaging for Detecting Metastasis to Level II and III Axillary Lymph Nodes after Axillary Lymph Node Dissection for Invasive Breast Cancer

OBJECTIVES

The diagnostic value of axillary ultrasound (US) for level II and III axillary lymph node metastasis after axillary lymph node dissection for invasive breast cancer is currently not clear. The objectives of this study were to retrospectively analyze the diagnostic value of axillar US for level II and III axillary lymph node metastasis and compare it with palpation and to analyze the US features of level II and III axillary lymph nodes that are predictive of metastatic recurrence during follow-up.

METHODS

Cases with level II or III axillary lymph nodes detected by US between January 2005 and December 2017 at a cancer center were divided into 2 groups according to a retrospective analysis of US findings: potential malignancy group and follow-up group. Biopsy was performed in all patients in the potential malignancy group. In the follow-up group, the patients were followed for at least 2 years, and biopsy was performed if suspicious US features were detected.

RESULTS

The 401 enrolled cases were followed by axillary US and physical examination (PE) for comparison. Finally, 55 axillary metastases were pathologically confirmed (14%). The sensitivity, specificity, and area under the receiver operating characteristic curve for axillary US were 92.7%, 93.9%, and 0.933, respectively, and the corresponding values for PE were 49.1%, 91.3%, and 0.702 (P < .001). An increase in the major or minor axis diameter of the lymph nodes of greater than 2 mm, a Solbiati index value of less than 1.5, and the presence of new suspicious lesions in other regions were significant predictors of lymph node metastasis based on the US findings (P = .013, .006, .015, and .036).

CONCLUSIONS

Axillary is helpful in the follow-up of level II and III axillary lymph nodes after axillary lymph node dissection for invasive breast cancer and can detect cancer recurrence earlier than PE.

Cystic masses of the lateral neck: Diagnostic value comparison between fine-needle aspiration, core-needle biopsy, and frozen section

BACKGROUND

The usefulness of fine-needle aspiration (FNA), core-needle biopsy (CNB), and frozen section (FS) for assessing lateral cystic neck masses (LCNM) remains unclear.

METHODS

A retrospective review of patients presenting with a LCNM was undertaken.

RESULTS

In total, 135 patients were included. FNA had a lower sensitivity then CNB (59% vs 83%; P = .036) and FS (59% vs 93%; P = .01). FS had a better negative predictive value (NPV) when compared to FNA (92% vs 40%; P < .001) and CNB (92% vs 50%; P = .062). Positive predictive values (PPV) and sensitivities were similar among all groups.

CONCLUSION

Given its adequate PPV (92%), FNA should be used initially on LCNM. Because of its high sensitivity, CNB should be considered if FNA is not diagnostic of malignancy. FS should always follow a CNB indicative of malignancy, because of low NPV. A diagnosis of malignancy on FNA, CNB, or FS strongly indicates presence of malignancy.

The role of ultrasound-guided tissue sampling techniques in the management of extra-ocular orbital lesions

Background

Multiple disease processes may arise within the orbit and imaging plays a vital role in the evaluation of such lesions. The anterior orbital contents are readily amenable to evaluation by ultrasonography. Furthermore, the modality can be used to guide tissue sampling (fine needle aspiration or core biopsy) and may obviate the requirement for invasive surgical biopsy.

Methods

We carried out a retrospective review of ultrasound-guided fine needle aspirations/core biopsies of extra-ocular orbital lesions undertaken at our institution. The anatomical locations, sonographic appearances and sampling techniques were analysed.

Results

There were 7 fine needle aspirations and 1 core biopsy carried out during the period analysed. Multimodality imaging was available in all cases. The majority of lesions were located in the region of the lacrimal gland. All procedures were well-tolerated and there were no post-procedure complications.

Conclusion

Many extra-ocular, orbital neoplasms are amenable to ultrasound-guided tissue sampling and the procedure is well tolerated. However, a clear understanding of orbital anatomy, differential diagnosis and technique is required to enable safe sampling. Furthermore, a collaborative, multimodality approach is imperative for optimal patient management.

The value of shear wave elastography in predicting for undiagnosed small cervical lymph node metastasis in nasopharyngeal carcinoma: A preliminary study

BACKGROUND

To investigate the diagnostic value of shear wave elastography (SWE) in identifying cervical small lymph node metastases in nasopharyngeal carcinoma (NPC) patients.

MATERIALS AND METHODS

This prospective study was approved by the local institutional review board. From July 2014 to March 2016, 114 sLNs from 62 newly diagnosed NPC patients (47 men, 15 women) were assessed. Target small lymph nodes (sLNs), which were undiagnosed by magnetic resonance imaging (MRI), were defined as scattered cervical lymph nodes that had no evidence of central necrosis or extracapsular spread and exhibited a maximum transverse diameter ≥5 mm and <10 mm in MRI. The mean (Emean), minimum (Emin) and maximum (Emax) of the elasticity indices (EIs) were measured by SWE at the stiffest part of the sLN (kPa). Biopsy pathology was served as the reference standard. Diagnostic performances were assessed using receiver operating curve (ROC) analysis on a node-by-node basis.

RESULTS

Of the 114 small cervical lymph nodes, 88 (77.2%) were benign, and 26 (22.8%) were malignant. All SWE EIs were significantly higher in malignant sLNs than in benign sLNs (p < 0.001). Emean exhibited the highest diagnostic value (area under the curve = 0.879 ± 0.036) (p < 0.001) and the corresponding sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 84.6%, 83.0%, 59.5%, 94.8% and 83.3%, respectively. The intra-observer reproducibility of all SWE EIs were significant, with intra-class correlation coefficient (ICC) of 0.745 in Emean, 0.716 in Emax and 0.702 in Emin.

CONCLUSION

Shear wave elastography is an optional supplementary imaging modality to routine MRI examination to diagnose cervical lymph nodes in NPC patients.

Does needle biopsy cause an increased risk of extracapsular extension in the diagnosis of metastatic lymph node in melanoma?

BACKGROUND

Needle biopsy is a rapid, reliable, and reproducible procedure for histological confirmation of metastatic melanoma localization. Nonetheless, this procedure presents a theoretical risk of a mechanical weakening of the lymph node capsule with perinodal tumor seeding. The objective of the study was to evaluate the incidence of extracapsular extension after needle biopsy in comparison with surgical adenectomy in patients suspected of metastatic lymph node of melanoma.

METHODS

We conducted a retrospective study of 1056 patients who underwent lymphadenectomy for melanoma between 2000 and 2016 in our unit. Sixty-nine patients were clinically and/or radiologically suspected of metastatic lymph node of melanoma. Patients were divided according to external lymph node biopsy or surgical adenectomy before lymphadenectomy. The primary endpoint was the histopathological identification of extracapsular extension in analyzed lymph nodes.

RESULTS

The two populations were comparable except for the mitotic index, which was more frequently > 1/mm² in the group with surgical adenectomy (P = 0.005). The proportion of extracapsular extension was significantly greater in the needle biopsy group (28/37) than in patients who underwent surgical adenectomy (14/32) (P = 0.0067; OR = 4 [95% CI: 1.4-11]).

CONCLUSION

Our results suggest an increased risk of extracapsular extension after external lymph node biopsy in cases of suspicion of metastatic lymph node of melanoma. Thus, this encourages us to prefer surgical adenectomy in patients with suspected adenopathy accessible surgically. In other cases, needle biopsy should be carried out under radiological guidance using devices limiting tumor seeding.

US-guided core-needle biopsy versus US-guided fine-needle aspiration of suspicious cervical lymph nodes for staging workup of non-head and neck malignancies: A propensity score matching study

BACKGROUND AND OBJECTIVES

To compare US-guided core-needle biopsy (USCNB) and US-guided fine-needle aspiration (USFNA) of suspicious cervical lymph nodes for staging workup of malignancies in locations other than the head and neck using propensity score matching (PSM).

METHODS

This retrospective cohort study included 108 patients who underwent USFNA and 1058 who underwent USCNB for suspicious cervical lymph nodes detected by imaging modalities during the staging workup for malignancies located in regions other than the head and neck. The primary outcome was defined as the inconclusive results. To evaluate the procedures according to the outcome, we performed univariate and multivariate logistic regression analyses and a 1:1 PSM of USCNB and USFNA.

RESULTS

There was no complication for both USFNA and USCNB. The inconclusive results were 6.5% (7/108) for USFNA and 1.6% (17/1058) for USCNB. A significantly lower rate of the inconclusive results in USCNB than in USFNA before matching was maintained after a 1:1 PSM of 103 patients from each group (before PSM, odds ratio (OR) = 4.489, 95% confidence interval (CI) [1.803-11.177], P = 0.001; after PSM, OR = 1.060, 95%CI [1.013-1.109], P = 0.012).

CONCLUSIONS

Because USCNB can reduce inconclusive results compared to USFNA, it could be more helpful for staging workup of malignancies in locations other than the head and neck in patients with suspicious cervical lymph nodes.

The application of ultrasound in detecting lymph nodal recurrence in the treated neck of head and neck cancer patients

Early detection of neck lymph node (LN) recurrence is paramount in improving the prognosis of treated head and neck cancer patients. Ultrasound (US) with US-guided fine needle aspiration (FNA) and core needle biopsy (CNB) have been shown to have great accuracy for LN diagnoses in the untreated neck. However, in the treated neck with fibrosis, their roles are not clarified. Here, we retrospectively review 153 treated head and neck cancer patients who had received US and US-guided FNA/CNB. In multivariate logistic regression analyses, size (short-axis diameter >0.8 cm) (odds ratio (OR) 4.19, P = 0.007), round shape (short/long axis ratio >0.5) (OR 3.44, P = 0.03), heterogeneous internal echo (OR 3.92, P = 0.009) and irregular margin (OR 7.32, P < 0.001) are effective US features in predicting recurrent LNs in the treated neck. However, hypoechogenicity (OR 2.38, P = 0.289) and chaotic/absent vascular pattern (OR 3.04, P = 0.33) are ineffective. US-guided FNA (sensitivity/specificity: 95.24%/97.92%) is effective in the treated neck, though with high non-diagnostic rate (29.69%). US-guided CNB (sensitivity/specificity: 84.62%/100%) is also effective, though with low negative predictive value (62.5%). Overall, US with US-guided FNA/CNB are still effective diagnostic tools for neck nodal recurrence surveillance.

Ultrasound-Guided Needle Biopsy for Diagnosis of Advanced-Stage Malignancies of the Upper Aerodigestive Tract

Objective

Traditionally, direct laryngoscopy confirms stage and tissue diagnosis prior to treatment planning. Patients who are frail or have tenuous airway anatomy may incur risks while undergoing anesthesia. Further, direct laryngoscopy is scheduled after initial examination, introducing diagnosis delay. This study investigates the impact of ultrasound examination with guided needle biopsy compared with traditional operative biopsy.

Study Design

Case series.

Setting

Tertiary head and neck clinic.

Subjects and Methods

The records of patients at the Veterans Affairs Medical Center Memphis and Regional One Health who had supraglottic, oropharyngeal, and hypopharyngeal cancer that was diagnosed by ultrasound needle biopsy were reviewed from 2011 to 2016. Demographics, stage, biopsy results, and treatment were abstracted.

Results

Seventeen patients who underwent ultrasound-guided needle biopsy of the primary site were included. Average age was 63 years old, and 65% of patients were stage T4 (11/17). Needle biopsy yielded malignant cells in 76% (13/17). Eleven patients were included in subsequent analysis because 6 patients underwent needle biopsy only. Fisher exact test showed no difference between the 2 methods (P = .27). Sensitivity was 86% and specificity was 100%. Seven patients had a median potential delay in diagnosis of 10 days.

Conclusions

Ultrasound can be used effectively to obtain a tissue diagnosis, circumventing an operative biopsy. Moreover, ultrasound may provide additional imaging details to support accurate staging. This strategy may prove worthwhile to cut costs and reduce delay to staging, reduce risk for those with contraindications to anesthesia, and increase staging accuracy via enhanced imaging details.

Interventional radiology neck procedures

Ultrasonography has become extremely useful in the evaluation of masses in the head and neck. It enables us to determine the anatomic location of the masses as well as the characteristics of the tissues that compose them, thus making it possible to orient the differential diagnosis toward inflammatory, neoplastic, congenital, traumatic, or vascular lesions, although it is necessary to use computed tomography or magnetic resonance imaging to determine the complete extension of certain lesions. The growing range of interventional procedures, mostly guided by ultrasonography, now includes biopsies, drainages, infiltrations, sclerosing treatments, and tumor ablation.

Fine-Needle Aspiration Followed by Core-Needle Biopsy in the Same Setting: Modifying Our Approach

Fine-needle aspiration biopsy (FNAB) is a well-established initial diagnostic tool. However, in some instances limitations and shortcomings arise, making it insufficient for determining a specific diagnosis. Consequently, patients have to undergo another diagnostic procedure. The second procedure is either repeat FNAB, core-needle or open biopsy, and can be inconvenient and costly. In some centers, the FNAB is immediately followed by core-needle biopsy (CNB) in the same setting after assuring adequacy on the initial FNAB utilizing rapid on-site specimen evaluation (ROSE). It is argued that implementing such an approach will eventually have additional critical advantages that include the following: (a) it is more convenient to patients to have both procedures in one visit, (b) the tissue procured by both procedures will be more adequate, enabling cytopathologists to reach an accurate diagnosis, and (c) it is ultimately a cost-effective approach if we take into consideration the avoidance of a potential second more invasive diagnostic procedure. Since we are living in an era of patient-centered medicine coupled with cost-cutting strategies, we present here a brief review of the topic with analysis of this alternative approach, review of the pertinent literature and shed light on a few scenarios that justify this approach.

Tumour seeding after fine-needle aspiration and core biopsy of the head and neck--a systematic review

Although fine-needle aspiration cytology (FNAC) and core needle biopsy are essential diagnostic investigations of lumps in the head and neck, seeding along the needle track has long been a concern, and various factors have been implicated. We therefore searched the Medline database for relevant English language papers published between 1970 and 2014, excluding those on the thyroid and parathyroid, and systematically reviewed them to assess the risk. In the 610 articles reviewed we found only 7 reports of seeding (5 after FNAC and 2 after core needle biopsy). Tumours were found between 3 months and 3 years after the procedure in 4 cases, and in 3, tumour cells were found along the needle track between 0 and 33 days after the procedure. The needles varied in size from 18 - 22 gauge (G) and there were 3 to 4 passes. Four cases occurred after investigation of a mass in the salivary glands, and 3 after assessment of a cervical lymph node. Disease was benign in one and malignant in 6. Seeding along the needle track after FNAC or core needle biopsy of a lump in the head and neck is rarely reported, and an accurate estimate of its incidence is difficult to ascertain. Crude estimates suggest 0.00012% and 0.0011% after FNA and core needle biopsy, respectively. A distinction should be made between seeding that is seen shortly after the procedure and the development of tumour along the needle track.

A systematic review of ultrasound-guided FNA of lesions in the head and neck--focusing on operator, sample inadequacy and presence of on-spot cytology service

The objective of this review is to perform a systematic review of ultrasound-guided fine-needle aspiration (FNA) services for head and neck lesions with assessment of inadequacy rates and related variables such as the presence of immediate cytological assessment. A computer-based systematic search of articles in English language was performed using MEDLINE (1950 to date) from National Health Service evidence healthcare database and PubMed. Full texts of all relevant articles were obtained and scrutinized independently by two authors according to the stated inclusion and exclusion criteria. The primary search identified 932 articles, but only 78 met all the study criteria. The overall inadequacy rate was 9.3%, 16 studies had on-site evaluation by a cytopathologist/specialist clinician with a rate of 6.0%. In seven studies, a cytotechnician was available to either assess the sample or prepare the slides with an average inadequacy rate of 11.4%. In 1 study, the assessment was unclear, but the inadequacy rate for the remaining 54 studies, without immediate assessment, was 10.3%. The rate for the cytopathologist/specialist clinicians was significantly different to no on-site assessment but this was not found for assessment by cytotechnicians. The review suggests that the best results are obtained with a cytopathologist-led FNA service, where the pathologist reviews the specimen immediately, in relation to the clinical context, thereby deciding on adequacy and need for further biopsies. A systematic review looking at ultrasound-guided FNA of head and neck lesions has not been published previously.

Diagnostic challenge of a deep minor salivary gland neoplasm

Core needle biopsy represents a safe and cheap alternative diagnostic method to open biopsy and fine-needle aspiration cytology in head and neck tumors. There is little evidence in the literature about the use of core needle biopsy in minor salivary gland lesions. This single case report presents a 60-year-old woman with a painless swelling in the soft palate, breathing and swallowing difficulties, and a feeling of suffocation. Two open biopsies had inconclusive diagnosis and the lesion could only be assessed and diagnosed as pleomorphic adenoma through core needle biopsy. Recognizing the correct indication of core needle biopsy can benefit both health professionals and patients; thus, it is important to consider the possibility of performing this method to diagnose minor salivary gland tumors.

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.

Ultrasound-guided core needle biopsy of salivary gland lesions: a systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

To obtain summary estimates of the sensitivity and specificity of core needle biopsy for assessment of salivary gland lesions and to investigate sources of variation in accuracy between study locations.

STUDY DESIGN

Data sources were PubMed, Embase, CAB Abstracts, CINAHL, BIOSIS, LILACS, PakMediNet, Trip Database, and the National Guideline Clearinghouse. Scopus was used to perform forward (citation) and backward (reference) searches of all potentially relevant studies.

METHODS

Screening, data extraction, and quality assessment were independently performed by two different assessors. Meta-analysis was performed using bivariate mixed-effects binary regression as implemented in Stata 12. Quality assessment was performed using the QUADAS-2.

RESULTS

The summary estimates of sensitivity and specificity of core needle biopsy for diagnosis of malignancy were 96% (95% confidence interval [CI] = 87-99) and 100% (95% CI = 84-100), respectively. There was no significant heterogeneity in accuracy between studies. The quality of included studies was high, with low risk of verification bias. The risk of hematoma was 1.6% per procedure.

CONCLUSIONS

Core needle biopsy has high sensitivity and specificity, and has low risk of complications. There is no significant variation in accuracy between study locations.

CORE needle biopsy of orbital tumors

BACKGROUND

In some orbital mass lesions, histology may be the only way to establish an accurate diagnosis. Core needle biopsy (CNB) is widely performed in oncology, and unlike fine needle aspiration biopsy (FNAB), it can provide sufficient tissue sample for histology and immunohistochemistry. The purpose of this study was to evaluate the usefulness and possible complications of CNB of orbital tumors.

METHODS

Fifty orbital lesions from 46 patients (age: 2-84 years) were biopsied using 20-gauge and 18-gauge semi-automated needles; 11 procedures were performed under ultrasound guidance. All 50 samples received routine histopathological examination and immunohistochemical analysis.

RESULTS

Specimens diagnostically sufficient for histological analysis were obtained in all biopsies. The histopathological diagnosis was established in 94% of specimens: 30 tumors were malignant: lymphoma (20); rhabdomyosarcoma (six); lacrimal gland carcinoma (one); breast carcinoma metastasis (two); melanoma (one); three were benign; ten inflammatory; and four were orbital fibrosis. Three biopsies were nondiagnostic: two (lymphoma, angiofibroma) showed undetermined identification and one was a false-negative (lacrimal gland adenocarcinoma was misdiagnosed as fibrous tissue). The diagnoses were confirmed by excisional or incisional biopsy in 26 patients. The concordance rate in patients with a surgically confirmed diagnosis was 88%. The sensitivity, specificity and accuracy for differentiating malignant from benign lesions were 94%, 100%, and 96%, respectively. Two patients suffered complications: mild retrobulbar hematoma with no decreased visual acuity. There was no damage to the globe or optic nerve, motility disorder, or infection.

CONCLUSIONS

CNB of orbital mass lesions is a safe procedure that provides a sufficient amount of tissue for histology and immunohistochemistry, and may be useful for improving the quality of the pathological diagnosis of orbital tumors.

Comparison of ultrasound-guided core biopsy versus fine-needle aspiration biopsy in the evaluation of salivary gland lesions

Ultrasound-guided core biopsy provides many benefits compared with fine-needle aspiration cytology and has begun to emerge as part of the diagnostic work-up for a salivary gland lesion. Although the increased potential for tumor-seeding and capsule rupture has been extensively discussed, the safety of this procedure is widely accepted based on infrequent reports of tumor-seeding. In fact, a review of the literature shows only 2 cases of salivary tumor seeding following biopsy with larger-gauge needle characteristics, with 2 reported cases of salivary tumor seeding following fine-needle aspiration cytology. However, the follow-up interval of such studies (<7 years) is substantially less than the 20-year follow-up typically necessary to detect remote recurrence. Studies on tumor recurrence of pleomorphic adenoma, the most common salivary gland lesion, suggest that as many as 16% of tumor recurrences occur at least 10 years following initial surgery, with average time to recurrence ranging anywhere from 6.1 to 11.8 years postoperatively. Despite the benefits of ultrasound-guided core biopsy over fine-needle aspiration biopsy, which include both improved consistency and diagnostic accuracy, current studies lack adequate patient numbers and follow-up duration to confirm comparable safety profile to currently accepted fine-needle aspiration cytology. In this report we: (1) compare the relative benefits of each procedure, (2) review evidence regarding tumor seeding in each procedure, (3) discuss time course and patient numbers necessary to detect tumor recurrence, and (4) describe how these uncertainties should be factored into clinical considerations.

Preoperative parathyroid needle localization: a minimally invasive novel technique in reoperative settings

Background. Reoperative parathyroid surgery for primary hyperparathyroidism can be challenging. Numerous preoperative localization techniques have been employed to facilitate a more focused surgical exploration. This paper describes a novel, minimally invasive, and highly successful method of parathyroid localization. Methods. Patients with recurrent or persistent primary hyperparathyroidism underwent parathyroidectomy following CT scan or ultrasound-guided wire localization of the parathyroid. Accurate placement was confirmed by fine-needle aspiration with immunocytochemistry or PTH washout. The guide wire was left in situ to guide surgical excision of the gland. Curative resection was established by monitoring intact serum PTH levels after excision of the adenoma. Results. All ten patients underwent successful redo-targeted parathyroidectomy. Nine of the ten patients were discharged on the day of surgery. One patient was observed overnight due to transient postoperative hypocalcemia, which resolved with calcium supplementation. Conclusion. Placement of a localization wire via preoperative high-resolution ultrasound or CT can expedite reoperative parathyroid surgery. It allows identification of parathyroid adenoma via a minimally invasive approach, especially in cases where a sestamibi scan is inconclusive.

Role of ultrasound-guided core-needle biopsy in the assessment of head and neck lesions: a meta-analysis and systematic review of the literature

BACKGROUND

Core-needle biopsy (CNB) has occasionally been used in the work-up of head and neck lesions. However, no systematic review of this simple, minimally invasive method has yet been performed.

METHODS

A systematic review of the literature and meta-analysis of data extracted from 16 included studies were performed. A total of 1291 cervical lesions in 1267 patients were examined by CNB. This resulted in 1232 adequate samples, from which 554 were subsequently confirmed by excisional biopsy.

RESULTS

CNB was able to identify true neoplasms and detect malignancy in head and neck lesions with an overall accuracy of 94% and 96%, respectively, even though there was a significant difference between the histologically verified and all adequate samples. CNB provided a correct specific diagnosis in 87% of cases without major complications and achieved a higher accuracy than that of fine-needle aspiration in detecting malignancy.

CONCLUSIONS

This meta-analysis confirms that CNB is an excellent method in the assessment of salivary gland lesions and lymphadenopathies inclusive of malignant lymphoma, but it is not ideal for evaluating thyroid lesions.

The benefits of on-site cytology with ultrasound-guided fine needle aspiration in a one-stop neck lump clinic

INTRODUCTION

In the National Institute for Health and Clinical Excellence (NICE) guidance on cancer services published in 2004, it was recommended that specialist clinics should be set up for the assessment of patients with neck lumps, structured in a similar way to one-stop breast lump clinics with a cytopathologist present and preferably ultrasound guidance. The aim of this study was to audit the performance of ultrasound-guided fine needle aspiration (FNA) with on-site cytology in a one-stop neck lump clinic at The Royal Liverpool University Hospital.

PATIENTS AND METHODS

Data were collected between November 2008 and May 2009 (7 months). Details of the adequacy rate for the FNA were recorded and whether multiple passes were required. The likely adequacy rate if ultrasound guidance was not available was also calculated.

RESULTS

A total of 274 patients were included in the audit. Of these, 227 (83%) patients required a single pass for adequate diagnostic material. Of the remaining, 45 (16%) required two passes and 2 (1%) required three passes. The overall sample inadequacy rate was 11 of 274 (4%). From these results, it could be predicted that, if immediate cytological evaluation was unavailable, the inadequacy rate would have been 41 of 274 (15%).

CONCLUSIONS

This audit has illustrated the benefits of a one-stop clinic with on-site cytology in providing a rapid diagnostic head and neck cancer service.

The benefits of on-site cytology with ultrasound-guided fine needle aspiration in a one-stop neck lump clinic

INTRODUCTION

In the National Institute for Health and Clinical Excellence (NICE) guidance on cancer services published in 2004, it was recommended that specialist clinics should be set up for the assessment of patients with neck lumps, structured in a similar way to one-stop breast lump clinics with a cytopathologist present and preferably ultrasound guidance. The aim of this study was to audit the performance of ultrasound-guided fine needle aspiration (FNA) with on-site cytology in a one-stop neck lump clinic at The Royal Liverpool University Hospital.

PATIENTS AND METHODS

Data were collected between November 2008 and May 2009 (7 months). Details of the adequacy rate for the FNA were recorded and whether multiple passes were required. The likely adequacy rate if ultrasound guidance was not available was also calculated.

RESULTS

A total of 274 patients were included in the audit. Of these, 227 (83%) patients required a single pass for adequate diagnostic material. Of the remaining, 45 (16%) required two passes and 2 (1%) required three passes. The overall sample inadequacy rate was 11 of 274 (4%). From these results, it could be predicted that, if immediate cytological evaluation was unavailable, the inadequacy rate would have been 41 of 274 (15%).

CONCLUSIONS

This audit has illustrated the benefits of a one-stop clinic with on-site cytology in providing a rapid diagnostic head and neck cancer service.

A targeted parathyroidectomy using guide wire technique in a pregnant patient with primary hyperparathyroidism

Primary hyperparathyroidism may cause fetal demise in pregnant patients if prompt diagnosis and treatment is not initiated. The paper describes a novel guide wire technique for a targeted parathyroidectomy, which may reduce the risk to mother and fetus and be useful in other related circumstances.