Ultrasound-Guided Fine-Needle Aspiration With Optional Core Needle Biopsy of Head and Neck Lymph Nodes and Masses: Comparison of Diagnostic Performance in Treated Squamous Cell Cancer Versus All Other Lesions

A case of fine-needle aspiration of a neck mass with atypical squamous cells and macrophages

Head and neck lesions often undergo fine-needle aspiration to determine the appropriate management and therapeutic decisions. However, there are numerous diagnostic challenges encountered with these specimens, particularly, if atypical squamous cells are identified. Here, we present a case of an enlarging right neck mass in a 38-year-old female and discuss the diagnostic difficulties and potential pitfalls. Additionally, we review the approach to diagnosis, including differential diagnostic considerations as well as available ancillary testing.

CT-guided core needle biopsies of head and neck tumors: a comprehensive monocenter analysis of safety and outcomes

BACKGROUND

Although core needle biopsy is an important tool in minimally invasive tissue sampling and diagnostics for head and neck masses, comprehensive data about safety and outcomes is lacking.

PURPOSE

To retrospectively evaluate the diagnostic performance and safety of computed tomography (CT)-guided percutaneous core needle biopsy of head and neck masses.

MATERIAL AND METHODS

This retrospective single-center study included patients from 04/2007 to 12/2021, and a total of 156 core needle biopsies were evaluated. The initial histopathological results were compared with the long-term final diagnosis to evaluate the diagnostic yield of CT-guided core needle biopsies. The patients' age, sex, and history of malignancy, as well as procedural complications and radiation exposure were collected.

RESULTS

A total of 156 biopsies of 150 patients (mean age 56 years ± 17; 89 men) were evaluated. 57.3% (86/150) of patients had a history of malignancy. 55.1% (86/156) of the lesions were accessed by an infrahyoid needle approach. 92.9% (145/156) of biopsies yielded conclusive results. There were no false positives and 4 false negatives, resulting in a total false negative rate of 2.7% (4/145) and a total diagnostic yield of 90.4% (141/156). There were nine puncture-related complications (9/156-5.7%). None of the complications required further reintervention. The average dose length product was 311.3 mGy × cm.

CONCLUSION

CT-guided core needle biopsies of head and neck masses showed excellent results with high diagnostic yield and clinical safety.

CLINICAL RELEVANCE STATEMENT

General anesthesia for open biopsy carries a higher risk for elderly patients, and fine needle aspiration has a poor reputation in terms of its diagnostic yield. This study focuses on safety and diagnostic yield of CT-guided core needle biopsies.

KEY POINTS

• CT-guided core needle biopsy in head and neck tumors was a reliable and safe procedure. • The most common cause for an inconclusive biopsy result was a shortage of tissue collected during the biopsy. • During our study period of nearly 15 years, the radiation exposure of head and neck biopsies decreased.

The role of transoral surgery in the diagnosis of the carcinoma of unknown origin of the head and neck

PURPOSE OF REVIEW

The aim of this article is to update readers on the most recent evidence on the role of trans oral surgery (TOS) in the diagnosis of carcinoma of the unknown primary of the head and neck.

RECENT FINDINGS

Tongue base mucosectomy has an important role in identifying the primary in patients who have had negative imaging, PET CT scans and ipsilateral tonsillectomy. In patients with bilateral nodal disease, tongue base mucosectomy should precede tonsillectomy. There are several unanswered questions that remain regarding sequencing of operations and use of intraoperative frozen section.

SUMMARY

An evidence-based approach to diagnosis is important to ensure the highest detection rates, and least morbidity, in patients with head and neck carcinoma of the unknown primary.

Ultrasound Guided Biopsy in Patients With HPV-Associated Oropharyngeal Squamous Cell Carcinoma

OBJECTIVES

To identify the differences in sensitivity and accuracy between ultrasound-guided and palpation-guided fine needle aspirations (FNA) of suspicious lymph nodes in patients with human papillomavirus (HPV) (+) oropharyngeal squamous cell carcinoma (OPSCC). Additional objectives included identifying patient specific factors affecting biopsy accuracy and evaluating potential differences in accuracy between fine and core needle biopsies.

STUDY DESIGN

Retrospective chart review.

MATERIALS AND METHODS

A retrospective study of diagnostic sensitivity was completed at a single tertiary care center between 1/1/2006-12/31/2016. Participants included patients who underwent pretreatment FNA biopsy with HPV(+)OPSCC confirmed pathologically following neck dissection or excisional lymph node biopsy. A true positive (TP) on FNA biopsy was defined as an FNA biopsy concerning for squamous cell carcinoma (SCC) that was confirmed on excisional biopsy or neck dissection. A false negative (FN) was defined as a negative FNA but metastatic disease identified on excisional biopsy or neck dissection. Sensitivity was calculated as TPs/(TPs + FNs). Sensitivity was compared among techniques using chi-square and Fisher exact tests.

RESULTS

A total of 209 FNA biopsies among 198 patients were included in the study, including 31 (15%) palpation-guided FNAs, 160 (77%) ultrasound-guided FNAs, and 18 (9%) ultrasound-guided FNA + core biopsies. Sensitivity was significantly different among palpation-guided FNA, ultrasound-guided FNA, and ultrasound-guided FNA + core biopsies (48% vs. 83% vs. 94%, respectively; P < .001) but there was no significant difference in sensitivity between ultrasound-guided FNA versus ultrasound-guided FNA + core biopsies (P = .31).

CONCLUSION

The use of ultrasound guidance in FNA biopsies of nodal metastases in HPV(+)OPSCC improves sensitivity compared to palpation guidance alone. Ultrasound guided biopsies are preferred in patients with suspected nodal metastasis from HPV(+)OPSCC.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2396-2402, 2022.

Performance Evaluation of an Ultrasonic Imaging System Using Tissue-Mimicking Phantoms for Quality Assurance

Diagnostic ultrasound or sonography is an image that can provide valuable information for diagnosing and treating a variety of diseases and conditions. The aim of this research study is to examine the performance and accuracy of the ultrasonic imaging system for the guarantee of diagnosis quality assurance, and to adjust the penetration settings to minimize the time of repeat scans and maintenance duration during research experiments. Measurements in this experiment included the resolution (axial and lateral) and focal zones. Moreover, the evaluation was done by completing all the measurements at different depths on a multipurpose phantom model 539. The phantom was bought from the market and was not fabricated by the author. The measurements were achieved by applying two different transducers: curved and linear (flat). The ultrasound images were obtained and tested by using calipers (electronic), and the estimations and observations were read by using all the taken measurements and images. As a result, because the phantom depths were different, the penetration settings were different too, indicating that the depth impacted the penetrations of the created ultrasound image. Moreover, after the comparison of the recorded measurements and results, it was found that all measurements were within the accepted (standard) value and that the true value was specified by the production of the phantom.

Diagnostic performance of core needle biopsy for nodal recurrences in patients with head and neck squamous cell carcinoma

This study investigated the diagnostic accuracy and affecting factors of ultrasound (US)-guided core-needle biopsy (CNB) in patients with treated head and neck squamous cell carcinoma (HNSCC). We retrospectively reviewed patients with treated HNSCC who received US-guided CNB from January 2011 to December 2018 with corresponding imaging. Pathological necrosis and fibrosis of targeted lymph nodes (LNs) were evaluated. We analyzed the correlation between CNB accuracy and clinical and pathological characteristics. In total, 260 patients were included. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CNB for nodal recurrence were 84.47%, 100%, 100%, 54.67%, and 86.92%, respectively. CNB of fibrotic LNs had significantly worse sensitivity, NPV, and accuracy than that of non-fibrotic LNs. Similarly, CNB of necrotic LNs had significantly worse sensitivity, NPV, and accuracy than non-necrotic LNs. Multivariate regression revealed that fibrotic LN was the only independent factor for a true positive rate, whereas both necrotic LN and fibrotic LN were independent factors for a false negative rate. The diagnostic accuracy of CNB in treated HNSCC patients is affected by LN necrosis and fibrosis. Therefore, CNB results, particularly for necrotic or fibrotic LNs, should be interpreted carefully.

[Risk and prognostic analysis of cervical lymph node metastasis in cN+ laryngeal squamous cell carcinoma]

Objective:To analyze the clinical, pathological features and metastatic regularity of cervical lymph node metastasis in cN+ laryngeal squamous cell carcinoma, and to explore its diagnosis and management. Methods:Among 1030 patients with laryngeal squamous cell carcinoma who underwent surgery in the Department of Otolaryngology, The First Affiliated Hospital of Chongqing Medical University from March 2011 to January 2021, 83 patients with cN+ were included in the retrospective analysis of clinical data and follow-up data. Results:Among the 83 cases of cN+ laryngeal carcinoma, there were pN+65 cases and pN-18 cases. The false positive rate of cN+ was 21.7%. cN+ cervical lymph node metastasis was related to classification and staging, and the difference was statistically significant（P<0.05）.The false positive rate of cN+ in different types of laryngeal carcinoma was 57.7% （16/27） in glottic type and 3.9% （2/55） in supraglottic type. With the increase of T stage, the false positive rate decreased.The false positive rates of different CT imaging features were as follows:①Size:the critical lymph nodes of more than 2 sizes were 27.3% （3/11）, the 1~3 cm of lymph nodes was 29.4% （15/51）, and the lymph nodes > 3 cm were not false positive （0/21）;②The enhancement types of uniform enhancement, non-uniform enhancement and circular enhancement were 34.3% （12/35）, 31.6% （6/19） and 0% （0/29） respectively. ③The proportion of unclear shape and boundary of lymph nodes was 0（0/24）.The neck recurrence rate was 2.4% in the selective neck dissection （SND） and 20.0% in the non-SND. The 3-year neck area control rates of SND and non-SND group were 93.7% and 81.1% respectively, and the difference was statistically significant （P < 0.05）. The 3-year cumulative survival rates of pN+ group and pN- group were 75.5% and 87.5%, respectively, and there was no significant difference between the two groups （P > 0.05）. The 3-year cumulative survival rates of lymph node extranodal extension ENE+ group and ENE- group were 50.6% and 79.3%, respectively, and the difference was statistically significant （P < 0.05）. Conclusion: There is false positive in cN+ laryngeal carcinoma, which is related to tumor classification and staging. Preoperative imaging diagnosis of cN+ should not be over-dependent on size, but should be combined with the specific manifestations of lymph node metastasis such as circular enhancement and unclear boundaries. Proper use of SND in the treatment of cN+ laryngeal carcinoma is safe and effective, and reduces the risk of overtreatment. In patients with pN+ laryngeal carcinoma, postoperative supplementary treatment can improve the neck control rate and survival rate. However, even if postoperative treatment is performed in patients with ENE+, it is still an unfavorable factor affecting the prognosis.

Performance Evaluation of Ultrasonic Imaging System (Part I)

Background:

Diagnostic ultrasound or sonography is an image which can provide valuable information for diagnosing and treating a variety of diseases and conditions. This experiment was done to check the performance and evaluate the ultrasonic imaging system. There were three tests performed in this experiment: dead zone (transducer ring-down), vertical measurement calibration, and horizontal measurement calibration.

Methods:

The evaluation was made by performed all the tests with different depth on two different multipurpose phantom model #539. The tests were also performed by two different probes which were curved and flat (linear probe). The images were taken, and the measurements were made by electronic calipers on the ultrasound machine system. Observations and evaluations were done via all images and measurements taken.

Results:

The images formed by two various probes were different. The penetration settings were different since the depths were different. The depth influenced the penetrations to the formed image. From the comparison of all results and measurements recorded were all under the accepted value of the standard that was given by the manufacture of the phantom.

Conclusion:

Therefore, it can be concluded that the measurements were all not exceeding 2% of the standard value given based on the result that we get.

Evaluation of thyroid nodules by shear wave elastography: a review of current knowledge

PURPOSE

Shear wave elastography (SWE), as a tool for diagnosing thyroid malignancy, has gathered considerable attention during the past decade. Diverging results exist regarding the diagnostic performance of thyroid SWE.

METHODS

A comprehensive literature review of thyroid SWE was conducted using the terms "Thyroid" and "shear wave elastography" in PubMed.

RESULTS

The majority of studies found SWE promising for differentiating malignant and benign thyroid nodules on a group level, whereas results are less convincing on the individual level due to huge overlap in elasticity indices. Further, there is lack of consensus on the optimum outcome reflecting nodule elasticity and the cut-off point predicting thyroid malignancy. While heterogeneity between studies hinders a clinically meaningful meta-analysis, the results are discussed in a clinical perspective with regard to applicability in clinical practice as well as methodological advantages and pitfalls of this technology.

CONCLUSION

Technological as well as biological hindrances seem to exist for SWE to be clinically reliable in assessing benign and malignant thyroid nodules. Structural heterogeneity of thyroid nodules in combination with operator-dependent factors such as pre-compression and selection of scanning plane are likely explanations for these findings. Standardization and consensus on the SWE acquisition process applied in future studies are needed for SWE to be considered a clinically reliable diagnostic tool for detection of thyroid cancer.

Fine Needle Biopsy Versus Core Needle Biopsy Combined With/Without Thyroglobulin or BRAF 600E Mutation Assessment for Detecting Cervical Nodal Metastasis of Papillary Thyroid Carcinoma

Objectives

To analyze the diagnostic benefit of fine needle aspiration biopsy cytology (FNAB-C) and core needle biopsy tissue (CNB-T) with the addition of thyroglobulin (Tg) in the washout of the needle or BRAF V600E mutation assessment in assessing cervical lymph node metastasis (LNM) in papillary thyroid carcinoma.

Materials and Methods

A total of 186 lymph nodes were punctured by fine or core needle. The diagnostic performance of FNAB-C and CNB-T with Tg in the washout or BRAF V600E mutation assessment was compared.

Results

The optimal cutoff value of FNAB-Tg was 1.0 ng/ml, with an AUC of 0.976. The sensitivity and specificity of FNAB-C in predicting cervical LNM were 97.4% and 71.4%, respectively, and the addition of FNAB-Tg could contribute to a sensitivity of 100% and a specificity of 95%, but the introduction of BRAF V600E mutation assessment was associated with a decreased sensitivity of 96.3% and a decreased specificity of 50.0%. The FNAB-Tg level showed a comparable distribution in malignant lymph nodes with different TgAb statuses, serum TSH levels, and serum Tg levels. The sensitivity and specificity of CNB-T in predicting cervical LNM were 98.9% and 100%, respectively. The addition of CNB-Tg did not alter the diagnostic ability, but the introduction of BRAF V600E mutation assessment obtained the best performance, with a sensitivity of 100% and specificity of 100%.

Conclusion

The sensitivity and specificity of FNAB-C could be increased if combined with FNAB-Tg. CNB-T alone could provide satisfactory diagnostic reliability.

Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline

PURPOSE

To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP).

METHODS

The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy.

RECOMMENDATIONS

Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.