Ultrasound core biopsies of neck lumps: an experience from a tertiary head and neck cancer unit

BACKGROUND

Traditionally, fine needle aspiration cytology was the primary diagnostic investigation for head and neck lumps; however, ultrasound-guided core biopsy offers the advantage of preserving tissue architecture with increased tissue yield. This study reviews the diagnostic utility of ultrasound-guided core biopsy for investigating head and neck lumps.

METHODS

Overall, 287 ultrasound-guided core biopsies were reviewed between May 2017 and April 2019 at a single tertiary site for head and neck cancer.

RESULTS

On initial ultrasound-guided core biopsy, a diagnostic sample was obtained in 94.4 per cent of patients and in 83.7 per cent of patients with lymphoma. Where the initial ultrasound-guided core biopsy was non-diagnostic, 50 per cent of samples were diagnostic on repeat ultrasound-guided core biopsy. Overall, five complications were seen related to ultrasound-guided core biopsy, and all were managed conservatively. No cases of disease recurrence were identified at the biopsy site.

CONCLUSION

Ultrasound-guided core biopsy is a safe procedure with a high diagnostic yield when investigating head and neck lumps. Patients whose ultrasound-guided core biopsies were non-diagnostic should be considered for excisional biopsy over repeat ultrasound-guided core biopsy.

Core needle biopsy for diagnosing lymphoma in cervical lymphadenopathy: Meta-analysis

BACKGROUND

The diagnostic yield of core needle biopsies (CNB) in cervical lymphadenopathy for lymphoma diagnosis is controversial. The aim of this study was to calculate the accuracy of cervical CNB in diagnosing lymphoma.

METHODS

We conducted a meta-analysis of all studies on patients presenting with cervical lymphadenopathy and referred to CNB. Patients with a diagnosis other than lymphoma were excluded. All cases diagnosed with lymphoma sufficient to guide treatment based on CNB outcome were considered accurate (actionable) results. A separate meta-analysis was performed for various lymphoma subtypes.

RESULTS

Three prospective and 19 retrospective studies, comprising 1120 patients, met the inclusion criteria. The rate of actionable lymphoma diagnoses following CNB ranged from 30% to 96.3%, with a random-effects model of 82.45% (95% confidence interval [CI] =0.76-0.88) and a fixed-effects model of 78.3% (95% CI =0.75-0.80).

CONCLUSION

CNB for cervical lymphadenopathy in lymphoma cases is relatively accurate in guiding treatment.

Investigation of the value of ultrasound-guided core needle biopsy from pathologic lymph nodes to the diagnosis of lymphoma

Introduction:

In recent years, techniques with minimally invasive have been gradually developed and used in the diagnosis of lymphoma. Among minimally invasive techniques, core needle biopsy (CNB) has been widely accepted as an effective tool for the diagnosis of malignant lymphoma, carcinoma and deep tumors that are only accessible via CT or endoscopic-guided. This study was conducted to investigate of diagnostic value of ultrasound guided CNB in the diagnosis of lymphoma in all parts of the body compared to surgical excisional biopsy (SEB).

Materials and Methods:

This is an descriptive epidemiological study that was performed on patients with suspected lymphoma referred to the intervention ward of Golestan Hospital in Ahvaz in 2019. For all patients with suspected lymphoma, CNB of lymph nodes was performed by ultrasound-guided. Finally, the final diagnosis of CNB was compared with the results of surgical biopsy in the studied specimens.

Results:

In this study, 40 patients were evaluated with suspected lymphoma. At initial diagnosis with CNB, 12 (30%) had NHL, 19 (47.5%) had Hodgkin's lymphoma, and 2 had high-grade lymphoma. Of the 40 patients examined, 29 required IHC to confirm the diagnosis. In 8 cases, the final diagnosis was done using SEB. Final diagnosis in 9 (22.5%) patients was confirmed by CNB only. The CNB along with the IHC also led to the final diagnosis in 23 (57.5%) patients. However, another 8 patients required biopsy to confirm the diagnosis by SEB.

Conclusion:

The findings of this study indicated that US-CNB is a highly efficient method of diagnosis of lymphoma with high specificity, in the fastest possible mode and with the least complications.

Image-guided core needle biopsy in the diagnosis of malignant lymphoma: comparison with surgical excision biopsy

PURPOSE

This study aimed to compare the efficacy and safety of image-guided core needle biopsy (CNB) with those of surgical excision biopsy (SEB) for the diagnosis of lymphoma, and to clarify the indication of CNB in clinical practice.

METHOD

This retrospective study included 263 image-guided CNB cases and 108 SEB cases that were performed at our institution between January 2014 and December 2018. The rate of patients with performance status of grade 1-4 was higher in the CNB group than in the SEB group (43.7% vs. 24.1%, P <  0.01). Waiting time to biopsy and diagnosis was shorter for CNB group than for SEB group (4 days vs. 7 days, 13 days vs. 15 days, P <  0.01). The rate of biopsy at the deep sites was higher in the CNB group than in the SEB group (53.2% vs. 8.3%, P <  0.01). Successful biopsy and complication rates were compared between the 2 groups.

RESULTS

There were no significant differences between the CNB and SEB groups in successful biopsy rates (89.0% vs. 93.5%, P =  0.25). The grade 3 complication rate was significantly lower for CNB group than for SEB group (0% vs. 4.6%, P <  0.01), although there was no significant difference in overall complication rates (4.9% vs. 6.5%, respectively, P =  0.61).

CONCLUSIONS

CNB showed high diagnostic yield comparable to SEB for suspected lymphoma. CNB was especially recommended to the cases with low-PS, lesions in the deep sites, and requiring early pathological diagnosis.

Value and Diagnostic Accuracy of Ultrasound-Guided Full Core Needle Biopsy in the Diagnosis of Lymphadenopathy: A Retrospective Evaluation of 793 Cases

OBJECTIVES

Whole surgical lymph node excision (SNE) is considered the standard diagnostic method in the primary diagnosis of lymphadenopathy (LA) suspected of malignancy. Ultrasound-guided full core needle biopsy (UFCNB) offers an alternative method to SNE. This study examined the accuracy of UFCNB in the diagnosis of unexplained LA in 793 cases.

METHODS

From January 2006 to June 2015, a total of 793 cases of LA of unknown origin received a UFCNB. The lymph nodes were located peripherally (68%) or abdominally (32%). The final diagnoses from histopathologic examinations were non-Hodgkin lymphoma (n = 245), Hodgkin lymphoma (n = 53), solid nonlymphocytic lymph node metastases (n = 359), and benign LA (n = 136). The results of the biopsies were retrospectively evaluated with regard to sensitivity, specificity, and diagnostic accuracy.

RESULTS

In the total collective of 793 biopsies, the sensitivity of UFCNB was 94.4%; the specificity was 97.8%; and the diagnostic accuracy was 95.0%. In the subgroups, the following results were obtained: non-Hodgkin lymphoma (sensitivity, 97.2%), Hodgkin lymphoma (sensitivity, 88.7%), metastases (sensitivity, 93.3%), and benign LA (specificity, 97.8%). In 17 cases (2.2%), an additional rebiopsy of the lymph node was needed, and in 85 cases (10.7%), an additional SNE was performed.

CONCLUSIONS

Due to the diagnostic accuracy of 95.0% in the total collective, UFCNB seems to be an alternative diagnostic procedure to the standard procedure of SNE for LA of unknown origin. A prospective comparative study to definitively clarify the diagnostic value of UFCNB compared to SNE in the unexplained LA is warranted.

Diagnosing Lymphoproliferative Disorders Using Core Needle Biopsy Versus Surgical Excisional Biopsy: Three-Year Experience of a Reference Center in Lebanon

BACKGROUND

Despite current guidelines, a significant increase in the use of core needle biopsy (CNB) has been noted. Our aims were to determine the profile of patients referred for image-guided biopsies, to assess the diagnostic yield of these biopsies, and to learn whether CNB is an effective alternative to surgical excisional biopsy (SEB).

PATIENTS AND METHODS

All lymph node biopsy samples evaluated in the Department of Pathology and Laboratory Medicine from 2014 to 2017 were included. Patients' demographics, biopsy type, and final diagnosis were recorded and classified as diagnostic or nondiagnostic. The reasons for the latter were evaluated and follow-up was obtained, where available.

RESULTS

A total of 373 cases, 210 CNB and 163 SEB, were collected. The diagnostic yield was 79% for CNB compared to 97% for SEB. The choice of CNB versus SEB was not dependent on patient's age, gender, or clinical suspicion of malignancy. Failure to reach a diagnosis was due to insufficient or suboptimal tissue in most nondiagnostic CNBs. Lymphoma was equally diagnosed among CNB and SEB. CNB was at an advantage in diagnosing large B-cell lymphomas.

CONCLUSION

When performed adequately, CNB is a good substitute for SEB. Strict and specific guidelines need to be updated and adopted to indicate how and when it can be used, including the recommendation of concomitant complementary diagnostic laboratory testing such as flow cytometry. The latter should be readily available in order to not compromise the quality and accuracy of the diagnoses.

Lymph node abscess caused by Francisella tularensis - a rare differential diagnosis for cervical lymph node swelling: a case report

BACKGROUND

Cervical lymph node swelling is quite a common symptom mainly caused by infections in the face or as metastasis of a malignant tumor. In infection cases in particular, rare diseases should never be overlooked. With an incidence of 120 cases in the United States of America (USA) and approximately 25 cases in Germany per year, infection with the pathogen Francisella tularensis is one of these rare diseases that can cause massive lymph node swellings and might even be fatal.

CASE PRESENTATION

The example of a healthy 67-year-old German woman who was treated at our university hospital presents a typical progression of a localized form of tularemia. The pathogen could be identified in a universal 16S ribosomal deoxyribonucleic acid (DNA) polymerase chain reaction. Pathogen-specific treatment with lymph node abscess incision, daily rinsing of the abscess cavity, and orally administered antibiotic therapy with doxycycline could cure our patient completely without any remaining complications.

CONCLUSION

In patients with cervical lymph node swelling caused by infection it is indispensable to perform specific identification of the pathogen for further local and specific antibiotic treatment. Possible infections with atypical bacteria like Francisella tularensis should never be ignored. Universal polymerase chain reactions are a suitable method for early detection of such rare pathogens.

Ultrasonography-guided core needle biopsy of cervical lymph nodes for diagnosing head and neck lymphoma compared with open surgical biopsy: Exploration for factors that shape diagnostic yield

PURPOSE

This study was conducted to compare the diagnostic yields of Ultrasonography-guided core needle biopsy (USG-CNB) and open surgical biopsy (OSB) in head and neck (HN) lymphoma and to identify the factors that shape USG-CNB diagnostic yield.

MATERIALS AND METHODS

All consecutive patients who were diagnosed with HN lymphoma in our hospital were analyzed. The frequencies with which these first-line procedures yielded a sample that permitted histological confirmation of lymphoma were determined. To identify the factors that shape the diagnostic yield of USG-CNB, the patients in whom USG-CNB was and was not sufficiently confirmatory were compared in terms of demographics, computed tomography (CT) and pathological findings.

RESULTS

In total, 83 patients underwent USG-CNB (n = 26, 31.3%) or OSB (n = 57, 68.7%) for confirming lymphoma. USG-CNB yielded a fully sufficient diagnosis in 18 (69.2%) patients. By contrast, OSB yielded a confirmative diagnosis in 56 (98.2%) patients. Maximal standardized uptake value (SUVmax) of targeted LN on positron emission tomography-CT (PET-CT) in confirmatively diagnosed subjects was much higher than deferred counterparts (22.9 ± 13.4 vs. 10.1 ± 5.2, p = 0.017), however, there was no significant difference in other parameters associated with the first-line USG-CNB diagnostic success.

CONCLUSIONS

First-line USG-CNB was less frequently successful than OSB for diagnosing HN lymphoma involving cervical LN. Mean SUVmax of LN on PET-CT in confirmatively diagnosed subjects was higher than deferred counterparts on USG-CNB.

Clinical factors indicating the presence of malignant lymphoma before lymph node dissection

CONCLUSION

Lymph node swelling in the neck is one of the initial symptoms of malignant lymphoma (ML). The present study showed that clinical factors including higher age, higher level of maximum standardized uptake value (SUV-max) of positron-emission tomography, elevated serum lactate dehydrogenase (LDH), and elevated serum soluble interleukin-2 receptor (sIL-2R) were all useful indicators to suggest the diagnosis of ML, so may be helpful in the selection of patients for lymph node dissection.

OBJECTIVE

Lymph node dissection is essential for the diagnosis of ML. The factors important for the diagnosis of ML were investigated, to establish surgical indicators.

METHODS

Preoperative data including age, number and side of lymph nodes, SUV-max, serum LDH, serum sIL-2R, and size of lymph nodes were obtained from medical records. The cut-off level for each factor was calculated using the Youden Index for logistic regression analysis.

RESULTS

Multivariate logistic regression analysis showed that the following factors were associated with ML: higher age (≥ 53 years), higher level of SUV-max (≥ 9.0), elevated serum LDH (≥ 203 U/L), elevated serum sIL-2R (≥ 2590 U/ml), with odds ratios of 3.7, 4.9, 3.7, and 11.9, respectively.

Systematic review of the effectiveness of fine-needle aspiration and/or core needle biopsy for subclassifying lymphoma

CONTEXT

The World Health Organization system for lymphoma classification relies on histologic findings from excisional biopsies. In contradistinction to expert guidelines, practitioners increasingly rely on fine-needle aspiration cytology and core needle biopsies rather than excisional biopsies to diagnose lymphomas.

OBJECTIVE

To determine a rate at which fine-needle aspiration cytology and core needle biopsies, combined with flow cytometry and/or genetic techniques, can provide a diagnosis sufficient for optimal medical management of lymphoma.

DATA SOURCES

The English-language literature on fine-needle aspiration cytology and core needle biopsies for lymphoma was reviewed to identify studies that provided interpretations of all specimens regardless of whether these were deemed diagnostic.

CONCLUSIONS

Forty-two studies (1989-2012) specified the lymphoma subtypes for each diagnosis or indicated a rate at which the methods failed to provide a diagnosis. The median rate at which fine-needle aspiration cytology and core needle biopsies yielded a subtype-specific diagnosis of lymphoma was 74%. Strictly adhering to expert guidelines, which state that follicular lymphoma cannot be graded by these techniques, decreased the diagnostic yield further to 66%. Thus, 25% to 35% of fine-needle aspirates and/or core biopsies of nodes must be followed by an excisional lymph node biopsy to fully classify lymphoma.

Diagnosis of Kikuchi-Fujimoto disease: a comparison between open biopsy and minimally invasive ultrasound-guided core biopsy

Kikuchi-Fujimoto disease (KFD) is a self-limited disease without any need of surgical treatments. Sampling of tissue is the only invasive procedure during the clinical course. However, the standard sampling procedure with accuracy, minimal invasiveness, and esthetic maintenance has not been established yet. In this study, a retrospective review of clinical utility and pathological presentations of the ultrasound-guided core biopsy (USCB) and the open biopsy (OB) in consecutive KFD patients. From 2010 to 2012, 34 consecutive patients were enrolled. USCB was performed in 11 patients, and OB was done in 26 patients. KFD was confirmed in 82% cases by USCB. Similar pathological presentations were found both in the specimens of USCB and OB. In the three patients who had received both USCB and OB, KFD was confirmed by USCB in one case, while two by OB. Sampling errors were found both in USCB and OB. For diagnosing KFD, USCB can serve as the first-line diagnostic tool. OB can be applied only in the failed cases of USCB.

CT-guided needle biopsy performed with modified coaxial technique in patients with refractory or recurrent lymphomas

The aim of this study was to evaluate the role of computed tomography (CT)-guided core needle biopsy (CNB) performed by modified coaxial technique as an alternative tool to surgical biopsy in patients with refractory or recurrent lymphomas. Between May 2005 and May 2012, 57 CT-guided CNB of deep lesions were performed in patients with a previous diagnosis of lymphoma and suspected for refractory or recurrent disease. A modified coaxial technique was used in all cases and multiple samples were obtained for histological and immunohistochemical studies. A diagnosis of lymphoma with specification of subtype according to the World Health Organization (WHO) classification was established in 30/57 cases (52.6 %). The previous diagnosis of lymphoma was confirmed in 27/57 patients (47.4 %), whereas histological progression in 3/57 (5.3 %) and other malignant neoplasms in 17/57 (29.8 %) were found. Lymphoma without subtype specification was diagnosed in 6/57 (10.5 %), and no conclusive diagnosis could be established in 4/57 cases (7 %). Overall diagnostic accuracy was 82.5 %. In patients with a final diagnosis of malignant lymphoma, accuracy was 75 %. No complications occurred. Percutaneous CT-guided CNB is a safe, effective and reliable tool in the management of patients with refractory or recurrent lymphomas without superficial lymphadenopathy and can be considered as alternative to surgical sampling.

Cutting needle biopsy combined with immunohistochemical study of myeloperoxidase for the diagnosis of histiocytic necrotizing lymphadenitis

CONCLUSION

Cutting needle biopsy (CNB) combined with immunohistochemical study of myeloperoxidase (MPO) is a useful minimally invasive diagnostic procedure for histiocytic necrotizing lymphadenitis (HNL).

OBJECTIVES

HNL is mainly diagnosed by pathological findings of open surgical biopsy (OSB) specimens. Recently the appearance of anti-MPO positive histiocytes has been reported as a highly specific pathological diagnosis for HNL. Considering the cosmetic impact and burden on the patients, we performed CNB combined with immunohistochemical study of MPO for the diagnosis of HNL. Few studies have reported the utility of this method in the diagnosis of HNL.

METHODS

A retrospective study was conducted using clinical data from 20 HNL patients.

RESULTS

CNB was performed in 8 patients and OSB in 13 (OSB after CNB in 1). MPO-positive histiocytes were observed in all of the 20 cases. The accuracy of the diagnoses was finally confirmed by the clinical courses in all cases.

[Ultrasound in the diagnostic management of malignant lymphomas]

Ultrasound is most useful in detecting and characterizing peripheral and abdominal lymph nodes and infiltration of solid organs. B-mode criteria, such as size, shape, number, distribution architecture, echogenicity and delineation of margins are the basis for characterizing lymph nodes. Additionally color coding techniques such as color Doppler, B-flow and contrast-enhanced ultrasound (CEUS) contribute to the evaluation of the nodal vasculature and vessel architecture. Whenever possible high frequency probes should not only be used for evaluating peripheral lymph nodes but also for lymphatic infiltration of solid organs, especially the spleen. The CEUS technique will be of additional benefit in detecting characterizing potential lymphatic organ infiltration. Ultrasound is an ideal tool for guided punctures, for which core biopsies should be preferred over fine needle aspiration biopsy and CEUS can also be used for proving residual viable tissue after chemotherapy or radiation therapy.

Cervical lymph node extirpation for the diagnosis of malignant lymphoma

PURPOSE

Lymph node enlargement in the neck is a common presentation of malignant lymphoma (ML) and requires tissue sampling for accurate diagnosis. Although delayed diagnosis may be critical for some patients, unnecessary biopsy should be avoided wherever possible. This study examined the process for determining the necessity to perform a biopsy and evaluated the value of an open biopsy as a diagnostic tool to enable definite subclassification of the disease.

METHODS

The subjects included 20 patients with suspected ML who underwent cervical lymph node extirpation at Okayama Saiseikai general hospital between 2007 and 2010. The decision to perform a biopsy was made based on the results of sonographic evaluation, fine needle aspiration cytology (FNAC), and serum levels of lactate dehydrase (LDH) and soluble interleukin-2 receptor (sIL-2r).

RESULTS

The diagnosis was ML in 15 patients (75%), Castleman's disease in 1 (5%), and benign lymphadenopathy in 4 (20%).

CONCLUSIONS

A lymph node biopsy remains the gold standard for the diagnostic evaluation of ML. Sonographic evaluation combined with serum levels of LDH and sIL-2r is useful in determining the need for biopsy. Many of the cases of ML where it was difficult to determine whether a biopsy should be performed were relatively low grade and critical conditions could be avoided by close observation of the patient.

Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches

In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important.

Ultrasound-guided core biopsy in the diagnosis of lymphoma of the head and neck. A 9 year experience

OBJECTIVES

This retrospective study aimed to evaluate the diagnostic utility of ultrasound-guided core biopsy (USCB) in lymphoma of the head and neck, in particular whether core biopsy can provide sufficient diagnostic information for definitive treatment.

METHODS

All lymphomas diagnosed in the head and neck at Eastbourne General Hospital between January 2000 and June 2009 were identified. Radiology and pathology reports were reviewed and the diagnostic techniques recorded. The type of biopsy (fine needle aspiration, needle core, surgical excision biopsy) used to establish a diagnosis sufficient to allow treatment, i.e. the "index" diagnostic technique, was identified. Previous inconclusive or inadequate biopsies were noted. Pathology reports based on USCB were graded 0-3 according to diagnostic completeness and ability to provide treatment information.

RESULTS

Of 691 overall cases of lymphoma diagnosed over the 9 year period, 171 different patients presented with lymphoma in the head and neck. Of these 171, 83 had USCB biopsy during diagnostic work up. 60 were regarded as grade 3 where a confident diagnosis of lymphoma was made. In seven patients, clinical management proceeded on the basis of a suggestive (grade 2) pathology report without surgical excision, and these were therefore also included as "index" biopsies. Overall therefore, 67/83 core biopsies (81%) provided adequate information to allow treatment. Surgical excision biopsy was the index modality in 104 cases.

CONCLUSION

In the majority of cases USCB is adequate for confident histopathological diagnosis avoiding the need for surgical excision biopsy in cases of suspected head and neck lymphoma.

Pediatric head and neck malignancies

PURPOSE OF REVIEW

Although head and neck masses represent a common entity in children, malignancy is uncommon. The otolaryngologist may be the first physician to see these children, and early recognition of malignancy is of obvious importance. This review aims to discuss the cause, diagnosis, investigation, treatment options, and prognosis for the most common head and neck malignancies of childhood.

RECENT FINDINGS

Over recent years, significant developments have been made in characterizing the epidemiologic, phenotypic, and genotypic variability of childhood head and neck cancers. Improved awareness of tumor biology is reflected by more sophisticated diagnostics, estimates of prognosis, and an increasing individualization of treatment regimens.

SUMMARY

The latest evidence for the diagnosis and management of childhood head and neck malignancy is summarized. The rarity of these tumors inevitably results in a paucity of high-level evidence to guide treatment. A combination of translational research from tumor biology studies, multicenter clinical trials, and smaller case series and case reports will continue to guide new advances in diagnosis and treatment.