Use of transoral sonography with an endocavitary transducer in diagnosis, fine-needle aspiration biopsy, and intraoperative localization of retropharyngeal masses

Saline-aided ultrasound-guided transoral biopsy of retropharyngeal nodes in head and neck cancer: A feasibility study of five patients

BACKGROUND

The purpose of this study was to determine the feasibility of the novel technique of intra-cavitary saline-aided ultrasound (US) guided transoral biopsy or excision of retropharyngeal nodes.

METHODS

We followed the IDEAL 2a framework to develop this technique. Procedures were performed between July 2020 and July 2022 at a tertiary head and neck center.

RESULTS

Five patients in total underwent an ultrasound-guided biopsy of a retropharyngeal node. They underwent seven procedures between them: three transoral robotic surgery (TORS) procedures, three fine needle aspirations (FNA) and/or core biopsy procedures, and one US assessment under general anesthetic. The six patients with histology taken (three TORS and three FNA/core biopsies) all had diagnostically adequate samples enabling appropriate treatment planning. There were no significant complications from the procedure.

CONCLUSION

Saline-aided US-guided biopsy of a retropharyngeal node is a safe and useful tool enabling accurate tissue sampling and tumor excision and ongoing appropriate treatment planning.

Endonasopharyngeal ultrasound and magnetic resonance imaging features of recurrent retropharyngeal nodes in nasopharyngeal carcinoma patients: A radiologic-histopathologic study

BACKGROUND

The imaging criteria of malignant retropharyngeal lymph node (RLN) in nasopharyngeal cancer (NPC) have yet to be fully elucidated. This study aimed to establish predictive models based on ultrasound (US) and magnetic resonance (MR) characteristics for identifying malignant RLN in NPC patients after radiotherapy.

METHODS

81 post-radiotherapy NPC patients with abnormal enlargement of RLN underwent endonasopharyngeal ultrasound-guided fine-needle aspirations (EPUS-FNA) to access the nature of RLN. The following features were assessed on US and MR: size, margin, vascular signal, echogenicity, enhancement signal and accompany with suspicious cervical nodes or not. A multivariate analysis was performed to screen out high-risk imaging features for recurrent RLN (RRLN), and models for the diagnosis of RRLN was constructed and tested with internal verification. We evaluated the clinical usefulness of the models through comparison of C-index and decision curve analysis.

RESULTS

High-risk features of RRLN were heterogeneous echo (p < 0.01), vascular signal (p < 0.01) on EPUS, heterogeneous enhancement (p < 0.01) and minimum axis diameter > 10 mm (p < 0.01) on MR. The models based on the US and MR features showed good discrimination (AUC of 0.76 in the US model, 0.74 in the MR model and 0.77 in the US + MR model) and good net benefit in the validation group.

CONCLUSION

Prediction models based on the US and MR features show good diagnostic performance for RRLN after radiotherapy in NPC patients. The combination of EPUS and MR may be constructed to provide prompt and reliable guidance to manage RLN.

Comparative study on efficacy and safety of ultrasound guided transoral and transcutaneous core needle biopsy in patients with oral masses

Background

Ultrasound (US) guided transoral biopsy is a novel and safe procedure for obtaining tissue in patients with oral masses. However, this procedure is less commonly used in comparison to US guided transcutaneous biopsy. The aim of this study is to compare the efficacy and safety of US-guided transoral and transcutaneous core needle biopsy (CNB) in patients with oral masses.

Methods

From November 2019 to March 2021, consecutive patients with oral masses were randomly assigned to undergo US-guided transoral CNB (transoral group) and US-guided transcutaneous CNB from a submental approach (transcutaneous group). During the operation, procedure time, intra‑operative blood loss volume, diagnostic performance, rate of complications and pain level were recorded and compared.

Results

There were 112 patients (62 in the transoral group and 50 in the transcutaneous group) evaluated in this study. The postprocedural complication rate of the transcutaneous group was significantly higher than the transoral group (24% vs. 0%, P = 0.000). There was no significant difference in accuracy (95.2% vs. 88%, P = 0.30), biopsy time (76 ± 12 s vs. 80 ± 13 s, p = 0.09), blood losses (2.6 ± 0.5 mL vs. 2.7 ± 0.4 mL, p = 0.17) and visual analogue score (p = 0.327 and p = 0.444 before and after the sampling procedure) between the two groups.

Conclusion

US-guided transoral CNB results in high rates of technical success and lower rates of postprocedural complications.

Diagnostic and procedural intraoperative ultrasound: technique, tips and tricks for optimizing results

Intraoperative ultrasound (IOUS) is a valuable adjunctive tool that can provide real-time diagnostic information in surgery that has the potential to alter patient management and decrease complications. Lesion localization, characterization and staging can be performed, as well as surveying for additional lesions and metastatic disease. IOUS is commonly used in the liver for hepatic metastatic disease and hepatocellular carcinoma, in the pancreas for neuroendocrine tumors, and in the kidney for renal cell carcinoma. IOUS allows real-time evaluation of vascular patency and perfusion in organ transplantation and allows for early intervention for anastomotic complications. It can also be used to guide intraoperative procedures such as biopsy, fiducial placement, radiation, or ablation. A variety of adjuncts including microbubble contrast and elastography may provide additional information at IOUS. It is important for the radiologist to be familiar with the available equipment, common clinical indications, technique, relevant anatomy and intraoperative imaging appearance to optimize performance of this valuable imaging modality.

Contrast-Enhanced Ultrasound Guided Transoral Core Needle Biopsy: A Novel, Safe and Well-Tolerated Procedure for Obtaining High-Quality Tissue in Patients with Oral Cancer

The aim of the prospective study described here was to compare the tolerability, safety and diagnostic value of contrast-enhanced ultrasound-guided transoral core needle biopsy (CEUS-CNB) with that of conventional US-guided transoral CNB (US-CNB) and standard incisional biopsy in patients with oral masses. Between June 2017 and November 2019, consecutive patients with oral masses referred for biopsy were randomly assigned to undergo incisional biopsy, US-CNB or CEUS-CNB. Procedure time, intra‑operative blood loss volume, diagnostic performance and pain level before and after the procedure assessed by visual analogue score (VAS) were recorded and compared among the three procedures. Finally, 238 patients with pathology confirmation were analyzed: 80 patients underwent incisional biopsy, 78 patients US-CNB and 80 patients CEUS-CNB. In this study, no significant difference was found in biopsy time between CEUS-CNB, US-CNB and incisional biopsy (75 ± 11 s vs. 73.6 ± 12 s vs. 77 ± 13 s, p = 0.24). CEUS-CNB achieved the highest sensitivity (CEUS-CNB: 100%, US-CNB: 88.5%, incisional biopsy: 84.3%), negative predictive value (CEUS-CNB: 100%, US-CNB: 81.3%, incisional biopsy: 78.4%) and accuracy (CEUS-CNB: 100%, US-CNB: 92.3%, incisional biopsy: 90%). The VAS score for incision biopsy was higher (p = 0.01) and the amount of bleeding was larger (p < 0.001), yet there was no significant difference between CEUS-CNB and US-CNB. Our results indicate CEUS-guided transoral CNB is an efficient, safe and well-tolerated procedure, with biopsy time comparable to and diagnostic performance better than those of conventional US-guided transoral CNB and incisional biopsy.

Integrated surgery and radiology: trans-oral robotic surgery guided by real-time radiologist-operated intraoral ultrasound

PURPOSE

We aimed to evaluate the feasibility and utility of intraoral ultrasound as a real-time guidance technique in trans-oral robotic surgery (TORS).

METHODS

We report our early experiences of radiologist-operated intraoral ultrasound during TORS, providing information on tumour margin and important adjacent structures. Resection specimens were sonographically imaged for margin assessment.

RESULTS

Four patients underwent ultrasound-guided TORS, with a close correlation between intraoperative and preoperative imaging in each case. The tumour was fully excised in three cases (one did not proceed due to difficult access). No ultrasound-related adverse events occurred, surgical margins were negative, and the treated patients are currently in a state of remission, with functional swallows.

CONCLUSION

Intraoperative ultrasound can allow previously inaccessible disease to be robotically resected with confidence. Sonographic interrogation of the resected specimen correlated closely with histological margin analysis, and a novel technique of using saline to improve ultrasound conductance and therefore image quality is described.

The role of transoral fine needle aspiration in expediting diagnosis and reducing risk in head and neck cancer patients in the coronavirus disease 2019 (COVID-19) era: a single-institution experience

OBJECTIVE

The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study.

METHOD

Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic.

RESULTS

Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis.

CONCLUSION

Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.

Diagnostic Accuracy and Scope of Intraoperative Transoral Ultrasound and Transoral Ultrasound-Guided Fine-Needle Aspiration of Retropharyngeal Masses

The use of transoral sonography-guided fine-needle aspiration for intraoperative localization of retropharyngeal masses has been described by Fornage et al. The purpose of this study was to assess the accuracy of this technique. We reviewed the images and medical records of 26 patients with a retropharyngeal lesion suspicious for a metastatic lymph node of Rouviere identified on CT and/or PET/CT. There were 14 patients with a history of thyroid cancer, 7 with mucosal squamous cell carcinoma, 1 with renal cell carcinoma, 1 with parotid acinic cell cancer, 1 with metastatic colon adenocarcinoma, and 2 with no history of cancer. Intraoperative transoral sonography was performed using a commercially available endovaginal transducer. A transoral sonography-guided fine-needle aspiration was performed with a 25-cm-long 20-ga Chiba needle through a needle guide attached to the transducer shaft. Cytopathologic results were categorized as malignant, benign, or nondiagnostic. Transoral sonography and transoral sonography-guided fine-needle aspiration were performed in all patients. A diagnostic specimen was obtained in 25 of 26 (96%) patients with a 100% overall accuracy. Twelve patients underwent subsequent transoral resection of the retropharyngeal mass. In each patient, surgical pathology confirmed the fine-needle aspiration biopsy result. In 4 patients, transoral sonography-guided injection of methylene blue was used to facilitate intraoperative localization of the metastatic retropharyngeal mass. Transoral sonography and transoral sonography-guided fine-needle aspiration of suspicious masses in the retropharyngeal space are highly accurate procedures for identification and cytologic evaluation of benign and metastatic lymph nodes of Rouviere and for presurgical localization.

Treatment for retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site: results of a prospective study with irradiation to nasopharyngeal mucosa plus bilateral neck

Background and Objective

To evaluate treatment outcomes for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma (SCC) from an unknown primary site.

Methods

From January 2005 to January 2015, patients who presented with enlarged retropharyngeal nodes underwent transoral sonography-guided fine-needle aspiration to confirm histology. Those with metastatic undifferentiated SCC with unknown primary tumors were treated with radical radiotherapy to nasopharyngeal mucosa plus bilateral neck. Chemotherapy was administered for patients staged N2-3. Endpoints included metastatic nodes control, the appearance of primary tumor, overall survival and treatment-related toxicities.

Results

A total of 49 patients were recruited into this study. Retropharyngeal and cervical nodal disease was controlled in 96% of all patients. The incidence of occult primary cancer appearance was 8%. No primary cancer other than of the nasopharynx was detected during the course of follow-up. Ten patients developed distant metastases. The 5-year overall survival, progression-free survival, regional relapse free survival, distant metastasis free survival were 79.6%, 61.1%, 83.4%, 73.8%, respectively. Common late adverse effects included xerostomia (57%) and hearing impairment (35%).

Conclusion

Radical radiotherapy to both the nasopharynx and bilateral neck can achieve excellent outcome with mild toxicities for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site.

Tailored multimodality therapy guided by a two-step decision making process for head-and-neck cancer of unknown primary

Background

There is no consensus on the treatment of head-and-neck cancer of unknown primary (HNCUP). The objective of this study is to report our single institution's experience of a tailored multimodality therapy guided by a two-step decision making process.

Materials and Methods

From January 2007 to November 2013, 92 consecutive patients of HNCUP were treated. 77 patients were treated according the process above, 24 were treated by radiotherapy to the nasopharyngeal site, 7 received neck dissection and radiotherapy to other putative mucosal site, 30 were treated by neck dissection alone, and 16 received neck dissection followed by radiotherapy to the neck. SPSS 20.0 software was used for statistical analysis.

Results

After a median follow-up of 34 months, the 3-year overall survival rate was 84.5%. The 3-year mucosal control rate, neck control rate, distant metastasis-free survival rate and disease-free survival rate were 80.9%, 76.2%, and 92.0%, respectively. Of the 24 patients treated as putative nasopharyngeal carcinoma, no primary emerged from any site. Primary tumor emerged in 14 patients, and no primary emerged in the 31 patients treated with putative site radiation (3-year mucosal control rate: 100% vs. 67.9%, p = 0.010). Of the 46 patients treated with neck dissection with/without postoperative radiation, 14 developed neck recurrence, and patients without postoperative radiation suffered more ipsilateral neck recurrence.

Conclusions

The two-step decision-making process seem to be reasonable in treating Chinese HNCUP patients. However, this results need to be prospectively validated.

Ultrasound-Guided Transoral Videolaryngoscopic Surgery for Retropharyngeal Lymph Node Metastasis of Papillary Thyroid Cancer

Background

Endoscopic-assisted transoral surgery, including transoral robotic surgery for metastatic retropharyngeal lymph node (RPN) from well-differentiated thyroid cancer, has been reported to reduce the complications resulting from transcervical and transmandibular approaches. However, the narrow working space and difficulty identifying RPN are problematic. To solve these issues, several studies have used intraoperative ultrasound in endoscopic-assisted transoral surgery. However, the type of ultrasonography suitable for this purpose remains unclear.

Case Presentation

A 60-year-old female with thyroid papillary carcinoma (T4aN1bM0) initially underwent total thyroidectomy and paratracheal and selective neck dissections (D2a), with resectional management of recurrent laryngeal nerve, trachea, and esophagus. Three years later, she was diagnosed with left retropharyngeal and upper mediastinal lymph node metastases of papillary thyroid cancer. Transoral videolaryngoscopic surgery was performed with a combination of ultrasonography with a flexible laparoscopic transducer manipulated with forceps for identifying RPN intraoperatively. Due to the transducer's small size and thin, flexible cable, the transducer interrupted the procedure in spite of the narrowness of oral cavity. RPN was resected completely without adverse events.

Conclusion

We performed intraoperative ultrasound-guided endoscopic transoral surgery for metastatic RPN from papillary thyroid cancer and achieved complete resection as well as preservation of swallowing function.

Trans-oral robotic surgery and surgeon-performed trans-oral ultrasound for intraoperative location and excision of an isolated retropharyngeal lymph node metastasis of papillary thyroid carcinoma

BACKGROUND

Retropharyngeal metastases are uncommon but a well-known location for regional spread of well-differentiated thyroid carcinoma (WDTC). Surgeon-performed, trans-oral ultrasound (SP-TO-US) and trans-oral robot-assisted surgical (TORS) excision represent a unique combination of technology and techniques in the treatment of isolated retropharyngeal thyroid metastases.

PATIENT FINDINGS

A patient with a history of T3N1b papillary thyroid carcinoma (PTC) previously treated with total thyroidectomy, left central and lateral neck dissection, and radioactive iodine presented with progressive elevations in serum thyroglobulin (Tg) from baseline of 0.2 to 0.6 μg/L. She was found to have an isolated 2.6 cm left retropharyngeal nodal metastasis on MRI that was confirmed to be PTC on fine needle aspiration biopsy. She underwent SP-TO-US for identification of the node in the operating room immediately prior to TORS excision. There were no complications. Additional radioactive iodine was administered. Post-treatment iodine scans revealed resolution of avid uptake in left retropharynx and return of Tg to 0.2 μg/L.

SUMMARY

The combination of SP-TO-US and TORS represents a novel combination of technology and technique for treatment of isolated retropharyngeal metastasis in WDTC. Trans-oral ultrasound allows for rapid localization of the lesion in relation to the adjacent neurovascular structures in the parapharynx while the robot-assisted approach affords a safe and effective dissection through the improved visualization and dexterity in a small working space. Our patient had no complications and only short-term dysphagia that resolved after temporary diet alteration. Risks and long-term morbidities associated with classical approaches to the retropharynx including trans-cervical and trans-mandibular, particularly in a previously dissected field, are avoided through this trans-oral approach.

CONCLUSIONS

Retropharyngeal metastases are a known location for regional spread of WDTC and are amenable to evaluation and biopsy using TO-US by both surgical and non-surgical providers. In cases where lateral neck dissection has already been performed or when traditional transcervical or transmandibular approaches to the retropharynx represent a comparatively extensive procedure for isolated metastases, SP-TO-US and TORS are safe and effective combination for surgical management of disease.