Image-Guided Needle Biopsy of Inaccessible Head and Neck Lesions K. Thomas Robbins, MD; Eric
vanSonnenberg, MD; Giovanna Casola, MD; Robert R. Varney, MD
\s=b\ Fine-needle
core
biopsy and large-needle biopsy of inaccessible and deep\x=req-\
space lesions of the head and neck are difficult and sometimes hazardous to perform. Patients subsequently may have to undergo a major surgical procedure with exploration of the neck and open biopsy. We describe our experience with computed tomography and ultrasound-guided fine-needle and core-needle biopsy for 11 patients with inaccessible lesions in the head and neck. Carcinoma was diagnosed in three patients and nonmalignant pathologic findings in eight patients. Three of the needle biopsy findings were confirmed by surgical excision. The initial diagnoses made from the cytopathologic findings have remained unchanged in all patients. Compared with the alternative of open biopsy, we have found this method to be technically easy, diagnostically expeditious, and safe. Head and neck surgical oncologists should be familiar with image\x=req-\ guided biopsy techniques, since many of their patients may benefit from these di-
agnostic procedures. (Arch Otolaryngol Head Neck Surg. 1990;116:957-961) Accepted for publication March 20, 1990. From the Division of Otolaryngology\p=n-\Head and Neck Surgery (Dr Robbins) and Department of Radiology (Drs vanSonnenberg, Casola, and Varney), University of California at San Diego
Medical Center. Presented at the Second International Conference for Head and Neck Cancer, Boston, Mass, July 30-August 5, 1988. Reprint requests to the Division of Otolaryngology\p=n-\Head and Neck Surgery, University of California at San Diego Medical Center, 225 Dickinson St, H891B, San Diego, CA 92103 (Dr
Robbins).
of needle
types biopsies Various using large-core gained diagnostic fine- or wide
needles have usage for patients presenting with lesions of various types involving almost any body site. The head and neck region is no exception. The technical advantage of needle biopsy is the capability to re¬ move tissue for pathological examina¬ tion that avoids more extensive proce¬ dures that may compromise the even¬ tual treatment. Fine-needle biopsy provides cyto¬ logie material for diagnostic interpre¬ tation. When sufficient numbers of cells can be harvested, a pellet of cells for histologie sectioning can be made by centrifugation of the yield. The ac¬ curacy of this technique in the hands of experienced cytopathologists is ex¬ tremely reliable. This approach has gained substantial popularity in the past decade for head and neck lesions, particularly thyroid nodules and pal¬ pable masses of the neck.13 Since some lesions presenting in the head and neck are not readily palpable, conventional needle biopsy techniques are usually unsuitable and sometimes hazardous. We have been successful in obtaining a high yield of representa¬ tive tissue and avoiding significant
complications by using image-guided techniques to direct the accurate placement of the needle tip. The imag¬ ing techniques include the use of com-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
puted tomography (CT) and ultra¬ sound. We describe our experience with this diagnostic approach and pro¬ vide case examples to illustrate the advantages over open biopsy proce¬ dures.
MATERIALS AND METHODS Eleven patients who presented to our in¬ stitution between January 1986 and June 1988, with lesions of the head and neck un¬ derwent image-guided needle biopsy proce¬ dures. Included were four patients with thyroid nodules that were difficult to pal¬ pate, but were clearly depicted by ultra¬ sound; three patients with cervical retrotracheal masses that were visible by CT and/or ultrasound; three patients with deep-neck masses demonstrated on CT scan; and one patient with a lytic lesion of the mandible (Table). Biopsy was performed with ultrasound or CT guidance. Ultrasound was chosen when lesions and surrounding vital structures were well visualized. Computed tomog¬ raphy was reserved for lesions that were poorly seen or nonvisualized on ultrasound, or were located posterior to the trachea and shielded by air. Several commercially avail¬ able real-time, high-resolution ultrasound units were used for biopsy guidance; 7.5, 5, and 3.5 MHZ transducers were used. Com¬
puted tomographic guidance was provided by Scanners (GE 9800 and Technicare 2020 and 2060 scanners). Coagulation studies (prothrombin time, partial thromboplastin time, and platelets) were performed in all patients and the re¬ sults were normal before biopsies were
Summary of Patients* Other Methods Patient
Clinical Presentation Dysphagia, retrotracheal
Image-Guided Biopsy Technique
Results of Guided Needle Biopsy
CT fine needle
Squamous
cell
carcinoma
mass
Dysphagia, retrotracheal diagnosis of
CT fine needle
Chronic inflammation
trauma /mass
Neck mass
Jaw
pain; S/P surgery radiotherapy for malignant melanoma
the lower
and
retrotracheal
mass
*CT
indicates
lymph
Transtracheal needle biopsy
Ultrasound fine needle CT core needle
Branchial cleft
Surgical
cyst Osteonecrosis
resection None
Ultrasound
3 of 4
CT fine needle Ultrasound fine needle
Carcinoma Metastatic carcinoma No malignancy
status
performed. Needle placement and biopsy passes were then performed using either the tandem or the coaxial technique. Using the tandem technique, a 22-gauge Chiba (15 cm) or spinal needle (6 or 9 cm) was initially placed into the lesion as a localizing land¬ mark. If the original needle was malpositioned, another needle was inserted until the lesion was engaged. Once in place, a second needle was inserted adjacent to the localizing needle. Multiple passes were ob¬ tained with the second needle. Biopsy passes were made with similar needles or with 18- to 22-gauge cutting needles (Surecut). With the coaxial technique, the initial localizing needle was 23 gauge. The hub of the needle was removed and a 19-gauge needle was inserted over the inner localiz¬ ing needle until there was engagement of the lesion. At that point, the inner needle was removed and biopsy passes were made through the 19-gauge cannula with 22gauge needles (coaxial system). Two to four passes were made routinely (Fig 1). Cytol¬ ogy technologists processed the material immediately and a preliminary cytologie evaluation of the quick stains was available within 15 minutes. The remaining material was put in Ringer's solution and filtered for permanent stains. RESULTS
Cytopathological findings patients undergoing image-guided bi¬
opsy are shown in the Table. Two of the three patients who were diagnosed to
subsequently under-
of
mass over
6
mo
in
keeping with the diagnosis Surgical findings confirmed the diagnosis Response to hyperbaric oxygen therapy in keeping with diagnosis
Excision
Surgical findings confirmed
(Fig 5)
post.
surgical procedures with confir¬ mation of the needle biopsy findings. Follow-up of all patients with nonmalignant findings on cytopathology did not result in the diagnosis being changed. One of these patients under¬ went surgery for a branchial cleft cyst. went
REPORT OF CASES The following case examples depict the indications and usefulness of the imageguided needle biopsy technique. Case I.—A 74-year-old man presented with progressive dysphagia. Fiberoptic gastroscopy revealed stenosis of the esoph¬ ageal inlet and the esophagoscope could not be passed beyond this site. A CT scan of the neck showed a retrotracheal mass approx¬ imately 4 cm below the glottis. Rigid esophagoscopy and bronchoscopy confirmed this finding, but endoscopie punch biopsies were nondiagnostic. The CT-guided needle bi¬ opsy demonstrated squamous cell carci¬ noma. The patient subsequently underwent a total laryngopharyngoesophagectomy and gastric transposition for carcinoma of the cervical esophagus (Fig 2). Comment.—Deep visceral space lesions of the neck and thoracic inlet are often non-
palpable; they are difficult to biopsy by con¬
for the 11
Comments
biopsy of carcinoma confirmed by surgical pathologic findings Similar findings with both biopsies, slow regression Needle
biopsies provided representative thyroid tissue with benign lesions (Fig 4)
Ultrasound fine needle
node
computed tomography; S/P,
have carcinoma
resection
of
Neck
Cervical
Surgical
lip_
Thyroid
lump Dysphagia,
of Tissue Removal
ventional techniques without exposure through a cervical incision. This approach is not ideal, since the surgeon should be prepared to proceed with a definitive resec¬ tion if indicated. The CT-guided biopsy technique used in this case provided suffi-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
cient information to allow proper treat¬ ment planning and counseling for a major extirpative and reconstructive endeavor. Case 2.—A 26-year-old man presented with a fluctuating mass on the right side of the neck overlying the middle portion of the carotid sheath. The mass intermittently enlarged to a maximum of 10 cm in diame¬ ter, with interval regression to a nondis¬ crete 2-cm firmness. Tenderness and dis¬ comfort were associated with enlargement of the mass. Nonguided fine-needle biopsies were attempted on two occasions, each of which provided inconclusive cytopathologic material. Computed tomography of the neck showed a solid tissue mass immedi¬ ately overlying the carotid sheath. Using the CT image for guidance, a needle biopsy was performed. The cytologie findings re¬ vealed a mixture of lymphocytes, plasma cells, and epithelial cells. This was believed to be consistent with an infected branchial cleft cyst and the diagnosis was subse¬ quently confirmed when the mass was ex¬
cised (Fig 3). Comment.—Previous needle biopsies in this case were inconclusive, probably be¬ cause nonrepresentative inflammatory tis¬ sue was erroneously sampled. The imageguided technique permitted sampling of solid tissue within the mass immediately overlying the carotid sheath without injury to the surrounding major vessels. The cyto¬ pathologic findings were consistent with an
inflammatory process occurring in a con¬ genital cyst rather than an isolated inflam¬ matory process. Surgical intervention was based on the findings of the needle biopsy.
Fig 1.—The variety of needles used for imag¡ng-guided head and neck biopsies (from top: 3 sizes of Surecut modified Menghini needles (19-, 21-, 22-gauge); vanSonnenberg coaxial set (Cook Co Ine, Bloomington, Ind) 10-cm re¬ movable hub, 23-gauge; 15-cm Chiba biopsy needle; 10 cm, Chiba biopsy needle; and 5-cm 19-gauge outer cannula.
Fig 2.—Computed tomographic-guided retro¬ tracheal biopsy after unsuccessful endoscopie biopsy; the needle is passed between the tra¬ chea and the carotid sheath into the mass. The cytopathologic findings were squamous cell carcinoma.
COMMENT
The usefulness of the image-guided needle biopsy technique for lesions of the head and neck is directly related to the expertise of the interventional ra¬ diologist and the cytopathologist, working with the head and neck sur-
geon. Interventional
first needle developed image-guided biopsy techniques for evaluation of intrathoracic and intra-abdominal lesions. Vir¬ tually any lesion larger than 0.5 cm can be reached by these methods and a bi¬ opsy obtained. The method of guidance is tailored to the individual patient.
radiologists
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
Fluoroscopy, ultrasound, and CT are all used routinely. Goldfinger et al3 re¬ ported ultrasound-guided needle bi¬ opsy to be highly effective for obtain¬ ing diagnostic samples from thyroid nodules in 13 of 14 patients who other¬ wise could not have a diagnostic thy¬ roid aspiration because their nodules
Fig 3.—Computed tomographic-guided biopsy of an infected branchial cleft cyst. Left, Low-density lesion (arrowheads) in right lateral tissues of the neck in a patient with recurrent fever. Right, Needle in lesion.
the
Fig 4.—Ultrasound-guided biopsy of a thyroid nodule that was difficult palpate. The echogenic needle (arrowhead) is seen within the inferior right lobe nodule. The cytopathologic findings were consistent with a thyroid adenoma. to
Fig 5.—Ultrasound-guided biopsy of lateral neck mass; echogenic nee¬ dle (arrow) is seen within the hypoechoic lymph node.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
were
in difficult locations
or were
not
palpable. Recently magnetic reso¬ nance imaging has been used for ab¬ dominal, thoracic, and neck lesions, using minimally magnetic "needle" materials guided by the magnetic res¬ onance image. The benefit of ultra¬ sound, CT, and magnetic resonance imaging is the capability to visualize not only small lesions, but adjacent vi¬
tal structures and to avoid the latter with the needles. With these sectional imaging methods, the needle tip is seen with certainty, proving accurate nee¬ dle position for the biopsy. The success of image-guided needle biopsy also depends on the expertise of the cytopathologist. Effective commu¬ nication between this person and the head and neck surgeon is important for accurate interpretation of the find¬ ings. While malignant abnormalities may be readily identified, cytologie features that indicate benign disease also are possible, since the level of confidence for obtaining representa¬ tive tissue is high. It is also advanta¬ geous to perform immediate cytologie smears for preliminary evaluation to insure that sufficient representative tissue has been removed. Needle biopsy techniques also can be
performed endoscopically in the head and neck region. Specially designed elongated needles are available, which can be passed through a rigid scope and into the suspected lesion. Al¬ though the endoscopie technique may be satisfactory for selected lesions of the upper aerodigestive tract, it does not provide the operator with the vi¬ sual image of the needle tip and its spatial relation to the mass. Imageguided techniques provide precise spa¬ tial localization of the needle tip within the most suspicious area of the lesion. The three patients with retro¬ tracheal masses described in this arti¬ cle had the transcutaneous needle bi¬ opsy without needle transgression of any portion of the upper aerodigestive tract or of any major vessels. Traditionally, large-bore needles have been used to provide a core of tis¬ sue for histologie examination, and small-bore needles have been used to examine the cytologie features of tis¬ sue. However, we have been able to use small-bore needles to harvest core pieces of tissue in sufficient quantities to permit histologie evaluation. The advantage of this technique is avoid¬ ance of excessive bleeding following the biopsy, which is sometimes en-
countered using large-bore needles. Accuracy of needle placement pro¬ vided by imaging guidance in most cases obviates the need to place larger and more hazardous needles. In conclusion, we have found that the image-guided needle biopsy tech¬ nique for patients with selected lesions of the head and neck to be a valuable diagnostic procedure. Useful informa¬ tion is obtained with this approach
and, in
many instances, proper ther¬ apy can be planned based on the biopsy
diagnosis. However, image-guided needle biopsy technique requires the expertise of an interventional radiolo¬ gist and a cytopathologist. Effective communication between them and the head and neck surgeon is crucial to op¬ timize the usefulness of this approach. References 1. Gersengoin MC, McClung MR, Chu EW, Hanson TAS, Weintraub BD, Robbins J. Fine\x=req-\ needle aspiration cytology in the pre-operative diagnosis of thyroid nodules. Ann Intern Med.
1977;87:265-269. 2. Zajicek J. Aspiration biopsy cytology, I: cytology of supradiaphragmatic organs. In: Wied GIL, ed. Monographs in Clinical Cytology. New York, NY: S Karger; 1974;4. 3. Goldfinger M, Rothberg R, Stoll S. Sonographic guidance of thyroid needle biopsy. J Can Assoc Radiol. 1986;37:186-188.
In Other AMA Journals JAMA
International and Interstate Comparisons of Homicide Among Young Males L. A. Fingerhut, J. C. Kleinman (JAMA. 1990;263:3292) The Worldwide Smoking Epidemic Council on Scientific Affairs (JAMA. 1990,263:3312) The Human Genome Project and International Health J. D. Watson, R. M. Cook-Degan (JAMA. 1990;263:3322)
Seeking New Dimensions in International Health Research P. E. Schambra (JAMA. 1990;263:3325)
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
vanSonnenberg, MD; Giovanna Casola, MD; Robert R. Varney, MD
\s=b\ Fine-needle
core
biopsy and large-needle biopsy of inaccessible and deep\x=req-\
space lesions of the head and neck are difficult and sometimes hazardous to perform. Patients subsequently may have to undergo a major surgical procedure with exploration of the neck and open biopsy. We describe our experience with computed tomography and ultrasound-guided fine-needle and core-needle biopsy for 11 patients with inaccessible lesions in the head and neck. Carcinoma was diagnosed in three patients and nonmalignant pathologic findings in eight patients. Three of the needle biopsy findings were confirmed by surgical excision. The initial diagnoses made from the cytopathologic findings have remained unchanged in all patients. Compared with the alternative of open biopsy, we have found this method to be technically easy, diagnostically expeditious, and safe. Head and neck surgical oncologists should be familiar with image\x=req-\ guided biopsy techniques, since many of their patients may benefit from these di-
agnostic procedures. (Arch Otolaryngol Head Neck Surg. 1990;116:957-961) Accepted for publication March 20, 1990. From the Division of Otolaryngology\p=n-\Head and Neck Surgery (Dr Robbins) and Department of Radiology (Drs vanSonnenberg, Casola, and Varney), University of California at San Diego
Medical Center. Presented at the Second International Conference for Head and Neck Cancer, Boston, Mass, July 30-August 5, 1988. Reprint requests to the Division of Otolaryngology\p=n-\Head and Neck Surgery, University of California at San Diego Medical Center, 225 Dickinson St, H891B, San Diego, CA 92103 (Dr
Robbins).
of needle
types biopsies Various using large-core gained diagnostic fine- or wide
needles have usage for patients presenting with lesions of various types involving almost any body site. The head and neck region is no exception. The technical advantage of needle biopsy is the capability to re¬ move tissue for pathological examina¬ tion that avoids more extensive proce¬ dures that may compromise the even¬ tual treatment. Fine-needle biopsy provides cyto¬ logie material for diagnostic interpre¬ tation. When sufficient numbers of cells can be harvested, a pellet of cells for histologie sectioning can be made by centrifugation of the yield. The ac¬ curacy of this technique in the hands of experienced cytopathologists is ex¬ tremely reliable. This approach has gained substantial popularity in the past decade for head and neck lesions, particularly thyroid nodules and pal¬ pable masses of the neck.13 Since some lesions presenting in the head and neck are not readily palpable, conventional needle biopsy techniques are usually unsuitable and sometimes hazardous. We have been successful in obtaining a high yield of representa¬ tive tissue and avoiding significant
complications by using image-guided techniques to direct the accurate placement of the needle tip. The imag¬ ing techniques include the use of com-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
puted tomography (CT) and ultra¬ sound. We describe our experience with this diagnostic approach and pro¬ vide case examples to illustrate the advantages over open biopsy proce¬ dures.
MATERIALS AND METHODS Eleven patients who presented to our in¬ stitution between January 1986 and June 1988, with lesions of the head and neck un¬ derwent image-guided needle biopsy proce¬ dures. Included were four patients with thyroid nodules that were difficult to pal¬ pate, but were clearly depicted by ultra¬ sound; three patients with cervical retrotracheal masses that were visible by CT and/or ultrasound; three patients with deep-neck masses demonstrated on CT scan; and one patient with a lytic lesion of the mandible (Table). Biopsy was performed with ultrasound or CT guidance. Ultrasound was chosen when lesions and surrounding vital structures were well visualized. Computed tomog¬ raphy was reserved for lesions that were poorly seen or nonvisualized on ultrasound, or were located posterior to the trachea and shielded by air. Several commercially avail¬ able real-time, high-resolution ultrasound units were used for biopsy guidance; 7.5, 5, and 3.5 MHZ transducers were used. Com¬
puted tomographic guidance was provided by Scanners (GE 9800 and Technicare 2020 and 2060 scanners). Coagulation studies (prothrombin time, partial thromboplastin time, and platelets) were performed in all patients and the re¬ sults were normal before biopsies were
Summary of Patients* Other Methods Patient
Clinical Presentation Dysphagia, retrotracheal
Image-Guided Biopsy Technique
Results of Guided Needle Biopsy
CT fine needle
Squamous
cell
carcinoma
mass
Dysphagia, retrotracheal diagnosis of
CT fine needle
Chronic inflammation
trauma /mass
Neck mass
Jaw
pain; S/P surgery radiotherapy for malignant melanoma
the lower
and
retrotracheal
mass
*CT
indicates
lymph
Transtracheal needle biopsy
Ultrasound fine needle CT core needle
Branchial cleft
Surgical
cyst Osteonecrosis
resection None
Ultrasound
3 of 4
CT fine needle Ultrasound fine needle
Carcinoma Metastatic carcinoma No malignancy
status
performed. Needle placement and biopsy passes were then performed using either the tandem or the coaxial technique. Using the tandem technique, a 22-gauge Chiba (15 cm) or spinal needle (6 or 9 cm) was initially placed into the lesion as a localizing land¬ mark. If the original needle was malpositioned, another needle was inserted until the lesion was engaged. Once in place, a second needle was inserted adjacent to the localizing needle. Multiple passes were ob¬ tained with the second needle. Biopsy passes were made with similar needles or with 18- to 22-gauge cutting needles (Surecut). With the coaxial technique, the initial localizing needle was 23 gauge. The hub of the needle was removed and a 19-gauge needle was inserted over the inner localiz¬ ing needle until there was engagement of the lesion. At that point, the inner needle was removed and biopsy passes were made through the 19-gauge cannula with 22gauge needles (coaxial system). Two to four passes were made routinely (Fig 1). Cytol¬ ogy technologists processed the material immediately and a preliminary cytologie evaluation of the quick stains was available within 15 minutes. The remaining material was put in Ringer's solution and filtered for permanent stains. RESULTS
Cytopathological findings patients undergoing image-guided bi¬
opsy are shown in the Table. Two of the three patients who were diagnosed to
subsequently under-
of
mass over
6
mo
in
keeping with the diagnosis Surgical findings confirmed the diagnosis Response to hyperbaric oxygen therapy in keeping with diagnosis
Excision
Surgical findings confirmed
(Fig 5)
post.
surgical procedures with confir¬ mation of the needle biopsy findings. Follow-up of all patients with nonmalignant findings on cytopathology did not result in the diagnosis being changed. One of these patients under¬ went surgery for a branchial cleft cyst. went
REPORT OF CASES The following case examples depict the indications and usefulness of the imageguided needle biopsy technique. Case I.—A 74-year-old man presented with progressive dysphagia. Fiberoptic gastroscopy revealed stenosis of the esoph¬ ageal inlet and the esophagoscope could not be passed beyond this site. A CT scan of the neck showed a retrotracheal mass approx¬ imately 4 cm below the glottis. Rigid esophagoscopy and bronchoscopy confirmed this finding, but endoscopie punch biopsies were nondiagnostic. The CT-guided needle bi¬ opsy demonstrated squamous cell carci¬ noma. The patient subsequently underwent a total laryngopharyngoesophagectomy and gastric transposition for carcinoma of the cervical esophagus (Fig 2). Comment.—Deep visceral space lesions of the neck and thoracic inlet are often non-
palpable; they are difficult to biopsy by con¬
for the 11
Comments
biopsy of carcinoma confirmed by surgical pathologic findings Similar findings with both biopsies, slow regression Needle
biopsies provided representative thyroid tissue with benign lesions (Fig 4)
Ultrasound fine needle
node
computed tomography; S/P,
have carcinoma
resection
of
Neck
Cervical
Surgical
lip_
Thyroid
lump Dysphagia,
of Tissue Removal
ventional techniques without exposure through a cervical incision. This approach is not ideal, since the surgeon should be prepared to proceed with a definitive resec¬ tion if indicated. The CT-guided biopsy technique used in this case provided suffi-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
cient information to allow proper treat¬ ment planning and counseling for a major extirpative and reconstructive endeavor. Case 2.—A 26-year-old man presented with a fluctuating mass on the right side of the neck overlying the middle portion of the carotid sheath. The mass intermittently enlarged to a maximum of 10 cm in diame¬ ter, with interval regression to a nondis¬ crete 2-cm firmness. Tenderness and dis¬ comfort were associated with enlargement of the mass. Nonguided fine-needle biopsies were attempted on two occasions, each of which provided inconclusive cytopathologic material. Computed tomography of the neck showed a solid tissue mass immedi¬ ately overlying the carotid sheath. Using the CT image for guidance, a needle biopsy was performed. The cytologie findings re¬ vealed a mixture of lymphocytes, plasma cells, and epithelial cells. This was believed to be consistent with an infected branchial cleft cyst and the diagnosis was subse¬ quently confirmed when the mass was ex¬
cised (Fig 3). Comment.—Previous needle biopsies in this case were inconclusive, probably be¬ cause nonrepresentative inflammatory tis¬ sue was erroneously sampled. The imageguided technique permitted sampling of solid tissue within the mass immediately overlying the carotid sheath without injury to the surrounding major vessels. The cyto¬ pathologic findings were consistent with an
inflammatory process occurring in a con¬ genital cyst rather than an isolated inflam¬ matory process. Surgical intervention was based on the findings of the needle biopsy.
Fig 1.—The variety of needles used for imag¡ng-guided head and neck biopsies (from top: 3 sizes of Surecut modified Menghini needles (19-, 21-, 22-gauge); vanSonnenberg coaxial set (Cook Co Ine, Bloomington, Ind) 10-cm re¬ movable hub, 23-gauge; 15-cm Chiba biopsy needle; 10 cm, Chiba biopsy needle; and 5-cm 19-gauge outer cannula.
Fig 2.—Computed tomographic-guided retro¬ tracheal biopsy after unsuccessful endoscopie biopsy; the needle is passed between the tra¬ chea and the carotid sheath into the mass. The cytopathologic findings were squamous cell carcinoma.
COMMENT
The usefulness of the image-guided needle biopsy technique for lesions of the head and neck is directly related to the expertise of the interventional ra¬ diologist and the cytopathologist, working with the head and neck sur-
geon. Interventional
first needle developed image-guided biopsy techniques for evaluation of intrathoracic and intra-abdominal lesions. Vir¬ tually any lesion larger than 0.5 cm can be reached by these methods and a bi¬ opsy obtained. The method of guidance is tailored to the individual patient.
radiologists
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
Fluoroscopy, ultrasound, and CT are all used routinely. Goldfinger et al3 re¬ ported ultrasound-guided needle bi¬ opsy to be highly effective for obtain¬ ing diagnostic samples from thyroid nodules in 13 of 14 patients who other¬ wise could not have a diagnostic thy¬ roid aspiration because their nodules
Fig 3.—Computed tomographic-guided biopsy of an infected branchial cleft cyst. Left, Low-density lesion (arrowheads) in right lateral tissues of the neck in a patient with recurrent fever. Right, Needle in lesion.
the
Fig 4.—Ultrasound-guided biopsy of a thyroid nodule that was difficult palpate. The echogenic needle (arrowhead) is seen within the inferior right lobe nodule. The cytopathologic findings were consistent with a thyroid adenoma. to
Fig 5.—Ultrasound-guided biopsy of lateral neck mass; echogenic nee¬ dle (arrow) is seen within the hypoechoic lymph node.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
were
in difficult locations
or were
not
palpable. Recently magnetic reso¬ nance imaging has been used for ab¬ dominal, thoracic, and neck lesions, using minimally magnetic "needle" materials guided by the magnetic res¬ onance image. The benefit of ultra¬ sound, CT, and magnetic resonance imaging is the capability to visualize not only small lesions, but adjacent vi¬
tal structures and to avoid the latter with the needles. With these sectional imaging methods, the needle tip is seen with certainty, proving accurate nee¬ dle position for the biopsy. The success of image-guided needle biopsy also depends on the expertise of the cytopathologist. Effective commu¬ nication between this person and the head and neck surgeon is important for accurate interpretation of the find¬ ings. While malignant abnormalities may be readily identified, cytologie features that indicate benign disease also are possible, since the level of confidence for obtaining representa¬ tive tissue is high. It is also advanta¬ geous to perform immediate cytologie smears for preliminary evaluation to insure that sufficient representative tissue has been removed. Needle biopsy techniques also can be
performed endoscopically in the head and neck region. Specially designed elongated needles are available, which can be passed through a rigid scope and into the suspected lesion. Al¬ though the endoscopie technique may be satisfactory for selected lesions of the upper aerodigestive tract, it does not provide the operator with the vi¬ sual image of the needle tip and its spatial relation to the mass. Imageguided techniques provide precise spa¬ tial localization of the needle tip within the most suspicious area of the lesion. The three patients with retro¬ tracheal masses described in this arti¬ cle had the transcutaneous needle bi¬ opsy without needle transgression of any portion of the upper aerodigestive tract or of any major vessels. Traditionally, large-bore needles have been used to provide a core of tis¬ sue for histologie examination, and small-bore needles have been used to examine the cytologie features of tis¬ sue. However, we have been able to use small-bore needles to harvest core pieces of tissue in sufficient quantities to permit histologie evaluation. The advantage of this technique is avoid¬ ance of excessive bleeding following the biopsy, which is sometimes en-
countered using large-bore needles. Accuracy of needle placement pro¬ vided by imaging guidance in most cases obviates the need to place larger and more hazardous needles. In conclusion, we have found that the image-guided needle biopsy tech¬ nique for patients with selected lesions of the head and neck to be a valuable diagnostic procedure. Useful informa¬ tion is obtained with this approach
and, in
many instances, proper ther¬ apy can be planned based on the biopsy
diagnosis. However, image-guided needle biopsy technique requires the expertise of an interventional radiolo¬ gist and a cytopathologist. Effective communication between them and the head and neck surgeon is crucial to op¬ timize the usefulness of this approach. References 1. Gersengoin MC, McClung MR, Chu EW, Hanson TAS, Weintraub BD, Robbins J. Fine\x=req-\ needle aspiration cytology in the pre-operative diagnosis of thyroid nodules. Ann Intern Med.
1977;87:265-269. 2. Zajicek J. Aspiration biopsy cytology, I: cytology of supradiaphragmatic organs. In: Wied GIL, ed. Monographs in Clinical Cytology. New York, NY: S Karger; 1974;4. 3. Goldfinger M, Rothberg R, Stoll S. Sonographic guidance of thyroid needle biopsy. J Can Assoc Radiol. 1986;37:186-188.
In Other AMA Journals JAMA
International and Interstate Comparisons of Homicide Among Young Males L. A. Fingerhut, J. C. Kleinman (JAMA. 1990;263:3292) The Worldwide Smoking Epidemic Council on Scientific Affairs (JAMA. 1990,263:3312) The Human Genome Project and International Health J. D. Watson, R. M. Cook-Degan (JAMA. 1990;263:3322)
Seeking New Dimensions in International Health Research P. E. Schambra (JAMA. 1990;263:3325)
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 05/27/2015
