Technical Meckel Biopsy

Cave Lesions: Cytology’

Developments

and

Percutaneous

Instrumentation

Fine-Needle-Aspiration

Stefan H. J. Dresel, MD Kevin Mackey, MD Robert B. Lufkin, MD Bradley A. Jabour, MD Antonio A. F. Desalles, MD Lester J. Layfield, MD Gary R. Duckwiler, MD Donald P. Becker, MD John R. Bentson, MD William N. Hanafee, MD

J.

a.

b.

The authors describe the novel combination of two traditional methods to facilitate diagnosis of Meckel cave lesions,

years tionship

which may otherwise my to obtain adequate

and

require tissue

Figure

craniotosamples.

procedure.

This

new

applica-

biopsy cypatient mor-

bidity

and

significant

reduction.

Index

terms:

Biopsies.

neoplasms, 12.36,

20.37 12.38

139.34

a

#{149} Head

Meninges,

a

Face,

neck

neoplasms.

diagnosis.

124.34,

neoplasms,

139.34

glands,

neoplasms,

Salivary

a

and

Lymphoma,

a

trigeminal

technology

a

to assess

cavernous

Nerves,

tnigeminal

Radiology

glycerol In the

179:579-581

mors,

T

use of fine-needle-aspiration biopsy cytology to enable diagnosis of head and neck lesions is not new, having been reported first, to our knowledge, in 1930 by Martin and Ellis (1). Aspiration biopsy cytolHE

ogy

is a simple

sampling

method

that

causes minimal enal advantages

trauma and has sevoven open surgical biopsy procedures (2). Because of the number of vital structures situated in the head and neck, especially in the region at the base of the skull, it might be expected that this pnocedune would be difficult to perform.

I

From

the

Departments

(S.H.J.D.,

J.K.M.,

W.N.H.),

Neurosurgery

Pathology Angeles the

(L.J.L.), (UCLA),

Health

sion

RSNA,

Volume

University Medical 10833

90024-1721. requested

received

Address

B.A.J.,

January

reprint

G.R.D.,

(A.A.F.D.,

Sciences,

Angeles, CA 1990; revision

of Radiology

R.B.L.,

of California, Center, Center LeConte Received January

21;

requests

accepted

Ave.

Number

2

the

placement

tip

of

the

needle

of the

to

the first patient (38 show the needle in relacave. (c) The lateral view

in

the

floor

of

the

sella

turcica

needle.

Los

by

retnogassenian

(4-6). staging

it is important

to

old

woman

gland.

She

silateral temporal

IV,

In

this

study,

the

combination

fine-needle-aspiration ogy

and

of

biopsy

the

percutaneous

cytolapproach

via the fonamen ovale to Meckel cave is described as a new procedure to enable diagnosis of deep lesions involving Meckel cave in the middle cranial fossa. To our knowledge, the combination of these two techniques has not been described in the litenatune. Lesions in this region may othrequire

craniotomy

tissue with histologic

sufficient

to

which diagnosis.

obtain

to make

Los

tnigeminal sided

Materials

and

Methods

Two

patients

aspiration

underwent biopsy

cytology

of

III,

in

the

distribution

branch

nerve.

She

loss, that

vertigo

of

pain

led

with

the

right

developed

right-

associated

with

to a 20-lb

weight

ambulation,

and

dip-

lopia. All

percutaneous

aspiration

studies

lesions

of

were in of

our

the

radiology

institution,

was

cave

departwith

After

obtained,

mentovertex,

biopsy Meckel

as outpatient

guidance.

consent ten,

these

performed

procedures

C-arm

and

lateral

flu-

informed

preliminary

sub-

anteropostenior

obtained.

plain

or

Wa-

radiographs

Intravenous

were

analgesia

was

used. With tion ed

the

and

patient

with

in

use

fluoroscopy, of

was

achieved,

the

Mass)

was which

was cm-long

ovale

required

rotation.

Lido-

lateral

and

1.5

arch. spinal

site

typically

cm

administered

Westboro,

at the

was

to cm

as an

of

needle

approxithe

conner

inferior

Additional needle

rotated visualiza-

foramen

Astra,

injected

3.5

was

usually

20#{176} of

entry,

posiangulat-

optimal

which

(Xylocaine;

supine

head

ipsilateral

approximately

mouth

the cephalic,

until

tion

caine

of the

contralaterally

zygomatic

pencutane-

pain

hearing

loss,

the

28.

Clini-

nerves

involved.

mandibular

mately 6,

cervical dipbopia.

cranial

were

and

the

oroscopic

tab importance.

left

ipleft

second patient, a 52-year-old presented with right facial

ment

fundamen-

parotid

sharp

ipsilateral VI

of

left

developed

and

V. and

of

the

numbness,

headache,

The woman,

history

of

lymphadenopathy, the

foramen

a 38-year-

a 4-month

subsequently

facial

cally,

the

was

enlargement

suspected

of

via

patient

with

painless

cytology

is therefore

lesions

first

weakness

of tuwheth-

know

cave

The

basal foramina are significantly altened. Obtaining tissue for pathologic examination when this extension is

a definite

for

or

rhizotomy preoperative

Meckel

ovale.

mastication

ous

a

nerve

erwise

and

December 3, 1991; reviJanuary

of

distal

en there is extension of tumor through the basal skull foramina. The treatment and prognosis of neoplasms that have transgressed the

to J.K.M.

1991

179

J.R.B.,

D.P.B.),

relationship

to avoid

The percutaneous approach to Meckel cave via the fonamen ovale is also an old technique, introduced in 1932 by Kirschner for the purpose of electrocoagulation of the tnigeminal nerve (3). Improvements in equipment and technique have resulted in widespread acceptance of the procedune for treatment of medically nefractory tnigeminal neuralgia either by means of electrocoagulation of the

264.373

1991;

the

sinus,

of needle position (b) plain radiographs positioned in Meckel

a

tion of fine-needle-aspiration tology results in decreased cost

c.

Plain radiographs enable verification The Water (a) and submentovertex to the enlarged foramen ovale when

is essential

Fine-needle-aspiration biopsy cytology was performed on tissue obtained with percutaneous approach via the foramen ovale with use of fluoroscopic guidance and intravenous analgesia during an outpatient

1. old).

to

of the

lidocaine

18-gauge, was

10-

advanced

Radiology

a

579

Figure 2. Adenoid cystic carcinoma that has metastasized from the parotid gland, involving Meckel cave in the first patient. (a) MR image in the transverse plane obtamed with repetition time of 600 msec and echo time of 15 msec (600/15). Axial view shows slight asymmetry in left region of the gasserian ganglion. The mass appears isointense to brain tissue and is poorly delineated (arrow). (b) MR image in the transverse plane (2,000/84). In the T2-weighted image, an isointense mass is revealed in the left Meckel cave (arrow). (c) Gadolinium-enhanced MR image in the transverse plane (600/ 15) demonstrates that the lesion is increased in signal intensity and is sharply delineated laterally from brain tissue. The medial aspect shows beginning of infiltration of the sheath of the internal carotid artery. The exit of the fifth cranial nerve out of the brain stem is shown clearly on both sides. (d) Gadolinium-enhanced MR coronal image (600/ 15) demonstrates again the interface between the lesion (arrow) and the medial temporal lobe. (e) Fine-needle aspiration specimen (Papanicolaou stain; original magnification, X100) shows clusters of cohesive small cells with modest amounts of cytoplasm, which are consistent with the solid pattern of adenoid cystic carcinoma.

toward the foramen ovale, with intermittent fluoroscopic observation. Particular attention was paid to needle bocation to avoid puncturing the internal carotid artery, which runs immediately adjacent to the foramen lacerum. Shortacting intravenous analgesia administered by an anesthesiologist was helpful, as patient discomfort was greatest when the needle entered the foramen ovale. Correct location of the needle tip within Meckel cave was verified by means of three plain radiognaphs that were obtained in different projections (Fig 1) (4). Multiple aspiration samples were obtamed, with fluoroscopic guidance, by sequentially placing 22-gauge needles through the 18-gauge spinal needle in a coaxial fashion. The coaxial system albowed multiple aspiration specimens to be obtained without repositioning the guiding needle (7). Preliminary staining and microscopic review of each specimen were performed immediately in the radiology department by the attending cytopathobogist. Both patients were released after two hours of observation.

Results

a.

b.

d.

e.

a. Figure 3. Intracranial (a) Contrast-enhanced

b.

atypical mononuclear lymphoma in the second patient (52 years old). (Conray; iothalamate meglumine; Mallinckrodt, St Louis) CT scan shows the lesion (arrows) within the cavernous sinus and Meckel cave region, with moderate contrast enhancement and sharp delineation. (b) Fine-needle aspiration specimen (hematoxylin-eosin stain; original magnification, X100) shows small round cells in a fibrous tissue stroma, consistent with a lymphoma.

eral

foramen

ovale

to be

increased

In the first patient, an ipsilatenal parotid gland mass and cervical lymphadenopathy had both been found to be adenoid cystic carcinoma at previous bi-

size. Exact not possible

delineation of the due to the similar

tion

lesion

opsies.

Magnetic resonance ed and T2-weighted

Computed

scans or

also aspect

of

belbopontine with bone 580

the

a mass cistern

angle. windows

Radiology

#{149}

tomognaphic

revealed

of

(CT) in the

the left

antenicere-

Scans obtained showed the ipsilat-

c.

of

the

and

adjacent

in

lesion was attenuabrain

2b).

also

an

isointense

Meckel cave that was ated from surrounding

(MR) images mass

poorly brain

Ti-weightboth dem-

The

12-weighted

revealed

silateral

foramen

there

NJ) within

differentitissue (Fig

to

forarnen

in

ovale diagnosed

ip-

sequences, enhancement

Meckel

the

gadolini-

Laboratories,

Ti-weighted

lesion

sequence

dirneglu-

Berlex

marked

within

the

With

(gadopentetate

was

previously

signal

ovale.

Magnevist;

Wayne,

MR

abnormal

urn-enhanced mine;

tissue.

onstrated

2a,

of

cave, (Fig

the

extending 2c,

primary

2d).

The

adenoid

May

1991

cystic carcinoma of the parotid gland and the ipsilateral cervical adneopathy, however, were hypenintense on T2weighted images. Biopsy of the isointense area seen on T2-weighted images of the Meckel cave mass was necessary to rule out the presence of concurrent tumor of another origin. The coaxial needle was placed with fluoroscopic guidance, and its position was confirmed by obtaining plain radiographs (Fig 1). The aspiration cytology study was performed without difficulty and revealed solidpattern

adenoid

cystic

carcinoma

(Fig 2e). The CT and MR images of the second patient showed a lesion in the right cavernous sinus and Meckel cave, with extension posteriorly along the course of the night fifth cranial nerve into the posterior cranial fossa (Fig 3a). The lesion had spread along the posterior sunface of the clivus and into the left cayernous sinus area. The needle was inserted into Meckel cave and the aspirate was found to reveal atypical mononuclear cells that were consistent with lymphoma (Fig 3b).

Discussion Fine-needle-aspiration

biopsy

cytol-

for the evaluation of head and neck masses (2,8-10). Specific diagnoses are routinely obtained for more than 90% of sampled lymph nodes and salivary gland, ogy

is currently

thyroid,

and

well

other

accepted

soft-tissue

masses

procedure has limited complications and is relatively inexpensive, and, if the findings are positive, the clinician can proceed immediately with appropriate therapy. The introduction of CT and MR imaging has greatly expanded the ability to depict deep besions of the head and neck, including lesions of the tnigeminal nerve and Meckel cave (11-14); unfortunately, however, these advanced imaging modalities are not tissue specific. CT- and MR-guided aspiration biopsy has become a valuable tool in the evaluation of deep extracranial lesions (i5). Using the well-established percutaneous approach to Meckel cave that was developed for tnigeminal rhizotomy (3-6), we find the fine-needle-aspiration cytology technique to be useful for evaluation of the wide variety of masses involving Meckel cave. (8,9).

This

Intrinsic

tumors

arising

within

Meckel cave include tnigeminal schwannoma; meningiorna; and congenital tumors such as epidermoid, lipoma, and denmoid (13,14). Secondary tumors of Meckel cave consist pnimarily of retrograde penineural extension along the tnigeminal nerve. Head and neck tumors commonly spread in this manner, often extending a consider-

Volume

179

a

Number

2

able distance along the tnigeminal nerve, without invading adjacent structunes or lymph nodes (16,17). This penneural tumor extension to Meckel cave may

occur

with

squamous

cell,

adenoid

cystic, or mucoepidermoid carcinomas, or with lymphoma (14,16-18). Subarachnoid dissemination and distant metastasis from extracranial malignancy

are

two

rare

additional

modes

of

ac-

quining secondary Meckel cave tumors. Clinical evidence of perineural tumor infiltration is often not detected or is nonspecific (12). Recognition of this mode of spread has important thenapeutic implications and may alter the form of treatment and the prognosis. Depending on the histologic analysis of tumors invading the foramen ovale, treatment may be largely palliative. Thus, management of a lesion is often altered and surgery can be avoided if intracranial extension can be confirmed preoperatively. Results of fine-needle-aspiration cytology were positive in both of our cases. The first case established the diagnosis of intracranial penineural tumon spread from a known adenoid cystic carcinoma of the parotid gland. This tumor has a high propensity for penneural spread and a low cure rate when penineural involvement is present (16). Cytologic evaluation in the second case revealed atypical mononuclear cells consistent with lymphoma, which had been suspected when CT showed multiple areas of tumor involvement in the basilar cisterns. Both patients had concurrent facial pain and diplopia, clinically implicating involvement of the tnigeminal and extraocular muscle cranial nerves. A single lesion that spanned the ipsilateral cavernous sinus and Meckel cave region was clearly identified to be carcinoma at CT and MR imaging. From the technical point of view, needle penetration of the fonamen ovale may present some difficulty, but, in our study, once the foramen ovale was identified with fluoroscopy, accurate needle placement was readily achieved. Definitive confirmation of the correct placement of the needle to avoid accidental penetration of surrounding structures must be obtained by means of careful fluoroscopy and should be verified by obtaining plain radiographs in

various No

complications

could

References 1.

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