CT-guided core needle biopsy for deep facial and skull base lesion En-Haw Wu, Yao-Liang Chen, Yi-Ming Wu, Shu-Hang Ng Department of Diagnostic Radiology, Chang Gung Memorial Hospital , Linkou, Taoyuan, Taiwan.
Introduction Dx for deep H&N lesions is crucial but hard. Inaccessible clinically. Posing surgical risk. Alternative approach Image-guided fine needle aspiration (FNA) / core needle biopsy (CNB)
US-guided needle approach US-guided CNB Real-time; no radiation. Reliable in Dx of H&N lesions Radiology 2002; 224: 75– 81; Head Neck 2007; 29: 1033– 40 Limited acoustic window in deep H&N due to intervening osseous and vital structure. Radiographics 2007; 27: 371– 90.
CT-guided FNA Reported diagnostic yield 90. 3% and accuracy 88. 4% in 216 cases. Sherman et al. , AJNR Am J Neuroradiol 25: 1603– 1607 Result depends on cytology expertise, may be biased by specimen quality. Howlett et al. , J Laryngol Otol 2007; 121: 571– 9
CT-guided CNB W/ automated cutting needle Offering histopathological / immunochemical study. Challenging in deep H&N due to intervening neurovascular structure. Reported accuracy as 86. 7% in 18 biopsies. Conner et al, Clin Radiol 2008; 63(9): 986 -94.
Material and methods Patients From 2004 to 2010, 31 patients / 31 biopsies of deep head and neck lesion. Mean age ± SD (years)= 52. 16 ± 11. 38. Gender (F/M) = 5/26 H&N cancer pts= 24 Lesions Clinically inaccessible Deep supra-hyoid head and neck
Biopsy Technique CT images reviewed for best needle approach Neurovascular structure. IV contrast enhancement. Local anesthesia, 1 % Lidocaine. Positioning of patient's head Tilting away from the lesion site.
Biopsy Technique Co-axial needle set – Cardinal. Health / Temno® Biopsy Systems. 17/19 G introducer system + 18/20 G semi-automatic tru-cut biopsy needle
Needle approach Connor et al, Clin Radiol 2008; 63(9): 986 -94. Gupta et al, Radiographics 2007; 27(2): 371 -90. Subzygomatic (sigmoid notch) Paramaxillary (retromaxillary) Tu, A. S. , et al. , AJNR Am J Neuroradiol 1998; 19(4): 728 -31. Retromandibular (transparotid)
Diagnosis • Diagnoses standard – histopathology Dx from surgical excision. – treatment response. – clinical follow-up. • Diagnostic yield = adequate / all specimen. • Diagnostic accuracy = needle dx / final dx.
• Case presentation
• 59 y/o male, hx of oral cancer, with right masticator space tumor. • 17 / 18 G needle, paramaxillary approach, three needle passes. • Yield: recurrent SCC. • Tx: RT.
• 37 y/o male with right parapharyngeal lesion. • 19 / 20 G, subzygomatic approach, two needle passes. • Yield: fibrosis. • Skull base OP: fibrosis.
• 42 y/o male with odynophagia and occasional choking. • Bx: 19/20 G needle, retromandibular approach • Yield: inadequate specimen • Dx: Schwannoma Inadequate specimen
• 76 y/o male with right zygomatic eminence. • Bx: 17/18 G, subzygomatic approach, two passes. • Yield: fibrosis. • OP: meningioma en plaque (diploic meningioma) Sampling error
Complication • 64 y/o male, with hx of left buccal cancer, s/p OP and RT • BX: 17/18 G needle set, subzygomatic approach, two needle passes • Yield: recurrent cancer. • Complication: Local hematoma.
Complication • 40 y/o male, with left deep parotid tumor. • 17/18 G needle, retromandibular approach, two needle passes. • Yield: adenoid cystic carcinoma. • Complication: transient facial nerve palsy.
Results Lesion location Patients infratemporal fossa 14 parapharyngeal space 3 retropharyngeal space 9 carotid space 1 deep parotid space 2 pterygopalatine fossa 2 Total 31 Size of biopsy needle 18 G 19 20 G 12 Needle passes (Average = 2. 1) one 4 two 20 three 7
Result Diagnostic yield (%) sufficient specimen insufficient specimen Malignancy undifferentiated carcinoma squamous cell carcinoma adenoid cystic carcinoma Benign fibrosis inflammatory process paraganglioma pleomorphic adenoma Diagnostic accuracy (%) Complication rate (%) n 30/31 (96. 8%) 30 1* 18 2 15 1 12 5 5 1(lost f/u) 27/29† (93. 1%) 2/31† †(6. 5%) *Rt parapharyngeal schwannoma †One sampling error †† Subcutaneous hematoma and transient facial palsy
Discussion Dx Connor* Our study Yield 88. 9% 96. 8% Accuracy 86. 7% 93. 1% 17 31 2/17 24/31 Patients Cancer pt * Clin Radiol. 2008 Sep; 63(9): 986 -94.
CT-guided FNA or CNB? Dx FNA - Sherman* FNA - Del. Gaudio** Our study Yield 90. 3% 90. 5% 96. 8% Accuracy 88. 4% 85. 7% 96. 4% 216 42 31 Patients *AJNR Am J Neuroradiol. 2004 Oct; 25(9): 1603 -7. **Arch Otolaryngol Head Neck Surg. 2000 Mar; 126(3): 366 -70. • FNA have limited value in treated cancer prior surgery and irradiation can alter the normal structure. Toh et al, Head Neck. 2007 Apr; 29(4): 370 -7.
Collision lesion • CNB of skull base area in a treated NPC patient – Yielding granulation + recurrent undifferentiated carcinoma. – FNA may not be feasible.
CNB in H&N cancer patients • In subgroup of the 24 H&N cancer patients, – Diagnostic yield = 100 % – Diagnostic accuracy = 100 % • Avoiding unnecessary surgery.
Conclusion • CT-guided CNB – an accurate and safe in deep head and neck areas with few minor complications (6. 5%) – offering tissue diagnosis and avoidance of unnecessary surgery, esp. in H&N cancer.
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