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CT-guided core needle biopsy for deep facial and skull base lesion En-Haw Wu, Yao-Liang 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 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 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. 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 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 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. 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 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, 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. – 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 • Case presentation

 • 59 y/o male, hx of oral cancer, with right masticator space tumor. • 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, • 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 • 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 • 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 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, 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 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 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. 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 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 – 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, 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 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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