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):

Material and methods Patients From 2004 to 2010, 31 patients / 31 biopsies of deep head and neck lesion. Mean age ± SD (years)= ± 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 – CardinalHealth / Temno® Biopsy Systems. 17/19G introducer system + 18/20G semi-automatic tru-cut biopsy needle

Needle approach Connor et al, Clin Radiol 2008; 63(9): Gupta et al, Radiographics 2007; 27(2): Subzygomatic (sigmoid notch) Paramaxillary (retromaxillary) Tu, A.S., et al., AJNR Am J Neuroradiol 1998; 19(4): 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.

Inadequate specimen 42 y/o male with odynophagia and occasional choking. Bx: 19/20 G needle, retromandibular approach Yield: inadequate specimen Dx: Schwannoma

Sampling error 76 y/o male with right zygomatic eminence. Bx: 17/18 G, subzygomatic approach, two passes. Yield: fibrosis. OP: meningioma en plaque (diploic meningioma)

Complication 64 y/o male, with hx of left buccal cancer, s/p OP and RT BX: 17/18G needle set, subzygomatic approach, two needle passes Yield: recurrent cancer. Complication: Local hematoma.

Complication 40 y/o male, with left deep parotid tumor. 17/18G needle, retromandibular approach, two needle passes. Yield: adenoid cystic carcinoma. Complication: transient facial nerve palsy.

Results Lesion locationPatients infratemporal fossa14 parapharyngeal space3 retropharyngeal space9 carotid space1 deep parotid space2 pterygopalatine fossa2 Total31 Size of biopsy needle 18G19 20G12 Needle passes (Average = 2.1) one4 two20 three 7

Resultn Diagnostic yield (%)30/31 (96.8%) sufficient specimen30 insufficient specimen1* Malignancy18 undifferentiated carcinoma2 squamous cell carcinoma15 adenoid cystic carcinoma1 Benign12 fibrosis5 inflammatory process5 paraganglioma1(lost f/u) pleomorphic adenoma1(lost f/u) Diagnostic accuracy (%)27/29† (93.1%) Complication rate (%)2/31† †(6.5%) *Rt parapharyngeal schwannoma †One sampling error †† Subcutaneous hematoma and transient facial palsy

Discussion DxConnor*Our study Yield88.9%96.8% Accuracy86.7%93.1% Patients1731 Cancer pt2/1724/31 * Clin Radiol Sep;63(9):

CT-guided FNA or CNB? FNA have limited value in treated cancer  prior surgery and irradiation can alter the normal structure. Toh et al, Head Neck Apr;29(4): Dx FNA - Sherman*FNA - DelGaudio**Our study Yield90.3%90.5%96.8% Accuracy88.4%85.7%96.4% Patients *AJNR Am J Neuroradiol Oct;25(9): **Arch Otolaryngol Head Neck Surg Mar;126(3):

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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