CT or US?

HEAD & NECK BIOPSY 101 Kim O. Learned, MD ? Recurrent SCCA node SUV of 6

Head & Neck Biopsy 101 Patient Selection & Preparation • Differential considerations " Biopsy technique, !Patient Selection & Preparation Ancillary test

!Optimization of instrument and Biopsy Technique

!Real time US evaluation and correlation with Pre-procedure CT and MR neck imaging

Learned. Radiographics 2016

Biopsy Technique Imaging-guided Biopsy

• Sterile. • Entry angle & Biopsy route • US"4% Chlorhexidine Gluconate • Expected trajectory of the • Fine Needle Aspiration (FNA) needle should be away • 25-18 gauge from critical structure • Capillarity (to-and-fro motion) +/- Aspiration • Core Needle Biopsy (CNB) • 18-16 gauge

Patient Selection & Preparation Patient Selection & Preparation

!US: Superficial lesion with !CT: Deep lesion without Accessible acoustic window acoustic window • 1% lidocaine local anesthesia • Deep neck spaces at skull base • 1% lidocaine local anesthesia +/- IV midazolam & fentanyl conscious sedation • Iodine contrast

Gupta. Radiographics 2007 Gupta. Radiographics 2007

TMJ- pigmented villonodular synovitis Optimization of US Instrumentation

Mass ! Transducer for high imaging resolution of the biopsy area Mass • High-frequency (10-7MHz): 5 cm depth (a) (b) (c) • Low-frequency (8-5 MHz): deeper Bone Defect tissue Mass

Acoustic Window: bone defect Biopsy needle (d)

Optimization of US Instrumentation CT or US? !Transducer fits acoustic window • Small footprint: small acoustic window • Curved array probe: • Larger wide sector field of view • Small and uneven anatomic spaces • Deeper lesion Advantages of Ultrasound-guided Biopsy Real-time Visualization ! US real-time scanning capability • Live visualization of the needle " Instantaneous adjustment • Tissue compressibility to adjust tissue depth and to manipulate the surrounding structure and biopsy target

Advantage of Ultrasound

Trachea IJV Real-time US Tissue Compression/ Manipulation CCA LAD Curved 8-5 MHz probe: Small footprint a Wide-sector view Deeper neck soft tissue Papillary Thyroid Carcinoma, Elevated thyroglobulin visualization Suspicious LAD in the left tracheoesophageal groove

Real-time Visualization & Tissue Manipulation ULTRASOUND: How to find the lesion ! Identify normal structures ! Lesion Localization Apply knowledge of 3-D neck , pre-procedure analysis of the lesion location and its relationship with normal structures ! Avoid confusing random scan orientation Scan patient in supine neutral neck position using planes similar to cross-sectional imaging planes

Anatomical Locations Lateral Face Subsites

• Lateral face • • Superficial Masticator • Angle of the Jaw space • Buccal space • Lateral neck • • Facial artery • Midline neck

Parotid Masticator Space: superficial portion

! Pre-procedure Lesion Localization: 3-D anatomical relationship ! US appearance of normal tissues Parotid Carcinoma Incidental lesion found on brain MRI for blurry vision

Submandibular Gland-SMG Angle of the Jaw Subsites Rim of SMG Rim of SMG Biopsy • Tail of Parotid Gland needle

Lesion Lesion • Lymph nodes Rim of SMG SMG SMG Lesion • Level IB or IIA a b •

! Accurate Lesion Localization Non-tender palpable lump in submandibular fossa. US images show a well-defined hypoechoic solid SMG lesion surrounded by a rim of normal submandibular glandular tissue.

Lymphadenopathy SGM Lateral neck Subsites Level IB LAD Level IB LAD LAD • Carotid space • Lymph nodes Levels II-V

(a)

Biopsy Diffuse large B-cell lymphoma 2 months needle after treatment with FDG + node

! US probes for Diagnostic vs Biopsy Small acoustic window, steep angle " small curved-array probe

Carotid space Midline neck

• Submental Space • Floor of Mouth • Oral Cavity • Para-glottis/hypopharynx 80-year-old patient with non-tender • Thyroid asymptomatic palpable neck mass. • ! Knowledge of Diagnostic • Level IA, VI Imaging, disease processes " Biopsy Technique, Ancillary Test

Sub-Mental Approach Submental Approach: Floor of Mouth • Floor of Mouth • • Root of Floor of Mouth FOM Mesothelioma Metastasis

! Avoid lingual artery (hypoglossal & lingual nerves) in Sublingual space From medial to lateral

Supraglottis & Hypopharynx Paraglottic Space

Acoustic window: Strap muscle, Thyro-hyoid Inflammatory pseudotumor membrane

Hypopharynx Hypopharynx

ICA

Needle in lesion

! Acoustic window: Thyrohyoid membrane Hypopharynx

ICA

Needle

Acoustic window Transverse plane through Thyrohyoid Anterior to Posterior membrane

CT-guided Biopsy Paramaxillary Approach

!Deep neck spaces at the skull base 1. Pterygoid space !Paramaxillary or Subzygomatic 2. approaches 3. Carotid space 4. !Tilting head away from the side of 5. lesion !Flexion vs Extension of the neck !Contrast " Vasculature

Gupta. Radiographics 2007 Gupta. Radiographics 2007 Loevner. Otolaryngol 2008

Paramaxillary Approach Paramaxillary Approach

!Through buccal space: • Styloid process protects Carotid • Facial artery Recurrent SCCA • Parotid duct Subzygomatic Approach Subzygomatic

Right nasopharynx SCCA status post chemoradiation

• Infratemporal fossa, Masticator space, PPS, PPF Right nasopharynx SCCA s/p chemoradiation, recent OR biopsy showed no tumor recurrence • Internal maxillary artery, middle meningeal artery, pterygoid venous plexus, V3

CONCLUSION

• Practical considerations in selecting patient for US or CT-guided biopsy • Pre-procedure: Differential diagnosis, Lesion localization, Biopsy technique, Ancillary test • Quality and Outcome of our patient’s care