Ultrasound guided Core Biopsy, Fine Needle Aspiration Cytology and Surgical Excision Biopsy in the diagnosis of metastatic squamous cell carcinoma in the head and neck: an eleven year experience

Accuracy of ultrasound-guided fine-needle aspiration for small cervical lymph nodes: A retrospective review of 505 cases

Purpose

The overall diagnostic value of fine-needle aspiration (FNA) is not as excellent as that of core needle biopsy (CNB). Limited research has investigated small cervical lymph nodes inaccessible to ultrasound-guided CNB due to technical challenges associated with their small size. Therefore, this study aimed to evaluate the accuracy of ultrasound-guided FNA in determining the etiology of small cervical lymph nodes.

Methods

A retrospective analysis was conducted on patients who underwent FNA between May 2018 and May 2021 at our hospital. Cytological, histopathological, and clinical follow-up data were analyzed. The diagnostic yield of FNA was assessed based on sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy calculations.

Results

This study included 505 patients, each with a small cervical lymph node under evaluation (total number of lymph nodes: 505). The average maximal diameter of the lymph nodes was 14.6 ± 6.2 mm. According to the Sydney system, the cytology results were as follows: Category I in 26 lymph nodes (5.1 %); Category II in 269 (53.3 %); Category III in 35 (6.9 %); Category IV in 17 (3.4 %); and Category V in 158 (31.3 %). We identified 212 malignant cases (203 metastases and 9 lymphomas) and 293 benign lymph nodes. FNA achieved high sensitivity (88.8 %), specificity (99.6 %), PPV (99.4 %), NPV (91.8 %), and overall accuracy (94.8 %) in determining the etiology of small cervical lymph nodes.

Conclusion

FNA cytology is suitable for small lesions inaccessible by CNB and provides a diagnostic basis for implementing clinically appropriate treatment measures.

Comparison of liquid based cytology and conventional smears on lymph node aspirates: A cytomorphological study

Objective

In an era of minimally invasive and rapid diagnostic technologies, fine-needle aspiration cytology (FNAC) is most useful when it comes to patients with lymphadenopathies especially of the cervical region. Liquid-based cytology (LBC) is an alternative processing method which is used for both gynecological and non-gynecological samples. Because of the remarkable advantages of LBC smears in gynecological samples, nowadays, many studies have been done to assess its utility in various other lesions. Hereby, with the help of this study, we would like to evaluate the efficiency of LBC smears in comparison to conventional FNAC smears conventional smears (CS) on lymph node aspirates.

Material and Methods

A retrospective study was done over a 1-year period in which 253 cases of lymph node aspirates were included in the study. The slides were prepared using standard conventional and LBC techniques and compared for adequacy, cellularity, cell architecture, necrosis, background debris, presence of cells in monolayer sheets, and nuclear/cytoplasmic details.

Results

Of the total 253 cases, 171 (67.6%) were and 67 (26.5%) were diagnosed as non-neoplastic and malignant, respectively. Although the LBC smears were useful in the diagnosis of malignant cases, they did pose some challenges especially in the non-neoplastic lymph node aspirates due to loss of the background necrosis. In addition, the cellular yield in LBC smears was low in comparison to CS.

Conclusion

LBC smears from lymph node aspirates results in better diagnostic accuracy for malignant cases due to better cellular and nuclear details. However, for non-neoplastic etiology, it should not be considered better than CS as loss of the background necrosis and inflammation may result in an incorrect diagnosis.

Diagnostic performance of core needle biopsy for nodal recurrences in patients with head and neck squamous cell carcinoma

This study investigated the diagnostic accuracy and affecting factors of ultrasound (US)-guided core-needle biopsy (CNB) in patients with treated head and neck squamous cell carcinoma (HNSCC). We retrospectively reviewed patients with treated HNSCC who received US-guided CNB from January 2011 to December 2018 with corresponding imaging. Pathological necrosis and fibrosis of targeted lymph nodes (LNs) were evaluated. We analyzed the correlation between CNB accuracy and clinical and pathological characteristics. In total, 260 patients were included. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CNB for nodal recurrence were 84.47%, 100%, 100%, 54.67%, and 86.92%, respectively. CNB of fibrotic LNs had significantly worse sensitivity, NPV, and accuracy than that of non-fibrotic LNs. Similarly, CNB of necrotic LNs had significantly worse sensitivity, NPV, and accuracy than non-necrotic LNs. Multivariate regression revealed that fibrotic LN was the only independent factor for a true positive rate, whereas both necrotic LN and fibrotic LN were independent factors for a false negative rate. The diagnostic accuracy of CNB in treated HNSCC patients is affected by LN necrosis and fibrosis. Therefore, CNB results, particularly for necrotic or fibrotic LNs, should be interpreted carefully.

Comparison of Ultrasound-Guided Core Needle Biopsy Under the Assistance of Hydrodissection With Fine Needle Aspiration in the Diagnosis of High-Risk Cervical Lymph Nodes: A Randomized Controlled Trial

A randomized comparison of ultrasound (US)-guided core needle biopsy (CNB) under the assistance of hydrodissection with fine needle aspiration (FNA) was performed to evaluate the feasibility, safety and effectiveness for the diagnosis of high-risk cervical lymph nodes. Patients from December 2018 to May 2020 were randomly assigned to the CNB group and the FNA group at a ratio of 1:1. This study protocol was approved by the Ethics Committee of our hospital and registered in the Chinese Clinical Trial Registry (ChiCTR1800019370). The feasibility of CNB for high-risk cervical lymph nodes was evaluated by observing and recording the separation success rate (SSR) and technical success rate (TSR) of the CNB group. Safety was evaluated by comparing the incidence of major complications in the two groups. The diagnostic efficacy was evaluated by comparing the diagnostic accuracy, sensitivity, and specificity of the two groups. A total of 84 patients (84 lymph nodes) were randomized into the CNB (n = 42) and FNA (n = 42) groups. All patients in the CNB group achieved successful hydrodissection and biopsy. The SSR and TSR were both 100% in the CNB group. There were no major complications during or after the process in the two groups. Compared with the FNA group, the CNB group was significantly superior in terms of diagnostic accuracy and sensitivity (100% vs. 81.0%, P = 0.009; 100% vs. 79.2%, P = 0.035, respectively). The specificity of the two groups was 100%, and there was no significant difference. Compared with FNA, CNB under the assistance of hydrodissection is a feasible and safe method but is more effective for the diagnosis of high-risk cervical lymph nodes.

Ultrasound core biopsies of neck lumps: an experience from a tertiary head and neck cancer unit

BACKGROUND

Traditionally, fine needle aspiration cytology was the primary diagnostic investigation for head and neck lumps; however, ultrasound-guided core biopsy offers the advantage of preserving tissue architecture with increased tissue yield. This study reviews the diagnostic utility of ultrasound-guided core biopsy for investigating head and neck lumps.

METHODS

Overall, 287 ultrasound-guided core biopsies were reviewed between May 2017 and April 2019 at a single tertiary site for head and neck cancer.

RESULTS

On initial ultrasound-guided core biopsy, a diagnostic sample was obtained in 94.4 per cent of patients and in 83.7 per cent of patients with lymphoma. Where the initial ultrasound-guided core biopsy was non-diagnostic, 50 per cent of samples were diagnostic on repeat ultrasound-guided core biopsy. Overall, five complications were seen related to ultrasound-guided core biopsy, and all were managed conservatively. No cases of disease recurrence were identified at the biopsy site.

CONCLUSION

Ultrasound-guided core biopsy is a safe procedure with a high diagnostic yield when investigating head and neck lumps. Patients whose ultrasound-guided core biopsies were non-diagnostic should be considered for excisional biopsy over repeat ultrasound-guided core biopsy.

[Ultrasound-guided minimally invasive diagnostics and treatment in the head and neck area]

Tumoral lesions in the head and neck region represent a diagnostic and therapeutic challenge in otorhinolaryngologic routine. High-resolution ultrasound is usually able to guide diagnosis. Nevertheless, a definite differentiation between benign and malignant lesions can only be achieved by tissue biopsy. The various options for obtaining samples for histopathological or cytological examination-from minimally invasive ultrasound-guided fine-needle biopsy to punch biopsy and open surgical biopsy-will be discussed in the first part along with the associated advantages and disadvantages. In the second part of this CME article, minimally invasive ultrasound-guided therapeutic options in the head and neck region which can be performed on an outpatient basis are depicted.

Diagnosis and Management of Squamous Cell Carcinoma of Unknown Primary in the Head and Neck: ASCO Guideline

PURPOSE

To provide evidence-based recommendations to practicing physicians and other health care providers on the diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck (SCCUP).

METHODS

The American Society of Clinical Oncology convened an Expert Panel of medical oncology, surgery, radiation oncology, radiology, pathology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2008 through 2019. Outcomes of interest included survival, local and regional disease control, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 100 relevant studies to inform the evidence base for this guideline. Four main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate pathology techniques, and adjuvant therapy.

RECOMMENDATIONS

Evidence-based recommendations were developed to address preoperative evaluation for patients with a neck mass, surgical diagnostic and therapeutic procedures, appropriate treatment options in unilateral versus bilateral SCCUP.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

A clinical compilation of lymph node pathologies comparing the diagnostic performance of biopsy methods

PURPOSE

It is critical to obtain sufficient tissue, both in quality and quantity, in biopsy applications for histopathological review. Our aim was to compare fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) techniques in terms of their diagnostic performance in lymph node biopsies. This was a clinical compilation, and histopathological results from biopsies were also evaluated.

METHODS

A total of 242 patients and 246 lymph nodes were prospectively evaluated. All histopathologic specimens were obtained through ultrasonography-guided biopsies performed at our institute between April 2015 and October 2017. Histopathological results were grouped according to diagnostic performance, and the mean performance scores of the two methods were compared.

RESULTS

For FNAC, the mean diagnostic score was calculated to be 1.63, whereas for CNB, the mean diagnostic score was calculated to be 1.89. The difference between diagnostic scores of the two techniques was statistically significant (p < 0.01).

CONCLUSION

We recommend that interventional radiologists perform vacuum-assisted biopsies if there are no financial hindrances or evidence of psychological issues in patients. We recommend this not only for lymph nodes of malignant appearance but also for those that appear benign.

Predictors of care for patients with cancer of unknown primary site in three Australian hospitals

AIM

Cancer of unknown primary site (CUP) is a medically challenging malignancy with a poor prognosis. We describe an incident tertiary CUP patient cohort and identify factors predictive of specific types of health care.

METHODS

We reviewed the medical records of 217 patients diagnosed with CUP (2006-2011) in three public hospitals in New South Wales, Australia. We systematically abstracted data and performed multivariable logistic regression to identify factors predictive of tumor biopsy, surgery, chemotherapy, radiotherapy and palliative care.

RESULTS

The median age at CUP diagnosis was 75 years (range 23-98) and 52% were male. The most common mode of presentation was emergency department admission (57%). Serum tumor markers were performed in 42%, fine needle aspiration alone in 15% and core biopsy in 52%. Younger age, health service referral, oncologist review and a family history of cancer predicted receipt of a biopsy (77%). Cancer-related surgery (17%) was more likely in younger patients, those presenting with pain, and those with single lymph node metastases. Younger age and good performance score predicted receipt of chemotherapy (22%). The location of metastases predicted receipt of radiotherapy (28%). Older age, emergency presentation, poor performance score and no oncology review predicted receipt of palliative care only (52%); 77% were referred for palliative care during hospitalization.

CONCLUSION

The determinants of care were generally consistent with international CUP clinical guidelines. Areas of future research include potential underinvestigation and undertreatment of older patients, overuse of certain low-value diagnostic tests, suboptimal use of immunohistochemistry and mammography and underreferral to palliative care.

The application of ultrasound in detecting lymph nodal recurrence in the treated neck of head and neck cancer patients

Early detection of neck lymph node (LN) recurrence is paramount in improving the prognosis of treated head and neck cancer patients. Ultrasound (US) with US-guided fine needle aspiration (FNA) and core needle biopsy (CNB) have been shown to have great accuracy for LN diagnoses in the untreated neck. However, in the treated neck with fibrosis, their roles are not clarified. Here, we retrospectively review 153 treated head and neck cancer patients who had received US and US-guided FNA/CNB. In multivariate logistic regression analyses, size (short-axis diameter >0.8 cm) (odds ratio (OR) 4.19, P = 0.007), round shape (short/long axis ratio >0.5) (OR 3.44, P = 0.03), heterogeneous internal echo (OR 3.92, P = 0.009) and irregular margin (OR 7.32, P < 0.001) are effective US features in predicting recurrent LNs in the treated neck. However, hypoechogenicity (OR 2.38, P = 0.289) and chaotic/absent vascular pattern (OR 3.04, P = 0.33) are ineffective. US-guided FNA (sensitivity/specificity: 95.24%/97.92%) is effective in the treated neck, though with high non-diagnostic rate (29.69%). US-guided CNB (sensitivity/specificity: 84.62%/100%) is also effective, though with low negative predictive value (62.5%). Overall, US with US-guided FNA/CNB are still effective diagnostic tools for neck nodal recurrence surveillance.

Chapter 5 Ultrasound Characteristics of Benign vs Malignant Cervical Lymph Nodes

With approximately 800 lymph nodes in the body, and more than one-third found within the head and neck, lymph nodes are a common site for neck pathology. Differentiation between benign and malignant lymph nodes is critical in accurate prognosis; similarly, treatment hinges on accurate identification of the etiology of the pathologic process. Key gray-scale and color Doppler ultrasound criteria can help accurately distinguish between benign and malignant lymph nodes.

Ultrasound-Guided Needle Biopsy for Diagnosis of Advanced-Stage Malignancies of the Upper Aerodigestive Tract

Objective

Traditionally, direct laryngoscopy confirms stage and tissue diagnosis prior to treatment planning. Patients who are frail or have tenuous airway anatomy may incur risks while undergoing anesthesia. Further, direct laryngoscopy is scheduled after initial examination, introducing diagnosis delay. This study investigates the impact of ultrasound examination with guided needle biopsy compared with traditional operative biopsy.

Study Design

Case series.

Setting

Tertiary head and neck clinic.

Subjects and Methods

The records of patients at the Veterans Affairs Medical Center Memphis and Regional One Health who had supraglottic, oropharyngeal, and hypopharyngeal cancer that was diagnosed by ultrasound needle biopsy were reviewed from 2011 to 2016. Demographics, stage, biopsy results, and treatment were abstracted.

Results

Seventeen patients who underwent ultrasound-guided needle biopsy of the primary site were included. Average age was 63 years old, and 65% of patients were stage T4 (11/17). Needle biopsy yielded malignant cells in 76% (13/17). Eleven patients were included in subsequent analysis because 6 patients underwent needle biopsy only. Fisher exact test showed no difference between the 2 methods (P = .27). Sensitivity was 86% and specificity was 100%. Seven patients had a median potential delay in diagnosis of 10 days.

Conclusions

Ultrasound can be used effectively to obtain a tissue diagnosis, circumventing an operative biopsy. Moreover, ultrasound may provide additional imaging details to support accurate staging. This strategy may prove worthwhile to cut costs and reduce delay to staging, reduce risk for those with contraindications to anesthesia, and increase staging accuracy via enhanced imaging details.

Accuracy, Sensitivity and Specificity of Fine Needle Aspiration Biopsy for Salivary Gland Tumors: A Retrospective Study from 2006 to 2011

Objective:

This article concerns evaluation of the sensitivity, specificity and accuracy of FNAB for pre-surgical diagnosis of benign and malignant lesions of major and minor salivary glands of patients treated in the Department of Head and Neck Surgery of Erasto Gartner Hospital.

Methods:

This retrospective study analyzed medical records from January 2006 to December 2011 from patients with salivary gland lesions who underwent preoperative FNAB and, after surgical excision of the lesion, histopathological examination.

Results:

The study had a cohort of 130 cases, but 34 cases (26.2%) were considered unsatisfactory regarding cytology analyses. Based on the data, sensitivity was 66.7% (6/9), specificity was 81.6% (71/87), accuracy was 80.2% (77/96), the positive predictive value was 66,7% (6/9) and the negative predictive value was 81.6% (71/87).

Conclusion:

Despite the high rate of inadequate samples obtained in the FNAB in this study the technique offers high specificity, accuracy and acceptable sensitivity.

Charcoal suspension tattoo: new tool for the localization of malignant laterocervical lymph nodes

We present a retrospective study to evaluate safety and effectiveness of ultrasound (US)-guided tattooing with charcoal of suspicious laterocervical lymph nodes. When an open biopsy of a laterocervical lymph node is needed, the choice of the lymph node to excise and examine is fundamental to avoid rebiopsy. Surgeons tend to choose the most surgical approachable enlarged lymph node that does not always correspond to the one with worst echographic aspect. We present 16 cases of patients with laterocervical adenopathy with inconclusive or non-adequate results at fine needle aspiration cytology addressed to open biopsy. Those patients underwent US-guided preoperative injection of a charcoal suspension inside the lymph node to excise to mark it, and then excisional biopsy was performed. Sixteen marked lesions (100 %) were detected intraoperatively and dissected. The injected charcoal was detected intraoperatively in all cases. In 14 patients (87, 5 %) it was inside the lesion; in two cases (12, 5 %), the charcoal suspension was found in the tissues above the lesion. The procedure was well tolerated in all cases. No major procedure-related complications were encountered. US-guided charcoal tattooing is a new, safe, well-tolerated, and easy-to-perform technique for the marking of US suspicious laterocervical lymph nodes. This preliminary study shows a high technical success rate (76 %) and high percentage of intraoperative detection of marked lesions (100 %) with a low rate of complications.

Diagnostic value of liquid-based cytology with fine needle aspiration specimens for cervical lymphadenopathy

Background

Cervical lymphadenopathy is a symptom that is frequently seen among outpatients, and it is important to differentiate malignant lesions from reactive lymphoid hyperplasia. Fine needle aspiration (FNA) cytology has been widely used for the diagnosis of cervical lymphadenopathy. However, some limitations of the diagnostic accuracy using conventional smear (CS) cytology have been pointed out. The diagnostic value of liquid‐based cytology (LBC) with FNA specimens has not yet been fully proven.

Methods

Forty‐two patients with cervical lymphadenopathy who underwent FNA with CS cytology from 2007 to 2011 and 123 patients who underwent FNA with LBC utilizing LBCPREP2™ from 2011 to 2015 were studied. Diagnostic values were compared between the CS and the LBC groups.

Results

Of the total 165 patients representing the combined CS and LBC groups, 81 (49.1%) were diagnosed as benign lymph node and 84 (50.9%) were malignant diseases including 37 (22.4%) of metastatic carcinoma except for thyroid carcinoma, 30 (18.2%) of metastatic thyroid carcinoma, and 17 (10.3%) of malignant lymphoma. The overall statistical values including sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CS were 75%, 100%, 100%, 78.9%, and 87.1%, respectively, whereas those values for LBC were 91.2%, 100%, 100%, 90.7%, and 95.3%, respectively. The sensitivity of LBC for malignant diseases tended to be higher than that of CS cytology (p = 0.081).

Conclusion

LBC with FNA specimens from cervical lymphadenopathy is a useful and reliable method for the diagnosis of malignant diseases, especially of metastatic carcinomas, due to its increased sensitivity compared with CS cytology. Diagn. Cytopathol. 2016;44:169–176. © 2016 Wiley Periodicals, Inc.

Parotid gland metastases of distant primary tumours: A diagnostic challenge

OBJECTIVE

Metastatic disease is common among parotid malignancies. The majority of primary tumours are located in the head and neck, but primary tumours below the clavicle must also be considered, especially in histological types not usually found in primary parotid or skin tumours.

METHODS

We performed 644 consecutive parotidectomies between 1980 and 2012. Benign tumours were found in 555 patients (86%) and malignant tumours in 89 patients (14%).

RESULTS

Of 89 malignant tumours, 39 were metastases (44%). In 5 cases, the primary tumour was located below the clavicle (6% of malignant tumours). A carcinoma of the bronchus was subsequently diagnosed in three patients: one patient had breast carcinoma and one renal cell carcinoma.

CONCLUSION

The majority of metastases in the parotid gland arise from primary tumours of the head and neck. In 10-20% of metastases, the primary tumour arises below the clavicle. Parotid metastases can be the first clinical manifestation of a malignant tumour, and can also occur years after curative intent treatment. Histopathology and immunohistochemistry will offer clues to a possible metastatic process and to primary tumour location. Parotidectomy with complete excision of the tumour can be a curative measure or form an essential part of symptom control and should be considered in all but the most moribund patients.

Sonographic Evaluation of Cervical Lymphadenopathy; Comparison of Metastatic and Reactive Lymph Nodes in Patients With Head and Neck Squamous Cell Carcinoma Using Gray Scale and Doppler Techniques

Background:

Cervical lymphadenopathy could be seen in several pathologic processes. An accurate differentiation between these conditions is of utmost importance to select an appropriate therapy and assess the prognosis. Gray scale and Doppler are appropriate sonographic techniques for evaluating internal and external features of lymph nodes. Although, various criteria have been proposed to differentiate metastatic lymph nodes from benign ones, the most valuable and specific sonographic features are still under dispute.

Objectives:

The present study was designed to determine valuable sonographic features for differentiating metastasis from benign nodes using gray scale and Doppler sonography.

Patients and Methods:

A prospective diagnostic study was performed on 63 patients with head and neck squamous cell carcinoma (SCC) treated and referred to surgery clinic of Hazrat Rasoul Akram hospital from November 2010 to June 2012 with complaint of palpable cervical lymph node. All patients’ necks were scanned multidirectionally by gray-scale and Doppler techniques. After sonography, lymph nodes were biopsied and investigated to find out whether they were metastatic or reactive. Finally, demographic, sonographic and pathologic data were statistically analyzed by SPSS ver. 16 software using t-test, a nonparametric test and ROC analysis. Ninety five percent confidence interval was considered for all parameters.

Results:

The study included 41 males and 22 females with a mean age of 57.56 ± 13.79 years. The number of metastatic lymph nodes was 47, while the remaining 16 were reactive. There were significant differences in length (P = 0.037), width (P = 0.001), resistance index (P < 0.001), pulsatility index (P < 0.001) and systolic velocity (P < 0.001) of metastatic and reactive lymph nodes. Cut points for resistive and pulsatility indexes and systolic velocity were calculated as 0.695, 1.35 and 16.5, respectively. The most valuable factor for defining a lymph node as metastatic was circulation pattern with accuracy, sensitivity and specificity of 94%, 85% and 93%, respectively.

Conclusion:

Gray scale sonography in combination with Doppler sonography could be a trustworthy technique in differentiating metastatic lymph nodes from reactive ones. Although, circulation pattern had a higher diagnostic accuracy in the present study, combination of sonographic characteristics could be more beneficial in differentiating metastatic cervical nodes from reactive ones.

Management of regional metastatic disease in head and neck cutaneous malignancy. 1. Cutaneous squamous cell carcinoma

This overview is the first of 2 articles on the current evidence for management of the neck and parotid in cutaneous cancers of the head and neck. In this paper we discuss cutaneous squamous cell carcinoma (SCC) and review the latest evidence for management of the regional nodes.

Surgical errors and risks - the head and neck cancer patient

Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. It can lead to functional impairment and has impact in future chances for disease related survival. There are many risks for head and neck surgeons that can cause errors and malpractice.

To avoid surgical mistakes, thorough preoperative management of patients is mandatory. As there are ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of the medical studies and data as well as qualification in modern surgical techniques and the surgeons ability for critical self assessment are basic and important prerequisites for head and neck surgeons in order to make out risks and to prevent from mistakes. Additionally it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and to be able to deal with complications, when they occur.

Despite all precaution and surgical care, errors and mistakes cannot always be avoided. For that it is important to be able to deal with mistakes and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery.

Early recurrence or submucosal residual of laryngeal squamous cell carcinoma: diagnosis by CT-guided endolaryngeal core biopsy on a transcutaneous approach

BACKGROUND

Ultrasound and CT-guided biopsy is a common procedure for histologic diagnosis of recurrence of head and neck squamous cell carcinoma. The present study describes a novel CT-guided endolaryngeal puncture site.

METHODS AND RESULTS

A 59-year-old man was treated for a T2N0M0 supraglottic laryngeal tumor by laser resection and bilateral lymph node dissection; exeresis was judged complete. Six-month follow-up found persistent dysphonia. Endoscopic examination and iterative biopsy gave reassuring results, but (18) fluorodeoxyglucose positron emission tomography-CT ((18) FDG PET-CT) found highly suspicious increased right hemilaryngeal metabolic activity. Diagnosis of residual tumor was confirmed on CT-guided endolaryngeal biopsy.

CONCLUSIONS

Image-guided biopsy is the technique of choice in head and neck lesions that are deep or difficult to palpate and inaccessible to endoscopy. It is especially useful when recurrence is suspected after radiation therapy or cancer surgery. Many puncture sites have been reported in the literature; the present novel laryngeal approach extends the range of image-guided biopsy, although further studies will be needed to assess possible morbidity.