Ultrasound-Guided Needle Biopsy in the Diagnosis of Malignant Cervical Lymphadenopathies
Condition: Lymphadenopathy; Malignancy
MeSH terms: Lymphadenopathy
Study type: Observational

Summary: 
      The objective of the present study was to compare ultrasound (US) characteristics and
      ultrasound-guided core-needle biopsy (US-CNB) with US-guided fine-needle aspiration (US-FNA)
      in the assessment of different malignant cervical lymphadenopathies. Patients with malignant
      cervical lymphadenopathie with either US-FNA or US-CNB over a 3-year period from 2007 July to
      2010 Dec were retrospectively reviewed. There are two major study groups according to the
      treatment status of the patient's population, including patients who had pathology proofed
      previous cancer and with clinically cervical lymphadenopathies after treatment. The second
      group included patients with cervical lymphaenopathies but without previous diagnosis of
      malignancy and treatment. The results of cytology, or pathology and time of needle biopsy to
      final diagnosis were traced and recorded. Morphologic US parameters and vascular features
      were thoroughly evaluated and compared in different disease.
    

Detailed description: 
      Introduction

      In the absence of infection signs, lateral neck lymphadenopathies should be suspected as
      metastatic carcinoma or lymphoma until proved otherwise. Previously, the most commonly used
      sampling techniques in the head and neck are the open excisional biopsy and fine-needle
      aspiration (FNA) cytology. Open biopsy and lymph node excision provides material suitable for
      histological analysis but is invasive and may entail general anesthesia and hospital
      admission. Besides, excisional and incisional biopsy of cervical metastases results in a 2-3
      times increased incidence of local treatment failure when compared with FNA cytology.

      High-resolution ultrasound is widely used imaging modality to evaluate the morphology,
      internal architecture, size and shape of cervical lymph nodes. In the head and neck, the
      image guidance technique most commonly used has been ultrasound. The real-time capability and
      ease of use makes ultrasound the procedure of choice. The evidence of improved efficacy of
      ultrasound-guided FNA over palpation-guided FNA in the head and neck also has been well
      documented, leading to its acceptance as the standard procedure.

      Disadvantages of FNA include a high rate of nondiagnostic samples and incomplete
      classification of lymphoma with delayed diagnosis. The core-needle biopsy (CNB) is an
      alternative to the established ways of tissue sampling and used very successfully for many
      years. As the histologic architecture of the lesion is preserved, it provides a sample that
      is adequate for histopathologic and immunohistochemical examination.

      To our knowledge, there was only one prospective investigation comparing ultrasound guided
      CNB with FNA in the head and neck region. However, the studied population was heterogeneous
      and case numbers were limited. The result revealed no significant difference between both
      methods. The objective of the present study was to compare ultrasound-guided CNB with FNA in
      the assessment of different malignant cervical lymphadenopathies.

      Patients and methods

      A retrospective study will be performed including consecutive patients over a 3-year period
      from 2007 July to 2010 Dec. All patients were seen at our institution with malignant cervical
      lymphadenopathies. The biopsies were performed on an outpatient basis, unless the patient was
      hospitalized for alternative reasons. Equipment for sonographic studies consisted of a color
      Doppler US unit (Philips HDI 5000, Bothell, WA, US) and a 5-12 MHz broadband linear array
      transducer.

      Morphologic US parameters and vascular features were thoroughly evaluated and recorded on the
      PACS system (Marotech Inc, Seoul, South Korea) for the largest nodal lesion in each patient.
      Every lymph node was assessed first with gray-scale sonography for morphologic parameters in
      horizontal and then longitudinal sections. The short-axis diameter, long-axis diameter and
      diameter ratio of short to long axis (S/L ratio) were measured. Echogenicity with respect to
      the surrounding soft tissue was assessed and classified as hypoechoic, isoechoic, or
      hyperechoic. Lymph node margin was defined as regular or irregular. Echogenic hilus was
      distinguished between its presence or absence. Internal echo pattern was divided into
      heterogeneity or homogeneity. Vascular patterns were then surveyed by power Doppler
      sonography and categorized as the group of avascular or hilar type versus that of mixed,
      spotted, or peripheral type.

      With the data on history, physical examination, and ultrasound result, we decided that
      ultrasound guided needle biopsies would be the first line of investigation for these lesions.
      Informed consent for the procedure was obtained from all the patients before biopsy. In
      general, FNA was carried out with the array probe guiding the placement of a 22-gauge fine
      needle within the largest node after sterilization without anesthesia. For CNB, the skin was
      sterilized and locally anaesthetized with 2% lidocaine. A modified non-advancing, disposable,
      spring-loaded cutting biopsy needle (Temno biopsy system, Allegiance Healthcare Corporation,
      McGaw Park, IL, USA) with 15-mm side-notch of 9 cm length and 18-gauge were used. All
      biopsies were done by the same experienced otolaryngologist (Li-Jen Liao) under real-time
      ultrasound guidance with freehand technique. Three times of tissue core biopsies were done
      for each patient. After the biopsy, all patients were asked to compress the puncture site and
      were evaluated for possible complications such as bleeding or bruising for half an hour
      before leaving the examination room.

      The specimens were put in 10% formalin solution for pathologic studies. In the Department of
      Pathology, formalin-fixed, paraffin-embeddedm sections from the biopsies were stained with
      hematoxylin and eosin for morphologic examination. Further immunohistochemical studies were
      performed as necessary.

      There are two major study groups according to the treatment status of the patient's
      population. The first group included patients who had pathology proofed previous cancer and
      with clinically cervical lymphadenopathies after treatment. The second group included
      patients with cervical lymphaenopathies but without previous diagnosis of malignancy and
      treatment. The disease groups were further classified as metastatic nodes from nonthyroid
      primary (META), lymphoma (LYM) and metastatic nodes from papillary carcinoma of the thyroid
      (PAP).

      The results of cytology and pathology were graded as false negative, suspicious and positive
      for malignancy. The final diagnoses of patients were established by the histopathology. The
      time of needle biopsy and final diagnosis were traced and recorded.

      Statistically, continuous variables were compared by performing the Kruskal-Wallis test.
      Category data were compared by using the Chi-square test or Fisher's exact test. The time
      from procedure to final diagnosis were expressed in K-M plot and tested with Log-rank test.
      All statistical analyses were accomplished using SAS software, version 9.1 (SAS Institute,
      Inc, Cary, North Carolina).

      Expected Results:

      We will know the differential US characteristics in different malignant cervical
      lymphadenopathies. Besides, we will know US-FNA or US-CNB is preferred in which situation.
    

Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Patients with malignant cervical lymphadenopathie with either US-FNA or US-CNB over a
        3-year period from 2007 July to 2010 Dec were retrospectively reviewed. There are two major
        study groups according to the treatment status of the patient's population, including
        patients who had pathology proofed previous cancer and with clinically cervical
        lymphadenopathies after treatment. The second group included patients with cervical
        lymphaenopathies but without previous diagnosis of malignancy and treatment.
      
Keywords: lymphadenopathy; needle biopsy; sonography