image-guided head and neck biopsy

DIAGNÓSTICO POR IMAGEM

Image-guided biopsy of head and neck

Thiago Julio, MD


Deep-seated head and neck lesions, which were traditionally evaluated by surgical means, are now accessible with less invasive image-guided percutaneous needle biopsy techniques.


CT: High spatial and contrast resolution Allows excellent delineation of intervening vital structures,

permitting safe biopsy path planning Imaging modality of choice for biopsies of deep-seated

head and neck lesions

US: Superficial targets Transoral approach (endocavitary) Puncture point planning Doppler


Major complications are rare. The potential of major vascular injury with the small-caliber biopsy

needles is extremely low.

Minor complications: Pain Vasovagal reaction Minor infection Minor bleeding

Familiarity with the cross-sectional anatomy and careful attention to planning the needle path minimize the chances of clinically significant hemorrhage.

think for nine seconds

and then act


Strategy ! Tactical:

triangulation method change in the degree of neck side flexion multimodality

Technical: 20 – 22G blunt F ine-tunning


Hawkins-Akins blunt needle

Anatomy

Suprahyoid

Infrahyoid Each one requires different percutaneous biopsy approaches.


Approaches

Skull base, head, and suprahyoid neck lesions (including upper cervical vertebrae):

Infrahyoid neck and lower cervical vertebrae lesions:

Subzygomatic Retromandibular Paramaxillary Submastoid Transoral Posterior approaches

Anterolateral The needle advance between the

carotid sheath and airway. Posterolateral

The needle advanced posterior to the carotid sheath.

Posterior

Transfacial paramaxillary approach

Safe access to lesions located:

Infrazygomatic portion of the

masticator space

Posterior portions of the

parapharyngeal and

pharyngeal mucosal spaces

Carotid sheath space

Deep portion of the parotid space

The needle is inserted through the buccal space inferior to the zygomatic process of the maxilla and advanced posteriorly between the maxilla and mandible

• It is important to avoid the facial artery, which courses in the buccal space

• Changing the angulation of the needle can be necessary


Limitations for needle trajectory and angulation:

Shape and size of the adjacent bones: Posterolateral wall of the maxillary antrum Alveolar ridge Lateral pterygoid plate Anterior margin of the mandibular ramus

In patients with a large maxillary antrum, the space between the maxilla and the mandible may be very narrow, limiting needle placement.


Female

64

History of breast and thyroid cancer

PET-CT: high metabolic activity on right retropharingeal cervical lymph node

T1T2 fat sat

Vol fat 3D Gd DWI ADC

Female, 21 years old. Headache, left earache and tinnitus. Alveolar soft tissue sarcoma.


Subzygomatic approach


Masticator space

Parapharyngeal and


Retropharingeal space

Prevertebral space


easy angulation of the needle in various directions (anterior, posterior, cranial, or caudal)

access to multiple target sites

the needle traverses the masticator and parapharyngeal spaces


Retromandibular approach


Parapharyngeal and


Deep parotid space

Retropharingeal space

transparotid


Transoral approach

general anesthesia supine position mouth opener retractor or nasal tube antibiotics


Particularly useful for lesions in

the posterior pharyngeal mucosal and part of the

retropharyngeal space and the prevertebral portion of the perivertebral space

These lesions are difficult to access with other approaches.


This approach can also be used for sampling lesions at: Anterior arch of C1 The odontoid and body

of C2

It can be also used to access the foramen ovale and other skull base lesions by using cranial needle angulation.

Infrahyoid Neck and Lower Cervical Vertebrae Lesions


Take Home Messages

Deep head and neck lesions may be accessed by using a variety of percutaneous approaches, each one with its own set of advantages and limitations.

The location and extent of the lesions and their relationship to adjacent structures influence the choice of the needle path.

Familiarity with head and neck anatomy and careful planning of the

procedure are necessary for a biopsy that is both precise and safe.


References

Percutaneous biopsy of head and neck lesions with CT guidance: various approaches and relevant anatomic and technical considerations. Gupta S et al. Radiographics 2007 Mar-Apr;27(2):371-90.

The Buccal Space: A Doorway for Percutaneous CT-Guided Biopsy of the Parapharyngeal Region. Tu AS et al. AJNR Am J Neuroradiol 19:728–731, April 1998.

CT-Guided Percutaneous Biopsies of Head and Neck Masses. Gatenby RA et al. Radiology 146: 717-719, March 1983.

Biopsy of Parapharyngeal Space Lesions. Yousem DM et al. Radiology 1994; 193:619-622.

Percutaneous CT-Guided Aspiration of Deep Neck Abscesses. Poe LB et al. AJNR Am J Neuroradiol 17:1359–1363, August 1996.

CT-Guided Aspirations in the Head and Neck: Assessment of the First 216 Cases. Sherman PM et al. AJNR Am J Neuroradiol 25:1603–1607, October 2004.

Computed tomography guided needle biopsy: experience with 1,300 procedures. Chojniak R et al. Sao Paulo Med J. 2006; 124(1):10-4.


@thiago37 [email protected]

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image-guided head and neck biopsy

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