DIAGNÓSTICO POR IMAGEM Image-guided biopsy of head and neck Thiago Julio, MD
May 24, 2015
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Image-guided biopsy of head and neck
Thiago Julio, MD
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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.
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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
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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
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Strategy ! Tactical:
triangulation method change in the degree of neck side flexion multimodality
Technical: 20 – 22G blunt F ine-tunning
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Hawkins-Akins blunt needle
Anatomy
Suprahyoid
Infrahyoid Each one requires different percutaneous biopsy approaches.
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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
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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.
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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.
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Subzygomatic approach
Safe access to lesions located:
Masticator space
Parapharyngeal and
pharyngeal mucosal spaces
Retropharingeal space
Prevertebral space
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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
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Retromandibular approach
Safe access to lesions located:
Parapharyngeal and
pharyngeal mucosal spaces
Deep parotid space
Retropharingeal space
transparotid
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Transoral approach
general anesthesia supine position mouth opener retractor or nasal tube antibiotics
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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.
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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
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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.
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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.