Abstract
Aim: To study the value of ultrasound-guided core needle biopsy (CNB) in the diagnosis of T3 or T4 stage laryngeal and hypopharyngeal cancer, which is difficult by routine methods. Patients and Methods: Nineteen cases of T3 or T4 stage laryngeal or hypopharyngeal carcinoma with abnormal pharyngeal sensitivity, severe dyspnea, submucous cancer recurrence, cardiovascular and pulmonary dysfunction were reviewed retrospectively from October 2012 to October 2014 in the Yuhuangding Hospital of Qingdao University. Ultrasound-guided coarse needle biopsies were used on primary lesions after assessing the patients with neck-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) scan(s). The clinical value of ultrasound-guided CNB in the diagnosis of laryngeal and hypopharyngeal cancer was analyzed. Results: All patients underwent successful pathological diagnosis by ultrasound-guided CNB without any serious complications. Dyspnea, cardiovascular and pulmonary dysfunction did not deteriorate. Conclusion: Ultrasound-guided CNB is a highly safe and efficient method for the pathological diagnosis of T3 or T4 stage laryngeal and hypopharyngeal cancer. It should be used especially when the fiberoptic or laryngoscope biopsy are of high risk.
High-frequency ultrasonography is routinely used as an imaging method to evaluate the involvement of cervical lymph nodes, soft tissues and thyroid gland in patients with laryngeal or hypopharyngeal carcinoma, but rarely to evaluate the tumor itself, mainly because of the calcified thyroid cartilages in adults and the interference of air within the laryngeal cavities. Nevertheless, attempts have been made to use ultrasonography in this area, largely to take advantage of its non-invasive and real-time imaging features. Since the 1970's, ultrasonography has been used to evaluate laryngeal tumors in a few studies, with some of these proving that ultrasonography may assist tumor staging in patients with advanced laryngeal cancer (1).
Core needle biopsy (CNB) has been proposed as an additional diagnostic method to ultrasound-guided fine needle aspiration biopsy (US-FNA), mainly to overcome the limitations of inconclusive cytologic diagnosis. CNB provides a large amount of tissue that enables histological diagnosis and additional immunohistochemical staining, if needed. Several studies have shown the usefulness of CNB in providing definitive diagnosis for thyroid nodules (2-5).
Therefore, for the above two reasons, ultrasound-guided CNB in the diagnosis of laryngeal or hypopharyngeal cancer, especially in T3 or T4 stage, is, theoretically, feasible. We applied this technique in the clinic to patients who had difficulties in pathological diagnosis by conventional biopsy for reasons, such as abnormal pharyngeal sensitivity, severe dyspnea, submucous cancer recurrence, cardiovascular and pulmonary dysfunction.
Patients and Methods
Patients and clinical data. Nineteen cases of T3 or T4 stage laryngeal or hypopharyngeal carcinoma with abnormal pharyngeal sensitivity, severe dyspnea, submucous cancer recurrence, cardiovascular and pulmonary dysfunction were reviewed retrospectively from October 2012 to October 2014 in Yuhuangding Hospital of Qingdao University. Of these patients, all were males aged 60-92 years (mean=70.53), 4 cases had abnormal pharyngeal sensitivity and I to II degree of laryngeal obstruction, 9 cases had severe cardiovascular-pulmonary dysfunction and I to II degree of laryngeal obstruction, 3 cases had submucous cancer recurrence, 3 cases had II degree of laryngeal obstruction (Table I). They all underwent a contrast-enhanced computed tomography (CT) and/or magnetic resonance imaging (MRI) examination prior to the ultrasound-guided CNB. Tumor-node-metastasis (TNM) staging was analyzed according to the standard of the International Union against Cancer (IUCC) in 2002. The clinical value of ultrasound-guided CNB in the diagnosis of laryngeal and hypopharyngeal cancer was analyzed by the clinical outcome.
Patients and clinical data.
Ultrasound-guided CNB procedure. We used an American Logiq E9 GE color ultrasonic diagnostic instrument (GE healthcare China, Wuxi, China), a United States Bard automatic ejection biopsy gun and the special matching 18G groove type tissue cutting needle (C. R. Bard, Inc., Murray Hill, NJ, USA). Carefully reading the CT and/or MRI data before puncture was necessary to determine the location of the tumor and surrounding tissue involvement (Figures 1 and 2). The location, size, shape, internal echo, boundary and internal blood flow distribution of the tumors had to be evaluated again by ultrasonic examination. Ultrasound imaging can display the vascular and blood flow area well in the neck. This helps the doctor choose the best puncture site and direction. We chose to puncture at the nearest skin site to the tumor and avoid the abundant blood circulation area and large blood vessels (Figures 3 and 4).
The patients were in the supine position, head backward (not too backward, avoiding the aggravation of laryngeal obstruction), with the anterior region of the neck being exposed. The puncture point was located and the depth of inserting was measured using an American Logiq E9 GE color ultrasonic diagnostic instrument. The skin of the anterior neck was sterilized with 0.5% iodophor. The puncture point was locally anesthetized with 4 mg/kg 1% lidocaine. The biopsy needle punctured into different tumor areas, 2-3 times, along the long axis of the ultrasonic probe under the real-time ultrasonic monitoring (Figure 5) allowing for the collection of some pathological tissue (Figure 6). The pathological tissue was fixed with 4% formalin solution for further histological diagnosis and additional immunohistochemical staining examination.
Results
Of the patients involved in the study, 13 cases were laryngeal carcinoma, 6 cases hypopharyngeal carcinoma, 14 cases were in the T3 stage and 5 cases in the T4 stage. All patients had successful pathological diagnosis by only using ultrasound-guided CNB without any serious complications. Dyspnea, cardiovascular and pulmonary dysfunction did not deteriorate. All 19 cases were pathologically diagnosed as squamous cell carcinomas.
Discussion
Due to the calcified thyroid cartilage in adults and the interference of air within the laryngeal cavities, ultrasonography is rarely used to evaluate laryngeal or hypopharyngeal carcinoma structure(s). Nevertheless, attempts have been made to use ultrasonography in this area. Ultrasonography has been used to evaluate laryngeal tumors in a few studies since the 1970's and some of these have proved that ultrasonography can assist in tumor staging in patients with advanced laryngeal cancer (1, 6-8). With the application of a wide band and high frequency ultrasonic probe, ultrasound can clearly show the main structures of laryngeal cartilage, ligament, muscle, pre-epiglottic space and para-glottic space for their superficial location and, to a certain extent, the sound transmission of laryngeal cartilage. The occupying solid tumor displaces the throat cavity and infiltrates and destroys the thyroid cartilage. It provides a favorable condition for ultrasound imaging (6, 7). The high resolution ultrasound for laryngeal imaging has the advantage of real-time, dynamic, multi-plane, as well as multi-directional, imaging, which limits MRI and CT imaging (8). A T3 or T4 stage laryngeal and hypopharyngeal carcinoma is usually larger and has a wide range of infiltration. This, therefore, not only makes CNB under ultrasound guidance possible but also makes this method of very high clinical value.
Enhanced computed tomography (CT) scan shows left laryngeal space and thyroid cartilage destruction.
Computed tomography (CT) scan shows left pharyngeal space and partial thyroid cartilage destruction.
Ultrasound color imaging displays tumor and blood circulation.
Gray-scale ultrasound imaging shows tumor adjacent to a cervical blood vessel.
Ultrasound-guided needle biopsy of the solid part of the tumor.
At present, the fiber-optic and suspension laryngoscope biopsy are the two most common methods used to obtain histopathological tissue for laryngeal and hypopharyngeal carcinoma. However, these two kinds of methods are poorly tolerated by patients with abnormal pharyngeal sensitivity, severe dyspnea, submucous cancer recurrence, cardiovascular and pulmonary dysfunction. For the T3 or T4 stage laryngeal and hypopharyngeal cancer, most patients are elderly. In clinic, it is not unusual for the above criteria to be found together. Ultrasound-guided CNB can not only avoid the significant interference of the airway and cardiopulmonary function affecting the fiber-optic and supporting laryngoscopy biopsy but also has minimally invasive characteristics. It has an unparalleled advantage for the submucous recurrent carcinoma, which is highly difficult to sample using the fiber-optic and suspension laryngoscope biopsy. Imaging examination plays a very important role in the diagnosis of the recurrence of laryngeal and hypolaryngeal carcinoma; however, the final diagnosis still relies on pathological biopsy. Early surgery and radiotherapy result in extensive cervical edema, fibrosis, stiffness and stenosis of the larynx and trachea, which makes routine biopsy almost impossible. In this study, there were 3 cases of suspected recurrent cancer whose fiber-optic or supporting laryngoscopy biopsy showed negative results. We applied ultrasound-guided CNB and, finally, diagnosed submucosal squamous cell carcinoma recurrence. This approach provided an important basis for the next step of treatment options.
Core biopsy needle with pathological tissue.
Ultrasound imaging can display the vascular and blood flow area well in the neck. This helps the doctor choose the best puncture site and direction and, effectively, avoid accidental injury. There were no serious complications for all patients in our study. Eight patients complained about mild pain in the puncture site, though this pain subsided within two days without the prescription of painkillers. Even so, it is necessary to carry out this operation to be performed by a senior ultrasonic doctor.
US-FNA is widely used in the pathological diagnosis of neck tumors, especially in thyroid tumors (9). The main difference between the fine needle biopsy and the coarse needle biopsy is the diameter of the cutting section. The material from the fine needle biopsy is enough for cytology examination, but not enough for immunohistochemical tests. CNB, on the other hand, is able to obtain adequate tissue to make up for this defect of the fine needle biopsy (2, 4, 10-12).
Ultrasound examination is performed in real-time and is dynamic. The operator can observe the position of puncture needle throughout the whole procedure. It has been reported that CT-guided biopsy achieves satisfactory results (13). However, it is not real-time dynamic monitoring and patients have to receive more X-ray irradiation (1, 7, 14-16). Some have reported that three-dimensional Doppler ultrasound imaging has a high diagnostic value for laryngeal and hypopharyngeal cancer. However, the operation technique and image recognition still need to be improved (17, 18).
Ultrasound examination of laryngeal and pharyngeal cancer has certain limitations. Laryngeal cartilage calcification can reduce the sonolucency and affect the imaging of the posterior tumors. In order to show the panorama of the tumor, the cartilage between the ligaments has to be taken as an acoustic window to scan the tumor. It is not as accurate as the fiber laryngoscope to diagnose the ulcerative and early tumors. The air in the laryngeal cavity affects both the display of the posterior structure and color Doppler flow imaging by producing color flicker artifacts. The coronal scan should be done on both sides of the throat in order to reduce the influence of air interference. In this regard, it is necessary to strictly choose and evaluate patients.
Acknowledgements
This study was financially supported by Yantai Science and Technology Planning Project 2016WS010.
Footnotes
↵* These Authors contributed equally to this study.
- Received May 2, 2017.
- Revision received May 28, 2017.
- Accepted May 30, 2017.
- Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
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