Keith Ramesar

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.

INTRODUCTION This study aims to review our 11 year experience of diagnosing metastatic squamous cell carcinoma presenting as head and neck lumps. The techniques of Ultrasound guided Core Biopsy (USCB), Fine Needle Aspiration Cytology (FNAC) and Surgical Excision Biopsy (SEB) are compared. MATERIALS AND METHODS All patients with metastatic squamous cell carcinoma (SCC) involving the lymph nodes of the head and neck or parotid gland, diagnosed at Eastbourne District General Hospital between January 1998 and November 2009 were identified. The following data items were collated: biopsy location (e.g. cervical lymph node or parotid), any history of likely primary SCC and site, type of biopsy used to establish a conclusive diagnosis (index diagnostic technique), previous biopsies, the technique and their results, subsequent histology results. RESULTS A total of 90 patients were diagnosed with metastatic squamous cell carcinoma. The index diagnostic technique was USCB in 48 patients, FNAC in 29 and SEB in 13. In 72 (80%) patients the index biopsy was the sole tissue sample taken prior to surgery or other treatment. The remaining 18 patients underwent a total of 22 previous biopsies prior to the index biopsy. 95% (21/22) of these previous biopsies were non-definitive FNAC and 5% (1/22) was a non-definitive USCB. FNACs also demonstrated the highest non-diagnostic rate (42%). The accuracy of USCB and FNAC in correlating with final histopathology was 97% and 85% respectively. CONCLUSIONS USCB demonstrates excellent results in the diagnosis of metastatic SCC in the head and neck with higher accuracy and greater reliability than FNAC.

Image-guided core needle biopsy in the diagnosis of malignant lymphoma

OBJECTIVE Current European Society for Medical Oncology (ESMO) guidelines recommend that when feasible, surgical excision biopsy (SEB) is the ideal for diagnosis, sub-typing and grading of malignant lymphoma. We undertook this retrospective study to assess the diagnostic accuracy of image-guided core needle biopsy (CNB) in the diagnosis of malignant lymphoma, to identify the proportion of cases from which oncological treatment was subsequently instigated from the CNB diagnosis, and to evaluate the potential role for minimally invasive CNB techniques in the diagnostic pathway of malignant lymphoma. METHODS All cases of lymphoma amenable to CNB between 2008 and 2013 were included. Patient records were reviewed to identify the biopsy diagnostic pathway undertaken (fine needle aspiration cytology, CNB, surgical excision biopsy). CNB specimens were graded as fully diagnostic (tumour sub-typing/grading and treatment initiated), partially diagnostic (diagnosis of lymphoma but more tissue required for sub-typing/grading), equivocal or inadequate. The effects of anatomical location, needle gauge, number of core specimens and sub-type of disease on the diagnostic yield of the sample were analysed. RESULTS 262 patients and 323 biopsy specimens were included in the study. 237 patients underwent CNB as the initial diagnostic intervention. In 230/237 CNB was fully diagnostic (97%), allowing initiation of treatment. In 7 patients, SEB was necessary in addition to CNB to provide additional diagnostic information to allow initiation of treatment. In 72 patients, SEB was the only diagnostic test performed. CONCLUSION Our study showed that in 97% of suitable cases, CNB provided sufficient diagnostic information to allow treatment of malignant lymphoma to be instigated. This minimally-invasive technique is well tolerated and has advantages over surgical techniques, including reduced costs, post-procedural complications and delays on the diagnostic pathway. CNB may obviate the use of surgical techniques in the majority of suitable cases, however its success is dependent on close collaboration and acceptance by clinicians and pathologists.

Ultrasound-guided core biopsy for investigation of cervical lymph node: chronic lymphocytic leukaemia and metastatic squamous cell carcinoma.

We describe a case in which ultrasound-guided fine needle core biopsy of a cervical lymph node enabled diagnosis of dual disease. Histological examination of the core biopsy confirmed unsuspected chronic lymphocytic leukaemia with an isolated focus of metastatic squamous cell carcinoma (SCC), and enabled optimal preoperative planning of treatment. Such a case is extremely unusual and provides evidence of the accurate diagnosis that can be obtained from nodal investigations using ultrasound-guided core biopsy.

Warthin's tumour and facial nerve palsy: an unusual association

We describe a man with Warthins tumour diagnosed on core biopsy, who presented with ipsilateral facial palsy. He was managed conservatively with subsequent resolution of the palsy, which suggested many diseases. The association of a benign parotid neoplasm with facial palsy is unusual, and appropriate investigations are essential for accurate diagnosis and surgical planning.

Myoepithelial carcinoma of the parotid: a rare tumour that may provide diagnostic difficulty

This report presents the case of a 57-year-old man with a 6-week history of a slowly enlarging lump in the right parotid gland. Initial ultrasound investigation confirmed a 3 cm solid mass located within the superficial lobe of the right parotid gland. Sonographically, the mass demonstrated possible malignant features with internal heterogeneity of architecture and some loss of marginal clarity. Ultrasound-guided core biopsy (USCB) of the mass reported a mixed neoplasm with epithelial and myoepithelial appearances consistent with likely benign adenoma or myoepithelioma. A right superficial parotidectomy was subsequently performed. Histological and immunohistochemical analysis of the excised specimen showed a myoepithelial carcinoma. Postoperative CT and MR staging scans did not show evidence of metastases and no further treatment was given following discussion of the case at the regional speciality multidisciplinary meeting. This case illustrates the clinical and pathological features of this rare salivary gland tumour, but also discusses the diagnostic difficulties that may be encountered preoperatively.