www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Ultrasonography
guided
fine
needle
aspiration
cytology
in
patients
with
laryngo-hypopharyngeal
lesions
夽
Lakshminarasimman
Parasuraman
∗,
Chirom
Amit
Singh
,
Suresh
C.
Sharma,
Alok
Thakar
AllIndiaInstituteofMedicalSciences,DepartmentofOtorhinolaryngology,NewDelhi,India Received2May2018;accepted26November2018
Availableonline28December2018
KEYWORDS Laryngealcancer; Ultrasoundguided transcutaneousfine needleaspiration cytology; Laryngealpharyngeal lesions; Cytology Abstract
Introduction:Laryngeal lesions are usually evaluated by microlaryngoscopy/direct laryn-goscopyunderanaesthesiafor diseasemapping andtissuediagnosis.Howeverpatientswith anticipated airwaycompromise dueto laryngeal massmay require either a protective tra-cheotomy or emergency tracheotomy tosecure the airway. Tominimise risk ofunplanned tracheotomyandexpeditethediagnosisweperformedultrasound-guidedtranscutaneousfine needleaspirationcytology.
Objective: Toevaluate thefeasibilityandperformanceofultrasound-guidedtranscutaneous fineneedleaspirationcytologyofsuspicious/recurrentlaryngo-hypopharyngealmasses. Methods:Fineneedleaspirationcytologywasperformedunderultrasoundguidance. Twenty-fourpatientswererecruited,ofwhich17hadapurelaryngeallesion;6patientshad laryngo-pharyngeal,andonepatienthadabasetonguelesionwithsupra-glottisextension.
Results:Outof24patients,21hadpositivecytologyforsquamouscellcarcinoma,2patients had non-diagnosticcytology(atypicalcells)and theotherhadinadequate tissuefor defini-tivediagnosis.Patientswithnegativeandinconclusivecytologyunderwentdirectlaryngoscopy biopsy,whichwaspositiveforsquamousmalignancy.Allpatientstoleratedtheprocedurewell andnoadverseeventswerenoted.
Conclusion: Althoughdirectlaryngoscopyremainsthestandardofcareinevaluationof laryngo-hypopharyngeallesions,thispilotstudyhasshownthatultrasound-guidedtranscutaneousfine needleaspirationcytologywasfeasibleasanout-patientprocedure,employingsafeand sen-sitivetechniqueenablingrapiddiagnosisandavoidingtheneedfordirectlaryngoscopyunder GAfortissuediagnosis.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:ParasuramanL,SinghCA,SharmaSC,ThakarA.Ultrasonographyguidedfineneedleaspirationcytologyin patientswithlaryngo-hypopharyngeallesions.BrazJOtorhinolaryngol.2020;86:237---41.
∗Correspondingauthor.
E-mail:lakshminarasimmanp@gmail.com(L.Parasuraman).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2018.11.005
1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PAFF-USGTC; Lesões laríngeo-hipofaríngeas; Citologia
Resumo
Introduc¸ão:Aslesõeslaríngeassãogeralmenteavaliadaspormicrolaringoscopia/laringoscopia direta sob anestesia para mapeamento da doenc¸a e diagnóstico tecidual. No entanto, em pacientes comcomprometimento prévio das viasaéreas devidoà lesão laríngea,pode ser necessáriaumatraqueostomiaprotetoraoutraqueostomiadeemergênciaparaassegurarasvias aéreas.Paraminimizaroriscodeumatraqueostomianãoplanejadaefacilitarodiagnóstico, realizamospunc¸ãoaspirativaporagulhafinaguiadaporultrassonografiatranscutânea. Objetivo:Avaliaraviabilidadeeodesempenhodapunc¸ãoaspirativaporagulhafinaguiadapor ultrassonografiatranscutâneaemlesõeslaríngeo-hipofaríngeassuspeitas/recorrentes. Método: A punc¸ão aspirativapor agulha finafoi realizada sob orientac¸ão ultrassonográfica. Foramrecrutados24pacientes,17comlesãolaríngeaapenas,6comlesãolaríngeo-faríngeae umcomlesãonabasedalínguacomextensãosupraglótica.
Resultados: Dos24pacientes,21apresentaramcitologiapositivaparacarcinomaespinocelular, 2 citologia não diagnóstica (células atípicas) e o outro tecidoinadequado para o diagnós-ticodefinitivo.Ospacientescomcitologianegativaeinconclusivaforamsubmetidosàbiópsia atravésde laringoscopiadireta, quefoi positiva paralesão malignaespinocelular. Todosos pacientestolerarambemoprocedimentoenenhumeventoadversofoiobservado.
Conclusão:Emboraalaringoscopiadiretacontinueaseropadrãodecuidadonaavaliac¸ãodas lesõeslaríngeo-hipofaríngeas,esteestudopilotodemonstrouqueapunc¸ãoaspirativaporagulha finaguiadaporultrassonografiatranscutâneaéumatécnicaviável,ambulatorial,segurae sen-sível,permiterápidodiagnósticoeevitaanecessidadedelaringoscopiadiretasobanestesia geralparadiagnósticotecidual.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Over the last two decades the technique of fine needle aspiration cytology has become the first line tissue diag-nosticprocedurefor palpableheadandneckmasslesions. Forthoseclinicallyinaccessiblelesionsimagingmodalities suchasultrasound,computedtomography,magnetic reso-nanceimaginghadbeenusedtoreachthetargetedtissue fordiagnosis.1
Laryngeal lesions are usually evaluated by microlaryn-goscopy or direct laryngoscopy under anaesthesia for mappingthediseaseandtoobtaintissuediagnosis.Inafew cases,thebulkofthediseasemightbesubmucosalinnature, or in recurrent cases (i.e.) post treatment (radiother-apy/chemoradiotherapy)superficialmucosalbiopsymaynot beadequatefordiagnosis.2
InapilotstudybyAnsarinetal.Ultrasound-Guided Tran-scutaneoustru-cutBiopsy(USGTCB)wasshowntobeauseful techniquefor tissuediagnosis ofbulkylaryngealmassesin patientswhoareatriskforgeneralanaesthesia.
Ultrasound-guidedfineneedleaspirationwasperformed in two patients for rapid tissue diagnosis who presented withsupraglotticmasslesionwithnormalappearingsurface mucosa.Cytologyinbothcaseswasdiagnosticforsquamous cellcarcinoma.3
Preoperativefactors likedifficult intubation and antic-ipated compromised airway due to laryngeal mass after
biopsy may necessitate either a protective or emergency tracheotomytosecureairway.Thepresenceoftracheotomy impliesanon-functionallarynxinthemajorityofpatients, makingtheoptionoforganpreservationimpractical.
Cervical spondylosis, multiple comorbidities and advancedageareafew patientfactorsthatmayat times makethemunfitforevaluationundergeneralanaesthesia.
The purposeof this study was toassess the feasibility andperformanceofUSGTC-FNACinuntreatedorpreviously treated suspicious laryngopharyngeal masses under local anaesthesia,aswellastoevaluateitsefficacyinobtaining ahistologicaldiagnosis.
Methods
The studywasconductedbetweenJanuary2013andJune 2013. Patients with untreated or previously treated sus-picious laryngeal pharyngeal masses were prospectively enrolled in the study after fulfilling the following inclu-sion criteria: (1) Advanced laryngeal and hypopharyngeal mass lesions (correspondingto T3 and T4 stage according
to AJCC 7th edition); (2) At risk for tracheotomy (bulky laryngealgrowth,signsindicatingdifficultintubation)4;(3)
Contraindicationsforgeneralanaesthesia.
The study was approved by the institutional ethical committee (IEC/NP-421/2012 & RP-12/2012) and written informedconsentwasobtainedfromallpatients.
Figure1 (A)72years/Malepatientwithsuspectedcarcinomalarynx:CECTscanshowinganenhancinglesioninleftsidelarynx andpyriformsinuswitherosionofthyroidcartilageandcriticalglottisopening.(B)USGTC-FNACobtainedusinga25gaugespinal needle(solidline)whichhasbeenintroducedthrougherodedthyroidcartilage.
Thosepatientswithearly(T1,T2)lesions,massively
calci-fiedthyroidcartilage,vascularlesions,lesionsnotdetected byultrasoundandthosewithabnormalcoagulationprofile wereexcludedfromthestudy.
All patients were evaluated by history, physical exam-ination, coagulation profile, examination by Hopkins (90 degree)/flexible fibreoptic laryngoscopy, and multi- slice spiralContrastEnhancedComputedTomography(CECT)of faceandneck.
Technique
Afterselection ofpatientforUSGTC-FNAC,theinitialstep wastoevaluatethecomputedtomographyimages(Fig.1A andB),tolocalisethemassandthepotentialneedletrack. Thenacheckultrasoundwasperformedusinga7.5MHz lin-eartransducerafterpositioningthepatientduringreclining andhead extended. The skin wascleaned withantiseptic andcoveredwithasterile drape,and3---5mLof2% ligno-caine was injected using 25gauge spinal needles. Before infiltrating the local anaesthetic, ultrasound (US) images ofthelesionswasobtained.Computedtomographyimages obtained during the preoperative work up were studied andlesionsapproachedaccordinglythroughthethyrohyoid, cricothyroidmembraneorthyroidcartilage,ifitwaseroded bytumourasshowninFig.1AandB.
Afterlocatingthesite,theneedlewasadvancedunderUS guidanceuntilitreachedtheinteriorofthelesion(Fig.1B). Adropoftheaspiratewasplacedonglassslides,whichwas laterplacedin10%phosphatebufferedformalin,followed bystandard(H&E)haematoxylinandeosinstaining.Atthe endofprocedure,patientswerekeptunderobservationfor 30minandthendischarged.
Results
A totalof 24 patients underwent USGTC-FNAC(male, 21; female, 3) for laryngo-hypopharyngeal masses in the age groupof40---73yearswiththemeanageof56.7years.Of these24patients,23patientshadsuspiciousuntreatedmass lesionsobstructingthelaryngeallumen,andonepatienthad receivedlasercordectomyforglottiscancerT1N0M0(AJCC
8thedition)(Table1).
Thetumourwaslocalisedwithoutanydifficultyby ultra-sound in all 24 patients. Ultrasound-guided fine needle aspiration was undertaken in all. Since all patients had advanced(T3/T4)diseasewedidnotexperienceany
tech-nicaldifficulty either in localising the lesion or obtaining thetissuefordiagnosis.Allpatientstoleratedtheprocedure wellwithoutanycomplicationsortechnicalproblems.
Cytologyevaluationrevealedsquamouscarcinomain21 cases(87.5%)and2cases(8%)atypicalcells,andthe remain-ingbiopsycontainedaninadequatesample(4%).Thosethree patients with equivocal/negative tests underwent direct laryngoscopyandwereconfirmedtohavesquamous carci-nomaonbiopsy.
Discussion
Ourexperience of USGTC-FNAC in 24 patients with bulky laryngeal pharyngeal lesions suggests that this technique wasfeasible andquite sufficient for diagnosis in 21of 24 caseswithdiagnosticsensitivityof87.5%.
Dedivitisetal.studied28patientswithtranscutaneous fineneedleaspirationbiopsyofthepre-epiglotticspacewho underwentpartiallaryngectomy forsupraglotticsquamous cellcarcinomaandcomparedthatwithhistopathologic anal-ysisofthelaryngectomyspecimens.Efficiencywasfoundto beinrangeof96.4%,withoutanymorbidity.5
Ansarin etal. performed Ultrasound-Guided Transcuta-neousTru-CutBiopsyintenpatients:4weretreatmentnaïve hadmasslesionobstructingthelaryngeallumenand6were previously treated for laryngeal cancer. Out of these 10 patients,9patientshadadequatetissueanddiagnosedwith 100percentsensitivityoncytology.6
Preda et al. followed the same biopsy procedure in selectedpatients(withstenosisofairwaysordifficult intu-bationorcontraindicationtogeneralanaesthesia)asAnsrin et al. and proved the sensitivity of this technique was 92.5%.7
Kohlietal.studied25patientsofcarcinomalarynxand laryngealpharynxwithfineneedleaspirationcytologyand exfoliativecytologyanddirectlaryngoscopybiopsy.The pos-itivityratewithFNACwas80%.8
Aspirationcytologytechniquesinlarynxlesionsarequite sensitiveacrossvariousstudieswithsensitivityrangingfrom
1 55/F Supraglottis Malignancy Nil SCC T3N2cM0
2 73/M Transglottic Malignancy Nil PDSCC T4aN0M0
3 55/M Supraglottis Malignancy Nil SCC T4aN2bM0
4 45/M Transglottic Malignancy Laserresection SCC T4aN2bM0
5 68/M Transglottic Malignancy Nil SCC T4bN0M0
6 40/M Supraglottis Malignancy Nil Atypicalcells T3N1M0
7 53/M Supraglottis Malignancy Nil PDSCC T4aN2cM0
8 45/F Transglottic Malignancy Nil SCC T3N0M0
9 65/M Laryngopharynx Malignancy Nil Inadequatesample T3N0M1
10 50/M Laryngopharynx Malignancy Nil SCC T4aN2bM0
11 40/M Supraglottis Malignancy Nil SCC T4aN0M0
12 60/M Supraglottis Malignancy Nil SCC T4aN1M0
13 71/M Laryngopharynx Malignancy Nil SCC T3N1M0
14 58/M Supraglottis Malignancy Nil PDSCC T3N1M0
15 58/M Laryngopharynx Malignancy Nil Atypicalcells T3N1M0
16 65/M Supraglottis Malignancy Nil SCC T3N1M0
17 50/M Transglottic Malignancy Nil SCC T3N0M0
18 72/M Supraglottis Malignancy Nil SCC T3N3BM0
19 67/M Baseoftongue Malignancy Nil SCC T4aN0M0
20 50/F Transglottic Malignancy Nil SCC T4aN1M0
21 50/M Transglottic Malignancy Nil SCC T4bN0M0
22 60/M Laryngopharynx Malignancy Nil SCC T3N0M0
23 55/M Laryngopharynx Malignancy Nil SCC T4aN0M0
24 56/M Transglottic Malignancy Nil SCC T4N0M0
M,male;SCC, squamouscellcarcinoma;PDSCC,poorlydifferentiatedsquamouscellcarcinoma;T,tumour;N,node;M,metastasis; USGTC-FNAC,UltrasoundGuidedTransCutaneousFineNeedleAspirationCytology.
80%to100%,whichis comparablewithourstudy,withno majorcomplications.
WithrespecttofeasibilityandsafetyofUSGTC-FNAC,it wasperformed successfully inall24 patients,makingthis procedurea viable optionfor patients whoarenotfit for directlaryngoscopy biopsy under general anaesthesia.All procedureswereperformedunderlocalanaesthesiawithout anytechnicalproblemsorcomplications.
Onlyonepatienthadan inadequatespecimenfor mak-inganydefinitivediagnosis,whichcouldhavebeenavoided if adequacy of the specimen was checked immediately postprocedure.Majoradvantagesofthistechniqueinclude lessinvasiveness,lowercost,andperformanceunderlocal anaesthesiaon an outpatient basis. This avoids the need forgeneralanaesthesia,therisksandcostsassociatedwith directlaryngoscopy like damage toteeth, and protective tracheostomyincaseofairwaycompromise.
We did not have post-therapy (chemo-radiotherapy) patientsinourstudypopulationtocommentonthe feasibil-ityofperformingthecytologyinthatsubgroupofpatients. Tru cut biopsy was tried in few studies with acceptable results.
Tumour cellimplantationalong the needletractisone of the rare complications in needle aspirations of malig-nant lesionsin head and neck. In our institute we rarely cameacrossimplantationmetastasis inthepast.Asearch ofliteraturealsorevealsveryfewreports ofimplantation metastasis in thyroid, submandibular glands, and cervical
nodes.Accurateestimate is difficultto ascertainin these rare conditions, since crude estimates are 0.00012% for FNAC.9,10
DirectLaryngoscopyandbiopsyundergeneral anaesthe-siaiscurrentlythe‘‘GoldStandard’’techniquefortumour evaluationandfortissuediagnosis.Tumourevaluationtoday canhoweverbealmostequallywellundertakenwith flexi-bleendoscopyandsectionalimaging.Furtherlaryngoscopy under anaesthesia is however associated with a definite riskofprecipitatingairwaycompromiseandtracheotomyin somesituations.ThetechniqueofUltrasoundguidedFNAC as reported here is noted to be feasible and reliable in patientswithlocallyadvanced(T3---T4)supraglotticcancer
andoffersanalternateandsafeoptionfortissuediagnosis insuchpatients.
Conclusion
USGTC-FNAC for advanced laryngeal lesions is a feasible optionbutnotanalternativefordirectlaryngoscopybiopsy. Inaselectgroupofpatients,USGTC-FNACcanbedoneasan out-patientprocedure withoutanypreparation,whichwill enablethecliniciantomakerapiddiagnosisandtreatment plan.Intheeraoforganconservation,rapiddiagnosiswith minimally invasive technique will go a long way in expe-ditingdecision-making,avoidingrisksandcostsassociated withthestandarddirectlaryngoscopyevaluation.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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