|Year : 2014 | Volume
| Issue : 7 | Page : 229-231
Evaluation of computed tomography-guided parapharyngeal mass needle biopsy through mandibular notch for diagnosis of recurrent nasopharygeal carcinoma
Liming Jiang1, Haimiao Xu1, Jun Lin1, Lirong Tang1, Tiemin Xie1, Xing Yan1, Hao Jiang2
1 Department of Radiology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, China
2 Department of Oncology, Zhejiang Hospital, Hangzhou, Zhejiang 310013, China
|Date of Web Publication||29-Nov-2014|
Department of Oncology, Zhejiang Hospital, Hangzhou, Zhejiang 310013
Source of Support: None, Conflict of Interest: None
Objective: The aim was to evaluate the effectiveness of computed tomography (CT)-guided fine-needle aspiration biopsy (FNAB) from Mandibular notch and under the zygomatic arch for pathological diagnosis of recurrence nasopharyngeal carcinoma (NPC) after radiotherapy (RT).
Materials and Methods: Between October 2007 and December 2013, 48 patients with suspected recurrent NPC underwent CT-guided FNAB. A modified coaxial technique was used in all cases, and multiple samples were obtained for histological studies.
Results: We obtained a definite histological diagnosis with 87.5% (42/48) overall diagnostic accuracy. In 42 patients the needle aspirate confirmed a clinical suspicion of recurrent disease and the histologic finding was positive (10 cases of squamous cell carcinoma, 3 cases of adenocarcinoma, finding tumor cells tend to squamous cell carcinoma in 24 patients and undifferentiated carcinoma in 5 patients). In the six cases of "no tumor seen" confirmation was made by clinical and imaging follow-up showing 2 tumor relapse and 4 fibrillation.
Conclusion: CT-guided FNAB from Mandibular notch and under the zygomatic arch is a safe and accurate technique useful for pathological diagnosis of recurrence NPC after RT.
Keywords: CT-guided FNAB, mandibular notch, recurrent Nasopharygeal Carcinoma
|How to cite this article:|
Jiang L, Xu H, Lin J, Tang L, Xie T, Yan X, Jiang H. Evaluation of computed tomography-guided parapharyngeal mass needle biopsy through mandibular notch for diagnosis of recurrent nasopharygeal carcinoma. J Can Res Ther 2014;10, Suppl S3:229-31
|How to cite this URL:|
Jiang L, Xu H, Lin J, Tang L, Xie T, Yan X, Jiang H. Evaluation of computed tomography-guided parapharyngeal mass needle biopsy through mandibular notch for diagnosis of recurrent nasopharygeal carcinoma. J Can Res Ther [serial online] 2014 [cited 2019 Aug 20];10:229-31. Available from: http://www.cancerjournal.net/text.asp?2014/10/7/229/145887
| > Introduction|| |
Nasopharyngeal carcinoma (NPC) is one of the most common tumours of the head and neck in China, northern Africa, and certain other geographic regions.  Non-keratinizing undifferentiated carcinoma is the most common of the three forms of NPC.  This form is sensitive to radiation, and radiotherapy (RT) has been the main treatment for NPC because radical resection is typically not possible.  Now the 5-year survival rate of patients with locally advanced NPC after RT or chemoradiation is about 50-70%. ,,,,, However, due to the presence of tumour cell heterogeneity, surviving cell sub-lines that are resistance to RT can lead to local recurrence and distant metastasis. Recurrence rate of NPC after RT is 10-50% and occurred within 3 years.  A significant proportion of patients can achieve long-term survival following salvage therapy. Percutaneous computed tomography (CT)-guided fine needle aspiration biopsy (FNAB) is a widely used procedure in the diagnosis and follow-up of neoplasms, having high accuracy values ranging from 80% to 93% and a low complication rate.  In patients with a suspected diagnosis of recurrent NPC, in the absence of superficial lesions, CT-guided FNAB has been suggested as a viable alternative to surgical intervention. Recurrent NPC imaging showed thickening parapharyngeal space but smooth in nasopharyngeal cavity surface.  It is hard to obtain tissues for pathology due to the deep location of Parapharyngeal anatomic structure. The aim of our study was to verify the effectiveness of CT-guided FNAB performed with a modified coaxial technique in a group of patients with refractory or recurrent NPC.
| > Materials and methods|| |
Between October 2007 and December 2013, 48 patients (35 men and 13 women, age range 27-74 years, mean 50, KPS >70, Radiation dose 70 Gy, range 65-82 Gy, relapse interval >10 months, follow up >24 months) were recruited with positive imaging and negative nasopharyngeal biopsy pathology.
Before the biopsy, written informed consent was obtained from all patients. Prothrombin time, partial thromboplastin time and platelet count were measured. Contrast-enhanced CT scans were preliminarily assessed to determine site, presence of tumor areas and anatomical relationships between lesions so as to select lesions to be sampled, access site and safest needle path. Immediately before the biopsy, scans were obtained of the area of interest, with anatomical landmarks placed on the skin surface using multi-detector CT scanner to determine the distance and angle of the needle in relation to the target. We used Split type semi-automatic cutting biopsy needles, ranging from 18 to 20 gauge in diameter and 150-200 mm in length, depending on lesion location and size. A coaxial technique was used for facilitating multiple sampling that involves the introduction of a chiba needle (18G, 100 mm) after administration of locoregional anaesthesia (10 ml lidocaine hydrochloric acid 2%) from Mandibular notch and under the zygomatic arch. After checking correct needle position with serial CT scans (3-mm thickness, 3-mm increment, 1.25 pitch, 0.5-s rotation time, 120 kVp, 250 mAs), the Split type semi-automatic cutting biopsy needle (20G 150 mm) was used for subsequent biopsies. Specimens were fixed in 95% ethanol.
| > Results|| |
Forty-eight patients with suspected recurrent NPC underwent CT-guided FNAB [Figure 1]. No complications occurred.
|Figure 1: An 18 gauge needle tip is positioned to pass between the Mandibular notch and under the zygomatic arch to hit the mass. Through the 18 gauge open needle, a 20 gauge needle is inserted with its tip. Once the cytology team is present, puncture into the mass is performed|
Click here to view
We obtained a definite histological diagnosis with 87.5% (42/48) overall diagnostic accuracy. In 42 patients the needle aspirate confirmed a clinical suspicion of recurrent disease and the histologic finding was positive (10 cases of squamous cell carcinoma, 3 cases of adenocarcinoma, finding tumor cells tend to squamous cell carcinoma in 24 patients and undifferentiated carcinoma in 5 patients) [Figure 2]. In the 6 cases of "no tumor seen" confirmation was made by clinical and imaging follow-up showing 2 tumor relapse and 4 fibrillation.
|Figure 2: Histology shows undifferentiated malignant cells (hematoxylin and eosin, ×20)|
Click here to view
| > Discussion|| |
Even though NPC are curable, most cases relapse and eventually die of progressive disease. In the patients with recurrent NPC, parapharyngeal masses formed under local mucosa and deep location. It was difficult for nasopharyngoscopy biopsies because of local fibrosis after RT. The clinical diagnosis of recurrence after RT often rely on enhanced CT scan and magnetic resonance imaging (MRI) of the nasopharynx, but not the pathological basis of tumor recurrence. In recent years, with the gradual maturation updated machinery and equipment, puncture technique, CT-guided percutaneous needle aspiration biopsy of head and neck lesions has become more and more important in pathological diagnosis.
Nasopharyngeal carcinoma is related to the virology of Epstein-Barr virus, a gamma-herpes DNA virus that infects about 90% of world's population.  Since recurrent NPC is possibly derived from those NPC cells that could escape from RT, the recurrent NPC might exhibit distinctive mRNA. The expression levels of miR-98, TR-α2 mRNA, MDR-1 protein, and GST-π protein were different between recurrent and primary NPC. , Similarly lnc., RNAs might play distinct roles in the initiation and progression of recurrent and primary NPC. 
In our study, we verify the effectiveness of CT-guided FNAB from mandibular notch and under the zygomatic arch for pathological diagnosis of recurrence NPC after RT. Early studies suggested that the diagnostic accuracy of biopsy in these patients was 75-93.7%. , In our study, 48 biopsies were performed, and diagnostic accuracy was 87.5%. Parapharyngeal space can be divided into three adjacent gap: (1) Pre-styloid space: V3 cranial nerve is located in this passage that is the common site of recurrent NPC. (2) Space after styloid process: Internal jugular vein, cranial nerve (IV, V, VI, VII) and cervical sympathetic chain are located in this passage. (3) retropharyngeal space: Lymphonodi retropharynici is located in this passage. If this gap disappears (CT or MRI), it suggests a possible invasion. The puncture site is located in the temporal pathway through subcutaneous fat between the zygomatic arch and the mandible mandibular notch. The pathway from outside to inside, respectively, through the masseter muscle, temporal muscle, musculi pterygoideus, musculi pterygoideus internus and Wing Fat clearance. , The advantage of this pathway involves less important neurovascular, the shortest distance from the skin to the nasopharynx without limitation of bone structure and adjusting the direction of needles.
The coaxial technique for obtaining multiple biopsies in a single session is very useful. , In our study, in patients with access points that were difficult to reach or in close proximity to vascular structures, the modified coaxial technique allowed us to easily obtain multiple specimens. The use of a cannula caused less trauma to the superficial and deep structures, whereas the diameter of the sampled material remained unvaried. Another advantage is the ease with which small changes can be made in the angle of the introducing cannula to obtain a larger sampling area. However, the disadvantage of this technique is the presence of an external cannula that increases the total diameter of the biopsy system, leading to a higher risk of complications. ,
| > Conclusions|| |
Computed tomography-guided FNAB from Mandibular notch and under the zygomatic arch is a safe and accurate technique useful for pathological diagnosis of recurrence NPC after RT. It was possible to use a CT-guided biopsy to make the specific diagnosis of recurrent cases, and it played a very important role in determining the treatment modalities.
| > Acknowledgments|| |
The present study was supported by grants from the National Natural Science Foundation of China (grant no. 81303274; and grant no. 81202947).
| > References|| |
Chang ET, Adami HO. The enigmatic epidemiology of nasopharyngeal carcinoma. Cancer Epidemiol Biomarkers Prev 2006;15:1765-77.
Greene FL, Page DL, Fleming ID, Fritz A. AJCC Cancer Staging Manual. 6 th
ed. New York, NY: Springer; 2002.
Lee AW, Lin JC, Ng WT. Current management of nasopharyngeal cancer. Semin Radiat Oncol 2012;22:233-44.
Wee J, Tan EH, Tai BC, Wong HB, Leong SS, Tan T, et al.
Randomized trial of radiotherapy versus concurrent chemoradiotherapy followed by adjuvant chemotherapy in patients with American Joint Committee on Cancer/International Union against cancer stage III and IV nasopharyngeal cancer of the endemic variety. J Clin Oncol 2005;23:6730-8.
Langendijk JA, Leemans CR, Buter J, Berkhof J, Slotman BJ. The additional value of chemotherapy to radiotherapy in locally advanced nasopharyngeal carcinoma: A meta-analysis of the published literature. J Clin Oncol 2004;22:4604-12.
Kwong DL, Sham JS, Au GK, Chua DT, Kwong PW, Cheng AC, et al.
Concurrent and adjuvant chemotherapy for nasopharyngeal carcinoma: A factorial study. J Clin Oncol 2004;22:2643-53.
Lin JC, Jan JS, Hsu CY, Liang WM, Jiang RS, Wang WY. Phase III study of concurrent chemoradiotherapy versus radiotherapy alone for advanced nasopharyngeal carcinoma: Positive effect on overall and progression-free survival. J Clin Oncol 2003;21:631-7.
Chua DT, Ma J, Sham JS, Mai HQ, Choy DT, Hong MH, et al.
Long-term survival after cisplatin-based induction chemotherapy and radiotherapy for nasopharyngeal carcinoma: A pooled data analysis of two phase III trials. J Clin Oncol 2005;23:1118-24.
Carman J, Strojan P. Nasopharyngeal carcinoma in Slovenia, 1990-2003 (results of treatment with conventional two-dimensional radiotherapy). Rep Pract Oncol Radiother 2012;17:71-8.
Chang CC, Chen MK, Liu MT, Wu HK. The effect of primary tumor volumes in advanced T-staged nasopharyngeal tumors. Head Neck 2002;24:940-6.
Cardella JF, Bakal CW, Bertino RE, Burke DR, Drooz A, Haskal Z, et al.
Quality improvement guidelines for image-guided percutaneous biopsy in adults. J Vasc Interv Radiol 2003;14:S227-30.
Chua DT, Sham JS, Kwong DL, Tai KS, Wu PM, Lo M, et al.
Volumetric analysis of tumor extent in nasopharyngeal carcinoma and correlation with treatment outcome. Int J Radiat Oncol Biol Phys 1997;39:711-9.
Alajez NM, Shi W, Hui AB, Bruce J, Lenarduzzi M, Ito E, et al.
Enhancer of Zeste homolog 2 (EZH2) is overexpressed in recurrent nasopharyngeal carcinoma and is regulated by miR-26a, miR-101, and miR-98. Cell Death Dis 2010;1:e85.
Chen CL, Sheen TS, Lou IU, Huang AC. Expression of multidrug resistance 1 and glutathione-S-transferase-Pi protein in nasopharyngeal carcinoma. Hum Pathol 2001;32:1240-4.
Gao W, Chan JY, Wong TS. Differential expression of long noncoding RNA in primary and recurrent nasopharyngeal carcinoma. Biomed Res Int 2014;2014:404567.
Wu DH, Chen LH. Clinical value of 18F fluero-2-deoxy-D-glucose positron emissin tomography in detecting recurrent nasopharyngeal carcinoma at the Parapharyngeal space after radiotherapy. J First Mil Mod Univ 2003;23:159-61.
Costache MI, Iordache S, Karstensen JG, Saftoiu A, Vilmann P. Endoscopic ultrasound-guided fine needle aspiration: From the past to the future. Endosc Ultrasound 2013;2:77-85.
Sherman PM, Yousem DM, Loevner LA. CT-guided aspirations in the head and neck: Assessment of the first 216 cases. AJNR Am J Neuroradiol 2004;25:1603-7.
van der Heijden HF, Looijen-Salamon MG, Schuurbiers OC, Bussink J, Ligtenberg MJ. EBUS and EUS guided fine needle aspirations for molecular diagnostic analysis in lung cancer. Thorac Cancer 2012;3:201-6.
De Kerviler E, Guermazi A, Zagdanski AM, Meignin V, Gossot D, Oksenhendler E, et al
. Image-guided core-needle biopsy in patients with suspected or recurrent lymphomas. Cancer 2000;89:647-52.
Stattaus J, Kalkmann J, Kuehl H, Metz KA, Nowrousian MR, Forsting M, et al.
Diagnostic yield of computed tomography-guided coaxial core biopsy of undetermined masses in the free retroperitoneal space: Single-center experience. Cardiovasc Intervent Radiol 2008;31:919-25.
Tian Q, Chen LA, Wang RT, Yang Z, An Y. The reasons of false negative results of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of intrapulmonary and mediastinal malignancy. Thorac Cancer 2013;4:186-90.
[Figure 1], [Figure 2]