The diagnostic performance of ultrasound-guided core biopsy in the diagnosis of head and neck lymphoma: results in 226 patients.

Many clinical guidelines for investigating lymphomas advise that surgical excision biopsy (SEB) should be performed for a confident diagnosis. It is increasingly recognized in clinical practice that ultrasound-guided core needle biopsy (USCNB) is a reliable diagnostic technique. We aimed to investigate the diagnostic efficacy of USCNB in head and neck lymphoma. A retrospective analysis of all diagnosed head and neck lymphomas between 2013 and 2018 was performed. Patient records, radiology and histopathology reports along with the biopsy technique: fine needle aspiration cytology (FNAC), USCNB, and SEB used were reviewed. The technique providing diagnosis and leading to initiation of treatment was identified. Two-hundred and thirty patients and 267 biopsy samples were included. A total of 226 patients underwent USCN. In 215 of 226 (95.1%) USCNB patients were fully diagnostic allowing for initiation of oncological treatment; 11 patients required a subsequent SEB to provide diagnosis. In four patients, SEB was the only investigation performed. Of the USCNB total number of procedures (number of patients n=230 is the same coincidentally as the number of USCNB procedures), 215 of 230 (93.5%) were fully diagnostic samples. In the majority of cases, USCNB provided a definitive diagnosis allowing initiation of oncological treatment, avoiding the need for SEB. USCNB should be considered the first-line diagnostic modality in appropriate cases, as it reduces time to initiate treatment, costs and avoids patients having to undergo unnecessary surgery and possible complications.

An amelanotic malignant melanoma masquerading as hypergranulation tissue.

We report a case of amelanotic malignant melanoma occurring in the nail sulcus of the hallux, which on initial presentation was mistaken for hypergranulation tissue due to an in-growing toenail. We highlight the importance of this differential diagnosis as such lesions can have serious sequelae.

A study to evaluate the efficacy of image-guided core biopsy in the diagnosis and management of lymphoma--results in 103 biopsies.

The reason for this study was to evaluate the ability of image-guided core biopsy to replace surgical excision by providing sufficient diagnostic and treatment information. All consecutive image-guided core biopsies in patients with a final diagnosis of lymphoma over a 6-year period at our institution were collected retrospectively. Case notes and pathology reports were reviewed and the diagnostic techniques used were recorded. Pathology reports were graded according to their diagnostic completeness and their ability to provide treatment information. Out of a total of 328 instances of lymphoma, 103 image-guided core biopsies were performed in 96 patients. In 78% of these, the diagnostic information obtained from the biopsy provided a fully graded and subtyped diagnosis of lymphoma with sufficient information to initiate therapy. In the head and neck 67% of core biopsies were fully diagnostic for treatment purposes compared to 91% in the thorax, abdomen and pelvis. Image-guided core biopsy has a number of cost and safety advantages over surgical excision biopsy and in suitable cases it can obviate the need for surgery in cases of suspected lymphoma. This is especially relevant for elderly patients and those with poor performance status.

Pleomorphic adenoma arising from accessory parotid tissue presenting as dysphonia.

This article describes an unusual presentation of pleomorphic adenoma arising from accessory parotid tissue. A patient who had recently been diagnosed with Parkinson's disease, presented with worsening dysphonia. Magnetic resonance imaging and ultrasound guided core biopsies confirmed the diagnosis and the mass was removed by extra capsular dissection through a lip split mandibulotomy approach. This case confirms the need for careful examination of the oropharynx in patients with preexisting neurological conditions that develop speech disturbance. It also demonstrates the importance of these imaging techniques in the diagnosis of parapharyngeal lesions.

Ultrasound-guided core biopsy for the diagnosis of lumps in the neck: results in 82 patients.

Ultrasound-guided core biopsy of nodes (n = 78) and other lumps (n = 4) in the neck allowed a firm histological diagnosis in 76 of 82 patients (93%). Of the remaining six patients, histological examination was equivocal in four and valueless in two. Of 18 patients with a diagnosis of lymphoma only 3 required excision of the node to provide additional information for the planning of treatment.

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.

Diagnostic investigation of parotid neoplasms: a 16-year experience of freehand fine needle aspiration cytology and ultrasound-guided core needle biopsy.

This study aimed to examine the diagnostic yield of fine needle aspiration cytology (FNAC) and ultrasound-guided core needle biopsy (USCB) in the diagnosis of parotid neoplasia. A 16-year retrospective analysis was performed of patients entered into our pathology database with a final diagnosis of parotid neoplasia. FNAC and USCB data were compared to surgical excision where available. One hundred and twenty FNAC, 313 USCB, and 259 surgical specimens were analyzed from 397 patients. Fifty-six percent of FNAC and 4% of USCB were non-diagnostic. One hundred and thirty-two (33%) patients had a final diagnosis made by USCB and did not undergo surgery. Surgery was performed in 257 (65%) patients, 226 (88%) of whom had a preoperative biopsy. Most lesions were benign, but there were 62 parotid and 13 haematological malignancies diagnosed; false-negative results were obtained in three FNAC and two USCB samples. The sensitivity and specificity of FNAC were 70% and 89%, respectively, and for USCB were 93% and 100%, respectively. This study represents the largest series of patients with a parotid neoplasm undergoing USCB for diagnosis. USCB is highly accurate with a low non-diagnostic rate and should be considered an integral part of parotid assessment.

A new method for semi-automated quantitation of E-rosettes using a particle size analyser (Coulter Channelyzer).

Visual counts of the number of SRBC attached to individual lymphocytes in E-rosette preparations from 3 healthy young adults were made by 3 experienced observers: from these data the size distribution profile of particles in each E-rosette preparation was calculated. In parallel experiments the size distribution profile was measured directly with a particle size analyser (Coulter Counter and Channelyzer): in every case the observed profile lay within the 95% confidence band around the reconstructed profiles. It was concluded that the Coulter Channelyzer profile is an accurate measurement of the E-rosette size distribution and that particle sizing could provide a reasonable basis for semi-automated tests for E-rosettes. A mathematical model has been developed by which the percentage of lymphocytes forming E-rosettes, the distribution of number of attached SRBC and the average avidity of the lymphocyte receptor for SRBC could be deduced from the size-distribution profiles. The method has a high degree of precision, and a good correlation (P less than 0.01) was obtained when the percentage of E-rosettes (defined for this purpose as having three or more attached SRBC) obtained from the new method was compared with results from standard light microscopy.

Limited value of type III intestinal metaplasia in predicting risk of gastric carcinoma.

Endoscopic gastric biopsy specimens taken in 1976 from 174 patients were reviewed. Biopsy specimens from 44 patients showed intestinal metaplasia, and subtyping by mucin histochemistry showed that 16 were of type I, 14 of type II, and 14 of type III. Only two of these 174 patients developed gastric adenocarcinoma over the next 10 to 11 years: one with type II and one with type III intestinal metaplasia. Case notes of a separate group of 68 patients with gastric adenocarcinoma diagnosed in 1985 were reviewed for evidence of intestinal metaplasia in a previous gastric biopsy. Only two patients had previously been biopsied; one of these biopsy specimens showed type II intestinal metaplasia and the other showed no intestinal metaplasia. These findings suggest that subtyping of intestinal metaplasia in endoscopic gastric biopsy specimens is of only limited value in identifying patients at risk of gastric adenocarcinoma who require long term follow up.

Local and systemic effects of repeated intraperitoneal epirubicin treatment.

The local toxicity, general morbidity and mortality of repeated intraperitoneal administration of epirubicin (0.5 mg/kg in 100 ml isotonic saline) was investigated using a rat model. This dose is equivalent to that which would be used in the human. After six perfusions, the incidence of peritoneal inflammation was similar in the epirubicin group and saline controls. The vesicant properties of the drug were reflected in a significantly higher incidence of peritoneal fibrosis (P = 0.0015) but adhesions were more common in the controls (29%) than in the epirubicin perfused animals (4%). Animals from both groups showed inflammatory collections within the liver. There were no chronic hepatic lesions such as fibrosis/cirrhosis. This may be owing to portal bacteraemia caused by repeated cannulation of the peritoneal cavity. Evidence of microabscess formation in the hepatic parenchyma was observed in both animals. No histologically demonstrable toxicity was observed in the heart or gastrointestinal tract of the animals included in this study. The mortality of the epirubicin treated rats (2/146 perfusions) was similar to that of the saline controls (2/84 perfusions). These findings indicate that repeated intraperitoneal perfusion with epirubicin is not associated with significant toxicity. This anthracycline is therefore suitable for prolonged cyclical intraperitoneal chemotherapy.

Primary malignant melanoma of the esophagus.

Primary malignant melanoma of the esophagus, first recognized as a primary tumor by de la Pava et al. in 1963, is rare. It usually presents as an aggressive polypoidal darkly colored or non-pigmented tumor in the mid to lower esophagus which may be diagnosed preoperatively by the use of immunohistochemical stains such as HMB-45 (melanoma specific antigen). The treatment of choice is surgical resection however the overall prognosis is poor with only 4 per cent of patients surviving 5 years.

Laryngeal cysts: clinical relevance of a modified working classification.

Laryngeal cysts from 72 patients were examined and reclassified according to a modified working classification. In this series, 47 patients (66 per cent) had epithelial cysts, 11 patients (15 per cent) oncocytic cysts and 14 patients (19 per cent) tonsillar cysts. Epithelial cysts were commonest in the region of the epiglottis (20/47) and laryngeal ventricle (24/47). Oncocytic cysts tended to lie in the region of the ventricle whereas tonsillar cysts occurred almost exclusively in the valleculae, epiglottis and pyriform region (13/14). The authors conclude that the modified working classification of laryngeal cysts is easy to apply, of clinical relevance, and allows classification of cysts where operative trauma to the specimen obscures the relationship of the cyst to the surface epithelium. The origin and significance of tonsillar cysts are discussed and a relationship to the lympho-epithelial cyst of the oral cavity is suggested.

Plasma cell granuloma of the larynx (case report and review of the literature).

A case is reported of Plasma Cell Granuloma of the larynx treated successfully with steroids and antibiotics.

Granular cell tumour of the larynx.

A granular cell tumour may present as clinically innocuous lesions on the vocal cords and the diagnosis is usually made by histopathology. However, the granular cells characteristic of this tumour may not be obvious and accompanying epithelial hyperplasia may be interpreted by the pathologist as invasive squamous cell carcinoma. Good communication between pathologist and surgeon is required to ensure that clinically benign lesions on the vocal cords are not misdiagnosed. The diagnosis of granular cell tumour can be confirmed by immunocytochemical staining for S100 antigen.

Evaluation of biopsy methods in the diagnosis of submandibular space pathology.

The aim of this study was to evaluate the performance of fine needle aspiration cytology (FNAC), ultrasound-guided core needle biopsy (USCNB), punch biopsy, and surgical excision biopsy in neoplasms presenting within the submandibular space. A retrospective analysis of all patients with a pathological diagnosis of a submandibular space neoplasm within a 12-year period (February 1999 to June 2011) was performed. Biopsy results were compared to histopathological diagnosis obtained from surgical excision biopsy. Eighty-one specimens from 44 patients met the search criteria (15 FNAC, 24 USCNB, 7 punch biopsy, and 35 surgical excision biopsy). The final diagnosis was established by USCNB, punch biopsy, or surgical excision biopsy and not by FNAC alone. Surgical excision biopsy was performed as a primary diagnostic (n = 8), secondary diagnostic (n = 15), or as a post-diagnostic therapeutic procedure (n = 12). Non-diagnostic results were: FNAC 11/15, USCNB 2/24, and punch biopsy 1/7. Diagnostic results were: FNAC 2/15, USCNB 20/24, and punch biopsy 5/7. No complications were reported. Although punch biopsy demonstrated good yield and accuracy, its use is restricted to a small cohort of patients. USCNB is a safe and accurate technique in the submandibular space, with a low non-diagnostic rate.

Ultrasound-guided core biopsy in the diagnosis of lymphoma of the head and neck. A 9 year experience.

OBJECTIVES: This retrospective study aimed to evaluate the diagnostic utility of ultrasound-guided core biopsy (USCB) in lymphoma of the head and neck, in particular whether core biopsy can provide sufficient diagnostic information for definitive treatment. METHODS: All lymphomas diagnosed in the head and neck at Eastbourne General Hospital between January 2000 and June 2009 were identified. Radiology and pathology reports were reviewed and the diagnostic techniques recorded. The type of biopsy (fine needle aspiration, needle core, surgical excision biopsy) used to establish a diagnosis sufficient to allow treatment, i.e. the "index" diagnostic technique, was identified. Previous inconclusive or inadequate biopsies were noted. Pathology reports based on USCB were graded 0-3 according to diagnostic completeness and ability to provide treatment information. RESULTS: Of 691 overall cases of lymphoma diagnosed over the 9 year period, 171 different patients presented with lymphoma in the head and neck. Of these 171, 83 had USCB biopsy during diagnostic work up. 60 were regarded as grade 3 where a confident diagnosis of lymphoma was made. In seven patients, clinical management proceeded on the basis of a suggestive (grade 2) pathology report without surgical excision, and these were therefore also included as "index" biopsies. Overall therefore, 67/83 core biopsies (81%) provided adequate information to allow treatment. Surgical excision biopsy was the index modality in 104 cases. CONCLUSION: In the majority of cases USCB is adequate for confident histopathological diagnosis avoiding the need for surgical excision biopsy in cases of suspected head and neck lymphoma.

Diagnostic adequacy and accuracy of fine needle aspiration cytology in neck lump assessment: results from a regional cancer network over a one year period.

AIM: To establish the diagnostic accuracy and adequacy of fine needle aspiration cytology (FNAC) within a regional cancer network, and to determine what service improvements may be required to allow successful implementation of an FNAC-based, 'one-stop' head and neck clinic, as proposed by the current National Institute for Clinical Excellence guidelines. MATERIALS AND METHODS: The Sussex cancer network serves a population of 1,200,000 and contains five hospitals within three acute trusts. In 2004, an audit was undertaken retrospectively to examine the diagnostic adequacy and accuracy of head and neck FNAC across the network. Comparisons were then made with the results of subsequent relevant surgery. For the purposes of the audit, FNAC was subdivided into three main groups: salivary gland, thyroid gland and neck node. As part of the data analysis, we also noted the clinical source of the FNAC and whether it was performed blind or under image guidance. RESULTS: In 2004, 712 FNAC procedures were undertaken in 647 patients, 276 of whom underwent subsequent surgery. Fine needle aspiration cytology was non-diagnostic in 52 per cent of patients in the neck node group, in 50 per cent in the salivary gland group and in 30 per cent in the thyroid group. With these non-diagnostic results removed, statistical analysis was performed on data from those patients who had undergone both FNAC and subsequent surgery. This gave a sensitivity of 89 per cent and a specificity of 57 per cent in the neck node group, a sensitivity of 64 per cent and specificity of 100 per cent in the salivary gland group, and a sensitivity of 62 per cent and specificity of 86 per cent in the thyroid group. Diagnostic problems with FNAC were noted, particularly in the differentiation of reactive nodal hyperplasia from lymphoma and in diagnosing follicular thyroid lesions. Ultrasound guidance was used in 50 per cent of the thyroid FNAC procedures but in only a minority of patients in the neck node and salivary gland groups. CONCLUSION: This audit demonstrated widespread diagnostic difficulties associated with head and neck FNAC in a large patient sample. It is likely that these problems will be mirrored in other cancer networks. In order for one-stop head and neck clinics to succeed, the non-diagnostic rate of FNAC in particular must be minimised. There are strategies to enable this, depending on local resources, including increased access to cytologists or cytology technicians, diagnostic ultrasound, image guidance for FNAC and the use of ultrasound-guided core biopsy.

Use of intraoperative cytologic assessment of mandibular marrow scrapings to predict resection margin status in patients with squamous cell carcinoma.

PURPOSE: This study assessed the feasibility of intraoperative microscopic assessment of mandibular bone resection margins in patients undergoing segmental resection of mandible for treatment of squamous cell carcinoma. PATIENTS AND METHODS: This prospective pilot study involved 7 consecutive patients undergoing segmental resection of mandible as part of surgical treatment of oral squamous cell carcinoma. Cytologic examination of smear/touch preparations of 35 bone marrow scrapings, including simulated positive margins, was performed. RESULTS: "Malignant" excision margins produced a high cell yield, and it was easy to assign samples to malignant or benign categories on microscopic examination. All the simulated positive margins were easily identified. No false positive results were found. CONCLUSION: Cytologic examination of bone excision margin scrapings is a rapid, inexpensive, and accurate technique. This study confirms its feasibility and accuracy in cases of mandibular resection for squamous cell carcinoma.

Cystic hygroma in an adult: a case report.

Cystic hygromas are benign lesions arising due to an abnormality in lymphatic development and only rarely present in adults. Adequate radiological imaging prior to surgery is important as incomplete excision often leads to recurrence. Several adjunctive therapies have been shown to be beneficial in recurrent or inaccessible lesions but these are not in common use. We describe the case of a cystic lymphangioma appearing in adulthood that presented a diagnostic and therapeutic challenge.

The effect of strenuous physical exercise on circulating blood lymphocytes and serum cortisol levels.

Venous blood was removed from healthy subjects immediately before and at intervals after exercise on a bicycle ergometer. Immediately after exercise, the subjects developed a lymphocytosis in which (a) the E-rosette percentage fell by 10% but their absolute number in the circulating blood rose by more than 70%, (b) the percentage of PHA-stimulated cells fell, but their absolute numbers increased considerably and (c) the absolute numbers of Con A- and PWM-responding cells increased. The numbers of lymphocytes in the various subpopulations had returned virtually to the pre-exercise levels 15 minutes after stopping exercise. During the response to exercise, the characteristics of the cells in the various subpopulations did not show any major changes, despite considerable and rapid fluctuations in numbers: it is suggested that exercise discharges intravascularly sequestered cells and that cortisol may be involved in re-sequestration of stress-released cells. It is recommended that, in clinical studies on circulating lymphocyte numbers and populations, the patient should be rested for at least 15 minutes before venesection.