US Guided FNA (USGFNA) of neck masses INTERVENTIONAL HEAD & NECK ULTRASOUND Brendan C. Stack, Jr., MD., FACS, FACE Professor Otolaryngology-Head and Neck Surgery Indications Technique Interpretation Results Future Directions USGFNA of thyroid nodules 4-7% of adult population have palpable thyroid nodule(s) Nodules are more common in women and increase in frequency with age and decreased iodine intake US reveals nodules in up to 65% of adults Incidental finding on imaging for other reasons (spine and vascular imaging) 5-10% of these nodules are malignant Solitary thyroid nodule: clinical features suggestive of cancer Rapid growth Very firm or fixed mass Lymphadenopathy Hoarseness Family history of MTC or MEN2 History of neck irradiation Male gender Age <20 or >70 1
When to biopsy a thyroid nodule? Clinically suspicious for thyroid cancer Size criteria : 1 cm suggested US appearance: Irregular border Heterogeneous density Increasing nodule size Microcalcifications Invasion Regional adenopathy Peripheral flow on CFD Serial evaluation for thyroid cancer TSH-stimulated thyroglobulin levels US surveillance of neck for locoregional recurrence USGFNA of suspicious masses Radioiodine scan USGFNA of parathyroid lesions USGFNA: Scanning Technique Suspected intrathyroidal adenoma (<1%) Suspected parathyroid cyst Recurrent or persistent hyperparathyroidism Aspirate tested for PTH Patient Position Examiner Position 7-13 MHz linear array transducer 2
USGFNA: Scanning technique - Scanning Technique - Confirm lesion Orient transducer for optimal lesion acquisition -maximum dimension -shortest needle path -avoid vital structures (vessels) Optimize the view Ski to move the lesion from left to right Paint to view the widest diameter of the lesion SKIING PAINTING - Equipment - - Equipment - 7.5 (or greater) MHz linear array transducer Better than sector scan - wider near field Needles for aspiration 21-25 g (use local anesthetic via 25g) Ultravue needle Cytology fixative Slides Cytolyte solution 3
10/22/2010 - Equipment - - Patient Positioning - Betadine and/or Alcohol Gauze Marking pen (Sterile) gel Pillow/cervical rest to extend neck 1% lidocaine (Sterile drape) (Saran wrap) Adhesive bandages - Procedure - - Targeting Painting Brings lesion into view at a given location Finds the widest diameter After patient positioned and lesion location optimized prep & drape Re-orient optimal transducer position 4
- Targeting - Skiing - moves lesion left or right - - Procedure - Anesthetize skin ( and path to lesion) - Targeting - AIM - Line up needle with probe then lesion WRONG WAY - Targeting - AIM - Line up needle with probe then lesion RIGHT WAY image image 5
- Procedure - - Procedure - Ultrasound image of thin, hyperechoic line (25 g needle) within thyroid nodule FNA vs Core - Procedure - Needle placement Left vs. right hand - FNA - Aim image 6
- FNA - - FNA - Photo and Confirmation Scan image Syringe attached to needle and aspirated as needle passes through lesion minimum of 4 times Capillary technique (no aspiration) ULTRASOUND GUIDED - FNA - Syringe holder for aspirating vs. Syringe without barrel ULTRASOUND GUIDED - FNA - Advance needle across width of lesion (Apply suction) Oscillate and fan needle tip through lesion Release suction and remove needle 7
- Procedure - Compression for 5 minutes Adhesive bandage ULTRASOUND GUIDED FNA Handling Specimen Expel aspirate onto slide Place second slide against specimen and smear by sliding apart Place in fixative or air dry ULTRASOUND GUIDED FNA Handling Specimen USGFNA: Long axis technique (upright, standing to patient s right) Flick hub of needle to expel residual material Cytolyte solution for cell block Rinse needle/syringe with fixative into same jar for cell block 8
USGFNA: Long axis technique (inverted, standing at patient s head) USGFNA: Long axis technique USGFNA: Long axis technique (video) USGFNA: Short axis technique (upright, standing to patient s right) 9
USGFNA: Short axis technique (inverted, standing at patient s head) USGFNA: Short axis technique USGFNA: Short axis technique (video) - Equipment - 14g automated core bx needle Use with large matted nodes (e.g. lymphoma, anaplastic thyroid cancer) Length of travel is critical for safe use near vital structures 10
- Equipment - : Incidental thyroid lesions Formalin Management of small or incidental thyroid nodules - Accuracy - Incidence vs Malignancy Evaluation of thyroid incidentalomas Thyroid incidentaloma: which to biopsy? Retrospective review of 267 pts who underwent USGFNA of 317 incidentally discovered nonpalpable thyroid masses Mean size of thyroid nodule was 0.9 ± 0.3 cm (range 0.2 1.5 cm) 12% proved to be malignant Nam-Goong IS et al, Clin Endocrinol 2004 Patients with a history of other cancers Lesions > 1 cm Lesions with suspicious US appearance Patient uncomfortable with observation approach Some with H/O head and neck irradiation (PET + lesions: 14-63% malignant) King et al, Otolaryngol Head Neck Surg 2007 11
Limitations of thyroid FNA Unskilled physician doing biopsy or cytologist interpreting the specimen Failure to report a benign result No malignant cells seen on a hypocellular sample Cystic lesions US to access/biopsy solid component Suspicious nodules Follicular neoplasms Hurthle cell neoplasms Nondiagnostic specimen slide preparation Future US guided thyroid interventions? Samples for molecular analysis to predict malignancy or aggressiveness US guided ablation by ethanol injection, radiofrequency, laser or US energy US-guided injections Visual tracer Radionuclide I131 Tc 99 18FDG US-guided PTH assay (video) US-guided aspiration and sclerotherapy (video) 12
Theraclion for Hyperparathyroidism MRgFUS combines: What is MR guided Focused Ultrasound? High intensity focused ultrasound that heats and destroys targeted tissue, non-invasively. Magnetic resonance imaging system (MRI) which allows the physician to identify and target tumors, and provides temperature monitoring of the treated tissue in real time. USGFNA of other head & neck lesions Procedure similar Pathology varied Adjustments must be made for optimal viewing Regional anatomy must be navigated for interventions - Summary - Getting started is a natural progressioneasy to more difficult Control view of lesion and needle through proper technique Preparation and judgment are imperative 13
NCI conference on thyroid FNA October 2007 http://thyroidfna.cancer.gov/ http://thyroid fna.cancer.gov/pages/info/agenda/ 14