Ultrasound-guided wire localisation: a GPS for hidden head and neck tumours? A case series| ACTA Otorhinolaryngologica Italica

Abstract

Objectives. Ultrasound-guided wire (USGW) localisation for small non-palpable tumours before a revision head-and-neck surgery is an attractive pre-operative option to facilitate tumour identification and decrease potential complications. We describe five cases of pre-operative USGW localisation of non-palpable head and neck lesions to facilitate surgical localisation and resection.
Methods. All patients undergoing pre-operative USGW localisation for non-palpable tumours of the head-and-neck region at London Health and Sciences Center, London, Ontario, Canada, were included. All the USGW localisations were performed by the same interventional radiologist, and the surgeries were performed by fellowship trained Head-and-Neck surgeons.
Results. Five patients were included. All patients were undergoing revision surgery for recurrent or persistent disease. All successfully underwent a pre-operative USGW localisation of the non-palpable lesion before revision surgery. All lesions were localised intra-operatively with no peri-operative complications.
Conclusions. USGW localisation is a safe and effective pre-operative technique for the identification of small non-palpable head and neck tumours.

Introduction

The head and neck region anatomically contains critical vascular, nerve and lymphatic structures. In many patients, this anatomy can be distorted due to previous surgeries and/or radiation therapy ¹. In this complex scenario, a revision head and neck surgery for small, non-palpable lesions can be technically challenging and potentially morbid due to injury to adjacent structures ^2,3.

The use of USGW localisation for non-palpable breast lesions is standard practice to facilitate intra-operative identification ⁴. In the last two decades, this technique has been applied to pre-operatively localise both benign and malignant small head and neck lesions ⁵.

USGW localisation is a simple technique in which pre-operatively a percutaneous wire is placed to help localise a lesion. It is particularly useful in patients who have received previous surgery and/or radiotherapy with subsequent alteration of the normal anatomy. Following the needle down to the lesion, a simpler dissection is performed, increasing the chance of finding a small lesion and potentially reducing morbidity by avoiding vital structures ⁵.

Herein, we describe five cases of pre-operative USGW localisation of non-palpable head and neck lesions to facilitate surgical localisation.

Materials and methods

A retrospective chart review of all patients undergoing pre-operative USGW localisation for non-palpable tumours of the head and neck region at London Health and Sciences Center, London, Ontario, Canada, between January 2019 and May 2022, was done. All the USGW localisations were performed by the same interventional radiologist (GB). The patients were taken to the operating room and the localisation procedure was performed under general anaesthesia immediately before the surgery. All the patients were prepped and draped in the usual sterile fashion. Following infiltration of the skin and subcutaneous tissue with 1% lidocaine, a wire localiser 20 gauge needle was inserted into the lesion that was intended for resection, leaving the localisation wire inside the lesion and removing the needle after the wire was in the right location. On average, the procedure took from 10 to 15 minutes.

Results

Case 1

A 47-year-old male had a history of papillary thyroid cancer resected in 2017 (T2 N1b) including a total thyroidectomy, right central and right lateral neck dissections and radioiodine therapy. After 4 years of follow-up, the patient’s antithyroglobulin antibodies were elevated which prompted an ultrasound that showed a recurrence in the right paratracheal space. An ultrasound-guided fine-needle aspiration (FNA) of the lymph node in the right paratracheal region was positive for papillary thyroid cancer. The computed tomography showed an enlarged right paratracheal lymph node (Fig. 1). Focused ultrasound of the right neck demonstrated a hypoechoic paratracheal nodule of 1.7 cm in maximum dimension. The patient consented to pre-operative wire localiser insertion. In a sterile fashion and following infiltration of the skin and subcutaneous tissue with 1% lidocaine, a wire localiser needle was inserted into the right paratracheal nodule. The hooked tip of the wire was placed at the anterior/inferior aspect of the nodule. During the surgical procedure, the needle was followed down. The carotid and the vagus were retracted anteriorly and medially. The needle localisation went into a pocket that was deep to the medial aspect of the anterior scalene and posterior to the carotid sheath. Using blunt dissection, the lymph node packet was dissected and the lymph node was identified with the wire in it. There was significant surrounding scar tissue from the prior operation. The specimen was sent for frozen sections and was found to be positive for papillary thyroid cancer. After the surgery, the patient recovered uneventfully and was discharged on post-operative day 1. The final histopathologic report was papillary thyroid cancer with margins free of disease.

Case 2

A 49-year-old female with a history of recurrent primary hyperparathyroidism was referred to our attention. The first operation was in 2017, where a very large left inferior parathyroid adenoma was found. Parathormone (PTH) and calcium levels returned within normal limits after surgery; however, a very aggressive relapse was recorded 2 years later with a value of PTH = 24.7 pmol/L (normal 1.6-6.9 pmol/L), and calcium 3.18 mmol/L (normal 2.15-2.5 mmol/L). A bilateral central neck dissection was performed. One parathyroid gland was removed in the right central neck, and the right superior parathyroid was removed as well. Despite this, elevated calcium (2.9 mmol/L) and PTH levels (20.7 pmol/L) were still present. The patient was significantly symptomatic, requiring repeated intravenous bisphosphonate infusions. A computed tomography (CT) scan was performed that showed some pretracheal soft tissue thickening with an enlarged nodule on the left side of the anterior trachea. An ultrasound-guided biopsy of the nodule with PTH rinse was done suggesting a recurrent parathyroid adenoma and a revision operation was planned (Fig. 2). Prior to the operation, the parathyroid adenoma was localised with an USGW percutaneously. Intra-operatively, the wire was followed down to the level of the parathyroid adenoma, which was adherent to the underside of the left sternothyroid muscle. A cuff of the strap muscles, which was containing the parathyroid adenoma, was dissected away. A small piece was sent for frozen sections and confirmed to be parathyroid tissue. Intra-operative PTH level was then drawn 15 minutes after extraction of the parathyroid adenoma confirming cure. The patient recovered well after the procedure, without complications, and 1 year later she has no clinical or laboratory (PTH 3.1 pmol/L, calcium 2.4 mmol/L) evidence of hyperparathyroidism recurrence.

Case 3

A 50-year-old female with a history of lipomatous hemangiopericytoma of the neck (suboccipital region), which was originally resected in 2011 was evaluated. In 2014, she underwent a repeat resection followed by adjuvant chemoradiation therapy for a local recurrence in the right posterior neck, and an additional salvage surgery for a new recurrence in 2016. Unfortunately, in 2021 follow-up magnetic resonance imaging (MRI) identified a well-circumscribed local recurrence in the right posterior neck, deep to the rectus capitis muscle of 1.5 x 1 x 1 cm, superficial to and separate from the V3 segment of the right vertebral artery (Fig. 3). Surgical treatment was decided, and an ultrasound-guided placement of a wire directly into the tumour, which was just lateral to the vertebral artery, was performed. An elliptical excision of skin around the previously placed USGW, was made including the subcutaneous tissue and all surrounding muscles of the area. The mass was found located approximately 1.5 cm deep to the plane of the skin. Once getting down to the tumour itself and performing blunt dissection all the way around, it was resected. An additional margin of soft tissue was taken as a separate soft tissue margin. The patient recovered well and was discharged the day after the surgery. The final pathology was spindle cell neoplasm, consistent with recurrent solitary fibrous tumour/lipomatous haemangiopericytoma with free oncologic margins.

Case 4

A 61-year-old man who had history of a left a preauricular skin lesion with a parotid lymph node was referred to us. A biopsy from this area showed a poorly differentiated carcinoma. He underwent a left superficial parotidectomy and a II, III, and IV levels neck dissection. The biopsy of the skin lesion and the lymph nodes revealed no morphological abnormalities. Three months later he was reexamined at the clinic without being able to clinically detect any of the lesions that he initially presented with. A CT was performed which showed a small 1 cm circumscribed nodule, and apparently located in a fairly superficial plane just above the parotid gland. A fine-needle aspiration (FNA) biopsy from this lesion confirmed carcinoma. Salvage surgery was planned. Pre-operatively, the area was marked with an USGW. We began by demarcating out an incision just in the left preauricular area from the level of the helix down to the level of the lobule. After elevation of anterior and posterior flaps, we were able to bluntly trace the wire which was placed within the lesion. We then identified a well-circumscribed lesion. A blunt dissection around this lesion was performed and a cuff of parotid tissue was removed, and was then sent en-bloc as a revision parotidectomy. The facial nerve was preserved using neuromonitoring. The final histopathological specimen revealed the parotid with a metastatic poorly differentiated squamous cell carcinoma with margins free of disease. The patient evolved well and was discharged 24 hours after surgery.

Case 5

A 59-year-old man had a prior history of a left hemithyroidectomy for a nodule that was indeterminate for papillary thyroid carcinoma in 2015. Final pathology revealed a 4.5 cm classical follicular and oncocytic variant of papillary thyroid carcinoma. In September 2015, he underwent a right completion hemithyroidectomy. In September 2016, he underwent a right lateral and right central neck compartment dissection for nodal metastases. Four of 24 nodes were positive for papillary thyroid cancer. After the last surgery, he underwent radioactive iodine treatment. On follow-up in 2020, a CT revealed a 1.2 cm focus in the levels 2/3 of the right neck (Fig. 4). FNA biopsy was positive for papillary thyroid carcinoma and salvage surgery was planned. An USGW localisation of the lesion was performed. During the surgical procedure, the needle was followed down among the fibrotic tissue of the previous surgery. Using electrocautery dissection, the scar and the soft tissue were dissected, offering a 1.5 cm solid lesion 2 cm from the skin (Fig. 5). It was sent for frozen section and was found to be positive for papillary thyroid cancer. The final histopathologic report was metastases of papillary thyroid cancer with extracapsular extension. After surgery, the patient recovered well, without complications, and was discharged on post-operative day 1. The patient underwent iodine therapy after central compartment dissection and after two years of follow-up he remains disease-free.

Discussion

In this case series, we describe 5 cases of pre-operative USGW localisation for non-palpable head and neck lesions to facilitate surgical resection. We showed that this technique is useful for finding and resecting challenging lesions, particularly in the setting of prior surgery or adjuvant therapy which can obscure surgical landmarks.

USGW localisation for non-palpable lesions is a well-known and helpful technique for surgeons ⁴. Breast surgeons have long shown its utility for the localisation of non-palpable breast tumours since the 90’s ⁴. Since then, this procedure has expanded with several potential applications ^5-7. Thereby, it has been described for pre-operative soft tissue tumours (intramuscular haemangiomas, neuromas) localisation in orthopaedics ^6,7, or even for non-palpable anterior abdominal wall scar endometriomas in gynaecology ⁸. However, surprisingly, its first report in head and neck surgery was in 2004 for pre-operative localisation of a recurrent neck lymph node ⁹. Since then, applications in the parotid, thyroid, branchial and thyroglossal cysts have been described with encouraging outcomes, highlighting the versatility and efficacy of this technique ^5,10-12.

Contrasting other imaging techniques, ultrasound does not expose patients to ionising radiation, it is widely available, and does not require a working synchronisation between the surgeon and the interventional radiologist. On the other hand, unlike CT or magnetic resonance-guided wire localisation, ultrasound is a non-invasive method (does not require intravenous contrast) and its price is significantly lower ¹³. Nevertheless, though no complications have been reported in the literature regarding USGW localisation of head and neck hidden lesions, it could be potentially associated with needle puncture complications such as bleeding ¹⁴, wire migration, or needle tract tumour-cell seeding ^13,15,16. An additional consideration is that ultrasound accuracy is highly user dependent, and experience is particularly important for these wire placements in heavily pretreated patients ¹⁷.

Revision head and neck surgery is often challenging secondary to scarring, fibrosis, and oedema, which can increase the risk of complications such as nerve or vessels injury, parathyroid lesions, or chyle leak fistulas ¹³. In this complex scenario, non-palpable lesions can be hard to find in the intra-operative setting. In particular, USGW localisation allows visualisation of the needle, and safe surgical access following the needle down, reducing operating time and surgical complications ¹².

We acknowledge some limitations of this study. First, a small number of patients was analysed. In addition, selection bias is inevitable due to its retrospective nature.

Conclusions

USGW localisation of non-palpable head and neck lesions is a safe and highly efficient technique that should be into the head and neck surgeon’s armamentarium, and specifically for patients undergoing a revisional surgery where the head and neck anatomy is altered.

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

FL, TG, AS, ACN: substantial contributions to the conception or design of the work, or the acquisition, or interpretation of data for the work; FL, TG, GB, JY, SDM, KF, AM, AS, ACN: drafting the work or revising it critically for important intellectual content; FL, TG, GB, JY, SDM, KF, AM, AS, ACN: final approval of the version to be published.

Ethical consideration

Institutional Research Ethics Board (London Health and Sciences Center) approval was obtained (17222E).The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki. Written informed consent was obtained from each participant/patient for study participation and data publication.

Figures and tables

Figure 1.(A) Computed tomography showing a right upper paratracheal lymph node (yellow arrow); (B) ultrasound-guided wire localisation of the lesion. Wire entering the lesion (yellow arrow).

Figure 2.(A) Computed tomography showing pretracheal soft tissue thickening with an enlarged nodule on the left side of the anterior trachea (yellow arrow); (B) ultrasound-guided wire localisation of the lesion. Wire entering the lesion (yellow arrow).

Figure 3.(A) Magnetic resonance imaging showing a well-circumscribed lesion in the right posterior neck, deep to the rectus capitis muscle of 1.5 x 1 x 1 cm (yellow arrow); (B) ultrasound-guided wire localisation of the lesion. Wire entering the lesion (yellow arrow).

Figure 4.(A) Computed tomography showing a 1.2 cm lesion in the levels 2-3 of the right neck (yellow arrow); (B) ultrasound-guided wire localisation of the lesion. Wire entering the lesion (yellow arrows).

Figure 5.(A) wire penetrating the skin (yellow arrow); (B) wire going through the fibrotic and soft tissue (yellow arrow); (C) lesion finding. Wire tip inside the lesion (yellow arrow); (D) surgical specimen of 1.5 cm with the wire tip inside.

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