Application of Ultrasound-Guided Core Biopsy to Minimal-Invasively Diagnose Supraclavicular Fossa Tumors and Minimize the Requirement of Invasive Diagnostic Surgery

Abstract

Tumors of the supraclavicular fossa (SC) is clinically challenging because of anatomical complexity and tumor pathological diversity. Because of varied diseases entities and treatment choices of SC tumors, making the accurate decision among numerous differential diagnoses is imperative. Sampling by open biopsy (OB) remains the standard procedure for pathological confirmation. However, complicated anatomical structures of SC always render surgical intervention difficult to perform. Ultrasound-guided core biopsy (USCB) is a minimally invasive and office-based procedure for tissue sampling widely applied in many diseases of head and neck. This study aims to evaluate the clinical efficacy and utility of using USCB as the sampling method of SC tumors. From 2009 to 2014, consecutive patients who presented clinical symptoms and signs of supraclavicular tumors and were scheduled to receive sampling procedures for diagnostic confirmation were recruited. The patients received USCB or OB respectively in the initial tissue sampling. The accurate diagnostic rate based on pathological results was 90.2% for USCB, and 93.6% for OB. No significant difference was noted between USCB and OB groups in terms of diagnostic accuracy and the percentage of inadequate specimens. All cases in the USCB group had the sampling procedure completed within 10 minutes, but not in the OB group. No scars larger than 1 cm were found in USCB. Only patients in the OB groups had the need to receive general anesthesia and hospitalization and had scars postoperatively. Accordingly, USCB can serve as the first-line sampling tool for SC tumors with high diagnostic accuracy, minimal invasiveness, and low medical cost.

FIGURE 1

The flowchart of inclusion and exclusion criteria in enrolled patients. USCB, ultrasound-guided core biopsy; OB, open biopsy; SC, supraclavicular fossa.

FIGURE 2

Ultrasound imaging and the procedure of USCB in diagnosing SC tumors. (A) The axial view of CT images and (B) the coronal view demonstrated a tumor with heterogeneously contrast enhancement (white arrow) located at the left supraclavicular fossa. (C) Ultrasound imaging revealed the hypoechoic nature of tumor (T) with punctate vascularity. (D) USCB was performed for tumor tissue harvest (double arrows: tip of the core needle).

FIGURE 3

Ultrasound imaging and the procedure of USCB in diagnosing SC tumors close to the great vessel. (A) The axial view and (B) the coronal view of T1WI MRI showed an ill-defined and heterogeneous tumor (white arrow) located in the right supraclavicular fossa. (C) The ultrasound demonstrated that the SC tumor (T) is adjacent to the common carotid artery (CCA). (D) USCB was performed for sampling of the SC tumor without CCA perturbation (orange arrow).

FIGURE 4

The USCB procedure of SC tumors. (A) USCB was performed under ultrasound guidance by a free hand method. (B) The needle was inserted along the axis of the linear probe. (C) Only a puncture wound was left without any additional sutures (arrow). (D) Bleeding was easily controlled by the standard compression maneuver (arrow).

FIGURE 5

The OB procedure for SC tumors. (A) An OB procedure was performed for a SC tumor located adjacently to the great vessels. (B) The internal jugular vein was exposed in a close view during OB procedure. (C) An OB procedure was performed for a SC tumor located close to the nerve trunk. (D) The nerve branches and vessels were identified during the OB procedure. (E) An obvious scar was left in the SC area after the OB procedure for tumor sampling (arrow).

FIGURE 6

The pathological presentations of a SC tumor harvested by USCB. A 62-year-old male with treated NPC presented with a left SC tumor and was diagnosed as lung cancer metastasis by USCB. (A) HE staining of the specimens harvested from the SC tumor by USCB, 100×. (B) Immunostaining with cytokeratin showed strongly positive responses, 100×. (C) A high power view with HE staining demonstrated that soft tissue was infiltrated by nested cells. These cells had increased nuclear-cytoplasmic ratio and pleomorphism. Focal clear changes of cells characterized by clear cytoplasm were noticed, 400×. (D) Epstein–Barr virus in situ hybridization was negative, 400×.

FIGURE 7

Comparison of the pathological presentations of specimens harvested form SC tumors by USCB and OB. A case diagnosed as lymphoma presenting with SC tumors. The pathological figures including HE and immunohistochemical staining in the upper panel are based on the specimens harvested from USCB, whereas those in the lower panel are from the specimens harvested by OB. (A) HE, 400×. (B) CD3, 400×. (C) CD20, 400×. (D) HE, 100×. (E) CD3, 100×. (F) CD20, 100×.