10.14639/0392-100X-N2280
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.
text/xml
1827-675X
2280
en
Anthony C. Nichols
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
revision surgery
Ultrasound-guided wire localisation: a GPS for hidden head and neck tumours? A case series
Text.Serial.Journal
https://www.actaitalica.it/
43
Head and neck
2023-07-28
2022-08-16
2023-12-19
2023-12-19
375-381
1
Anthony C. Nichols
2023/07/28
10.14639/0392-100X-N2280
375
Department of Otolaryngology - Head and Neck Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
1827-675X
revision surgery
en
381
Ultrasound-guided wire localisation: a GPS for hidden head and neck tumours? A case series
https://www.actaitalica.it/article/download/2280/1025
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:375-381; doi: 10.14639/0392-100X-N2280




Head and neck


Ultrasound-guided wire localisation: a GPS for hidden
head and neck tumours? A case series
Posizionamento ecoguidato di repere: un GPS per tumori testa e collo di difficile
localizzazione? Una serie clinica
Francisco Laxague1, Tommaso Gualtieri2, Gary Brahm3, John Yoo1, S. Danielle MacNeil1, Kevin Fung1, Adrian Mendez1,
Axel Sahovaler4, Anthony C. Nichols1
1
  Department of Otolaryngology - Head and Neck Surgery, Schulich School of Medicine & Dentistry, Western University, London,
Ontario, Canada; 2 Department of Otorhinolaryngology - Head & Neck Surgery, “Nuovo Santo Stefano” Civil Hospital, Prato, PO,
Italy; 3 Department of Medical Imaging, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada;
4
  Department of Head & Neck Surgery, University College London Hospitals, London, United Kingdom


SUMMARY
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 tu-
mours 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 interven-
tional 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
                                                                                                 Received: August 16, 2022
recurrent or persistent disease. All successfully underwent a pre-operative USGW localisa-
                                                                                                 Accepted: April 11, 2023
tion of the non-palpable lesion before revision surgery. All lesions were localised intra-
                                                                                                 Published online: July 28, 2023
operatively with no peri-operative complications.
Conclusions. USGW localisation is a safe and effective pre-operative technique for the           Correspondence
identification of small non-palpable head and neck tumours.                                      Anthony C. Nichols
                                                                                                 Department of Otolaryngology - Head and Neck
KEY WORDS: ultrasound-guided wire localisation, ultrasound, head and neck tumours,
                                                                                                 Surgery, London Health Sciences Centre, Schulich
non-palpable lesions, revision surgery                                                           School of Medicine & Dentistry, Western Univer-
                                                                                                 sity, 800 Commissioners Road East, London ON
RIASSUNTO                                                                                        N6A 5W9, Canada
                                                                                                 E-mail: Anthony.nichols@lhsc.on.ca
Obiettivi. Il posizionamento ecoguidato di un repere in piccoli tumori non palpabili del
distretto testa collo, può essere una valida opzione per facilitarne la localizzazione intra-
operatoria e diminuire le potenziali complicanze. Lo scopo di questo articolo è dimostrare         How to cite this article: Laxague F, Gual-
l’applicazione di questa tecnica tramite la descrizione di cinque casi clinici.                    tieri T, Brahm G, et al. Ultrasound-guided
                                                                                                   wire localisation: a GPS for hidden head and
Metodi. Tutti i pazienti sottoposti a posizionamento ecoguidato di un repere in tumori dif-
                                                                                                   neck tumours? A case series. Acta Otorhi-
ficilmente localizzzabili e non palpabili del distretto testa collo sono stati inclusi nello       nolaryngol Ital 2023;43:375-381. https://doi.
studio. Il repere è stato posizionato sempre dal medesimo radiologo interventista e l’inter-       org/10.14639/0392-100X-N2280
vento eseguito da chirurghi testa collo esperti.
Risultati. Sono stati inclusi cinque pazienti, tutti candidati a chirurgia di revisione per      © Società Italiana di Otorinolaringoiatria
recidiva o persistenza di malattia. In tutti i casi il posizionamento ecoguidato del repere      e Chirurgia Cervico-Facciale

è avvenuto con successo prima della chirurgia. Tutte le lesioni sono state localizzate intra-
                                                                                                                OPEN ACCESS
operativamente, e asportate senza complicanze.
Conclusioni. Questa tecnica pre-operatoria si è dimostrata sicura ed efficace per la lo-         This is an open access article distributed in accordance with
calizzazione di piccole neoplasie, altrimenti difficilmente localizzabili, del distretto testa   the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                 Commercial-NoDerivatives 4.0 International) license. The
collo.                                                                                           article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: posizionamento ecoguidato, ecografia, tumori testa collo, tumori non              only in the original version. For further information: https://
palpabili, chirurgia di revisione                                                                creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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F. Laxague et al.




Introduction                                                                    the head and neck region at London Health and Sciences
                                                                                Center, London, Ontario, Canada, between January 2019
The head and neck region anatomically contains critical
                                                                                and May 2022, was done. All the USGW localisations
vascular, nerve and lymphatic structures. In many patients,
                                                                                were performed by the same interventional radiologist
this anatomy can be distorted due to previous surgeries and/
                                                                                (GB). The patients were taken to the operating room and
or radiation therapy 1. In this complex scenario, a revision
                                                                                the localisation procedure was performed under general an-
head and neck surgery for small, non-palpable lesions can
                                                                                aesthesia immediately before the surgery. All the patients
be technically challenging and potentially morbid due to
                                                                                were prepped and draped in the usual sterile fashion. Fol-
injury to adjacent structures 2,3.
The use of USGW localisation for non-palpable breast le-                        lowing infiltration of the skin and subcutaneous tissue with
sions is standard practice to facilitate intra-operative iden-                  1% lidocaine, a wire localiser 20 gauge needle was inserted
tification 4. In the last two decades, this technique has been                  into the lesion that was intended for resection, leaving the
applied to pre-operatively localise both benign and malig-                      localisation wire inside the lesion and removing the needle
nant small head and neck lesions 5.                                             after the wire was in the right location. On average, the
USGW localisation is a simple technique in which pre-op-                        procedure took from 10 to 15 minutes.
eratively a percutaneous wire is placed to help localise a le-
sion. It is particularly useful in patients who have received                   Results
previous surgery and/or radiotherapy with subsequent al-
                                                                                Case 1
teration of the normal anatomy. Following the needle down
                                                                                A 47-year-old male had a history of papillary thyroid can-
to the lesion, a simpler dissection is performed, increasing
                                                                                cer resected in 2017 (T2 N1b) including a total thyroidec-
the chance of finding a small lesion and potentially reduc-
ing morbidity by avoiding vital structures 5.                                   tomy, right central and right lateral neck dissections and ra-
Herein, we describe five cases of pre-operative USGW lo-                        dioiodine therapy. After 4 years of follow-up, the patient’s
calisation of non-palpable head and neck lesions to facili-                     antithyroglobulin antibodies were elevated which prompt-
tate surgical localisation.                                                     ed an ultrasound that showed a recurrence in the right para-
                                                                                tracheal space. An ultrasound-guided fine-needle aspiration
                                                                                (FNA) of the lymph node in the right paratracheal region
Materials and methods                                                           was positive for papillary thyroid cancer. The computed
A retrospective chart review of all patients undergoing pre-                    tomography showed an enlarged right paratracheal lymph
operative USGW localisation for non-palpable tumours of                         node (Fig. 1). Focused ultrasound of the right neck dem-



  A                                                                             B




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).



376
                                                                                       Ultrasound-guided wire localisation for hidden head and neck tumours




  A                                                                            B




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).


onstrated a hypoechoic paratracheal nodule of 1.7 cm in                          formed. One parathyroid gland was removed in the right
maximum dimension. The patient consented to pre-oper-                            central neck, and the right superior parathyroid was re-
ative wire localiser insertion. In a sterile fashion and fol-                    moved as well. Despite this, elevated calcium (2.9 mmol/L)
lowing infiltration of the skin and subcutaneous tissue with                     and PTH levels (20.7 pmol/L) were still present. The patient
1% lidocaine, a wire localiser needle was inserted into the                      was significantly symptomatic, requiring repeated intrave-
right paratracheal nodule. The hooked tip of the wire was                        nous bisphosphonate infusions. A computed tomography
placed at the anterior/inferior aspect of the nodule. During                     (CT) scan was performed that showed some pretracheal
the surgical procedure, the needle was followed down. The                        soft tissue thickening with an enlarged nodule on the left
carotid and the vagus were retracted anteriorly and medial-                      side of the anterior trachea. An ultrasound-guided biopsy of
ly. The needle localisation went into a pocket that was deep                     the nodule with PTH rinse was done suggesting a recurrent
to the medial aspect of the anterior scalene and posterior to                    parathyroid adenoma and a revision operation was planned
the carotid sheath. Using blunt dissection, the lymph node                       (Fig. 2). Prior to the operation, the parathyroid adenoma was
packet was dissected and the lymph node was identified                           localised with an USGW percutaneously. Intra-operatively,
with the wire in it. There was significant surrounding scar                      the wire was followed down to the level of the parathyroid
tissue from the prior operation. The specimen was sent for                       adenoma, which was adherent to the underside of the left
frozen sections and was found to be positive for papillary                       sternothyroid muscle. A cuff of the strap muscles, which
thyroid cancer. After the surgery, the patient recovered un-                     was containing the parathyroid adenoma, was dissected
eventfully and was discharged on post-operative day 1. The                       away. A small piece was sent for frozen sections and con-
final histopathologic report was papillary thyroid cancer                        firmed to be parathyroid tissue. Intra-operative PTH level
with margins free of disease.                                                    was then drawn 15 minutes after extraction of the parathy-
                                                                                 roid adenoma confirming cure. The patient recovered well
Case 2                                                                           after the procedure, without complications, and 1 year later
A 49-year-old female with a history of recurrent primary                         she has no clinical or laboratory (PTH 3.1 pmol/L, calcium
hyperparathyroidism was referred to our attention. The                           2.4 mmol/L) evidence of hyperparathyroidism recurrence.
first operation was in 2017, where a very large left infe-
rior parathyroid adenoma was found. Parathormone (PTH)                           Case 3
and calcium levels returned within normal limits after sur-                      A 50-year-old female with a history of lipomatous he-
gery; however, a very aggressive relapse was recorded 2                          mangiopericytoma of the neck (suboccipital region),
years later with a value of PTH = 24.7 pmol/L (normal                            which was originally resected in 2011 was evaluated. In
1.6-6.9 pmol/L), and calcium 3.18 mmol/L (normal 2.15-                           2014, she underwent a repeat resection followed by adju-
2.5 mmol/L). A bilateral central neck dissection was per-                        vant chemoradiation therapy for a local recurrence in the



                                                                                                                                                       377
F. Laxague et al.




   A                                                                           B




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).


right posterior neck, and an additional salvage surgery for                        skin lesion and the lymph nodes revealed no morphological
a new recurrence in 2016. Unfortunately, in 2021 follow-                           abnormalities. Three months later he was reexamined at the
up magnetic resonance imaging (MRI) identified a well-                             clinic without being able to clinically detect any of the le-
circumscribed local recurrence in the right posterior neck,                        sions that he initially presented with. A CT was performed
deep to the rectus capitis muscle of 1.5 x 1 x 1 cm, su-                           which showed a small 1 cm circumscribed nodule, and
perficial to and separate from the V3 segment of the right                         apparently located in a fairly superficial plane just above
vertebral artery (Fig. 3). Surgical treatment was decided,                         the parotid gland. A fine-needle aspiration (FNA) biopsy
and an ultrasound-guided placement of a wire directly into                         from this lesion confirmed carcinoma. Salvage surgery
the tumour, which was just lateral to the vertebral artery,                        was planned. Pre-operatively, the area was marked with an
was performed. An elliptical excision of skin around the                           USGW. We began by demarcating out an incision just in
previously placed USGW, was made including the subcu-                              the left preauricular area from the level of the helix down
taneous tissue and all surrounding muscles of the area. The                        to the level of the lobule. After elevation of anterior and
mass was found located approximately 1.5 cm deep to the                            posterior flaps, we were able to bluntly trace the wire which
plane of the skin. Once getting down to the tumour itself                          was placed within the lesion. We then identified a well-
and performing blunt dissection all the way around, it was                         circumscribed lesion. A blunt dissection around this lesion
resected. An additional margin of soft tissue was taken as a                       was performed and a cuff of parotid tissue was removed,
separate soft tissue margin. The patient recovered well and                        and was then sent en-bloc as a revision parotidectomy. The
was discharged the day after the surgery. The final pathol-                        facial nerve was preserved using neuromonitoring. The fi-
ogy was spindle cell neoplasm, consistent with recurrent                           nal histopathological specimen revealed the parotid with a
solitary fibrous tumour/lipomatous haemangiopericytoma                             metastatic poorly differentiated squamous cell carcinoma
with free oncologic margins.                                                       with margins free of disease. The patient evolved well and
                                                                                   was discharged 24 hours after surgery.
Case 4
A 61-year-old man who had history of a left a preauricular                         Case 5
skin lesion with a parotid lymph node was referred to us.                          A 59-year-old man had a prior history of a left hemithy-
A biopsy from this area showed a poorly differentiated car-                        roidectomy for a nodule that was indeterminate for papil-
cinoma. He underwent a left superficial parotidectomy and                          lary thyroid carcinoma in 2015. Final pathology revealed a
a II, III, and IV levels neck dissection. The biopsy of the                        4.5 cm classical follicular and oncocytic variant of papil-



378
                                                                                       Ultrasound-guided wire localisation for hidden head and neck tumours




  A                                                                          B




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).


lary thyroid carcinoma. In September 2015, he underwent                           A                                         B
a right completion hemithyroidectomy. In September 2016,
he underwent a right lateral and right central neck compart-
ment 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 papil-
lary thyroid carcinoma and salvage surgery was planned.
An USGW localisation of the lesion was performed. Dur-                            C                                         D

ing 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 histopatho-
logic report was metastases of papillary thyroid cancer with
                                                                                 Figure 5. (A) wire penetrating the skin (yellow arrow); (B) wire going through
extracapsular extension. After surgery, the patient recov-
                                                                                 the fibrotic and soft tissue (yellow arrow); (C) lesion finding. Wire tip inside the
ered well, without complications, and was discharged on                          lesion (yellow arrow); (D) surgical specimen of 1.5 cm with the wire tip inside.
post-operative day 1. The patient underwent iodine therapy
after central compartment dissection and after two years of
follow-up he remains disease-free.                                               is useful for finding and resecting challenging lesions, par-
                                                                                 ticularly in the setting of prior surgery or adjuvant therapy
                                                                                 which can obscure surgical landmarks.
Discussion
                                                                                 USGW localisation for non-palpable lesions is a well-
In this case series, we describe 5 cases of pre-operative US-                    known and helpful technique for surgeons 4. Breast sur-
GW localisation for non-palpable head and neck lesions to                        geons have long shown its utility for the localisation of
facilitate surgical resection. We showed that this technique                     non-palpable breast tumours since the 90’s 4. Since then,



                                                                                                                                                               379
F. Laxague et al.




this procedure has expanded with several potential applica-       Funding
tions 5-7. Thereby, it has been described for pre-operative       This research did not receive any specific grant from fund-
soft tissue tumours (intramuscular haemangiomas, neuro-           ing agencies in the public, commercial, or not-for-profit
mas) localisation in orthopaedics 6,7, or even for non-palpa-     sectors.
ble anterior abdominal wall scar endometriomas in gynae-
cology 8. However, surprisingly, its first report in head and     Author contributions
neck surgery was in 2004 for pre-operative localisation of        FL, TG, AS, ACN: substantial contributions to the concep-
a recurrent neck lymph node 9. Since then, applications in        tion or design of the work, or the acquisition, or interpre-
the parotid, thyroid, branchial and thyroglossal cysts have       tation of data for the work; FL, TG, GB, JY, SDM, KF,
been described with encouraging outcomes, highlighting            AM, AS, ACN: drafting the work or revising it critically
the versatility and efficacy of this technique 5,10-12.           for important intellectual content; FL, TG, GB, JY, SDM,
Contrasting other imaging techniques, ultrasound does not         KF, AM, AS, ACN: final approval of the version to be pub-
expose patients to ionising radiation, it is widely available,    lished.
and does not require a working synchronisation between
the surgeon and the interventional radiologist. On the other      Ethical consideration
hand, unlike CT or magnetic resonance-guided wire lo-             Institutional Research Ethics Board (London Health and
calisation, ultrasound is a non-invasive method (does not         Sciences Center) approval was obtained (17222E).The re-
require intravenous contrast) and its price is significantly      search was conducted ethically, with all study procedures
lower 13. Nevertheless, though no complications have been         being performed in accordance with the requirements of
reported in the literature regarding USGW localisation of         the World Medical Association’s Declaration of Helsinki.
head and neck hidden lesions, it could be potentially as-         Written informed consent was obtained from each partici-
sociated with needle puncture complications such as bleed-        pant/patient for study participation and data publication.
ing 14, wire migration, or needle tract tumour-cell seed-
ing 13,15,16. An additional consideration is that ultrasound      References
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