DOI: 10.1148/rg.272065101
Percutaneous Biopsy of Head and Neck Lesions with CT Guidance: Various Approaches and Relevant Anatomic and Technical Considerations1
Sanjay Gupta, MD,
Joy A. Henningsen, MD,
Michael J. Wallace, MD,
David C. Madoff, MD,
Frank A. Morello, Jr, MD,
Kamran Ahrar, MD,
Ravi Murthy, MD and
Marshall E. Hicks, MD
1 From the Department of Diagnostic Radiology, Unit 325, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. Recipient of a Magna Cum Laude award for an education exhibit at the 2005 RSNA Annual Meeting. Received May 16, 2006; revision requested July 25 and received August 22; accepted August 23. R.M. is a research consultant for Sirtex Medical (Lake Forest, Ill); M.E.H. is a stockholder in Pfizer (New York, NY), General Electric (Fairfield, Conn), and St Jude Medical (St Paul, Minn); all other authors have no financial relationships to disclose.
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Figure 1a. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 1b. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 1c. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 1d. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 1e. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 1f. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 1g. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 1h. (a) Axial cross-sectional anatomy at the level of the skull base. Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. (b, c) Axial cross-sectional anatomy at the level of the upper maxillary antrum (b) and lower maxillary antrum (c). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (d, e) Axial cross-sectional anatomy at the level of the alveolar ridge (d) and mandible (e). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side. CN = cranial nerve. (f–h) Axial cross-sectional anatomy at the level of the C4 vertebra (f ), C6 vertebra (g), and C7 vertebra (h). Anatomic structures are shown on the left side of the diagram; spaces are shown on the right side.
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Figure 3. CT scan shows a biopsy needle (solid arrow) that was inserted inferior to the zygomatic arch (Z) and advanced between the coronoid process (arrowhead) and mandibular condyle (open arrow) into a mass (M) in the left masticator space. The patient had undergone previous maxillectomy for maxillary sinus carcinoma.
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Figure 4a. Subzygomatic approach. (a) CT scan shows a soft-tissue mass (arrowheads) in the right pterygopalatine fossa. A direct lateral approach is precluded by the zygomatic arch (Z). (b) CT scan shows a biopsy needle (arrow) inserted at a level caudad to the zygomatic arch. The needle was advanced in a cranial direction by using the triangulation method. (c) CT scan obtained at a more cranial level shows the needle tip (arrow) within the soft-tissue mass (M) in the pterygopalatine fossa.
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Figure 4b. Subzygomatic approach. (a) CT scan shows a soft-tissue mass (arrowheads) in the right pterygopalatine fossa. A direct lateral approach is precluded by the zygomatic arch (Z). (b) CT scan shows a biopsy needle (arrow) inserted at a level caudad to the zygomatic arch. The needle was advanced in a cranial direction by using the triangulation method. (c) CT scan obtained at a more cranial level shows the needle tip (arrow) within the soft-tissue mass (M) in the pterygopalatine fossa.
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Figure 4c. Subzygomatic approach. (a) CT scan shows a soft-tissue mass (arrowheads) in the right pterygopalatine fossa. A direct lateral approach is precluded by the zygomatic arch (Z). (b) CT scan shows a biopsy needle (arrow) inserted at a level caudad to the zygomatic arch. The needle was advanced in a cranial direction by using the triangulation method. (c) CT scan obtained at a more cranial level shows the needle tip (arrow) within the soft-tissue mass (M) in the pterygopalatine fossa.
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Figure 5a. Subzygomatic approach. (a) CT scan shows a mass (M) in the right pharyngeal mucosal space that extends into the carotid space and encases the carotid artery (arrowhead). (b) CT scan shows a biopsy needle (solid arrow) inserted through a small anterior portion of the parotid gland (arrowhead). The needle passes anterior to the mandibular condyle (c) and through the lateral pterygoid muscle (m) and parapharyngeal space (open arrow) into the anterior portion of the mass (M), away from the expected position of the internal carotid artery.
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Figure 5b. Subzygomatic approach. (a) CT scan shows a mass (M) in the right pharyngeal mucosal space that extends into the carotid space and encases the carotid artery (arrowhead). (b) CT scan shows a biopsy needle (solid arrow) inserted through a small anterior portion of the parotid gland (arrowhead). The needle passes anterior to the mandibular condyle (c) and through the lateral pterygoid muscle (m) and parapharyngeal space (open arrow) into the anterior portion of the mass (M), away from the expected position of the internal carotid artery.
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Figure 7a. Retromandibular approach. (a) CT scan shows a right parapharyngeal mass (M). Note the presence of the external carotid artery and retromandibular vein (arrow) in the anterior portion of the parotid gland (P). The carotid sheath vessels are located posterior to the styloid process (arrowhead). (b) CT scan shows a biopsy needle (solid arrow) inserted through the parotid gland (P) posterior to the vessels (open arrow). The needle passes anterior to the styloid process (arrowhead) and into the mass (M).
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Figure 7b. Retromandibular approach. (a) CT scan shows a right parapharyngeal mass (M). Note the presence of the external carotid artery and retromandibular vein (arrow) in the anterior portion of the parotid gland (P). The carotid sheath vessels are located posterior to the styloid process (arrowhead). (b) CT scan shows a biopsy needle (solid arrow) inserted through the parotid gland (P) posterior to the vessels (open arrow). The needle passes anterior to the styloid process (arrowhead) and into the mass (M).
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Figure 8a. Retromandibular approach. (a) CT scan shows a mass (M) in the carotid space with medial displacement of the carotid artery (arrowhead). Note the presence of vessels (arrow) in the parotid gland (P) immediately posterior to the mandibular ramus. (b) CT scan shows a biopsy needle (solid arrow) passing immediately posterior to the vessels (open arrow) in the parotid gland (P) and into the mass (M).
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Figure 8b. Retromandibular approach. (a) CT scan shows a mass (M) in the carotid space with medial displacement of the carotid artery (arrowhead). Note the presence of vessels (arrow) in the parotid gland (P) immediately posterior to the mandibular ramus. (b) CT scan shows a biopsy needle (solid arrow) passing immediately posterior to the vessels (open arrow) in the parotid gland (P) and into the mass (M).
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Figure 9a. Retromandibular approach. (a) CT scan shows a prevertebral mass (M). Needle placement posterior to the styloid process is not possible because of the presence of the internal carotid artery (arrow) and jugular vein (V) directly lateral to the mass. (b) As seen on the CT scan, the presence of vessels (open arrow) in the parotid gland (P) and of the styloid process (arrowhead) limits the angulation of the needle (solid arrow), restricting access to the mass (M).
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Figure 9b. Retromandibular approach. (a) CT scan shows a prevertebral mass (M). Needle placement posterior to the styloid process is not possible because of the presence of the internal carotid artery (arrow) and jugular vein (V) directly lateral to the mass. (b) As seen on the CT scan, the presence of vessels (open arrow) in the parotid gland (P) and of the styloid process (arrowhead) limits the angulation of the needle (solid arrow), restricting access to the mass (M).
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Figure 11a. Paramaxillary approach. (a) MR image shows an enlarged lateral retropharyngeal node (M) medial to the carotid artery (arrowhead). (b) CT scan shows an 18-gauge Hawkins needle (solid arrow) passing lateral to the facial artery (open arrow) and through the medial pterygoid muscle (m). A 22-gauge biopsy needle (arrowhead) was advanced coaxially through the guide needle into the mass (M).
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Figure 11b. Paramaxillary approach. (a) MR image shows an enlarged lateral retropharyngeal node (M) medial to the carotid artery (arrowhead). (b) CT scan shows an 18-gauge Hawkins needle (solid arrow) passing lateral to the facial artery (open arrow) and through the medial pterygoid muscle (m). A 22-gauge biopsy needle (arrowhead) was advanced coaxially through the guide needle into the mass (M).
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Figure 12a. Paramaxillary approach. (a) CT scan shows an enhancing mass (M) in the left carotid space medial to the carotid artery (arrowhead). (b) CT scan shows a needle (arrow) passing through the masticator and parapharyngeal spaces into the mass (M).
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Figure 12b. Paramaxillary approach. (a) CT scan shows an enhancing mass (M) in the left carotid space medial to the carotid artery (arrowhead). (b) CT scan shows a needle (arrow) passing through the masticator and parapharyngeal spaces into the mass (M).
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Figure 13. Paramaxillary approach. CT scan shows a biopsy needle (arrow) advanced through the masticator and parapharyngeal spaces and through the prevertebral muscles into a lesion (arrowheads) posterior to the anterior arch of the atlas.
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Figure 15. Submastoid approach. CT scan obtained with the patient’s head turned to the contralateral side shows a biopsy needle (arrow) passing through the sternocleidomastoid muscle (m) into a left carotid space mass (M). Note the carotid artery (arrowhead), which is displaced anteriorly by the mass. The needle was inserted at a level 1 cm below the tip of the mastoid process (not shown).
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Figure 16. Transoral approach. CT scan shows a needle (arrow) inserted through the open mouth and advanced through the retropharyngeal and prevertebral tissues into a soft-tissue mass (arrowheads) involving the tip of the odontoid and the anterior arch of the atlas.
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Figure 17. Posterior approach. CT scan obtained with the patient in the prone position shows a needle (arrow) advanced through the posterior paravertebral muscles for biopsy of a lytic lesion (arrowheads) involving the spinous process and lamina of the C2 vertebra.
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Figure 18. Posterior approach. CT scan obtained with the patient in the prone position shows a needle (white arrow) passing through the posterior paravertebral muscles into a lytic process (black arrows) involving the lamina, articular pillar, and pedicle of the C3 vertebra.
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Figure 19a. Posterior approach. (a) Contrast-enhanced CT scan of a prone patient shows a lytic lesion (arrowheads) involving the body and lateral mass of C2. The vertebral artery (arrow) is encased and narrowed by the lesion. (b) CT scan shows a biopsy needle (solid arrow) passing through the anterior portion of the lamina into the lesion, posterior to the expected location of the vertebral artery (open arrow).
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Figure 19b. Posterior approach. (a) Contrast-enhanced CT scan of a prone patient shows a lytic lesion (arrowheads) involving the body and lateral mass of C2. The vertebral artery (arrow) is encased and narrowed by the lesion. (b) CT scan shows a biopsy needle (solid arrow) passing through the anterior portion of the lamina into the lesion, posterior to the expected location of the vertebral artery (open arrow).
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Figure 20a. Needle trajectories for the anterolateral (AL), posterolateral (PL), and posterior (P) approaches in the infrahyoid neck region at the C4 (a), C6 (b), and C7 (c) vertebral levels.
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Figure 20b. Needle trajectories for the anterolateral (AL), posterolateral (PL), and posterior (P) approaches in the infrahyoid neck region at the C4 (a), C6 (b), and C7 (c) vertebral levels.
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Figure 20c. Needle trajectories for the anterolateral (AL), posterolateral (PL), and posterior (P) approaches in the infrahyoid neck region at the C4 (a), C6 (b), and C7 (c) vertebral levels.
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Figure 21. Anterolateral approach. CT scan shows a biopsy needle (arrow) advanced between the trachea (T) and carotid vessels (V) through the surgical bed (the right lobe of the thyroid gland was removed in a previous surgery) and into a mass (M).
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Figure 22. Anterolateral approach. CT scan shows an 18-gauge guide needle (arrow) placed in the soft tissues and a coaxially placed 22-gauge needle (arrowhead) passing through the left lobe of the thyroid gland (t) medial to the carotid artery (a) and internal jugular vein (v) and into a paraesophageal mass (M).
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Figure 23. Anterolateral approach. CT scan shows a biopsy needle (arrow) inserted medial to the sternocleidomastoid muscle (m) and advanced between the thyroid cartilage (arrowhead) and the common carotid artery (a) and internal jugular vein (v) for biopsy of a lytic lesion of the C5 vertebral body.
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Figure 24a. Posterolateral approach. (a) MR image shows a hyperintense lesion (arrowheads) involving the right transverse process of the C6 vertebra and extending into the prevertebral space. The vertebral artery (arrow) is immediately posterior to the mass. (b) CT scan shows the needle tip (arrow) in the prevertebral portion of the mass (M). The needle was inserted at a more cranial level, directed caudally, and advanced posterior to the internal jugular vein (V) and common carotid artery (arrowhead).
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Figure 24b. Posterolateral approach. (a) MR image shows a hyperintense lesion (arrowheads) involving the right transverse process of the C6 vertebra and extending into the prevertebral space. The vertebral artery (arrow) is immediately posterior to the mass. (b) CT scan shows the needle tip (arrow) in the prevertebral portion of the mass (M). The needle was inserted at a more cranial level, directed caudally, and advanced posterior to the internal jugular vein (V) and common carotid artery (arrowhead).
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Figure 25. Posterolateral approach. CT scan shows a biopsy needle (solid arrow) inserted through the posterior part of the sternocleidomastoid muscle (m) and advanced in an anteromedial direction. The needle passes posterior to the jugular vein (v) and common carotid artery (a) into a prevertebral mass (arrowheads) involving the left transverse process of the C4 vertebra, away from the expected location of the vertebral artery (open arrow).
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Figure 26. Posterior approach. CT scan obtained with the patient in the prone position shows a needle (arrow) passing through the posterior paravertebral muscles into a lytic process (arrowheads) involving the articular pillar and pedicle of the C5 vertebra.
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Copyright © 2007 by the Radiological Society of North America.
