What about its accuracy ? It is about 90% accurate if done properly by a trained or experienced personnel. Any more accurate would need an open biopsy and sending the three-dimensional tissue block to the pathologist. But beware the great disadvantage of the reason given just in the paragraph above. (open biopsy pic) So what is the advantage of the surgeon doing the biopsy procedure ? While this is not common, as the special skills need to be acquired though further advanced training and experience. Here the advantage lies in the fact that the surgeon whom you had consulted has the heads-up in knowing your disease history, a clinical examination of the mass by inspection and palpation. A more holistic approach would be possible as h/she is able to collate all these data and relate to your ultrasound and/or biopsy results. Furthermore, the same data would be useful for correlation should a surgery be needed for the mass in the near future. Here we are a firm believer in this holistic approach of management. Is It painful ? It is just like drawing blood from your veins, but now the needle is aimed towards the mass of concern in the head and neck region instead. To get a better sample, sometimes the needle is angled at many different angles all around within the mass concerned for a wider coverage to get the most representative/best sample. So at most, there may be a bit slightly more discomfort than a routine blood taking but very tolerable. An option of using local anesthesia prior to the procedure is available upon request.

An open incisional biopsy (as the last resort)

Endosopic assessment of the nose and throat important

The truth about head and neck swellings: • Common swellings originate from the lymph nodes, thyroid gland, salivary gland, skin • Most swellings are not cancerous. • Some will respond to medication, some will not. • Not all need surgery. Some will. • Before a swelling is surgically removed, it is important to best know its content as it affects surgical planning and patient treatment outcome (‘ask, then shoot’ approach) • Rather than ‘shoot, then ask’ approach – cutting into a swelling as first line approach (where applicable with further clarification below) then find out what is the content

Hence, modern technology nowadays has allowed us to use minimally invasive techniques to understand a swelling before we plan our next move on its treatment. At the forefront of such studies of swelling are cytology and/biopsy studies using needles or fine biopsy instruments. To increase its accuracy, imaging equipment (commonly ultrasound) is used to guide its placement for the best possible sampling. What is the most important difference of using ultrasound and non-usage of ultrasound in performing the biopsies or cytology studies ? The usage of real-time imaging allows an accurate ‘live’ pinpoint of the mass you worry about. The problem is, in a mass there may be areas where it is hard/solid or areas where the fluid gather (cystic). Usually the solid part tends to be the part that harbours cancerous cells or has the potential to transform into a cancerous growth. Without an imaging guidance system, differentiating it externally by the any doctor looking at it (inspection) or feeling it (palpation) is rather impossible to be done with great accuracy. So many combination of the different solid and cystic mass can exist in many different parts of the mass (see pic). Even if a needle is inserted into the mass by the doctor as in a non-image guided biopsy,, how would he know which component is at the needle tip ? The possibilities are the different arrangement of structure types are many (The next paragraph further details the 2 main components ie. sold and cystic and their implications) Another real advantage of this approach Is that even deep- seated swellings not visible from the outside (meaning the neck looks absolutely normal) but seen by ultrasound deep under the skin (maybe 2cm under the skin) can be sampled. While we acknowledge that ultrasound guidance cost more, the accuracy and all the other advantages ensures that it is a worthwhile procedure/endeavor. The advantages (especially the ability to pinpoint the suspicious part of the mass) far outweigh the cost disadvantage What is the significance of the solid and cystic parts ? It is natural that most, if not all, patients worry about cancer changes. And those changes tend to happen way more commonly in the solid part of the mass. The added bonus is that once the cystic part is pinpointed, the fluid, if it is watery/serous enough to be drained through the needle puncturing it, the swelling can be decompressed, shrinking the mass as an added bonus (think of that as an added bonus should you need to ‘show off a new neck’ during an important social function tomorrow !) The possibilities of the different combinations of the solid and cystic swellings in a gland are too many, as seen in the pictures below.

A thyroid gland swelling

A parotid salivary gland swelling

“Don’t shoot then ask !”

(graphic credit: www.historyisnowmagazine.com)

“Cant’ see well, can’t aim well Can’t aim well, can’t get good results”

So what are the other advantages of ultrasound ? • Ultrasound uses NO radiation hence it is safe in child or even pregnant ladies. (think pregnant ladies with their regular antenatal ultrasound checks. So there Is no denying that all of us would have had ultrasound done on us in our moms’ womb before we saw the light of this world !) • Ultrasound guidance allow a real-time ‘live’ assessment of the mass and its component • It is a reliable yet much cheaper modality as compared to CT scan (which also has a much higher dose of radiation). For thyroid swellings, the minute feature details are better seen on ultrasound rather than CT scan. • It is light-weight and hence a very portable system to move/lug around. • Not only can it differentiate the solid and the cystic part, it also allows the study of each solid and cystic part to further suggest if each component is more likely to be cancerous or not, based on its ultrasound features/attributes. • It can be applied to all head and neck masses (commonly the thyroid, salivary and lymph nodes) and the necessary procedures performed eg biopsy, cytology studies, drainage, sclerotherapy etc. • This procedure is applicable in both children and adults. (though for uncooperative children, general anesthesia maybe needed) What if the mass studied is actually a cancerous mass ? The FNAC study has been proven to NOT increase the risk of any cancer spread (tumour seedling). Cutting into the mass without verifying if it is cancerous, via an open incisional biopsy in fact cause tumour seedling ie the cancer cells spreading along the open wound into the skin surface. This has been proven to confer a worse prognosis ie a worse outcome in the cancer cure. Open biopsy should only be used as a last resort or in some cases where the FNAC cannot confirm the true nature of the tumour. In any head and neck mass, especially if the swelling is suspected to be a lymph node, it is Imperative that the entire ear, nose and throat system be scanned via ENT endoscopy prior to any investigation of the secondary neck swelling. Any inflammation or tumours of the ENT system can potentially spread to the neck lymph nodes.

The possible variations are too many, beyond what the eyes can see and hands can feel

“Ask first (the nature of swelling), then shoot (treat/remove surgically if needed).”