Introduction
Ultrasound-guided wire localisation is one of the most favoured techniques for localising non-palpable breast lesions. The use of ultrasound-guided wire localisation in the head and neck at present, however, is less commonplace. Non-palpable recurrent cervical lymphadenopathy in a previously treated neck, be it surgical or in some combination with radiotherapy and chemotherapy, is a particular difficulty faced by the head and neck multidisciplinary team during follow up. The reasons are twofold: the lymphatic drainage pattern may change, and initial cancer management can cause significant anatomical distortion to disguise post-treatment changes from recurrence, leading to non-representative false-negative histology samples. This makes operating extremely challenging. Ultrasound-guided wire localisation is one possible proposed solution for the head and neck team to this diagnostic challenge.
At our tertiary referral centre, as a collaboration between the imaging and the ENT departments, we have been undertaking more pre-operative ultrasound-guided wire localisation for head and neck cases over recent years. This study has two primary aims. First, we present a literature search to assess the utility, safety and effectiveness of ultrasound-guided wire localisation in a head and neck patient cohort. Second, we present our case series, which is the largest in the UK to date known to us, to determine safety and efficacy, and compare our case selection with the current literature.
Materials and methods
Literature review
The authors conducted a literature search between 1974 and up to 29 April 2024 using Ovid to search Medline and Embase databases. A ‘PICO’ (Population, Interventions, Control, and Outcomes) search strategy designed to construct parameters (Table 1) was adopted to identify all relevant articles.
PICO search strategy
[1] head or neck or cervical or thyroid or parotid or salivary or maxillofacial or ENT or otolaryngolog* or otorhinolaryngolog* or otolog* or rhinolog* or laryng*
[2] cancer or carcinoma or malignan* or metastas*
[3] ultrasound or US or USS or img* or sonograph* or radiolog* or radiograph* or guid* or local*
[4] wire
Parameters of our search used to identify the population of interest are shown above, each of which was formed of multiple keywords linked with the operator “OR”. These four parameters were then combined using the operator “AND” to create our final search criteria. The wildcard character “*” was used to account for multiple derivations of the intended keyword.
One author screened 796 articles by title relevance and then abstracts where necessary. Conference abstracts in absence of full texts were excluded as were studies not in the English language. References of selected studies were also evaluated for relevance and prior inclusion within our search criteria. The full text of the selected studies were then comprehensively reviewed for various criteria, demographics and characteristics, as shown in the results.
Case series
Between February 2021 and April 2024, over the course of 38 months, we performed and recorded 22 ultrasound-guided wire localisations on 20 unique patients with prior neck surgery or radiotherapy or a combination of the two. Mean patient age was 57 years (range 28–82 years) with 55 per cent male and 45 per cent female.
The steps to perform ultrasound-guided wire localisation are generally similar irrespective of the location of the procedure (within the imaging department/ultrasound suite or within the operating theatre) and what underlying pathology is suspected. A focused ultrasound of the target lesion is performed with the patient in the supine position, with comparison made to previous imaging if able, to confirm suitability and stability of the lesion. Note that subcutaneous local anaesthetic should be used for patients not already under a general anaesthetic within the operating theatre. Then, using an aseptic technique and under ultrasound guidance throughout, the needle/wire system is placed and confirmed at the lesion of interest before the wire is deployed by an appropriately trained consultant radiologist, or senior sonographer under the supervision of a radiologist. An added visual aid in the form of external skin markers can be included. Figure 1 shows a surgically excised lesion with wire still in-situ. If performed outside the operating theatre, the external wire can be carefully coiled and fixed to the skin by sterile dressing, which reduces risk of migration, before the patient is escorted to the operating theatre by a clinician. The appropriately selective neck dissection or other head and neck operation would then be performed by the ENT surgeons. Immediate complications following the ultrasound-guided wire localisation are recorded alongside all other relevant factors relating to the post-operative management.
Surgical-excised lesion, with barbed wire in situ, which was pre-operatively identified with ultrasound-guided wire localisation.
Results and analysis
Literature review
Our search identified 17 studies for inclusion with a combined total of 92 patients who underwent some form of ultrasound-guided wire localisation for head and neck masses. Of the 17 studies, the majority were single case reports (n = 8). The remainder of studies were divided among a retrospective cohort study (n = 1), case-control series (n = 1), and other case series (n = 7), the latter ranging 2–17 patients. The studies are shown in Table 2.
Summary of included studies from literature search
US = Ultrasound; LA = Local anaesthetic; GA = General anaesthetic; SCC = Squamous cell carcinoma; PTC = Papillary thyroid cancer; FC = Follicular carcinoma; EBV = Epstein-Barr virus.
Proof of concept (i.e. accurate localisation for surgical excision), the primary outcome, was achieved in all 92 cases from our literature review. Where specified, patient age was 10–81 years, which included four paediatric cases within a single case series (Table 2, study 5). From the included studies, 15 patients had an untreated neck compared to 70 who had previous neck surgery; two patients had prior radiotherapy in absence of surgery; the remaining five cases were unspecified. Ultrasound-guided wire localisation was utilised in all cases due to the non-palpable nature of a target head and neck mass. The procedure was performed outside of the operating theatre (within an ultrasound suite) in four studies, within the operating theatre in six studies, and was unspecified in a further seven. The modal average for needle size used in the hookwire procedure was 20-gauge, which was used in six studies. Thereafter, in order of decreasing frequency, needle sizes included 19-gauge (n = 3), 19.5-gauge (n = 2), 21-gauge (n = 2), and was unspecified in four studies. Only one complication was reported from the 17 studies: one case of small-volume bleeding from an anterior jugular vein, which was managed with gentle compression. No other immediate complications were reported that were presumed related to the ultrasound-guided wire localisation procedure, only related to the subsequent surgical procedure.
Case series
Our complete case series is summarised in Table 3. Five patients had ultrasound-guided wire localisation within the ultrasound suite and then transported to the operating theatre while the remaining 15 were performed under general anaesthesia within the operating theatre prior to the surgical procedure. Two minor post-ultrasound-guided wire localisation complications were reported. The first (patient 1) was a vasovagal syncope with rapid spontaneous recovery within the ultrasound suite, which did not further complicate the ultrasound-guided wire localisation procedure or surgery. The second, more technical complication was in a different patient (patient 15) with difficulty deploying the wire prompting a second pass, although this was all within the operating theatre under general anaesthesia, thus once more not altering the overall ultrasound-guided wire localisation technique. Two patients (patients 5 and 16) had two guidewires for separate lesions inserted at the same occasion. Final histology included a mix of benign and malignant pathology (Table 3).
our USGWL case series with histological and surgical outcomes and complications
EBER = Epstein-Barr virus; MDT = Multidisciplinary team; CEA = carcinoembryonic antigen.
Discussion
The current standard is to localise lymph nodes using a surgical skin marker, which lacks depth and spatial information. While this remains an option for palpable lesions and in untreated necks, we have seen how ultrasound-guided wire localisation in a previously treated neck is beneficial to each of the head and neck multidisciplinary team members. With the addition of our case series into the current literature, which is the largest in the UK to our knowledge, 112 patients with head and neck lesions and prior treatment have had ultrasound-guided wire localisation utilised successfully. The diversity of patients in whom it has been successfully performed is large, indicating that it can likely be considered for the relevant majority being discussed in the head and neck multidisciplinary meeting. However, appropriate targeted selection of patients to those who would gain the most benefit that this technique has to offer, given the additional workload to the imaging department, should be considered further for optimal resource management. At our own tertiary centre, we propose the protocol criteria for inclusion that is shown in Figure 2.
Proposed ultrasound-guided wire localisation (USGWL) patient inclusion criteria.
The choice of performing ultrasound-guided wire localisation in the imaging department or in the operating theatre should also be decided when designing a protocol for the regular practice of ultrasound-guided wire localisation. We have successfully performed cases in both environments. The imaging department provides optimal ultrasound conditions with a more familiar environment for those most likely to be performing ultrasound-guided wire localisation. However, coordination with the operating theatre staff is an organisational hurdle in our experience. Ultrasound-guided wire localisation within the operating theatre therefore removes this hurdle alongside reducing the risk of non-surgical retrieval of wire and risk of wire migration, in addition to allowing the procedure to be performed under general anaesthetic. The latter point would avoid the vasovagal complication encountered within our case series. Nevertheless, the operating theatre has its own pitfalls to consider including use of less-than-optimal portable equipment and lighting, extra general anaesthetic time, and requiring dedicated staff allocation to the operating theatre for the day. We envisage each department would have to make this choice of environment individually for their unit and patient, although authors of this study express a slight preference for the operating theatre with the patient first positioned in the intended operative position prior to ultrasound-guided wire localisation.
Despite few complications arising throughout all documented cases to date, theoretical risks do still exist, as explored within other specialty literature. These include vasovagal syncope, discomfort, bleeding/haematoma, wire migration (internal or external), fragmentation of the wire, infection, tumour-cell dissemination, and, depending on location, pneumothorax.Reference Bick, Trimboli, Athanasiou, Balleyguier, Baltzer and Bernathova18, Reference Carlino, Rinaldi, Giuliani, Rella, Bufi and Padovano19 Various strategies exist for reducing the risk of each, as previously mentioned and as already incorporated in our own ultrasound-guided wire localisation technique, including: (1) performing ultrasound-guided wire localisation under aseptic or sterile conditions with the patient supine, (2) ultrasound-guided wire localisation done only by operators trained to be able to use ultrasound guidance throughout the entirety of the procedure, and (3) securing the external wire component to the skin, especially if done outside the operating theatre when the patient requires ongoing transportation.
Minor bleeding likely can be managed conservatively and perhaps more easily within the operating theatre. We suggest avoiding the prospect of serious bleeding and pseudoaneurysm by very cautious selection of patients with lesions in closer proximity to larger vessels or with bleeding disorders. Neoplastic seeding is a rare complication within breast ultrasound-guided wire localisation that has disputed significance and alleged early detection.Reference Bick, Trimboli, Athanasiou, Balleyguier, Baltzer and Bernathova18 On a similar theme, in our own series, patient 3 was discussed within the multidisciplinary team about whether the extracapsular extension may be due to the ultrasound-guided wire localisation procedure, although consensus could not be reached. It may be advisable to send the specimen to pathology with the barbed-wire in situ (Figure 1), along with a warning of potential sharps injury to avoid false apparent extracapsular spread.
Our case series involved a wide variety of pathologies and therefore types of surgical operation with an expected wide range of operative timings. The view shared by the head and neck team, however, is that irrespective of this, ultrasound-guided wire localisation reduces the overall operative time and stress. This is particularly true in cases where nodes are found in otherwise difficult-to-reach places, for example behind the carotid sheath, or where few abnormal lymph nodes are identified amongst a cluster of sonographically normal lymph nodes, and most helpful in nodes embedded within scar tissue, with ultrasound-guided wire localisation pivotal in providing a target and direction to the operating surgeon.
Figure 3 demonstrates how recurrence of disease seen on fluoro-deoxy-glucose positron emission tomography–computed tomography (FDG PET–CT) is ever so subtle on ultrasound and without the addition of wire-localisation may be incredibly difficult to identify intra-operatively. Moreover, the confidence that comes with this technique translates to later confidence in histopathology results, particularly where benignity is shown. In none of our 20 cases was a repeat or redo operation necessary. Surgical outcomes appear to be acceptable and comparable to outcomes without ultrasound-guided wire localisation, given no structures were damaged intra-operatively secondary to ultrasound-guided wire localisation, despite the close proximity to important structures commented on in some cases (although one patient did experience weakness of the marginal mandibular nerve post-operatively that was related to the operation and not to the ultrasound-guided wire localisation). Statistical analysis about non-inferiority, however, was not performed and was beyond the scope of our heterogeneous series.
Fluoro-deoxy-glucose positron emission tomography–computed tomography (FDG PET–CT) (left) and ultrasound images pre- (top right) and post- (bottom right) ultrasound-guided wire localisation insertion demonstrating an example of the subtlety of recurrent disease in patient 16.
Localisation alternatives to ultrasound-guided wire localisation within breast cancer care include, but are not limited to, ultrasound-guided surgery with surgeons competent at using a hand-held probe intra-operatively, carbon marking with injection of powdered sterile charcoal, methylene-blue injection, radioguided occult-lesion localisation with pre-operative injection of a radioactive tracer and intra-operative gamma ray detection probe, and other novel radiolabeled injectable tissue markers.Reference Carlino, Rinaldi, Giuliani, Rella, Bufi and Padovano19–Reference Schaarup-Jensen, Jensen, Hansen, El Ali, Hammershøj and Jølck22 Additional techniques used specifically within the head and neck include computed tomography- (CT-) guided and magnetic resonance imaging- (MRI-) guided wire localisation, however, cases appear to be even fewer than ultrasound-guided wire localisation.Reference Hoang, De Jesus, Eastwood, Gafton and Witsell23, Reference Thompson, Gorny, Jondal, Rech, Mardini and Woodrum24
It is beyond the scope of this study to compare the above techniques and to our knowledge they are not commonplace, if used at all, within the head and neck. We also propose that none of the above techniques is as safe and low cost a method as ultrasound-guided wire localisation for cervical masses, as their use involves radioactivity or significant time training to be implemented into protocol. Moreover, ultrasound is highly flexible, adaptable and extrapolatable. For example, ultrasound-guided wire localisation also has been used successfully intra-orally.Reference Tahim, Aludden, Jawad and Sadiq25 We therefore hope that more imaging and ENT departments can see the utility and effectiveness of ultrasound-guided wire localisation, particularly with non-palpable lesions, and begin adapting it into local protocol for wider use and thus benefiting patients.
• Ultrasound-guided wire localisation of lymph nodes has been proven in breast radiology but is not commonly used in the head and neck
• A literature search revealed 17 studies with 92 patients combined undergoing ultrasound-guided wire localisation in the head and neck with minimal complications
• We present the largest case series of ultrasound-guided wire localisation known to us from the UK, featuring 20 patients with apparent non-palpable cervical lymphadenopathy
• Ultrasound-guided wire localisation appears to be an effective, safe and low-cost technique to aid the head and neck team with minimal observed complications
• Ultrasound-guided wire localisation is a flexible and simple technique, although consideration should be given to patient selection for optimal resource management
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Author contributions
BJS: Performed search, analysed data, wrote the paper. RH: Analysed data; reviewed and revised manuscript. TM: Integral in study concept and execution; reviewed manuscript. RC: Integral in study concept and execution; reviewed manuscript. RW: Study concept and execution. AH: Study concept and execution. PC: Conceptualised and designed study; reviewed and revised manuscript.
