Objective: Head and neck sarcomas are rare and diverse tumors, which less has been studied. Choosing a precise biopsy technique is of paramount importance to prevent unnecessary resection and morbidity for the patient. In this study, the aim is to assess the accuracy of two common techniques in dignity, histology, subtyping, and grading.

Methods: In this retrospective study, patients discussed in Head and Neck MDT meetings between 2018 and April 2024 have been reviewed. Inclusion

criteria were patients with an available diagnostic histopathology report as well as an available final histopathology report after surgical resection.

Results: Ninety patients were included in the study. The accuracy of open biopsy in determining tumor dignity, histology, and subtyping were 95%, 90%, and 85%, respectively, which did not show a statistically significant difference with core needle biopsy with 86% accuracy in tumor dignity, 76 % in tumor histology and 76% in subtyping. However, the open biopsy was significantly superior to the core needle biopsy in terms of tumor grading (87% versus 62%). No significant difference between soft tissue and bone sarcoma was detected in diagnostic biopsy accuracy.

Conclusion: Core needle biopsy is an accurate and safe option for the diagnosis of sarcoma tumors in the head and neck area. A larger sample size is recommended for future studies.

• Sarcoma
• Head and Neck
• Core needle biopsy

Sadeghian G, Sinha D (2024) Comparative Accuracy of Core-Needle and Open Biopsy in Diagnosis, Subtyping, and Grading of Head and Neck Sarcomas. Ann Clin Pathol 11(1): 1170.

According to epidemiologic studies, sarcoma affects less than 1% of solid tumor malignancies in adult [1]. There are various known subtypes of sarcoma, but all its subtypes are not yet fully known and studied. This variety and rarity have made it challenging to study this group of tumors. This is even more difficult when it comes to head and neck sarcomas as it counts for only 1% of all head and neck malignancies and 5% of the total sarcoma population [2], among which 80% originates from soft tissue and 20% from bones. Accordingly, very few studies have been done regarding head and neck sarcomas, and very few centers in the world are dedicated to head and neck sarcomas.

On the other hand, early diagnosis of head and neck cancers is of paramount importance. This is not only because it increases survival but also reduces the massive morbidity that surgical resection of cancers in this area may have on the patients. For example, surgical treatments such as total laryngectomy, glossectomy, and orbital exenteration could have a considerable impact on a patient’s lifestyle, communication, feeding, self- confidence, as well as facial aesthetic issues.

Routinely, there are a couple of investigations that can be used to diagnose a sarcoma lesion, including open biopsies (OB), involving incisional and excisional biopsy, and needle biopsy which can be done with or without the guidance of ultrasound, by fine or core needles.

According to different studies [3], needle biopsy has been introduced as a reliable, safe, and accurate diagnostic test for soft tissues. On the other hand, using open biopsy in sarcomas despite having more accuracy, comes with more complications as it is a more invasive investigation. In another study, the complications of open biopsy have been reported in 18.2 % of cases which even resulted in an unnecessary amputation in some cases [4]. Although all these studies have investigated tumors located in extremities, this issue may be even more concerning in the head and neck areas as an open biopsy could cause more morbidity and aesthetic issues for the patients.

The difference between core needle biopsy and open biopsy has been assessed in other studies for other types of cancers [5] such as lymphoma, carcinoma, and melanoma, in which the accuracy of core needle biopsy has been reported up to 90% [6].

This accuracy is not all about the diagnosis of sarcoma, but about reporting an accurate subtype and grade. Also, the difference between soft tissue sarcoma (STS) and bone sarcoma (BS) should not be underestimated. In terms of precision in sarcoma subtyping in diagnostic needle biopsies, it has been reported [7] as easier in BS than STS; however, in STS, although subtyping was not correct all the time, it didn’t change the treatment strategies eventually. This superiority in bone sarcoma diagnosis has been shown in other studies as well although it was not statistically significant [8].

Overall, the accuracy of the core needle biopsy in terms of entity, subtype, and grade of tumor, ranging between 80 to 90 percent in studies [9-11], has been reported as sometimes inferior and sometimes superior to open biopsy although this was not statistically significant most of the time [12-14].

The other point that has been addressed in the studies and should not be disregarded, is the risk of local recurrence especially in needle biopsy. In a study, this has been investigated in soft tissue sarcoma cases who underwent needle biopsy. As a result, no significant difference was reported between needle and open biopsy in terms of local recurrence [15].

In one of the few studies on the role of diagnostic strategies in head and neck sarcomas, fine needle biopsy compared (FNAC) with core needle biopsy (CNB). The accuracy of FNAC and CNB in the dignity of sarcoma (benign versus malignant) was 76 % and 92%, retrospectively [16]. As a result, performing a core needle biopsy is more favorable than a fine needle biopsy in the diagnosis of sarcoma.

Overall, the accuracy of the mentioned types of procedures is one of the key factors when it comes to choosing the best diagnostic procedure for a patient. Especially in head and neck sarcomas the accuracy has not much been studied and compared. In this study, the aim is to assess the accuracy of different diagnostic biopsy approaches by comparing them with the histopathology report after surgical resection. Furthermore, a comparison has been made between bone and soft tissue sarcomas. This study has been done on the cases referred to head and neck sarcoma (HNS) multidisciplinary team (MDT) in the main head and neck sarcoma center in the UK [17].

In this retrospective cohort study, all patients discussed in Head and Neck Sarcoma MDT meetings between 2018 and April 2024 have been reviewed. Patients with an available diagnostic and post-resection histopathology report were included in the study. Patients who did not undergo surgical resection as the first treatment approach and were chosen to receive palliative care or to receive chemoradiotherapy before surgical resection (neoadjuvant treatment) were excluded from the study. Patients who did not receive the treatment in our service were not included in the study. Finally, patients who underwent surgical resection, but no residual malignancy found on the resected tissue were excluded from the study.

Histopathology report details, anatomical sites, and MDT recommendations were obtained from the electronic health record system (Epic) and analyzed accordingly using Microsoft Excel.

Ninety patients were included in the study, out of the total number of 338 cases discussed in head and neck sarcoma MDT between 2018 and April 2024. Overall, a total number of 51 and 39 cases were diagnosed with soft tissue sarcoma (STS) and bone sarcoma (BS), respectively.

Tumor locations were most common in the maxilla, mandible, and neck. Table 1 summarizes the locations and pathologies of sarcoma lesions.

Table 1: Sites and types of sarcomas. Other types of sarcomas mainly include synovial sarcoma, adenosarcoma, angiosarcoma, derma-based sarcomas, alveolar soft part sarcoma, and ultra rare soft tissue sarcomas.

As shown in Table 3, 61 cases underwent open biopsy for diagnosis, in 58 cases the malignancy has been correctly identified. In 55 cases sarcoma histology has been correctly determined. In 52 cases, the subtype was matched with the final histopathology report after resection. This was 53 cases in the grading report.

In contrast, 29 cases underwent core needle biopsy for diagnosis, in 25 cases the malignancy has been correctly identified. In 22 cases sarcoma histology has been correctly determined. In 22 cases, the subtype was matched with the final histopathology report after resection. This was 22 cases in the grading report.

The P values of the differences between CNB and OB have been demonstrated in Table 3. The only statistically significant difference was between core needle biopsy and open biopsy in the grading of tumors (P-value 0.007).

Table 3: P values of the difference between needle biopsy and open biopsy.

Table 2 demonstrates the diagnostic biopsy accuracy in bone sarcoma (BS) and soft tissue sarcomas (STS) separately. Thirty- nine patients were diagnosed with bone sarcoma, 55% of which were osteosarcoma. Fifty-one patients were diagnosed with soft tissue sarcoma, 37 % of which were undifferentiated sarcomas.

Generally, in both CNB and OB, STS has shown slightly more precise results, but this was not statistically significant (P-value >0.05).

Table 2: Concordance of diagnostic histopathology report with final histopathology report after resection

In open biopsy, the accuracy in determining tumor dignity (benign versus malignant), and in identifying the histology (sarcoma versus non-sarcoma) were 95% and 90% respectively. In 85% of cases, the subtype was matched with the final histopathology report after resection. This was 87% in the grading report.

In contrast, in core needle biopsy, determining the tumor dignity and histology were correct in 86% and 76% of cases, respectively. In 76% of cases, the subtype was matched with the final histopathology report after resection. This was 62% in the grading report. The accuracy of core needle biopsy is approximately the same as other studies in extremities sarcoma.

Although the accuracy in open biopsy was superior to needle biopsy, the difference between these two types of biopsy strategy was not statistically significant apart from grading, which was significantly better in open biopsy. Despite this superiority, open biopsy is less recommended as a first approach due to being more invasive, especially in the head and neck area with vital structures. Besides, subtyping may not change the treatment approach significantly as the main decision will be based on the size, location, grading, nodal disease, and distant metastases [18,19]. Also, the decision for post-operative chemoradiotherapy can be made based on the final histopathology report and is not reliant on diagnostic biopsy results.

Another point that should be considered is the number of core biopsies sent to the lab. Although the greater number of cores increases the size of tissue, according to the studies this will not affect the accuracy [6]. However, it has been advised that needle biopsies should be done by an expert radiologist for a suitable outcome [9]. The sufficiency of the sample is very important as it may be used for research purposes and other molecular analyses. Nowadays, genomic analyses are being widely used for sarcoma diagnosis and prognosis estimation. Accordingly, the sample needs to be of good quality and sufficient, which can be warranted by utilizing an ultrasound [20].

Seeding of tumor cells during biopsy is another point that has been debated and studied. As per studies, to reduce the chance of tumor seeding, the tract of biopsy should be resected during operation or be included in the radiotherapy target [3].

The other factor that may affect the assessment regardless of the biopsy technique is the histopathology analyses of the tissue. A second opinion from a regional or national expert is recommended in sarcoma diagnosis. It has been shown in a study that more than 40% of the first histological diagnoses of sarcoma cases have been modified in the second reading, which can affect the treatment [21]. In this study, all samples have been sent through a second opinion. It is necessary to provide comprehensive information to the histopathologist such as the size, duration, growth rate, and risk factors to help with the accurate diagnosis.

Lastly, the difference between bone sarcoma and soft tissue sarcoma in diagnostic biopsy was not significant although the results in STS were generally superior to bone sarcoma.

Our limitation in this study was the small sample size despite initially a large number of patients who were discussed in head and neck MDT were reviewed. This was mainly because, for a large number of patients, it was decided to go for palliative or non-surgical treatments. For a more precise assessment and statistically significant results, a larger size of study is necessary. We aim to repeat this study in the next few years with more sample sizes.

In conclusion, core needle biopsy under the guidance of ultrasound if sufficient tissue is taken to be enough for analyses, can be the first choice of investigation for head and neck suspected sarcoma lesions.

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