Ultrasound of malignant cervical lymph nodes

Tumor markers in fine-needle aspiration washout for cervical lymphadenopathy in patients with known malignancy: preliminary study

OBJECTIVE

The purposes of our study were to assess whether tumor marker concentration in fine-needle aspiration (FNA) washout from cervical lymph nodes (LNs) differs between metastatic and nonmetastatic LNs and whether tumor marker concentrations in FNA washout can contribute to the diagnosis of metastatic LNs.

SUBJECTS AND METHODS

Ultrasound-guided FNA was performed for 157 neck nodes in 157 patients, including 136 patients with known malignancy (28 breast, 34 lung, 41 head and neck, seven esophagus, nine cervix, 10 gastrointestinal [GI] tract, and seven ovary cancers) and 21 patients without known malignancy (control group). Immediately after an FNA cytology specimen was obtained, the needle was rinsed with 1 mL of normal saline solution, and variable tumor marker concentrations were measured in the washout: carcinoembryonic antigen (CEA) and cancer antigen (CA) 15-3 for breast; CEA and cytokeratin 19 fragment for lung; squamous cell antigen for head and neck, esophagus, and cervix; CEA and CA 19-9 for GI; CA 125 for ovarian cancer; and all the tumor marker concentrations for the control group. The tumor marker concentration was compared between the metastatic and nonmetastatic LNs in the control group and between the metastatic and nonmetastatic LNs in the known malignancy group, according to the known malignancy.

RESULTS

At final diagnosis, 104 LNs were metastatic and 53 were nonmetastatic (including 21 LNs in the control group). The tumor marker concentrations of cases with negative or nondiagnostic cytologic results were evaluated. The sensitivity of FNA cytology alone was compared with the combined sensitivity of FNA cytology and tumor marker concentration. Metastatic LNs had higher corresponding FNA tumor marker concentrations than did nonmetastatic LNs in both the control and known malignancy groups (p < 0.05), except for CA 19-9 in GI cancer. Eight of 10 cases (80%) with negative or nondiagnostic cytologic results but metastatic LNs at final diagnosis showed elevated tumor marker concentrations. The sensitivity of FNA cytology (90.4%) increased to 98.1% when combined with tumor marker concentration (p < 0.05). Tumor marker concentrations in FNA washout with cervical metastatic LNs were elevated in comparison with those of nonmetastatic LNs.

CONCLUSION

Evaluation of tumor marker concentrations in FNA washout could improve the detection of metastatic LNs in patients with known malignancy.

The reliability of high resolution ultrasound in the identification of pus collections in head and neck swellings

Head and neck swellings often present to oral and maxillofacial surgeons. It is often unclear whether a collection of pus is present. This information is essential for decisions regarding surgical intervention. Although ultrasound scanning (USS) is widely used to investigate the presence of a collection, the reliability and validity of this investigation in this context is uncertain. A retrospective review of 4000 consecutive head and neck USS reports over a 4 year period in the Cardiff University Health Board produced 43 cases in which ultrasound had been used to look for evidence of pus collection. The management and treatment outcome of these patients were reviewed and the data analysed. 36 of 43 patients had their swelling incised in theatre, and in 92% of these cases USS and clinical findings corresponded. Of the seven not taken to theatre, four were USS negative and three USS positive; in all seven cases the swelling resolved with antimicrobial therapy. Sensitivity and specificity of USS imaging to identify pus collection were very high, 96% and 82%, respectively. The evidence in this study indicates that USS is a very reliable diagnostic tool in the diagnosis of a collection as well as providing evidence that small collections of pus can resolve without surgical drainage.

Assessment of glottic squamous cell carcinoma: comparison of sonography and non-contrast-enhanced magnetic resonance imaging

OBJECTIVES

The purpose of this study was to compare the use of sonography and non-contrast-enhanced magnetic resonance imaging (MRI) for detection and staging of glottic carcinoma.

METHODS

In this study, 30 consecutive patients with glottic squamous cell carcinoma underwent high-frequency sonography and non-contrast-enhanced MRI before surgical treatment. Tumor detectability and imaging findings were evaluated independently and then compared with the surgical and postoperative pathologic findings.

RESULTS

Sonography showed a trend toward higher detectability than MRI in early (stage T1 and T2) glottic carcinoma (94.1% [16 of 17 patients] for sonography versus 76.5% [13 of 17 patients] for MRI; P = .335). With regard to T staging, the overall accuracy rates were 80.0% (24 of 30) for sonography and 76.7% (23 of 30) for MRI; the difference was not statistically significant (P > .99). Non-contrast-enhanced MRI was superior to sonography in showing tumor involvement in the retrolaryngeal extent of glottic carcinoma.

CONCLUSIONS

Sonography is suggested as a noninvasive complementary modality for detection and initial staging of glottic carcinoma.

Optical differentiation between malignant and benign lymphadenopathy by grey scale texture analysis of endobronchial ultrasound convex probe images

BACKGROUND

Morphologic and sonographic features of endobronchial ultrasound (EBUS) convex probe images are helpful in predicting metastatic lymph nodes. Grey scale texture analysis is a well-established methodology that has been applied to ultrasound images in other fields of medicine. The aim of this study was to determine if this methodology could differentiate between benign and malignant lymphadenopathy of EBUS images.

METHODS

Lymph nodes from digital images of EBUS procedures were manually mapped to obtain a region of interest and were analyzed in a prediction set. The regions of interest were analyzed for the following grey scale texture features in MATLAB (version 7.8.0.347 [R2009a]): mean pixel value, difference between maximal and minimal pixel value, SEM pixel value, entropy, correlation, energy, and homogeneity. Significant grey scale texture features were used to assess a validation set compared with fluoro-D-glucose (FDG)-PET-CT scan findings where available.

RESULTS

Fifty-two malignant nodes and 48 benign nodes were in the prediction set. Malignant nodes had a greater difference in the maximal and minimal pixel values, SEM pixel value, entropy, and correlation, and a lower energy (P < .0001 for all values). Fifty-one lymph nodes were in the validation set; 44 of 51 (86.3%) were classified correctly. Eighteen of these lymph nodes also had FDG-PET-CT scan assessment, which correctly classified 14 of 18 nodes (77.8%), compared with grey scale texture analysis, which correctly classified 16 of 18 nodes (88.9%).

CONCLUSIONS

Grey scale texture analysis of EBUS convex probe images can be used to differentiate malignant and benign lymphadenopathy. Preliminary results are comparable to FDG-PET-CT scan.

Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer

BACKGROUND AND PURPOSE

Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer.

MATERIALS AND METHODS

This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome.

RESULTS

Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence.

CONCLUSIONS

In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

Contrast-enhanced ultrasound imaging of sentinel lymph nodes after peritumoral administration of Sonazoid in a melanoma tumor animal model

OBJECTIVES

The purpose of this study was to compare lymphosonography (ie, contrast-enhanced ultrasound imaging [US] after interstitial injection of a US contrast agent) for the detection of sentinel lymph nodes (SLNs) in swine with naturally occurring melanoma tumors to lymphoscintigraphy using blue dye-guided surgical dissection as the reference standard. Also, we sought to determine if lymphosonography can be used to characterize SLNs.

METHODS

Sixty-three swine with 104 melanomas were evaluated. Contrast-specific US was performed after peritumoral injection (1 mL dose) of Sonazoid (GE Healthcare, Oslo, Norway). Lymphoscintigraphy was performed after peritumoral injections of technetium Tc 99m sulfur colloid. Peritumoral injection of 1% Lymphazurin (Ben Venue Labs, Inc, Bedford, OH) was used to guide SLN resection. The accuracy of SLN detection with the two imaging modalities was compared using the McNemar test. The SLNs were qualitatively and quantitatively characterized as benign or malignant based on the lymphosonography results with histopathology and RNA analyses used as the reference standards.

RESULTS

Blue dye-guided surgery identified 351 SLNs. Lymphosonography detected 293 SLNs and 11 false-positives, while lymphoscintigraphy detected 231 SLNs and 20 false-positives. The accuracy of SLN detection was 81.8% for lymphosonography, which was significantly higher than the 63.2% achieved with lymphoscintigraphy (P < .0001). The accuracy of lymphosonography for SLN characterization was 80%. When the size of the enhanced SLN was taken into consideration to characterize SLNs, the accuracy was 86%.

CONCLUSIONS

Lymphosonography is statistically better than lymphoscintigraphy for the detection of SLNs in this animal model. The ability to use lymphosonography as a means to characterize SLNs as benign or malignant is limited.

[Sonographic differential diagnosis of cervical masses]

One of the main indications for the use of ultrasound by the head and neck specialist is the diagnosis of cervical masses. The examination can be easily performed since all structures of interest are located superficially and are not covered by boney or air-filled structures. Further advantages of ultrasound in contrast to other imaging techniques such as MRI or CT include its high resolution and lack of side effects. Even structures of <5 mm in diameter can be interpreted well. Since ultrasound is fast, has no side effects and can be performed as often as necessary, it represents an excellent diagnostic instrument in the follow-up of patients with head and neck cancer. In addition to the conventional B-scan technique, colour duplex sonography is also often performed today to obtain additional information on the nature of cervical masses. Thus, different entities of cervical lymph nodes can be well differentiated by their pattern of vascularization.

Diffusion-weighted MRI in head and neck cancer

PURPOSE OF REVIEW

Diffusion-weighted MRI (DWI) is a noninvasive imaging technique allowing some degree of tissue characterization by showing and quantifying molecular diffusion. Cell size, density and integrity influence the signal intensity seen on diffusion-weighted images. A number of recent reports suggest that this technique may have interesting applications in the evaluation of head and neck cancer, by distinguishing tumoural from nontumoural tissue.

RECENT FINDINGS

In squamous cell cancer, DWI appears helpful in staging neck nodal disease and in distinguishing radiotherapy-induced tissue changes from persistent or recurrent cancer. DWI may also have prognostic value before and during radiotherapy of head and neck cancer. The technique may also be useful in characterizing thyroid nodules and salivary gland neoplasms.

SUMMARY

Early evidence suggests that DWI may become a useful tool, complementary to existing imaging techniques, in the evaluation of head and neck malignancies. Further technical improvements and clinical validation are needed.

Imaging as a surveillance tool in rectal cancer

Despite advances in diagnosis and treatment, half of patients with treated rectal cancer will die owing to recurrent disease. There is no evidence of benefit on survival from an intensive surveillance program, even if presymptomatic recurrent disease is detected. The aim of this article is to review the results described for the different imaging techniques in diagnosing rectal cancer recurrence in different sites and to discuss their relative clinical impact. The sensitivity of imaging techniques is related to the performance of the machines and the site being examined. Computed tomography is the most used technique owing to its availability, speed, panoramic images and ease of use, while MRI of the pelvis and the liver produces the highest resolution, sensitivity and specificity in these anatomical areas. Owing to its high cost, [(18)F] fluorodeoxyglucose-PET should be used as a third-level examination, a 'problem-solving' method when the site of recurrence is unknown or to rule out other possible sites of recurrence before a second surgery, and, finally, because it offers the possibility to investigate the whole body. The follow-up must be designed for individual patients, taking into account a number of factors. In the near future, whole-body imaging, probably by MRI, that is free from radiation will become the method of choice for screening for recurrent disease.

An update on the use of ultrasound imaging in oral and maxillofacial surgery

Ultrasound is a relatively inexpensive, non-invasive, and readily available technique that is well tolerated by patients. It is particularly useful in the examination of superficial structures where the use of a high frequency linear probe (7.5-12 MHz) produces high definition multi-planar images. The spatial resolution achieved is superior to other methods of cross-sectional imaging and, when combined with tissue biopsying techniques such as fine needle aspiration cytology (FNAC) or core biopsy samples, it is rendered a highly specific diagnostic tool. This article provides an overview of the use of ultrasound for common head and neck conditions, including its use in salivary gland disease, and for the assessment of cervical lymphadenopathy.

Role of diagnostic imaging to malignant sinus tumors in presurgical staging

The aim of this study is to describe the current role of imaging in pre-surgical planning, reporting 25 cases of paranasal sinus tumors examined in our Institute. Between June 2006 and May 2008, we identified 25 patients with malignant tumors of the paranasal sinuses. All of the patients were evaluated with CT and/or MR exams. US were used to assess regional lymph node involvement. When necessary CT-PET scanning using FDG, was done. Diagnostic imaging is essential during the initial work-up of a patient suspected of having a paranasal sinus tumor. The role of imaging is to define the tumor extension, nodal involvement, metastases and recurrences in the postoperative patient. CT and MR imaging are the primary modalities employed; each have advantages and disadvantages but tend to be complementary. The involvement of fine bone structures is best evaluated with CT. In assessing the extent of the tumor, MR provides excellent soft tissue detail, allowing for delineation of neoplasm from surrounding inflammatory tissue and secretions. For evaluation of lymph node enlargement color-Doppler US, CT and MR provide morphologic data, while CT-PET provides metabolic data. CT-PET can be used to stage nodal and metastatic disease and for assessing the efficacy of therapy or recurrent disease.