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Xie H, Huang W, Li S, Huang M, Luo C, Li S, Cui C, Ma H, Li H, Liu L, Wang X, Fu G. Radiomics-based lymph nodes prognostic models from three MRI regions in nasopharyngeal carcinoma. Heliyon 2024; 10:e31557. [PMID: 38803981 PMCID: PMC11128517 DOI: 10.1016/j.heliyon.2024.e31557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024] Open
Abstract
Accurate prediction of the prognosis of nasopharyngeal carcinoma (NPC) is important for treatment. Lymph nodes metastasis is an important predictor for distant failure and regional recurrence in patients with NPC. Traditionally, subjective radiological evaluation increases concerns regarding the accuracy and consistency of predictions. Radiomics is an objective and quantitative evaluation algorithm for medical images. This retrospective analysis was conducted based on the data of 729 patients newly diagnosed with NPC without distant metastases to evaluate the performance of radiomics pretreatment using magnetic resonance imaging (MRI)-determined metastatic lymph nodes models to predict NPC prognosis with three delineation methods. Radiomics features were extracted from all lymph nodes (ALN), largest lymph node (LLN), and largest slice of the largest lymph node (LSLN) to generate three radiomics signatures. The radiomics signatures, clinical model, and radiomics-clinic merged models were developed in training cohort for predicting overall survival (OS). The results showed that LSLN signature with clinical factors predicted OS with high accuracy and robustness using pretreatment MR-determined metastatic lymph nodes (C-index [95 % confidence interval]: 0.762[0.760-0.763]), providing a new tool for treatment planning in NPC.
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Affiliation(s)
- Hui Xie
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wenjie Huang
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shaolong Li
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Manqian Huang
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chao Luo
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shuqi Li
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chunyan Cui
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huali Ma
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Haojiang Li
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lizhi Liu
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaoyi Wang
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, China
| | - Gui Fu
- Department of Radiology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
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Mair M, Singhavi H, Pai A, Khan M, Conboy P, Olaleye O, Salha R, Ameerally P, Vaidhyanath R, Chaturvedi P. A Systematic Review and Meta-Analysis of 29 Studies Predicting Diagnostic Accuracy of CT, MRI, PET, and USG in Detecting Extracapsular Spread in Head and Neck Cancers. Cancers (Basel) 2024; 16:1457. [PMID: 38672539 PMCID: PMC11047869 DOI: 10.3390/cancers16081457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/27/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Extracapsular spread (ECS) is the extension of cancer cells beyond the lymph node capsule and is a significant prognostic factor in head and neck cancers. This meta-analysis compared the diagnostic accuracy of CT, MRI, PET, and USG in detecting ECS in head and neck cancers. METHODOLOGY The authors conducted a systematic review and meta-analysis of studies that compared the diagnostic accuracy of CT, MRI, PET, and USG in detecting ECS in head and neck cancers. They included studies that were published between 1990 and December 2023 and that used histopathology as the reference standard for ECS. RESULTS The pooled sensitivity and specificity of CT scan were 0.63 (95% CI = 0.53-0.73) and 0.85 (95% CI = 0.74-0.91), respectively. The pooled sensitivity and specificity of MRI were 0.83 (95% CI = 0.71-0.90) and 0.85 (95% CI = 0.73-0.92), respectively. The pooled sensitivity and specificity of PET were 0.80 (95% CI = 0.74-0.85) and 0.93 (95% CI = 0.92-0.94), respectively. The pooled sensitivity and specificity of USG were 0.80 (95% CI = 0.68-0.88) and 0.84 (95% CI = 0.74-0.91), respectively. MRI had significantly higher sensitivity than CT scan (p-0.05). The specificity of CT and MRI was not significantly different (p-0.99). PET scan had the highest specificity among all imaging modalities. CONCLUSION MRI is the most accurate imaging modality for detecting ECS in head and neck cancers. CT scan is a reasonable alternative, but PET scan may be considered when high specificity is required. USG may not add any further benefit in detecting ECS.
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Affiliation(s)
- Manish Mair
- Head and Neck Surgery, University Hospital of Leicester, Leicester LE1 5WW, UK
| | | | - Ameya Pai
- Tata Memorial Hospital, Mumbai 400012, India; (A.P.); (P.C.)
| | - Mariya Khan
- Fortis Hospital, Mumbai 400016, India; (H.S.); (M.K.)
| | - Peter Conboy
- Head and Neck Surgery, University Hospital of Leicester, Leicester LE1 5WW, UK
| | - Oladejo Olaleye
- Head and Neck Surgery, University Hospital of Leicester, Leicester LE1 5WW, UK
| | - Rami Salha
- Head and Neck Surgery, University Hospital of Northampton, Northampton NN1 5BD, UK (P.A.)
| | - Phil Ameerally
- Head and Neck Surgery, University Hospital of Northampton, Northampton NN1 5BD, UK (P.A.)
| | - Ram Vaidhyanath
- Radiology Department, University Hospital of Leicester, Leicester LE1 5WW, UK
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Jang S, Lee S, Chung JH, Lee KW, Lee KH. Radiologic Extranodal Extension of Metastatic Lymph Nodes in Patients With Non-Small Cell Lung Cancer: Prognostic Utility and Diagnostic Performance. AJR Am J Roentgenol 2023; 221:471-484. [PMID: 37255045 DOI: 10.2214/ajr.23.29285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND. Pathologic extranodal extension (ENE) in metastatic lymph nodes (LNs) has been associated with unfavorable prognosis in patients with non-small cell lung cancer (NSCLC). OBJECTIVE. The purpose of this article was to evaluate the prognostic utility of radiologic ENE and its diagnostic performance in predicting pathologic ENE in patients with NSCLC. METHODS. This retrospective study included 382 patients (mean age, 67 ± 10 [SD] years; 297 men, 85 women) diagnosed with NSCLC and clinical N1 or N2 disease between January 2010 and December 2016. Two thoracic radiologists reviewed staging chest CT examinations to record subjective overall impression for radiologic ENE (no ENE, possible/probable ENE, or unambiguous ENE), reviewing 30 examinations in consensus and the remaining examinations independently. Kaplan-Meier survival analysis and multivariable Cox proportional hazards model were used to evaluate the utility of radiologic ENE in predicting overall survival (OS). Prognostic utility of radiologic ENE was also assessed in patients with clinical N2a disease. In patients who underwent surgery, sensitivity and specificity were determined of radiologic unambiguous ENE in predicting pathologic ENE. RESULTS. The 5-year OS rates for no ENE, possible/probable ENE, and unambiguous ENE were 44.4%, 39.1%, and 20.9% for reader 1 and 45.7%, 36.6%, and 25.6% for reader 2, respectively. Unambiguous ENE was an independent prognostic factor for worse OS (reader 1: adjusted HR, 1.72, p = .008; reader 2: adjusted HR, 1.56, p = .03), whereas possible/probable ENE was not (reader 1: adjusted HR, 1.18, p = .33; reader 2: adjusted HR, 1.21, p = .25). In patients with clinical N2a disease, 5-year OS rate in patients with versus without unambiguous ENE for reader 1 was 22.2% versus 40.6% (p = .59) and for reader 2 was 27.6% versus 41.0% (p = .49). In 203 patients who underwent surgery (66 with pathologic ENE), sensitivity and specificity of radiologic unambiguous ENE for predicting pathologic ENE were 11% and 93% for reader 1 and 23% and 87% for reader 2. CONCLUSION. Radiologic unambiguous ENE was an independent predictor of worse OS in patients with NSCLC. The finding had low sensitivity but high specificity for pathologic ENE. CLINICAL IMPACT. Radiologic ENE may have a role in NSCLC staging workup and treatment selection.
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Affiliation(s)
- Sowon Jang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seungjae Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Jin-Haeng Chung
- Department of Pathology and Translational Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyung Won Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyung Hee Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea
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Henson CE, Abou-Foul AK, Morton DJ, McDowell L, Baliga S, Bates J, Lee A, Bonomo P, Szturz P, Nankivell P, Huang SH, Lydiatt WM, O’Sullivan B, Mehanna H. Diagnostic challenges and prognostic implications of extranodal extension in head and neck cancer: a state of the art review and gap analysis. Front Oncol 2023; 13:1263347. [PMID: 37799466 PMCID: PMC10548228 DOI: 10.3389/fonc.2023.1263347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Extranodal extension (ENE) is a pattern of cancer growth from within the lymph node (LN) outward into perinodal tissues, critically defined by disruption and penetration of the tumor through the entire thickness of the LN capsule. The presence of ENE is often associated with an aggressive cancer phenotype in various malignancies including head and neck squamous cell carcinoma (HNSCC). In HNSCC, ENE is associated with increased risk of distant metastasis and lower rates of locoregional control. ENE detected on histopathology (pathologic ENE; pENE) is now incorporated as a risk-stratification factor in human papillomavirus (HPV)-negative HNSCC in the eighth edition of the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) TNM classification. Although ENE was first described almost a century ago, several issues remain unresolved, including lack of consensus on definitions, terminology, and widely accepted assessment criteria and grading systems for both pENE and ENE detected on radiological imaging (imaging-detected ENE; iENE). Moreover, there is conflicting data on the prognostic significance of iENE and pENE, particularly in the context of HPV-associated HNSCC. Herein, we review the existing literature on ENE in HNSCC, highlighting areas of controversy and identifying critical gaps requiring concerted research efforts.
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Affiliation(s)
- Christina E. Henson
- Department of Radiation Oncology and Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Ahmad K. Abou-Foul
- Institute of Head and Neck Studies and Education, School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Daniel J. Morton
- Department of Pediatrics and Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Lachlan McDowell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Sujith Baliga
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - James Bates
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Anna Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Pierluigi Bonomo
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Petr Szturz
- Department of Oncology, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland
| | - Paul Nankivell
- Institute of Head and Neck Studies and Education, School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - William M. Lydiatt
- Department of Surgery, Creighton University, and Nebraska Methodist Health System, Omaha, NE, United States
| | - Brian O’Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education, School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
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Mahajan A, Chand A, Agarwal U, Patil V, Vaish R, Noronha V, Joshi A, Kapoor A, Sable N, Ahuja A, Shukla S, Menon N, Agarwal JP, Laskar SG, D' Cruz A, Chaturvedi P, Chaukar D, Pai PS, Pantvaidya G, Thiagarajan S, Rane S, Prabhash K. Prognostic Value of Radiological Extranodal Extension Detected by Computed Tomography for Predicting Outcomes in Patients With Locally Advanced Head and Neck Squamous Cell Cancer Treated With Radical Concurrent Chemoradiotherapy. Front Oncol 2022; 12:814895. [PMID: 35719994 PMCID: PMC9202501 DOI: 10.3389/fonc.2022.814895] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 04/13/2022] [Indexed: 11/14/2022] Open
Abstract
Objective Extra Nodal Extension (ENE) assessment in locally advanced head and neck cancers (LAHNCC) treated with concurrent chemo radiotherapy (CCRT) is challenging and hence the American Joint Committee on Cancer (AJCC) N staging. We hypothesized that radiology-based ENE (rENE) may directly impact outcomes in LAHNSCC treated with radical CCRT. Materials and Methods Open-label, investigator-initiated, randomized controlled trial (RCT) (2012–2018), which included LAHNSCC planned for CCRT. Patients were randomized 1:1 to radical radiotherapy (66–70 grays) with concurrent weekly cisplatin (30 mg/m2) [cisplatin radiation arm (CRT)] or same schedule of CRT with weekly nimotuzumab (200 mg) [nimotuzumab plus CRT (NCRT)]. A total of 536 patients were accrued and 182 were excluded due to the non-availability of Digital Imaging and Communications in Medicine (DICOM) computed tomography (CT) data. A total of 354 patients were analyzed for rENE. Metastatic nodes were evaluated based on five criteria and further classified as rENE as positive/negative based on three-criteria capsule irregularity with fat stranding, fat invasion, and muscle/vessel invasion. We evaluated the association of rENE and disease-free survival (DFS), loco-regional recurrence-free survival (LRRFS), and overall survival (OS). Results A total of 244 (68.9%) patients had radiologically metastatic nodes (rN), out of which 140 (57.3%) had rENE. Distribution of rENE was balanced in the two study groups CRT or NCRT (p-value 0.412). The median follow-up period was 39 months (ranging from 35.5 to 42.8 months). Complete response (CR) was seen in 204 (57.6%); incomplete response (IR), i.e., partial response plus stable disease (PR + SD), in 126 (35.6%); and progressive disease (PD) in 24 (6.8%). rENE-positive group had poor survival compared to rENE-negative group 3-year OS (46.7% vs. 63.6%), poor DFS (48.8% vs. 87%), and LRRFS (39.9% vs. 60.4%). rENE positive had 1.71 times increased risk of IR than rENE negative. Overall stage, site, clinical metastatic node (cN), response, and rENE were the significant factors for predicting OS, DFS, and LRRFS on univariate analysis. After making adjustment on multivariate analysis, rENE was an independent prognostic factor for DFS and trending to be significant for OS. Conclusion Pre-treatment rENE is an independent prognostic marker for survival in patients with LAHNSCC treated radically with CCRT that can be used as a potential predictive marker for response to treatment and hence stratify patients into responders vs. non-responders. We propose the mahajan rENE grading system applicable on CT, magnetic resonance imaging, positron emission tomography–contrast-enhanced CT, and ultrasound.
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Affiliation(s)
- Abhishek Mahajan
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Ankur Chand
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Ujjwal Agarwal
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Richa Vaish
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Akhil Kapoor
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Nilesh Sable
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Ankita Ahuja
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Shreya Shukla
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Nandini Menon
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Anil D' Cruz
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Pankaj Chaturvedi
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Devendra Chaukar
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - P S Pai
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Gouri Pantvaidya
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Shivakumar Thiagarajan
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Swapnil Rane
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Dhara V, Hoda N, Rajini BC, Sabitha KS, Vinitha A, Nathani J. Significance of cervical node necrosis in preoperative MRI as a prognostic indicator: retrospective study of patients with SCC of tongue. JOURNAL OF ORAL MEDICINE AND ORAL SURGERY 2021. [DOI: 10.1051/mbcb/2021021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Aim: To ascertain the prognostic value of cervical nodal necrosis (CNN) observed in patients of tongue squamous cell carcinoma with magnetic resonance imaging. Materials and methods: In this retrospective observational study, records of 144 patients diagnosed with newly diagnosed SCC of tongue were considered. Preoperative MRI study, demographic and clinical data were reviewed. Based on MRI reports, patients were categorised into: with or without the presence of cervical node necrosis (CNN or non CNN). Subsequent treatments, histopathological reports and follow up data were studied to determine key prognostic elements, overall survival and disease free survival by statistical analysis. Results: The incidence of CNN was 55.55% in the study sample. CNN category, depth of invasion, N stage and extra nodal extension were significant negative prognostic factors for overall and disease free survival. Conclusion: Based on our results, pre operative MRI based presence of cervical node necrosis in tongue squamous cell carcinoma is an independent prognostic indicator for poor overall and disease free survival. Long term prospective studies with larger cohorts could be undertaken to establish its role as an important biomarker for precision treatments.
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Vengaloor Thomas T, Kanakamedala MR, Bhanat E, Abraham A, Mundra E, Albert AA, Giri S, Bhandari R, Vijayakumar S. Predictors of Extracapsular Extension in Patients With Squamous Cell Carcinoma of the Head and Neck and Outcome Analysis. Cureus 2021; 13:e16680. [PMID: 34466317 PMCID: PMC8392822 DOI: 10.7759/cureus.16680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Extracapsular extension (ECE) in the lymph nodes for patients with head and neck cancer has been found to be a poor prognostic factor in multiple studies. The purpose of the study is to evaluate the predictive factors for ECE on computer tomography (CT) imaging for patients undergoing surgery and to analyze outcomes. Methods We conducted an Institutional Review Board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective review of 82 patients with biopsy-proven squamous cell carcinomas of the head and neck who underwent definitive surgery without neoadjuvant chemotherapy or radiation therapy. CT scans were evaluated for the level of involvement, size, and presence or absence of central necrosis. Extracapsular extension in lymph nodes on the postoperative pathology was correlated with the central necrosis in the lymph nodes appreciated on the CT neck with contrast. Survival estimates were evaluated using the Kaplan-Meier test. Results ECE on postoperative pathology was seen in 74.07% of patients who had evidence of central necrosis in lymph nodes on preoperative CT neck compared to 46.43% without CT necrosis (p=0.013). The incidence of ECE is higher in poorly differentiated tumors and also nodal stages >N2c at presentation. Patents with ECE had inferior disease-free and overall survival (OS). Conclusions Our results reveal that patients with necrosis on CT and with moderately to poorly differentiated tumors have a high incidence of extracapsular extension. There was no difference in local control (LC) between the groups of patients, but the OS was inferior in patients with ECE. Predicting extracapsular extension upfront helps to formulate the appropriate treatment. We propose to study additional chemotherapy to improve outcomes in patients with positive extracapsular extension.
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Affiliation(s)
| | | | - Eldrin Bhanat
- Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, USA
| | - Anu Abraham
- Pathology, Universtiy of Mississippi Medical Center, Jackson, USA
| | - Eswar Mundra
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Ashley A Albert
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Shankar Giri
- Radiation Oncology, G.V. (Sonny) Montgomery VA Medical Center, Jackson, USA
| | - Rahul Bhandari
- Radiation Oncology, G.V. (Sonny) Montgomery VA Medical Center, Jackson, USA
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8
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Sabiq F, Huang K, Patel A, Banerjee R, Debenham B, Lau H, Skarsgard D, Chen G, Lysack JT, Quon HC. Novel imaging classification system of nodal disease in human papillomavirus-mediated oropharyngeal squamous cell carcinoma prognostic of patient outcomes. Head Neck 2021; 43:1854-1863. [PMID: 33638232 DOI: 10.1002/hed.26657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/21/2021] [Accepted: 02/09/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Matted nodes in human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPC) is an independent predictor of distant metastases and decreased overall survival. We aimed to classify imaging patterns of metastatic lymphadenopathy, analyze our classification system for reproducibility, and assess its prognostic value. METHODS The metastatic lymphadenopathy was classified based on radiological characteristics for 216 patients with HPV-mediated OPC. Patient outcomes were compared and inter-rater reliability was calculated. RESULTS The presence of ≥3 abutting lymph nodes with imaging features of surrounding extranodal extension (ENE), one subtype of matted nodes, was associated with worse 5-year overall survival, overall recurrence-free survival, regional recurrence-free survival, and distant recurrence-free survival (p ≤ 0.03). Other patterns were not significantly associated with outcome measures. Overall inter-rater agreement was substantial (κ = 0.73). CONCLUSION One subtype of matted nodes defined by ≥3 abutting lymph nodes with imaging features of surrounding ENE is the radiological marker of worst prognosis.
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Affiliation(s)
- Farahna Sabiq
- Department of Radiology, Division of Neuroradiology, University of Calgary, Calgary, Alberta, Canada
| | - Kitty Huang
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Adarsh Patel
- Department of Radiology, Division of Neuroradiology, University of Calgary, Calgary, Alberta, Canada
| | - Robyn Banerjee
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Brock Debenham
- Department of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Harold Lau
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - David Skarsgard
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Guanmin Chen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - John T Lysack
- Department of Radiology, Division of Neuroradiology, University of Calgary, Calgary, Alberta, Canada
| | - Harvey C Quon
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
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Abdel-Halim CN, Rosenberg T, Dyrvig AK, Høilund-Carlsen PF, Sørensen JA, Rohde M, Godballe C. Diagnostic accuracy of imaging modalities in detection of histopathological extranodal extension: A systematic review and meta-analysis. Oral Oncol 2021; 114:105169. [PMID: 33493691 DOI: 10.1016/j.oraloncology.2020.105169] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/30/2020] [Accepted: 12/24/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To present an up to date systematic review and meta-analysis evaluating the diagnostic accuracy of the most used imaging modalities in detection of histopathological extra nodal extension (ENE) in head and neck squamous cell carcinoma. MATERIALS AND METHODS Medline, Embase, and Cochrane databases were systematically searched on March 27th 2020. Screening, inclusion, quality assessment, and data extraction were done by two reviewers. Meta-analysis was conducted using the bivariate model approach after pooling the studies according to imaging modality. Heterogeneity was explored by meta-regression. Comparison was done by meta-regression and sub-group analyses. RESULTS Out of 476 initial hits, 25 studies were included for analysis. Of these, 14 dealt with CT, nine with PET/CT, four with MRI, two with ultrasound, and none with PET/MRI. Meta-analysis based on a total sample size of 3391 showed that CT had a sensitivity of 76% [67-82%] and specificity of 77% [69-83%], MRI a sensitivity of 72% [64-79%] and specificity of 78% [57-90%], and PET/CT a sensitivity of 80% [76-84%] and specificity of 83% [74-90%] in the ability to predict ENE. No meta-analysis could be done on ultrasound. There were no significant differences between modalities in overall accuracy; however, PET/CT had significantly higher sensitivity than CT and MRI. CONCLUSION There was no significant difference in the ability of CT, MRI, and PET/CT to diagnose histopathological ENE, except that PET/CT had a significantly higher sensitivity than CT and MRI.
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Affiliation(s)
- Chadi Nimeh Abdel-Halim
- Department of ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
| | - Tine Rosenberg
- Department of ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | | | | | - Jens Ahm Sørensen
- Department of Plastic Surgery, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Max Rohde
- Department of ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Christian Godballe
- Department of ORL - Head and Neck Surgery and Audiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
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10
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The diagnostic performance of CT and MRI for detecting extranodal extension in patients with head and neck squamous cell carcinoma: a systematic review and diagnostic meta-analysis. Eur Radiol 2020; 31:2048-2061. [PMID: 32949282 DOI: 10.1007/s00330-020-07281-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/15/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To review the diagnostic performance of CT and MRI for detecting extranodal extension (ENE) in head and neck squamous cell carcinoma (HNSCC) patients. METHODS MEDLINE and EMBASE databases were searched up to October 7, 2019. Studies that evaluated the diagnostic performance of CT and/or MRI for detecting ENE in HNSCC patients were included. A 2 × 2 table was reconstructed for each study. Pooled sensitivity and specificity were calculated using the bivariate model and hierarchical summary receiver operating characteristic (HSROC) model. Subgroup analyses were performed according to HPV status and radiological features. Pooled correlation coefficient for interobserver agreement was calculated. RESULTS Twenty-two studies including 2478 patients were included. The pooled sensitivity and specificity for detecting ENE were 73% (95% CI, 62-82%) and 83% (95% CI, 75-89%), respectively, for CT, and 60% (95% CI, 49-70%) and 96% (95% CI, 85-99%), respectively, for MRI. There was substantial heterogeneity for both CT and MRI. A threshold effect was present for MRI. On subgroup analysis, the pooled specificity of CT was significantly lower in patients with HPV+ OPSCC than in patients with HPV‑ oral cavity cancer or all HNSCC (74% vs. 87%; p = 0.01). Central node necrosis showed significantly higher pooled sensitivity (81% vs. 51%; p = 0.02), while infiltration of adjacent planes showed significantly higher pooled specificity (94% vs. 65%; p = 0.03). The pooled correlation coefficient was 0.72 (95% CI, 0.60-0.81). CONCLUSION Both CT and MRI show reasonable diagnostic performance for detecting ENE in HNSCC patients and interobserver agreement was substantial. KEY POINTS • Pooled sensitivity and specificity were 73% and 83% for CT and 60% and 96% for MRI without significant difference. • Pooled specificity was lower for HPV+ OPSCC than for HPV‑ oral cavity cancer or all HNSCC (74% vs. 87%, p = 0.01), likely due to central node necrosis. • Central node necrosis showed higher sensitivity (81% vs. 51%; p = 0.02), while infiltration of adjacent planes showed higher specificity (94% vs. 65%; p = 0.03).
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11
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Douglas C, Crosbie R, Young D, Montgomery J, O'Neill G, McArthur C. Accuracy of contrast-enhanced CT and predictive factors for extracapsular spread in unknown primary head and neck squamous cell cancer. Clin Radiol 2019; 75:77.e23-77.e28. [PMID: 31679816 DOI: 10.1016/j.crad.2019.09.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
AIM To determine the accuracy of contrast-enhanced computed tomography (CECT) for nodal extracapsular spread (ECS) and identify predictive radiological signs and clinicopathological features for ECS in unknown-primary head and neck squamous cell cancer (UPHNSCC). MATERIALS AND METHODS The CECT imaging of patients who underwent primary neck dissection for UPHNSCC during 2011-2015 was analysed. The largest pathological-looking node at each radiologically involved level was evaluated in consensus by two head and neck radiologists. Parameters included longest diameter, margin sharpness, haziness in adjacent fat, necrosis, and loss of fat plane with adjacent structures. Independent assessment was also made regarding the presence/absence of ECS. Findings and clinicopathological parameters were correlated with histopathology. RESULTS Thirty-one patients with 39 neck levels had metastatic nodal involvement determined on CECT. Confirmed ECS was found at 26 levels in 23 patients. Sensitivity of radiological assessment for ECS by nodal level was 81-85% (95% confidence interval [CI]=65-93%) and specificity 46-54% (95% CI=19-81%); kappa 0.87. On univariate analysis based on the largest involved node per patient, longest diameter being ≥30 mm (p=0.007), haziness in adjacent fat (p=0.023), increasing age (p=0.006), and more advanced pathological nodal status (p=0.027) were statistically significantly associated with ECS. Haziness and increasing age were independent predictors on multivariate analysis (odds ratio [OR]=26.4 and 1.24). CONCLUSION Expert assessment of ECS on CECT had good sensitivity with excellent interobserver agreement. A longest nodal diameter of ≥30 mm, haziness in the surrounding fat on CECT, advanced pathological nodal status, and advancing patient age were significantly associated with ECS in UPHNSCC patients, findings not previously reported.
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Affiliation(s)
- C Douglas
- Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow G51 4TF, UK
| | - R Crosbie
- Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow G51 4TF, UK
| | - D Young
- Department of Mathematics and Statistics, Strathclyde University, 16 Richmond Street, Glasgow G1 1XQ, UK
| | - J Montgomery
- Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow G51 4TF, UK
| | - G O'Neill
- Department of Radiology - Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK
| | - C McArthur
- Department of Radiology - Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK.
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12
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Du YY, Luo DH, Sun XS, Tang LQ, Mai HQ, Chen QY, Zhong JH, Mai DM, Zhang WR, Chen WH, Mo HY. Combining pretreatment plasma Epstein-Barr virus DNA level and cervical node necrosis improves prognostic stratification in patients with nasopharyngeal carcinoma: A cohort study. Cancer Med 2019; 8:6841-6852. [PMID: 31513364 PMCID: PMC6853822 DOI: 10.1002/cam4.2481] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/26/2019] [Accepted: 07/27/2019] [Indexed: 01/17/2023] Open
Abstract
This study aimed to evaluate the prognostic value of combining pretreatment Epstein‐Barr virus (EBV) DNA level and cervical node necrosis (CNN) for patients with nasopharyngeal carcinoma (NPC) receiving intensity‐modulated radiotherapy (IMRT). A total of 607 incident nonmetastatic NPC patients treated with IMRT ± chemotherapy were reviewed. Patients were divided into four groups based on EBV DNA level and CNN status. The primary endpoint was progression‐free survival (PFS). Kaplan‐Meier curves with log‐rank test were applied to compare survival outcomes and the Cox proportional model was used to identify independent prognostic factors. Pretreatment EBV DNA level and CNN status were independent prognostic factors. Patients in the low‐level EBV DNA group or non‐CNN group had significantly better 5‐year PFS. Multivariate analyses demonstrated that CNN was an independent prognostic factor for overall survival (OS) (HR = 1.927, 95% CI: 1.129‐3.290, P = .016), PFS (HR = 1.492, 95% CI: 1.005‐2.214, P = .047), distant metastasis‐free survival (DMFS) (HR = 1.661, 95% CI: 1.044‐2.644, P = .032), but not locoregional relapse‐free survival. EBV DNA levels correlated significantly with CNN with a correlation coefficient of .324 (P < .001). Compared with low‐level EBV DNA and non‐CNN grouping, high‐level EBV DNA and CNN grouping had poor PFS. The combined classification was an independent prognostic factor for OS (P < .001), PFS (P = .001), and DMFS (P = .018). Pretreatment plasma EBV DNA level and CNN status both closely correlated with prognosis of NPC patients in the IMRT era. Combined EBV DNA level and CNN status improves risk stratification and prognostic value.
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Affiliation(s)
- Yu-Yun Du
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Dong-Hua Luo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Xue-Song Sun
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Lin-Quan Tang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Hai-Qiang Mai
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Qiu-Yan Chen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Jing-Hua Zhong
- Department of Oncology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, P. R. China
| | - Dong-Mei Mai
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Wan-Ru Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Wen-Hui Chen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Oncology, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Hao-Yuan Mo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
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13
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Prognostic Value of Cervical Nodal Necrosis Observed in Preoperative CT and MRI of Patients With Tongue Squamous Cell Carcinoma and Cervical Node Metastases: A Retrospective Study. AJR Am J Roentgenol 2019; 213:437-443. [PMID: 31039018 DOI: 10.2214/ajr.18.20405] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The prognosis of tongue squamous cell carcinoma (SCC) with cervical lymph node metastases is poor, and a subset of patients with aggressive disease experiences treatment failure. The current study evaluated the prognostic value of cervical nodal necrosis (CNN) observed on preoperative imaging studies of patients with tongue SCC and cervical node metastases. MATERIALS AND METHODS. We identified patients with tongue SCC who had undergone preoperative neck CT or MRI (or both) and retrospectively reviewed their demographic and clinical data. Patients with metastatic cervical lymph nodes were divided into two groups according to the presence (CNN group) or absence (non-CNN group) of necrosis, and radiologic extranodal extension (ENE) was assessed for all patients. Follow-up biopsy, imaging, and clinical examinations were used to determine survival and treatment failure. Cox proportional hazard regression analyses were performed to determine clinical, demographic, and pathologic factors for survival. RESULTS. Seventy-two patients with a mean follow-up period of 28.4 months were included. The incidence of CNN was 55.6% (40/72). In univariate analysis, patient age, evidence of CNN on preoperative imaging, radiologic ENE, clinical N classification, and overall stage were significantly associated with survival. The multivariate Cox proportional hazard model showed that patient age and CNN on preoperative imaging were independent negative prognostic factors. CONCLUSION. CNN observed on preoperative imaging studies is an independent predictor of a poor prognosis for patients with tongue SCC, and it may serve as a useful imaging biomarker for tailoring individual treatment regimens.
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14
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Can MR textural analysis improve the prediction of extracapsular nodal spread in patients with oral cavity cancer? Eur Radiol 2018; 28:5010-5018. [DOI: 10.1007/s00330-018-5524-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/23/2018] [Accepted: 05/03/2018] [Indexed: 01/18/2023]
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15
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Lu L, Wei X, Li YH, Li WB. Sentinel node necrosis is a negative prognostic factor in patients with nasopharyngeal carcinoma: a magnetic resonance imaging study of 252 patients. ACTA ACUST UNITED AC 2017; 24:e220-e225. [PMID: 28680290 DOI: 10.3747/co.24.3168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE We explored the patterns of sentinel node metastasis and investigated the prognostic value of sentinel node necrosis (snn) in patients with nasopharyngeal carcinoma (npc), based on magnetic resonance imaging (mri). METHODS This retrospective study enrolled 252 patients at our institution who had metastatic lymph nodes from biopsy-confirmed npc and who were treated with definitive radiation therapy, with or without chemotherapy. All participants underwent mri before treatment, and the resulting images were reviewed to evaluate lymph node status. The patients were divided into snn and non-snn groups. Overall survival (os), tumour-free survival (tfs), regional relapse-free survival (rrfs), and distant metastasis-free survival (dmfs) were calculated by the Kaplan-Meier method, and differences were compared using the log-rank test. Factors predictive of outcome were determined by univariate and multivariate analysis. RESULTS Of the 252 patients, 189 (75%) had retropharyngeal lymph node metastasis, and 189 (75%) had level iia or iib lymph node necrosis. The incidence of snn was 43.4% (91 of 210 patients with lymph node metastasis or necrosis, or both). After a median follow-up of 54 months, the 5-year rates of os, tfs, rrfs, and dmfs in the snn and non-snn groups were, respectively, 79.4% and 95.3%, 73.5% and 93.3%, 80.4% and 96.6%, and 75.5% and 95.3% (all p < 0.01). Age greater than 40 years, snn, T stage, and N stage were significant independent negative prognostic factors for os, tfs, rrfs, and dmfs. CONCLUSIONS Metastatic retropharyngeal lymph nodes and necrotic level ii nodes both seem to act as sentinels. Sentinel node necrosis is an negative prognostic factor in patients with npc. Patients with snn have a worse prognosis.
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Affiliation(s)
- L Lu
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing
| | - X Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, and
| | - Y H Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, and
| | - W B Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, and.,Imaging Center, Kashgar Prefecture Second People's Hospital, Xinjiang, P.R.C
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16
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Ting Y, Chee J, Charn TC, Loh KS, Choong CC, Ting E, Lim CM. Prognostic significance of cystic lymph nodal metastasis in nasopharyngeal carcinoma. Head Neck 2017. [PMID: 28640471 DOI: 10.1002/hed.24844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine the prevalence of cystic lymph nodal metastasis (CLNM) and its prognostic value in patients with nasopharyngeal carcinoma (NPC). METHODS A retrospective review was conducted on 257 patients with NPC, analyzing the presence of CLNM on MRI or CT scans. Oncologic outcomes were performed using the Kaplan-Meier analysis. RESULTS One hundred eleven patients (43.2%) had CLNM at diagnosis. Overall, patients with CLNM had a poorer disease-specific survival (DSS; P < .001) and overall survival (OS; P < .001) compared with patients without CLNM. When analyzed according to nodal status, CLNM was associated with a higher rate of distant metastasis recurrence (P = .007), a poorer DSS (P < .001), and a poorer OS (P < .001) among patients with N2 disease. CONCLUSION The prevalence of CLNM was 43.2%. In patients with N2 disease, the presence of CLNM was significantly associated with a poorer DSS, OS, and increased risk of distant metastasis recurrence.
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Affiliation(s)
- Yohanes Ting
- Department of Otolaryngology - Head and Neck Surgery, National University Health System, Singapore
| | - Jeremy Chee
- Department of Otolaryngology - Head and Neck Surgery, National University Health System, Singapore
| | - Tze Choong Charn
- Department of Otolaryngology - Head and Neck Surgery, National University Health System, Singapore
| | - Kwok Seng Loh
- Department of Otolaryngology - Head and Neck Surgery, National University Health System, Singapore
| | - Chih Ching Choong
- Department of Diagnostic Radiology, National University Health System, Singapore
| | - Eric Ting
- Department of Diagnostic Radiology, National University Health System, Singapore
| | - Chwee Ming Lim
- Department of Otolaryngology - Head and Neck Surgery, National University Health System, Singapore
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17
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García J, López M, López L, Bagué S, Granell E, Quer M, León X. Validation of the pathological classification of lymph node metastasis for head and neck tumors according to the 8th edition of the TNM Classification of Malignant Tumors. Oral Oncol 2017. [PMID: 28622888 DOI: 10.1016/j.oraloncology.2017.05.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES One of the main changes in the 8th edition of the TNM Classification for head and neck tumors is the inclusion of extracapsular spread (ECS) as a criterion for evaluating the regional extension, both clinical (cN) and pathological (pN). The objective of our study is to evaluate the prognostic capacity derived from the inclusion of the ECS in the pathological classification of head and neck squamous cell carcinoma (HNSCC) patients treated with a neck dissection, as established by the 8th edition TNM Classification. MATERIALS AND METHODS Retrospective study of 1188 patients with HNSCC treated with a neck dissection between1990 and 2013. RESULTS There were lymph node metastasis in 50.1% of the neck dissections. The pathological record revealed ECS in 50.5% of the positive neck dissections. The implementation of the changes of the 8th edition TNM classification produced the upstaging of 20.9% of the patients classified as pN1 with the 7th edition TNM classification to pN2a¸ and the upstaging of 58.4% of the patients classified as pN2 with the 7th edition TNM classification to pN3b. We conducted an objective comparison of the quality of both classifications. The 8th TNM classification edition achieved better results regarding both the discrimination in cause-specific survival between pN categories and in the distribution in the number of cases between categories than the 7th edition TNM classification. CONCLUSION The inclusion of ECS in the pathological classification (pN) of the neck nodes improves the prognostic capacity of the 8th TNM Classification edition.
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Affiliation(s)
- Jacinto García
- Otorhinolaryngology Department, Hospital de Sant Pau, Barcelona, Spain
| | - Montserrat López
- Otorhinolaryngology Department, Hospital de Sant Pau, Barcelona, Spain
| | - Laura López
- Pathology Department, Hospital de Sant Pau, Barcelona, Spain
| | - Silvia Bagué
- Pathology Department, Hospital de Sant Pau, Barcelona, Spain
| | - Esther Granell
- Radiology Department, Hospital de Sant Pau, Barcelona, Spain
| | - Miquel Quer
- Otorhinolaryngology Department, Hospital de Sant Pau, Barcelona, Spain
| | - Xavier León
- Otorhinolaryngology Department, Hospital de Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain.
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18
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Sharma A, Jaiswal AA, Umredkar G, Barle R, Sharma N, Banerjee PK, Garg AK, Membally R. Lymph Node Central Necrosis on the Computed Tomography as the Predictor of the Extra Capsular Spread in Metastatic Head and Neck Squamous Cell Carcinoma. Indian J Otolaryngol Head Neck Surg 2017; 69:323-332. [PMID: 28929063 DOI: 10.1007/s12070-017-1131-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/05/2017] [Indexed: 11/25/2022] Open
Abstract
The aim of this study is to investigate the relationship between the presence of the cervical lymph node with central necrosis as on the preoperative imaging and postoperative histopathological identification of the lymph node extra capsular spread. This study is a prospective study conducted at J.L.N. Hospital and Research Centre, Bhilai (C.G), from August 2011 to January 2014. Thirty patients with metastatic head and neck squamous cell carcinoma were enrolled. All candidates were subjected to a detailed history taking and clinical examination. Their preoperative computed tomography (CT) scans were assessed with attention to the presence and absence of lymph node, lymph node size, shape, level, presence or absence of the lymph node central necrosis and other signs of the ECS such as thick walled enhancing nodal margin, loss of margin definition, alteration of adjacent fat planes. These patients then underwent surgery which included resection of the primary with the neck dissection. The preoperative records of the lymph node size and location were observed radio-graphically and analyzed with the resected lymph node histopathologically. These data was used for finding out correlation. Of the total 30 patients studied, 24 patients were male and 6 patients female with ratio of 4:1. The most common group of the patients were of malignancy of gingivobuccal sulcus. Out of the 30 patients 19 patients had the radiographic evidence of the central necrosis, out of which 11 had the extra capsular spread on the histological analysis. In no patients did we found histopathology extra capsular spread without central necrosis. Thus the central necrosis on the CT has the high sensitivity for detection of the extra capsular spread. Out of the 19 lymph node without extra capsular spread, 11 lymph nodes had no central necrosis on the preoperative CT, remaining 8 lymph node were having central necrosis on CT whereas post op histopathology of these 8 lymph nodes showed metastatic deposit, indicating the low specificity of the central necrosis in detection of the ECS. Lymph node central necrosis on pre-operative CT is sensitive indicator with a high negative predictive value for lymph node extra capsular spread. Future studies focusing on identifying molecular mediator involved in ECS to determine targets for adjuvant therapies in this subset of patients are recommended.
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Affiliation(s)
- Aditi Sharma
- Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
| | - Ashwin Ashok Jaiswal
- Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
| | - Girish Umredkar
- Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
| | - Ratiram Barle
- Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
| | - Neeta Sharma
- Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
| | - Praveer Kumar Banerjee
- Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
| | - Amrish Kumar Garg
- Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
| | - Ravindranath Membally
- Department of Pathology, J.L.N. Hospital and Research Centre, Sector 9, Bhilai, District Durg, 490009 Chhattisgarh India
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19
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Carlton JA, Maxwell AW, Bauer LB, McElroy SM, Layfield LJ, Ahsan H, Agarwal A. Computed tomography detection of extracapsular spread of squamous cell carcinoma of the head and neck in metastatic cervical lymph nodes. Neuroradiol J 2017. [PMID: 28627989 DOI: 10.1177/1971400917694048] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and purpose In patients with squamous cell carcinoma of the head and neck (HNSCC), extracapsular spread (ECS) of metastases in cervical lymph nodes affects prognosis and therapy. We assessed the accuracy of intravenous contrast-enhanced computed tomography (CT) and the utility of imaging criteria for preoperative detection of ECS in metastatic cervical lymph nodes in patients with HNSCC. Materials and methods Preoperative intravenous contrast-enhanced neck CT images of 93 patients with histopathological HNSCC metastatic nodes were retrospectively assessed by two neuroradiologists for ECS status and ECS imaging criteria. Radiological assessments were compared with histopathological assessments of neck dissection specimens, and interobserver agreement of ECS status and ECS imaging criteria were measured. Results Sensitivity, specificity, positive predictive value, and accuracy for overall ECS assessment were 57%, 81%, 82% and 67% for observer 1, and 66%, 76%, 80% and 70% for observer 2, respectively. Correlating three or more ECS imaging criteria with histopathological ECS increased specificity and positive predictive value, but decreased sensitivity and accuracy. Interobserver agreement for overall ECS assessment demonstrated a kappa of 0.59. Central necrosis had the highest kappa of 0.74. Conclusion CT has moderate specificity for ECS assessment in HNSCC metastatic cervical nodes. Identifying three or more ECS imaging criteria raises specificity and positive predictive value, therefore preoperative identification of multiple criteria may be clinically useful. Interobserver agreement is moderate for overall ECS assessment, substantial for central necrosis. Other ECS CT criteria had moderate agreement at best and therefore should not be used individually as criteria for detecting ECS by CT.
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Affiliation(s)
- Joshua A Carlton
- Departments of Radiology and Pathology, University of Missouri Columbia School of Medicine, USA
| | - Adam W Maxwell
- Departments of Radiology and Pathology, University of Missouri Columbia School of Medicine, USA
| | - Lyndsey B Bauer
- Departments of Radiology and Pathology, University of Missouri Columbia School of Medicine, USA
| | - Sara M McElroy
- Departments of Radiology and Pathology, University of Missouri Columbia School of Medicine, USA
| | - Lester J Layfield
- Departments of Radiology and Pathology, University of Missouri Columbia School of Medicine, USA
| | - Humera Ahsan
- Departments of Radiology and Pathology, University of Missouri Columbia School of Medicine, USA
| | - Ajay Agarwal
- Departments of Radiology and Pathology, University of Missouri Columbia School of Medicine, USA
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Chung M, Cheng K, Choi Y, Roh J, Lee Y, Lee S, Lee J, Baek J. Interobserver reproducibility of cervical lymph node measurements at CT in patients with head and neck squamous cell carcinoma. Clin Radiol 2016; 71:1226-1232. [DOI: 10.1016/j.crad.2016.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/08/2016] [Accepted: 07/25/2016] [Indexed: 11/24/2022]
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Luo Y, Ren J, Zhou P, Gao Y, Yang G, Lang J. Cervical nodal necrosis is an independent survival predictor in nasopharyngeal carcinoma: an observational cohort study. Onco Targets Ther 2016; 9:6775-6783. [PMID: 27843328 PMCID: PMC5098587 DOI: 10.2147/ott.s110558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Most nasopharyngeal carcinoma (NPC) patients present with locoregionally advanced disease at the time of diagnosis; however, there is a lack of consensus on specific prognostic factors potentially improving overall survival, especially in late-stage disease. Herein, we conducted a retrospective study to evaluate various potential prognostic factors in order to provide useful information for clinical treatment of T3/T4-stage NPC. PATIENTS AND METHODS A total of 189 previously untreated NPC patients were enrolled in the current study. All patients received intensity-modulated radiotherapy. Survival, death, relapse-free survival (both local and regional), and metastasis were recorded during follow-up. Factors affecting patient survival were assessed by using univariate and multivariate analyses. RESULTS The median follow-up time was 69 months. The 5-year local-regional recurrence-free survival, distant metastasis-free survival, progression-free survival (PFS), and overall survival (OS) of the entire group were 89.8%, 71.5%, 66.3%, and 68.9%, respectively. Univariate analysis revealed significant differences in the 5-year PFS (58.5% vs 72.5%, P=0.015) and OS (59.5% vs 75.8%, P=0.033) rates of patients with and without cervical nodal necrosis (CNN). Subgroup analyses revealed that CNN was associated with poorer distant metastasis-free survival and PFS among patients with N2 stage (P=0.046 and P=0.005) and with poorer PFS among patients with T3 or III stage (all P=0.022). Multivariate analysis revealed CNN to be an independent prognostic factor for PFS and OS (PFS: adjusted hazard ratio, 1.860; 95% CI: 1.134-3.051; P=0.014; OS: adjusted hazard ratio, 1.754; 95% CI: 1.061-2.899; P=0.028). CONCLUSION CNN is a potential independent negative prognostic factor in NPC patients. Our results suggest that stratification of NPC patients based on their CNN status should be considered as part of NPC disease management.
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Affiliation(s)
| | - Jing Ren
- Department of Radiology, Sichuan Cancer Hospital, Chengdu
| | - Peng Zhou
- Department of Radiology, Sichuan Cancer Hospital, Chengdu
| | - Yang Gao
- Department of Radiation Oncology, Zigong No 4 People’s Hospital of Sichuan Province, Zigong, Sichuan, People’s Republic of China
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Mermod M, Tolstonog G, Simon C, Monnier Y. Extracapsular spread in head and neck squamous cell carcinoma: A systematic review and meta-analysis. Oral Oncol 2016; 62:60-71. [PMID: 27865373 DOI: 10.1016/j.oraloncology.2016.10.003] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/06/2016] [Accepted: 10/08/2016] [Indexed: 11/24/2022]
Abstract
Extracapsular spread (ECS) is one of the most important prognostic factors in head and neck squamous cell carcinoma (HNSCC). However, despite its major clinical relevance, there are still a number of important remaining issues regarding this condition. Indeed, standardized diagnostic and grading criteria of ECS are still lacking. The imaging modality of choice for its diagnosis is a matter of debate. Current research looking at the identification of specific biomarkers is ongoing. Recent findings demonstrate a direct correlation between the level of extension of ECS and a poor prognosis. Accumulating data show that ECS does not carry the same adverse features in human papilloma virus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). New treatment strategies based on these factors are currently considered to investigate the possibility of diminishing the toxicity of chemo-radiotherapy while maintaining similar outcomes. The goal of this article was to provide a systematic review of the literature covering all the issues related to ECS. As an additional component of the review, meta-analyses were performed on relevant aspects of ECS for which previous quantitative data were outdated or not available. The results of these meta-analyses confirm the negative impact of ECS on loco-regional recurrence and distant metastasis. They also demonstrate the absence of a negative impact of ECS in HPV-positive OPSCC.
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Affiliation(s)
- Maxime Mermod
- Department of Otolaryngology, Head & Neck Surgery, Head & Neck Tumor Laboratory, CHUV, University Hospital, Lausanne, Switzerland
| | - Genrich Tolstonog
- Department of Otolaryngology, Head & Neck Surgery, Head & Neck Tumor Laboratory, CHUV, University Hospital, Lausanne, Switzerland
| | - Christian Simon
- Department of Otolaryngology, Head & Neck Surgery, Head & Neck Tumor Laboratory, CHUV, University Hospital, Lausanne, Switzerland
| | - Yan Monnier
- Department of Otolaryngology, Head & Neck Surgery, Head & Neck Tumor Laboratory, CHUV, University Hospital, Lausanne, Switzerland.
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Lan M, Huang Y, Chen CY, Han F, Wu SX, Tian L, Zheng L, Lu TX. Prognostic Value of Cervical Nodal Necrosis in Nasopharyngeal Carcinoma: Analysis of 1800 Patients with Positive Cervical Nodal Metastasis at MR Imaging. Radiology 2015; 276:536-44. [PMID: 25759968 DOI: 10.1148/radiol.15141251] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the prognostic value of cervical nodal necrosis (CNN) in patients with nasopharyngeal carcinoma (NPC) with magnetic resonance (MR) imaging. MATERIALS AND METHODS This was an institutional review board-approved retrospective study of 1800 patients with newly diagnosed stage T1, 4N1, 3M0 NPC who were treated with definitive radiation therapy, with or without chemotherapy, between January 2007 and December 2009; the requirement to obtain informed consent was waived. MR images were reviewed to assess lymph node status, and patients were divided into CNN and non-CNN groups. The overall survival, disease-free survival, regional relapse-free survival (RRFS), and distant metastasis-free survival (DMFS) were calculated with the Kaplan-Meier method, and differences were compared by using the log-rank test. RESULTS The incidence of CNN was 44.0% (792 of 1800). After the median follow-up period of 53 months, the 5-year overall survival, disease-free survival, RRFS, and DMFS rates of the CNN and non-CNN groups were 78.8% and 91.8%, 78.2% and 91.2%, 78.6% and 91.8%, and 78.4% and 91.6%, respectively (for all rates, P < .001). The distant metastasis rate was 18.7% (148 of 792) for the CNN group versus 4.6% (46 of 1008) for the non-CNN group (P < .01). Subgroup analysis revealed similar survival outcomes between stage N1 disease with CNN and stage N2 disease without CNN, stage N2 disease with CNN, and stage N3 disease regardless of CNN. CNN, T stage, N stage, age older than 44 years, and male sex were significant independent negative prognostic factors for overall survival, disease-free survival, RRFS, and DMFS. CONCLUSION CNN is an independent negative prognostic factor in patients with NPC, and it may be appropriate to investigate whether N stage should be upgraded by one level in patients with CNN.
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Affiliation(s)
- Mei Lan
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
| | - Ying Huang
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
| | - Chun-Yan Chen
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
| | - Fei Han
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
| | - Shao-Xiong Wu
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
| | - Li Tian
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
| | - Lie Zheng
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
| | - Tai-Xiang Lu
- From the State Key Laboratory of Oncology in Southern China, Department of Radiation Oncology (M.L., Y.H., C.Y.C., F.H., S.X.W., T.X.L.) and Imaging Diagnosis and Interventional Center (L.T., L.Z.), Sun Yat-Sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, Guangdong 510060, PR China
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Lymph Node Disease and Advanced Head and Neck Imaging: A Review of the 2013 Literature. CURRENT RADIOLOGY REPORTS 2014. [DOI: 10.1007/s40134-014-0058-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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