Ultrasound accurately assesses depth of invasion in T1-T2 oral tongue cancer

Imaging Modalities for Head and Neck Cancer: Present and Future

Several imaging modalities are utilized in the diagnosis, treatment, and surveillance of head and neck cancer. First-line imaging remains computed tomography (CT); however, MRI, PET with CT (PET/CT), and ultrasound are often used. In the last decade, several new imaging modalities have been developed that have the potential to improve early detection, modify treatment, decrease treatment morbidity, and augment surveillance. Among these, molecular imaging, lymph node mapping, and adjustments to endoscopic techniques are promising. The present review focuses on existing imaging, novel techniques, and the recent changes to imaging practices within the field.

Prediction of nodal disease in oral squamous cell carcinoma of the tongue: histopathological risk assessment with the focus on depth of invasion

OBJECTIVE

Cervical lymph node metastasis (CLNM) is one of the most relevant influencing factors for the oncological outcome of patients with oral squamous cell carcinoma (OSCC). Several studies showed that the tumors depth of invasion (DOI) influences the risk for CLNM, however varying across the oral subsites. The aim of this study is to investigate the role of DOI and other risk factors in OSCC of the tongue in relation to the occurrence of occult CLNM.

MATERIALS AND METHODS

In this retrospective study, n = 139 patients with primary OSCC of the tongue, treated by complete surgical resection (R0) with curative intention between 2013 and 2021, were included. For data analysis, epidemiologic data as well as preoperative tumor staging, surgical therapy including neck management, histopathological tumor data and follow-up were considered. Uni- and multivariate logistic regression were used to determine association between histopathological risk factors and the occurrence of occult CLNM.

RESULTS

The rate of occult cervical metastasis was 19.4%. T-staging, cervical nodal disease (pN+) and lymphatic invasion were significantly associated with reduced OS and RFS. While DOI had no relevant influence on the OS and RFS (p = 0.88 and p = 0.91 respectively), there was significant correlation between DOI and the occurrence of occult CLNM (OR: 1.17, 95%CI: 1.05-1.30; p < 0.01). The optimal cutoff in predicting occult CLNM was 6 mm (Sensitivity: 84.2%, Specificity: 73.5%, AUC: 0.75).

CONCLUSIONS

The DOI is a helpful risk parameter to predict the occurrence of occult nodal disease in OSCC of the tongue. Given the critical decision cutoff between 2 and 4 mm DOI for performing elective neck dissection in the current guidelines, our data suggests that in these cases, surgical de-escalation could be feasible with close follow-up.

CLINICAL RELEVANCE

This study highlights the relevance of DOI as a risk parameter in the prediction of CLNM with the aim to specify the individual patient risk and to deescalate surgical therapy in order to decrease comorbidities while improving the oncological prognosis.

Feasibility of a Novel 3D Ultrasound Imaging Technique for Intraoperative Margin Assessment during Tongue Cancer Surgery

Squamous cell carcinoma (SCC) of the tongue is the most prevalent form of oral cavity cancer, with surgical intervention as the preferred method of treatment. Achieving negative or free resection margins of at least 5 mm is associated with improved local control and prolonged survival. Nonetheless, margins that are close (1-5 mm) or positive (less than 1 mm) are often observed in practice, especially for the deep margins. Ultrasound is a promising tool for assessing the depth of invasion, providing non-invasive, real-time imaging for accurate evaluation. We conducted a clinical trial using a novel portable 3D ultrasound imaging technique to assess ex vivo surgical margin assessment in the operating room. During the operation, resected surgical specimens underwent 3D ultrasound scanning. Four head and neck surgeons measured the surgical margins (deep, medial, and lateral) and tumor area on the 3D ultrasound volume. These results were then compared with the histopathology findings evaluated by two head and neck pathologists. Six patients diagnosed with tongue SCC (three T1 stage and three T2 stage) were enrolled for a consecutive cohort. The margin status was correctly categorized as free by 3D ultrasound in five cases, and one case with a "free" margin status was incorrectly categorized by 3D ultrasound as a "close" margin. The Pearson correlation between ultrasound and histopathology was 0.7 (p < 0.001), 0.6 (p < 0.001), and 0.3 (p < 0.05) for deep, medial, and lateral margin measurements, respectively. Bland-Altman analysis compared the mean difference and 95% limits of agreement (LOA) for deep margin measurement by 3D ultrasound and histopathology, with a mean difference of 0.7 mm (SD 1.15 mm). This clinical trial found that 3D ultrasound is accurate in deep margin measurements. The implementation of intraoperative 3D ultrasound imaging of surgical specimens may improve the number of free margins after tongue cancer treatment.

Tumor thickness and depth of invasion in squamous cell carcinoma of tongue as indicators of the loco-regional spread of the disease: A preliminary study

Background

Magnetic resonance imaging (MRI) is a routinely used imaging modality for pre-treatment radiologic evaluation of tongue carcinoma, providing accurate information regarding the extent of the disease.

Aims and objectives

To investigate the role of MRI-derived depth of invasion and tumor thickness evaluation in squamous cell carcinoma of the tongue, and to assess if any correlation exists between depth of invasion, tumor thickness, nodal metastasis, muscles, and space involved.

Materials and methods

Thirty-three patients with oral squamous cell carcinoma of the tongue who had undergone pre-treatment MRI and excisional biopsy were included. The tumor thickness (TT) and depth of invasion (DOI) were evaluated on MRI and histopathologic images.

Result

The relation between different methodologies for assessing showed a very high correlation for the tumor tissue thickness (r = 0.99, p < 0.05) and depth of invasion (r = 0.82, p < 0.05). The tumor thickness and the depth of invasion increased with the loss of differentiation in the carcinoma histopathologically. As the depth of invasion increases, the extent of the spread of the carcinoma to tongue musculature, lingual septum, and spaces also increases.

Conclusion

The present study has depicted a high correlation between the tumor thickness and the depth of invasion between MRI and histopathological findings and is the first of its kind to correlate DOI to the invasiveness of the disease.

Intraoral Ultrasound versus MRI for Depth of Invasion Measurement in Oral Tongue Squamous Cell Carcinoma: A Prospective Diagnostic Accuracy Study

Oral squamous cell carcinoma (OSCC) of the tongue is the most common type of oral cavity cancer, and tumor depth of invasion (DOI) is an important prognostic factor. In this study, we investigated the accuracy of intraoral ultrasound and magnetic resonance imaging (MRI) for assessing DOI in patients with OSCC. Histopathological measurement of DOI was used as a reference standard. We conducted a prospective study including patients planned for surgical treatment of OSCC in the tongue. The DOI was measured in an outpatient setting by intraoral ultrasound and MRI, and was compared to the histopathological DOI measurements. Bland-Altman analysis compared the mean difference and 95% limits of agreement (LOA) for ultrasound and MRI, and the Wilcoxon signed-rank test was used to test for significance. The correlation was evaluated using Pearson's correlation coefficient. We included 30 patients: 26 with T1 or T2 tumors, and 4 with T3 tumors. The mean difference from histopathology DOI was significantly lower for ultrasound compared to MRI (0.95 mm [95% LOA -4.15 mm to 6.06 mm] vs. 1.90 mm [95% LOA -9.02 mm and 12.81 mm], p = 0.023). Ultrasound also led to significantly more correct T-stage classifications in 86.7% (26) of patients compared to 56.7% (17) for MRI, p = 0.015. The Pearson correlation between MRI and histopathology was 0.57 (p < 0.001) and the correlation between ultrasound and histopathology was 0.86 (p < 0.001). This prospective study found that intraoral ultrasound is more accurate than MRI in assessing DOI and for the T-staging of oral tongue cancers. Clinical practice and guidelines should implement intraoral ultrasound accordingly.

Personalized Medicine in Oral Oncology: Imaging Methods and Biological Markers to Support Diagnosis of Oral Squamous Cell Carcinoma (OSCC): A Narrative Literature Review

For decades, oral squamous cell carcinoma (OSCC) has been one of the most prevalent and mortal cancers worldwide. The gold standard for OSCC diagnosis is still histopathology but this narrative multidisciplinary review has the aim to explore the literature about conventional OSCC prognostic indicators related to the pTNM stage at the diagnosis such as the depth of invasion and the lymphovascular invasion associated with distant metastasis as indicators of poor life expectancy. Despite its multifactorial nature and recognizable precursors, its diagnosis at the early stages is still challenging. We wanted to highlight the importance of the screening as a primary weapon that a stomatologist should consider, intercepting all at-risk conditions and lesions associated with OSCC and its early stages. This narrative review also overviews the most promising imaging techniques, such as CT, MRI, and US-echography, and their application related to clinical and surgical practice, but also the most-investigated prognostic and diagnostic tissue and salivary biomarkers helpful in OSCC diagnosis and prognostic assessment. Our work highlighted remarkable potential biomarkers that could have a leading role in the future. However, we are still far from defining an appropriate and concrete protocol to apply in clinical practice. The hope is that the present and future research will overcome these limitations to benefit patients, clinicians, and welfare.

The Reliability of Ultrasonographic Assessment of Depth of Invasion: A Systematic Review with Meta-Analysis

Depth of invasion (DOI) has been recognized to be a strong prognosticator for oral squamous cell carcinoma (OSCC). Several diagnostic techniques can be employed for DOI assessment, however intraoral ultrasonography has been increasingly applied for the intraoral evaluation of OSCCs. The aim of the present study is to review the evidence on the application of intraoral ultrasonography to the assessment of DOI in patients affected by OSCC. A systematic electronic and manual literature search was performed, and data from eligible studies were reviewed, selected, and extracted. The studies had to report the correlation between DOI estimated with ultrasonography versus histopathology. A meta-analysis was conducted on the quantitative data available. Sixteen articles were included in the review following the screening of the initial 228 studies retrieved from the literature. The meta-analysis showed a significant correlation between ultrasonographic and histopathologic measurements (p < 0.01). The studies were all at low/moderate risk of bias. Ultrasonography appears a valuable tool for DOI assessment.

3D Ultrasound and MRI in Assessing Resection Margins during Tongue Cancer Surgery: A Research Protocol for a Clinical Diagnostic Accuracy Study

Surgery is the primary treatment for tongue cancer. The goal is a complete resection of the tumor with an adequate margin of healthy tissue around the tumor.Inadequate margins lead to a high risk of local cancer recurrence and the need for adjuvant therapies. Ex vivo imaging of the resected surgical specimen has been suggested for margin assessment and improved surgical results. Therefore, we have developed a novel three-dimensional (3D) ultrasound imaging technique to improve the assessment of resection margins during surgery. In this research protocol, we describe a study comparing the accuracy of 3D ultrasound, magnetic resonance imaging (MRI), and clinical examination of the surgical specimen to assess the resection margins during cancer surgery. Tumor segmentation and margin measurement will be performed using 3D ultrasound and MRI of the ex vivo specimen. We will determine the accuracy of each method by comparing the margin measurements and the proportion of correctly classified margins (positive, close, and free) obtained by each technique with respect to the gold standard histopathology.

Image-Guided Intraoperative Assessment of Surgical Margins in Oral Cavity Squamous Cell Cancer: A Diagnostic Test Accuracy Review

(1) Background: The assessment of resection margins during surgery of oral cavity squamous cell cancer (OCSCC) dramatically impacts the prognosis of the patient as well as the need for adjuvant treatment in the future. Currently there is an unmet need to improve OCSCC surgical margins which appear to be involved in around 45% cases. Intraoperative imaging techniques, magnetic resonance imaging (MRI) and intraoral ultrasound (ioUS), have emerged as promising tools in guiding surgical resection, although the number of studies available on this subject is still low. The aim of this diagnostic test accuracy (DTA) review is to investigate the accuracy of intraoperative imaging in the assessment of OCSCC margins. (2) Methods: By using the Cochrane-supported platform Review Manager version 5.4, a systematic search was performed on the online databases MEDLINE-EMBASE-CENTRAL using the keywords "oral cavity cancer, squamous cell carcinoma, tongue cancer, surgical margins, magnetic resonance imaging, intraoperative, intra-oral ultrasound". (3) Results: Ten papers were identified for full-text analysis. The negative predictive value (cutoff < 5 mm) for ioUS ranged from 0.55 to 0.91, that of MRI ranged from 0.5 to 0.91; accuracy analysis performed on four selected studies showed a sensitivity ranging from 0.07 to 0.75 and specificity ranging from 0.81 to 1. Image guidance allowed for a mean improvement in free margin resection of 35%. (4) Conclusions: IoUS shows comparable accuracy to that of ex vivo MRI for the assessment of close and involved surgical margins, and should be preferred as the more affordable and reproducible technique. Both techniques showed higher diagnostic yield if applied to early OCSCC (T1-T2 stages), and when histology is favorable.

Matrix for Mucosal Regeneration in Transoral Glossectomy for Squamous Cell Carcinoma: Objective and Subjective Functional Evaluation

BACKGROUND

Numerous options to manage local reconstruction following transoral partial glossectomy are possible. In this work, we present our experience using a matrix for mucosal regeneration, Integra^®, after transoral resections of squamous cell carcinoma of the oral tongue.

METHODS

A retrospective analysis of patients treated for tongue carcinoma and reconstruction with Integra^®, from September 2017 to September 2022. Functional outcomes were evaluated by measuring swallowing and speech abilities, tongue motility, and subjective quality of life.

RESULTS

The series accounts for 13 consecutive patients, staged from Tis to T3, no positive resection margins were found, average defect size was 17.8 cm². The average histologically measured depth of invasion was 4.1 mm (range 2-12 mm), and no recurrences were observed during follow-up. All patients maintained excellent swallowing function, the average number of recognized words by an external listener during a phone call was 70.5 out of 75, the lingual motility test was good (a mean score of 4.5 out of 6 movements correctly executed) and subjective questionnaires results were optimal. Less satisfying functional results were recorded in elderly patients receiving a wider surgical resection.

CONCLUSIONS

This reconstructive technique for allows obtaining optimal healing and functional outcomes in patients with tumors suitable for transoral glossectomy.