Preoperative cervical lymph node size evaluation in patients with malignant head/neck tumors: comparison between ultrasound and computer tomography

Ultrasound Characteristics of Metastatic Occult Cervical Lymph Nodes in Early Tongue Cancer

Introduction: Identification of occult lymph node metastasis is challenging in early tongue cancers. We conducted a prospective study to determine the most characteristics ultrasonic feature suggestive of metastatic node. Material and Methods: A preliminary study based on feasibility was planned on twenty five patients with squamous cell carcinoma of tongue (T1,T2) and N0 neck underwent ultrasonography of neck. The results of each ultrasonic parameters (size, shape, echogenicity, margin and hilum) for suspicion were analysed. Pathologic evaluation of surgical resected neck specimen served as the reference standard. Results: USG yielded sensitivity and specificity by size, by morphology, either size or morphology are 50.0% and 87.5%, 75.0% and 87.5, 75.0 and 83.3% respectively. Morphology alone has highest negative predictive value (NPV:91.3%) with accuracy of 84.3%. Conclusion: Morphology of the lymph node had highest sensitivity and specificity with highest negative predictive value correlating with its metastatic nature.

Diagnostic accuracy of contrast-enhanced computed tomography in assessing cervical lymph node status in patients with oral squamous cell carcinoma

OBJECTIVE

Accurate preoperative prediction of lymph node (LN) status plays a pivotal role in determining the extension of neck dissection (ND) required for patients with oral squamous cell carcinoma (OSCC). This study aims to evaluate the diagnostic accuracy of contrast-enhanced computed tomography (CT) in detecting LN metastases (LNMs) and to explore clinicopathological factors associated with its reliability.

METHODS

Data from 239 patients with primary OSCC who underwent preoperative CT and subsequent radical surgery involving ND were retrospectively reviewed. Suspicious LNs were categorized into three groups: accentuated (< 10 mm), enlarged (≥ 10 mm), and melted. Statistical analysis encompassing correlation and comparative analysis, and determination of sensitivity, specificity, PPV, and NPV were performed.

RESULTS

Overall, sensitivity was significantly higher in the accentuated LNs group (83.54%) compared to the melted LNs group (39.24%, p < 0.05, t test). Conversely, specificity was significantly higher in the melted LNs group (98.19%) compared to the accentuated LNs group (55.15%, p < 0.05, t test). Accentuated LNs exhibited a false negative rate of 13.00%. False positive rates were 51.80%, 30.26% and 8.82%, respectively. Diagnostic accuracy for detecting LNMs in level IIa and IIb exceeded that of level III. Patients with solely accentuated LNs were more likely to have a small, well-differentiated tumor. However, no distinctions emerged in terms of the occurrence of T4 tumors among the three groups.

CONCLUSION

CT proves sufficient to predict LNMs in patients with OSCC. Looking ahead, the potential integration of artificial intelligence and deep learning holds promise to further enhance the reliability of CT in LNMs detection. However, this prospect necessitates further investigation.

Comparative analysis of diagnostic ultrasound and histopathology for detecting cervical lymph node metastases in head and neck cancer

PURPOSE

We evaluated the current performance of diagnostic ultrasound (US) for detecting cervical lymph node (LN) metastases based on objective measures and subjective findings in comparison to the gold standard, histopathological evaluation.

PATIENTS AND METHODS

From 2007 to 2016, we prospectively included patients with head and neck cancer who were scheduled for surgical therapy including neck dissection. LNs were examined by multimodal US by a level III head and neck sonologist and individually assigned to a map containing six AAO-HNS neck LN levels preoperatively. During the operation, LNs were dissected and then assessed by routine histopathology, with 86% of them examined individually and the remaining LNs (14%) per AAO-HNS neck LN level. The optimal cutoff points (OCPs) of four defined LN diameters and 2D and 3D roundness indices per AAO-HNS neck LN level were determined.

RESULTS

In total, 235 patients were included, and 4539 LNs were analyzed by US, 7237 by histopathology and 2684 by both methods. Of these, 259 (9.65%) were classified as suspicious for metastasis by US, whereas 299 (11.14%) were found to be positive by histopathology. Subjective US sensitivity and specificity were 0.79 and 0.99, respectively. The OCPs of the individual LN diameters and the 2D and 3D roundness index were determined individually for all AAO-HNS neck LN levels. Across all levels, the OCP for the 2D index was 1.79 and the 3D index was 14.97. The predictive performance of all distances, indices, and subjective findings improved with increasing metastasis size. Anticipation of pN stage was best achieved with subjective US findings and the smallest diameter (Cohen's κ = 0.713 and 0.438, respectively).

CONCLUSION

Our LN mapping and meticulous 1:1 node-by-node comparison reveals the usefulness of US for detecting metastatic involvement of neck LNs in head and neck carcinomas as compared to histopathology. The predictive ability for small tumor deposits less than 8 mm in size remains weak and urgently needs improvement.

[Cutaneous squamous cell carcinoma of the head and neck]

OBJECTIVE

Cutaneous squamous cell carcinoma (cSCC), predominantly located on the scalp and face, is the second most prevalent skin cancer globally. Due to the increasing elderly population and rising incidence of cSCC, it has been gaining relevance in otorhinolaryngology.

MATERIAL AND METHODS

This review article is based on a selective PubMed literature search, German and European guidelines and the clinic's own experience.

RESULTS

In addition to chronic UV exposure, a disruption of the body's own immune system is becoming increasingly important. Vertical tumor thickness is associated with the highest risk of metastatic spread and local recurrence. Other significant risk factors are: horizontal tumor diameter, dedifferentiation, desmoplasia, perineural growth and localization on the face. Most cases are manageable by local excision with histological control of the excision margins. If regional metastases are clinically suspected, the draining cervical lymph node levels should be dissected depending on primary tumor location. cSCC of the upper face and the auricle primarily metastasize to the parotid gland. With the approval of the PD-1-blocking antibody cemiplimab in Europe, an active ingredient has been made available for the treatment of advanced cSCC where surgery or radiotherapy are no longer an option.

CONCLUSIONS

The otherwise very low mortality rate of cSCC increases considerably with metastases. Therefore, imaging, surgical therapy and follow-up intervals should be based on risk factors. This allows early detection of metastases or local recurrences and improves the prognosis.

Value of Assessing Peripheral Vascularization with Micro-Flow Imaging, Resistive Index and Absent Hilum Sign as Predictor for Malignancy in Lymph Nodes in Head and Neck Squamous Cell Carcinoma

Simple Summary

Ultrasound-guided fine needle aspiration cytology (USgFNAC) is commonly used for N-staging in head and neck squamous cell carcinoma (HNSCC). The specificity of USgFNAC is always in the order of 100% as false positive cytology is rare. The difference in sensitivity is mainly attributable to selection of the lymph nodes to aspirate and aspiration technique. The aim of this study was to improve the selection criteria of lymph nodes to aspirate. Ultrasound features of nodes such as a short axis diameter, S/L ratio, loss of a fatty hilum sign, resistive index, and peripheral or mixed hilar and peripheral vascularization, obtained by Micro-flow imaging (MFI), which is a new technique to obtain micro-vascularization, were evaluated. To calculate the sensitivity and PPV of each feature, data of sonographic findings and cytological results of all aspirated nodes were statistically analyzed. We found that next to size, peripheral vascularisation obtained by MFI and absent hilum sign have a high predictive value for malignancy and should be added as selection criteria for fine needle aspiration in lymph nodes.

Abstract

Ultrasound-guided fine needle aspiration cytology (USgFNAC) is commonly used for nodal staging in head and neck squamous cell cancer (HNSCC). Peripheral vascularity is a described feature for node metastasis. Micro-flow imaging (MFI) is a new sensitive technique to evaluate micro-vascularization. Our goal is to assess the additional value of MFI to detect malignancy in lymph nodes. A total of 102 patients with HNSCC were included prospectively. USgFNAC was performed with the Philips eL18–4 transducer. Cytological results served as a reference standard to evaluate the prediction of cytological malignancy depending on ultrasound features such as resistive index (RI), absence of fatty hilum sign, and peripheral vascularization. Results were obtained for all US examinations and for the subgroup of clinically node-negative neck (cN0). USgFNAC was performed in 211 nodes. Peripheral vascularization had a positive predictive value (PPV) of 83% (cN0: 50%) and the absence of a fatty hilum had a PPV of 82% (cN0 50%) The combination of peripheral vascularization and absent fatty hilum had a PPV of 94% (cN0: 72%). RI (threshold: 0.705) had a PPV of 61% (cN0: RI-threshold 0.615, PPV 20%), whereas the PPV of short axis diameter (threshold of 6.5mm) was 59% for all patients and 19% in cN0 necks (threshold of 4 mm). Peripheral vascularization assessed by MFI and absent hilum has a high predictive value for cytological malignancy in neck metastases. Next to size, both features should be used as additional selection criteria for USgFNAC.

Is the prediction of one or two ipsilateral positive lymph nodes by computerized tomography and ultrasound reliable enough to restrict therapeutic neck dissection in oral squamous cell carcinoma (OSCC) patients?

INTRODUCTION

Proper management of the clinically involved neck in OSCC patients continues to be a matter of debate. Our aim was to analyze the accuracy of computerized tomography (CT) and ultrasound (US) in anticipating the exact location of lymph node (LN) metastases of OSCC patients across the AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) levels ipsi- and contralaterally. Furthermore, we wanted to assess the suitability of therapeutic selective neck dissection (SND) in patients with one or two ipsilateral positive nodes upon clinical staging (cN1/cN2a and cN2b(2/x) patients).

METHODS

We prospectively analyzed the LN status of patients with primary OSCC using CT and US from 2007 to 2013. LNs were individually assigned to a map containing the AAO-HNS levels; patients bearing a single or just two ipsilateral positive nodes (designated cN1/cN2a or cN2b(2/x) patients either by CT (CT group) or US alone (US group) or in a group combining findings of CT and US (CTUS group)) received an ipsi-ND (I-V) and a contra-ND (I-IV). 78% of the LNs were sent individually for routine histopathological examination; the remaining were dissected and analyzed per neck level.

RESULTS

Upon the analysis of 1.670 LNs of 57 patients, the exact location of pathology proven LN metastases in cN1 patients was more precisely predicted by US compared to CT with confirmed findings only in levels IA, IB und IIA. Clearly decreasing the number of missed lesions, the findings in the CTUS group nearly kept the spatial reliability of the US group. The same analysis for patients with exactly two supposed ipsilateral lesions (cN2b(2/x)) yielded confirmed metastases from levels I to V for both methods individually and in combination and, therefore, render SND insufficient for these cases.

CONCLUSION

Our findings stress the importance of conducting both, CT and US, in patients with primary OSCC. Only the combination of their findings warrants the application of therapeutic SND in patients with a single ipsilateral LN metastasis (cN1/cN2a patients) but not in patients with more than one lesion upon clinical staging (≥ cN2b).

ACR Appropriateness Criteria® Neck Mass-Adenopathy

A palpable neck mass may be the result of neoplastic, congenital, or inflammatory disease. Older age suggests neoplasia, and a congenital etiology is more prevalent in the pediatric population. The imaging approach is based on the patient age, mass location, and clinical pulsatility. Underlying human papillomavirus-related malignancy should be considered in all age groups. Although the imaging appearance of some processes in the head and neck overlap, choosing the appropriate imaging examination may allow a specific diagnosis, or a limited differential diagnosis. Tissue sampling is indicated to confirm suspected malignancy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Cancer Measurement at Ultrasound: State of the Art

Reliable and reproducible tumor measurement is fundamental in the oncologic decision making. In this article, we first highlight the importance of a precise tumor measurement, reviewing the correct modality of measuring tumor lesions at ultrasound. Then we analyze the measurement discrepancies between ultrasound and pathology as well as the discrepancies reported between ultrasound and other imaging modalities. Thereafter, basing on the existent literature and on our experience, we discuss the factors influencing the tumor size measurements at ultrasound. Finally, we illustrate the current strategies to improve the effectiveness of cancer lesions measurement.

Sonographic appearances of cervical lymph nodes in healthy young Japanese adults: Association with age, sex, and body mass index

PURPOSE

We investigated whether there was any association between age, sex, and body mass index (BMI) and nodal morphology and vascular pattern in healthy young Japanese adults.

METHODS

Three neck regions in 100 healthy subjects, 19-40 years old, were examined by gray-scale and color Doppler sonography. Vascular pattern was classified into three groups: avascular, hilar, or scattered. A linear mixed-effect model was used to identify associations of age, sex, or BMI with the short-axis diameter and the short-to-long axis diameter ratio (S/L). A cumulative link mixed model was used to identify any association between age, sex, BMI, and vascular pattern.

RESULTS

In the upper cervical region, a decrease in the short-axis diameter was statistically significantly associated with aging (p = 0.04), and an increase in the short-axis diameter was significantly associated with greater BMI (p < 0.001). An increase in short-axis diameter was significantly associated with female sex (p = 0.02) and higher BMI (p = 0.002) in the submandibular region, whereas it was associated with higher BMI (p = 0.001) in the submental region. A greater S/L was significantly associated with higher BMI and female sex in all regions. The scattered vascular pattern tended to be associated with lower BMI (p = 0.051) in the upper cervical region, but it was significantly associated with higher BMI (p = 0.01) in the submental region.

CONCLUSIONS

Nodal morphology and vascular pattern may be associated with age, sex, and BMI.

Contribution of Ultrasonography to the Diagnosis of Submucosal and Subcutaneous Nodular Lesions of the Oral and Maxillofacial Region: Analysis of Cases

OBJECTIVE

The aim of this study was to evaluate the contribution of ultrasonography in the establishment of the diagnosis of nonspecific nodular lesions of the oral soft tissues. We determined the indication of use and reliability of ultrasonography in the field of dentistry, considering whether it was of value in the conclusive diagnosis of these pathologies.

MATERIALS AND METHODS

We recruited 65 patients from the Oral Medicine Unit of São Lucas Hospital, who had submucosal and subcutaneous nodules, without established diagnosis. They were subjected to ultrasonography of the lesion, carried out with standardization of the protocol and equipment, utilizing a Doppler system. The ultrasonographic report was prepared by an experienced professional, noting the imaging characteristics as well as the possibility of diagnosis. Two calibrated examiners analyzed the data, comparing the ultrasonographic report with the final diagnosis. Accordingly, we used established scoring, where zero corresponded to no contribution to the final diagnosis, 1 helped in the management of the case, and 2 when imaging determined the diagnosis.

RESULTS

A zero score was obtained for 12.3 % of the examinations performed, and 1 and 2 accounted for respectively 41.5 and 46.1 %, totaling a contribution of about 88 %. Ultrasonography was of value in the diagnosis of vascular lesions in 93.3 % and of neoplasms in 87.5 %. In the salivary gland diseases, it contributed to the final diagnosis in 75 %.

CONCLUSION

The results demonstrated that ultrasonography is an effective tool in the determination of the definitive diagnosis of nonspecific nodular lesions of the soft tissues of the oral and maxillofacial region.

Review of ultrasonography of malignant neck nodes: greyscale, Doppler, contrast enhancement and elastography

Assessment of neck lymph nodes is essential in patients with head and neck cancers for predicting the patient’s prognosis and selecting the appropriate treatment. Ultrasonography is a useful imaging tool in the assessment of neck lymph nodes. Greyscale ultrasonography assesses the size, distribution, and internal architecture of lymph nodes. Doppler ultrasonography evaluates the intranodal vascular pattern and resistance of lymph nodes. Contrast-enhanced ultrasonography provides information on lymph node parenchymal perfusion. Elastography allows qualitative and quantitative assessment of lymph node stiffness. This article reviews the value of greyscale, Doppler and contrast-enhanced ultrasonography as well as elastography in the assessment of malignant nodes in the neck.

Quantitative evaluation of vascularity within cervical lymph nodes using Doppler ultrasound in patients with oral cancer: relation to lymph node size

OBJECTIVES

The aim of this study was to quantitatively evaluate the relationship between vascularity within lymph nodes and lymph node size on Doppler ultrasound images of patients with oral cancer.

METHODS

A total of 310 lymph nodes (86 metastatic, 224 benign) from 63 patients with oral cancer were classified into 4 groups according to their short axis diameters: Group 1, short axis diameters of 4-5 mm; Group 2, 6-7 mm; Group 3, 8-9 mm; and Group 4, ≥ 10 mm. Vascular and scattering indices of lymph nodes on Doppler ultrasound images were analysed quantitatively. The vascular index was defined as the ratio of blood flow area to the whole lymph node area and the scattering index was defined as the number of isolated blood flow signal units.

RESULTS

For metastatic lymph nodes, the vascular index was highest in Group 1 and decreased as lymph node size increased. The vascular index of benign lymph nodes did not differ significantly among the four groups. The vascular index of metastatic lymph nodes was significantly higher than that of benign lymph nodes in Group 1. For metastatic lymph nodes, the scattering index increased as lymph node size increased and was significantly higher than that of benign lymph nodes in Groups 2-4.

CONCLUSIONS

An increase in vascularity is a characteristic of Doppler ultrasound findings in small metastatic lymph nodes. As the metastatic lymph node size increases, blood flow signals become scattered, and the scattering index increases.

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

OBJECTIVE

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Clinical utility and prospective comparison of ultrasonography and computed tomography imaging in staging of neck metastases in head and neck squamous cell cancer in an Indian setup

BACKGROUND

Preoperative lymph node screening of all neck compartments is favored by clinicians for the management of the neck. The presence of a metastatic node on one side of the neck reduces the 5-year survival rate to 50%, and the presence of a metastatic node on both sides of the neck reduces the 5-year survival rate to 25%.

MATERIALS AND METHODS

This study compared the evaluation of lymph node metastases by ultrasonography (USG) and computed tomography (CT) in patients with squamous cell cancer of the head and neck region.

RESULTS

Five hundred and eighty-four patients with squamous cell cancer of the head and neck were prospectively evaluated for the presence of cervical lymph node metastases. All patients underwent clinical examination (palpation), USG and CT imaging. Neck dissection was performed in all the patients, and the results of the preoperative evaluation were correlated with the surgical and histopathological findings. Metastases in neck nodes were identified in 148 patients by histopathological examination. Doppler USG correctly identified 136 node-positive patients (n = 148; sensitivity 91.8%, specificity 97%). CT imaging correctly identified 122 patients with metastatic lymph nodes (n = 148; sensitivity 83%, specificity 93%). Positive predictive values of USG and CT imaging were 95.6% and 91.3%, respectively, whereas the negative predictive values of these two imaging studies were 95.4% and 89.6%, respectively.

CONCLUSIONS

The accuracy and sensitivity of USG in detection of cervical lymph node metastases make it a potentially promising and cheap preoperative tool for staging neck node metastases and optimizing the treatment plan for surgeons, especially in countries such as India.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Screening recurrence and lymph node metastases in head and neck cancer: the role of computer tomography in follow-up

Introduction

Follow-up of patients with oral cancer is being questioned with regard to financial costs and effectiveness. Therefore, the aim of the present study was to evaluate whether local recurrence and cervical lymph node metastases were first discovered clinically or by routine computer tomography.

Materials and methods

The records of all 317 patients that were treated for an oral cancer between 1998 and 2008 were systematically reviewed. Criteria for inclusion were tumor histology with a squamous cell carcinoma of the head and neck, and regular follow-up examinations with a minimum follow-up time of 12 months, including clinical and radiological (CT) controls. All patients had the first CT after 6 months, followed by yearly CT controls.

Results

Out of 315 patients with an oral squamous cell carcinoma, 294 were evaluated. Those experiencing neither recurrence of the tumor nor lymph node metastases constituted 62%. Local recurrence was seen in 36 (12%), lymph node metastases in 32 (11%), and both in 16 (6%). Of the 32 patients with lymph node metastases, 25 were recognized first clinically, and 7 were detected by routine CT scans; concerning local recurrence, 32 appeared clinically, and 4 were detected by routine CT scans.

Conclusion

Routine CT for follow-up is still indicated for detecting lymph node metastases as well as local recurrence.