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Sahin O, Kamel S, Wahid KA, Dede C, Taku N, He R, Naser MA, Sharafi S, Mäkitie A, Kann BH, Kaski K, Sahlsten J, Jaskari J, Amit M, Chronowski GM, Diaz EM, Garden AS, Goepfert RP, Guenette JP, Gunn GB, Hirvonen J, Hoebers F, Hutcheson KA, Guha-Thakurta N, Johnson J, Kaya D, Khanpara SD, Nyman K, Lai SY, Lango M, Learned KO, Lee A, Lewis CM, Maniakas A, Moreno AC, Myers JN, Phan J, Pytynia KB, Rosenthal DI, Sandulache VC, Schellingerhout D, Shah SJ, Sikora AG, Mohamed ASR, Chen MM, Fuller CD. International Multi-Specialty Expert Physician Preoperative Identification of Extranodal Extension n Oropharyngeal Cancer Patients using Computed Tomography: Prospective Blinded Human Inter-Observer Performance Evaluation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.02.25.23286432. [PMID: 36865096 PMCID: PMC9980252 DOI: 10.1101/2023.02.25.23286432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Importance Extranodal extension (pENE) is a critical prognostic factor in oropharyngeal cancer (OPC) that drives therapeutic disposition. Determination of pENE from radiological imaging has been associated with high inter-observer variability. However, the impact of clinician specialty on human observer performance of imaging-detected extranodal extension (iENE) remains poorly understood. Objective To characterize the impact of clinician specialty on the accuracy of pre-operative iENE in human papillomavirus-positive (HPV+) OPC using computed tomography (CT) images. Design Setting and Participants This prospective observational human performance study analyzed pre-therapy CT images from 24 HPV+ OPC patients, with duplication of 6 scans (n=30) of which 21 were pathologically confirmed pENE. Thirty-four expert observers, including 11 radiologists, 12 surgeons, and 11 radiation oncologists, independently assessed these scans for iENE and reported human-detected radiologic criteria and observer confidence. Main Outcomes and Measures The primary outcomes included accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and Brier score for each physician, compared to ground-truth pENE. The significance of radiographic signs for prediction of pENE were determined through logistic regression analysis. Fleiss' kappa measured interobserver agreement, and Hanley-MacNeil AUC discrimination testing. Results Median accuracy across all specialties was 0.57 (95%CI 0.39 to 0.73), with no specialty showing discriminate performance greater than random estimation (median AUC 0.64, 95%CI 0.44 to 0.83). Significant differences between radiologists and surgeons in Brier scores (0.33 vs. 0.26, p < 0.01), radiation oncologists and surgeons in sensitivity (0.48 vs. 0.69, p > 0.1), and radiation oncologists and radiologists/surgeons in specificity (0.89 vs. 0.56, p > 0.1). Indistinct capsular contour and nodal necrosis were significant predictors of correct pENE status among all specialties. Interobserver agreement was weak for all the radiographic criteria, regardless of specialty (κ<0.6). Conclusions and Relevance Multiobserver testing shows physician discrimination of HPV+OPC pENE on pre-operative CT remains non-different than blind guessing, with high interrater variability and low diagnostic accuracy, regardless of clinician specialty. While minor differences in diagnostic performance among specialties are noted, they do not significantly affect the overall poor agreement and discrimination rates observed. The findings underscore the need for further research into automated detection systems or enhanced imaging techniques to improve the accuracy and reliability of iENE assessments in clinical practice.
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Affiliation(s)
| | - Onur Sahin
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Kareem A. Wahid
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Cem Dede
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nicolette Taku
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Renjie He
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Setareh Sharafi
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Antti Mäkitie
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benjamin H. Kann
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | | | | | | | - Moran Amit
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Eduardo M. Diaz
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Adam S. Garden
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Jeffrey P. Guenette
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - G. Brandon Gunn
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jussi Hirvonen
- Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Frank Hoebers
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | | | | | - Jason Johnson
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Diana Kaya
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Kristofer Nyman
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Stephen Y. Lai
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Miriam Lango
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Kim O. Learned
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Anna Lee
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Carol M. Lewis
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Amy C. Moreno
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Jack Phan
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | | | - Vlad C. Sandulache
- Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | | | - Shalin J. Shah
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Abdallah S. R. Mohamed
- The University of Texas MD Anderson Cancer Center, Houston, USA
- Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, USA
| | - Melissa M. Chen
- The University of Texas MD Anderson Cancer Center, Houston, USA
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Bradley PJ. Extranodal extension in head and neck squamous cell carcinoma: need for accurate pretherapeutic staging to select optimum treatment and minimize toxicity. Curr Opin Otolaryngol Head Neck Surg 2024; 32:71-80. [PMID: 38116845 DOI: 10.1097/moo.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW In 2017, the American Joint Committee on Cancer (AJCC) introduced the inclusion of extracapsular nodal extension (ENE) into the N staging of nonviral head and neck squamous cell carcinoma (HNSCC), while retaining the traditional N classification based on the number and sizes of metastatic nodes. The extent of ENE was further defined as microscopic ENE (ENEmi) and major ENE (ENEma) based on extent of disease beyond the nodal capsule (≤ or > 2 mm). This article reviews the evidence and progress made since these changes were introduced. RECENT FINDINGS The 'gold standard' for evaluation ENE is histopathologic examination, the current preferred primary treatment of patients with HNSCC is by radiation-based therapy ± chemotherapy or biotherapy. The current pretreatment staging is by imaging, which needs improved reliability of radiologic rENE assessment with reporting needs to consider both sensitivity and specificity (currently computed tomography images have high-specificity but low-sensitivity). Adjuvant chemotherapy is indicated for patients with ENEma to enhance disease control, whereas for patients with ENEmi, there is a need to assess the benefit of adjuvant chemotherapy. Evidence that the presence of pENE in HPV-positive oropharyngeal carcinoma is an independent prognostic factor and should be considered for inclusion in future AJCC editions has recently emerged. SUMMARY There remains a paucity of data on the reliability of imaging in the staging of rENE, more so the for the accurate assessment of ENEmi. Optimistic early results from use of artificial intelligence/deep learning demonstrate progress and may pave the way for better capabilities in tumor staging, treatment outcome prediction, resulting in improved survival outcomes.
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Affiliation(s)
- Patrick J Bradley
- Department of Otorhinolaryngology, Head and Neck Surgery, Nottingham University Hospitals, Queens Medical Centre Campus, Nottingham, UK
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