Lymph node staging in patients with clinically negative neck examinations by ultrasound and ultrasound-guided aspiration cytology

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Evaluation of Metastatic Lymph Nodes in Oral Squamous Cell Carcinoma: A Comparative Study of Clinical, FNAC, Ultra Sonography and Computed Tomography with Post Operative Histopathology

All the head and neck tumours, more than 90% are squamous cell carcinomas (SCC). The presence of metastatic cervical lymph nodes histologically positive for SCC provides one of the simplest and most important prognostic factor in patients with head and neck cancer. In this study, all patients were examined clinically for, location, number, size, shape, consistency and fixation of cervical neck nodes to the underlying structure, and the same was carried out by FNAC, USG and CT. Findings of these modalities and histopathological results were compared for the overall metastases of lymph nodes in the neck. The accuracy of clinical examination was 87.77% and sensitivity only 41.66%. FNAC has the greatest specificity, 98.71% and least sensitivity, 33.33%. The accuracy of FNAC was 90%. The positive predictive value and negative predictive value of FNAC were 80.0% and 90.58% respectively. USG revealed 50% of sensitivity. Specificity of USG was 93.58% and accuracy 87.77%. CT scan have the highest sensitivity among all other tests, 66.66%.The negative predictive value for CT scan was also the highest, 94.59%. Specificity and accuracy of CT scan was 89.74% and 86.66% respectively. This study concludes that USG with FNAC is the most accurate in evaluating metastatic lymph nodes in oral squamous cell carcinoma patients along with other investigations like CT scan for staging of the oral squamous cell carcinoma.

Morphometric evaluation of canine hepatocellular carcinoma using computed tomography: a promising tool for predicting malignancy

The size of canine focal liver lesions (FLLs) is known to be one of the predicting criteria for malignancy. However, there are discrepancies for the measurement of maximum lesion size, resulting in contradicting results among studies and incidences of false positive outcomes. Thus far, the morphometric changes of FLLs for distinguishing malignancy from benignancy remains undocumented. This study aimed to investigate morphometric characteristics of FLLs using computed tomography (CT). CT images of 40 dogs with histopathological confirmation of 49 liver lesions, including 39 hepatocellular carcinomas and 10 nodular hyperplasias were retrospectively reviewed. The morphometric parameters including size (long and short axis diameters measured on transverse image), shape (measured by long to short axis (L/S) ratio), volume, and surface appearance of a liver lesion were evaluated using univariate and stepwise multivariate analyses, respectively. The results of univariate analysis showed that long and short axis diameters, L/S ratio, volume, and surface appearance of a lesion were significantly different between hepatocellular carcinomas and nodular hyperplasias. Multivariate analysis revealed that short axis diameter (>3.30 cm; odds ratio (OR): 36.1, 95% confidence interval (CI): 3.36–387.05, P=0.0031) and L/S ratio (>1.23; OR: 18.1, 95% CI: 1.61–205.12, P=0.0191) were independent predictors of malignancy, with the area under the curve of 0.9154. These results suggest that the combination of short axis diameter and L/S ratio is a promising tool for predicting liver malignancy with outstanding discriminating ability.

Ultrasound-Guided Fine-Needle Aspiration With Optional Core Needle Biopsy of Head and Neck Lymph Nodes and Masses: Comparison of Diagnostic Performance in Treated Squamous Cell Cancer Versus All Other Lesions

OBJECTIVES

To evaluate the diagnostic performance of ultrasound (US)-guided fine-needle aspiration with optional core needle biopsy of head and neck lymph nodes and masses, with attention to differences between biopsy of treated squamous cell carcinoma (SCC) and biopsy of other lesions.

METHODS

Institutional Review Board approval was obtained, and the need for consent was waived for this retrospective study. All 861 US-guided biopsies of head and neck lymph nodes and masses performed between March 1, 2012, and May 16, 2016, were reviewed.

RESULTS

Of the 861 biopsies, 53 targeted SCC with residual masses after treatment. The biopsy procedures yielded benign or malignant pathologic results in 71.7% (38 of 53) of treated SCC and 90.7% (733 of 808) of all other lesions (P < .001). A reference standard based on subsequent pathologic results or clinical and imaging follow-up was established in 68.4% of procedures. In cases with benign or malignant biopsy results and a subsequent reference standard, the sensitivity values for malignancy were 87.5% (95% confidence interval, 64.0%-96.5%) in treated SCC and 98.3% (95% confidence interval, 96.0%-99.3%) in all other cases (P = .047), and the specificity values were 63.6% (95% confidence interval, 35.4%-84.8%) in treated SCC and 99.5% (95% confidence interval, 97.3%-99.9%) in all other cases (P < .001). There were no major complications related to the biopsy procedures.

CONCLUSIONS

Excluding treated SCC, US-guided fine-needle aspiration with optional core needle biopsy of head and neck lymph nodes and masses has excellent diagnostic performance. Needle biopsy of head and neck SCC with a residual mass after therapy has a high rate of nondiagnostic samples, suboptimal sensitivity, and poor specificity.

In-Office Ultrasonographic Evaluation of Neck Masses/Thyroid Nodules

Office-based ultrasonography is increasingly becoming an integral part of an otolaryngology-head and neck surgery practice. A thorough knowledge of the ultrasonic appearance of normal and abnormal pathology are key for performing/interpreting office-based head and neck ultrasonography. A focused but systematic approach allows for efficient and effective office-based head and neck ultrasonography. Office-based ultrasonography also allows for imaging procedures expanding the otolaryngologist's armamentarium. Ultrasound-guided fine needle aspiration (USgFNA) is an integral part of clinician-performed ultrasonography because it allows cytologic diagnosis of suspicious lesions. Understanding the successful techniques and pitfalls in this procedure are critical for the otolaryngologist performing USgFNA.

The Role of In-Office Ultrasound in the Diagnosis of Neck Masses

To evaluate the efficacy of otolaryngologist-performed in-office ultrasound (US) in the clinical assessment of lateral neck masses, we performed a retrospective review of patients with lateral neck masses who had both a surgeon-performed US and US-guided fine-needle aspiration (USGFNA) at our tertiary academic center from 2012 to 2015. Fifty-nine patients were included. USGFNA results included 32 (54%) malignant lesions, 23 (39%) benign lesions, and 4 (6%) nondiagnostic lesions. USGFNA demonstrated 85% accuracy. In 22 (37%) patients, in-office US revealed additional findings that were not identified on physical examination (eg, nonpalpable lymph nodes or elucidated anatomical structures), which either assisted in surgical planning or altered treatment. In-office US and USGFNA on initial evaluation by the otolaryngologist augment physical examination and have potential value as the primary imaging and diagnostic modality in the workup of lateral neck masses.

Considerations in incorporating office-based ultrasound of the head and neck

OBJECTIVE: The purpose of this study was to determine the cost considerations and strategies for incorporating ultrasound (US) in a head and neck practice.

STUDY DESIGN AND SETTING: A retrospective chart review of office-based US procedures from 2001 to 2005 was completed at our academic medical center. Billing and coding for US and US guided fine needle aspiration (USFNA) were examined.

RESULTS: The appropriate CPT codes are 76536 for US and 76942 and 10022 for USFNA-related procedures. The USFNA codes should be used repeatedly for correct coding of biopsies from multiple sites. Cost (equipment) sharing between specialties is a potential strategy for office-based US incorporation.

CONCLUSION: Based on practice volume, specific CPT coding, and Medicare reimbursements, office-based US equipment and certification costs could be offset in 1 year.

SIGNIFICANCE: Office-based US can be readily incorporated with significant benefits to patients. Billing and usage strategies were identified that would improve the economics of providing office-based US.

A systematic review of ultrasound-guided FNA of lesions in the head and neck--focusing on operator, sample inadequacy and presence of on-spot cytology service

The objective of this review is to perform a systematic review of ultrasound-guided fine-needle aspiration (FNA) services for head and neck lesions with assessment of inadequacy rates and related variables such as the presence of immediate cytological assessment. A computer-based systematic search of articles in English language was performed using MEDLINE (1950 to date) from National Health Service evidence healthcare database and PubMed. Full texts of all relevant articles were obtained and scrutinized independently by two authors according to the stated inclusion and exclusion criteria. The primary search identified 932 articles, but only 78 met all the study criteria. The overall inadequacy rate was 9.3%, 16 studies had on-site evaluation by a cytopathologist/specialist clinician with a rate of 6.0%. In seven studies, a cytotechnician was available to either assess the sample or prepare the slides with an average inadequacy rate of 11.4%. In 1 study, the assessment was unclear, but the inadequacy rate for the remaining 54 studies, without immediate assessment, was 10.3%. The rate for the cytopathologist/specialist clinicians was significantly different to no on-site assessment but this was not found for assessment by cytotechnicians. The review suggests that the best results are obtained with a cytopathologist-led FNA service, where the pathologist reviews the specimen immediately, in relation to the clinical context, thereby deciding on adequacy and need for further biopsies. A systematic review looking at ultrasound-guided FNA of head and neck lesions has not been published previously.

Ultrasound-guided fine needle aspiration cytology in the assessment of cervical metastasis in patients undergoing elective neck dissection

BACKGROUND

In head and neck cancer patients, diagnosis of metastatic cervical adenopathy is essential for treatment planning and prognosis assessment. Treatment of patients with head and neck cancer with clinically negative cervical lymph node (N0) remains controversial. While routine neck treatment would result in overtreatment in many patients, observation may delay the diagnosis and decrease the patients' survival.

OBJECTIVES

To gain insights into the unclear questions regarding the value of diagnostic modalities in patients with N0 neck, this study was designed to compare the diagnostic efficacy of palpation, ultrasonography (US) and ultrasound-guided fine needle aspiration (USGFNA) in detecting cervical lymph node metastasis.

PATIENTS AND METHODS

Forty-two patients with head and neck cancer who underwent US and USGFNA prior to elective neck dissection were studied. Histopathologic findings of the neck specimens were compared with each diagnostic technique.

RESULTS

Of the 53 neck dissection specimens, histopathology showed metastases in 16 cases. The overall accuracy of USGFNA, US and palpation was 96%, 68% and 70%, respectively. The specificity of USGFNA was superior to palpation and US alone. USGFNA had the highest sensitivity, predictive value and accuracy in detecting cervical metastases compared with other performed tests.

CONCLUSIONS

In our study, USGFNA was superior to palpation and US in detecting metastasis in clinically negative necks. This method can be recommended as a diagnostic tool in preoperative assessment of patients without palpable metastasis, but further investigations are needed before this modality could be considered as an alternative to elective neck dissection.

Elective regional lymphadenectomy for advanced auricular squamous cell carcinoma

AIM: To investigate the rate of occult lymph node disease in elective parotidectomy and neck dissection specimens in patients with advanced auricular cutaneous squamous cell carcinoma (cSCC).

METHODS: At a single institution, from 2000 to 2010, 17 patients with advanced auricular cSCC were considered high risk for occult regional parotid and/or neck nodal metastases and, thus, underwent an auriculectomy and elective regional lymphadenectomy (parotidectomy and/or neck dissection). Indications for elective regional lymphadenectomy were large tumor size, locally invasive tumors, post-surgical and post-radiation recurrence, and being an immunosuppressed patient. We determined the presence of microscopic disease in the regional (parotid and neck dissection) pathology specimens.

RESULTS: There were 17 advanced auricular cSCC patients analyzed for this study. Fifteen (88%) patients were men. The average age was 69 (range: 33 to 86). Ten (59%) patients presented with post-surgical recurrence. Five (29%) patients presented with post-radiation recurrence. Four (24%) patients presented with both post-surgical and post-radiation recurrence. Four (24%) patients were immunosuppressed (2 (12%) were liver transplant patients, 2 (12%) were chronic lymphocytic leukemia patients, and 1 (6%) was both). The subsite distribution of cSCC included helix (3, 18%), antihelix (2, 12%), conchal bowl (7, 41%), tragus (2, 12%), and postauricular sulcus (3, 18%). Four (24%) patients presented with multifocal auricular cSCC. No patients had bilateral disease. All patients were confirmed to have cSCC on final pathology. The tumors were well (5, 29%), moderately (10, 59%), and poorly (2, 12%) differentiated SCC. The average size of the cSCC tumor was 2.9 cm (range: 1.7 to 7 cm). Twelve (70%) tumors were greater than 2 cm. Six (35%) patients underwent partial auriculectomy. Eleven (65%) patients underwent total auriculectomy. Eight (47%) patients underwent elective parotidectomy and elective neck dissections; 3 (18%) underwent only elective parotidectomy; 3 (18%) underwent only an elective neck dissection; 2 (12%) underwent an elective parotidectomy and therapeutic neck dissection; and 1 (6%) underwent a therapeutic parotidectomy and an elective neck dissection. None of the elective parotidectomy or neck dissection specimens were found to contain any malignant disease. All therapeutic parotidectomy and neck dissection specimens contained metastatic SCC. Fourteen (82%) underwent parotidectomy. Of these, 10 (71%) underwent superficial parotidectomy whereas 4 (29%) underwent total parotidectomy. Fourteen (82%) underwent neck dissections [levels II/Va (1, 7%), levels II/III/Va (2, 14%), levels I/II/III/Va (2, 14%), and complete levels I-V (9, 64%)]. Three (18%) underwent concurrent temporal bone resections for tumor extension from the auricle. The average follow-up for our patients was 44 mo (range: 4 to 123 mo). At the time of the review, 6 (35%) patients were alive and 11 (65%) had passed away.

CONCLUSION: This study suggests that, in patients with advanced auricular cutaneous SCC, elective regional lymphadenectomy is not necessary. However, furtherprospective studies are necessary to assess the necessity.

Post-therapeutic surveillance schedule for oral cancer: is there agreement?

INTRODUCTION

Patients with oral cavity squamous cell carcinoma represent a diverse group, and the treatment these patients undergo also varies widely. Some patients undergo local excision alone while others require extensive surgery, often with adjuvant chemoradiotherapy. The post-therapeutic surveillance schedule for these patients tends to be a "one size fits all" formula for all head and neck squamous cell carcinoma patients, which has often been dictated by institutional doctrine or a senior surgeon's dogma. The post-therapeutic needs and risks of a T1 oral cancer patient treated with surgery alone differ from those of a patient with advanced laryngeal carcinoma, and the follow-up regimen should be tailored to the specific patient's risk of loco-regional recurrence, distant metastasis, and other related medical issues.

RESOURCES AND MATERIALS

A total of 65 papers were identified, 18 of which either focused on follow-up strategy for oral cavity squamous cell carcinoma or their tabular data allowed these cases to be extracted. Internationally recognized cancer entities were also queried.

CONCLUSIONS

No international consensus was achieved about the follow-up strategies. The value of post-therapeutic surveillance schedule following oral cancer treatment is generally not in dispute, although patient-initiated symptom-driven visits can be effective in identifying tumor recurrence for oral cancer patients. The range of appointment interval schemes tends to identify a progressive escalation of visit intervals such that there are more visits in the first year than in the second, and fewer yet during the third. Patients may fail to comply with their clinic visit structure. Most references agree that follow-up beyond the third year is unnecessary and may waste medical resources as well as the time of both patient and surgeon. There is no agreement as to the need for or interval of imaging studies.

Cervical lymph node metastases in head & neck malignancy - A Clinical /ultrasonographic/ Histopathological comparative study

A study was conducted on the value of Ultrasound (US) in the detection of cervical lymph node metastases in cases of Head and Neck malignancy; and its usefulness in planning surgical management. The clinical, ullrasonographic and histopathological examination (HPE) findings were compared in 20 patients as a preliminary assessment of this ongoing study. Clinically and ultrasonogiaphically, patients were assessed for presence of nodes, their size, shape, mobility and overall positivity for malignancy. All patients then underwent neck dissection, and individual nodes from the specimens were assessed by HPE.It was found that US, when compared with clinical examination had a sensitivity of 47.62% versus 43.75%, specificity of 77.78% versus 25.0% and an accuracy of 61.54% as opposed to 38.9%. US proved valuable in detecting sub-clinical nodes, central necrosis, extra-capsular spread, pressure on large vessels - all indicators of metastatic spread. Hence, US was found to be efficient and cost-effective pre-operatively, in planning surgical management.

Observer variation in the histopathologic assessment of extranodal tumor spread in lymph node metastases in the neck

BACKGROUND

Extranodal spread (ENS) of tumors is widely used as a prognosticator for patients with head and neck cancer and is used as an indicator for postoperative treatment. However, the histopathologic agreement among pathologists on the assessment of the presence or absence of this criterion has never been studied.

METHODS

The interobserver and intraobserver agreement among 10 pathologists on the diagnosis of ENS in 41 tumor-positive lymph nodes was evaluated.

RESULTS

The kappa value of the interobserver agreement among pathologists varied between 0.14 and 0.75, the overall kappa value was 0.42 and 0.49 in the 2 scoring sessions. The intraobserver kappa value varied between 0.49 and 0.95.

CONCLUSION

The intraobserver and interobserver agreement among pathologists in the assessment of the presence of ENS was low in metastatic lymph nodes in the neck. Because of the widely accepted prognostic significance and therapeutic consequences of ENS, there is a need for internationally accepted reproducible criterion for the histopathologic assessment of ENS in metastatic lymph nodes in the neck.

Tumour thickness in oral cancer using an intra-oral ultrasound probe

Objectives

To investigate tumour-thickness measurement with an intra-operative ultrasound (US) probe.

Methods

A retrospective data analysis was undertaken for a total of 65 patients with a T1-2 oral cavity cancer, who were seen at a tertiary referral centre between 2004 and 2010. The correspondence between tumour thickness measured by ultrasonography and histopathology was assessed by Pearson’s correlation coefficient, and also between tumour thickness and the development of neck metastasis.

Results

In 11 cases, intra-oral measurement was not optimal due to limited mouth opening (n = 2) or impossibility to depict the lesion (n = 9). Tumour thickness measured by US correlated well with histopathology (n = 23, R = 0.93). Tumour thickness of ≤7 mm carries a risk of lymph node metastasis of 12%, whereas in tumours exceeding 7 mm this risk is 57% (p = 0.001). Twenty-five percent developed neck metastasis and 19% had local recurrence.

Conclusion

Tumour thickness is an important predictive marker for lymph node metastases. As such, it can help in decision-making with regard to management of the primary tumour and neck. Based upon our findings, a wait-and-see policy is only warranted for superficial lesions with tumour thickness of less than 7 mm, but only if regular follow-up using US-guided aspiration of the neck is ensured.

Cervical lymph node metastasis in oral squamous carcinoma preoperative assessment and histopathology after neck dissection

BACKGROUND

The presence or absence of nodal metastasis has a great impact on the prognosis and survival of patients with head and neck cancer. The risk of occult metastasis is related to the method by which the lymph nodes are evaluated. It is possible to reduce the risk of undiagnosed metastasis with accurate imaging techniques and thus probably reduce the number of elective neck treatments.

AIMS AND OBJECTIVES

To assess the accuracy of clinical palpation, CT Scan, Ultrasound and Ultrasound guided FNAC in prediction of lymph node metastasis in oral squamous cell carcinoma so that a suitable surgical neck dissection can be carried out.

METHODS

Ten patients with oral squamous cell carcinoma who underwent 10 neck dissections (4 RND, 6 SOND) were included. All the patients underwent examination of neck pre operatively by palpation, Computed Tomography with contrast, Ultrasound and Ultrasound guided FNAC for no detection. The findings were correlated with the results of histopathologic examination of the neck specimen. The results were obtained after statistical analysis.

RESULTS

Six neck dissection specimens showed metastatic lymph node involvement in postoperative histopathology. Lymph node involvement was identified preoperatively by palpation in 7 necks, CT in 3 necks, US in 9 necks and USFNAC was positive in 4 cases. The palpation showed 83% sensitivity, 50% specificity. CT showed sensitivity of 50%, specificity of 100%, US showed sensitivity of 100%, specificity of 25% and US-FNAC showed sensitivity of 67%, specificity of 100%.

CONCLUSION

The palpation, CT Scan and US are equally accurate but the USFNAC is the most accurate technique in assessing metastasis in lymph nodes in patients with oral squamous cell carcinoma.

Diagnostic benefit of thyroglobulin measurement in fine-needle aspiration for diagnosing metastatic cervical lymph nodes from papillary thyroid cancer: correlations with US features

OBJECTIVE

Our goals were to determine the added value of fine-needle aspiration biopsy (FNAB)-thyroglobulin (Tg) measurements over FNAB-cytology alone for diagnosing metastatic nodes, and to determine whether the ultrasound features of lymph nodes can be used to identify lymph nodes that may benefit from FNAB-Tg measurement in patients with papillary thyroid cancer.

MATERIALS AND METHODS

We retrospectively evaluated 76 surgically proven cervical lymph nodes. Twenty-nine patients were awaiting surgery and 18 patients had undergone thyroid surgery for papillary thyroid cancer. Ultrasound-guided FNAB and Tg measurements were performed and the ultrasound features were evaluated.

RESULTS

The accuracies, sensitivities, and specificities of FNAB-cytology, FNAB-Tg, and combined FNAB-Tg/cytology were 90%, 80%, and 100%; 92%, 95%, and 90%; and 93%, 96%, and 90%, respectively. The diagnostic sensitivity of FNAB-Tg for metastatic nodes was significantly higher than that of FNAB-cytology (p = 0.011). Furthermore, combined FNAB-Tg/cytology significantly increased sensitivity (p = 0.002) and accuracy (p = 0.03) as compared with FNAB-cytology.

CONCLUSION

Combined FNAB-Tg/cytology is significantly more sensitive and accurate at detecting metastatic nodes than FNAB-cytology alone. FNAB-Tg was better at diagnosing metastases in small lymph nodes.

Lateral lymph node metastasis in papillary thyroid carcinoma: results of therapeutic lymph node dissection

BACKGROUND

Cervical lymph node metastases are quite common in papillary thyroid cancer (PTC) and they usually spread in a contiguous fashion. However, "skip metastasis," defined as lateral lymph node metastasis without central lymph node metastasis, also occurs in patients with PTC. There is little information regarding skip metastasis in papillary thyroid microcarcinoma (PTMC). The goal of this study was to determine the prevalence and associated clinical and imaging features of skip metastasis in PTMC.

METHODS

We performed a retrospective study of 245 patients with PTMC who underwent either thyroidectomy and central lymph node dissection or thyroidectomy, central lymph node dissection, and lateral lymph node dissection if preoperative ultrasonography or computed tomography suggested lateral node metastasis. Clinicopathologic results were reviewed, and the patterns of cervical lymph node metastasis were analyzed.

RESULTS

Cervical lymph node metastases were present in 26.5% of cases. The frequency of lymph node metastases was 21.8% in the group that only had thyroidectomy and central lymph node dissection and 51.3% in the group that had thyroidectomy, central lymph node dissection, and lateral lymph node dissection. Younger age, larger tumor size, multiplicity, bilaterality, encapsulation, extrathyroid extension, and lymphatic invasion were associated with metastasis to nodes in the central or lateral compartment. Lateral lymph node dissection was performed in 15.9% of patients. Skip metastasis was observed in 7.7% of the cases in which combined central and lateral node dissection was performed. No features of the primary thyroid tumor could be associated with the development of skip metastasis.

CONCLUSIONS

Skip metastases occur in a minority of patients with PTMC. We recommend, therefore, that preoperative studies in patients suspected of having PTMC focus not only on nodes in the central compartment but also lateral cervical nodes since the information obtained would guide the extent of surgery.

Management of the N0 neck in oral squamous cell carcinoma

Oral squamous cell carcinoma (SCC) has an unpredictable capacity to metastasize to the neck, an event that dramatically worsens prognosis. Metastasis occurs even in earlier stages when no neck lymph node involvement is clinically detectable (N0). Management of the N0 neck, namely when and how to electively treat, has been debated extensively. This article presents the controversies surrounding management of the N0 neck, and the benefits and pitfalls of different approaches used in evaluation and treatment. As current methods of assessing the risk for occult metastasis are insufficiently accurate and prone to underestimation of actual risk, and because selective neck dissection (SND) is an effective treatment and has minimal long-term detriment to quality of life, the authors believe that all patients who have oral SCC, excluding lip SCC, should be prescribed elective treatment of the neck lymphatics. However, this opinion remains controversial. Because of the morbidity of radiation therapy and because treatment of the primary tumor is surgical, elective neck dissection is the preferred treatment. In deciding the extent of the neck dissection, several retrospective studies and one randomized clinical trial have shown SND of levels I through III to be highly efficacious.

Neck dissections: radical to conservative

BACKGROUND: Neck dissection is an important surgical procedure for the management of metastatic nodal disease in the neck. The gold standard of neck nodal management has been the radical neck dissection. Any modification in the neck dissection is always compared with this standard. Over the last few decades, in order to alleviate the morbidity of radical neck dissection, several modifications and conservative procedures have been advocated. These procedures retain certain lymphatic or non-lymphatic structures and have been shown not to compromise oncological safety. METHODS: A literature search of the Medline was carried out for all articles on neck dissections. The articles were systematically reviewed to analyze and trace the evolution of neck dissection. These were then categorized to address the nomenclature, management of node positive and node negative neck including those who had received chemoradiation. RESULTS: The present article discusses the neck nodal nomenclature, the radical neck dissection, its modifications and migration to more conservative procedures and possible advances in the near future. CONCLUSION: Radical neck dissection is now replaced with modified radical neck dissections in most situations. Attempts are being made to replace modified radical neck dissections with selective neck dissections for early node positivity. Sentinel node biopsy is being studied to address the issue of node negative neck. More conservative surgeries are likely to replace the 'radical' surgeries of bygone era. This process is facilitated by earlier detection of the disease and better understanding of cancer biology.

Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer

BACKGROUND

Lung cancer is the leading cause of death from cancer in the UK. Pathological diagnosis traditionally requires invasive procedures such as bronchoscopy, mediastinoscopy, or image guided biopsy. Ultrasound of the neck with fine needle aspiration cytology (FNAC) of enlarged but impalpable supraclavicular nodes has been used in patients with suspected lung cancer who have N2 or N3 disease on staging computed tomography (CT). If positive, this technique helps to both stage the patient and provide a cytological diagnosis.

METHODS

101 patients were enrolled prospectively over a 1 year period. FNAC was performed on all supraclavicular nodes over 5 mm in size using the capillary aspiration technique.

RESULTS

Sixty one of the 101 patients had enlarged supraclavicular nodes and underwent FNAC. The overall malignant yield was 45.5% of patients scanned and 75.4% of patients sampled. As a result of FNAC, 43 patients (42.6%) avoided more invasive procedures.

CONCLUSION

Ultrasound guided FNAC is a promising, relatively non-invasive technique for the staging and diagnosis of patients with lung cancer.

The clinical significance of follow-up sonography in the detection of cervical lymph node metastases in patients with stage I or II squamous cell carcinoma of the tongue

OBJECTIVE

We sought to assess the reliability of repeated sonography in the detection of cervical lymph node metastases at the earliest stage during a follow-up period in patients with stage I or stage II carcinoma of the tongue.

STUDY DESIGN

Eighteen consecutive patients with stage I or II squamous cell carcinoma of the tongue were included. When possible, every patient was examined with sonography approximately every 2 weeks during the follow-up period.

RESULTS

With repeated sonography on 18 patients, 7 metastatic nodes of 7 patients (39%) meeting our criteria were found. With the use of computed tomography, we diagnosed 10 nodes (including the 7 nodes observed with sonography) in these 7 patients as metastatic. A histopathologic examination revealed that 12 nodes in the same 7 patients had metastatic foci. For sonography, the sensitivity per node was 58%, whereas that of computed tomography was 83%.

CONCLUSIONS

Follow-up sonography enabled the detection of all patients who had subsequent subclinical lymph node metastases. However, the sensitivity of sonography in the detection of smaller metastatic nodes was lower than that of computed tomography.

Sonography of neck lymph nodes. Part I: normal lymph nodes

Grey scale and power Doppler sonography play an important role in assessment of cervical lymphadenopathy. However, before examination of pathological nodes, a clear understanding of the anatomy of cervical nodes, scanning technique and sonographic appearances of normal cervical nodes is essential. This article reviews these topics in order to provide a baseline for sonographic examination of cervical lymphadenopathy.

Is neck ultrasound necessary for early stage oral tongue carcinoma with clinically N0 neck?

OBJECTIVES

To define the necessity of neck ultrasound for investigation of T1 and T2 oral tongue carcinoma with N0 neck.

METHODS

The medical records of all patients with early stage (T1-2 N0) oral tongue cancer treated surgically between January 1985 and December 2000 were reviewed. Patients with 30 neck dissections were identified for analysis. The result of neck ultrasound examination was correlated with the histological examination.

RESULTS

The sensitivity, specificity and overall accuracy of ultrasound examination were found to be 47%, 93% and 70%, respectively. The implication of ultrasound examination with respect to elective neck treatment was discussed in the management of the N0 neck.

CONCLUSIONS

It is concluded that ultrasound alone is inadequate for making decisions regarding neck management of patients with T1 and T2 N0 carcinoma of the tongue and cannot replace a policy of elective neck dissection.

Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma

These guidelines for management of primary cutaneous squamous cell carcinoma present evidence based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the UK, this article is subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma

These guidelines for management of primary cutaneous squamous cell carcinoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Vascularity and grey-scale sonographic features of normal cervical lymph nodes: variations with nodal size

AIM

This study was undertaken to investigate variations in the vascularity and grey-scale sonographic features of cervical lymph nodes with their size.

MATERIALS AND METHODS

High resolution grey-scale sonography and power Doppler sonography were performed in 1133 cervical nodes in 109 volunteers who had a sonographic examination of the neck. Standardized parameters were used in power Doppler sonography.

RESULTS

About 90% of lymph nodes with a maximum transverse diameter greater than 5 mm showed vascularity and an echogenic hilus. Smaller nodes were less likely to show vascularity and an echogenic hilus. As the size of the lymph nodes increased, the intranodal blood flow velocity increased significantly (P < 0.05), whereas there was no significant variation in the vascular resistance(P> 0.05).

CONCLUSIONS

The findings provide a baseline for grey-scale and power Doppler sonography of normal cervical lymph nodes. Sonologists will find varying vascularity and grey-scale appearances when encountering nodes of different sizes.Ying, M.et al. (2001). Clinical Radiology, 56, 416-419.

Fine needle aspiration biopsy (FNAB) for lesions of the salivary glands

We examined 112 fine needle aspiration biopsy (FNAB) specimens of salivary glands (80 parotid and 32 submaxillary) taken between January 1989 and December 1995. Cytologic diagnoses were compared with the final histological diagnoses of the surgical specimens. The sensitivity and specificity were 84.8% and 93.7% respectively, and the accuracy was 91.1%. We conclude that FNAB by itself does not provide total security because of the high percentage of false-negatives. It is nevertheless useful when combined with an adequate clinical history, examination and radiological tests.

Contrast-enhanced color Doppler sonography for evaluation of enlarged cervical lymph nodes in head and neck tumors

OBJECTIVE

We determined whether contrast-enhanced color Doppler sonography can differentiate benign from malignant enlarged cervical lymph nodes in head and neck tumors.

SUBJECTS AND METHODS

Ninety-four enlarged lymph nodes in 39 adult patients (32 men and seven women; age range, 30-81 years) were examined with B-mode sonography and with unenhanced and contrast-enhanced color Doppler sonography. All patients had carcinoma of the oral cavity. Histologically, lymphadenitis was found in 57 nodes and metastases in 37 nodes. Geometric dimension, texture, and margin of the node and detection and location of vessels were noted. Histology and imaging findings were correlated.

RESULTS

The transverse-to-longitudinal diameter ratio in combination with texture and margin analysis resulted in a correct diagnosis in only approximately 79% of the nodes. With contrast-enhanced color Doppler sonography, 86% of nodes showed vessels, and 28% of nodes showed vessels with this technique exclusively. Characteristic configurations were identified: hilar vessels with branching indicated lymphadenitis (sensitivity, 98%; specificity, 100%), and predominantly peripheral vessels indicated metastases (100%, 98%). These findings changed the diagnosis in 13 nodes, changed the therapy in four patients, and led to an incorrect diagnosis in one patient.

CONCLUSION

Enlarged lymph nodes can be characterized as metastatic or inflammatory with high diagnostic accuracy on the basis of their vascular architecture as seen on contrast-enhanced color Doppler sonography.

Clinical Impact of Sonographically Guided Biopsy of Salivary Gland Masses and Surrounding Lymph Nodes

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands.

We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren ‘s-related lymphoid-epithelial lesion.

Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

Multicentre study of ultrasonographically guided axillary node biopsy in patients with breast cancer

BACKGROUND

Axillary lymph node dissection is still performed as a staging procedure since lymph node status is the most important prognostic factor in patients with breast cancer. Sentinel node biopsy may replace routine axillary lymphadenectomy, especially in patients with small breast cancers. This study investigated whether ultrasonographically guided fine-needle aspiration cytology (FNAC) of the axillary lymph nodes in clinically node-negative patients was an accurate staging procedure to select patients for sentinel node biopsy.

METHODS

One hundred and eighty-five consecutive patients were included. All had axillary ultrasonography and detected nodes were categorized according to their dimensions and echo patterns. Ultrasonographically guided FNAC was carried out if technically possible. These results were compared with the results of the sentinel node biopsy and subsequent axillary dissection.

RESULTS

In 116 patients no lymph nodes were detected by ultrasonographic imaging. Of 69 patients with visible nodes, 31 had malignant cells on FNAC. There were no false-positive results. Some 87 of 185 patients had axillary metastases on definitive histological examination. Ultrasonography was sensitive in patients with extensive nodal involvement. Failure of the examination was caused by problems learning the method, difficulty in puncturing small lymph nodes and sampling error.

CONCLUSION

In patients without palpable axillary nodes, a sentinel node biopsy could be avoided in 17 per cent since ultrasonography combined with FNAC had already diagnosed axillary metastases. The method is particularly valuable in larger breast cancers.

Lymph node metastases of cutaneous melanoma: diagnosis by B-scan and color Doppler sonography

BACKGROUND

Sonography is a sensitive, noninvasive method that can be used to detect regional lymph node metastases. Color Doppler sonography (CDS) can supply further information on lymph node perfusion.

OBJECTIVE

We evaluated the usefulness of CDS for differentiating between benign lymphadenopathies and lymph node metastases of cutaneous melanoma.

METHODS

In a prospective study, reactive inflammatory lymph nodes (rLN) and lymph node metastases of cutaneous melanoma (mLN) were examined by sonography and CDS. Lymph node echogenicity and shape (length/depth ratio) were determined by sonography. The vascularization pattern of the lymph nodes was established with CDS. We recorded the Doppler frequency spectra at the hili of the lymph nodes and then calculated the resistance and pulsatility indices (RI, PI).

RESULTS

The echogenicity of the lymph node centers had a sensitivity of 96% and a specificity of 100%. The shape differed highly significantly between the two groups (P <.001). The criterion length/depth ratio < 2 had a sensitivity of 85% and specificity of 86%. Hilus vessels could be detected in 14 of 22 rLN (64%). These vessels, however, were not present in any of the metastases. The RI and the PI in detectable lymph node vessels differed between the two groups (RI: P <.05; PI: not significant), but because of the overlap between the two groups, these indices were of no diagnostic value. In the presence of 2 or more of the following 3 criteria: length/depth ratio < 2, hypoechoic center, and the absence of hilus vessels, diagnosis of metastasis of malignant melanoma had a sensitivity of 100% and a specificity of 96%.

CONCLUSION

CDS improves the diagnostic accuracy of conventional sonography. The measurement of Doppler curves in lymph node vessels and the calculation of pulsatility and resistance indices, on the other hand, is time-consuming and seems to be of no diagnostic value.

Management of the neck in cancer of the larynx

In the Department of Otolaryngology at the University of Pittsburgh School of Medicine, cancer of the larynx is usually treated by primary surgery. Radiotherapy is used as adjuvant treatment in certain patients who have cancer that has adverse histologic features such as perineural, vascular, and/or cartilage invasion. With this approach, patients rarely develop local recurrence. Patient survival is therefore unlikely to be improved by changes to the management of the primary tumor. Survival may, however, be improved by reducing the incidence of recurrence in the neck, as well as distant. Hence, we have adopted an aggressive surgical approach to the cN+ as well as the N0 neck. The theoretical basis for this aggressive surgical approach to the neck will be considered under the following headings: staging, regional control, distant metastasis, survival, choice of neck dissection, and the pathologically positive elective neck dissection.

Management of the clinically negative cervical lymph nodes in patients with non-conventional squamous carcinoma of the larynx

This paper discusses the indications for neck dissection in those patients with laryngeal tumours which prove to be, on pathologic examination, not conventional squamous carcinomas but rather fall into the category either of one of the uncommon histological subtypes of carcinoma, or another type of unusual histological variant of laryngeal malignancy, a mesenchymal tumour. It appears as though these unusual laryngeal malignancies may manifest both biological behaviours and propensities to metastasize to regional lymph nodes that differ from those of the more commonly encountered conventional squamous carcinomas of the larynx. This heterogeneous group of tumours accounts for about 10 per cent of all malignant tumours of the larynx.

Pathology of the N0 neck

The incidence, extent and distribution of nodal metastasis is described in 152 neck dissections from patients with an NO neck undergoing surgery for an intraoral/oropharyngeal squamous cell carcinoma. The preoperative N stage had been determined by palpation under general anaesthesia and magnetic resonance imaging. Metastasis was detected histologically in 32 (21%) of the 152 NO necks. The number of positive nodes per NO neck ranged from 1 to 6. In total, 52 positive nodes were found and 29 (56%) measured 10 mm or less in maximum dimension. Twenty-one dissections (66%) contained a single positive node and 24 (75%) showed a single positive anatomical level. Three cases showed 'skipping' of levels within the neck and one case showed 'peppering'. Seventeen (53%) of the 32 positive NO necks and 31 (60%) of the 52 positive nodes contained only 'micrometastases' (deposits < 3 mm). Microscopic extracapsular spread was evident in five NO necks including one case with extracapsular spread at multiple levels. The study concludes that preoperative staging by palpation and routine magnetic resonance imaging cannot be relied upon to detect early cervical metastatic disease, and the topographic distribution of positive nodes indicates that modified neck dissections should include level IV when the primary tumour involves the tongue.

Micrometastasis in oral/oropharyngeal squamous cell carcinoma: incidence, histopathological features and clinical implications

The prognostic importance of accurate pathological staging of oral cancer patients with established lymph node metastases is well known. The present study sought to determine the incidence and clinical significance of minimal neck disease (only micrometastases) and to evaluate clinical features of the primary tumour in relation to the pathological metastatic status. Surgical resection specimens from 178 patients with oral/oropharyngeal squamous cell carcinoma were assessed by routine techniques. Micrometastases were defined as intranodal deposits measuring in total no more than 3 mm at any level of sectioning. Fourteen patients (8%) had only micrometastases and 72 (40%) had established nodal metastases. Patients with only micrometastases were younger than those with established metastases, but there were no differences in T site, T stage or sex. The outcome (2-6 years postsurgery) of patients with only micrometastases was similar to those without cervical node metastases. Hence, the main short-term significance of micrometastases seems to be in relation to clinical staging and elective management of the NO neck.

Magnetic resonance imaging in the assessment of cervical nodal metastasis in oral squamous cell carcinoma

OBJECTIVE

The accurate pre-operative assessment of cervical lymph nodes is a well recognized problem in the management of patients with oral squamous cell carcinoma. Imaging techniques have improved the accuracy of staging but cannot determine if nodal enlargement is due to reactive changes or malignant involvement. We assessed the diagnostic performance of magnetic resonance imaging (MRI) in detecting metastatic disease within the neck in oral cancer patients.

MATERIALS AND METHODS

A retrospective study was performed on 58 patients treated for oral squamous cell carcinoma. All patients had pre-operative MR imaging including axial and coronal short tau inversion recovery (STIR) sequences and pre- and post-gadolinium axial T1 weighted sequences. Nineteen patients had bilateral neck dissections giving 77 sides of neck for study. MR images were reviewed for nodal involvement at each anatomical level within the neck and correlated with findings at histology.

RESULTS

Twenty-seven of the 77 sides of neck contained histologically positive nodes (35.1%). MRI sensitivity was 66.7% and specificity 68%. There was a false-negative rate of 20.9% and false-positive rate of 47.1%. Some enlarged, histologically positive nodes were not detected by MRI. Furthermore, in five cases the only histological evidence of nodal malignancy was the presence of a micrometastasis (<3 mm tumour deposit). MRI detected two of these.

CONCLUSION

MRI lacks sufficient sensitivity and specificity to replace elective neck dissection for both staging and prognostic purposes.

Management of the N(0) neck

Paramount among the challenges and controversies among the head and neck surgeon is the proper treatment of the N0 neck. Therapeutic intervention for the N0 neck usually involves any of two treatment modalities alone or in combination: surgery or radiation therapy. This article discusses the potential treatment strategies for possible subclinical neck metastasis and the rationale for their use on a site by site basis for head and neck primary tumors.

Ultrasonographic evaluation of small cervical lymph nodes in head and neck cancer

To establish sonographic criteria for differentiating metastasis and nonmetastasis in small cervical lymph nodes, correlations between sonographic parameters and histological diagnosis were statistically examined in 117 lymph nodes with maximal diameter of up to 10 mm in the sonographic findings, consisting of 26 metastatic and 91 nonmetastatic nodes. The equations obtained with logistic regression analysis showed lambda predictive values of -1.5 and 0.5 as effective cutoff-point criteria, and were considered to be a reliable indicator for differentiating small nodes with predictive values outside of -1.5 < lambda < 0.5. The sensitivity, specificity and accuracy with predictive values outside of -1.5 < lambda < 0.5 were 83%, 97% and 95%, respectively.