Lymphoma presenting in the neck: current concepts in diagnosis

Differentiation of cancer of unknown primary and lymphoma in head and neck metastatic poorly differentiated cancer using 18 F-FDG PET/CT tumor metabolic heterogeneity index

OBJECTIVE

To explore the value of 18 F-FDG PET/CT tumor metabolic heterogeneity index (HI) and establish and validate a nomogram model for distinguishing head and neck cancer of unknown primary (HNCUP) from lymphoma with head and neck metastatic poorly differentiated cancer.

METHODS

This retrospective analysis was conducted on 1242 patients with cervical metastatic poorly differentiated cancer. 108 patients, who were clinically and pathologically confirmed as HNCUP or lymphoma, were finally enrolled. Two independent sample t-tests and χ 2 test were used to compare the clinical and imaging features. Binary logistic regression was used to screen for independent predictive factors.

RESULTS

Among the 108 patients), 65 patients were diagnosed with HNCUP and 43 were lymphoma. Gender ( P  = 0.001), SUV max ( P  < 0.001), SUV mean ( P  < 0.001), TLG ( P  = 0.012), and HI ( P  < 0.001) had statistical significance in distinguishing HNCUP and lymphoma. Female ( OR  = 4.546, P  = 0.003) and patients with HI ≥ 2.37 ( OR  = 3.461, P  = 0.047) were more likely to be diagnosed as lymphoma.

CONCLUSION

For patients with cervical metastatic poorly differentiated cancer, gender and HI were independent predictors of pathological type. For such patients, clinical attention should be paid to avoid misdiagnosing lymphoma as HNCUP, which may delay treatment.

The diagnostic performance of ultrasound-guided core biopsy in the diagnosis of head and neck lymphoma: results in 226 patients

Many clinical guidelines for investigating lymphomas advise that surgical excision biopsy (SEB) should be performed for a confident diagnosis. It is increasingly recognized in clinical practice that ultrasound-guided core needle biopsy (USCNB) is a reliable diagnostic technique. We aimed to investigate the diagnostic efficacy of USCNB in head and neck lymphoma. A retrospective analysis of all diagnosed head and neck lymphomas between 2013 and 2018 was performed. Patient records, radiology and histopathology reports along with the biopsy technique: fine needle aspiration cytology (FNAC), USCNB, and SEB used were reviewed. The technique providing diagnosis and leading to initiation of treatment was identified. Two-hundred and thirty patients and 267 biopsy samples were included. A total of 226 patients underwent USCN. In 215 of 226 (95.1%) USCNB patients were fully diagnostic allowing for initiation of oncological treatment; 11 patients required a subsequent SEB to provide diagnosis. In four patients, SEB was the only investigation performed. Of the USCNB total number of procedures (number of patients n=230 is the same coincidentally as the number of USCNB procedures), 215 of 230 (93.5%) were fully diagnostic samples. In the majority of cases, USCNB provided a definitive diagnosis allowing initiation of oncological treatment, avoiding the need for SEB. USCNB should be considered the first-line diagnostic modality in appropriate cases, as it reduces time to initiate treatment, costs and avoids patients having to undergo unnecessary surgery and possible complications.

The Predictive Value of Neutrophil-to-Lymphocyte Ratio for Hodgkin's Lymphoma Diagnosis in Patients with Asymptomatic Cervical Lymphadenopathy

In patients with asymptomatic cervical lymphadenopathy, the physician often has to choose between evaluation via follow-up or open biopsy. Follow-up evaluation may lead to a delayed diagnosis of lymphoma, while an open biopsy is associated with surgical risks and costs. This dilemma can be avoided using predictive parameters. In the present study, we aimed to investigate whether neutrophil-to-lymphocyte ratio (NLR), a parameter which can be assessed quickly with ease and at low cost, has predictive value for Hodgkin's lymphoma diagnosis in patients with asymptomatic cervical lymphadenopathy. A total of 46 patients with asymptomatic cervical lymphadenopathy who underwent open biopsy were included in the study. Based on the biopsy results, the patients were divided into two groups, Hodgkin lymphoma (26 patients) and reactive lymphadenopathy (20 patients). The mean NLR in the groups was calculated and compared based on the results of complete blood count performed before biopsy. We found that mean NLR (P = 0.022) and mean neutrophil count (P = 0.046) were higher and mean lymphocyte count was lower (P = 0.054) in patients with Hodgkin's lymphoma compared to those in patients with reactive lymphadenopathy. Our results indicate that a high NLR may have predictive value for Hodgkin's lymphoma diagnosis in patients with asymptomatic cervical lymphadenopathy.

Sonographic diagnosis in the head and neck region: from an educational lecture presented at the 56th General Assembly and Annual Scientific Congress of the Japanese Society for Oral and Maxillofacial Radiology

Sonography is a simple, inexpensive, and non-invasive diagnostic modality. Although tissues behind bony structures and deep tissues are not delineated, sonography can depict superficial soft tissues very clearly. In the head and neck region, however, it has not yet been used widely, as the anatomical structures are complicated, and considerable experience is needed both to perform an examination and to make a diagnosis. To perform examinations efficiently, operators must be familiar with the sonographic system in use, and take images at standard planes. To make a correct diagnosis, operators require knowledge of the sonographic anatomy on standard planes, representative sonographic signs and artifacts, and common diseases and their typical sonographic findings. In this paper, we have explained the sonographic anatomy on standard planes, and the sonographic findings of common diseases in the oral and maxillofacial region.

Cervical lymphadenopathy: can the histogram analysis of apparent diffusion coefficient help to differentiate between lymphoma and squamous cell carcinoma in patients with unknown clinical primary tumor?

PURPOSE

To retrospectively evaluate the value of whole-lesion histogram analysis of apparent diffusion coefficient (ADC) maps in differentiating between lymphoma and metastatic squamous cell carcinoma (SCC) of unknown clinical primary in neck nodes.

METHODS

A total of 39 patients, 20 affected by lymphoma and 19 affected by metastatic non-nasopharyngeal SCC, were included in this retrospective study. All patients underwent MR imaging with a 1.5 T scanner system, including diffusion-weighted imaging (DWI) with three different b values (b = 0, 500 and 800 s/mm²). The entire tumor volume was manually delineated on the ADC maps, using the T2-weighted images and DWIs with b = 800 s/mm² as a guide to the lesion location. The Mann-Whitney rank-sum test for independent samples was performed to compare the histogram parameters of patients with lymphoma and SCC.

RESULTS

The SCCs showed significantly higher median ADC (ADC_median) and mean ADC (ADC_mean) values, compared to lymphomas (p < 0.001), while they exhibited lower kurtosis and skewness without reaching significance (p = 0.066 and 0.148, respectively). The ADC_mean and ADC_median had the best discriminative powers for differentiating lymphoma and SCC, with an area under the curve of 87% and 85%, respectively. The optimal cutoff values for ADC_mean and ADC_median as predictors for lymphoma were ≤ 0.83 × 10^-3 mm²/s and ≤ 0.73 × 10^-3 mm²/s, respectively.

CONCLUSIONS

The whole-lesion ADC histogram analysis of cervical lymphadenopathy may help to discriminate lymphomas from non-nasopharyngeal SCC in patients with unknown clinical primary tumor.

Assessment of Neck Lumps in Relation to Dentistry

Neck lumps have a varied aetiology, from a benign inflammatory cause to the first presenting sign of a malignancy. Patients may present to primary care complaining of a neck lump or they may be identified as an incidental finding during routine examination. This article highlights a structured approach to the initial assessment including history taking, risk factor assessment and clinical examination. Further investigations undertaken in a secondary care setting, such as ultrasound and guided fine needle aspirations, are then discussed. The common congenital, inflammatory, infective, vascular and neoplastic causes of neck lumps and their management and specialist referral pathway are discussed.

Level 5 Lymphadenopathy Warrants Heightened Suspicion for Clinically Significant Pathology

We conclude that patients presenting with level 5 lymphadenopathy should be investigated with heightened clinical vigilance. Our results suggest that up to 80 % will harbour clinically significant pathology requiring further medical treatment, three quarters of which will be malignancy. We report an observational study of histological outcomes of level 5 lymph node biopsies from a regional histopathology department across 5 years. 184 subjects were identified as having a biopsy of a lymph node from the level 5 region within the study period. One hundred and fifty six cases (84.8 %) had clinically significant pathology on final histology requiring further medical treatment. Lymphoma accounted for the highest number of cases (n = 72, 39.1 %), followed by metastatic carcinoma (n = 65, 35.3 %) and granulomatous change (n = 17, 9.2 %). Gender and laterality were not shown to be independent predictors of pathology significance (p > 0.05).

[What would you do with an adult patient who complains of a neck mass?]

Family physicians frequently encounter patients with neck mass. There are multiple causes that range from no clinical importance to malignant tumours. The critical challenge for the primary care physician is to identify which cases are secondary to malignancies or other serious conditions. With a good knowledge of the complex anatomy of the neck and a careful clinical history, including a complete physical examination, the different causes can be narrowed down, as well as to differentiate between significant and non-significant neck masses and select the appropriate studies. Lymphoma commonly presents as a painless enlarged lump in the neck, as in the case of the patient presented. An algorithm is provided to help practioners.

Surgeon-performed ultrasound-guided fine-needle aspiration cytology of head and neck mass lesions: sampling adequacy and diagnostic accuracy

BACKGROUND

Studies of surgeon-performed ultrasound-guided fine-needle aspiration cytology (US-FNAC) have been limited largely to thyroid nodules. This study evaluated the sampling adequacy and diagnostic accuracy of surgeon-performed US-FNAC for a large range of head and neck mass lesions, including lesions of the thyroid, salivary glands, and lymph nodes.

METHODS

The study included 617 cases of US-FNAC performed by a single surgeon between 2009 and 2013. Their medical histories and ultrasound (US) findings were retrospectively reviewed. Sample adequacy was analyzed according to the surgeon's experience, anatomic tumor location, and US tumor characteristics. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of FNAC were calculated after correlation with the surgical histopathologic results.

RESULTS

The overall adequacy rate for surgeon-performed US-FNAC was 91.9 % (567/617). Inadequate specimens were obtained from 9.7 % (29/282) of the thyroid glands, 6.1 % of the salivary glands (6/98), and 6.3 % (15/237) of the lymph nodes. The effect of the surgeon's experience plateaued (inadequate sampling rate, 6-8 %) after 100 US-FNAC procedures. Inadequate sampling was associated with tumor characteristics such as cystic change and rim calcification. Overall, US-FNAC showed a sensitivity of 88.2 %, a specificity of 98.2 %, a PPV of 98.5 %, an NPV of 85.7 %, and a diagnostic accuracy of 91.6 %.

CONCLUSION

With proper training and experience managing at least 100 US-FNAC cases, surgeons can ensure a low inadequate sampling rate and good diagnostic accuracy for a range of head and neck mass lesions.