Ultrasound and fine needle aspiration cytology in the staging of neck lymph nodes in oral squamous cell carcinoma

N0 neck trial: Does intensification of follow-up (Ultrasound + Physical Examination) influence outcomes in early-stage oral cancer?

AIM OF THE STUDY

We previously reported a survival benefit of elective neck dissection (END) over therapeutic neck dissection (TND) in patients with clinically node-negative early-stage oral cancer. We now report the results of the second question in the same study addressing the impact of adding neck ultrasound to physical examination during follow-up on outcomes.

METHODS

Patients with lateralized T1/T2 oral squamous cell carcinoma (SCC) were randomized to END or TND and to follow-up with physical-examination plus neck ultrasound (PE+US) versus physical-examination (PE). The primary endpoint was overall survival (OS).

RESULTS

Between January 2004 and June 2014, 596 patients were enrolled. This is an intention to treat analysis of 592 analysable patients, of whom 295 were allocated to PE+US and 297 to PE with a median follow-up of 77.47 months (interquartile range (IQR) 54.51-126.48). There was no significant difference (unadjusted hazard ratio [HR], 0.92, 95% CI, 0.71-1.20, p = 0.54) in 5-year OS between PE+US (70.8%, 95% CI, 65.51-76.09) and PE (67.3%, 95% CI, 61.81-72.79). Among 131 patients with neck node relapse as the first event, the median time to relapse detection was 4.85 (IQR 2.33-9.60) and 7.62 (IQR 3.22-9.86) months in PE+US and PE arms, respectively. The N stage in the PE+US arm was N1 33.8%, N2a 7.4%, N2b/c 44.1% and N3 14.7% while in PE was N1 28.6%, N2a 9.5%, N2b/c 39.7%, N3 20.6% and unknown 1.6%.

CONCLUSION

Adding neck ultrasound to physical examination during follow-up detects nodal relapses earlier but does not improve overall survival.

The use of a battery of examination methods for detection of cervical metastases in squamous cell carcinoma of the oral cavity

INTRODUCTION

In patients with squamous cell carcinoma of the orofacial area, the presence of cervical metastases represents a single most significant prognostic factor. This fact underlines the importance of thorough examination of the cervical lymph nodes for potential tumor involvement. To verify this, the most common investigative methods are physical examination (PE), sonography (US) and computed tomography (CT), which have also been used to assess the stage of the disease in the patients in our research.

OBJECTIVE

To evaluate the performance of individual methods (physical examination, sonography, computed tomography) and combinations.

METHOD

Patients with squamous cell carcinoma of the oral cavity, who had undergone physical, US and CT examinations at our department followed by radical neck dissection were included in this retrospective study. A total of 57 patients were included.

RESULTS

The sensitivity of PE, US and CT were 38%, 69% and 61%, respectively, however CT+US combination yielded 83% sensitivity and combination of all these methods 86% sensitivity. The number of false positives was however relatively high with specificity of the 3-way combination at 65%.

CONCLUSION

A combination of our three widely available inexpensive methods detected 86% of metastases in cervical nodes. The large number of false positives however indicates that the method should rather be used for screening in selecting patients who need additional and more expensive imaging than for diagnosing cervical metastases. Also, as 14% of cervical metastases pass undetected using our method, we would recommend an additional examination at least by US+PE several weeks to a few months after the initial examination.

Touch Imprint Cytology: Can It Serve as an Alternative to Frozen Section in Intraoperative Assessment of Cervical Metastasis in Oral Squamous Cell Carcinoma?

PURPOSE

The purpose was to assess the diagnostic accuracy of touch imprint cytology (TIC) compared with frozen section (FS) analysis as an intraoperative diagnostic tool to assess nodal metastasis in oral squamous cell carcinoma.

MATERIALS AND METHODS

We intraoperatively assessed 38 patients undergoing neck dissection for oral squamous cell carcinoma, wherein a total of 248 nodes were sectioned and subjected to TIC and, subsequently, FS analysis and were finally submitted to the gold-standard histopathologic examination. The sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) of TIC and FS analysis for the detection of metastasis in the cervical nodes were determined with the corresponding 95% confidence intervals.

RESULTS

TIC had a sensitivity of 62.86%, specificity of 96.24%, PPV of 73.33%, NPV of 94.04%, and accuracy of 91.53% compared with histopathologic results. The sensitivity of FS analysis was 60%, specificity was 98.12%, PPV was 84%, NPV was 93.72%, and accuracy was 92.74% compared with histopathologic examination. These results of TIC were comparable to those of FS analysis.

CONCLUSIONS

TIC is a straightforward, quick, and reliable technique. It has a definitive role in being used as an adjunct to FS analysis to increase intraoperative diagnostic accuracy. It can serve as a useful technique in centers that do not have FS availability.

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.

Analysis of sentinel node biopsy combined with other diagnostic tools in staging cN0 head and neck cancer: A diagnostic meta-analysis

BACKGROUND

The purpose of this was to find a staging strategy sensitive enough to reduce the risk of occult metastases in cN0 head and neck cancer to below 15% to 20%.

METHODS

A total of 73 articles were selected for analysis of the diagnostic performance in staging cN0 head and neck cancer. Hypothetical estimation of negative predictive value (NPV) was calculated based on the Bayesian theory.

RESULTS

The pooled estimates for sensitivity were 56.4% and 84.9% for ultrasound-guided fine-needle aspiration (FNA) and sentinel node biopsy (SNB). The pooled estimates for sensitivity were 47.0%, 56.6%, 48.3%, and 63.3% for CT, MRI, positron emission tomography (PET), and ultrasound, respectively. The pooled estimates for specificity were 88.9%, 82.5%, 86.2%, and 79.1% for CT, MRI, PET, and ultrasound. In estimation, the CT or MRI with SNB strategies had NPV higher than 85% even when the pretest metastatic rate was 60%.

CONCLUSION

The SNB procedure has the best performance. A combination of CT/MRI and SNB for cN0 head and neck cancer is preferred.

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.

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.

Analysis of selected risk factors for nodal metastases in head and neck cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (cSCC) accounts for 20% of all skin malignancies and 20% of deaths. In contrast to mucosal SCC, treatment results are very good. However, regional metastases are present in 5-20% of cases, and the prognosis for patients with metastases is 50% lower. It has been reported that several risk factors are responsible for the head and neck lymph node regional metastasis, such as: poor cell differentiation, local recurrence, immunosuppression, and tumour dimension. Multivariate analysis of metastatic neck lesions in head and neck cSCC. Retrospective analysis of patients treated at our department for head and neck cSCC. The study includes 100 patients: 66 males (66%) and 34 females (34%), aged 26-98 years (mean age 74.6). The tumour was evaluated for: sex predilection, local recurrence, stage (according to 7th edition of American Joint Committee on Cancer TNM staging), differentiation, and site. Most patients (79 cases; 79%) were treated for primary cSCC, while the other 21 patients presented local recurrence of cSCC. Neck metastases were diagnosed in five patients with primary cSCC and in three with recurrent cSCC. No distant metastasis was observed. The most common tumour location was the auricle (29 cases; 29%). Neck dissection was performed most frequently in patients with lip tumours (17/22 cases; 77%). Neck metastasis was diagnosed most often in patients with cSCC on the lip (2 patients) and buccal region (2 patients). The most common tumour location in males was the auricle (25/66 cases; 38%) whereas in females the nasal and buccal regions were the most common locations, with 8 patients each (8/34 cases; 23%). Neck dissection was performed in 20 of the 66 males (30%) and in 12 of the 34 females (35%). Neck metastasis was confirmed in 5 females (15%) and 3 males (5%). The most common histopathological tumour stage was G2 (57 cases; 57%). Of the eight patients with confirmed neck metastasis, four had poorly-differentiated (histopathological stage G3). Thus, 4 of the 24 patients (17%) with stage G3 tumours experienced metastasis. Our findings suggest that factors such as local recurrence, degree of cell differentiation, tumour dimension and/or location, can increase the risk of neck metastases. For this reason, in patients with such risk factors, neck dissection should be considered to evaluate for metastatic lesions.

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.

Detection of cervical lymph node metastasis in head and neck cancer patients with clinically N0 neck-a meta-analysis comparing different imaging modalities

BACKGROUND

How to properly manage clinically negative neck of head and neck cancer patients is a controversial topic. Research is now directed toward finding a method sensitive enough to bring the risk of occult metastases below 20%. The aim of this review was to compare the diagnostic accuracy of different imaging modalities, including CT, MRI, PET and US, in clinically N0 head and neck cancer patients.

METHODS

For this systematic review and meta-analysis, PubMed and the Cochrane Database were searched for relevant original articles published up to May 2011. Inclusion criteria were as follows: articles were reported in English; CT, MRI, PET or US were performed to identify cervical metastases in clinically N0 head and neck squamous cell carcinoma; and data were sufficient for the calculation of true-positive or false-negative values. A bivariate random effect model was used to obtain pooled sensitivity and specificity. The positive and negative test probability of neck metastasis was generated based on Bayesian theory and collected data for different pre-test possibilities.

RESULTS

Of the 168 identified relevant articles, 7 studies fulfilled all inclusion criteria for CT, 6 studies for MRI, 11 studies for PET and 8 studies for US. There was no difference in sensitivity and specificity among these imaging modalities, except CT was superior to US in specificity. The pooled estimates for sensitivity were 52% (95% confidence interval [CI], 39% ~ 65%), 65% (34 ~ 87%) 66% (47 ~ 80%), and 66% (45 ~ 77%), on a per-neck basis for CT, MRI, PET and US, respectively. The pooled estimates for specificity were 93% (87% ~ 97%), 81% (64 ~ 91%), 87% (77 ~ 93%), and 78% (71 ~ 83%) for CT, MRI, PET and US, respectively. With pre-examination nodal metastasis probabilities set at 10%, 20% and 30%, the post-exam probabilities of positive nodal metastasis rates were 47%, 66% and 77% for CT; 27%, 46% and 59% for MRI; 36%, 56% and 69% for PET; and 25%, 42% and 56% for US, respectively. Negative nodal metastasis probabilities were 95%, 89% and 82% for CT; 95%, 90% and 84% for MRI; 96%, 91% and 86% for PET; and 95%, 90% and 84% for US, respectively.

CONCLUSIONS

Modern imaging modalities offer similar diagnostic accuracy to define and diagnose clinically N0 neck. Minimizing morbidity and avoiding elective neck dissection is acceptable in some select cases.

cTNM vs. pTNM: the effect of not applying ultrasonography in the identification of cervical nodal disease

Accurate clinical staging of oral squamous cell cancer can be quite difficult to achieve especially if nodal involvement is identified. Radiologically-assisted clinical staging is more accurate and informs the clinician of loco-regional and distant metastasis.In this study, we compared clinical TNM (cTNM) staging (not including ultrasonography) to pathological TNM (pTNM) staging in 245 patients presenting with carcinoma of the oral cavity and the oro-pharyngeal region. Tumour size differences and nodal involvement were highlighted. US reports of the neck were then added to the clinical staging and results compared.Tumour size was clinically underestimated in 4 T1, 2 T2 and 2 T3 oral diseases. Also 20 patients that were reported as nodal disease free had histological proven N1 or N2 nodal involvement; while 3 patients with cTNM showing N1 disease had histologically proven N2 disease.Overall the agreement between the 2 systems per 1 site was 86.6% (Kappa agreement = 0.80), per 2 sites 90.0% (Kappa agreement = 0.68) and per 3 sites 90.5% (Kappa agreement 0.62).An accurate clinical staging is of an utmost importance. It is the corner stone in which the surgical team build the surgical treatment plan and decide whether an adjuvant therapy is required to deal with any possible problem that might arise. The failure to achieve an accurate staging may lead to incomplete surgical planning and hence unforeseen problems that may adversely affect the patient's survival.

Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer

BACKGROUND AND PURPOSE

Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer.

MATERIALS AND METHODS

This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome.

RESULTS

Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence.

CONCLUSIONS

In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

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.

Impact of perioperative hyperbaric oxygen therapy on the quality of life of maxillofacial patients who undergo surgery in irradiated fields

From 2001 to 2005, 66 patients referred for perioperative hyperbaric oxygen therapy (HBO2) for debridement of necrotic tissue or prevention of radionecrosis were assessed with quality of life measures, before and after completion of HBO2 and surgery. The Medical Outcomes Short Form 36 (SF-36) and Hospital Anxiety and Depression Scale (HADS) showed no significant changes. The European Organisation for Research and Treatment of Cancer Core (EORTC-C30) questionnaire showed significant improvement in pain, global health, and dyspnoea (p=0.011; p=0.027; p=0.008, respectively). The Head and Neck sub-module (H&N35) identified significant improvements in teeth, dry mouth and social contact (p=0.002; p=0.038; p=0.029, respectively). The University of Washington Scale (UW), showed significant changes in relation to chewing and shoulders (p=0.031; p=0.047). When sub-group analysis using 'osteoradionecrosis' and 'dental extraction or implants' was performed on the EORTC and UW data, variations in the patterns of significance were found. Adjunctive HBO2 should be considered for the treatment and prevention of some of the long-term complications of radiotherapy.

[Systematic neck dissection in squamous cell carcinoma of the oral cavity]

OBJECTIVES

To evaluate the neck control after prior surgical management of patients with squamous cell carcinoma of the oral cavity and to quantify the ratio of patients among whom neck dissection did not have a real therapeutic value. To discuss the usefulness of the sentinel node biopsy in this group of patients.

METHOD

Retrospective analysis of patients with epidermoid carcinoma of the oral cavity who had systematically a neck dissection.

RESULTS

Thirty-nine files of patients have been processed. We found 45% patients classified pN0 (among whom about one half where classified pT4). With a mean follow-up of 19 months, we did not find any cervical lymph node relapse. Five patients died (13.5%) without any cervical disease.

CONCLUSION

The systematic cervical lymph node dissection remains the most effective means to obtain the neck control of squamous cell cancers of the oral cavity. It however was applied without therapeutic value for 45% of the patients of this series. The validation of the sentinel node concept as a method of cervical staging should make it possible to avoid this surgical procedure in more than one third of the cases.

What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck

Imaging of lymph node metastases in the neck can have two major indications: (1) prognosis and assisting with choice of treatment; (2) staging and detection of clinically occult metastases in different levels of the neck. Both indications are discussed. The role and limitations of US and US-guided fine-needle aspiration cytology are also reviewed.

Ultrasound-guided core biopsy for the diagnosis of lumps in the neck: results in 82 patients

Ultrasound-guided core biopsy of nodes (n = 78) and other lumps (n = 4) in the neck allowed a firm histological diagnosis in 76 of 82 patients (93%). Of the remaining six patients, histological examination was equivocal in four and valueless in two. Of 18 patients with a diagnosis of lymphoma only 3 required excision of the node to provide additional information for the planning of treatment.

Ultrasonographic changes in malignant neck nodes during radiotherapy in head and neck squamous carcinoma

Limited information is available about the sonomorphological changes in metastatic neck nodes during radiotherapy. The aim of this study was to evaluate the pattern of sonomorphological changes in metastatic neck nodes with radiotherapy. The study population consisted of 16 consecutive patients planned for radical radiotherapy to the head and neck. All patients were subjected to four ultrasound examinations: before therapy, at 46 Gy, at the conclusion of radiation and at first follow up. A total of 59 ultrasound examinations were performed on 16 patients. The difference between the mean number of nodes detected per patient before (10.6) and after (7.8) radiation was significant (P = 0.05). Sixteen nodes were categorized as malignant at first sonography, half of which reverted back to normal by the end of radiation. Changes in the sonomorphology of malignant cervical lymph nodes occur with radiotherapy with more that half demonstrating reversion to normal pattern. Future studies correlating this with histopathology should be considered.