The diagnostic value of ultrasonography to detect occult lymph node involvement at different levels in patients with squamous cell carcinoma in the maxillofacial region

Assessment of the Diagnostic Accuracy of Baseline Clinical Examination and Ultrasonographic Imaging for the Detection of Lymph Node Metastasis in Patients With High-risk Cutaneous Squamous Cell Carcinoma of the Head and Neck

IMPORTANCE

Patients with cutaneous squamous cell carcinoma (SCC) of the head and neck may develop lymph node metastasis; therefore, additional workup of the regional lymph nodes in these patients should be considered. However, there is uncertainty regarding the value of baseline ultrasonographic imaging in addition to clinical examination for the detection of metastasis.

OBJECTIVE

To assess the diagnostic accuracy of clinical examination and baseline ultrasonography for the detection of metastasis among patients with high-risk cutaneous SCC of the head and neck and to assess the accuracy of ultrasonography when baseline clinical examination produces negative results.

DESIGN, SETTING, AND PARTICIPANTS

This diagnostic study was conducted among a retrospective cohort of 233 patients with 246 high-risk cutaneous SCC tumors of the head and neck. The study included all patients with high-risk cutaneous SCC of the head and neck who received clinical examination and baseline ultrasonographic imaging of their lymph nodes at the Erasmus Medical Center Cancer Institute, a tertiary referral hospital for patients with skin cancer in Rotterdam, the Netherlands, between January 1, 2015, and December 31, 2017. Data were analyzed from October 13, 2020, to September 29, 2021.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Fine-needle aspiration cytologic biopsy and 6 months of follow-up per patient were used as the reference standards.

RESULTS

Among 233 patients (176 men [75.5%]; median age, 79.1 years [IQR, 71.5-83.7 years]; data on race and ethnicity were not collected) with 246 high-risk cutaneous SCC tumors of the head and neck, 20 metastases were cytologically confirmed at baseline, and 2 metastases were detected during 6 months of follow-up, yielding a 9% metastasis rate. The sensitivity of clinical examination was 50% (95% CI, 28%-72%), and the specificity was 96% (95% CI, 93%-98%). The PPV and NPV were 55% (95% CI, 36%-72%) and 95% (95% CI, 93%-97%), respectively. In the total cohort, ultrasonography had a sensitivity of 91% (95% CI, 71%-99%) and a specificity of 78% (95% CI, 72%-83%), with a PPV of 29% (95% CI, 23%-35%) and an NPV of 99% (95% CI, 96%-100%). In the group of patients with negative results at baseline clinical examination, 9 of 11 metastases were detected by ultrasonography, with 82% sensitivity (95% CI, 48%-98%); specificity was 79% (95% CI, 73%-84%), PPV was 17% (95% CI, 12%-23%), and NPV was 99% (95% CI, 96%-100%).

CONCLUSIONS AND RELEVANCE

In this diagnostic study, among a cohort of patients with high-risk cutaneous SCC of the head and neck, baseline ultrasonography was more sensitive than clinical examination alone for the detection of lymph node metastasis. In the setting of a negative result at baseline clinical examination, ultrasonography had high sensitivity for detecting nodal metastases, but this sensitivity should be evaluated against the high rate of false-positive findings.

Recent Advanced in the Treatment of Advanced SCC Tumors

Squamous cell carcinoma (SCC) is the second most frequent form of skin cancer after basal cell carcinoma. While most SCC can be treated by surgery or radiotherapy, some progress into an advanced form and are no longer suitable for these treatments. Guidelines and staging systems have help to define these advanced SCC (aSCC), for which prognosis was very poor until recently. Platin-based chemotherapy was traditionally used, but few prospective trials and no treatment regimen was recommended. Furthermore, toxicity in elderly patients limited its use. The development of immunotherapy has improved the prognosis of these difficult-to-treat aSCC. In this review, we define high risk and aSCC and explored current treatment strategies for these tumors.

Approaches to Perineural, Lymphovascular, and Single-Cell Disease

BACKGROUND

Mohs micrographic surgeons should be adept in identifying and managing perineural invasion (PNI), lymphovascular invasion (LVI), and single-cell spread (SCS), features denoting high-risk behavior of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC) and microcystic adnexal carcinoma (MAC).

OBJECTIVE

The purpose of this article is to review the literature and guidelines regarding the diagnosis of PNI, LVI, and SCS in BCC, cSCC, and MAC and examine the role of advanced diagnostic studies, adjuvant therapy, and reconstructive techniques of these high-risk tumors.

MATERIALS AND METHODS

We performed a literature search including the following terms: PNI, LVI, SCS, BCC, cSCC, keratinocyte carcinoma, MAC, sentinel lymph node biopsy, radiation, chemotherapy, and staging. Relevant studies, case reports, and review articles were included, as well as National Comprehensive Cancer Network guidelines.

RESULTS

Pancytokeratin immunohistochemistry may aid in the diagnosis of high-risk features of BCC and cSCC. Reconstruction of the Mohs defect should be carefully considered to allow for thorough inspection. Radiation therapy should be considered as an adjuvant treatment option for high-risk cSCC and BCC. Close surveillance for recurrence is warranted.

CONCLUSION

The Mohs surgeon should be competent in identification of high-risk tumors and to understand how best to manage, further treat, and follow these tumors.

Incidental Findings on Cone Beam Computed Tomography Studies outside of the Maxillofacial Skeleton

Objective. To define the presence and prevalence of incidental findings in and around the base of skull from large field-of-view CBCT of the maxillofacial region and to determine their clinical importance. Methods. Four hundred consecutive large fields of view CBCT scans viewed from January 1, 2007, to January 1, 2014, were retrospectively evaluated for incidental findings of the cervical vertebrae and surrounding structures. Findings were categorized into cervical vertebrae, intracranial, soft tissue, airway, carotid artery, lymph node, and skull base findings. Results. A total of 653 incidental findings were identified in 309 of the 400 CBCT scans. The most prevalent incidental findings were soft tissue calcifications (29.71%), followed by intracranial calcifications (27.11%), cervical vertebrae (20.06%), airway (11.49%), external carotid artery calcification (10.41%), lymph node calcification (0.77%), subcutaneous tissue calcification and calcified tendonitis of the longus colli muscle (0.3%), and skull base finding (0.15%). A significant portion of the incidental findings (31.24%) required referral, 17.76% required monitoring, and 51% did not require either. Conclusion. A comprehensive review of the CBCT images beyond the region of interest, especially incidental findings in the base of skull, cervical vertebrae, pharyngeal airway, and soft tissue, is necessary to avoid overlooking clinically significant lesions.

Merkel cell carcinoma: An algorithm for multidisciplinary management and decision-making

Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine tumor of the skin. Therapeutic approach is often unclear, and considerable controversy exists regarding MCC pathogenesis and optimal management. Due to its rising incidence and poor prognosis, it is imperative to establish the optimal therapy for both the tumor and the lymph node basin, and for treatment to include sentinel node biopsy. Sentinel node biopsy is currently the most consistent predictor of survival for MCC patients, although there are conflicting views and a lack of awareness regarding node management. Tumor and node management involve different specialists, and their respective decisions and interventions are interrelated. No effective systemic treatment has been made available to date, and therefore patients continue to experience distant failure, often without local failure. This review aims to improve multidisciplinary decision-making by presenting scientific evidence of the contributions of each team member implicated in MCC management. Following this review of previously published research, the authors conclude that multidisciplinary team management is beneficial for care, and propose a multidisciplinary decision algorithm for managing this tumor.

Sonographic Evaluation of Cervical Lymphadenopathy; Comparison of Metastatic and Reactive Lymph Nodes in Patients With Head and Neck Squamous Cell Carcinoma Using Gray Scale and Doppler Techniques

Background:

Cervical lymphadenopathy could be seen in several pathologic processes. An accurate differentiation between these conditions is of utmost importance to select an appropriate therapy and assess the prognosis. Gray scale and Doppler are appropriate sonographic techniques for evaluating internal and external features of lymph nodes. Although, various criteria have been proposed to differentiate metastatic lymph nodes from benign ones, the most valuable and specific sonographic features are still under dispute.

Objectives:

The present study was designed to determine valuable sonographic features for differentiating metastasis from benign nodes using gray scale and Doppler sonography.

Patients and Methods:

A prospective diagnostic study was performed on 63 patients with head and neck squamous cell carcinoma (SCC) treated and referred to surgery clinic of Hazrat Rasoul Akram hospital from November 2010 to June 2012 with complaint of palpable cervical lymph node. All patients’ necks were scanned multidirectionally by gray-scale and Doppler techniques. After sonography, lymph nodes were biopsied and investigated to find out whether they were metastatic or reactive. Finally, demographic, sonographic and pathologic data were statistically analyzed by SPSS ver. 16 software using t-test, a nonparametric test and ROC analysis. Ninety five percent confidence interval was considered for all parameters.

Results:

The study included 41 males and 22 females with a mean age of 57.56 ± 13.79 years. The number of metastatic lymph nodes was 47, while the remaining 16 were reactive. There were significant differences in length (P = 0.037), width (P = 0.001), resistance index (P < 0.001), pulsatility index (P < 0.001) and systolic velocity (P < 0.001) of metastatic and reactive lymph nodes. Cut points for resistive and pulsatility indexes and systolic velocity were calculated as 0.695, 1.35 and 16.5, respectively. The most valuable factor for defining a lymph node as metastatic was circulation pattern with accuracy, sensitivity and specificity of 94%, 85% and 93%, respectively.

Conclusion:

Gray scale sonography in combination with Doppler sonography could be a trustworthy technique in differentiating metastatic lymph nodes from reactive ones. Although, circulation pattern had a higher diagnostic accuracy in the present study, combination of sonographic characteristics could be more beneficial in differentiating metastatic cervical nodes from reactive ones.

Loco-regional recurrence after surgical treatment of oral squamous cell carcinoma: Proposals for follow-up imaging based on literature, national guidelines and institutional experience

The recurrence rate following the treatment of oral squamous cell carcinoma (OSCC) by primary surgery is about 10%-26%. The earliest possible diagnosis of residual tumour, recurrence of local tumour disease, and subsequent metastasis is essential for an improvement of the overall survival and of the survival period for affected patients. No international consensus exists for a post-therapeutic surveillance schedule for OSCCs. Based on a review of the literature, existing guidelines, and our institutional experience, we have established an algorithm for the follow-up of these patients regarding the timing and techniques of postoperative imaging. We recommend a follow-up interval of 6 weeks during the first half-year after discharge from hospital by single clinical and alternating clinical check-ups combined with computed tomography (CT) or magnetic resonance imaging (MRI), followed by an interval of 3 months in the second half-year, with clinical and radiological check-ups. In year 2, we recommend a follow-up interval of 3 months with single clinical and alternating clinical check-ups combined with CT or MRI. In year 3, we recommend screening every 6 months, both clinically and via imaging, because of the decreased risk of recurrence. From year 5 onwards, our recommendation is a clinical and imaging-based examination every 6-12 months, depending on patient risk factors and disease progression. Four standard imaging techniques, namely positron emission tomography (PET), CT, MRI, and ultrasound (US), are discussed concerning their range of application, sensitivity, and specificity. Furthermore, the technical aspects of our institutional protocols are described in detail. In highly frequented head and neck cancer centres, PET and US are of secondary importance, since CT and MRI are nowadays highly efficient tools in primary diagnostic and post-therapeutic surveillance.

Imaging in patients with merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine tumor of the skin with a mortality rate of approximately 25% (Peloschek et al., 2010). Accurate assessment of nodal involvement in patients with MCC predicts significantly overall outcome (Smith et al., 2012 and Ortin-Perez et al., 2007). Due to the rarity of this highly aggressive disease, only a few imaging reports on MCC were published, and subsequently still to date no accepted imaging algorithm for MCC is available. For primary staging of MCC, general recommendations have included ultrasonography, chest X-ray CT, and MRI, but recent articles show that the use of sentinel node and FDG-PET/PET-CT is gaining more and more importance.

One-step nucleic acid amplification for detecting lymph node metastasis of head and neck squamous cell carcinoma

OBJECTIVES

Lymph node stage is an important prognostic factor in head and neck squamous cell carcinoma (HNSCC). We previously reported the clinical usefulness of sentinel lymph node biopsy diagnosed by genetic analysis using quantitative RT-PCR. However, this method takes about 3h. In this study, we attempted to develop a more efficient method for the intraoperative genetic detection of lymph node metastasis in HNSCC.

MATERIALS AND METHODS

A total of 312 lymph nodes (65 patients) were diagnosed by the one-step nucleic acid amplification (OSNA) method using GD-100. OSNA consists of a short homogenization step followed by amplification of cytokeratin 19 (CK19) mRNA directly from the lysate. Each lymph node was divided into two to diagnose metastasis. One half was used for the OSNA assay, and the other was subjected to semi-serial sectioning, sliced at 200-μm intervals and examined by H&E and cytokeratin AE1/AE3 immunohistochemical staining. The accuracy of OSNA assay was evaluated based on histopathological diagnosis.

RESULTS

Sixty-one of 312 lymph nodes were pathologically metastasis-positive. The overall concordance rate between the OSNA assay using breast cancer criteria and histopathology was 94.2%. The optimal cut-off for the copy number of CK19 mRNA in assessing lymph node metastasis of HNSCC was 300 copies/μl, which had the highest diagnostic accuracy (95.2%). The OSNA assay can be completed within 30 min.

CONCLUSION

The OSNA assay, which shows high sensitivity and specificity, suggests the possibility to be used as a novel tool for the genetic detection of lymph node metastasis in HNSCC patients.

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.

Elastography: the next step

In the past few decades, various tools have emerged that claim to enhance detection of oral cancer. The most important prognostic factor in patients with oral cancer is lymph node status: the presence of nodal spread decreases the 5-year survival rate by approximately 50%. Differentiation between reactive and metastatic lymphadenopathy is thus vital, and one differentiating criterion is hardness (elasticity) of the lymph node. The purpose of this review is to highlight a promising new ultrasound technique, known as elastography, which measures the characteristics of tissue compliance. The principles underlying elastography are that tissue compression produces strain (displacement) within the tissue - which is lower in harder tissues than in softer tissues - and that malignant tissues are generally harder than normal surrounding tissue. Therefore, elastography might yield clinical information useful in diagnosing cervical metastasis and improving prognosis in oral cancer. It has long been used for cancers of the breast, pancreas, and thyroid, and its use in cervical lymphadenopathy is now being explored, which could lead to great advancements in the diagnosis and prognosis of oral cancer.

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.

Clinical significance of ultrasonographic examination including detection of thyroid gland diseases when surveying cervical lymph nodes in subjects with oral squamous cell carcinoma

OBJECTIVE

The objective of this study was to evaluate the clinical significance of ultrasonography (US) for screening for thyroid gland diseases when surveying the cervical lymph nodes to detect metastasis in subjects with oral squamous cell carcinoma (SCC).

METHODS

The detection rates and characteristics of abnormal thyroid findings detected by US in 301 subjects with oral SCC were analyzed. Subjects with abnormal findings were referred to thyroid specialists and the diagnoses and treatments from these specialists were noted. The ratio of subjects who consulted a thyroid specialist after indications of thyroid gland abnormalities to analyze subject compliance was also examined. Follow-up examinations were regularly conducted to assess any changes in the thyroid gland.

RESULTS

Of the 301 subjects with oral SCC, 91 had abnormal thyroid gland findings on US. As subject age increased, the rate of detection of abnormal thyroid gland findings on US significantly increased. The rate of detection of abnormal findings in women by US was significantly higher than that in men, but the male-to-female ratio was lower compared with that in previous reports. It was demonstrated that oral SCC in the floor of the mouth was associated with the highest prevalence of abnormal findings in the thyroid gland (40%), followed by oral SCC of the maxillary gingiva (39%). Of the 91 subjects with abnormal findings, 10 showed enlargement in the size of the lesion on follow-up examination with US. Eleven subjects with no abnormal findings on initial examination showed abnormal findings on follow-up examination.

CONCLUSION

The results suggest that subjects with oral SCC have a relatively high rate of abnormal findings in the thyroid gland that can be detected by US. Scans that include the thyroid gland should be performed when surveying cervical lymph nodes for metastasis during US examination. Particular attention should be paid to thyroid gland-related diseases in older men who have oral cancer and to thyroid gland abnormalities if patients had oral SCC in the floor of the mouth or of the maxillary gingiva. It is recommended that follow-up US examinations be regularly performed in cases of oral SCC.

Exploration of ultrasonography in assessment of fascial space spread of odontogenic infections

OBJECTIVE

The aim of this study was to explore the capability of ultrasonography (USG) as an alternative imaging modality to magnetic resonance imaging (MRI) in detection of fascial space spread of odontogenic infections.

STUDY DESIGN

Forty-two fascial spaces in 16 subjects, clinically diagnosed as odontogenic infections, were included in this prospective study. The fascial space involvements were examined with USG. The results were confirmed by MRI and microbiologic tests.

RESULTS

Ultrasonography demonstrated 32 (76%) of 42 involved fascial spaces. There was 100% agreement between USG and MRI on 32 superficial space involvements, including 13 buccal, 10 submandibular, 5 canine, 2 submasseteric, 1 submental, and 1 infraorbital. Ultrasonography did not detect 4 masticator spacs, 4 parapharyngeal spacs, and 2 sublingual space involvements. Ultrasonography was able to stage infections starting from edematous change to cellulitis to complete abscess formation.

CONCLUSIONS

Ultrasonography could be considered to be an effective method in detecting and staging spread of odontogenic infections to the superficial fascial spaces. However, it might be difficult to detect deep fascial space involvements.

Current trends in extended lymph node dissection for esophageal carcinoma

Extended lymph node dissection helps increase the curativeness of resection, the accuracy of surgical-pathological staging, and the prognosis of thoracic esophageal carcinoma. However, it is also associated with significantly increased surgical morbidity and has noticeable negative effects on the quality of life after surgery. Current trends for selective lymph node dissection based on clinical evidence may be helpful in reducing surgical risks while assuring the completeness of resection.

Increased incidence of papillary thyroid microcarcinoma with decreased tumor size of thyroid cancer

The prevalence of papillary thyroid microcarcinoma (PTMC) in thyroid cancer varies from 20.0% to 42.8% with a mean of 30.0%. Most of these patients have benign clinical courses and receive less aggressive therapeutic procedures in most medical centers. This study retrospectively reviewed 30 years data in one institute and compared it with recent publications to illustrate change in trends and influence of PTMC. Incidental PTMC is usually diagnosed as a postoperative microcarcinoma following thyroidectomy for presumably benign thyroid lesions. Subtotal thyroidectomy or lobectomy without radioactive iodide treatment is sufficient to treat incidental PTMC. In contrast, aggressive surgical treatment with (131)I therapy is indicated for non-incidental PTMC. Those with PTMC in the absence of extra-thyroid invasion diagnosed by postoperative permanent section received follow-up if they had initially received subtotal thyroidectomy. In long-term follow-up studies, cancer-specific mortality for PTMC ranged from 0% to 4%. Most of the mortality cases had distant metastasis at the time of surgery. The clinical course and therapeutic strategies for the non-incidental PTMC patients depend on the TNM stage at the time of diagnosis. One-third of PTMC with clinically aggressive behavior cannot be treated as indolent disease. Invasive tumor markers or larger tumor size are useful to predict tumor recurrence or distant metastasis for PTMC.

Diagnostic imaging in Merkel cell carcinoma: lessons to learn from 16 cases with correlation of sonography, CT, MRI and PET

OBJECTIVE

The authors report imaging findings in a series of 16 patients with MCC, a rare tumour which is often managed primarily by a dermatologist. To our knowledge, no equivalent series of MCC has been described in the nuclear medicine literature.

MATERIAL AND METHODS

In this IRB-approved retrospective noncomparative case series 16 patients with biopsy-proven Merkel cell carcinoma were included between January 1999 and October 2007. Twenty-nine whole body PET scans (18F-FDG n=24, 18F-FDOPA n=5) in 16 patients were retrospectively reviewed with regard to tracer uptake in six anatomical sites per patient. For 127/144 of FDG-PET evaluated regions and 68/144 of regions depicted by conventional imaging methods, a valid standard of reference could be obtained. A combined standard of reference was applied, which consisted of histopathology (lymphadenectomy or biopsy) or clinical or radiological follow-up for at least 12 months.

RESULTS

the mean FDG uptake over the clinicopatholigical verified FDG avid areas was 4.7 SUV (1.5-9.9 SUV). The region based assessment of diagnostic value, in consideration of the standard of reference, resulted in a sensitivity of 85.7% and a specificity of 96.2% of FDG-PET (n=127) and in a combined sensitivity of 95.5% and a specificity of 89.1% for morphological imaging methods (n=68). Differences between methods did not reach statistical significance (p=1.00, p=0.18).

CONCLUSIONS

FDG-PET is a highly useful whole body staging method of comparable value compared to conventional imaging methods with restricted field of view. The lessons learned from case series are discussed.

Accuracy of sonographic elastography in the differential diagnosis of enlarged cervical lymph nodes: comparison with conventional B-mode sonography

OBJECTIVE

The purpose of our study was to evaluate the diagnostic performance of sonographic elastography and B-mode sonography individually and combined in the differentiation of reactively and metastatically enlarged cervical lymph nodes.

SUBJECTS AND METHODS

Eighty-five lymph nodes (metastatic, n = 53; reactive, n = 32) from 37 patients were examined by both elastography and B-mode sonography in this prospective study. Elastographic patterns were determined on the distribution and percentage of the lymph node area with high elasticity (hard), with pattern 1 being an absent or very small hard area to pattern 5, a hard area occupying the entire lymph node. The cutoff line for reactive versus metastatic was set between patterns 2 and 3; patterns 3-5 were considered metastatic. B-mode sonographic diagnosis was based on the sum of scores for five criteria: short-axis diameter, shape, border (regular or irregular), echogenicity (homogeneous or inhomogeneous), and hilum (present or absent). The cutoff line for reactive versus metastatic was set between scores 6 and 7; scores 5 and 6 were considered reactive, and scores 7-10, metastatic.

RESULTS

Sensitivity, specificity, and accuracy of B-mode sonography were 98%, 59%, and 84%, respectively; 83%, 100%, and 89% for elastography; and 92%, 94%, and 93% for the combined evaluation.

CONCLUSION

The combination of highly specific elastography with highly sensitive conventional B-mode sonography has the potential to further improve the diagnosis of metastatic enlarged cervical lymph nodes.

Selective three-field lymphadenectomy for thoracic esophageal squamous carcinoma

The purpose of this study was to examine metastasis in different nodal stations and the extent of lymphadenectomy for esophageal carcinoma. Eighty-seven thoracic esophageal squamous carcinoma patients underwent esophagectomy with two-field or three-field lymphadenectomy based on cervical ultrasonography. Thirty-five patients (40.2%) with ultrasonography-detected cervical nodes underwent cervical dissection. Significantly more patients with primary tumors in the upper thoracic esophagus had cervical dissection than patients with tumors in the middle and lower esophagus (66.7%vs. 30.2%, P=0.002). Metastasis to cervical, superior mediastinal, mid-mediastinal, and abdominal nodes were 19.5%, 25.3%, 23%, and 24.1%, respectively. Cervical metastasis was 29.2%, 20.8%, and 10% for upper, middle, and lower thoracic esophageal tumors. Regional lymphadenopathy was found in 48 patients (55.2%) and was significantly related to cervical metastasis (31.3%vs. 5.1%, P=0.002). It was significantly less in upper (37.5%) than in middle (62.3%) and lower (60%) thoracic esophageal tumors (P=0.041). When cervical metastasis was included into regional lymphadenopathy, the difference was no longer significant (45.8%vs. 63.5%, P=0.135). Cervical dissection was associated with significantly more morbidities (60%vs. 34.6%, P=0.020), especially recurrent laryngeal nerve palsy (22.9%vs. 9.6%, P=0.089). Recurrent laryngeal nerve palsy was related significantly to anastomotic leakage (53.8%vs. 13.5%, P=0.001). There was no significant difference between the 2-year survivals for patients with or without cervical metastasis (50.0 vs. 72.0%, P=0.094). We conclude that cervical metastasis is of a similar rate as metastasis to mediastinal or abdominal nodes. Cervical nodes should be taken as regional lymph nodes for thoracic esophageal cancer. Cervical dissection is associated with increased morbidity and should be reserved for patients who may benefit from the procedure. Selective three-field dissection based on ultrasonography is helpful in reducing surgical morbidity while increasing the completeness of resection.

Evaluation of metastatic lymph nodes in head and neck cancer: a comparative study between palpation, ultrasonography, ultrasound-guided fine needle aspiration cytology and computed tomography

STUDY DESIGN

In head and neck cancer patients, diagnosis of metastatic lymph nodes of the neck is essential for treatment planning and prognosis assessment. In a retrospective study, we compared palpation, ultrasonography, ultrasound-guided fine needle aspiration and computed tomography in patients with head and neck cancer.

METHODS

Results of palpation, ultrasonography and computed tomography were available in 78 out of 110 patients diagnosed with head and neck cancer. Ultrasound-guided fine needle aspiration cytology was performed in 26 of these patients. Patients with suspected lymph node(s) observed in one or more techniques underwent neck dissection.

RESULTS

Twenty seven patients underwent neck dissection, studying 150 lymph node regions. The sensitivity, specificity, positive predictive value, negative predictive value and efficacy were calculated for palpation (48.7%, 95.5%, 79.2%, 84.1%, 83.3% respectively), ultrasonography (65.8%, 83.0%, 56.8%, 87.7%, 78.7% respectively), ultrasound-guided fine needle aspiration cytology (86.7%, 87.5%, 81.3%, 91.3%, 87.2% respectively) and computed tomography (52.5%, 83.6%, 53.9%, 82.9%, 75.3% respectively).

CONCLUSIONS

In the assessment of lymph node metastases of the neck in patients with primary head and neck cancer, we found a high specificity for palpation of the neck and an acceptable efficacy for both ultrasonography and computed tomography being comparable between the two methods. Efficacy of ultrasound-guided fine needle aspiration cytology was high approaching the value of 90%.

Intraoperative real-time genetic diagnosis for sentinel node navigation surgery

Sentinel node navigation surgery (SNNS) has received considerable attention for its role in deciding whether to perform neck dissection in patients with early oral cancer. However, diagnostic accuracy and its intraoperative availability of results remain important concerns. First, we shortened the examination time required for genetic diagnosis. Second, we assessed the quality of the extracted mRNA. Third, 10 patients with early N0 oral cancer underwent SNNS, using our new technique for genetic diagnosis to determine whether neck dissection was required. The examination time of our one-step reverse-transcriptase polymerase chain reaction method using a minicolumn and LightCycler was successfully shortened to 2 h, permitting intraoperative genetic diagnosis. The extracted mRNA was of high quality. Six sentinel nodes in four patients were diagnosed to be metastatic on genetic diagnosis; these patients underwent neck dissection. The other six patients avoided unnecessary surgery. We conclude that intraoperative genetic diagnosis of micrometastasis holds promise of being a sensitive method that can be used to support SNNS.