Utility of ultrasound-guided fine needle aspiration cytology in assessing malignancy in head and neck pathology

Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology - Head and Neck Surgery

Objective

Squamous cell carcinoma of the nasal vestibule (NV SCC) is a head and neck malignancy for which there is no established consensus on most aspects of clinical management. The purpose of this document is to give updated recommendations that incorporate recent evidence on its clinical characteristics and the high efficacy of brachytherapy as primary treatment modality.

Methods

A working group consisting of the members of the Scientific Committee for Oncology and Reconstructive Surgery of the Italian Society of Otorhinolaryngology Head and Neck Surgery and radiation oncologists expert in brachytherapy was formed to achieve a consensus.

Results

Consensus was reached on a set of recommendations, proposing a refined anatomical definition of the nasal vestibule, a novel T staging system of the NV SCC, and brachytherapy as standard of care, with a new method for catheter implantation.

Conclusions

The Committee emphasises the critical role of an accurate classification in clinical practice and encourages further research to validate the novel staging system and further improve treatment strategies. Where appropriate, it is recommended that patients be referred to centres with specific experience in brachytherapy for NV SCC.

Preoperative Diagnosis of Warthin Tumors Combining Cytological, Clinical and Ultrasonographic Information within a Multidisciplinary Approach in a Lump Clinic

(1) Background: Warthin tumors account for about 20% of all benign salivary tumors, approaching 50% if we consider only the parotid gland. Wait and see is considered a reasonable option, but the diagnosis should be certain. Diagnosis can be based on morphological and cytological data, but the sensitivity of the fine needle aspiration cytology (FNAC) is not absolute, with a high rate of non-diagnostic findings in the event of a Warthin tumor, hindering the counseling and therapeutic decisions. The aim of the study is to evaluate the reliability of FNAC and its combination with anamnestic, clinical, and ultrasonographic data in diagnosing Warthin tumors. (2) Methods: A total of 413 patients affected by masses within the major salivary gland and managed between 2017 and 2022 at our institution have been included in the present retrospective study. Each patient underwent fine needle aspiration biopsy (FNAB) with a subsequent cytological diagnosis; successively, for each patient, the clinician (otolaryngologist) and the histopathologist discussed the combination of cytological (even non-diagnostic), clinical, and ultrasonographic data in order to make a "multiparametric" diagnosis. A total of 214 cases were subsequently submitted to surgical resection and had a final histopathology report, to which the cytological and the multiparametric diagnoses can be compared. We extracted all the patients with a cytological, multiparametric, and/or histological diagnosis of Warthin tumors in order to assess the sensitivity and specificity of FNAC and of multiparametric analysis in diagnosing Warthin tumors in case of a major salivary gland mass. (3) Results: One hundred thirty-two cases had a cytological, multiparametric, and/or histological diagnosis of Warthin tumors. FNAC displays a sensitivity of 68.4% and a specificity of 98.7% in diagnosing Warthin tumors. The multiparametric evaluation allowed a considerable improvement in sensitivity (92.9% vs. 68.4%), minimizing the number of non-diagnostic results and preserving at the same time a similar value of specificity (95.5% vs. 98.7%). Notably, none of the patients with a cytological or multiparametric diagnosis of Warthin were affected by a malignant lesion in the final histopathological report. (4) Conclusions: In the case of Warthin tumors, a multiparametric evaluation encompassing anamnestic, clinical, and cytological data is effective in reducing the number of non-diagnostic reports and can safely guide the management of a tumor (e.g., antibiotic treatment of infectious complications, assign a low priority to surgery, even consider observation avoiding surgery) which is absolutely benign and can be associated with no clinically relevant issues.

SCC Antigen Concentrations in Fine-Needle Aspiration Samples to Detect Cervical Lymph Node Metastases: A Prospective Analysis

OBJECTIVE

To determine the diagnostic value of measuring squamous cell carcinoma antigen (SCC-Ag) and cancer antigen 15-3 (CA15-3) concentrations in fine-needle aspiration (FNA) samples for the detection of squamous cell carcinoma (SCC) metastases in cervical lymph nodes.

STUDY DESIGN

A prospective study with patients consecutively included between November 2018 and May 2021.

SETTING

A tertiary head and neck oncologic center.

METHODS

Out of 138 patients, SCC-Ag concentrations were analyzed in 168 FNA cervical lymph node samples and CA15-3 in 152 samples. Results were compared with FNA cytology (FNAC) or definitive histology to establish sensitivity and specificity rates.

RESULTS

For the detection of cervical SCC lymph node metastases, SCC-Ag measurement had an 89.4% sensitivity and 79.3% specificity at a cutoff concentration of 0.1 µg/L. Measurement of CA15-3 concentration in addition to SCC-Ag concentration did not lead to improved accuracy for the detection of SCC. In histology-confirmed cases, FNAC had an 80.0% sensitivity and 100% specificity, as opposed to 93.3% and 57.1%, respectively, for SCC-Ag.

CONCLUSION

Measurement of SCC-Ag concentration for detection of SCC lymph node metastases has a sensitivity at least comparable to FNAC and could be used as a relatively cheap screening tool in samples with nondiagnostic or indeterminate FNAC results or when multiple lymph nodes are sampled. However, SCC-Ag in FNA samples has a lower specificity than FNAC assessed by pathologists experienced in head and neck oncology. Addition of CA15-3 measurement did not lead to improved accuracy.

New standards for the management of nose vestibule malignancies

BACKGROUND

Nasal vestibule squamous cell carcinoma (NVSCC) is an ill-defined underestimated condition. Aim/objective: To define the current standard of care.

MATERIAL AND METHODS

We review recent acquisitions concerning clinical features and therapeutic approaches.

RESULTS

The current AJCC staging system, which attributes to nasal vestibule the same topographic code as nasal cavity proper and the same T-classification criteria as ethmoid, appears inadequate. As for treatment of primary lesions without bone invasion, current evidence suggests that brachytherapy is at least equivalent to surgery and superior to external beams in terms of oncological outcomes, and superior to both modalities in terms of cosmesis and function.

CONCLUSIONS

As for classification and staging, the nasal vestibule should be defined as a subsite of the nose and paranasal sinuses, distinct from the 'nasal cavity proper and ethmoid', with specific topographic code and T-classification criteria. This will improve the assessment of prognosis and prevalence, underestimated also because of misdiagnosis with skin cancers. Secondly, brachytherapy should become the new standard for the treatment of primary lesions without bone invasion. To optimize the advantages of brachytherapy, we propose novel anatomic criteria for the implantation. Significance: Increasing evidence supports a paradigm shift in staging and treatment of NVSCC.

Utility and Limitations of Fine-Needle Aspiration Cytology in the Diagnosis of Lymphadenopathy

BACKGROUND

Fine needle aspiration cytology (FNAC) is a valuable tool for evaluating lymphadenopathy. The purpose of this study was to assess the reliability and effectiveness of FNAC in the diagnosis of lymphadenopathy.

METHODS

Cytological characteristics were evaluated in 432 patients who underwent lymph node FNAC and follow-up biopsy at the Korea Cancer Center Hospital from January 2015 to December 2019.

RESULTS

Fifteen (3.5%) of the four hundred and thirty-two patients were diagnosed as inadequate by FNAC, with five (33.3%) of these diagnosed as metastatic carcinoma on histological examination. Of the 432 patients, 155 (35.9%) were diagnosed as benign by FNAC, with seven (4.5%) of these diagnosed histologically as metastatic carcinoma. A review of the FNAC slides, however, showed no evidence of cancer cells, suggesting that the negative results may have been due to FNAC sampling errors. An additional five samples regarded as benign on FNAC were diagnosed as non-Hodgkin lymphoma (NHL) by histological examination. Of the 432 patients, 223 (51.6%) were cytologically diagnosed as malignant, with 20 (9.0%) of these diagnosed as tissue insufficient for diagnosis (TIFD) or benign on histological examination. A review of the FNAC slides of these 20 patients, however, showed that 17 (85.0%) were positive for malignant cells. The sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and accuracy of FNAC were 97.8%, 97.5%, 98.7%, 96.0%, and 97.7%, respectively.

CONCLUSIONS

Preoperative FNAC was safe, practical, and effective in the early diagnosis of lymphadenopathy. This method, however, had limitations in some diagnoses, suggesting that additional attempts may be required according to the clinical situation.

Central Compartment Neck Dissection in Laryngeal and Hypopharyngeal Squamous Cell Carcinoma: Clinical Considerations

Metastatic lymph node involvement represents the most relevant prognostic factor in head and neck squamous cell carcinomas (HNSCCs), invariably affecting overall survival, disease-specific survival, and relapse-free survival. Among HNSCCs, laryngeal and hypopharyngeal cancers are known to be at highest risk to metastasize to the central neck compartment (CNC). However, prevalence and prognostic implications related to the CNC involvement are not well defined yet, and controversies still exist regarding the occult metastasis rate. Guidelines for the management of CNC in laryngeal and hypopharyngeal cancers are vague, resulting in highly variable selection criteria for the central neck dissection among different surgeons and institutions. With this review, the authors intend to reappraise the existing data related to the involvement of CNC in laryngeal and hypopharyngeal malignancies, in the attempt to define the principles of management while highlighting the debated aspects that are lacking in evidence and consensus. Furthermore, as definition and boundaries of the CNC have changed over the years, an up-to-date anatomical-surgical description of the CNC is provided.

Ectopic Cushing's Syndrome Secondary to Acinic Cell Carcinoma of the Parotid Gland: A Case Report

We present a case report of a patient with a rare high-grade transformation of an acinic cell carcinoma (ACC) of the parotid gland, who developed Cushing's syndrome (CS) as a result of ectopic secretion of adrenocorticotropic hormone by the tumour. The hypercortisolism was successfully treated with metyrapone, and the ACC was treated with local radiotherapy and a combined six cycles of gemcitabine and cisplatin, having achieved a partial response to the tumour. A multidisciplinary approach and combined medical treatment with radiotherapy and were essential for disease control and CS management. ACC should be considered in the differential diagnosis of ectopic CS.

Reliability of a Multidisciplinary Multiparametric Approach in the Surgical Planning of Laryngeal Squamous Cell Carcinomas: A Retrospective Observational Study

(1) Background: Endoscopy and morphological imaging are the mainstay of the diagnostic work up of laryngeal squamous cell carcinomas (LSCCs), which can be integrated in a multidisciplinary discussion to obtain a shared pretreatment staging. (2) Methods: A retrospective evaluation of patients, managed at a tertiary university hospital in Italy and submitted to major laryngeal surgery, has been performed. Four different stagings have been defined and compared: epTN (based on endoscopy and physical ENT examination); radTN (based on CT scan); cTN (based on multidisciplinary integration of the two above); pTN based on pathology on surgical samples. Oncological outcomes have been assessed. (3) Results: Three-year relapse free and disease specific survival were 88% and 92.5%, respectively, without significant differences between partial surgeries (n = 13) and total laryngectomies (n = 32). As for the pretreatment staging, and in particular the T classification, the cTN has been revealed as more reliable than epTN and radTN alone in predicting the final pT (Cohen kappa coefficient: 0.7 for cT, 0.44 for radT, 0.32 for epT). In the partial surgery group, we did not record any positive margin nor local recurrence, with a 100% overall and disease-specific survival. (4) Conclusions: The multidisciplinary approach is fundamental in the definition of the primary lesion in LSCC, in particular in order to safely perform surgical preservation of laryngeal function, which is associated with a higher laryngectomy-free survival than irradiation but to a lower salvageability in case of recurrence.

A radiologist's perspective of the value of ultrasound-guided fine needle aspiration cytology in the assessment of head and neck lesions

This viewpoint presents a radiologist's perspective of the value that can be added by close collaboration and teamwork with cytopathologist colleagues to maximise specimen quality, adequacy, and patient outcomes. Various models are discussed and service evolution through teamwork emphasised. The importance of utilising ultrasound guidance for fine needle aspiration in head and neck lesions and critical appraisal of the literature are reviewed.