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

Imaging of human papilloma virus associated oropharyngeal squamous cell carcinoma and its impact on diagnosis, prognostication, and response assessment

The clinical behaviour and outcomes of patients with oropharyngeal cancer (OPC) may be dichotomised according to their association with human papilloma virus (HPV) infection. Patients with HPV-associated disease (HPV+OPC) have a distinct demographic profile, clinical phenotype and demonstrate considerably better responses to chemoradiotherapy. This has led to a reappraisal of staging and treatment strategies for HPV+OPC, which are underpinned by radiological data. Structural modalities, such as CT and MRI can provide accurate staging information. These can be combined with ultrasound-guided tissue sampling and functional techniques (such as diffusion-weighted MRI and 18F-fludeoxyglucose positron emission tomography-CT) to monitor response to treatment, derive prognostic information, and to identify individuals who might benefit from intensification or deintensification strategies. Furthermore, advanced MRI techniques, such as intravoxel incoherent motion and perfusion MRI as well as application of artificial intelligence and radiomic techniques, have shown promise in treatment response monitoring and prognostication. The following review will consider the contemporary role and knowledge on imaging in HPV+OPC.

Accuracy of fine-needle aspiration cytology in detecting cervical node metastasis after radiotherapy: Systematic review and meta-analysis

PURPOSE

To define the accuracy of fine-needle aspiration cytology (FNAC) in diagnosing persistent or recurrent neck metastases in previously irradiated patients.

METHODS

The study was performed according to the PRISMA-DTA guidelines.

RESULTS

A total of 382 FNACs were used for calculation of diagnostic accuracy parameters. The overall pooled sensitivity and specificity in detecting malignant nodes were 69.1% (95% CI: 56.3%-80.7%; I² = 79.5%) and 84.2% (95% CI: 71.8%-93.5%; I² = 87.0%), respectively. Cumulative diagnostic odds ratio (DOR) was 16.54 (95% CI: 4.89-38.99; I² = 65.8%), while cumulative positive and negative likelihood ratio (PLR and NLR) were 5.4 (95% CI: 2.3-11.2) and 0.37 (95% CI: 0.22-0.54), respectively.

CONCLUSIONS

FNAC alone could not guide the decision to perform a salvage neck dissection in previously irradiated patients, but its results should be assessed in relation to the specific clinical context.

A Nomogram to Predict the Outcome of Fine Needle Aspiration Cytology in Head and Neck Masses

Fine needle aspiration cytology (FNAC) is an important diagnostic tool for tumors of the head and neck. However, non-diagnostic or inconclusive results may occur and lead to delay in treatment. The aim of this study was to evaluate the factors that predict a successful FNAC. A retrospective search was performed to identify all patients who received an FNAC at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna. The variables were patients’ age and sex, localization and size of the punctured structure, previous radiotherapy, experience of the head and neck surgeon, experience of the pathologist and the FNAC result. Based on these parameters, a nomogram was subsequently created to predict the probability of accurate diagnosis. After performing 1221 FNACs, the size of the punctured lesion (p = 0.0010), the experience of the surgeon and the pathologist (p = 0.00003) were important factors for a successfully procedure and reliable result. FNACs performed in nodes smaller than 20 mm had a significantly worse diagnostic outcome compared to larger nodes (p = 0.0004). In conclusion, the key factors for a successful FNAC are nodal size and the experience of the head and neck surgeon and the pathologist.

The prognostic value of location and size change of pathological lymph nodes evaluated on CT-scan following radiotherapy in head and neck cancer

BACKGROUND

Overall survival after chemo-radiotherapy (CRT) for head and neck cancer ranges between 50 and 60% after 5 year of follow-up. Local and/or regional recurrence is the most frequent form of therapy failure. The aim of this study is to investigate whether the initial location and size change of pathological lymph nodes as evaluated on Computed Tomography (CT) studies can help predict outcome.

METHODS

One hundred eighty-three patients with lymph node-positive head and neck cancer were treated with radiotherapy (RT) or CRT. CT studies pre- and post-treatment were reviewed for lymph node size and location. Data were correlated with local control, regional control, metastasis free survival, disease free survival and overall survival.

RESULTS

Regarding the risk for distant metastasis, a significant influence was seen for the location of the pathological lymph nodes. The metastatic risk increases when levels IV-V are affected rather than levels I-III. A similar observation is seen for levels VI-VII. Regional control improves with decreasing lymph node diameter and volume as evaluated on CT.

CONCLUSIONS

Both location and size change of pathological lymph nodes are of prognostic value after CRT for head and neck cancer.

CT-based follow-up following radiotherapy or radiochemotherapy for locally advanced head and neck cancer; outcome and development of a prognostic model for regional control

OBJECTIVE

The purpose of this study was to make a prognostic model for regional relapse in head and neck cancer using clinical and CT parameters.

METHODS

183 patients with lymph node-positive head and neck cancer were treated between 2002 and 2012 with radiotherapy or concurrent chemoradiotherapy. CT studies pre- and post-treatment were reviewed for lymph node size and the presence of necrosis, extracapsular spread (ECS) and calcifications. For every patient, correlations with 3-year regional control (RC), metastasis-free survival (MFS), disease-free survival (DFS) and overall survival (OS) were made.

RESULTS

3-year outcome rates were as follows: local control of 84%, RC of 80%, MFS of 74%, DFS of 61% and OS of 63%. Pre-treatment nodal size and the presence of necrosis were associated with a poorer outcome. This was also the case for post-treatment lymph node size, the presence of necrosis and ECS. We developed a CT-based prognostic model for RC with an area under the curve of 0.78 (95% confidence interval 0.63; 0.85).

CONCLUSION

We reached a good outcome in our patient cohort using a CT-based follow-up approach. A CT-based model was developed, which can aid in predicting RC. Advances in knowledge: A prognostic model is proposed, which can aid in predicting RC and the necessity for post-radiotherapy neck dissection using clinical parameters and parameters derived from the post-treatment CT study. This is the first article to propose a prognostic model for regional relapse in head and neck cancer based on these parameters.

Characteristics and kinetics of cervical lymph node regression after radiation therapy for human papillomavirus-associated oropharyngeal carcinoma: quantitative image analysis of post-radiotherapy response

BACKGROUND AND PURPOSE

We sought to characterize the pattern of lymph node regression and morphology following definitive radiation therapy (RT) for human papilloma virus (HPV)-associated oropharyngeal carcinoma in patients with disease control.

MATERIALS AND METHODS

Radiographically positive cervical lymph nodes from patients treated with definitive RT for HPV-associated oropharyngeal carcinoma were segmented on initial pre- and subsequent post-RT contrast enhanced CT images. Pre-specified quantitative nodal parameters were calculated. Initial nodal parameter correlates of final nodal size, final nodal volume, and time to <1 cm short-axis diameter were determined.

RESULTS

Sixty-six radiographically positive lymph node were analyzed in 36 patients. Lymph nodes exhibited initial volume decreases with size stabilization at ∼4 months. Fifteen nodes (23%) underwent complete radiographic response (median 6.4 months following RT; range 2.9-25.6 months). On multivariate time-to-event analysis, initial hypodense/fat component, nodal volume, and short-axis diameter exhibited inverse association, while higher HU standard deviation exhibited a positive association, with reaching <1 cm short-axis diameter (all p<0.05).

CONCLUSIONS

Our results showed a substantial decrease in nodal volume within the first 1-2 months following RT. These findings support our current nodal imaging paradigm, propose a quantitative methodology, and describe a reference dataset for further validation and comparison studies.

Improving imaging diagnosis of persistent nodal metastases after definitive therapy for oropharyngeal carcinoma: specific signs for CT and best performance of combined criteria

BACKGROUND AND PURPOSE

Criteria for detection of persistent nodal metastases in treated oropharyngeal tumors are sensitive but nonspecific, leading to unnecessary nodal dissections. Developing specific imaging criteria for persistent nodal metastases could improve diagnosis while decreasing patient morbidity.

MATERIALS AND METHODS

Patients with oropharyngeal squamous cell carcinoma with nodal metastases treated by definitive radiation therapy and subsequent nodal dissection were retrospectively evaluated. One hundred thirty-eight patients had pre- and posttherapy contrast-enhanced CTs evaluated by radiologists blinded to the status of pathologically proved hemineck persistent nodal metastases. Composite scoring criteria for CT, combined from individual parameters, were compared with radiologists' opinions, previous multiparameter criteria, and outcome data.

RESULTS

New low-attenuation areas and a lack of size change (<20% cross sectional area) were both highly specific for persistent nodal metastases (99%; P = .0004). Extranodal disease on pretherapy imaging was moderately specific (86%; P = .001). The CSC correctly placed 29 patients in a low-risk category compared with 14 by previously reported criteria and radiologist reports. With good second-rater reliability, the CSC cutoff values stratified patients at highest risk of persistent nodal metastases, thereby improving specificity while maintaining sensitivity.

CONCLUSIONS

Comparing pre- and posttherapy examinations improves specificity by discriminating focal findings and size change compared with a single time point. The CSC can categorize the risk of persistent nodal metastases more accurately than previous CT methods. This finding has the potential to improve resource use and reduce surgical morbidity.

Current practice in management of the neck after chemoradiotherapy for patients with locally advanced oropharyngeal squamous cell carcinoma

Patients whose necks respond completely to chemoradiation are unlikely to have residual viable tumour, which questions the need for planned neck dissection. Partial responders often need further assessment. Positron emission tomography/computed tomography (PET/CT) is becoming the standard method of assessing the response of both the primary site and neck to chemoradiation. There is debate, however, about the timing of assessment, the best imaging technique, and the extent of neck dissection, and emerging evidence supports more selective procedures with their attendant reductions in morbidity. Various trials have tried to settle these controversies, but we hypothesised that current practice varies across the United Kingdom (UK), so we set out to establish what it is. A total of 219 questionnaires were sent to head and neck surgeons of varying disciplines and their oncology counterparts, which outlined a clinical picture of a patient with persistent nodal disease after chemoradiotherapy, and requested information about the respondents' preferred choice and timing of investigations in addition to the type of neck dissection, if indicated. There were noticeable variations in practice, with a tendency towards personal choice rather than a multidisciplinary approach. Although there were some items of broad agreement, there was disparity about the timing of imaging and operation. There is inconsistency in the management of the neck in these patients in the UK, which may reflect an absence of guidelines and paucity of evidence-based information. We need to unify practice to improve the care of patients.

Prediction of neck dissection requirement after definitive radiotherapy for head-and-neck squamous cell carcinoma

BACKGROUND

This analysis was undertaken to assess the need for planned neck dissection in patients with a complete response (CR) of involved nodes after irradiation and to determine the benefit of a neck dissection in those with less than CR by tumor site.

METHODS

Our cohort included 880 patients with T1-4, N1-3M0 squamous cell carcinoma of the oropharynx, larynx, or hypopharynx who received treatment between 1994 and 2004. Survival curves were calculated by the Kaplan-Meier Method, comparisons of rates with the log-rank test and prognostic factors by Cox's proportional hazard model.

RESULTS

Nodal CR occurred in 377 (43%) patients, of whom 365 patients did not undergo nodal dissection. The 5-year actuarial regional control rate of patients with CR was 92%. Two hundred sixty-eight of the remaining patients (53%) underwent neck dissections. The 5-year actuarial regional control rate for patients without a CR was 84%. Those who had a neck dissection fared better with 5-year actuarial regional control rates of 90% and 76% for those operated and those not operated (p < 0.001). Variables associated with poorer regional control rates included higher T and N stage, non-oropharynx cancers, non-CR, both clinical and pathological.

CONCLUSIONS

With 92% 5-year neck control rate without neck dissection after CR, there is little justification for systematic neck dissection. The addition of a neck dissection resulted in higher neck control after partial response though patients with viable tumor on pathology specimens had poorer outcomes. The identification of that subgroup that benefits from additional treatment remains a challenge.