Positive Predictive Value of Neck Imaging Reporting and Data System Categories 3 and 4 Posttreatment FDG-PET/CT in Head and Neck Squamous Cell Carcinoma

Performance of Neck Imaging Reporting and Data System (NI-RADS) for Diagnosis of Recurrence of Head and Neck Squamous Cell Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The Neck Imaging Reporting and Data System (NI-RADS) is a reporting template used in head and neck cancer posttreatment follow-up imaging.

PURPOSE

Our aim was to evaluate the pooled detection rates of the recurrence of head and neck squamous cell carcinoma based on each NI-RADS category and to compare the diagnostic accuracy between NI-RADS 2 and 3 cutoffs.

DATA SOURCES

The MEDLINE, Scopus, and EMBASE databases were searched.

STUDY SELECTION

This systematic review identified 7 studies with a total of 694 patients (1233 lesions) that were eligible for the meta-analysis.

DATA ANALYSIS

The meta-analysis of pooled recurrence detection rate estimates for each NI-RADS category and the diagnostic accuracy of recurrence with NI-RADS 3 or 2 as the cutoff was performed.

DATA SYNTHESIS

The estimated recurrence rates in each category for primary lesions were 74.4% for NI-RADS 3, 29.0% for NI-RADS 2, and 4.2% for NI-RADS 1. The estimated recurrence rates in each category for cervical lymph nodes were 73.3% for NI-RADS 3, 14.3% for NI-RADS 2, and 3.5% for NI-RADS 1. The area under the curve of the summary receiver operating characteristic for recurrence detection with NI-RADS 3 as the cutoff was 0.887 and 0.983, respectively, higher than 0.869 and 0.919 for the primary sites and cervical lymph nodes, respectively, with NI-RADS 2 as the cutoff.

LIMITATIONS

Given the heterogeneity of the data of the studies, the conclusions should be interpreted with caution.

CONCLUSIONS

This meta-analysis revealed estimated recurrence rates for each NI-RADS category for primary lesions and cervical lymph nodes and showed that NI-RADS 3 has a high diagnostic performance for detecting recurrence.

Diagnostic Performance of Response Assessment FDG-PET/CECT in HNSCC Treated With Definitive Radio(chemo)therapy Using NI-RADS

OBJECTIVE

To assess the diagnostic performance of response assessment 18F-fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (FDG-PET/CECT) following definitive radio(chemo)therapy in head and neck squamous cell carcinoma (HNSCC) using Neck Imaging Reporting and Data System (NI-RADS).

STUDY DESIGN

A retrospective analysis from a prospectively maintained dataset.

SETTING

Tertiary-care comprehensive cancer center in a low-middle-income country.

METHODS

Adults with newly diagnosed, biopsy-proven, nonmetastatic HNSCC treated with definitive radio(chemo)therapy were included. Posttreatment response assessment FDG-PET/CECT scans were retrospectively assigned NI-RADS categories (1-3) for the primary site, neck, and both sites combined. Locoregional recurrence occurring within 2-years was defined as the event of interest. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were calculated. Locoregional control stratified by NI-RADS categories was computed with the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Posttreatment FDG-PET/CECT scans were available in 190 patients constituting the present study cohort. Sensitivity, specificity, PPV, NPV, and overall accuracy of the NI-RADS template for the primary site was 73.5%, 81.4%, 46.3%, 93.4%, and 80.0%, respectively. Similar metrics for the neck were 72.7%, 87.5%, 43.2%, 96.1%, and 85.8%, respectively. Combining primary site and neck, the corresponding metrics of diagnostic accuracy were 84.4%, 69.7%, 46.3%, 93.5%, and 73.2%, respectively. At a median follow-up of 40 months, Kaplan-Meier estimates of 2-year locoregional control were significantly higher for NI-RADS category 1 (94.2%) compared to NI-RADS category 2 (69.4%) and category 3 (20.4%), respectively (stratified log-rank p < .0001).

CONCLUSION

FDG-PET/CECT using the NI-RADS template is associated with good diagnostic performance and prognostic utility in HNSCC treated with definitive radio(chemo)therapy.

Personalizing Surveillance in Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) encompasses a spectrum of heterogeneous diseases originating in the oral cavity, pharynx, and larynx. Within the United States, head and neck cancer (HNC) accounts for 66,470 new cases, or 3% of all malignancies, annually.¹ The incidence of HNC is rising, largely driven by increases in oropharyngeal cancer.^2-4 Recent molecular and clinical advancements, particularly with regard to molecular and tumor biology, reflect the heterogeneity of the subsites contained within the head and neck. Despite this, existing guidelines for post-treatment surveillance remain broad without much consideration given to different anatomic subsites and etiologic factors (such as human papillomavirus [HPV] status or tobacco exposure).⁵ Surveillance incorporating the physical examination, imaging, and emerging molecular biomarkers is an essential part of care for patients treated for HNC and allows for the detection of locoregional recurrence, distant metastases, and second primary malignancies aiming for better functional and survival outcomes. Additionally, it allows for evaluation and management of post-treatment complications.

Performance of the Neck Imaging Reporting and Data System as applied by general neuroradiologists to predict recurrence of head and neck cancers

BACKGROUND

The Neck Imaging Reporting and Data System (NI-RADS) is used to assess imaging after head and neck cancer treatment. We evaluated NI-RADS with general neuroradiologists rather than with head and neck subspecialists.

METHODS

Computed tomography and magnetic resonance imaging examinations with/without positron emission tomography from May 2018 to September 2020 were retrospectively identified. NI-RADS scores at the primary site and lymph nodes were provided by 21 neuroradiologists. Recurrence status was based on clinical and imaging findings. Area under the curve (AUC) was used to assess accuracy.

RESULTS

We assessed 608 scans from 464 patients. For NI-RADS categories 1, 2, and 3, primary site recurrence rates were 5%, 29%, and 65% with AUC of 0.765, while lymph node recurrence rates were 3%, 10%, and 80% with AUC of 0.820.

CONCLUSIONS

NI-RADS as used by general neuroradiologists is effective in separating head and neck cancers into discrete categories for predicting recurrent disease.

Adding MR Diffusion Imaging and T2 Signal Intensity to Neck Imaging Reporting and Data System Categories 2 and 3 in Primary Sites of Postsurgical Oral Cavity Carcinoma Provides Incremental Diagnostic Value

BACKGROUND AND PURPOSE

The NI-RADS lexicon doesn't use ADC parameters and T2 weighted signal for ascribing categories. We explored ADC, DWI, and T2WI to examine the diagnostic accuracy in primary sites of postsurgical oral cavity carcinoma in the Neck Imaging Reporting and Data System (NI-RADS) categories 2 and 3.

MATERIALS AND METHODS

We performed a retrospective analysis in clinically asymptomatic post-surgically treated patients with oral cavity squamous cell carcinoma who underwent contrast-enhanced MRI between January 2013 and January 2016. Histopathology and follow-up imaging were used to ascertain the presence or absence of malignancy in subjects with "new enhancing lesions," which were interpreted according to the NI-RADS lexicon by experienced readers, including NI-RADS 2 and 3 lesions in the primary site. NI-RADS that included T2WI and DWI (referred to as NI-RADS A) and ADC (using the best cutoff from receiver operating characteristic curve analysis, NI-RADS B) was documented in an Excel sheet to up- or downgrade existing classic American College of Radiology NI-RADS and calculate diagnostic accuracy.

RESULTS

Sixty-one malignant and 23 benign lesions included in the study were assigned American College of Radiology NI-RADS 2 (n = 33) and NI-RADS 3 (n = 51) categories. The recurrence rate was 90% (46/51) for NI-RADS three, 45% (15/33) for NI-RADS 2, and 73% (61/84) overall. T2WI signal morphology was intermediate in 45 subjects (53.5%) and restricted DWI in 54 (64.2%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the American College of Radiology NI-RADS were the following: NI-RADS (75.4%, 78.3%, 90.1%, 54.5%, and 76.1%); NI-RADS A (79.1%, 81.2%, 91.9%, 59.1%, and 79.6%); and NI-RADS B (88.9%, 72.7%, 91.4%, 66.7%, and 85.1%), respectively.

CONCLUSIONS

Adding MR imaging diagnostic characteristics like T2WI, DWI, and ADC to the American College of Radiology NI-RADS improved diagnostic accuracy and sensitivity.

PET/MR Imaging in Evaluating Treatment Failure of Head and Neck Malignancies: A Neck Imaging Reporting and Data System-Based Study

BACKGROUND AND PURPOSE

PET/MR imaging is a relatively new hybrid technology that holds great promise for the evaluation of head and neck cancer. The aim of this study was to assess the performance of simultaneous PET/MR imaging versus MR imaging in the evaluation of posttreatment head and neck malignancies, as determined by its ability to predict locoregional recurrence or progression after imaging.

MATERIALS AND METHODS

The electronic medical records of patients who had posttreatment PET/MR imaging studies were reviewed, and after applying the exclusion criteria, we retrospectively included 46 studies. PET/MR imaging studies were independently reviewed by 2 neuroradiologists, who recorded scores based on the Neck Imaging Reporting and Data System (using CT/PET-CT criteria) for the diagnostic MR imaging sequences alone and the combined PET/MR imaging. Treatment failure was determined with either biopsy pathology or initiation of new treatment. Statistical analyses including univariate association, interobserver agreement, and receiver operating characteristic analysis were performed.

RESULTS

There was substantial interreader agreement among PET/MR imaging scores (κ = 0.634; 95% CI, 0.605-0.663). PET/MR imaging scores showed a strong association with treatment failure by univariate association analysis, with P < .001 for the primary site, neck lymph nodes, and combined sites. Receiver operating characteristic curves of PET/MR imaging scores versus treatment failure indicated statistically significant diagnostic accuracy (area under curve range, 0.864-0.987; P < .001).

CONCLUSIONS

Simultaneous PET/MR imaging has excellent discriminatory performance for treatment outcomes of head and neck malignancy when the Neck Imaging Reporting and Data System is applied. PET/MR imaging could play an important role in surveillance imaging for head and neck cancer.

MRI Posttreatment Surveillance for Head and Neck Squamous Cell Carcinoma: Proposed MR NI-RADS Criteria

BACKGROUND AND PURPOSE

The current Neck Imaging Reporting and Data System (NI-RADS) criteria were designed for contrast-enhanced CT with or without PET. Prior studies have revealed the capability of DWI and T2 signal intensity in distinguishing locoregional tumor residual and recurrence from posttreatment benign findings in head and neck cancers. We aimed to propose MR imaging NI-RADS criteria by adding diffusion criteria and T2 signal intensity to the American College of Radiology NI-RADS template.

MATERIALS AND METHODS

This retrospective study included 69 patients with head and neck squamous cell carcinoma (HNSCC) who underwent posttreatment contrast-enhanced MRI imaging surveillance using a 1.5T scanner. The scans were interpreted by 2 neuroradiologists. Image analysis assessed the primary tumor site using the current American College of Radiology NI-RADS morphologic lexicon (mainly designed for contrast-enhanced CT with or without PET). NI-RADS rescoring was then performed based on our proposed criteria using T2 signal and diffusion features. The reference standard was a defined set of criteria, including clinical and imaging follow-up and pathologic assessment.

RESULTS

Imaging assessment of treated HNSCC at the primary tumor site using T2 signal intensity and diffusion features as modifying rules to NI-RADS showed higher sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (92.3%, 90.7%, 85.7%, 95.1%, and 91.3%, respectively) compared with the current NI-RADS lexicon alone (84.6%, 81.4%, 73.3%, 89.8%, and 82.6%, respectively).

CONCLUSIONS

The addition of diffusion features and T2 signal to the American College of Radiology NI-RADS criteria for the primary tumor site enhances the specificity, sensitivity, positive predictive value, negative predictive value, and NI-RADS accuracy.

Interrater Reliability of NI-RADS on Posttreatment PET/Contrast-enhanced CT Scans in Head and Neck Squamous Cell Carcinoma

Purpose To evaluate the interrater reliability among radiologists examining posttreatment head and neck squamous cell carcinoma (HNSCC) fluorodeoxyglucose PET/contrast-enhanced CT (CECT) scans using Neck Imaging Reporting and Data System (NI-RADS). Materials and Methods In this retrospective study, images in 80 patients with HNSCC who underwent posttreatment surveillance PET/CECT and immediate prior comparison CECT or PET/CECT (from June 2014 to July 2016) were uploaded to the American College of Radiology's cloud-based website, Cortex. Eight radiologists from seven institutions with variable NI-RADS experience independently evaluated each case and assigned an appropriate prose description and NI-RADS category for the primary site and the neck site. Five of these individuals were experienced readers (> 5 years of experience), and three were novices (< 5 years of experience). In total, 640 lexicon-based and NI-RADS categories were assigned to lesions among the 80 included patients by the eight radiologists. Light generalization of Cohen κ for interrater reliability was performed. Results Of the 80 included patients (mean age, 63 years ± 10 [standard deviation]), there were 58 men (73%); 60 patients had stage IV HNSCC (75%), and the most common tumor location was oropharynx (n = 32; 40%). Light κ for lexicon was 0.30 (95% CI: 0.23, 0.36) at the primary site and 0.31 (95% CI: 0.24, 0.37) at the neck site. Light κ for NI-RADS category was 0.55 (95% CI: 0.46, 0.63) at the primary site and 0.60 (95% CI: 0.48, 0.69) at the neck site. Percent agreement between lexicon and correlative NI-RADS category was 84.4% (540 of 640) at the primary site and 92.6% (593 of 640) at the neck site. There was no significant difference in interobserver agreement among the experienced versus novice raters. Conclusion Moderate agreement was achieved among eight radiologists using NI-RADS at posttreatment HNSCC surveillance imaging. Keywords: CT, PET/CT, Head/Neck, Neck, Neoplasms-Primary, Observer Performance Supplemental material is available for this article. © RSNA, 2021.