Comparison of ultrasound-fine needle aspiration and computed tomography in patients undergoing elective neck dissection

Efficacy of Computed Tomography and Ultrasonography in Diagnosis of Metastatic Cervical Lymph Nodes in Orofacial Cancer

INTRODUCTION

There is no consensus on which imaging modality is better for the detection of metastatic cervical lymph nodes in orofacial malignancies. This study evaluates the efficacy of computed tomography (CT) and ultrasonography (US) in diagnosis of metastatic cervical lymph nodes in orofacial cancer.

MATERIALS AND METHODS

Sixty patients with various histologically diagnosed orofacial malignant lesions and clinical evidence of cervical lymph node metastasis were examined using US and CT. Further, the affected lymph nodes were biopsied and examined histologically. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the techniques were calculated. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 19 (SPSS Inc., Chicago, IL, USA) and Microsoft Excel 2010 (Microsoft, Redmond, WA, USA). Test of statistical significance was set at 0.05.

RESULTS

US recorded a sensitivity, specificity, PPV, NPV, and accuracy of 80.0%, 57.1%, 77.5%, 60.0%, and 71.7%, respectively (P = 0.004), while CT recorded a sensitivity, specificity, PPV, NPV, and accuracy of 87.1%, 71.4%, 85.0%, 75.0%, and 81.7%, respectively (P< 0.0001). Lymph node size was the commonest criterion in the diagnoses of metastases in cases with cervical lymph nodes.

CONCLUSION

Although we obtained great results using US, our results indicated CT to be a better imaging modality for detecting metastatic cervical lymph nodes in orofacial malignancies.

Elective Neck Dissection Versus Observation in Early-Stage (cT1/T2N0) Oral Squamous Cell Carcinoma

Objectives

Whether to perform elective neck dissection (END) or apply the observation (OBS) policy in patients with early‐stage oral squamous cell carcinoma (OSCC) without clinical evidence of cervical lymph node metastasis (cT1/T2N0) remains uncertain. The two most recent meta‐analyses include many studies published before the widespread availability of CT scanning in the 1990s. With the rapid advancement in imaging studies since 1990, the early clinical detection of cervical node metastasis has become more reliable without the need for END or pathological staging. Thus, we conducted a systematic review and meta‐analysis of studies comparing survival outcomes between END and OBS in patients with cT1/T2N0 OSCC.

Methods

We performed a systematic search of MEDLINE, PubMed, and Scopus for retrospective and prospective studies published between January 1, 1990, and January 1, 2018, comparing clinical outcomes between END and OBS in patients with cT1/T2N0 OSCC. Information on population characteristics, study design, overall survival (OS), disease‐specific survival (DSS), and disease‐free survival (DFS) was extracted and estimated. Effect measures for outcomes were hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

Thirteen retrospective and two prospective randomized studies (3,158 patients) met the inclusion criteria. Compared to OBS, END failed to significantly improve OS (HR, 1.02; 95% CI, 0.95–1.09; P = .77; fixed‐effects model), DSS (HR, 1.07; CI, 1.02–1.13; P = .31; fixed‐effects model), and DFS (HR, 0.86; CI, 0.72–1.01; P = .12; random‐effects model).

Conclusions

Our findings indicate that in patients with cT1T2N0 OSCC, the OBS policy can yield markedly similar OS, DSS, and DFS to those resulting from END.

Level of Evidence

2

Evaluation of the Expression of Matrix Metalloproteinase-1 of Laryngeal Squamous Cell Carcinoma by Ultrasound Molecular Imaging

Purpose: The aims of this study were to evaluate the expression of matrix metalloproteinase-1 (MMP-1) on laryngeal squamous cell carcinoma (LSCC) and improve the early diagnosis rate via ultrasound molecular imaging (USMI).

Methods: The microsized MMP-1-targeted microbubbles (MB_MMP-1) and the control MBs (MB_IgG) based on perfluorocarbon-filled lipid-shelled MBs were constructed and characterized. The in vitro binding experiment was performed with human epidermoid laryngeal cancer cells (HEp-2) and tested the binding efficiency of MB_MMP-1 and MB_IgG. In the in vivo study, the LSCC model was established in 10 mice. The MB_MMP-1 and MB_IgG were randomly injected into tumor-bearing mice via the tail vein at Day 7, Day 12, and Day 17 to dynamically evaluate the differential targeted enhancement (dTE) signals via USMI. Subsequent immunofluorescence analysis was used for confirmation of MMP-1 expression.

Result: The effective adhesion rate of MB_MMP-1 and MB_IgG to HEp-2 was 298.42 ± 16.57 versus 12.38 ± 3.26 bubbles/per field in vitro experiment, which shows a significant difference (P < 0.01). The in vivo ultrasound molecular imaging (USMI) results demonstrated that dTE signal intensity from MB_MMP-1 was significantly higher than that from the MB_IgG at Day 7, Day 12, and Day 17 (Day 7, 41.21 ± 15.00 versus 2.25 ± 0.6 a.u., P < 0.05; Day 12, 124.64 ± 5.19 versus 11.13 ± 1.13 a.u., P < 0. 05; Day 17, 332.01 ± 64.88 versus 42.99 ± 11.9 a.u., P < 0.01). Moreover, immunofluorescence analysis further confirmed the expression of MMP-1 in LSCC with a gradual increase with the tumor growth.

Conclusion: MB_MMP-1 could be a potential probe that can be used in the early diagnosis of LSCC by USMI.

Diagnostic accuracy of F-18 FDG PET or PET/CT for detection of lymph node metastasis in clinically node negative head and neck cancer patients; A systematic review and meta-analysis

OBJECTIVE

The purpose of the current study was to investigate the diagnostic performance of F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) or positron emission tomography/computed tomography (PET/CT) for the detection of cervical lymph node (LN) metastasis in clinically node negative head and neck squamous cell cancer (cN0 HNSCC) patients through a systematic review and meta-analysis.

METHODS

The PubMed and EMBASE database, from the earliest available date of indexing through April 30, 2018, were searched for studies evaluating the diagnostic performance of F-18 FDG PET or PET/CT for the detection of LN metastasis in cN0 HNSCC patients. We determined the sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR+ and LR-), and constructed summary receiver operating characteristic (SROC) curves.

RESULTS

Across 18 studies (1044 patients), the pooled sensitivity for F-18 FDG PET or PET/CT for the detection of LN metastasis was 0.58 and a pooled specificity of 0.87 for patient based analysis. Neck side based analysis showed the pooled sensitivity of 0.67 and a pooled specificity of 0.85. Level based study demonstrated the pooled sensitivity of 0.53 and a pooled specificity of 0.97 (95% CI; 0.95-0.98). In meta-regression analysis, no definite variable was the source of the study heterogeneity.

CONCLUSION

The current meta-analysis showed the low sensitivity and moderate specificity of F-18 FDG PET/CT for the detection of cervical LN metastasis in cN0 HNSCC patients. Level based analysis of F-18 FDG PET or PET/CT has a high specificity and NPV for the detection of cervical metastatic LN detection.

Exploring the Role of Intraoperative Frozen Section of the Sentinel Lymph Node in the Management of Early-Staged Oral Tongue Cancers

Background:

The present study aims to explore the role of sentinel lymph node biopsy (SLNB) with intraoperative frozen section in the management of early-staged oral tongue cancers.

Materials and Methods:

Fifty-two patients with clinical stages cT1/2N0 oral tongue cancers were included in the present study. The curative surgery was preceded by the performance of an SLNB using a dual technique.

Results:

The identification rate of sentinel lymph node (SLN) in this study was 98.07%. The sensitivity, specificity, positive predictive value (PPV), and the negative predictive value (NPV) of SLNB were 88.2%, 100%, 100%, and 94.5%, respectively. Further, the sensitivity, specificity, PPV, and the NPV of intraoperative frozen section of the SLN were 70.5%, 100%, 100%, and 87.5%, respectively.

Conclusions:

The addition of intraoperative frozen section could identify 70.5% of patients with occult metastasis. An intraoperative frozen section assessment of sentinel node has the potential to change the overall management of patients with early-oral tongue cancers.

Delineation of Neck Clinical Target Volume Specific to Nasopharyngeal Carcinoma Based on Lymph Node Distribution and the International Consensus Guidelines

PURPOSE

To establish the regional lymph node (LN) distribution probability map and draw the neck clinical target volume specific to nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

One thousand patients with pathologically proven NPC were enrolled from January 2010 to December 2011. The center point of the LNs with a minimal axial diameter of ≥4 mm was marked on a single treatment planning computed tomography scan. The neck LN levels I to X using the 2013 updated international consensus guidelines were also contoured. LN distribution probability maps and distribution curves were established. The relationships between the LN distribution and consensus guidelines were analyzed to propose modifications for clinical target volume boundaries specific to NPC.

RESULTS

A total of 10,651 LNs from 959 patients were marked. Based on the distribution of LNs and consensus guidelines, most of the LN levels defined in the 2013 updated consensus guidelines were confirmed to be comprehensive and applicable for NPC. However, for level Vb, 13.3% of cases (11 of 83) had LNs beyond the posteromedial border. For level VIIa (retropharyngeal LN), 1.5% of cases (12 of 819) had LNs above the cranial boundary, and 5 cases had LNs that emerged in the medial group. Moreover, we confirmed that no LN had been detected in certain areas of levels Ib, II, IVa, and Vc. Accordingly, a new level VIIc was proposed to include the medial group of retropharyngeal LNs, moderately extended boundaries for levels Vb and VIIa were recommended, and reduced boundaries are possibly adaptable for levels Ib, II, IV, and Vc.

CONCLUSIONS

Most LN levels in the 2013 updated consensus guidelines are comprehensive and applicable for NPC. We have proposed a new level VIIc to include a medial group of retropharyngeal LNs, recommended moderate extended boundaries for levels Vb and VIIa, and suggested that the boundaries for levels Ib, II, IV, and Vc might be reduced.

Indications and extent of elective neck dissection in patients with early stage oral and oropharyngeal carcinoma: nationwide survey in The Netherlands

Background:

Different strategies are available for the management of patients with early (i.e. tumour stage one or two) oral or oropharyngeal carcinoma and a clinically negative neck.

Material and methods:

In 2006, a questionnaire was sent to the eight head and neck cancer centres of the Dutch Head and Neck Oncology Cooperative Group. This questionnaire covered: the factors influencing the decision to perform an elective neck dissection; the neck staging procedure; and the types of neck dissection undertaken.

Results:

All eight questionnaires were returned completed. Respondents indicated that the site (n = 6), size (n = 7) and thickness (n = 6) of the primary tumour were important in decisions regarding elective neck dissection. Ultrasound-guided fine needle aspiration cytology was the most frequently used diagnostic technique (n = 7). Depending on the site and stage of the primary tumour presented, in the different cases 3–7 of the centres would perform an elective neck dissection. Selective neck dissections (i.e. levels I to III/IV) were more frequently performed than modified radical neck dissections.

Conclusion:

There was no uniformity regarding management of the clinically negative neck in patients with early stage oral and oropharyngeal carcinoma, within The Netherlands.

Applications of molecular diagnostics for personalized treatment of head and neck cancer: state of the art

Squamous cell carcinomas of the head and neck are the sixth most frequent tumors worldwide. Risk factors are carcinogenic exposure, infection with the human papillomavirus (HPV) and genetic predisposition. Lymph node metastasis in the neck and HPV status are major prognostic factors. There are several important clinical challenges that determine the research agenda in head and neck cancer. The first is more accurate staging, particularly of occult metastatic lymph nodes in the neck. A second challenge is the lack of biomarkers for personalized therapy. There are a number of treatment modalities that can be employed both single and in combination, but at present only site and stage of the tumor are used for treatment planning. Provided here is an overview of the successes and failures of molecular diagnostic approaches that have been and are being evaluated to address these clinical challenges.

Sentinel Node Biopsy for the Head and Neck Using Contrast-Enhanced Ultrasonography Combined with Indocyanine Green Fluorescence in Animal Models: A Feasibility Study

Background

Sentinel node navigation surgery is gaining popularity in oral cancer. We assessed application of sentinel lymph node navigation surgery to pharyngeal and laryngeal cancers by evaluating the combination of contrast-enhanced ultrasonography and indocyanine green fluorescence in animal models.

Methods

This was a prospective, nonrandomized, experimental study in rabbit and swine animal models. A mixture of indocyanine green and Sonazoid was used as the tracer. The tracer mixture was injected into the tongue, larynx, or pharynx. The sentinel lymph nodes were identified transcutaneously by infra-red camera and contrast-enhanced ultrasonography. Detection time and extraction time of the sentinel lymph nodes were measured. The safety of the tracer mixture in terms of mucosal reaction was evaluated macroscopically and microscopically.

Results

Sentinel lymph nodes were detected transcutaneously by contrast-enhanced ultrasonography alone. The number of sentinel lymph nodes detected was one or two. Despite observation of contrast enhancement of Sonazoid for at least 90 minutes, the number of sentinel lymph nodes detected did not change. The average extraction time of sentinel lymph nodes was 4.8 minutes. Indocyanine green fluorescence offered visual information during lymph node biopsy. The safety of the tracer was confirmed by absence of laryngeal edema both macro and microscopically.

Conclusions

The combination method of indocyanine green fluorescence and contrast-enhanced ultrasonography for detecting sentinel lymph nodes during surgery for head and neck cancer seems promising, especially for pharyngeal and laryngeal cancer. Further clinical studies to confirm this are warranted.

Is 18F-fluorodeoxyglucose positron emission tomography/computed tomography helpful in the decision-making process for neck dissection in patients with T1-T2 lingual cancer?

CONCLUSION

The usefulness of addition of positron emission tomography/computed tomography (PET/CT) in decisions as to whether to perform neck dissection in patients with T1-T2 lingual squamous cell carcinoma (SCC) might be limited, but adding the condition of lymph nodes with a maximum standardized uptake value (SUVmax) >4.5 to existing criteria would be helpful.

OBJECTIVES

The purpose of this study was to investigate the usefulness of PET/CT for performing neck dissection in patients with T1-T2 lingual SCC.

METHODS

This retrospective review surveyed 19 patients with T1-T2 lingual SCC who underwent neck dissection after meeting one or more of the following criteria: (1) clinically positive nodes; (2) >4 mm thickness; (3) ≥ 3 cm longest diameter of the primary tumor. Focal 18F-fluorodeoxyglucose (FDG) uptake was considered to indicate PET-positive nodes (PET + Ns). The relation between pathologically positive nodes (p + Ns) and PET + Ns was estimated.

RESULTS

There were 14 PET + Ns at 12 of 66 levels (18%) in 8 of the 19 (42%) patients. There were also 6 p + Ns (1%) among 412 nodes at 5 cervical lymph node levels (8%) in 5 patients (26%). The sensitivity and specificity for PET/CT were 80% and 64%, respectively. The SUVmax was measured, and receiver operating characteristic (ROC) analysis was undertaken to obtain better accuracy. The sensitivity and specificity were 60% and 100% when the SUVmax cut-off value was set at 4.5.

Advances in diagnostic modalities to detect occult lymph node metastases in head and neck squamous cell carcinoma

Regional metastasis is a prominent feature of head and neck squamous cell carcinoma (HNSCC) and is an important prognostic factor. The currently available imaging techniques for assessment of the neck have limitations in accuracy; thus, elective neck dissection has remained the usual choice of management of the clinically N0 neck (cN0) for tumors with significant (≥20%) incidence of occult regional metastasis. As a consequence, the majority of patients without regional metastasis will undergo unnecessary treatment. The purpose of this review was to discuss new developments in techniques that potentially improve the accuracy of the assessment of the neck in patients with HNSCC. Although imaging has improved in the last decades, a limitation common to all imaging techniques is a lack of sensitivity for small tumor deposits. Therefore, complementary to improvements in imaging techniques, developments in more invasive diagnostic procedures, such as sentinel node biopsy (SNB) will add to the accuracy of diagnostic algorithms for the staging of the neck.

Ultrasound-guided fine needle aspiration cytology in the assessment of cervical metastasis in patients undergoing elective neck dissection

BACKGROUND

In head and neck cancer patients, diagnosis of metastatic cervical adenopathy is essential for treatment planning and prognosis assessment. Treatment of patients with head and neck cancer with clinically negative cervical lymph node (N0) remains controversial. While routine neck treatment would result in overtreatment in many patients, observation may delay the diagnosis and decrease the patients' survival.

OBJECTIVES

To gain insights into the unclear questions regarding the value of diagnostic modalities in patients with N0 neck, this study was designed to compare the diagnostic efficacy of palpation, ultrasonography (US) and ultrasound-guided fine needle aspiration (USGFNA) in detecting cervical lymph node metastasis.

PATIENTS AND METHODS

Forty-two patients with head and neck cancer who underwent US and USGFNA prior to elective neck dissection were studied. Histopathologic findings of the neck specimens were compared with each diagnostic technique.

RESULTS

Of the 53 neck dissection specimens, histopathology showed metastases in 16 cases. The overall accuracy of USGFNA, US and palpation was 96%, 68% and 70%, respectively. The specificity of USGFNA was superior to palpation and US alone. USGFNA had the highest sensitivity, predictive value and accuracy in detecting cervical metastases compared with other performed tests.

CONCLUSIONS

In our study, USGFNA was superior to palpation and US in detecting metastasis in clinically negative necks. This method can be recommended as a diagnostic tool in preoperative assessment of patients without palpable metastasis, but further investigations are needed before this modality could be considered as an alternative to elective neck dissection.

Minimal invasive biopsy of intraconal expansion by PET/CT/MRI image-guided navigation: a new method

Intraorbital tumours are often undetected for a long period and may lead to compression of the optic nerve and loss of vision. Although CT, MRI's and ultrasound can help in determining the probable diagnosis, most orbital tumours are only diagnosed by surgical biopsy. In intraconal lesions this may prove especially difficult as the expansions are situated next to sensitive anatomical structures (eye bulb, optic nerve). In search of a minimally invasive access to the intraconal region, we describe a method of a three-dimensional, image-guided biopsy of orbital tumours using a combined technique of hardware fusion between (18)F-FDG Positron Emission Tomography ((18)F-FDG PET), magnetic resonance imaging (MRI) and Computed Tomography (CT).

METHOD AND MATERIAL

We present 6 patients with a total of 7 intraorbital lesions, all of them suffering from diplopia and/or exophthalmos. There were 3 female and 3 male patients. The patients age ranged from 20 to 75 years. One of the patients showed beginning loss of vision. Another of the patients had lesions in both orbits. The decision to obtain image-guided needle biopsies for treatment planning was discussed and decided at an interdisciplinary board comprising other sub-specialities (ophthalmology, neurosurgery, maxillofacial surgery, ENT, plastic surgery). All patients underwent 3D imaging preoperatively ((18)F-FDG PET/CT or (18)F-FDG PET/CT plus MRI). Data was transferred to 3D navigation system. Access to the lesions was planned preoperatively on a workstation monitor. Biopsy-needles were then calibrated intraoperatively and all patients underwent three-dimensional image-guided needle biopsies under general anaesthesia.

RESULTS

7 biopsies were performed. The histologic subtype was idiopathic orbital inflammation in 2 lesions, lymphoma in 2, Merkel cell carcinoma in 1, hamartoma in 1 and 1 malignant melanoma. The different pathologies were subsequently treated in consideration of the actual state of the art. In cases where surgical removal of the lesion was performed the histological diagnosis was confirmed in all cases.

CONCLUSION

There is a wide range of possible treatment modalities for orbital tumours depending on the nature of the lesion. Histological diagnosis is mandatory to select the proper management and operation. The presented method allows minimal-invasive biopsy even in deep intraconal lesions, enabling the surgeon to spare critical anatomical structures. Vascular lesions such as cavernous haemangioma, tumour of the lacrimal gland or dermoid cysts present a contraindication and have to be excluded.

Ultrasound examination and fine needle aspiration cytology-useful for followup of the regional nodes in penile cancer?

PURPOSE

Routine followup of the groins of patients with penile squamous cell carcinoma after primary treatment consists of physical examination together with ultrasound of the groins, followed by fine needle aspiration cytology if suspicious. We assessed the value of this routine followup.

MATERIALS AND METHODS

Using ultrasound and fine needle aspiration cytology we assessed 247 patients during followup who were treated from 2004 to 2010 and underwent dynamic sentinel node biopsy only or observation of the inguinal regions. A negative result was defined as no evidence of metastatic disease after at least 2 years of followup. We calculated the sensitivity, specificity, and positive and negative predictive values of ultrasound and ultrasound guided fine needle aspiration cytology using standard statistical methods.

RESULTS

Recurrence was diagnosed in 47 of 247 patients (55 groins). In 40 of 55 groins (73%) recurrence was detectable by physical examination. In 12 of 15 cases of nonpalpable recurrence (80%) ultrasound guided fine needle aspiration cytology revealed the recurrence. We considered 217 groins to be suspicious on ultrasound followed by fine needle aspiration cytology. Fine needle aspiration cytology revealed tumor in 49 groins and showed false-positive findings in 1 patient after negative completion lymphadenectomy. Sensitivity and specificity were 87.3% (48 of 55 cases) and 99.9% (1,304 of 1,305), respectively.

CONCLUSIONS

Although inguinal recurrence manifests clinically in most patients, ultrasound guided fine needle aspiration cytology detected 80% of metastatic disease in patients with nonpalpable disease. Therefore, it has great value for detecting lymph node metastases during followup.

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.

Sentinel lymph node mapping by indocyanin green fluorescence imaging in oropharyngeal cancer - preliminary experience

Background

Sentinel lymph node (SLN) detection and biopsy is gaining popularity in the treatment of Head and Neck cancer. Various methods in this regard have been described, each with their respective advantages and disadvantages. The aim of this paper was to evaluate the potential application of Indocyanin Green (ICG) in the mapping and detection of sentinel lymph nodes (SLN) in cancers of the head and neck.

Methods

Patients with oropharyngeal cancer and N0 neck who were scheduled for primary tumor ablation as well as a neck dissection were selected. One milliliter of Indocyanin green was injected around the tumor and the sentinel node detection was performed by aiming the infra red video camera on the cervical area. When no detection was possible transcutaneously, a cervical incision was made, a sub-platysmal flap raised and further detection was done to visualize the fluorescing lymph nodes.

Results

Detection of cervical SLN was only possible when 5 mm or less tissue covered the sentinel lymph node. Accurate and clear detection of the lymph drainage pattern and SLN was possible. There is some uptake in other tissues such as the submandibular gland which is easily distinguishable from lymphatic tissue.

Conclusion

Indocyanin green fluorescence is a potential valuable potential tool in the detection of SLN in patients with oropharyngeal cancer which warrants further investigation.

Oral cavity squamous cell carcinoma and the clinically n0 neck: the past, present, and future of sentinel lymph node biopsy

Oral cavity squamous cell carcinoma (OCSCC) has a yearly incidence of 274,000 patients. Twenty percent to 30% of patients will harbor occult regional metastases, an important feature that correlates with worse outcomes. Supraomohyoid neck dissection (SND) is the gold standard treatment, but because of recent successes of sentinel lymph node (SLN) biopsy in the management of breast cancer and melanoma, many have begun evaluating its use in head and neck mucosal cancers. SLN biopsy offers patients decreased morbidity compared with SND, and has shown reproducibly low false-negative rates, high-negative predictive values, and high sensitivities. Limitations with floor-of-mouth primaries and delayed secondary SNDs have been described, but a new agent designed to address these shortcomings, Lymphoseek (Neoprobe Corp.; Dublin, OH), is currently under investigation. This article reviews the current literature on SLN biopsy and introduces a phase 3 study evaluating the efficacy of Lymphoseek in SLN biopsy of OCSCCs.

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.

How diagnostic is ultrasound-guided neck mass biopsy (fine-needle capillary sampling biopsy technique)?: evaluation of 132 nonthyroid neck mass biopsies with pathologic analysis over 7 years at a single institution

OBJECTIVE

The purpose of this study was to evaluate the diagnostic value of ultrasound-guided neck mass biopsy (fine-needle capillary sampling biopsy [FNC] technique).

METHODS

With Institutional Review Board approval, all patients who had an ultrasound-guided neck mass FNC biopsy between January 2000 and December 2006 were retrieved from the ultrasound database. A total of 132 neck mass biopsies were performed in 124 patients. Patient demographics, procedure characteristics, and pathologic diagnoses were recorded.

RESULTS

Of the 124 patients, 73 were female (mean age, 51.4 years). Biopsies were performed twice in 8 patients. A significant 200% increase from 2000 through 2002 to 2003 through 2004 and from 2003 through 2004 to 2005 through 2006 was found (P < .05). The most biopsied location was in the lymph nodes (34.8%), followed by perithyroid soft tissue masses (28.0%). A 25-gauge needle was used most frequently (97.7%). A total of 41 biopsies were diagnostic for thyroid diseases (31.1%), with the most common being thyroid papillary carcinoma. We found metastases in 31 biopsies (23.5%). Following these 2 were 29 lymph node biopsies. No major complications were noted. Of the 132 neck masses biopsied, 8 were pathologically nondiagnostic (93.9% diagnostic yield), yielding sensitivity, specificity, and accuracy of greater than 95% (97.1%, 95.2%, and 95.8%, respectively).

CONCLUSIONS

Ultrasound-guided FNC of neck masses is highly diagnostic. The diagnostic yield is especially high for detection of malignancy, including metastases. Together with a high clinical suspicion, ultrasound-guided needle biopsy should be performed to form a correct diagnosis and make appropriate management plans.

Advances in imaging in the work-up of head and neck cancer patients

Accurate staging at the time of the diagnosis of head and neck squamous cell carcinoma (HNSCC) is critical for selection of the appropriate treatment strategy. Therefore, optimizing pre-treatment imaging in the diagnostic work-up is of great importance. CT and MRI are the corner stones of diagnostic work-up. Technical improvements will increase the value of these techniques even further. PET and PET-CT became a standard imaging techniques for HNSCC patients. It may be helpful for the detection of occult primary tumours, but its sensitivity for the detection of occult lymph node metastases is too low. Alternatively, the sentinel node procedure may be sufficiently accurate to avoid elective treatment of the neck. Screening for distant metastases should be performed only in HNSCC patients with high risk factors by FDG-PET-CT.

Staging of untreated nasopharyngeal carcinoma with PET/CT: comparison with conventional imaging work-up

PURPOSE

We prospectively compared PET/CT and conventional imaging for initial staging of nasopharyngeal carcinoma (NPC).

METHODS

A total of 111 patients with histologically proven NPC were investigated with PET/CT and conventional imaging (head-and-neck MRI, chest X-ray, abdominal ultrasound, and bone scan) before treatment. The respective findings were reviewed independently and then compared with each other.

RESULTS

With regard to T staging, PET/CT showed a discrepancy with head-and-neck MRI in 36 (32.4%) of the study subjects. With regard to N staging, PET/CT showed a discrepancy with head-and-neck MRI in 15 (13.5%) patients. Among the discordant cases, MRI was superior in demonstrating tumor involvement in the parapharyngeal space, skull base, intracranial area, sphenoid sinus, and retropharyngeal nodes while PET/CT was superior in demonstrating neck nodal metastasis. PET/CT disclosed 13 of 16 patients with distant malignancy compared with four patients disclosed by conventional imaging work-up. The false-positive rate of PET/CT was 18.8%. PET/CT correctly modified M staging in eight patients (7.2%) and disclosed a second primary lung malignancy in one patient (0.9%).

CONCLUSION

In NPC patients, MRI appears to be superior to PET/CT for the assessment of locoregional invasion and retropharyngeal nodal metastasis. PET/CT is more accurate than MRI for determining cervical nodal metastasis and should be the better reference for the neck status. PET/CT has an acceptable diagnostic yield and a low false-positive rate for the detection of distant malignancy and can replace conventional work-up to this aim. PET/CT and head-and-neck MRI are suggested for the initial staging of NPC patients.

Initial CT findings in early tongue and oral floor cancer as predictors of late neck metastasis

Detecting the risk factors for late neck metastasis (LNM) in early tongue and oral floor cancer is important for establishing an accurate prognosis, as well as for increasing survival rates. Patients with either stage I or II tongue and oral floor cancer underwent either a resection of the primary tumor or interstitial radiotherapy without neck dissection. We measured the short- and long-axis diameters of lymph nodes on initial CT images. Of the 38 patients, 20 had LNM and 18 did not. CT images showed a total of 161 lymph nodes. Twenty-five "occult lymph nodes" developed into LNM, whereas the remaining 136 "reactive lymph nodes" did not. Comparison between "occult" and "reactive" lymph nodes revealed significant differences in the short-axis diameters (p=0.01). The measure of short-axis diameters of neck lymph nodes on initial CT images is a useful predictor of LNM in patients with early tongue and oral floor cancer.

Clinicopathological factors related to cervical lymph node metastasis in a patient with carcinoma of the oral floor

CONCLUSION

Tumors developing into the muscle layer and tumor thickness > or =5 mm are the most important risk factors associated with nodal metastasis.

OBJECTIVE

It is necessary to identify the risk factors associated with cervical metastasis in patients with oral floor cancer to reveal the role of elective neck dissection for oral floor cancer.

PATIENTS AND METHODS

Forty-eight patients with oral floor cancer were retrospectively analyzed for a correlation between clinicopathologic factors and cervical lymph node metastasis using Fisher's exact test and a logistic regression test.

RESULTS

Univariate analysis showed significantly positive correlations for growth type, mitosis, perineural invasion, vascular invasion, lymphatic invasion, depth, thickness, and infiltration growth ratio. Multivariate analysis had a significantly positive correlation with nest formation and depth in all patients, and with thickness in patients with T1 or T2. In patients with bilateral cervical lymph node metastasis, lymph node metastasis was significantly positively correlated with perineural invasion.

The role of ultrasound in the detection of cervical lymph node metastases in clinically N0 squamous cell carcinoma of the head and neck

Nodal involvement is the most important prognostic factor in head and neck squamous cell carcinoma (HNSCC) of mucosal origin. The presence of a single ipsilateral or contralateral metastatic node reduces survival by 50% and bilateral disease by a further 50%. The management of N+ HNSCC is relatively clear-cut. By contrast, the investigation and treatment of patients with clinically N0 disease is controversial. Most institutions electively treat the neck with surgery or radiotherapy because the risk of occult metastases is over 20%, even though it will be unnecessary in the majority of cases. In this situation the main purpose of staging would be to assess those nodes that are not going to be removed. However, the optimal management of the clinically N0 neck remains controversial and there is growing interest in a more conservative approach. Research is now directed toward finding a method of staging sensitive enough to bring the risk of occult metastases below 20%. High spatial resolution, ease of multiplanar scanning, power Doppler and the ability to perform guided fine-needle aspiration for cytology give ultrasound (US) an advantage over other imaging techniques.

FDG PET in oral and oropharyngeal cancer. Value for confirmation of N0 neck and detection of occult metastases

Treatment of the clinical N0 neck in squamous cell carcinoma (SCC) of oral cavity and oropharynx remains a dilemma. None of the current imaging modalities are able to detect the presence of micrometastases in the lymph nodes of clinical N0 necks reliably. The aim of this study was to determine the diagnostic properties of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) in patients clinically staged as N0. FDG PET results of 38 patients were compared to histologic specimens obtained with neck dissections or to follow-up. FDG PET performance was compared to computed tomography (CT), magnetic resonance imaging (MRI) or ultrasonography-guided fine needle aspiration cytology (USgFNAC). Sensitivity and specificity of FDG PET in detecting occult cervical metastases were 50% and 97% respectively. Although FDG PET performed better than conventional imaging modalities, sensitivity was lower than desired. As a consequence, clinical application of FDG PET in the patient staged as N0 is limited.

High expressions of CD105 and VEGF in early oral cancer predict potential cervical metastasis

BACKGROUND AND OBJECTIVES

Although elective neck dissection has become a popular treatment modality for early oral cancer among most head and neck surgeons, a large portion of patients revealed pathological N0 postoperatively. Our study is aimed to evaluate the expressions of the angiogenic factors, vascular endothelial growth factor (VEGF), and CD105 (endoglin) on the prediction of neck metastasis for clinical N0 patients in early oral cancer.

PATIENTS AND METHODS

Between July 1996 and July 2005, the preoperative biopsy specimens among 176 patients who underwent surgical treatment for early oral cancer were retrieved for the immunohistochemical study for VEGF and CD105.

RESULTS

High expressions of CD105 and VEGF significantly correlated with positive nodal metastasis, respectively (P<0.001). The expression of CD105 also significantly correlated with that of VEGF (P<0.001). Furthermore, the sensitivity and specificity for prediction of cervical metastasis by high expressions of CD105 versus VEGF were 81.8% and 97.7% versus 93.2% and 72%, respectively. Low expression of CD105 and VEGF also significantly correlated with higher survival rate, respectively (P<0.001).

CONCLUSIONS

Besides the image studies, the expressions of both CD105 and VEGF could be useful to guide the elective treatment for clinical N0 neck in early oral cancer.

Imaging of oral cavity cancer

Despite many advances in surgical techniques, technology, radiation therapy, and chemotherapy, survival rates for head and neck cancer (HNCa) have not improved significantly in decades, with many patients being diagnosed at advanced disease stages. Adequate assessment of oral cavity malignancies is critical for appropriate planning of surgical, radiation, and chemotherapy treatment. Imaging modalities used to evaluate the oral cavity include plain radiography (panoramic radiography and intraoral radiography), nuclear medicine scintigraphy, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). This review describes these imaging techniques and their utility, primarily CT and MRI.

High Expression of CD105 as a Prognostic Predictor of Early Tongue Cancer

OBJECTIVES

The purpose of this article is to investigate the expressions of vascular endothelial growth factor (VEGF) and endoglin (CD105) in the biopsy tissues of squamous cell carcinoma of the tongue in early tumor stages and their relationship with the clinicopathologic features.

STUDY DESIGN AND METHODS

The authors conducted retrospective clinical and biologic studies. Immunohistochemistry was used to study the expressions of VEGF and CD105 in the biopsy tissues taken from 94 patients with T1 and T2 tongue cancers. The expressions of VEGF and CD105 were analyzed and correlated to the clinicopathologic features of these patients.

RESULTS

High expressions of VEGF and CD105 significantly correlated with a relatively advanced tumor stage (P=.001 and P<.001), positive nodal status (P<.001 and P<.001), presence of tumor necrosis (P=.022 and P=.01), and greater tumor thickness (P<.001 and P<.001), respectively. In addition, high expression of CD105 correlated with the presence of perineural invasion (P=.003). However, the expression of VEGF and CD105 did not significantly correlate with age, gender, vascular invasion, or histologic grading. The cumulative 5-year disease-free survival rate significantly correlated with low expression of VEGF (P=.003), CD105 (P<.001), positive nodal status (P<.001), a relatively advanced tumor stage (P=.024), greater tumor thickness (P=.023), and presence of tumor necrosis (P=.003). Nonetheless, Cox's regression analysis revealed that only the expression of CD105 was an independent prognostic predictor for survival (P<.001).

CONCLUSIONS

Higher expression of either CD105 or VEGF in the tumor bed implicates a more aggressive potential for T1 and T2 tongue cancers, and the expression of CD105 is a useful predictive prognostic factor in early tongue cancer.

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.

Histopathologic validation of the sentinel node concept in oral and oropharyngeal squamous cell carcinoma

BACKGROUND

In patients with head and neck squamous cell carcinoma (HNSCC), the presence of lymph node metastases is the most important prognosticator. Sentinel node (SN) biopsy has been shown to be an accurate staging technique for patients with breast cancer and melanoma and might also be suited for patients with HNSCC. This study was undertaken to determine whether the SN concept holds true for HNSCC and could be exploited for SN biopsy.

METHODS

In 22 patients with T2 to T4 N0 oral or oropharyngeal squamous cell carcinoma (SCC) who were scheduled to undergo combined primary tumor excision and elective unilateral (n = 17) or bilateral (n = 5) neck dissection, SN identification was performed the day before surgery by use of lymphoscintigraphy after peritumoral injections of 99mTc-labeled colloidal albumin. After the neck dissection specimens were removed, all SNs, all other radioactive lymph nodes, and all nonradioactive lymph nodes were retrieved for histopathologic analysis, including serial sectioning at 250-microm intervals and immunohistochemical analysis (IHC).

RESULTS

Overall, in 21 (78%) of 27 neck sides, an SN was identified by scintigraphy. Of the six neck sides in which SNs were not identified by scintigraphy, four were from three patients who underwent bilateral neck dissection. In another patient treated by bilateral neck dissection, the SN identified by scintigraphy could not be found in the specimen. In the remaining 20 neck dissection specimens, 23 SNs and 30 additional radioactive lymph nodes could be found. At histologic examination of the 20 neck specimens in which the SN was found, at least one SN was tumor positive in eight cases. In one neck specimen, a metastasis was detected in a nonradioactive lymph node, whereas the SN was tumor free, also at serial sectioning and IHC. In the remaining 11 neck sides in which the SN was tumor negative, none of the other radioactive (n = 13) and none of the nonradioactive (n = 279) lymph nodes contained tumor at histopathologic analysis, including serial sectioning and IHC. The sensitivity of the SN procedure for predicting lymph node metastases, therefore, was 89% (eight of nine neck specimens) when an SN was identified by scintigraphy and found in the specimen. The overall accuracy of the SN procedure for predicting the presence or absence of lymph node metastases in the neck was 95% (19 of 20 neck specimens).

CONCLUSIONS

Our study seems to validate the SN hypothesis for oral and oropharyngeal cancer. The role of SN biopsy in the management of the N0 neck in such patients has yet to be established through prospective trials. SN identification (and thus biopsy) does not seem to be reliable in patients with tumors located in or close to the midline.

Predictive markers for late cervical metastasis in stage I and II invasive squamous cell carcinoma of the oral tongue

PURPOSE

Patients with oral tongue carcinoma treated by intraoral excision only should be followed up carefully for cervical lymph node metastasis and salvaged immediately if found, because some patients have a more aggressive clinical course. The purpose of this study was to find useful markers for predicting late cervical metastasis in patients with stage I and II invasive squamous cell carcinoma of the oral tongue.

EXPERIMENTAL DESIGN

We investigated clinicopathologic factors and immunohistochemical biomarkers predicting late cervical metastasis in surgical specimens from 56 patients with T(1-2)N(0)M(0) invasive squamous cell carcinoma of the oral tongue who did not undergo elective neck dissection. Histopathologic factors including tumor thickness, mode of invasion, Broders grade, total score of three different malignancy grading systems, eight other clinicopathologic parameters, and immunohistochemical expression of p53, cyclin D1, Ki-67, epidermal growth factor receptor, microvessel density, cyclooxygenase-2, MUC1, laminin-5 gamma2, E-cadherin, and beta-catenin were examined. All of the clinicopathologic factors and immunohistochemical expression of biomarkers were compared in terms of survival.

RESULTS

In the univariate analysis, tumor thickness (P = 0.009), Broders grade (P = 0.017), nest shape (P = 0.005), mode of invasion (P < 0.001), Anneroth score (P = 0.029), Bryne score (P < 0.001), and E-cadherin expression (P = 0.003) were correlated with late cervical metastasis. Multivariate analysis on late cervical metastasis revealed that tumor thickness >4 mm, mode of invasion grade 3 or 4, and E-cadherin expression were independent factors. Late cervical metastasis was the only prognostic factor for overall survival (P = 0.002).

CONCLUSIONS

Our results indicate that patients with stage I and II invasive squamous cell carcinoma of the oral tongue with tumor thickness >4 mm, mode of invasion grade 3 or 4, and low expression of E-cadherin should be considered a high-risk group for late cervical metastasis when a wait-and-see policy for the neck is adopted.

Staging of the neck in patients with head and neck squamous cell cancer: Imaging techniques and biomarkers

Regional metastasis is an important factor in the treatment and prognosis of head and neck cancer patients. Current treatment strategies rely on staging based on the still limited accuracy of imaging techniques to detect regional metastases. If more certainty about the nodal status could be attained, treatment strategies concerning the neck could be better adjusted to the individual patient. The continuing improvement of established imaging techniques and the introduction of new imaging modalities will add to better staging. Moreover, the additional use of biomarkers studied on a protein, RNA or DNA level may provide even better information about the chance of occult nodal metastasis in head and neck cancer patients.

Sentinel Node Biopsy in Head and Neck Cancer: Preliminary Results of a Multicenter Trial

BACKGROUND

The aim was to determine the reliability and reproducibility of sentinel node biopsy (SNB) as a staging tool in head and neck squamous cell carcinoma (HNSCC) for T1/2 clinically N0 patients by means of a standardized technique.

METHODS

Between June 1998 and June 2002, 227 SNB procedures have been performed in HNSCC cases at six centers. One hundred thirty-four T1/2 tumors of the oral cavity/oropharynx in clinically N0 patients were investigated with preoperative lymphoscintigraphy (LSG), intraoperative use of blue dye/gamma probe, and pathological evaluation with step serial sectioning and immunohistochemistry, with a follow-up of at least 12 months. In 79 cases SNB alone was used to stage the neck carcinoma, and in 55 cases SNB was used in combination with an elective neck dissection (END).

RESULTS

In 125/134 cases (93%) a sentinel node was identified. Of 59 positive nodes, 57 were identified with the intraoperative gamma probe and 44 with blue dye. Upstaging of disease occurred in 42/125 cases (34%): with hematoxylin-eosin in 32/125 (26%) and with additional pathological staging in 10/93 (11%). The sensitivity of the technique with a mean follow-up of 24 months was 42/45 (93%). The identification of SNB for floor of mouth (FOM) tumors was 37/43 (86%), compared with 88/91 (97%) for other tumors. The sensitivity for FOM tumors was 12/15 (80%), compared with 30/30 (100%) for other tumor groups.

CONCLUSION

SNB can be successfully applied to early T1/2 tumors of the oral cavity/oropharynx in a standardized fashion by centers worldwide. For the majority of these tumors the SNB technique can be used alone as a staging tool.

Necrosis in metastatic neck nodes: diagnostic accuracy of CT, MR imaging, and US

PURPOSE

To compare the diagnostic accuracy of computed tomography (CT), magnetic resonance (MR) imaging, and ultrasonography (US) in the detection of necrosis in metastatic cervical nodes from patients with head and neck squamous cell carcinoma.

MATERIALS AND METHODS

Twenty-seven patients (age range, 39-85 years; mean age, 62 years) with squamous cell carcinoma in the head and neck underwent CT, MR imaging, and US. Three radiologists evaluated the images for nodal necrosis. The results of each modality were analyzed for sensitivity, specificity, and accuracy. Pathologic analysis of the surgical resection served as the reference standard. The three modalities were compared for specificity and sensitivity with the McNemar test.

RESULTS

Pathologic examination revealed 903 nodes, of which 89 were malignant. Of the malignant nodes, 43 were necrotic. Analysis of the detection of necrosis in the 89 malignant nodes showed an accuracy, sensitivity, and specificity of 92%, 91%, and 93% for CT; 91%, 93%, and 89% for MR imaging; and 85%, 77%, and 93% for US, respectively. All imaging modalities failed to depict necrotic areas of 3 mm or smaller in three nodes, and necrosis was missed in an additional seven nodes with US and in one node with CT. Necrosis could not be distinguished from other components of malignancy, such as viable tumor and scar tissue, in seven nodes (CT, 3; MR imaging, 5; US, 3). The sensitivity of both MR imaging and CT was significantly better than that of US (P =.0082 and P =.0339, respectively). There was no significant difference in sensitivity (P =.3173) between MR imaging and CT, or in the specificity of the three modalities.

CONCLUSION

MR imaging is comparable to CT for the detection of necrosis. The sensitivity of MR imaging and CT is better than that of US.