Initial staging of the neck in head and neck squamous cell carcinoma: A comparison of CT, PET/CT, and ultrasound-guided fine-needle aspiration cytology

Imaging and Pathology Concordance in Head and Neck Cancer: Retrospective Analysis

BACKGROUND

Lymph node metastasis critically impacts prognosis in head and neck malignancies. Preoperative imaging (CT/MRI) is vital for assessment but often yields false results. This study examines the concordance between preoperative imaging and postoperative pathology and identifies factors influencing imaging accuracy.

METHODS

A retrospective cohort study from 2014 to 2023 included patients with head and neck malignancies. Clinical and radiological data were analyzed, and the random forest algorithm was utilized for indeterminate cases.

RESULTS

Analyzing 1129 records, 26.1% had indeterminate imaging. Imaging accuracy for definitive findings was 72.8%, sensitivity 57.2%, and specificity 86.0%. Logistic regression highlighted alcohol, T, and clinical stage as accuracy influencers. The indeterminate group showed a link between multiple enlarged lymph nodes and positivity. A nomogram achieved 67.5% accuracy. The random forest model, focusing on lymph node diameter, stage, and T classification, improved accuracy to 75.5% over logistic regression.

CONCLUSION

Our study shows moderate imaging-pathology concordance. Key predictors like lymph node size suggest refining criteria with machine learning could enhance head and neck cancer diagnosis. These results could guide more accurate preoperative imaging assessments, leading to better surgical planning and patient outcomes. Subsequent exploration of adjusting lymph node size thresholds or integrating novel imaging technologies would be useful.

Quality of life following surgery for head and neck cancer: Evidence from ACRIN 6685

BACKGROUND

This study examined the trajectory of health-related quality of life (HRQoL) for patients with clinical stage N0 HNSCC enrolled in ACRIN 6685 who underwent elective neck dissection(s).

METHODS

HRQoL of 230 patients in the ACRIN 6685 trial was measured prospectively up to 2 years following surgery using the University of Washington Quality of Life instrument.

RESULTS

General Health Within the Last 7 Days did not differ significantly from baseline at any follow-up. General Health Relative to Before Cancer fell significantly by 5.8 points following surgery (p = 0.048), and then returned to 3.0 points above baseline at 1 year (p = 0.65). For Overall Quality of Life, HRQoL fell significantly by 4.3 points following surgery (p = 0.031) and then returned to levels not significantly different from baseline.

CONCLUSIONS

Patients with stage N0 HNSCC experience significant declines in HRQoL immediately following surgery, including neck dissection, which recovers to near or better than baseline within 1-2 years.

Enhanced Diagnostic Precision: Assessing Tumor Differentiation in Head and Neck Squamous Cell Carcinoma Using Multi-Slice Spiral CT Texture Analysis

This study explores the efficacy of texture analysis by using preoperative multi-slice spiral computed tomography (MSCT) to non-invasively determine the grade of cellular differentiation in head and neck squamous cell carcinoma (HNSCC). In a retrospective study, MSCT scans of patients with HNSCC were analyzed and classified based on its histological grade as moderately differentiated, well-differentiated, or poorly differentiated. The location of the tumor was categorized as either in the bone or in soft tissues. Segmentation of the lesion areas was conducted, followed by texture analysis. Eleven GLCM parameters across five different distances were calculated. Median values and correlations of texture parameters were examined in relation to tumor differentiation grade by using Spearman's correlation coefficient and Kruskal-Wallis and Dunn tests. Forty-six patients were included, predominantly female (87%), with a mean age of 66.7 years. Texture analysis revealed significant parameter correlations with histopathological grades of tumor differentiation. The study identified no significant age correlation with tumor differentiation, which underscores the potential of texture analysis as an age-independent biomarker. The strong correlations between texture parameters and histopathological grades support the integration of this technique into the clinical decision-making process.

The Importance of the Time Interval Between Preoperative 18F-FDG PET/CT Imaging and Neck Dissection for the Detection of Nodal Metastases in Patients with Head and Neck Squamous Cell Carcinoma

BACKGROUND

Detection of nodal metastasis is critical for the treatment and prognosis of head and neck cancer (HNC). Positron emission tomography/computed tomography (PET/CT) is increasingly being used to detect cervical lymph node involvement.

AIM

The purposes of this study were to (1) investigate the diagnostic accuracy of PET/CT for the detection of neck metastasis in patients with HNC and (2) determine the effect of the time interval between surgery and PET/CT.

METHODS

Fifty patients with head and neck squamous cell carcinoma who underwent PET/CT before surgery were included in this study. Preoperative PET/CT images that determined lymph node metastasis were compared with the histopathological analysis of neck dissection samples. Neck dissections were divided into three groups according to the time interval between surgery and PET/CT (0-2 weeks, >2-4 weeks, and >4 weeks). The concordance between PET/CT and histopathology was measured using the neck sides at different time intervals. The specificity, sensitivity, accuracy, negative predictive value (NPV), and positive predictive value (PPV) of PET/CT in detecting metastatic lymph nodes in the neck were calculated.

RESULTS

A total of 79 neck dissections were included in the study as 29 (58%) of the patients underwent bilateral neck dissection. The overall accuracy of PET/CT in detecting nodal metastasis was highest for the 0-2 weeks interval (95.6%). During this time interval, the sensitivity, specificity, NPV, and PPV of PET/CT were 100%, 90.9%, 100%, and 92.3%, respectively.

CONCLUSIONS

Although PET/CT is an important and reliable diagnostic method for detecting nodal metastases in patients with HNC, its reliability decreases as the time between surgeries increases. The optimal interval was 2 weeks; however, up to 4 weeks was acceptable.

Diagnostic accuracy of contrast-enhanced computed tomography in assessing bone invasion in patients with oral squamous cell carcinoma

OBJECTIVES

This study aimed to evaluate the diagnostic accuracy of contrast-enhanced computed tomography (CT) in detecting bone invasion in oral squamous cell carcinoma (OSCC) patients and to explore clinicopathological factors associated with its reliability.

MATERIALS AND METHODS

417 patients underwent preoperative contrast-enhanced CT followed by radical surgery. The presence or absence of bone invasion served as the outcome variable, with histopathologic examination of the resection specimen considered the gold standard. Statistical analyses, comprising correlation analyses and the determination of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were conducted.

RESULTS

CT exhibited 76.85% sensitivity, 82.20% specificity, 47.14% PPV, and 89.67% NPV. False-positive and false-negative rates were 11.27% and 5.99%, respectively. Artifacts affected assessment in 44 patients, but not in those with bone invasion. Tumor size, depth of invasion (DOI), tumor localization at the upper jaw, lymphatic invasion, and perineural invasion correlated with incorrect identification of bone invasion (Chi-square, p < 0.05).

CONCLUSIONS

Despite utilizing thin-section CT, notable false-positive and false-negative results persisted. Patients with T3 tumors, DOI ≥ 10 mm, or upper jaw tumors are at higher risk for misidentification of bone invasion. Combining multiple methods may enhance diagnostic accuracy, and the integration of artificial intelligence or tracking electrolyte disturbances by tumor depth profiling shows promise for further assessment of bone invasion before histopathology.

CLINICAL RELEVANCE

Surgeons should consider these insights when planning tumor resection. Supplementary imaging may be warranted in cases with high risk factors for misidentification. Further methodological advancements are crucial for enhancing diagnostic precision.

Twenty questions from the surgeon to the radiologist to better plan an open partial horizontal laryngectomy

Open partial horizontal laryngectomies (OPHLs) represent a valuable therapeutic option for tumors of the intermediate T-category and, in selected cases, for locally advanced tumors with low-volume extra-laryngeal extension. The eligibility of patients treated with this type of surgery has increased with the introduction of the modular approach to OPHL planning. This strategy follows the introduction of the classification proposed by the European Laryngological Society, based on the extent of horizontal resection. Optimization of the selection is the result of a meticulous work-up process involving close cooperation between experienced surgeons and radiologists, followed by final quality control by pathologists. Computed tomography and magnetic resonance imaging are study methods whose pearls and pitfalls are well known, especially when performed at a high level of expertise. In this paper, based on the experience of two high-volume centers, a checklist of 20 questions addressed by the surgeon to the radiologist before planning an OPHL was proposed. Considerations regarding case selection are reported for each of the questioned parameters. A very simple question-and-answer process is easy to understand and mainly addressed by less experienced colleagues who wish to increase their knowledge and skills in performing this type of surgery.

A 3 M Evaluation Protocol for Examining Lymph Nodes in Cancer Patients: Multi-Modal, Multi-Omics, Multi-Stage Approach

Through meticulous examination of lymph nodes, the stage and severity of cancer can be determined. This information is invaluable for doctors to select the most appropriate treatment plan and predict patient prognosis; however, any oversight in the examination of lymph nodes may lead to cancer metastasis and poor prognosis. In this review, we summarize a significant number of articles supported by statistical data and clinical experience, proposing a standardized evaluation protocol for lymph nodes. This protocol begins with preoperative imaging to assess the presence of lymph node metastasis. Radiomics has replaced the single-modality approach, and deep learning models have been constructed to assist in image analysis with superior performance to that of the human eye. The focus of this review lies in intraoperative lymphadenectomy. Multiple international authorities have recommended specific numbers for lymphadenectomy in various cancers, providing surgeons with clear guidelines. These numbers are calculated by applying various statistical methods and real-world data. In the third chapter, we mention the growing concern about immune impairment caused by lymph node dissection, as the lack of CD8 memory T cells may have a negative impact on postoperative immunotherapy. Both excessive and less lymph node dissection have led to conflicting findings on postoperative immunotherapy. In conclusion, we propose a protocol that can be referenced by surgeons. With the systematic management of lymph nodes, we can control tumor progression with the greatest possible likelihood, optimize the preoperative examination process, reduce intraoperative risks, and improve postoperative quality of life.

Diagnostic accuracy of contrast-enhanced computed tomography in assessing cervical lymph node status in patients with oral squamous cell carcinoma

OBJECTIVE

Accurate preoperative prediction of lymph node (LN) status plays a pivotal role in determining the extension of neck dissection (ND) required for patients with oral squamous cell carcinoma (OSCC). This study aims to evaluate the diagnostic accuracy of contrast-enhanced computed tomography (CT) in detecting LN metastases (LNMs) and to explore clinicopathological factors associated with its reliability.

METHODS

Data from 239 patients with primary OSCC who underwent preoperative CT and subsequent radical surgery involving ND were retrospectively reviewed. Suspicious LNs were categorized into three groups: accentuated (< 10 mm), enlarged (≥ 10 mm), and melted. Statistical analysis encompassing correlation and comparative analysis, and determination of sensitivity, specificity, PPV, and NPV were performed.

RESULTS

Overall, sensitivity was significantly higher in the accentuated LNs group (83.54%) compared to the melted LNs group (39.24%, p < 0.05, t test). Conversely, specificity was significantly higher in the melted LNs group (98.19%) compared to the accentuated LNs group (55.15%, p < 0.05, t test). Accentuated LNs exhibited a false negative rate of 13.00%. False positive rates were 51.80%, 30.26% and 8.82%, respectively. Diagnostic accuracy for detecting LNMs in level IIa and IIb exceeded that of level III. Patients with solely accentuated LNs were more likely to have a small, well-differentiated tumor. However, no distinctions emerged in terms of the occurrence of T4 tumors among the three groups.

CONCLUSION

CT proves sufficient to predict LNMs in patients with OSCC. Looking ahead, the potential integration of artificial intelligence and deep learning holds promise to further enhance the reliability of CT in LNMs detection. However, this prospect necessitates further investigation.

Comparing the Diagnostic Accuracy of Ultrasonography, CT, MRI, and PET/CT in Cervical Lymph Node Metastasis of Oral Squamous Cell Carcinoma

(1) Background: In oral cancer staging, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and 2-deoxy-2-[fluorine-18]fluoro-D-glucose (FDG) with positron emission tomography/computed tomography (PET/CT) are routinely used in clinical practice. The present study is a retrospective examination of the diagnostic accuracy of cervical lymph node metastasis using US, CT, MRI, and PET/CT, with histopathological diagnosis as a reference, to compare the different diagnostic imaging modalities. (2) Methods: The participants included 16 patients with oral squamous cell carcinoma who underwent US-, CT-, MRI-, and PET/CT-based preoperative diagnostic imaging and simultaneous primary lesion resection and neck dissection, including 82 level regions and 424 lymph nodes. We compared the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of each imaging modality based on the imaging results and the pathology results of metastasis. (3) Results: Of the four diagnostic imaging modalities, PET/CT exhibited the highest sensitivity but the lowest specificity and accuracy. US, CT, and MRI had high specificities. Comparing each level region and lymph node showed that differences were observed in PET/CT. (4) Conclusions: PET/CT to diagnose lymph node metastasis requires a comprehensive evaluation because it produces more false positives than other diagnostic imaging modalities. Using US, CT, and MRI, which have excellent spatial resolution, improves diagnostic accuracy at the lymph node level.

ACR Appropriateness Criteria® Staging and Post-Therapy Assessment of Head and Neck Cancer

Imaging of head and neck cancer at initial staging and as part of post-treatment surveillance is a key component of patient care as it guides treatment strategy and aids determination of prognosis. Head and neck cancer includes a heterogenous group of malignancies encompassing several anatomic sites and histologies, with squamous cell carcinoma the most common. Together this comprises the seventh most common cancer worldwide. At initial staging comprehensive imaging delineating the anatomic extent of the primary site, while also assessing the nodal involvement of the neck is necessary. The treatment of head and neck cancer often includes a combination of surgery, radiation, and chemotherapy. Post-treatment imaging is tailored for the evaluation of treatment response and early detection of local, locoregional, and distant recurrent tumor. Cross-sectional imaging with CT or MRI is recommended for the detailed anatomic delineation of the primary site. PET/CT provides complementary metabolic information and can map systemic involvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Sentinel node identification in laryngeal and pharyngeal carcinoma after flexible endoscopy-guided tracer injection under topical anesthesia: A feasibility study

BACKGROUND

The aim of this study was to investigate the feasibility of flexible endoscopy-guided tracer injection for sentinel lymph node (SLN) identification in patients with laryngeal and pharyngeal carcinoma.

METHODS

Sixteen cT1-4N0-2M0 patients with laryngeal or pharyngeal carcinoma underwent intra- and peritumoral [^99m Tc]Tc-nanocolloid injections after topical anesthesia under endoscopic guidance. SPECT-CT scans were performed at two time points.

RESULTS

Tracer injection and visualization of SLNs was successful in 15/16 (94%) patients. Median number of tracer injections was 1 intratumoral and 3 peritumoral. The median duration of the endoscopic procedure including tracer injection after biopsy taking was 7 min (range 4-16 min). A total of 28 SLNs were identified which were all visualized on the early and late SPECT-CT. Most SLNs were visualized in neck levels II and III.

CONCLUSIONS

Flexible endoscopy-guided tracer injection for SLN identification is a feasible and fast procedure in laryngeal and pharyngeal carcinoma patients.

The role of magnetic resonance imaging and computed tomography in oral squamous cell carcinoma patients' preoperative staging

INTRODUCTION

The aim of the study was to evaluate the accuracy of MRI and CT with regard to the detection of lymph node metastases based on the data of specific patients with OSCC who received bilateral neck dissection.

MATERIALS AND METHODS

In a retrospective analysis from 01/2014 to 12/2020 patients who underwent primary tumor resection and bilateral neck dissection were evaluated.

RESULTS

174 preoperative MRI (78.74%, N=137) and CT (21.26%, N=37) were correlated with the histopathological findings. CT had a sensitivity of 67% and specificity of 68% (p=0.76). MRI showed an overall sensitivity of 66% and a specificity of 68% (p=0.76). In 52.87% of all cases no differences between cN and pN were found. MRI is the method to overestimate lymph node involvement compared to CT (overestimation in 27% vs. 21.62%).

CONCLUSION

The current data indicate that MR and CT show poor efficacy in the detection of cervical metastases. Accordingly, attention must be paid to alternatives to correct local staging modalities. The application of structured bilateral neck dissection needs to be questioned.

Lipid metabolism marker CD36 is associated with 18FDG-PET/CT false negative lymph nodes in head and neck squamous cell carcinoma

Background

Lymph node metastasis frequently occurs in head and neck squamous cell carcinoma (HNSCC) patients, and [¹⁸F] fluorodeoxyglucose positron emission tomography with computed tomography (¹⁸FDG-PET/CT) examination for lymph node metastasis could result in false negativity and delay following treatment. However, the mechanism and resolution for ¹⁸FDG-PET/CT false negatives remain unclear. Our study was aim to found biomarkers for false negativity and true positivity from a metabolic perspective.

Methods

Ninety-two patients diagnosed with HNSCC who underwent preoperative ¹⁸FDG-PET/CT and subsequent surgery in our institution were reviewed. Immunohistochemistry (IHC) examinations of glucose metabolism (GLUT1 and GLUT5), amino acid metabolism4 (GLS and SLC1A5), and lipid metabolism (CPT1A and CD36) markers were conducted on their primary lesion and lymph node sections.

Results

We identified specific metabolic patterns of the false-negative group. Significantly, CD36 IHC score of primary lesions was higher in false-negative group than true-positive group. Moreover, we validated pro-invasive biological effects of CD36 by bioinformatics analysis as well as experiments. Conclusion: IHC examination of CD36 expression, which is a lipid metabolism marker, in primary lesions could distinguish HNSCC patients' lymph nodes false negatives in ¹⁸FDG-PET/CT.

The Applications and Potential Developments of Ultrasound in Oral Cancer Management

Oral cancer is endemic and causes a great burden in Southern Asia. It is preferably treated by surgery with/without adjuvant radiotherapy (RT) or chemoradiation therapy, depending on the stage of the disease. Close or positive resection margin and cervical lymph node (LN) metastasis are important prognostic factors that have been presented to be related to undesirable locoregional recurrence and poor survival. Ultrasound (US) is a simple, noninvasive, time-saving, and inexpensive diagnostic modality. It can depict soft tissues very clearly without the risk of radiation exposure. Additionally, it is real-time and continuous image is demonstrated during the exam. Furthermore, the clinician can perform US-guided fine needle aspiration (FNA) or core needle biopsy (CNB) at the same time. US with/without US-guided FNA/CNB is reported to be of value in determining tumor thickness (TT), depth of invasion (DOI), and cervical LN metastasis, and in aiding the staging of oral cancer. DOI has a relevant prognostic value as reported in the eighth edition of the American Joint Committee on Cancer staging of oral cancer. In the present review, we describe the clinical applications of US in oral cancer management in different phases and potential applications in the future. In the pretreatment and surgical phase, US can be used to evaluate TT/DOI and surgical margins of oral cancer in vivo and ex vivo. The prediction of a malignant cervical LN (nodal metastasis) by the US-based prediction model can guide the necessity of FNA/CNB and elective neck dissection in clinical early-stage oral cancer. In the posttreatment surveillance phase, US with/without US-guided FNA or CNB is helpful in the detection of nodal persistence or LN recurrence, and can assess the possibility and extent of carotid artery stenosis after irradiation therapy. Both US elastography and US swallowing assessment are potentially helpful to the management of oral cancer.

Image Fusion Improves Interdisciplinary Communication in the Treatment of Head and Neck Cancer

INTRODUCTION

The diagnosis and therapy of oral squamous cell carcinoma (Osee) in Germany is according to guidelines and relies on interdisciplinary board meetings. Standard examination techniques are computed tomography (CT) and magnet resonance imaging (MRI). These technologies are used as objective tools for serial presentation in an oncologic board meeting. The presentation of multiple series at different time points can be time consuming and might not often depict a patients case clearly for all involved disciplinaries. A conclusive image fusion could improve the communication. Thus, this study aims to introduce a novel idea of image fusion into the field of craniomaxillofacial surgery in order to ease understanding and improve therapy in complex Osee patients' cases.

MATERIALS AND METHODS

Three key data sets of a patient with OSCC at the right tongue have been merged by image fusion of 3 MRi of head and neck with 3 CT thorax and abdomen using Syngo via (Siemens). Fused images were used as at a glance picture for presenting and discussion a patients case. Focus was on presenting a case of a primary manifestation of OSCC with the potential of a local relapse and distant metastases in an interdisciplinary oncol-ogic board meeting.

RESULTS

Image fusion enabled to visualize the primary tumor, local relapse as well as distant pulmonary metastasis and within the suprarenal gland, which have been occurred in a linear time line of 13 months.

DISCUSSION

Image fusion of different modalities that is CT and MRi, which were gathered at different time points, presents a new approach within the field of craniomaxillofacial surgery and helped to understand cancer localization and relapse at 1 glance. This new approach will enable a compact data set of patients oncological history as a more decisive tool for all involved disciplinaries.

CONCLUSIONS

Image fusion might have the potential to become a standard approach in order to ease multiple therapists to make therapy decisions in oncologic board meetings on basis of current three-dimensional ready CT imaging and MRI.

Is the prediction of one or two ipsilateral positive lymph nodes by computerized tomography and ultrasound reliable enough to restrict therapeutic neck dissection in oral squamous cell carcinoma (OSCC) patients?

INTRODUCTION

Proper management of the clinically involved neck in OSCC patients continues to be a matter of debate. Our aim was to analyze the accuracy of computerized tomography (CT) and ultrasound (US) in anticipating the exact location of lymph node (LN) metastases of OSCC patients across the AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) levels ipsi- and contralaterally. Furthermore, we wanted to assess the suitability of therapeutic selective neck dissection (SND) in patients with one or two ipsilateral positive nodes upon clinical staging (cN1/cN2a and cN2b(2/x) patients).

METHODS

We prospectively analyzed the LN status of patients with primary OSCC using CT and US from 2007 to 2013. LNs were individually assigned to a map containing the AAO-HNS levels; patients bearing a single or just two ipsilateral positive nodes (designated cN1/cN2a or cN2b(2/x) patients either by CT (CT group) or US alone (US group) or in a group combining findings of CT and US (CTUS group)) received an ipsi-ND (I-V) and a contra-ND (I-IV). 78% of the LNs were sent individually for routine histopathological examination; the remaining were dissected and analyzed per neck level.

RESULTS

Upon the analysis of 1.670 LNs of 57 patients, the exact location of pathology proven LN metastases in cN1 patients was more precisely predicted by US compared to CT with confirmed findings only in levels IA, IB und IIA. Clearly decreasing the number of missed lesions, the findings in the CTUS group nearly kept the spatial reliability of the US group. The same analysis for patients with exactly two supposed ipsilateral lesions (cN2b(2/x)) yielded confirmed metastases from levels I to V for both methods individually and in combination and, therefore, render SND insufficient for these cases.

CONCLUSION

Our findings stress the importance of conducting both, CT and US, in patients with primary OSCC. Only the combination of their findings warrants the application of therapeutic SND in patients with a single ipsilateral LN metastasis (cN1/cN2a patients) but not in patients with more than one lesion upon clinical staging (≥ cN2b).

FDG-PET/CT and Pathology in Newly Diagnosed Head and Neck Cancer: ACRIN 6685 Trial, FDG-PET/CT cN0

OBJECTIVE

FDG-PET/CT (fluorodeoxyglucose-positron emission tomography/computed tomography) is effective to assess for occult neck nodal disease. We report risks and patterns of nodal disease based on primary site and nodal level from data on the dissected cN0 per the results from ACRIN 6685.

STUDY DESIGN

Prospective nonrandomized enrollment included participants with first-time head and neck squamous cell carcinoma and at least 1 cN0 neck side to be dissected.

SETTING

Twenty-four ACRIN-certified centers internationally (American College of Radiology Imaging Network).

METHODS

A total of 287 participants were enrolled. Preoperative FDG-PET/CT findings were centrally reviewed and compared with pathology. Incidence, relative risk, pattern of lymph node involvement, and impact upon neck dissection were reported.

RESULTS

An overall 983 nodal levels were dissected (n = 261 necks, n = 203 participants). The highest percentages of ipsilateral positive nodes by primary location and nodal level were oral cavity (level I, 17/110, 15.5%), pharynx (level II, 6/30, 20.0%), and larynx (level VI, 1/3, 33.3%).

CONCLUSION

Levels at greatest risk for nodal disease in cN0 in terms of ipsilateral neck dissection are level I (oral cavity), II (pharynx), and VI (larynx). These data should be considered when treating patients presenting with cN0. This is the first study to comprehensively report the incidence, location, and risk of metastases in cN0 in the FDG-PET/CT era.

Variability in Recommendations for Cervical Lymph Node Pathology for Staging of Canine Oral Neoplasia: A Survey Study

There is no clear guideline regarding the indication for routine lymph node extirpation and pathologic evaluation during staging of canine oral tumors, despite a relatively high reported nodal metastatic rate for select tumor types. It is particularly unclear if clinicians recommend removal of lymph nodes only when there is confirmation of metastasis, defined as the N+ neck, or if elective neck dissection (END) is routinely recommended to confirm the true pathologic metastatic status of lymph nodes in the clinical N0 neck (no evidence of metastasis on clinical staging with diagnostic imaging or cytology). When clinicians are recommending END as a staging tool to confirm nodal status, there is also ambiguity regarding the surgical extent for subsequent histopathologic evaluation. The objective of this cross-sectional survey study was to determine the current recommendations given by practicing specialists regarding lymph node removal for dogs with oral tumors. Overall, 87 responses were obtained from 49 private practices (56%) and 38 academic institutions (44%). Respondents identified as oncologists (44%, N = 38), soft tissue surgeons (40%, N = 35), and dentists (16%, N = 14). Regardless of tumor type and stage, extirpation and histopathology were most commonly recommended in the clinical N+ neck only. The recommendation to routinely perform END in the N0 neck was significantly associated with tumor type. Bilateral removal of the mandibular and retropharyngeal lymph nodes was recommended more often for oral malignant melanoma (OMM) than for oral squamous cell carcinoma (OSCC; p ≤ 0.0039) or for oral fibrosarcoma (OFSA; p ≤ 0.0007). The likelihood of recommending END increased with increasing tumor size. Academic clinicians were significantly (p < 0.01) more likely to recommend END compared to private practitioners for canine T1-T3 OMM, T3 OSCC, T2 OFSA, and MCT. This study highlights the variability in recommendations for lymph node pathology for dogs with oral tumors. While tumor type and size influenced the decision to pursue END, it was not routinely recommended, even for tumor types with a known propensity for metastasis. Prospective studies are warranted to determine the potential diagnostic and therapeutic value of END in the N0 neck in veterinary patients such that a consensus approach can be made.

Cervical Lymph Node Metastases in Oral Squamous Cell Carcinoma-How Much Imaging Do We Need?

Cervical lymph node metastases in oral squamous cell carcinoma (OSCC) are key predictors of disease specific survival. It was therefore the aim of this study to evaluate how much imaging is minimally needed for reliable and efficient identification of cervical lymph node metastases. In this retrospective cross-sectional study, results (metastasis yes/no) of ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) were compared to the final histopathological results of the corresponding neck dissection (ND) specimens (metastasis yes/no). A score was calculated to account for cervical lymph node size, shape, clustering, peripheral enhancement, hilus sign, architecture, blood flow, and central necrosis. Sensitivity and specificity were analyzed for each imaging technique separately. In 164 patients diagnosed with OSCC, 96 underwent uni- or bilateral ND (122 ND in total). One hundred percent sensitivity was achieved by CT+MRI, MRI+PET, US+CT+MRI, US+MRI+PET, CT+MRI+PET, and US+CT+MRI+PET. The highest specificity was realized by US with 79% (95% CI [0.698–0.890]). Specificity for CT+MRI and PET+MRI was 51% (95% CI [0.359–0.665]) and 70% (95% CI [0.416–0.984]), respectively. Regarding 100% sensitivity with acceptable specificity, the combination of CT+MRI or PET+MRI appeared to be suitable for staging cervical lymph nodes in primary OSCC.

Management of the Neck in Oral Squamous Cell Carcinoma: Background, Classification, and Current Philosophy

Nodal metastasis is the single most prognostic determinant in patients with oral squamous cell carcinoma (OSCC). Since its inception more than a century ago, the management of the neck has led to decreased surgical morbidity, with continued preservation of oncologic safety for OSCC. Nodal metastasis is the single most prognostic determinant in patients with OSCC. The decision for the extent of the neck dissection is tailored to tumor-specific characteristics, which dictate the probability and extent of nodal metastasis, including tumor size, location, histopathologic characteristics, and the presence or absence of clinical nodal disease. These factors are tools to aid diagnosticians in their decision making for individual patients.

Surgical consensus guidelines on sentinel node biopsy (SNB) in patients with oral cancer

BACKGROUND

The eighth international symposium for sentinel node biopsy (SNB) in head and neck cancer was held in 2018. This consensus conference aimed to deliver current multidisciplinary guidelines. This document focuses on the surgical aspects of SNB for oral cancer.

METHOD

Invited expert faculty selected topics requiring guidelines. Topics were reviewed and evidence evaluated where available. Data were presented at the consensus meeting, with live debate from panels comprising expert, nonexpert, and patient representatives followed by voting to assess the level of support for proposed recommendations. Evidence review, debate, and voting results were all considered in constructing these guidelines.

RESULTS/CONCLUSION

A range of topics were considered, from patient selection to surgical technique and follow-up schedule. Consensus was not achieved in all areas, highlighting potential issues that would benefit from prospective studies. Nevertheless these guidelines represent an up-to-date pragmatic recommendation based on current evidence and expert opinion.

Multicenter Trial of [18F]fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Staging of Head and Neck Cancer and Negative Predictive Value and Surgical Impact in the N0 Neck: Results From ACRIN 6685

PURPOSE

The objective of this study was to determine the negative predictive value (NPV) of positron emission tomography (PET)/computed tomography (CT) for the clinically N0 neck on the basis of neck dissection.

METHODS

Participants with newly diagnosed, first-time, head and neck squamous cell carcinoma (HNSCC) and at least one clinically N0 neck side for which dissection was planned were included. A total of 287 participants were prospectively enrolled from 23 American College of Radiology Imaging Network-qualified institutions. PET/CT was compared with findings at neck dissection.

RESULTS

PET/CT scans and pathology findings were available for 270 N0 neck sides from 212 participants. For visual assessment, the NPV specific to the clinical-N0 sides was 0.868 (95% CI, 0.803 to 0.925). For dichotomized maximum standardized uptake value, the NPVs specific to the nodal basins were 0.940 (95% CI, 0.928 to 0.952) and 0.937 (95% CI, 0.925 to 0.949) at prespecified cutoffs of 2.5 and 3.5, respectively. The optimal cutoff maximum standardized uptake value was determined to be 1.8, with an NPV of 0.942 (95% CI, 0.930 to 0.953). The PET/CT-informed surgical treatment plan was changed in 51 of 237 participants (22%) compared with the PET/CT-blinded surgical plan. In 34 participants (14%), this led to planned dissection of additional nodal levels. In 12 participants (5%), this led to fewer planned dissected nodal levels. Negative PET/CT scans in N0 necks was true negative in 87% and false negative in 13%.

CONCLUSION

[¹⁸F]fluorodeoxyglucose-PET/CT has high NPV for the N0 neck in T2 to T4 HNSCC. The surgical treatment plans on the basis of PET/CT findings may be changed in approximately 22% of this group. These findings suggest that [¹⁸F]fluorodeoxyglucose-PET/CT may assist the clinician in deciding on the best therapy for the clinically N0 neck in HNSCC. Well-designed clinical trials should be performed to test the outcome of omitting neck dissection by using PET/CT.

Pre-treatment Neutrophil-to-Lymphocyte Ratio as a predictor for occult cervical metastasis in early stage (T1-T2 cN0) squamous cell carcinoma of the oral tongue

BACKGROUND

Optimum management of clinically negative neck (cN0) remains controversial in early stage (T1-T2) squamous cell cancer of the oral tongue (OTSCC). The purpose of this study was to investigate the value of pre-treatment Neutrophil-to lymphocyte ratio (NLR) in predicting occult cervical metastasis in stage I and II OTSCC.

METHODS

We carried out a retrospective chart review on 110 patients suffering from early stage OTSCC who were surgically treated with tumour excision and elective neck dissection (END). Our cohort was divided in pN+ and pN0 groups basing on histopathological examination after elective neck dissection. For each patient pre-treatment NLR was calculated.

RESULTS

A statistically significant relationship between high levels of pre-treatment NLR and probability rate for neck occult metastases (0.000496 p-value) has been found. On our model the cut-off value was set for NLR >2.93. Above this level the probability to finding metastasis in a clinically negative neck increases exponentially.

CONCLUSION

These preliminary results offer clinicians an easily obtainable tool to stratify patients based on risks of metastatic node in whom END could be indicated.

Chapter 8 On the Horizon: Advanced Imaging Techniques to Improve Noninvasive Assessment of Cervical Lymph Nodes

Conventional imaging modalities are limited in the evaluation of lymph nodes as they predominantly rely on size and morphology, which have suboptimal sensitivity and specificity for malignancy. In this review we will explore the role of "on the horizon" advanced imaging modalities that can look beyond the size and morphologic features of a cervical lymph node and explore its molecular nature and can aid in personalizing therapy rather than use the "one-size-fits-all" approach.

Ultrasound-Guided Needle Biopsy for Diagnosis of Advanced-Stage Malignancies of the Upper Aerodigestive Tract

Objective

Traditionally, direct laryngoscopy confirms stage and tissue diagnosis prior to treatment planning. Patients who are frail or have tenuous airway anatomy may incur risks while undergoing anesthesia. Further, direct laryngoscopy is scheduled after initial examination, introducing diagnosis delay. This study investigates the impact of ultrasound examination with guided needle biopsy compared with traditional operative biopsy.

Study Design

Case series.

Setting

Tertiary head and neck clinic.

Subjects and Methods

The records of patients at the Veterans Affairs Medical Center Memphis and Regional One Health who had supraglottic, oropharyngeal, and hypopharyngeal cancer that was diagnosed by ultrasound needle biopsy were reviewed from 2011 to 2016. Demographics, stage, biopsy results, and treatment were abstracted.

Results

Seventeen patients who underwent ultrasound-guided needle biopsy of the primary site were included. Average age was 63 years old, and 65% of patients were stage T4 (11/17). Needle biopsy yielded malignant cells in 76% (13/17). Eleven patients were included in subsequent analysis because 6 patients underwent needle biopsy only. Fisher exact test showed no difference between the 2 methods (P = .27). Sensitivity was 86% and specificity was 100%. Seven patients had a median potential delay in diagnosis of 10 days.

Conclusions

Ultrasound can be used effectively to obtain a tissue diagnosis, circumventing an operative biopsy. Moreover, ultrasound may provide additional imaging details to support accurate staging. This strategy may prove worthwhile to cut costs and reduce delay to staging, reduce risk for those with contraindications to anesthesia, and increase staging accuracy via enhanced imaging details.

Shear Wave Elastography in Head and Neck Lymph Node Assessment: Image Quality and Diagnostic Impact Compared with B-Mode and Doppler Ultrasonography

The aim of this study was to assess the diagnostic performance of shear wave elastography (SWE) in comparison to B-mode and Doppler ultrasonography in differentiating benign from malignant head and neck lymph nodes (HNLNs). Sixty-two HNLNs from 56 patients were prospectively examined using B-mode, Doppler and SWE. The standard of reference was histopathology or cytology and follow-up. Qualitative malignant criteria (hilum infiltration, cortical hypo-echogenicity, irregular margins, abnormal vessels) were assessed on a five-point scale. Four quantitative parameters were obtained: long axis length, short axis length, short axis/long axis ratio, resistive index and maximum shear elasticity modulus (μmax). Diagnostic performance was analyzed with special emphasis on the sub-centimeter HNLN subgroup. Thirty HNLNs were malignant (48%). μmax intra-observer reproducibility was 0.899 (0.728 in sub-centimeter subgroup). Malignant HNLNs were stiffer (μmax = 72.4 ± 59.0 kPa) compared with benign nodes (μmax = 23.3 ± 25.3 kPa) (p < 0.001). Among the quantitative criteria, μmax had the highest diagnostic accuracy (area under the curve = 0.903 ± 0.042), especially in the sub-centimeter subgroup (area under the curve = 0.929 ± 0.045; p < 0.001) in which the area under the curve was significantly higher compared with the other quantitative criteria (p < 0.05). The additional use of SWE combined with B-mode tended to improve diagnostic accuracy (p > 0.05). SWE is a promising reproducible quantitative tool with which to predict malignant HNLNs, especially sub-centimeter nodes.

Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer

PURPOSE

Optimum management of the N0 neck is unresolved in oral cancer. Sentinel node biopsy (SNB) can reliably detect microscopic lymph node metastasis. The object of this study was to establish whether the technique was both reliable in staging the N0 neck and a safe oncological procedure in patients with early-stage oral squamous cell carcinoma.

METHODS

An European Organisation for Research and Treatment of Cancer-approved prospective, observational study commenced in 2005. Fourteen European centres recruited 415 patients with radiologically staged T1-T2N0 squamous cell carcinoma. SNB was undertaken with an average of 3.2 nodes removed per patient. Patients were excluded if the sentinel node (SN) could not be identified. A positive SN led to a neck dissection within 3 weeks. Analysis was performed at 3-year follow-up.

RESULTS

An SN was found in 99.5% of cases. Positive SNs were found in 23% (94 in 415). A false-negative result occurred in 14% (15 in 109) of patients, of whom eight were subsequently rescued by salvage therapy. Recurrence after a positive SNB and subsequent neck dissection occurred in 22 patients, of which 16 (73%) were in the neck and just six patients were rescued. Only minor complications (3%) were reported following SNB. Disease-specific survival was 94%. The sensitivity of SNB was 86% and the negative predictive value 95%.

CONCLUSION

These data show that SNB is a reliable and safe oncological technique for staging the clinically N0 neck in patients with T1 and T2 oral cancer. EORTC Protocol 24021: Sentinel Node Biopsy in the Management of Oral and Oropharyngeal Squamous Cell Carcinoma.

High-frequency Ultrasound Imaging of Mouse Cervical Lymph Nodes

High-frequency ultrasound (HFUS) is widely employed as a non-invasive method for imaging internal anatomic structures in experimental small animal systems. HFUS has the ability to detect structures as small as 30 µm, a property that has been utilized for visualizing superficial lymph nodes in rodents in brightness (B)-mode. Combining power Doppler with B-mode imaging allows for measuring circulatory blood flow within lymph nodes and other organs. While HFUS has been utilized for lymph node imaging in a number of mouse  model systems, a detailed protocol describing HFUS imaging and characterization of the cervical lymph nodes in mice has not been reported. Here, we show that HFUS can be adapted to detect and characterize cervical lymph nodes in mice. Combined B-mode and power Doppler imaging can be used to detect increases in blood flow in immunologically-enlarged cervical nodes. We also describe the use of B-mode imaging to conduct fine needle biopsies of cervical lymph nodes to retrieve lymph tissue for histological  analysis. Finally, software-aided steps are described to calculate changes in lymph node volume and to visualize changes in lymph node morphology following image reconstruction. The ability to visually monitor changes in cervical lymph node biology over time provides a simple and powerful technique for the non-invasive monitoring of cervical lymph node alterations in preclinical mouse models of oral cavity disease.

Correlation of fine-needle aspiration with fluorodeoxyglucose positron emission tomography and ultrasonography imaging in head and neck lymph nodes

INTRODUCTION

Fluorodeoxyglucose positron emission tomography (FDG-PET) is a well-established tracer technique, particularly useful for oncologic conditions. However, in the head and neck region, this modality may have limitations due to the complex anatomy and high frequency of normal variants in FDG-PET uptake resulting in diagnostic errors. Hence, FDG-PET results often require additional diagnostic investigations including ultrasonography (US), and guided fine-needle aspirations (FNAs) in order to improve diagnosis and patient care.

MATERIALS AND METHODS

A total of 87 cases of head and neck lymph node FNA were accessioned in the cytopathology laboratory between 2010 and 2013, 75 cases with corresponding standard uptake values (SUVs) were selected to form the current study cohort. Patient demographics, primary tumor site, size of the biopsied lymph node, PET SUV, and US findings, as well as FNA diagnoses and surgical follow-ups were reviewed. SUVs were grouped into 5 ranges: A (2.2-2.9), B (3.0-4.9), C (5.0-6.9), D (7.0-9.9), and E (10.0 +).

RESULTS

The SUV cutoff of 5.0 was seen in the groups C, D, and E, which increased the probability of malignancy in the FNA specimens from 67% to 100%. The average size of the lymph nodes was 18.57 mm (range 6-41 mm); it was 13.4, 14.2, 19.7, 18.4, and 20.2 for groups A, B, C, D, and E, respectively. The lymph node measurements represented similarities in groups A and B (13.4, 14.2), and groups C, D, and E (19.7, 18.4, 20.2). Albeit a few exceptions, an increase in the lymph node size 14.2 to 19.7 (ie, from groups A and B to groups C, D, and E) correlated with SUV and US abnormalities. Abnormal US findings were pronounced (100%) in group E, and ranged between 67% and 73% of the cases in other groups.

CONCLUSIONS

This study documents the usefulness of SUV range in FDG-PET results and not an absolute "cutoff" number for diagnosing suspicious head and neck lymph nodes due to an overlap in the SUVs between malignant and benign lesions. False positive and negative results may occur in hyperplastic and necrotic lymph nodes. An increase in the lymph node size generally compares well with SUVs and US abnormalities; use of US-guided FNAs in these cases can be helpful to achieve definite diagnosis.

Imaging evaluation of lymphadenopathy and patterns of lymph node spread in head and neck cancer

Accurate and consistent characterization of metastatic cervical adenopathy is essential for the initial staging, treatment planning and surveillance of head and neck cancer patients. While enlarged superficial nodes may be clinically palpated, imaging allows identification of deeper adenopathy as well as clinically unsuspected pathology and thus imaging has become an integral part of the evaluation of most head and neck cancers patients. This review will focus on the evaluation of cervical adenopathy, summarizing the currently used nomenclature and imaging approach for determining cervical lymph node metastases in head and neck malignancies. The imaging-based classification, which has also been adopted by the American Joint Committee on Cancer, will be presented, the morphologic characteristics used to identify metastatic nodes will be reviewed and the typical nodal spread patterns of the major mucosal cancers of the head and neck will be examined.

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.

Use of high frequency ultrasound to monitor cervical lymph node alterations in mice

Cervical lymph node evaluation by clinical ultrasound is a non-invasive procedure used in diagnosing nodal status, and when combined with fine-needle aspiration cytology (FNAC), provides an effective method to assess nodal pathologies. Development of high-frequency ultrasound (HF US) allows real-time monitoring of lymph node alterations in animal models. While HF US is frequently used in animal models of tumor biology, use of HF US for studying cervical lymph nodes alterations associated with murine models of head and neck cancer, or any other model of lymphadenopathy, is lacking. Here we utilize HF US to monitor cervical lymph nodes changes in mice following exposure to the oral cancer-inducing carcinogen 4-nitroquinoline-1-oxide (4-NQO) and in mice with systemic autoimmunity. 4-NQO induces tumors within the mouse oral cavity as early as 19 wks that recapitulate HNSCC. Monitoring of cervical (mandibular) lymph nodes by gray scale and power Doppler sonography revealed changes in lymph node size eight weeks after 4-NQO treatment, prior to tumor formation. 4-NQO causes changes in cervical node blood flow resulting from oral tumor progression. Histological evaluation indicated that the early 4-NQO induced changes in lymph node volume were due to specific hyperproliferation of T-cell enriched zones in the paracortex. We also show that HF US can be used to perform image-guided fine needle aspirate (FNA) biopsies on mice with enlarged mandibular lymph nodes due to genetic mutation of Fas ligand (Fasl). Collectively these studies indicate that HF US is an effective technique for the non-invasive study of cervical lymph node alterations in live mouse models of oral cancer and other mouse models containing cervical lymphadenopathy.

Staging of cervical lymph nodes in oral squamous cell carcinoma: adding ultrasound in clinically lymph node negative patients may improve diagnostic work-up

INTRODUCTION

Clinical staging of patients with oral squamous cell carcinoma (OSCC) is crucial for the choice of treatment. Computed tomography (CT) and/or magnetic resonance imaging (MRI) are typically recommended and used for staging of the cervical lymph nodes (LNs). Although ultrasonography (US) is a non-expensive, accessible and non-ionising imaging modality this method is not consistently used. This study aimed to investigate if addition of US of patients classified as clinically LN negative (cN0) by CT and/or MRI, increases the detection of LN metastases. Also, we aimed to identify which of the sonographic characteristics: echogenicity, border, shape, appearance of hilum and nodal blood-flow pattern best detect metastases in this patient group.

METHOD

Fifty-one patients with OSCC classified as cN0 by CT/MRI were consecutively included and prospectively examined with US prior to sentinel node biopsy or selective neck dissection. Localisation, size and sonographic characteristics were registered for each LN and compared with the pathological findings. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for different size measurements and sonographic characteristics.

RESULTS

We found that short axial diameter was the best size criterion for detection of metastases. However, the sonographic characteristics were better predictors than size and the presence at least four of the sonographic characteristics: hypo-echoic or heterogeneous appearance; irregular border; spherical shape; absence of nodal hilum; and peripheral nodal blood-flow resulted in a sensitivity of 43.8; specificity 91.4; PPV 70.0; and NPV 78.0. The number of patients with occult metastases decreased from 16 out of 51 (31%) to nine out of 51 (18%). Three patients (6%) were over-staged by US.

CONCLUSION

The addition of US to the clinical work-up of patients with cN0 OSCC increases the detection of metastases, thus US potentially reduces the number of patients requiring a secondary neck surgery after sentinel node biopsy.

Imaging in head and neck squamous cell carcinoma: the potential role of PET/MRI

In head and neck oncology, the information provided by positron emission tomography (PET)/CT and MRI is often complementary because both the methods are based on different biophysical foundations. Therefore, combining diagnostic information from both modalities can provide additional diagnostic gain. Debates about integrated PET/MRI systems have become fashionable during the past few years, since the introduction and wide adoption of software-based multimodality image registration and fusion and the hardware implementation of integrated hybrid PET/MRI systems in pre-clinical and clinical settings. However, combining PET with MRI has proven to be technically and clinically more challenging than initially expected and, as such, research into the potential clinical role of PET/MRI in comparison with PET/CT, diffusion-weighted MRI (DW MRI) or the combination thereof is still ongoing. This review focuses on the clinical applications of PET/MRI in head and neck squamous cell carcinoma (HNSCC). We first discuss current evidence about the use of combined PET/CT and DW MRI, and, then, we explain the rationale and principles of PET/MR image fusion before summarizing the state-of-the-art knowledge regarding the diagnostic performance of PET/MRI in HNSCC. Feasibility and quantification issues, diagnostic pitfalls and challenges in clinical settings as well as ongoing research and potential future applications are also discussed.

Role of positron emission tomography/computed tomography (PET/CT) in head and neck cancer

Positron emission tomography/computed tomography (PET/CT) has an important role in the diagnosis and treatment of head and neck cancer. The technique can aid in the detection of an unknown primary tumor, assist in locoregional staging, evaluate for distant metastases or second primary tumors, and be a component of restaging and tumor surveillance. This article reviews the basic principles, pitfalls, and uses of PET/CT in head and neck cancer, as well as potential future applications.

Physiologic [18F]fluorodeoxyglucose uptake of floor of mouth muscles in PET/CT imaging: a problem of body position during FDG uptake?

OBJECTIVE

Assess the influence of 2 different patient positions during [18F]fluorodeoxyglucose (FDG) uptake phase on physiologic FDG accumulation of the floor of mouth (FOM) muscles.

STUDY DESIGN

A prospective study design was used.

METHODS

Two hundred prospectively enrolled patients were included in the study: (a) head and neck cancer (HNC) patients in supine or (b) sitting position, (c) patients with other malignant tumours in supine or (d) sitting position. An intra-individual analysis was done on patients (b) and (d) when such scans were available. Maximum standardized uptake values without correction and corrected for blood pool activity were assessed.

RESULTS

The inter-individual analysis (sitting vs supine) revealed no significant differences (P = 0.17 and P = 0.56). The subgroup analysis on the patients with HNC (P = 0.56 and P = 0.15) and in patients with other malignancies (P = 0.14 and P = 0.08) revealed no significant difference; neither did the intra-individual analysis.

CONCLUSIONS

The supine or sitting position during the uptake phase for FDG-positron emission tomography/computed tomography has no effect on the amount and distribution of physiologic FDG activity in the muscles of the FOM.

Four-protein signature accurately predicts lymph node metastasis and survival in oral squamous cell carcinoma

The presence of lymph node (LN) metastasis significantly affects the survival of patients with oral squamous cell carcinoma (OSCC). Successful detection and removal of positive LNs are crucial in the treatment of this disease. Current evaluation methods still have their limitations in detecting the presence of tumor cells in the LNs, where up to a third of clinically diagnosed metastasis-negative (N0) patients actually have metastasis-positive LNs in the neck. We developed a molecular signature in the primary tumor that could predict LN metastasis in OSCC. A total of 211 cores from 55 individuals were included in the study. Eleven proteins were evaluated using immunohistochemical analysis in a tissue microarray. Of the 11 biomarkers evaluated using receiver operating curve analysis, epidermal growth factor receptor (EGFR), v-erb-b2 erythroblastic leukemia viral oncogene homolog 2 (HER-2/neu), laminin, gamma 2 (LAMC2), and ras homolog family member C (RHOC) were found to be significantly associated with the presence of LN metastasis. Unsupervised hierarchical clustering-demonstrated expression patterns of these 4 proteins could be used to differentiate specimens that have positive LN metastasis from those that are negative for LN metastasis. Collectively, EGFR, HER-2/neu, LAMC2, and RHOC have a specificity of 87.5% and a sensitivity of 70%, with a prognostic accuracy of 83.4% for LN metastasis. We also demonstrated that the LN signature could independently predict disease-specific survival (P = .036). The 4-protein LN signature validated in an independent set of samples strongly suggests that it could reliably distinguish patients with LN metastasis from those who were metastasis-free and therefore could be a prognostic tool for the management of patients with OSCC.