Imaging in head and neck cancer

Positron Emission Tomography-Magnetic Resonance Imaging, a New Hybrid Imaging Modality for Dentomaxillofacial Malignancies-A Systematic Review

Background/Objectives: Emerging hybrid imaging modalities, like Positron Emission Tomography/Computed Tomography (PET/CT) and Positron Emission Tomography/Magnetic Resonance Imaging (PET/MRI), are useful for assessing head and neck cancer (HNC) and its prognosis during follow-up. PET/MRI systems enable simultaneous PET and MRI scans within a single session. These combined PET/MRI scanners merge MRI's better soft tissue contrast and the molecular metabolic information offered by PET. Aim: To review scientific articles on the use of hybrid PET/MRI techniques in diagnosing dentomaxillofacial malignancies. Method: The available literature on the use of PET/MRI for the diagnosis of dentomaxillofacial malignancies in four online databases (Scopus, PubMed, Web of Science, and the Cochrane Library) was searched. Eligible for this review were original full-text articles on PET/MRI imaging, published between January 2010 and November 2024, based on experimental or clinical research involving humans. Results: Out of the 783 articles retrieved, only twelve articles were included in this systematic review. Nearly half of the articles (5 out of 12) concluded that PET/MRI is superior to PET, MRI, and PET/CT imaging in relation to defining malignancies' size. Six articles found no statistically significant results and the diagnostic accuracy presented was similar in PET/MRI versus MRI and PET/CT images. Regarding the overall risk of bias, most articles had a moderate risk. Conclusions: The use of PET/MRI in HNC cases provides a more accurate diagnosis regarding dimensions of the tumor and thus a more accurate surgical approach if needed. Further prospective studies on a larger cohort of patients are required to obtain more accurate results on the application of hybrid PET/MRI.

Head and Neck Tumor Segmentation of MRI from Pre- and Mid-Radiotherapy with Pre-Training, Data Augmentation and Dual Flow UNet

Head and neck tumors and metastatic lymph nodes are crucial for treatment planning and prognostic analysis. Accurate segmentation and quantitative analysis of these structures require pixel-level annotation, making automated segmentation techniques essential for the diagnosis and treatment of head and neck cancer. In this study, we investigated the effects of multiple strategies on the segmentation of pre-radiotherapy (pre-RT) and mid-radiotherapy (mid-RT) images. For the segmentation of pre-RT images, we utilized: 1) a fully supervised learning approach, and 2) the same approach enhanced with pre-trained weights and the MixUp data augmentation technique. For mid-RT images, we introduced a novel computational-friendly network architecture that features separate encoders for mid-RT images and registered pre-RT images with their labels. The mid-RT encoder branch integrates information from pre-RT images and labels progressively during the forward propagation. We selected the highest-performing model from each fold and used their predictions to create an ensemble average for inference. In the final test, our models achieved a segmentation performance of 82.38% for pre-RT and 72.53% for mid-RT on aggregated Dice Similarity Coefficient (DSC) as HiLab. Our code is available at https://github.com/WltyBY/HNTS-MRG2024_train_code.

Unusual pulmonary nodules diffusion from epithelial‑myoepithelial carcinoma on 18F‑FDG PET/CT: A case report

Epithelial-myoepithelial carcinoma (EMC) is a rare low-grade malignant tumor with uncommon regional lymph node metastasis and distant metastasis. The diagnosis of this disease primarily relies on the examination of pathological morphology and immunohistochemical staining, as its clinical symptoms and imaging findings are non-specific. This makes it more difficult to provide specific information about EMC lung metastasis. The present report describes a biopsy-confirmed case of pulmonary metastases arising from EMC of the parotid. The pulmonary nodules were dispersed throughout both lungs and exhibited varying degrees of fluorodeoxyglucose (FDG) uptake on positron emission tomography-computed tomography scans. Additionally, the pathological and immunohistological presentation of the lung mass was similar to that of the primary lesion. Several pulmonary nodules exhibiting varying degrees of FDG uptake may be considered a distinctive sign of metastasis on EMC imaging. Reviewing the present case, along with other similar rare cases in the literature, is crucial to accurately evaluate the imaging examinations of such patients to identify and establish an appropriate treatment plan for potential metastatic lung cancer. It also highlights the importance of not underestimating the malignant potential of EMC and the necessity for close follow-up.

Can Hounsfield unit density value accurately predict prelaryngeal invasion in laryngeal carcinoma cases

OBJECTIVE

The Hounsfield unit density value (HUDV) is a relative quantitative measurement of radio density used by radiologists in the interpretation of computed tomography (CT) images. Our aim is to investigate the role of HUDV in evaluating pre-epiglottic space (PES) involvement of laryngeal carcinoma.

METHODS

Seventy-four patients treated for laryngeal carcinoma in our clinic between 2014 and 2019 were included in the study. The invasion status of PES was determined radiologically and pathologically. HUDV was measured with a circular selected region of interest, with a constant size of 10 mm2 for PES. The relationship between patological PES invasion, radiological PES invasion, and HUDV was evaluated.

RESULTS

Measuring HUDV to determine PES invasion (74.3 %) was significantly higher than​​ conventional CT evaluation (59.5 %) (p = 0.001). The agreement coefficient (kappa value) of the conventional CT evaluation and the HUDV regarding PES involvement was 0.673, which was interpreted as 'good'.

CONCLUSION

HUDV could be used as an additional tool in diagnosing pre-epiglottic space invasion in laryngeal cancer.

Detecting recurrent disease and surgical outcomes in patients with locally advanced tongue cancer after multimodal treatment using ¹⁸F-FDG-PET/CT

The purpose of this study was to evaluate the utility of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FPCT) parameters for detecting recurrent disease and the outcomes of salvage surgery in patients with locally advanced oral tongue squamous cell carcinoma (TSCC) after multimodal treatment. In total, 69 patients with locally advanced TSCC were treated with multimodal therapy. All patients underwent whole-body FPCT scans 4-10 months after the initial surgery. The analysis included FPCT parameters, such as maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Histological examination was used as the reference standard. Patients with recurrent TSCC underwent salvage surgery or surgery plus systemic treatment. This study included 69 patients: 36 in the recurrent TSCC group and 33 in the non-recurrent TSCC group. The SUVmax, MTV, and TLG in the recurrent TSCC group were 11.3 ± 3.6, 28.3 ± 15.6 cm3, and 113.2 ± 46.8 g, respectively; these values were 5.9 ± 3.6, 5.1 ± 2.2 cm3, and 13.4 ± 4.8 g, in the non-recurrent TSCC group respectively. The two groups had significant differences in terms of SUVmax, MTV, and TLG. In the recurrent TSCC group, 91.6 % of patients presented with local, locoregional, and regional disease and underwent salvage surgery plus systemic therapy, whereas 8.4 % had locoregional recurrence with distant metastases alone and underwent surgery plus systemic therapy. The patients were followed up for 12-60 months; 19 and 20 patients in the recurrent and non-recurrent TSCC groups showed no evidence of disease, whereas 11 and 8 were alive with the disease. Local recurrence or distant metastases led to the deaths of six patients in the recurrent TSCC group and five in the non-recurrent TSCC group. No significant differences in survival were observed between the two groups. FPCT parameters can detect the recurrence of locally advanced TSCC after multimodal treatment. Early salvage surgery can improve the treatment outcomes for recurrent TSCC.

Transoral robotic tongue base mucosectomy for head and neck cancer of unknown primary: six-year outcome experience

BACKGROUND AND OBJECTIVE

Head and neck carcinoma of unknown primary is a diagnostic dilemma. The clinical and imaging workup remains ineffective in two-thirds of patients. Transoral robotic surgery has shown an advantage in the primary detection over the previous standard panendoscopy.

METHODS

This is an observational cohort study that took place at a large healthcare centre with robotic surgery experience in head and neck over six-years. All included carcinoma of unknown primary patients followed the standard recommendation for primary identification. Final diagnostic step of robotic tongue base mucosectomy with or without tonsillectomy was introduced. The cancer detection rate in tongue base only, the functional outcome and the effect on the cancer pathway were evaluated.

RESULTS

Carcinoma of unknown primary was reported in 44 per cent of patients. All identified specimens were human papillomavirus positive. There was no significant effect on functional outcome of swallowing and the national 62-day cancer pathway. Robotic surgery allowed optimum treatment of carcinoma of unknown primary in early nodal disease.

CONCLUSION

Robotic surgery is a useful paradigm in the management of carcinoma of unknown primary. It is safe with minimal morbidity and good functional outcome after the surgery.

CT-based peritumoral radiomics nomogram on prediction of response and survival to induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma

PURPOSE

The study aims to harness the value of radiomics models combining intratumoral and peritumoral features obtained from pretreatment CT to predict treatment response as well as the survival of LA-NPC(locoregionally advanced nasopharyngeal carcinoma) patients receiving multiple types of induction chemotherapies, including immunotherapy and targeted therapy.

METHODS

276 LA-NPC patients (221 in the training and 55 in the testing cohort) were retrospectively enrolled. Various statistical analyses and feature selection techniques were applied to identify the most relevant radiomics features. Multiple machine learning models were trained and compared to build signatures for the intratumoral and each peritumoral region, along with a clinical signature. The performance of each model was evaluated using different metrics. Subsequently, a nomogram model was constructed by combining the best-performing radiomics and clinical models.

RESULTS

In the testing cohort, the nomogram model exhibited an AUC of 0.816, outperforming the other models. The nomogram model's calibration curve showed good agreement between predicted and observed outcomes in both the training and testing sets. When predicting survival, the model's concordance index (C-index) was 0.888 in the training cohort and 0.899 in the testing cohort, indicating its robust predictive ability.

CONCLUSION

In conclusion, the combined nomogram model, incorporating radiomics and clinical features, outperformed other models in predicting treatment response and survival outcomes for LA-NPC patients receiving induction chemotherapies. These findings highlight the potential clinical utility of the model, suggesting its value in individualized treatment planning and decision-making.

Radiomics for Diagnosis and Radiotherapy of Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma (NPC) is a malignant tumor of the head and neck. The primary clinical manifestations are nasal congestion, blood-stained nasal discharge, headache, and hearing loss. It occurs frequently in Southeast Asia, North Africa, and especially in southern China. Radiotherapy is the main treatment, and currently, imaging examinations used for the diagnosis, treatment, and prognosis of NPC include computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET)-CT, and PET-MRI. These methods play an important role in target delineation, radiotherapy planning design, dose evaluation, and outcome prediction. However, the anatomical and metabolic information obtained at the macro level of images may not meet the increasing accuracy required for radiotherapy. As a technology used for mining deep image information, radiomics can provide further information for the diagnosis and treatment of NPC and promote individualized precision radiotherapy in the future. This paper reviews the application of radiomics in the diagnosis and treatment of nasopharyngeal carcinoma.

Comparison of the value of ultrasound and enhanced magnetic resonance imaging in judging cervical lymph node metastasis in patients with oral cancer

BACKGROUND

Oral cancer is the twelfth largest malignant tumor in the world. Oral cancer is prone to lymph node metastasis in the early stages of the disease, and lymph node metastasis will directly affect the treatment and survival rate. Therefore, whether the lymph node metastasis can be accurately evaluated is of great significance to the treatment and prognosis of patients.

OBJECTIVE

The diagnostic efficacy of three methods of preoperative ultrasound, enhanced magnetic resonance (enhanced MR), and ultrasound combined with enhanced MR on cervical lymph node metastasis of oral cancer were compared.

MATERIALS AND METHODS

A retrospective analysis of 399 cases of oral cancer completed by head and neck surgery at Cancer Center of Sun Yat-sen University, China. In all cases, the maxillofacial and neck enhanced MR and cervical lymph node ultrasound examinations were performed before surgery, and imaging diagnosis was made for cervical lymph node metastasis and compared with pathology. All judgment results were statistically processed using the chi-square test.

RESULTS

Compared with the above three methods, the diagnostic efficiency of ultrasound alone is better, and the diagnostic efficiency of enhanced MR combined ultrasound is not significantly better than that of ultrasound alone. There are differences in the diagnostic efficacy of the three inspection methods in different clinical sub-periods, all of which are better for the diagnosis of stage I. For patients with stage I, II, and III, there were no differences between the three examination methods. However, for stage IV patients,the diagnostic efficiency of ultrasound alone is better. For patients with stage N0, there was no difference in diagnostic efficacy between the three methods. For the assessment of lymph nodes in the I-III region, there are differences between the three methods of examination: the diagnostic efficiency of ultrasound alone is better, and enhanced MR combined ultrasound is not significantly better than ultrasound alone. For the evaluation of lymph nodes in the IV-VII region, there was no difference in diagnostic efficacy between the three methods.

CONCLUSION

According to the clinical characteristics and prognosis of patients with oral cancer, although enhanced MR can better evaluate the tumor, ultrasound may be considered as the preferred imaging method for cervical lymph node metastasis.

SIGNIFICANCE

Accurate assessment and proper and timely treatment of lymph node metastasis can help improve the survival rate of patients.

Review of Perineural Invasion in Keratinocyte Carcinomas

Perineural invasion is an infiltrative process of peripheral nerves by the primary neoplasm within the immediate vicinity. Aggressive forms of keratinocyte carcinomas, such as basal cell and squamous cell carcinomas, may feature perineural invasion, which is often associated with tumor recurrence and poorer prognosis. Diagnosis requires a high clinical suspicion. Imaging and histopathology are used to assess for extent of disease while surgical excision with complete circumferential peripheral and margin assessment is the treatment goal. However, there is still significant uncertainty about adjuvant chemotherapy and definitive management guidelines. Here, we summarize the current understanding of this complex pathogenic process, the clinical presentation, and the significance of perineural inflammation. We also discuss the recommendations about staging, prognosis, adjuvant radiotherapy, and general guidelines for managing keratinocyte carcinomas with perineural invasion. A better understanding of perineural invasion is essential to improve diagnosis, tailor interventions, and mitigate patient morbidity and mortality.

Human Papillomavirus and Squamous Cell Carcinoma of Unknown Primary in the Head and Neck Region: A Comprehensive Review on Clinical Implications

Squamous cell carcinoma of unknown primary (SCCUP) is a challenging diagnostic subgroup of oropharyngeal squamous cell carcinoma (OPSCC). The incidence of SCCUP is increasing in parallel with the well-documented increase in OPSCC and is likewise driven by the increase in human papillomavirus (HPV). The SCCUP patient often presents with a cystic lymph node metastasis and undergoes an aggressive diagnostic and treatment program. Detection of HPV in cytologic specimens indicates an oropharyngeal primary tumor origin and can guide the further diagnostic strategy. Advances in diagnostic modalities, e.g., transoral robotic surgery and transoral laser microsurgery, have increased the successful identification of the primary tumor site in HPV-induced SCCUP, and this harbors a potential for de-escalation treatment and increased survival. This review provides an overview of HPV-induced SCCUP, diagnostic modalities, and treatment options.

Defining the needs of patients with recurrent and/or metastatic head and neck cancer: An expert opinion

The clinical and biological heterogeneity of head and neck cancer (HNC) is paralleled by a plethora of different symptoms that affect the patient's quality of life. These symptoms include, for instance, pain, fatigue, nutritional issues, airways obstruction, voice alterations and psychological distress. In addition, patients with HNC are prone to a high risk of infection, and may also suffer from acute complications, such as hypercalcemia, spine compression by bone metastasis or bleeding. Prolonging survival is also an inherent expectation for all patients. Addressing the above needs is crucial in all patients with HNC, and especially in those with recurrent and/or metastatic (RM) disease. However, research on how to address patients' needs in RM-HNC remains scarce. This paper defines patients' needs for RM HNC and presents an Expert Opinion on how to address them, proposing also some lines of research.

Comparison of Ultrasonography and CT for Determining the Preoperative Benign or Malignant Nature of Thyroid Nodules: Diagnostic Performance According to Calcification

Background:

The present study was designed to investigate the presence or absence of calcification and whether calcification size affect the diagnostic accuracy of ultrasonography (US) and computed tomography (CT) in predicting the benign or malignant nature of thyroid nodules.

Material and Methods:

From May 2014 to April 2019, 445 patients underwent thyroid US and neck CT before thyroid surgery. In each case, US and CT were retrospectively examined by radiologists. We divided the patients into 3 groups according to the type of calcification: no calcification, microcalcification, and macrocalcification. And macrocalcification group divided into rim calcifications and non-rim calcifications groups. We evaluated the diagnostic accuracy of US and CT for differentiating malignant from benign thyroid nodules using histopathological results as a reference standard.

Results:

In the overall population, adding CT to US resulted in greater sensitivity, lower specificity, and lower accuracy in the prediction of the benign or malignant nature of nodules. In the group with no calcification, US had a significantly greater accuracy than CT and combined US/CT. In the group with macrocalcification, especially in rim calcifications, adding CT to US resulted in greater sensitivity than US, and CT exhibited greater sensitivity and accuracy than US.

Conclusion:

US is superior to CT for the prediction of the benign or malignant nature of nodules in thyroid lesions according to calcification and CT is also currently not recommended as a routine imaging tool for thyroid nodules. However, the superior sensitivity and accuracy of CT in lesions with macrocalcification especially in rim calcifications may enable CT to play a complementary role in identifying benign and malignant nodules.

Intraoperative Primary Tumor Identification and Margin Assessment in Head and Neck Unknown Primary Tumors

OBJECTIVE

Surgical management of the unknown primary head and neck squamous cell carcinoma (UP HNSCC) remains controversial due to challenging clinical diagnosis. This study compares positron emission tomography-computed tomography (PET-CT) findings with intraoperative identification of primary tumors and compares intraoperative frozen-section margins to final histopathology. In addition, adjuvant therapy indications are provided.

STUDY DESIGN

Prospective cohort study.

SETTING

Academic university hospital.

SUBJECTS AND METHODS

Sixty-one patients with UP HNSCC were included. Patients received PET-CT, followed by oropharyngeal transoral laser microsurgery (TLM). Margins were assessed intraoperatively using frozen sections and afterward by final histopathology. Adjuvant treatment was based on final histopathology.

RESULTS

The sensitivity of localizing the primary tumor with PET-CT was 50.9% with a specificity of 82.5%. The primary tumor was found intraoperatively on frozen sections in 82% (n = 50) of patients. Five more tumors were identified on final histopathology, leading to a total of 90% (n = 55). Of the 50 intraoperatively found tumors, 98% (n = 49) had negative margins on frozen sections, and 90% (n = 45) were truly negative on final histopathology. Eighteen patients (29.5%) avoided adjuvant treatment.

CONCLUSION

PET-CT localized the primary tumor in fewer than half the cases. This protocol identified 90% of primary tumors. Intraoperative frozen-section margin assessment has shown potential with a specificity of 92% compared to final histopathology. As a result, adjuvant therapy was avoided in almost one-third of our patients.

18F-FDG-PET/CT Imaging in Advanced Glottic Cancer: A Tool for Clinical Decision in Comparison with Conventional Imaging

This study assessed the role of ¹⁸F-FDG PET-CT (PET/CT) to detect the cartilage and paraglottic infiltration in advanced glottic cancer comparing the results with those of conventional imaging (CI) (contrast-enhanced computed tomography and/or magnetic resonance). In addition, we assessed the prognostic value of quantitative parameters, measured on baseline PET/CT, in terms of event-free survival (EFS) and overall survival (OS). We retrospectively analyzed 27 patients with glottic squamous cell carcinoma stage III and IVA, treated in our institute between 2010 and 2016, comparing PET/CT, performed for staging and radiotherapy planning, and CI findings. Cohen's K was used to compare concordance between PET/CT and CI. Imaging findings were correlated with endoscopic evaluation and histological reports (gold standard (GS)). All lesions shown by CI were also detected by PET/CT imaging, and in 5 cases, a better definition of local infiltration was achieved with PET/CT than CI (5 CT). Sensitivity, specificity, and accuracy of PET/CT and CT were 95%, 86%, and 93% and 70%, 86%, and 74% for, respectively. MRI showed sensitivity and specificity of 100%. One false-negative (FN) cases and 1 false-positive (FP) case were observed with PET/CT with no difference compared to MRI (10 cases). Six FN cases and 1 FP case were observed with CT. Cohen's K was 0.60 (PET vs. CI) and 0.80 (PET vs. GS). Patients were followed-up for at least 24 months to calculate EFS and OS. 13 local recurrence and 7 deaths were recorded. Among quantitative PET parameters, baseline MTV was the most powerful predictor of outcome. Our data suggest a reliable sensitivity and accuracy of PET/CT in the evaluation of local extension, proving a useful method for initial local staging in addition to the well-established role in lymph-node and distant sites assessment. Furthermore, pretreatment MTV provides better prognostic information than other PET/CT parameters.

Head and neck carcinoma of unknown primary

In adult cervicofacial pathology, carcinoma of unknown primary is defined as lymph-node metastasis the anatomic origin of which is not known at the time of initial management. It constitutes up to 5% of head and neck cancers. Presentation may suggest benign pathology, delaying and confusing oncologic treatment. Diagnostic strategy in cervical lymph node with suspicion of neoplasia requires exhaustive work-up to diagnose malignancy and, in 45% to 80% of cases, depending on the series, to identify the primary site. Histologic types comprise squamous cell carcinoma, thyroid carcinoma, adenocarcinoma, neuroendocrine carcinoma and undifferentiated carcinoma. Association is sometimes found with human papilloma virus or Epstein Barr virus, guiding treatment. The objective of the present study was to provide clinicians with the necessary diagnostic tools, based on the current state of clinical, imaging and pathologic knowledge, and to detail treatment options.

Transoral tongue base mucosectomy for the identification of the primary site in the work-up of cancers of unknown origin: Systematic review and meta-analysis

BACKGROUND

The use of transoral robotic surgery (TORS) and laser microsurgery (TLM) in the diagnosis and identification of the site of the unknown primary has become increasingly common. This systematic review and meta-analysis aims to assess the use and efficacy of TORS and TLM for this indication.

METHOD

Systematic review and meta-analysis of studies employing TORS or TLM in diagnosis of the unknown primary tumor site in patients with cervical nodal metastases of squamous cell origin. MEDLINE, EMBASE and CINHAL were searched from inception to July 2018 for all studies that used TORS and or TLM in identifying the unknown primary.

RESULTS

251 studies were identified, of which 21 were eligible for inclusion. The primary tumour was identified by TORS/TLM in 78% of patients (433 out of 556). Tongue base mucosectomy (TBM) identified the primary in 222 of 427 cases (53%). In patients with negative physical examination, diagnostic imaging and PETCT, TBM identified the primary in 64% (95% CI 50, 79) cases. In patients who had negative CT/MRI imaging, negative PETCT and negative EUA and tonsillectomy, TBM identified a tongue base primary in 78% (95% CI 41, 92) cases. Haemorrhage, the commonest complication, was reported in 4.9% cases. Mean length of stay varied between 1.4 and 6.3 days.

CONCLUSION

Tongue base mucosectomy, performed by TORS or TLM, is highly efficacious in identifying the unknown primary in the head and neck region.

Diagnostic Value of Lingual Tonsillectomy in Unknown Primary Head and Neck Carcinoma Identification After a Negative Clinical Workup and Positron Emission Tomography-Computed Tomography

Objective

Diagnostic rates of unknown primary head and neck carcinoma (UPHNC) using lingual tonsillectomy (LT) are highly variable. This study sought to determine the diagnostic value of LT in UPHNC identification using strict inclusion criteria and definitions to produce a more accurate estimate of diagnosis rate.

Methods

In this retrospective chart review, records of patients who underwent LT for UPHNC were reviewed. Inclusion criteria included absence of suspicious findings on physical exam and positron emission tomography-computed tomography as well as negative biopsies after panendoscopy and palatine tonsillectomy. Following inclusion criteria, 16 patients were reviewed. A systematic literature review on LT for the workup of CUP was also performed.

Results

LT was performed using transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or transoral microsurgery with cautery (TMC). Following LT, primary tumor was identified in 4 patients out of 16. Detection rate by technique was 1/6, 2/7, and 1/3 for TORS, TLM, and TMC respectively. Postoperative bleeding occurred in three patients (19%); however, this was not related to the LT. Following literature review, 12 studies were identified; however, only 3 had enough data to compare against. All three studies had a cohort with suspicious findings on clinical exam. A total of 34 patients had a negative workup, with no suspicious findings on clinical exam and subsequently received an LT.

Conclusion

This study suggests that LT should be considered initially in the diagnostic algorithm for UPHNC. This study can increase the patient size in this cohort by approximately 47%.

Management of head and neck primary unknown squamous cell carcinoma using combined positron emission tomography-computed tomography and transoral laser microsurgery

OBJECTIVES/HYPOTHESIS

The unknown primary of the neck is commonly encountered by the head and neck surgeon. Despite the exhaustive diagnostic tools employed in traditional detection protocols, many unknown primaries are not found, and the patient is subjected to wide-field radiation and chemotherapy during treatment. Localizing the primary tumor has demonstrated therapeutic benefits, improved quality of life, and overall survival. The authors' objective was to determine the efficacy of a new management protocol for unknown primaries of the head and neck.

STUDY DESIGN

Prospective cohort study.

METHODS

Our technique involved a preoperative positron emission tomography-computed tomography (PET-CT) followed by a planned transoral laser microsurgery (TLM) approach. Efficacy was assessed based on survival statistics, disease control, detection rates, the proportion of patients not receiving adjuvant therapy, and the proportion of PET-CT scans helpful for detection of the primary cancer.

RESULTS

The occult primary was located in 25 of the 27 patients (93%), with the majority found in the palatine tonsil (52%). Both overall survival and disease-specific survival was 80% at 36 months. Local control was achieved in 100% of patients. After surgery, 37.0% (n = 10) received adjuvant radiation alone and 33.3% (n = 9) of patients went on to receive adjuvant chemoradiation. On imaging, 72% (n = 18) of PET-CT scans correctly localized the primary tumor.

CONCLUSIONS

Occult head and neck primaries present a diagnostic challenge that is not adequately overcome using traditional detection protocols. The current study presents our unique protocol at Dalhousie University, which demonstrates the efficacy of the PET-CT TLM protocol from both a detection and therapeutic perspective.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2307-2311, 2018.

Computed tomography features of the major salivary glands after radioactive iodine ablation in patients with papillary thyroid carcinoma

OBJECTIVE

No previous study has investigated computed tomography (CT) features of the major salivary glands (MSGs) after postoperative radioactive iodine ablation (RIA). This study aimed to assess CT features of the MSGs after RIA in patients with papillary thyroid carcinoma (PTC).

METHODS

The study population comprised consecutively registered PTC patients who had undergone total thyroidectomy, RIA, follow-up neck ultrasonography (US), and neck CT. The US and CT features of the parotid and submandibular glands in each patient were retrospectively evaluated by a single radiologist. Post-RIA changes were determined by comparisons between follow-up neck US results (main reference) and between preoperative and post-RIA neck CT features.

RESULTS

Of the 28 patients, 13 (46.4%) showed post-RIA changes in the parotid glands (n = 8), submandibular glands (n = 0), or both (n = 5) on neck CT. Of the 56 MSGs in 28 patients, post-RIA changes were more common in the parotid glands (n = 23, 41.1%) than in the submandibular glands (n = 8, 14.3%). The common CT findings of post-RIA changes in the parotid gland included low parenchymal attenuation, decreased glandular size, a lobulated margin, decreased or increased parenchymal enhancement, and an inhomogeneous enhancement pattern, whereas common CT findings of post-RIA changes in the submandibular gland included decreased glandular size, a lobulated margin, iso-enhancement, and an inhomogeneous enhancement pattern.

CONCLUSION

The common CT features of post-RIA changes in MSGs include decreased glandular size, a lobulated margin, and an inhomogeneous enhancement pattern.

Does CT help in predicting preepiglottic space invasion in laryngeal carcinoma?

OBJECTIVE

Evaluating preepiglottic space involvement in laryngeal cancer by CT may lead misinterpretation. We sought to understand the causes of misinterpretation in evaluating the preepiglottic space by CT and assessed the effects of misinterpretation in treatment plans of patients with laryngeal squamous cell carcinomas.

METHODS

Specimen histopathology reports of 102 (99 male, 3 female) patients who underwent total or partial laryngectomy due to supraglottic and/or transglottic laryngeal carcinoma were reviewed. Neck CTs were also re-assessed for preepiglottic space involvement by three radiologists. The initial surgical treatment choices were re-examined according to the current radiological evaluation in combination with pathological results of the specimens and physical examination findings in the patients. Interobserver agreement regarding image interpretation was based on a kappa analysis.

RESULTS

The interclass correlation coefficient in predicting preepiglottic space invasion was 0.74; this was considered 'good.' Among the three radiologists, sensitivity, specificity, accuracy of CT in detecting preepiglottic space involvement were 86-93%, 75-93%, and 77-93%, respectively, while the negative and positive predictive values were 97-98% and 38-50%, respectively. Given the previous treatments applied, false-positive diagnoses for PES involvement resulted in overtreatment in 2.9% of cases. False-negative diagnoses of PES involvement (1.9% of cases) did not result in any undertreatment.

CONCLUSIONS

Although CT is a practical and inexpensive imaging tool for evaluating laryngeal carcinomas, the PPV of CT in assessing preepiglottic space invasion, especially in advanced tumors, is low and may lead to overtreatment.

Imaging of endoscopic approaches to the anterior and central skull base

Sinonasal endoscopy for treatment of benign sinonasal diseases is a well-established procedure. Recent advances in endoscope technology have substantially expanded its application with many institutions now offering resection of skull base lesions and sinonasal malignancies via the endoscopic approach. Its minimally invasive nature leads to faster recovery time, better cosmetic results, and fewer complications. Unfortunately, not all lesions involving the sinonasal region and skull base are accessible to sinonasal endoscopy. In addition, many of these disease processes are not directly visible on clinical examination. Therefore, the surgeon relies upon imaging to (1) determine the extent and possible nature of the disease; (2) provide guidance for surgical planning purposes, in particular, if a lesion is accessible to endoscopic surgery or if an open surgical approach is indicated. The radiologist, on the other hand, needs to be familiar with the technical limitations and contraindications of sinonasal endoscopy to provide a meaningful radiology report to the surgeon. The relative and absolute contraindications to endoscopic surgery can be categorised into technical factors, extent of a lesion, tumour vascularity, and anatomical variations and are discussed in this review article.

Diagnostic accuracy of magnetic resonance imaging techniques for treatment response evaluation in patients with head and neck tumors, a systematic review and meta-analysis

Background

Novel advanced MRI techniques are investigated in patients treated for head and neck tumors as conventional anatomical MRI is unreliable to differentiate tumor from treatment related imaging changes.

Purpose

As the diagnostic accuracy of MRI techniques to detect tumor residual or recurrence during or after treatment is variable reported in the literature, we performed a systematic meta-analysis.

Data sources

Pubmed, EMBASE and Web of Science were searched from their first record to September 23^th 2014.

Study selection

Studies reporting diagnostic accuracy of anatomical, ADC, perfusion or spectroscopy to identify tumor response confirmed by histology or follow-up in treated patients for head and neck tumors were selected by two authors independently.

Data analysis

Two authors independently performed data extraction including true positives, false positives, true negatives, false negatives and general study characteristics. Meta-analysis was performed using bivariate random effect models when ≥5 studies per test were included.

Data synthesis

We identified 16 relevant studies with anatomical MRI and ADC. No perfusion or spectroscopy studies were identified. Pooled analysis of anatomical MRI of the primary site (11 studies, N = 854) displayed a sensitivity of 84% (95%CI 72–92) and specificity of 82% (71–89). ADC of the primary site (6 studies, N = 287) showed a pooled sensitivity of 89% (74–96) and specificity of 86% (69–94).

Limitations

Main limitation are the low, but comparable quality of the included studies and the variability between the studies.

Conclusions

The higher diagnostic accuracy of ADC values over anatomical MRI for the primary tumor location emphases the relevance to include DWI with ADC for response evaluation of treated head and neck tumor patients.

Differentiating recurrent tumours from post-treatment changes in head and neck cancers: does diffusion-weighted MRI solve the eternal dilemma?

AIM

To evaluate the utility of diffusion-weighted imaging (DWI) in differentiating post-treatment changes from tumour recurrence in head and neck cancers and to establish a threshold apparent diffusion coefficient (ADC) value to differentiate the two conditions.

MATERIALS AND METHODS

This was a prospective study of 80 treated head and neck cancer patients. The patient cohort consisted of a wide spectrum of head and neck sites, including the oral cavity, oropharynx, larynx, hypopharynx, paranasal sinuses, orbits, salivary glands, and infra-temporal fossa. Qualitative analysis of the diffusion images and quantitative analysis of the corresponding ADC maps was performed and the data were correlated with histopathological findings and clinical examinations.

RESULTS

The mean ADC value of recurrent tumours in the present cohort was 0. 932±0.19×10^-3 mm²/s and the mean ADC value of lesions representing post-treatment changes was 1.394±0.32×10^-3 mm²/s. A threshold ADC value of 1.2×10^-3mm²/s used to differentiate post-treatment changes from recurrent head and neck cancers showed the highest combined sensitivity of 90.13%, specificity of 82.5%, accuracy of 86.4%, positive predictive value of 84.4%, negative predictive value of 88.9%, and mean kappa measurement of agreement of 72.8.

CONCLUSION

Combined qualitative and quantitative analysis of DWI is a useful non-invasive technique to differentiate recurrent head and neck malignancies from post-treatment changes using a threshold ADC value.

Thyroid cartilage invasion in laryngeal and hypopharyngeal squamous cell carcinoma treated with total laryngectomy

The objective of this study is to analyze the accuracy of computed tomography in detecting malignant thyroid cartilage invasion. In a retrospective chart review, 120 patients with carcinoma of the larynx and hypopharynx underwent computed tomography before total laryngectomy. These data were compared with the histological specimens. Multidetector computed tomography (MDCT) scan had a positive predictive value (PPV) of 76 % and a negative predictive value (NPV) of 69 %. The specificity of MDCT was 89 % and sensitivity was 46 %. Comparison between radiologic suspected cartilage invasion and histologic results showed a significant correlation (p < 0.02). We found no significant impact of cartilage invasion concerning survival rates (5-year overall survival p = 0.683; 5-year disease-free survival p = 0.711). Preoperative CT scan is an important instrument in detecting neoplastic cartilage invasion.

The role of transoral robotic surgery, transoral laser microsurgery, and lingual tonsillectomy in the identification of head and neck squamous cell carcinoma of unknown primary origin: a systematic review

BACKGROUND

Squamous cell carcinoma of the head and neck can present as a cervical metastasis from an unknown primary site. Recently, transoral robotic surgery (TORS) and transoral laser microsurgery (TLM) have been incorporated in the workup of unknown primary tumors.

METHODS

We searched MEDLINE, EMBASE, Cochrane, and CINAHL from inception to June 2015 for all English-language studies that utilized TORS, TLM, or lingual tonsillectomy in the approach to an unknown primary.

RESULTS

Of 217 identified studies, eight were reviewed. TORS/TLM identified the primary tumor in 111/139 (80 %) patients overall, and 36/54 (67 %) patients with no remarkable findings following physical exam, radiologic imaging, and panendoscopy with directed biopsies. Lingual tonsillectomy identified the primary tumor in 18/25 (72 %) patients with no findings. Hemorrhage (5 %) was the most common perioperative complication.

CONCLUSION

Lingual tonsillectomy using new approaches such as TORS/TLM may improve the identification of occult primary tumors.

Computed tomography features of benign and malignant solid thyroid nodules

BACKGROUND

No previous study has investigated computed tomography (CT) features of benign and malignant solid thyroid nodules using detailed CT features and histopathological results.

PURPOSE

To assess CT features of benign and malignant solid thyroid nodules in patients who underwent thyroid surgery.

MATERIAL AND METHODS

From January to April 2014, 151 consecutive patients underwent neck CT before thyroid surgery. In each case, neck CT was retrospectively examined by a single radiologist. We evaluated the diagnostic accuracy of specific CT features for differentiating malignant from benign thyroid nodules using histopathological results as a reference standard.

RESULTS

Of 173 thyroid nodules in 142 patients, 162 (mean diameter, 12.8 ± 10.3 mm; range, 5.0-93.7 mm) were visualized on neck CT. Of 162 nodules in 133 patients, 116 were malignant and 46 were benign as confirmed by histopathology. A multivariate logistic regression analysis showed a significant difference between malignant and benign thyroid nodules in the degree and pattern of nodular enhancement, but there were no significant differences in other CT features. In particular, thyroid nodules with exophytic configuration, irregular margin, taller-than-wide shape, punctate calcifications, or homogeneously decreased enhancement showed a high malignancy rate.

CONCLUSION

The study demonstrated that the degree and pattern of nodular enhancement are helpful CT features for differentiating malignant from benign solid thyroid nodules.

Oral cavity and oropharyngeal squamous cell carcinoma--an update

Oral cavity squamous cell carcinoma (OC-SCC) is the most common malignancy of the head and neck (excluding nonmelanoma skin cancer). Recent trends have shown a dramatic rise in the incidence of oropharyngeal squamous cell carcinoma (OP-SCC), with a marked increase in lesions related to human papillomavirus infection. This update presents the latest evidence regarding OC-SCC and OP-SCC. In particular, the authors compare and contrast tumors at these two sites with respect to epidemiology, etiopathogenesis, clinicopathologic presentation, clinical assessment, imaging, management, and prognosis. It is important for clinicians to be aware of differences between OC-SCC and OP-SCC so that appropriate patient education and multidisciplinary care can be provided to optimize outcomes.

Computed tomography versus magnetic resonance imaging for diagnosing cervical lymph node metastasis of head and neck cancer: a systematic review and meta-analysis

Computed tomography (CT) and magnetic resonance imaging (MRI) are common imaging methods to detect cervical lymph node metastasis of head and neck cancer. We aimed to assess the diagnostic efficacy of CT and MRI in detecting cervical lymph node metastasis, and to establish unified diagnostic criteria via systematic review and meta-analysis. A systematic literature search in five databases until January 2014 was carried out. All retrieved studies were reviewed and eligible studies were qualitatively summarized. Besides pooling the sensitivity (SEN) and specificity (SPE) data of CT and MRI, summary receiver operating characteristic curves were generated. A total of 63 studies including 3,029 participants were involved. The pooled results of meta-analysis showed that CT had a higher SEN (0.77 [95% confidence interval {CI} 0.73–0.87]) than MRI (0.72 [95% CI 0.70–0.74]) when node was considered as unit of analysis (P<0.05); MRI had a higher SPE (0.81 [95% CI 0.80–0.82]) than CT (0.72 [95% CI 0.69–0.74]) when neck level was considered as unit of analysis (P<0.05) and MRI had a higher area under concentration-time curve than CT when the patient was considered as unit of analysis (P<0.05). With regards to diagnostic criteria, for MRI, the results showed that the minimal axial diameter of 10 mm could be considered as the best size criterion, compared to 12 mm for CT. Overall, MRI conferred significantly higher SPE while CT demonstrated higher SEN. The diagnostic criteria for MRI and CT on size of metastatic lymph nodes were suggested as 10 and 12 mm, respectively.

Pre-operative ultrasound diagnosis of nodal metastasis in papillary thyroid carcinoma patients according to nodal compartment

The aim of this study was to assess the accuracy of ultrasound (US) and individual US features in the diagnosis of nodal metastasis in patients with papillary thyroid carcinoma (PTC) with respect to nodal compartment. US diagnoses and individual US features of nodal metastases with respect to nodal compartment were investigated in 184 consecutive PTC patients who underwent pre-operative US. Histopathologic results were used as a reference standard. One hundred thirty-six of 368 (37.0%) central compartments contained one or more metastatic nodes, whereas 44 of 48 (91.7%) lateral compartments had one or more metastatic nodes. The malignancy rates of suspicious US diagnoses in the central and lateral compartments were 66.3% (53/80) and 93.3% (42/45), respectively. The central and lateral compartments differed significantly in nodal composition, echogenicity, calcification, shape, hilar echogenicity and vascularity. The accuracy of US in the diagnosis of nodal metastases from PTC was lower in the central compartment than in the lateral compartment.

Management of squamous cell and basal cell carcinomas of the head and neck with perineural invasion

Perineural invasion (PNI) occurring in non-melanoma skin cancers (NMSC) is associated with an increased risk of locoregional recurrence and reduced disease-free survival. This necessitates early and accurate diagnosis, appropriate risk-stratification and a clear management strategy. The diagnosis of PNI is based on careful clinical assessment, imaging and histopathology. Surgery, preferably with margin control, and definitive or adjuvant radiotherapy (ART) are established treatment strategies for PNI. Clinical uncertainty remains over the role of ART in incidental PNI. This review synthesises current literature to ascertain which clinicopathological features impart a higher risk to individuals with PNI in NMSC, in order to provide treatment algorithms, including the identification of patient subsets that are most likely to benefit from ART. This includes those with extratumoural PNI, involvement of larger-calibre nerves, tumour invasion beyond dermis, recurrent tumour or diffuse intratumoural spread. Patients with clinical PNI may be optimally managed by a multidisciplinary head and neck cancer service that is best placed to offer skull base surgery and intensity-modulated radiation therapy (IMRT). The management options presented are stratified by histological subtype and a new classification of PNI into low-risk, medium-risk and high-risk groups.

Diagnostic value of retrospective PET-MRI fusion in head-and-neck cancer

Background

To assess the diagnostic value of retrospective PET-MRI fusion and to compare the results with side-by-side analysis and single modality use of PET and of MRI alone for locoregional tumour and nodal staging of head-and-neck cancer.

Methods

Thirty-three patients with head-and-neck cancer underwent preoperative contrast-enhanced MRI and PET/CT for staging. The diagnostic data of MRI, PET, side-by-side analysis of MRI and PET images and retrospective PET-MRI fusion were systematically analysed for tumour and lymph node staging using receiver operating characteristic (ROC) analysis. The results were correlated to the histopathological evaluation.

Results

The overall sensitivity/specificity for tumour staging for MRI, PET, side-by-side analysis and retrospective PET-MRI fusion was 79%/66%, 82%/100%, 86%/100% and 89%/100%, respectively. The overall sensitivity/specificity for nodal staging on a patient basis for MRI, PET, side-by-side analysis and PET-MRI fusion was 94%/64%, 94%/91%, 94%/82% and 94%/82%, respectively. MRI, PET, side-by-side analysis and retrospective image fusion were associated with correct diagnosis/over-staging/under-staging of N-staging in 70.4%/18.5%/11.1%, 81.5%/7.4%/11.1%, 81.5%/11.1%/7.4% and 81.5%/11.1%/7.4%, respectively.

ROC analysis showed no significant differences in tumor detection between the investigated methods. The Area Under the Curve (AUC) for MRI, PET, side-by-side analysis and retrospective PET-MRI fusion were 0.667/0.667/0.702/0.708 (p > 0.05). The most reliable technique in detection of cervical lymph node metastases was PET imaging (AUC: 0.95), followed by side-by-side analysis and retrospective image fusion technique (AUC: 0.941), which however, was not significantly better then the MRI (AUC 0.935; p > 0.05).

Conclusions

We found a beneficial use of multimodal imaging, compared with MRI or PET imaging alone, particular in individual cases of recurrent tumour disease. Side-by-side analysis and retrospective image fusion analysis did not perform significantly differently.

Accuracy of (18)F-flurodeoxyglucose-positron emission tomography/computed tomography in the staging of newly diagnosed nasopharyngeal carcinoma: a systematic review and meta-analysis

Background

The specific role of 18F-flurodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in staging of nasopharyngeal carcinoma (NPC) remains to be validated. A systematic review and meta-analysis were performed to assess the accuracy of staging FDG-PET/CT for newly diagnosed NPC.

Methods

We searched various biomedical databases and conference proceedings for relevant studies. We determined the pooled sensitivities and specificities, diagnostic odds ratios (DOR) and constructed summary receiver operating characteristic (SROC) curves using the hierarchical regression model.

Results

15 relevant studies including 851 patients were identified. Five addressed primary tumor (T), nine addressed regional lymph nodes (N) and seven addressed distant metastasis (M). The combined sensitivity estimate for FDG-PET/CT in T classification was 0.77 (95% confidence interval [CI] 0.59–0.95). For N classification, combined sensitivity was 0.84 (95% CI 0.76–0.91), specificity was 0.90 (95% CI 0.83–0.97), DOR was 82.4 (23.2–292.6) and Q*-index was 0.90. For M classification, the combined sensitivity estimate was 0.87 (95% CI 0.74–1.00), specificity was 0.98 (95% CI 0.96–1.00), DOR was 120.9 (43.0–340.0) and Q*-index was 0.89.

Conclusion

FDG-PET/CT showed good accuracy in N and M but not T classification for newly diagnosed NPC. FDG-PET/CT, together with Magnetic resonance imaging (MRI) of the nasopharynx, should be part of the routine staging investigations.

Rare infraglottic lesions in magnetic resonance imaging

Background

Primary pathological laryngeal lesions occur rarely in infraglottic space. Modern possibilities of diagnostic imaging of infraglottic space include computed tomography (CT) and magnetic resonance (MR). Diagnostic imaging was performed in potential lesions in this area: inflammatory process – cicatrical pemphigoid, benign neoplastic process – chondroma, malignant neoplastic – squamous cell carcinoma.

The aim of the paper is to present clinical and radiographical characteristics of selected lesions located in infraglottic space in MRI examination.

Material/Methods

Three patients examined at the Department of Radiology and Diagnostic Imaging of University Hospital No. 1 in Lodz (SPZOZ USK nr 1) from 2010–2011 with a pathological mass in infraglottic space. Standard imaging protocol for MRI of the neck was used in all patients: field of 1.5 T, slice thickness 3 mm, the distance between the scans 10–20%, FOV – 3 mm, sequences: T1 (TR/TE 455/9, 7 ms, T2 (TR/TE 5300/67 ms), T1 + Gd-DTPA (contrast agent Gd-DTPA at 0.2 mmol/kg).

Conclusions

1. It is possible to determine characteristic signal pattern for rare lesions of the infraglottic space in MRI. 2. MRI is a valuable complementary modality for the diagnostics and differentiation of lesions in infraglottic space, the evaluation of their advancement and treatment planning.

Diagnostic Approach, Treatment, and Outcomes of Cervical Sympathetic Chain Schwannomas

Objective

This review examined the diagnostic approach, surgical treatment, and outcomes of cervical sympathetic chain schwannomas (CSCS) to guide clinical decision making.

Data Sources

Medline, EMBASE, and Cochrane databases.

Review Methods

A literature review from 1998 to 2013 identified 156 articles of which 51 representing 89 CSCS cases were evaluated in detail. Demographic, clinical, and outcomes data were extracted by 2 independent reviewers with high interrater reliability (κ = .79). Cases were mostly international (82%), predominantly from Asia (50%) and Europe (27%).

Conclusions

On average, patients were 42.6 years old (SD = 13.3) and had a neck mass ranging between 2 to 4 cm (52.7%) or >4 cm (43.2%). Nearly 70% of cases were asymptomatic at presentation. Presurgical diagnosis relied on CT (63.4%), MRI (59.8%), or both (19.5%), supplemented by cytology (33.7%), which was nearly always inconclusive (96.7%). US-treated cases were significantly more likely to receive presurgical MRI than internationally treated cases but less likely to have cytology ( P < .05). Presurgical diagnosis was challenging, with only 11% confirmatory accuracy postsurgically. Irrespective of mass size, extracapsular resection (ie, complete resection with nerve sacrifice) was the most frequently (87.6%) performed surgical procedure. Common postsurgical adverse events included Horner’s syndrome (91.1%), first bite syndrome (21.1%), or both (15.7%), with higher prevalence when mass size was >4 cm. Adverse events persisted in 82.3% of cases at an average 30.0 months (SD = 30.1) follow-up time.

Implications for Practice

Given the typical CSCS patient is young and asymptomatic and the likelihood of persistent morbidity is high with standard surgical approaches, less invasive treatment options warrant consideration.

The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation

OBJECTIVE

The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a "new" head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners' training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon's perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask.

DATA SOURCES

Available peer-reviewed literature and practice guidelines.

REVIEW METHODS

Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation and the American Head and Neck Society.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The dramatic rise in OPSSC related to HPV is characterized by a "new" cancer patient who is younger and lacks traditional risk factors. Today's caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.

Comparative study of ultrasound and computed tomography for incidentally detecting diffuse thyroid disease

The aim of this study was to compare the diagnostic values of thyroid ultrasound (US) and neck computed tomography (CT) in incidentally detecting diffuse thyroid disease (DTD). A single radiologist made US and CT diagnoses of incidentally detected DTD in 130 consecutive patients before thyroidectomy for various malignancies. Histopathologic examinations confirmed normal thyroid (n = 80), Hashimoto thyroiditis (n = 20), non-Hashimoto lymphocytic thyroiditis (n = 28) and diffuse hyperplasia (n = 2). Receiver operating characteristic curves revealed that the best diagnostic indices of both imaging methods were achieved on the basis of two or more abnormal imaging findings. The sensitivity, specificity and accuracy of US and CT in incidentally detecting DTD by this classification were 72% and 72%, 87.5% and 91.3% and 81.5% and 83.8%, respectively. Thyroid US and neck CT have similar diagnostic values for differentiating incidental DTD from normal thyroid.

The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation

OBJECTIVE

The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a "new" head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners' training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon's perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask.

DATA SOURCES

Available peer-reviewed literature and practice guidelines.

REVIEW METHODS

Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation and the American Head and Neck Society.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The dramatic rise in OPSSC related to HPV is characterized by a "new" cancer patient who is younger and lacks traditional risk factors. Today's caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.

Computed tomography features of incidentally detected diffuse thyroid disease

Objective. This study aimed to evaluate the CT features of incidentally detected DTD in the patients who underwent thyroidectomy and to assess the diagnostic accuracy of CT diagnosis. Methods. We enrolled 209 consecutive patients who received preoperative neck CT and subsequent thyroid surgery. Neck CT in each case was retrospectively investigated by a single radiologist. We evaluated the diagnostic accuracy of individual CT features and the cut-off CT criteria for detecting DTD by comparing the CT features with histopathological results. Results. Histopathological examination of the 209 cases revealed normal thyroid (n = 157), Hashimoto thyroiditis (n = 17), non-Hashimoto lymphocytic thyroiditis (n = 34), and diffuse hyperplasia (n = 1). The CT features suggestive of DTD included low attenuation, inhomogeneous attenuation, increased glandular size, lobulated margin, and inhomogeneous enhancement. ROC curve analysis revealed that CT diagnosis of DTD based on the CT classification of "3 or more" abnormal CT features was superior. When the "3 or more" CT classification was selected, the sensitivity, specificity, positive and negative predictive values, and accuracy of CT diagnosis for DTD were 55.8%, 95.5%, 80.6%, 86.7%, and 85.6%, respectively. Conclusion. Neck CT may be helpful for the detection of incidental DTD.

Surgical errors and risks - the head and neck cancer patient

Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. It can lead to functional impairment and has impact in future chances for disease related survival. There are many risks for head and neck surgeons that can cause errors and malpractice.

To avoid surgical mistakes, thorough preoperative management of patients is mandatory. As there are ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of the medical studies and data as well as qualification in modern surgical techniques and the surgeons ability for critical self assessment are basic and important prerequisites for head and neck surgeons in order to make out risks and to prevent from mistakes. Additionally it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and to be able to deal with complications, when they occur.

Despite all precaution and surgical care, errors and mistakes cannot always be avoided. For that it is important to be able to deal with mistakes and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery.