Comparison between ultrasonography and MR imaging for discriminating squamous cell carcinoma nodes with extranodal spread in the neck

Head and Neck Cancer of Unknown Primary: A Surgical Perspective

Head and neck squamous cell carcinoma of unknown primary (SSCUP) presents a clinically challenge disease process requiring elaborate multidisciplinary collaboration for effective treatment. With the rise in prevalence HPV associated squamous cell carcinoma, it has become the predominant etiology SCCUP of the head and neck. Advances in the diagnostic evaluation and treatment of SCCUP have led to higher detection rates of primary lesions, improved disease-free and overall survival outcomes, and reduced morbidity for patients. Furthermore, delineation of the molecular implications of HPV positivity and disease behavior has opened avenues for successful de-escalation of treatment. Transoral robotic surgery (TORS), as well as dose reduction protocols show significant promise for oncologic efficacy with minimization of treatment related morbidity.

A Systematic Review and Meta-Analysis of 29 Studies Predicting Diagnostic Accuracy of CT, MRI, PET, and USG in Detecting Extracapsular Spread in Head and Neck Cancers

BACKGROUND

Extracapsular spread (ECS) is the extension of cancer cells beyond the lymph node capsule and is a significant prognostic factor in head and neck cancers. This meta-analysis compared the diagnostic accuracy of CT, MRI, PET, and USG in detecting ECS in head and neck cancers.

METHODOLOGY

The authors conducted a systematic review and meta-analysis of studies that compared the diagnostic accuracy of CT, MRI, PET, and USG in detecting ECS in head and neck cancers. They included studies that were published between 1990 and December 2023 and that used histopathology as the reference standard for ECS.

RESULTS

The pooled sensitivity and specificity of CT scan were 0.63 (95% CI = 0.53-0.73) and 0.85 (95% CI = 0.74-0.91), respectively. The pooled sensitivity and specificity of MRI were 0.83 (95% CI = 0.71-0.90) and 0.85 (95% CI = 0.73-0.92), respectively. The pooled sensitivity and specificity of PET were 0.80 (95% CI = 0.74-0.85) and 0.93 (95% CI = 0.92-0.94), respectively. The pooled sensitivity and specificity of USG were 0.80 (95% CI = 0.68-0.88) and 0.84 (95% CI = 0.74-0.91), respectively. MRI had significantly higher sensitivity than CT scan (p-0.05). The specificity of CT and MRI was not significantly different (p-0.99). PET scan had the highest specificity among all imaging modalities.

CONCLUSION

MRI is the most accurate imaging modality for detecting ECS in head and neck cancers. CT scan is a reasonable alternative, but PET scan may be considered when high specificity is required. USG may not add any further benefit in detecting ECS.

Assessment of Radiologic Extranodal Extension Using Combinatorial Analysis of Nodal Margin Breakdown and Metastatic Burden in Oropharyngeal Cancer

The importance of risk stratification in the management of oropharyngeal squamous cell carcinoma (OPSCC) is becoming increasingly obvious with the growing evidence of its variable prognosis. We identified and evaluated imaging characteristics predictive of extranodal extension (ENE) in OPSCC. Preoperative computed tomography and histopathologic results of 108 OPSCC patients who underwent neck dissection as primary treatment were analyzed. Imaging characteristics were reassessed for factors associated with nodal margin breakdown and metastatic burden. Moreover, the predictability of pathological ENE (pENE) was analyzed. Univariate and multivariate binomial logistic regression analyses were performed to examine the predictive power of ENE-related radiologic features. Imaging-based characteristics showed variable degrees of association with pENE. Factors associated with nodal margin breakdown (indistinct capsular contour, irregular margin, and perinodal fat stranding) and factors associated with nodal burden (nodal matting, lower neck metastasis, and presence of >4 lymph node metastases) were significantly predictive of ENE (odds ratio (OR) = 11.170 and 12.121, respectively). The combined utilization of the nodal margin and burden factors further increased the predictive ability (OR = 14.710). Factors associated with nodal margin breakdown and nodal burden were associated with pENE, demonstrating the use of combinatorial analysis for more accurate ENE prediction.

Imaging in oral cancers: A comprehensive review

This review aims at simplifying the relevant imaging anatomy, guiding the optimal imaging method and highlighting the key imaging findings that influence prognosis and management of oral cavity squamous cell carcinoma (OSCC). Early OSCC can be treated with either surgery alone while advanced cancers are treated with a combination of surgery, radiotherapy and/or chemotherapy. Considering the complex anatomy of the oral cavity and its surrounding structures, imaging plays an indispensable role not only in locoregional staging but also in the distant metastatic work-up and post treatment follow-up. Knowledge of the anatomy with understanding of common routes of spread of cancer, allows the radiologist to accurately determine disease extent and augment clinical findings to plan appropriate therapy. This review aims at simplifying the relevant imaging anatomy, guiding the optimal imaging method and highlighting the key imaging findings that influence prognosis and management.

Ultrasonography of Cervical Lymph Nodes

Ultrasonography is an excellent method for imaging evaluation of cervical lymph nodes. This article provides an image-rich review of the sonographic manifestations of diseases involving the cervical lymph nodes, with an emphasis on the expected anatomic distribution of diseases.

Value of extranodal extension detected by computed tomography for predicting clinical response after chemoradiotherapy in head and neck squamous cell cancer

OBJECTIVES

Radiological extranodal extension (rENE) upon CT is obtained before concurrent chemoradiation therapy (CCRT) for head and neck squamous cell carcinoma (HNSCC). We evaluated the prognostic value of rENE, rather than pathologically proven ENE, in patients who received CCRT for HNSCC.

MATERIALS AND METHODS

We reviewed 117 patients. We divided the patients into rENE(+) and rENE(-) groups and evaluated overall survival (OS) and disease-specific survival (DSS), and factors affecting these outcomes.

RESULTS

Median follow-up was 37.4 months; 31 patients (26.2%) died and 26 (22.2%) had recurrence. Thirty patients were rENE(+) and these had worse 5-year OS (74% vs. 94%, p < .01) and DSS (42% vs. 84%, p < .01) rates compared with the rENE(-) group (n = 87). rENE (hazard ratio [HR] 3.57, p < .05) and complete response (HR 3.55, p < .05) affected OS. Clinical T stage (HR 2.86, p < .05), rENE (HR 2.88, p < .05), and complete response (HR 7.03, p < .01) affected DSS. rENE(+) increased risk of incomplete response (IR) compared with the rENE(-) group (p < .05).

CONCLUSIONS

CT findings suggesting ENE predicts treatment response to CCRT and prognosis, and could be used to determine the treatment modality for HNSCC.

Extranodal spread of primary and secondary metastatic nodes: The dominant risk factor of survival in patients with head and neck squamous cell carcinoma

Extranodal spread (ENS) in patients with head and neck squamous cell carcinoma (HNSCC) can greatly influence the prognostic outcomes. However, the relative risks of ENS in the primary (1st) and secondary (2nd) metastatic nodes (mets) are not well documented. We retrospectively analyzed the hazard ratios (HRs) of ENS in the 1st and 2nd mets from 516 HNSCC patients who had undergone primary tumor excision. The impact of clinically and/or histologically confirmed ENS-positive mets on prognosis in terms of cancer-specific survival was analyzed. Cox proportional hazard regression analysis indicated that ENS-positive 1st met (adjusted HR = 3.15; 95% CI, 1.40-7.56; p = 0.006) and ENS-positive 2nd met (adjusted HR = 4.03; 95% CI, 1.41-16.96; p = 0.007) significantly and independently predicted poor prognosis; however, other variables including primary site, met size or numbers, and met location in the contralateral side of the primary lesion, did not. Cumulative incidence function and Cox analyses indicated that differences in ENS profiles of 1st and 2nd mets stratified HNSCC patients with varying risks of poor outcome; HRs relative to patients with ENS-positive 1st met (-)/ENS-positive 2nd met (-) were 4.02 (95% CI, 1.78-8.24; p = 0.002), 8.29 (95% CI, 4.58-14.76; p <0.001), and 25.80 (95% CI, 10.15-57.69; p <0.001) for patients with ENS-positive 1st met (+)/ENS-positive 2nd met (-), ENS-positive 1st met (-)/ENS-positive 2nd met (+), and ENS-positive 1st met (+)/ENS-positive 2nd met (+) patients, respectively. Kaplan-Meier analysis indicated that the 2nd met that appeared in the neck side with a history of 1st met and neck dissection had a higher risk of ENS than the 2nd met in the neck side without the history (p = 0.003). These results suggested that ENS is a dominant prognostic predictor of HNSCC patients, with double-positive ENS in the 1st and 2nd mets predicting the most devastating outcome.