Tongue and tonsil cancer: staging with US

Ultrasonography use for tongue cancer management: A scoping review

BACKGROUND

Tongue cancer is associated with debilitating diseases and poor prognostic outcomes. The use of imaging techniques like ultrasonography to assist in the clinical management of affected patients is desirable, but its reliability remains debatable. Therefore, the aim of this study is to investigate the importance of ultrasound use for the clinicopathological management of tongue cancer.

METHODS

A scoping review was carried out using specific search strategies in the following electronic databases: PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar. Collected data included bibliographical information, study design, ultrasound equipment, the aim of the ultrasonography use, the timing of ultrasound use during oncological treatment (pre-, trans-, and/or post-operatively), and the advantages and disadvantages of the use of the ultrasound.

RESULTS

A total of 47 studies were included in this review after following the selection process. The majority of the studies investigated the use of ultrasound pre-operatively for the investigation of lymph node metastases or to determine the tumor thickness and depth of invasion. The sensitivity, specificity, and accuracy of ultrasound to determine clinical lymph node metastases ranged from 47% to 87.2%, from 84.3% to 95.8%, and from 70% to 86.2%, respectively. The sensitivity and specificity to determine the microscopic depth of invasion were 92.3% and from 70.6% to 82.1%, respectively.

CONCLUSION

Ultrasonography seems to be a reliable imaging technique for the investigation of important prognostic parameters for tongue cancer, including depth of invasion and lymph node metastases.

Preoperative ultrasonography for tumor thickness evaluation in guiding management in patients with early oral tongue squamous cell carcinoma

Objectives:

(1) To assess the statistical correlation between the tumor thickness (TT) by ultrasonography (USG) and microscopic measurement in cases of early oral tongue squamous cell carcinoma (OTSCC). (2) To assess the predictive capacity of TT by ultrasound in detecting nodal metastasis.

Materials and Methods:

Prospective analysis was performed in 24 patients for a period of 2 years from 2012 to 2013. Nodal status and TT measurement was done preoperatively by neck and intraoral USG respectively in cases of early (pT1 & T2, clinically N0) OTSCC. As per the institution protocol after histopathological confirmation of malignancy, all patients underwent resection of primary lesion and ipsilateral elective neck dissection (Level - I to IV). Measurement of TT was obtained intraoperatively from fresh glossectomy specimen and postoperatively from histopathological paraffin section examination. The statistical correlation between TT measured by USG and histopathology was assessed by Pearson's correlation coefficient. Chi-square test was used to find the association of pathological T stage, TT with pathological nodal status.

Results:

Significant statistical correlation was seen between TT by USG and microscopic measures. Between the two, TT measurements were within 1 mm in 37.5% (9/24) of cases, within 2 mm in 29.16% (7/24), and was greater than 2 mm in 8 cases. The Pearson's correlation r is 0.678 (P < 0.001) and ICC (interclass correlation coefficient) is 0.808. The average difference between microscopic and US thickness (Bias) is -0.14637 and the limits of agreement is (4.717, -4.863) with 95% limits of agreement. The rate of occult nodal metastasis was 16.6% and TT of <4 mm had no incidence of nodal metastasis.

Conclusion:

Ultrasonographic evaluation is reliable and cost-effective tool to measure the TT preoperatively, which will be of help in deciding the management in early OTSCC. TT of 4 mm and above was predictor of occult cervical nodal metastasis.

Sonographic Staging of Cancer of the Mobile Tongue

In order to determine the value of sonography (US), in staging cancer of the mobile tongue, 57 patients were studied prospectively. Real-time sector scanners (5 and 7.5 MHz) were used with a submental approach. The findings by US were compared with those obtained by inspection and palpation and in 13 operated patients with the surgical results. US failed to visualize the tumor in 3 of the 57 patients (5%); in 30 patients (53%), the tumor was considered to be of nearly the same size by US and by palpation, but in 17 cases (30%), to be larger by US than by palpation, and in the remaining 7 cases (12%), to be smaller by US. Extension across the midline (8/8), and depth of tumor penetration, or extension to adjacent structures (5/5) were more correctly evaluated by US. We conclude that US is useful for staging work-up of tumors of the mobile tongue.

Evaluation of Tongue Cancer Using High-Resolution Sonography: Comparison With Magnetic Resonance Imaging

OBJECTIVES

To evaluate the role of sonography in assessing tongue cancer compared with magnetic resonance imaging (MRI).

METHODS

A randomized prospective study was performed on 40 cases of tongue cancer. Magnetic resonance imaging and sonography of the tongue were performed, tumor spreading to particular sites was recorded in all cases. Sonographic and MRI findings were correlated with histopathologic findings in 18 operable cases. In 22 inoperable cases, sonography was compared only with MRI.

RESULTS

In operable patients, sonography achieved sensitivity of 61.1%, whereas MRI achieved sensitivity of 94.4%. The difference was statistically significant (P < .05). The results for detection of individual site involvement on sonography and MRI were as follows: intrinsic muscles only, 0 and 6, respectively; tongue base, 5 and 5; genioglossus muscle, 34 and 34; mylohyoid muscle, 9 and 8; sublingual space, 12 and 14; sublingual neurovascular bundle, 12 and 12; submandibular gland, 3 and 3; spread across the lingual septum, 17 and 17; and alveolar involvement, 0 and 1. There was no significant difference (P> .05) between sonography and MRI in detecting involvement of the above-mentioned sites except for cases with only intrinsic muscles and alveolar involvement. Tumors involving intrinsic tongue muscles only were not visualized on sonography. They all underwent surgery, resulting in reduced sensitivity of sonography in operable cases.

CONCLUSIONS

Even though small tumors were difficult to visualize, sonography can play an important role in assessment of tumor extension in large growths, especially when MRI is unavailable, contraindicated, or unaffordable, and for posttreatment follow-up.

Transcervical ultrasonography is feasible to visualize and evaluate base of tongue cancers

Background

Base of tongue (BOT) is a difficult subsite to examine clinically and radiographically. Yet, anatomic delineation of the primary tumor site, its extension to adjacent sites or across midline, and endophytic vs. exophytic extent are important characteristics for staging and treatment planning. We hypothesized that ultrasound could be used to visualize and describe BOT tumors.

Methods

Transcervical ultrasound was performed using a standardized protocol in cases and controls. Cases had suspected or confirmed BOT malignancy. Controls were healthy individuals without known malignancy.

Results

100% of BOT tumors were visualized. On ultrasound BOT tumors were hypoechoic (90.9%) with irregular margins (95.5%). Ultrasound could be used to characterize adjacent site involvement, midline extent, and endophytic extent, and visualize the lingual artery. No tumors were suspected for controls.

Conclusions

Ultrasonography can be used to transcervically visualize BOT tumors and provides clinically relevant characteristics that may not otherwise be appreciable.

Intraoral Sonography–Assisted Resection of T1–2 tongue Cancer for Adequate deep Resection

Objective

To investigate the clinical usefulness of intraoral sonography-assisted resection for securing adequate deep resection margins in T1–2 tongue cancers.

Study Design

Prospective clinical trial.

Materials and Methods

Twenty consecutive patients with clinical T1–2 tongue cancers were enrolled and their lesions were removed by intraoral sonography-assisted resection. We then retrospectively collected data from 20 T stage-matched patients without intraoral sonography-assisted resection as the control group. All resections were performed with a goal of 15 mm margin. The mucosal and deep safety margins were compared between the two groups.

Results

Intraoral sonography could predict the paraffin-embedded tumor thickness with an error of 3.16 ± 2.24 mm. The deep safety margins were more adequate for intraoral sonography–assisted resection (9.8 ± 5.2 mm) than for conventional resection (4.0 ± 2.03 mm) ( P < 0.001), while the mucosal safety margins were not different

Conclusion

Intraoral sonography-assisted resection provides a more adequate deep resection margin for early T-stage tongue cancers.

Observation of tumour thickness and resection margin at surgical excision of primary oral squamous cell carcinoma—assessment by ultrasound

Tumour thickness and the status of resection margins are of prognostic significance in the treatment of oral cancer. In a single blind prospective study, 14 patients with biopsy proven oral squamous cell carcinoma had intraoral ultrasound imaging done preoperatively to measure tumour thickness, and intraoperatively to measure the deep surgical margin half way during resection. The cut surface was demonstrated on ultrasound by placing a metal, ultrasound-reflective, retractor into the surgical cut. The ultrasound measurements were compared to the subsequent histological measurements. Using the threshold of 5mm as indicator of margin clearance, there was agreement in 10 out of 14 cases between ultrasound and histology. Ultrasound detection of close surgical margins had a sensitivity of 83% and a specificity of 63%. For preoperative tumour thickness measurement, ultrasound imaging showed a high degree of correlation with histology (Pearson correlation coefficient=0.95, P<0.01). This original paper demonstrates that high resolution ultrasound imaging applied intraorally is a reliable tool in objectively assessing both the tumour thickness and the surgical margin clearance at the time of surgery.

[Intraoperative endosonographic guided resection of tongue carcinoma]

BACKGROUND

Exact estimation of a tumor's size and the definition of adequate resection margins in carcinomas of the tongue are often difficult because of the tumor's extension and deep infiltration.

METHODS

We have developed a method that allows intraoperative visualisation and marking of tumor margins. Intra-operative endosonography was performed on nine patients with carcinomas of the tongue using a 8-12 MHz linear array transducer. The oral cavity was flooded with normal saline solution and the transducer was immersed therein. This allowed scanning in a non-contact mode. The tumor margins were marked with a surgical suture under endosonographic monitoring.

RESULTS

In the nine patients studied, the histological margins corresponded to the sonographic margins. The sonographic marking proved to be useful during the resection of the tumor and histological safety margins were respected in each case.

CONCLUSIONS

This non-invasive procedure provides a quick and reliable orientation during the resection of tongue carcinoma, and a more precise and individual definition of resection margins is possible. Intraoperative non-contact use of endosonography is a promising method.

Intraoral sonographic features of tongue cancer after radical radiotherapy

PURPOSE

The purpose was to illustrate the sonographic changes of tongue cancer after radical radiotherapy.

MATERIALS AND METHODS

In 24 patients with tongue cancer treated by interstitial brachytherapy (BRT) (uneventful recovery n = 16 , recurrence n = 5, severe soft tissue complication n = 3), follow-up examination were performed and both the margin and the vascular pattern were retrospectively assessed. We basically performed US examination at least once every 3 months after BRT within 1 year during follow-up period.

RESULTS

In the healing process, intraoral sonography shows an unclear margin immediately after brachytherapy and a transient increase of the vascularity lasted within 6 months after BRT, followed by a decrease in the vascularity. The large difference in echogenicity between the primary site and the surrounding tissue and the increased difference suggested the possibility of either radiation ulceration or recurrence.

CONCLUSION

Intraoral sonography could depict the sequence changes of the tongue after BRT, and it was thus useful to confirm the clinical findings of either radiation ulcers or recurrence.

Correlating MRI and Histologic Tumor Thickness in the Assessment of Oral Tongue Cancer

OBJECTIVE

Tumor thickness in oral tongue cancer is an important independent prognostic factor for local recurrence, nodal metastasis, and patient survival. An accurate preoperative assessment of tumor thickness is therefore essential for optimal treatment planning. The aim of our study was to evaluate the accuracy of MRI findings for the preoperative measurement of tumor thickness. SUBJECTS AND METHODS. Eighteen patients with oral tongue cancer underwent preoperative MRI of the tongue. After surgery, the glossectomy specimens were serially sectioned. The radiologic tumor thickness of contrast-enhanced T1-weighted and T2-weighted images was compared with the histologic tumor thickness using our proposed tumor thickness staging classifications. These included stage I (tumor < or = 3 mm), stage II (> 3 mm but < or = 9 mm) and stage III (> 9 mm).

RESULTS

The overall accuracy in assessment of proposed tumor thickness staging using contrast-enhanced T1-weighted and T2-weighted images was 83% and 56%, respectively. The radiologic tumor thickness as measured on contrast-enhanced T1-weighted and T2-weighted images had significant correlation with histologic tumor thickness (R = 0.938 and 0.941, respectively).

CONCLUSION

MR images provide satisfactory accuracy for the measurement of tumor thickness and staging of oral tongue cancer. Preoperative MRI is recommended to assist in treatment planning for patients with this disease.

An overview of neck node sonography

RATIONALE AND OBJECTIVES

Gray scale and power Doppler sonography are commonly used to evaluate cervical lymph nodes. This study was undertaken to identify which of the features used in ultrasound of cervical lymph nodes is readily applicable in routine clinical practice.

METHODS

Two hundred and eight-six patients diagnosed with cervical lymphadenopathy were included in the study. The largest node in each patient was included in the study and the nature of the node was assessed by fine-needle aspiration cytology. Lymph nodes were assessed for their gray scale and Doppler sonographic features.

RESULTS

Metastatic, lymphomatous, and tuberculous nodes were round (63-94%) and without echogenic hilus (57-91%). Sharp borders were found in metastatic and lymphomatous nodes (56-100%), but uncommon in tuberculosis (49%). Capsular or mixed vascularity is common in metastatic, lymphomatous, and tuberculous nodes but not found in reactive nodes. Except metastatic nodes from papillary carcinoma of the thyroid that showed low resistance, metastatic nodes had a higher vascular resistance than reactive nodes. Micronodular echo pattern is common in lymphomatous nodes. Hyperechogenicity and punctate calcification are typical features for metastatic nodes from papillary carcinoma of the thyroid. Intranodal cystic necrosis, adjacent soft tissue edema, matting and displaced hilar vascularity are common features in tuberculosis.

CONCLUSIONS

Using gray scale and power Doppler sonography, metastatic, lymphomatous, and tuberculous nodes can be differentiated from reactive nodes. Metastatic nodes from papillary carcinoma, lymphoma, and tuberculosis can be identified. However, it is difficult to differentiate metastatic nodes from squamous cell carcinomas, nasopharyngeal carcinoma, and infraclavicular carcinomas, and differentiate metastatic nodes (nonthyroid primary) from tuberculous lymphadenitis.

Intraoperative B-mode endosonography of tongue carcinoma

BACKGROUND

Exact estimation of a tumor's size and definition of adequate resection margins in carcinomas of the tongue are often difficult because of the tumor's extension and deep infiltration.

METHODS

We developed a method that allows intraoperative visualization and marking of tumor margins: intraoperative endosonography was performed in five patients with carcinomas of the tongue with an 8- to 12-MHz linear array transducer. The oral cavity was flooded with normal saline solution, and the transducer was immersed therein. This allowed scanning in a noncontact mode. The tumor margins were marked with a surgical suture under endosonographic monitoring.

RESULTS

In the five patients studied, histologic margins corresponded to sonographic margins. The sonographic marking proved to be useful during the resection of the tumor, and histologic safety margins were respected in each case.

CONCLUSIONS

This noninvasive procedure provides a quick and reliable orientation during resection of tongue carcinoma, and a more precise and individual definition of resection margins is possible. Intraoperative noncontact use of endosonography is a promising method, and further studies may confirm this.

Short-time ultrasound of head and neck squamous cell carcinoma under radiotherapy

To evaluate the efficacy of ultrasonography for patients with head and neck squamous cell carcinoma before and during radiotherapy (RT), consecutive patients with macroscopic lesions were examined before and during RT. Each scan was performed percutaneously in a short time (less than 5 min). The demonstration rate of primary tumors and the largest node of previously known metastatic cervical nodes were measured. Of all 190 patients, 91 primary tumors were detected (47.9%). Primary tumors in oral cavity, oropharynx, hypopharynx and cervical esophagus were determined in over 70% and, for those of nasopharynx and larynx, the demonstration rates were 30% or less. Nodal metastases were visualized in 78 of 80 patients with regional metastases (97.5%). Using the above information, 73 patients (38.4%) received the benefit of radiation therapy. Short-time sonography is a valuable modality for patients with selected sites of head and neck cancers.

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

BACKGROUND

Ultrasound of the neck with fine needle aspiration (US-FNA) of suspicious lymph nodes has potential advantages over other radiologic techniques as a screening method for the NO neck in head and neck cancer.

METHODS

Twenty-five patients with head and neck cancer who underwent both US of the neck with FNA of any suspicious lymph nodes and neck computed tomography (CT) prior to elective neck dissection were studied. The majority of patients had squamous cell carcinoma (SCC) of the upper aerodigestive tract. Histopathologic results of the neck specimens were compared with each screening technique (palpation, US, US-FNA, CT).

RESULTS

Computed tomography (87.9%) and US-FNA (84.9%) had similar overall accuracy in terms of screening the NO neck in our study and were superior to palpation (69.7%) and US alone (72.7%). Specificity was 100% for both CT and US-FNA, with a sensitivity of 60% for CT and 50% for US-FNA. Ultrasound-FNA and CT showed false-negative examinations on virtually the same cases.

CONCLUSIONS

Overall, US-FNA was comparable to CT in screening the NO neck in our study. The choice of which modality to employ for imaging the clinically negative neck depends on a number of factors, including the location and clinical extent of the primary tumor as well as the experience and preference of the head and neck surgeon and radiologist.

Prognostic significance of color Doppler findings in head and neck tumors

We examined whether or not the degree of tumor vascularity in lymph node metastases as depicted by color Doppler is associated with a patient's prognosis. Cervical lymph node metastases in 25 patients with head and neck cancer were examined before combined accelerated radiotherapy and chemotherapy. The findings were quantified using a computer-assisted protocol that quantitatively describes color Doppler images by the relative color pixel density (CPD) and the color hues, which are numerically expressed by the mean color value (MCV). We found that, in the patient group with a CPD below median, the median survival was 958 days and, in the group with a higher CPD, it was 423 days (p = 0.05). The time to detection of distant metastases was 18 months with a low CPD, and 6 months with a high CPD (p = 0.05). However, the time to local or nodal progression was not different between the groups. The MCV was not correlated with prognostic data. These results indicate that, in patients with metastatic head and neck cancer, highly vascularized lymph nodes detected with color Doppler sonography may indicate a shorter survival and earlier occurrence of distant metastases.

Ultrasound versus physical examination in staging carcinoma of the mobile tongue

Surgical therapy for early lesions of the tongue should have the potential to be both oncologically sound and easy to rehabilitate. Obviously, the amount of tongue left behind after surgery is proportional to the post-operative function. Hence accurate mapping of the diseased tongue is of paramount importance in order to limit or extend the resection margins. We have evaluated the use of ultrasound in carcinoma of the tongue, and also compared its relative accuracy with physical examination for determining the extent of growth, keeping the histopathological size as a gold standard. We found that ultrasound is more accurate in detecting T2 and T3 tumours than T1 lesions. Intraoral sonographic mapping may be the answer for such small lesions. In addition, ultrasonography is beneficial in showing spread to contiguous areas of the tongue. However, post-radiation fibrosis and frank residual disease were not differentiated accurately by ultrasound. Thus ultrasonography can be an effective investigative tool and together with physical examination it can increase diagnostic accuracy leading to precise surgery for carcinoma of the tongue.

Tongue cancer treated with irradiation: assessment with MR imaging

We examined the usefulness of MRI in differentiating post-radiation scar tissue from the residual tumour. Ten consecutive patients who underwent MR imaging before and after radiation therapy were assessed prospectively. T1- and T2-weighted images using a 1.5 unit were obtained in 10 patients (3 T1, 6 T2, 1 T3) at 1 week before irradiation, and 2 weeks, 2 months, 4 months, 6 months and every 6 months thereafter following completion of radiation. Although all T2 and T3 tumours demonstrated high signal intensity compared to muscle on T2-weighted images, the T1 tumour could be demonstrated in only one of three patients. Six patients in whom the primary tumour clinically disappeared demonstrated low signal intensity on T2-weighted images until 4 months after completion of radiation therapy (range 1 week to 4 months). This study suggests that MRI can detect primary tumours larger than T2 (2 cm), and may be useful in assessing the effectiveness of therapy for tongue cancer.

Ultrasonography and ultrasonographically guided fine-needle aspiration biopsy of impalpable cervical lymph nodes in patients with non-small cell lung cancer

BACKGROUND

Neck ultrasonography (US) and ultrasonographically guided fine-needle aspiration (UGFNA) cytologic examination were used in the staging work-up of 51 consecutive patients with non-small cell lung cancer (NSCLC) with clinically impalpable cervical lymphadenopathy.

METHODS

All patients had chest radiography, fiberoptic bronchoscopic examination, computed tomography (CT) scans of the chest and abdomen, bone scan, and US of the abdomen and the neck.

RESULTS

Six patients (12%) were found to have cervical lymph nodes by neck US. The cytologic examination of the lymph node aspirates obtained from UGFNA confirmed the metastasis. The clinical stage thus was changed from Stage IIIa to Stage IIIb in one patient. In the other five patients, UGFNA of cervical lymph nodes prevented more invasive diagnostic procedures.

CONCLUSIONS

This preliminary study shows that neck US and UGFNA of lymph nodes may be helpful in the pretreatment evaluation of patients with NSCLC with impalpable cervical lymph nodes. However, additional study is needed to confirm this result.

The role of flexible endosonography in diagnostic imaging of carcinomas of the oral cavity and oropharynx

Currently-used imaging methods often fail to depict carcinomas of the oral cavity and oropharynx properly. Scanning these tumours with recently developed digitally-guided transducers of 5 and 7.5 MHz, we found that diagnosis and assessment are significantly facilitated by flexible endosonography. The demonstration of T1- and T2-tumours was shown to be facilitated by this technique as compared to other imaging methods. The assessment of large tumours is improved in special areas. Nonetheless, we recommend that in such cases flexible endosonography be supported by CT or MRI for a complete demonstration of the extent of the tumour.