Keratinization and necrosis. Morphologic aspects of lymphatic metastases in ultrasound.
Mäurer J,Willam C,Steinkamp H J,Knollmann F D,Felix R
RATIONALE AND OBJECTIVE:The authors performed a retrospective study in ultrasound to investigate new aspects in the sonomorphology of lymph node metastases of the neck. In this study, it could be demonstrated the first time that the histologic characteristics of the metastases determine the sonographic appearance. In addition to criteria such as the longitudinal/ transversal quotient, sonomorphology could support a more precise differential diagnosis of neck lymph nodes. METHODS:In 105 of 145 patients with histologically proved head and neck carcinomas, 187 lymph node metastases were detected by ultrasound. Sonomorphology was compared with the corresponding histology. RESULTS:Five sonomorphologic groups could be differentiated. (1) Thirty-one percent of the metastases were homogenous. (2) Concerning the more complex morphology of lymph node metastases in ultrasound, echolucent forms could be differentiated from echogenic textures: low- or nondifferentiated and nonkeratinizing metastases appeared echolucent and cyst-like, with dorsal signal amplification. (3) Nonkeratinizing lymphomas with necrosis showed single or multiple echolucent intranodal lesions. (4) In correlation with an increasing keratinization, the echogenecity of the lymph nodes increased and intranodal echogenic inclusions appeared. (5) An extended keratinization correlated with a central echogenecity. CONCLUSIONS:The morphologic assessment of lymph nodes in ultrasound allows for primary histologic and prognostic evaluation of lymph node metastases.
Imaging of lymphadenopathy in the neck.
Castelijns Jonas A,van den Brekel Michiel W M
Imaging is playing a major role in the assessment of cervical lymphadenopathy. In infectious disease, the assessment of abscess formation and the relation of the abscess to surrounding vital structures is crucial for its management. In head and neck malignancies, imaging can be helpful for staging. Imaging of the neck for the assessment of nodal metastases can be used to detect occult metastases or to assess operability of palpable metastases. The detection of small occult metastases has limitations, as micrometastases cannot be depicted; however, imaging can fulfill a role in diminishing the risk of occult metastases, and thus influence management. For this purpose a very sensitive technique is necessary. The currently used radiological criteria are not sensitive enough to accomplish enough reduction of the risk of occult metastases; therefore, more sensitive CT and MRI criteria, but especially ultrasound-guided aspiration, should be employed to assess the clinically negative neck.
[Possibilities of ultrasonographic differentiation of neck and axillary lymphadenopathy].
Hrazdira I,Krupová M,Kyselová H
Technical development of ultrasonography connected with improvement of resolving power has enlarged possibilities in detection and differentiation of lymph nodes. In the current clinical practice ultrasonic examination is most frequently requested for assessment of lymph nodes in neck and axillary regions in connection with inflammatory or tumour diseases. Although the final diagnosis must be confirmed histopathologically, there exist some echographic criteria enabling with a great probability to appoint the malignant character of lymph nodes: round shape expressed by the shape index near to 1, sharp edges, heterogeneous echostructure and mainly loss of the hilar sign. In highly enlarged lymph nodes these criteria can be completed by colour Doppler examination revealing a peripheral type of intranodal vascularity and increased value of impedance indices in supply artery (RI > 0.8, PI > 1.8).
Computed tomography and ultrasonographic evaluation of metastatic cervical lymph nodes with surgicoclinicopathologic correlation.
Sarvanan K,Bapuraj J Rajiv,Sharma Suresh C,Radotra B D,Khandelwal N,Suri S
The Journal of laryngology and otology
The detection of cervical lymph nodal metastasis and carotid artery invasion by metastatic lymph nodes is an important issue in the management of head and neck malignancies. This study compared the evaluation of metastasis by palpation, ultrasonography (USG) and computed tomography (CT) in patients with known head and neck malignancies. Twenty-five consecutive patients with head and neck malignancy were prospectively evaluated for the presence of cervical lymphadenopathy and carotid artery invasion. All patients underwent clinical examination (palpation), USG and CT examination. A modified CT criteria was employed which yielded acceptable results for the detection of metastatic nodes. Radical neck dissection was performed for 26 neck sides, and the results of pre-operative evaluation were confirmed by the surgical and histopathological findings. Palpation, ultrasound and CT have comparable sensitivity in the determination of metastasis involving cervical lymph nodes. Thus palpation should be employed as the primary method of assessment of secondaries in the neck. However, palpation is less sensitive than CT and USG in the detection of carotid artery involvement, hence the clinical suspicion of arterial invasion should be confirmed by either CT or USG which have similar accuracy in the detection of carotid artery invasion.
Pre-operative evaluation of cervical adenopathies in tumours of the upper aerodigestive tract.
Giancarlo T,Palmieri A,Giacomarra V,Russolo M
BACKGROUND:Carcinomas of the upper aerodigestive tract are characterized by a high incidence of local metastasis in the neck. The presence of lymph node metastasis represents the most unfavorable prognostic factor for these tumors. A diagnostic routine is needed in order to identify the highest number of neck metastasis, thereby optimizing the selection of patients eligible for surgical neck treatment and reduce costs and length of hospital stay. MATERIALS AND METHODS:Our study analyzes the sensibility, specificity, and diagnostic accuracy of clinical examination, echography (US), computed tomography (CT) in cervical metastasis detection by comparing them with the histopathological examination of the neck dissection specimens (pN) in 53 patients suffering from carcinoma of the upper aerodigestive tract. RESULTS:Clinical examination: sensibility 82.1%; specificity 80%; diagnostic accuracy 81.1%; US with a cut off point for minimal adenopathy diameter of 0.5 cm 92.8% sensibility, 60% specificity, 77.3% diagnostic accuracy; US with cut off point 1 cm 82.1% sensibility, 80% specificity, 81.1% diagnostic accuracy; US with cut off point 1 cm, also considering round shape or multiplicity of the adenopathy: 82.1 sensibility, 80% specificity, 81.1% diagnostic accuracy; CT with cut off point 0.5 cm: 92.8% sensibility, 32% specificity, 64.1% diagnostic accuracy; CT with cut off point 1 cm: 85.7% sensibility, 64% specificity, 75.4% diagnostic accuracy; CT with cut off point 1 cm, also considering central necrosis, extracapsular spread, multiplicity of the adenopathy 89.2 sensibility, 60% specificity, 75.5% diagnostic accuracy. CONCLUSIONS:By relating the results obtained from preoperative methods to the anatomopathological analysis of the surgical specimens we can draw the following conclusions: a) a neck positive to palpation in a subject with carcinoma of the upper aero digestive tract must be submitted to neck dissection. Such patients have an 81.1% likelihood of having a metastasis. In these patients the use of radiologic studies of the neck must be restricted to cases with uncertain involvement of retropharingeal, mediastinic, paratracheal lymph nodes or in the follow-up after treatment; b) a neck negative to palpation in a subject with carcinoma of the upper aero digestive tract, must be further investigated. The US and the CT must use a cut-off point of 1 cm to consider a neck positive. Radiologic criteria for malignancy, i.e., multiplicity, roundish shape, central necrosis and capsular invasion do not significantly increase the diagnostic accuracy of the radiographic methods; c) the combined use of US and CT does not offer significant advantages in the detection of metastasis, in any case CT is preferable when primary tumor has to be evaluated; d) the assessment of patients that are negative to palpation and to US and to CT must consider the parameters linked with primary tumor, such as site and size, Broder's grading, Invasive Cell Grading, and thickness.
[Ultrasound diagnosis of regional lymph node metastasis of the neck in patients with head-neck neoplasms: sono-morphologic criteria and diagnostic accuracy].
Rainer T,Ofner G,Marckhgott E
Laryngo- rhino- otologie
High resolution sonography is generally considered a diagnostic tool with high sensitivity but low specificity in the assessment of cervical lymph node metastases. This study shows, that excellent sonographic results regarding sensitivity and specificity can be achieved, if sonomorphologic parameters, such as size, shape, delineation and type of echo pattern are included in the evaluation. We compared sonomorphology and histology of 82 patients operated for head and neck malignancies. The sonomorphological and histological findings in the largest lymph nodes in all neck areas were compared, and if a definite identification was possible, also in the second largest ones. Virtually, all longitudinal nodes of any size and practically all oval nodes of an axial diameter of up to 20 mm were found to be free of metastases, whereas 80% of round nodes with an axial diameter of up to 20 mm and practically all round and oval nodes exceeding 20 mm in axial diameter as well as irregularly shaped, poorly delineated and structurally inhomogeneous nodes demonstrated metastatic disease. On the basis of these results we have established the following criteria for the assessment of cervical lymph node metastases: All findings demonstrating longitudinal nodes of any size and oval nodes less than 20 mm in axial diameter are to be considered sonographically negative, whereas findings in which oval nodes exceeding 20 mm in axial diameter, as well as round, irregularly shaped, poorly delineated or inhomogeneous lymph nodes are found to be classified malignant. Of 58 sonographically positive neck areas, 54 were found to be malignant on histological examination, while 23 of 24 sonographically negative areas corresponded with histologically benign findings.(ABSTRACT TRUNCATED AT 250 WORDS)
Contribution of doppler sonography blood flow information to the diagnosis of metastatic cervical nodes in patients with head and neck cancer: assessment in relation to anatomic levels of the neck.
Yonetsu K,Sumi M,Izumi M,Ohki M,Eida S,Nakamura T
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Although sonographic evaluation of cervical adenopathy by use of size criteria is effective, the sensitivity and specificity fall short of that required to make adequate judgments regarding neck dissection. Therefore, we tested whether the combined use of size criteria and Doppler sonographic findings would improve the predictive ability for metastatic cervical nodes. METHODS:We analyzed 338 histologically proved cervical lymph nodes (108 metastatic and 230 nonmetastatic) in 73 patients with head and neck cancer. The sonographic topography of the nodes was compared with dissected specimens, and their position in the neck was categorized into three levels (I, II, and III+IV). The diagnostic accuracy of sonography was evaluated by using the single criterion of short-axis diameter of the node or by the combined criteria of short-axis diameter and Doppler blood flow features (the absence or presence of normal hilar flow). RESULTS:As compared with the single criterion of short-axis nodal diameter, the combined criteria of nodal size and Doppler blood flow patterns increased the diagnostic accuracy of sonography at all levels in the neck. Accordingly, the best cut-off values were improved to 6, 7, and 5 mm for nodes at levels I, II, and III+IV, respectively. In addition, the combined criteria yielded high sensitivites (> or = 89%) and specificities (> or = 94%). CONCLUSION:Hilar blood flow information obtained by Doppler sonography significantly improves diagnostic accuracy for the detection of nodes metastatic from head and neck squamous cell carcinoma.
Sonography for the detection of cervical lymph node metastases among patients with tongue cancer: criteria for early detection and assessment of follow-up examination intervals.
Yuasa K,Kawazu T,Kunitake N,Uehara S,Omagari J,Yoshiura K,Nakayama E,Kanda S
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Because the presence of cervical metastasis is one of the factors influencing the outcome of patients with carcinoma of the head and neck, its early detection is potentially very important. The purpose of this study was to evaluate the characteristic changes of cervical metastasis revealed by sonography during follow-up and to assess an adequate interval for follow-up sonography of the neck among patients with tongue cancer. METHODS:Forty-three of 44 consecutive patients with squamous cell carcinoma of the tongue, who had undergone interstitial brachytherapy, were examined with sonography of the neck during the posttherapeutic follow-up period. RESULTS:Seventeen cervical lymph node metastases were found in 12 of 43 patients during follow-up. Of these 17 cervical metastases, 16 (94.1%) were accurately diagnosed and one (5.9%) was misdiagnosed as nonmetastatic based on sonographic findings. Sonography of the neck performed in seven patients at an interval of less than 1 month since the last follow-up imaging showed 9 (90.0%) of 10 metastases increased by up to 2 mm in short-axis diameter. Five patients who were followed up at an interval of more than 1 month since the last follow-up imaging had seven metastases increase by 3 to 8 mm in short-axis diameter or a change of echogenicity in the internal structure of lymph nodes or both. Pathologic examinations showed extranodal spread in 3 (42.9%) of these 7 metastases. CONCLUSION:Changes both in size and internal echogenicity can occur as quickly as 2 to 4 weeks between sonographic examinations. Therefore, in high-risk patients, or in those with suspicious sonographic findings, short-interval follow-up sonographic examinations are recommended at least during the first posttherapeutic year. Our findings suggest that follow-up sonography of the neck should be performed monthly, at least during the first posttherapeutic year.
Cervical lymph node metastasis: assessment of radiologic criteria.
van den Brekel M W,Stel H V,Castelijns J A,Nauta J J,van der Waal I,Valk J,Meyer C J,Snow G B
To estimate the accuracy of different radiologic criteria used to detect cervical lymph node metastasis in patients with head and neck carcinoma, seven different characteristics of 2,719 lymph nodes in 71 neck dissection specimens from 55 patients were assessed. Three lymph node diameters, their location, their number, the presence of a tumor, and the amount of necrosis and fatty metaplasia were recorded. The minimal diameter in the axial plane was found to be the most accurate size criterion for predicting lymph node metastasis. A minimal axial diameter of 10 mm was determined to be the most effective size criterion. The size criterion for lymph nodes in the subdigastric region was 1 mm larger (11 mm). Groups of three or more borderline nodes were proved to increase the sensitivity but did not significantly decrease the specificity. Radiologically detectable necrosis (3 mm or larger) was found only in tumorous nodes and was present in 74% of the positive neck dissection specimens. Shape was not a valuable criterion for the radiologic assessment of the cervical lymph node status.
Cervical lymph nodes.
Mack Martin G,Rieger Jörg,Baghi Mehran,Bisdas Sotirios,Vogl Thomas J
European journal of radiology
The lymph node staging is a very important prognostic parameter for patients with presenting with head neck cancer and is influencing the selection of the different therapeutic strategies including surgery, chemotherapy, radiotherapy or a combination of them. The accuracy of imaging techniques, such as US, MR imaging, and CT, depends on the appropriateness of radiological criteria used for diagnosing lymph node metastases. Size of nodes and evidence of necrosis are still the most important radiological criteria. However, the size shows great variability. A spherical lymph node larger than 10mm is an indicator for a malignant node, whereas an oval shape and/or a fatty hilus are more benign signs. But there are many limitations and different cut offs published in the literature, indicating that the size of a lymph node is not a reliable criteria for the assessment of lymph nodes in the head and neck region. Today new high-resolution MRI sequences and the development of specific contrast agents are offering new possibilities in the diagnostic work-up of head and neck lymph nodes. Ultrasmall superparamagnetic iron oxide particles (USPIO's) are resulting after intravenous application in a reduction of the T2 relaxation time. This is causing a signal decrease on T2-weighted MR images in benign lymph nodes after administration of USPIO's, whereas malignant lymph nodes do not show a significant signal decrease. Some clinical studies presented already very promising results. Based on the fact, that the size evaluation of lymph nodes in the head and neck has not changed during the last decade, this paper will mainly focus on MRI with new contrast agents and new techniques as diffusion weighted imaging (DWI).
The utility of lymph node mapping sonogram and thyroglobulin surveillance in post thyroidectomy papillary thyroid cancer patients.
Miah Chowdhury F,Zaman Jessica A,Simon Mitchell,Davidov Tomer,Trooskin Stanley Z
BACKGROUND:The American Thyroid Association recommends lymph node mapping (LNM) ultrasonography 6-12 months after thyroidectomy for patients with papillary thyroid cancer (PTC). The yield of LNM over thyroglobulin (TG) screening is not well defined. We sought to investigate this relationship. METHODS:Post thyroidectomy LNM was performed on 163 patients with PTC. LNM was considered positive based on these criteria: Loss of fatty hilum (LOFH), microcalcifications, hypervascularity, architectural distortion, or short axis (>8 mm). Serum TG levels were compared to LNM and fine needle aspiration (FNA). RESULTS:Sixty-nine patients had suspicious LNM (42%) and 17 had PTC on FNA (25%). There were 135 suspicious lymph nodes described with malignant nodes found in 6 of 65 patients (9%) with LOFH, 13 of 18 patients (76%) with microcalcifications, 11 of 12 patients (92%) with hypervascularity, 16 of 28 patients (52%) with architectural distortion, and 4 of 7 patients (52%) with enlarged size on FNA. The positive predictive value of LNM was 0.34, increasing to 0.66 when LOFH was excluded. Among 152 patients with documented TG data, LNM identified cervical nodal metastasis in 4 patients with TG < 0.5 pg/mL (anti-TG antibody negative, thyroid-stimulating hormone suppressed). Of the 15 patients with positive anti-TG antibody, 3 with recurrence were found on LNM. CONCLUSION:LNM can detect recurrent PTC when TG level is undetectable, and LOFH is a low-yield sonographic characteristic.
Predictive role of intraoperative clinicopathological features of the central compartment in estimating lymph nodes metastasis status.
Sun Rong-Hao,Li Chao,Zhou Yu-Qiu,Cai Yong-Cong,Shui Chun-Yan,Liu Wei,Wang Xu,Zeng Din-Fen,Jiang Jian,Zhu Jing-Qiang
Annals of translational medicine
Background:To explore the feasibility of immediate assessment, which focuses on clinicopathological characteristics of central lymph nodes (LNs) during operation. Moreover, to analyze the predictive effect of various evaluated indicators on the nature, quantities, and ratios of central lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC), to provide the basis for precise individualized central lymph node dissection (LND). Methods:According to the inclusion and exclusion criteria, 1,271 PTC patients were selected in this cohort study. In the study, the clinical and pathological characteristics of the central LNs were evaluated by the treatment groups during the operation, which had a similar therapeutic experience. The parameters including the texture, volume, maximum/vertical meridian, extracapsular infiltration, adhesion or fusion, and nano-carbon staining status of the central LNs were collected. According to the pathological results after the operation, the nature, quantities, and rate of LNM in the central compartment were counted. The relationship between these parameters and metastatic nature, quantities, and ratios was analyzed and compared. Results:Univariate analysis showed that when the larger size of LNs (especially the maximum meridian >0.9 cm), extracapsular infiltration, adhesion and fusion being found, A higher possibility of LNM in the central compartment (P<0.05), higher number and ratio of metastasis (P<0.05) might be existed. Moreover, more than two positive LNs were more likely to appear. Maximum/vertical meridian <2 and texture hardness could not indicate metastasis (P>0.05) and higher metastasis ratio (P>0.05), but could only be used as a reference for the existence of metastasis (P<0.05). The number of metastatic LNs dissected by carbon nanoparticles during operation could be increased (P<0.05). However, it has no predictive effect on the nature and rate of LNM (P>0.05). Multivariate analysis showed that larger central LNs, the maximum meridian >0.9 cm, extracapsular infiltration, adhesion, and fusion were independent prognostic factors for central LNM (P<0.05), which could be used as a predictor of the properties of central LNs during operation. At the same time, larger LNs, extracapsular infiltration, adhesion and fusion, and nano-carbon black staining were independent predictors of LNM in the central compartment, which are more than two (P<0.05). Conclusions:It is practical and feasible to evaluate the clinicopathological features of central LNs immediately during the operation. Intraoperative assessment of central LNs volume, capsular infiltration, maximum/vertical meridian, carbon nano tracking, and adhesion and fusion has predictive effects differently on the nature, quantities, and ratios of central LNM. In order to make an early prediction and advance judgment, surgeons should pay more attention to evaluate clinicopathological features of central LNs during operation, which is conducive to the proper implementation of LND in the central compartment.
Patterns of retropharyngeal node metastasis in nasopharyngeal carcinoma.
Wang Xiao Shen,Hu Chao Su,Ying Hong Mei,Zhou Zheng Rong,Ding Jian Hui,Feng Yan
International journal of radiation oncology, biology, physics
PURPOSE:To explore the pattern of metastasis to retropharyngeal lymph nodes (RLN) and its relationship with tumor range in nasopharyngeal carcinoma (NPC) patients by using magnetic resonance imaging. METHODS AND MATERIALS:Magnetic resonance images of 618 NPC patients were reviewed. Nodes were classified as metastatic on the basis of size criteria, the presence of nodal necrosis, and extracapsular spread. RESULTS:A total of 597 involved RLN were detected in 392 patients (63.4%). The sites of RLN metastasis included occipital bone, 37 (6.2%); first cervical vertebra (C1), 453 (75.9%); second cervical vertebra (C2), 104 (17.4%); and third cervical vertebra (C3), 3 (0.5%). The incidence of RLN involvement was less than that of Level IIb node involvement (72.2% vs. 86.5%) in 543 patients with lymphadenopathy. The incidence of RLN metastasis was significantly higher in cases of parapharyngeal space invasion or involvement of Level II, Level III, Level IV, and/or Level V nodes and significantly lower in N0 and Stage I disease. Conversely, the incidence of RLN metastasis did not differ significantly among T1, 2, 3, and 4 disease or among Stage II, III, and IV disease. CONCLUSIONS:Level IIb nodes, rather than RLN, seem to be the first-echelon nodes in NPC. The incidence of RLN metastasis decreases steadily from level C1 to level C3. Retropharyngeal lymph node metastasis correlates well with involvement of the parapharyngeal space and metastases to Level II, III, IV, and/or V nodes but not with T stage.
Is level IIb lymph node dissection always necessary in N1b papillary thyroid carcinoma patients?
Lee Jandee,Sung Tae-Yon,Nam Kee-Hyun,Chung Woung Youn,Soh Euy-Young,Park Cheong Soo
World journal of surgery
INTRODUCTION:Papillary thyroid carcinoma (PTC) patients show a high rate of cervical lymphatic metastasis. However, there are no universal binding guidelines for the extent of lateral cervical lymph node dissection (LND) in such cases. In particular, the need for LND above the spinal accessory nerve (SAN) remains controversial. The present study examined whether level IIb lymph node (LN) dissection is always necessary in PTC patients with lateral cervical LN metastasis. MATERIALS AND METHODS:The study prospectively examined 167 PTC patients with lateral cervical LN metastasis who underwent modified radical neck dissection (MRND) in our institution from November 2005 to March 2007. The MRND was bilateral in 24 cases. All patients underwent level II, III, IV, and V LND. Levels IIa and IIb LNs were individually dissected in all cases. All LND was performed using strict leveling criteria by a single operating team. The patterns of lymphatic metastasis and potential risk factors for level IIb LN involvement were evaluated. RESULTS:The most common site of metastasis was level III (80.6% of cases), followed by level IV (74.9%) and II (55.5%). The metastasis rates in level IIa and IIb were 55.5% and 6.8%, respectively; all level IIb LN metastasis was accompanied by level IIa metastasis (p=0.001). In addition, level IIb LN metastasis was found to be associated with the aggressiveness of lymphatic metastasis (i.e., the total number of metastatic LNs) (p<0.0001). CONCLUSIONS:A level IIb LND should be performed when there is clinical or radiological evidence of lymphatic metastasis. In the absence of such evidence, the findings suggest that level IIb LND is not necessary in N1b PTC patients when there is no level IIa LN metastasis, or when the metastasis is not aggressive.
Accuracy of computed tomography in the prediction of extracapsular spread of lymph node metastases in squamous cell carcinoma of the head and neck.
Chai Raymond L,Rath Tanya J,Johnson Jonas T,Ferris Robert L,Kubicek Gregory J,Duvvuri Umamaheswar,Branstetter Barton F
JAMA otolaryngology-- head & neck surgery
IMPORTANCE:At many institutions, computed tomography with iodinated intravenous contrast medium is the preferred imaging modality for staging of the neck in squamous cell carcinoma of the head and neck. However, few studies have specifically assessed the diagnostic accuracy of computed tomography for determining the presence or absence of extracapsular spread (ECS). OBJECTIVE:To determine the accuracy of modern, contrast-enhanced, multidetector computed tomography in the diagnosis of ECS of cervical lymph node metastases from squamous cell carcinoma of the head and neck. DESIGN, SETTING, AND PARTICIPANTS:Retrospective observational study at an academic tertiary referral center among 100 consecutive patients between May 1, 2007, and February 1, 2012, who underwent a lateral cervical neck dissection for squamous cell carcinoma of the head and neck with neck metastases of at least 1 cm in diameter on pathologic assessment. Exclusion criteria included malignant neoplasms other than squamous cell carcinoma, a delay in surgery longer than 6 weeks from the time of staging computed tomography, and prior treatment of the neck or recurrent disease or a second primary. MAIN OUTCOMES AND MEASURES:Each patient was independently assigned a subjective score for the presence of ECS by 2 Certificate of Added Qualification-certified neuroradiologists according to a 5-point scale. Receiver operating characteristic curves were generated, and sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for each observer. RESULTS:The areas under the receiver operating characteristic curve for observers 1 and 2 are 0.678 (95% CI, 0.578-0.768) and 0.621 (95% CI, 0.518-0.716), respectively. For observer 1, the positive and negative predictive values for the detection of ECS were 84% (95% CI, 68%-93%) and 49% (95% CI, 36%-62%), respectively. For observer 2, the positive and negative predictive values for the detection of ECS were 71% (95% CI, 57%-82%) and 48% (95% CI, 32%-64%), respectively. CONCLUSIONS AND RELEVANCE:Computed tomography cannot be used to reliably determine the presence of pathologic ECS. Radiologic findings suggestive of ECS should not be relied on for treatment planning in squamous cell carcinoma of the head and neck.
Does [18F] fluorodeoxyglucose-positron emission tomography/computed tomography have a role in cervical nodal staging for esophageal squamous cell carcinoma?
Li Bin,Li Nan,Liu Shuoyan,Li Yin,Qian Bin,Zhang Yawei,He Hao,Chen Xiankai,Sun Yihua,Xiang Jiaqing,Hu Hong,Chen Haiquan
The Journal of thoracic and cardiovascular surgery
OBJECTIVE:Accurate nodal staging is crucial for esophageal cancer. A prospective study was performed to assess the value of [18F] fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) for diagnosing cervical lymph node metastasis (LNM) of esophageal squamous cell carcinoma. METHODS:From June 2018 to November 2018, 110 patients with resectable esophageal cancer were prospectively enrolled. Esophagectomy with 3-field lymphadenectomy was performed after FDG-PET/CT scanning. The primary end point was cervical LNM determined via postoperative histologic examination. The sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), and accuracy (AC) of FDG-PET/CT for the assessment of LNM were determined using histologic results as reference standards. RESULTS:Positive lymph nodes as determined via FDG-PET/CT were detected in 61 patients (55.5%), of whom 13 (11.8%) had positive cervical lymph nodes. After surgery, 59 patients (53.6%) exhibited pathologic LNM, of whom 20 (18.2%) had cervical LNM. SE, SP, PPV, NPV, and AC were 65.6%, 61.2%, 67.8%, 58.8%, and 63.6%, respectively, with regards to diagnosing overall LNM, and were 45.0%, 95.6%, 69.2%, 88.7%, and 86.4%, respectively, for diagnosing cervical LNM. Of the 110 patients, 90 underwent both FDG-PET/CT scanning and ultrasonography in the neck, and there were no significant differences in SE, SP, PPV, NPV, or AC with respect to cervical LNM diagnosis between FDG-PET/CT and ultrasonography. CONCLUSIONS:For cervical LNM of esophageal squamous cell carcinoma, FDG-PET/CT scanning exhibited high specificity but low sensitivity, suggesting that it is of limited value for this purpose.
Therapy Response Assessment and Patient Outcomes in Head and Neck Squamous Cell Carcinoma: FDG PET Hopkins Criteria Versus Residual Neck Node Size and Morphologic Features.
Wray Rick,Sheikhbahaei Sara,Marcus Charles,Zan Elcin,Ferraro Regan,Rahmim Arman,Subramaniam Rathan M
AJR. American journal of roentgenology
OBJECTIVE:This study investigates the prognostic value of (18)F-FDG PET/CT qualitative therapy assessment (Hopkins criteria) in patients with head and neck squamous cell carcinomas (HNSCCs) with residual neck nodes after definitive chemoradiation therapy and compares the Hopkins criteria with anatomic nodal size and morphologic features for prediction of survival outcomes. MATERIALS AND METHODS:A total of 72 patients with HNSCC, with negative primary tumor and positive residual neck nodes (CT criteria > 1 cm short-axis diameter) after the completion of definitive chemoradiation therapy, were included. PET/CT was performed 6-24 weeks after completion of treatment. FDG uptake in residual nodes on PET/CT was interpreted using a structured qualitative 5-point scale (Hopkins criteria). The 5-point scale was dichotomized to negative (scores 1, 2, and 3) or positive (scores 4 and 5) results. Cystic or necrotic nodes were defined as those with central low attenuation with a relatively hyperdense capsule. Kaplan-Meier curve and Cox regression analysis were performed. RESULTS:On the basis of the Hopkins criteria, 10 (13.9%) patients had positive findings and 62 (86.1%) had negative findings for residual nodal disease. According to CT interpretation, 25 patients (34.7%) had residual cervical lymph nodes greater than or equal to 1.5 cm in diameter, and 41 (56.9%) patients had cystic or necrotic nodes. Patients were followed for a median of 27 months after posttherapy PET/CT. There was a statistically significant difference in overall survival (OS) (hazard ratio, 7.06; p < 0.001) and progression-free survival (PFS) (hazard ratio, 6.18; p < 0.001) between patients with negative versus positive residual FDG nodal uptake. There was no statistically significant difference in OS and PFS in patients categorized on the basis of nodal size or morphologic features. CONCLUSION:PET-based structured qualitative therapy assessment (Hopkins criteria) can predict survival outcomes of patients with HNSCC with residual neck nodes after definitive chemoradiotherapy.
Prediction of ultrasound guided fine needle aspiration cytology results by FDG PET-CT for lymph node metastases in head and neck squamous cell carcinoma patients.
Peltenburg Boris,de Keizer Bart,Dankbaar Jan Willem,de Boer Mirthe,Willems Stefan M,Philippens Marielle E P,Terhaard Chris H J,de Bree Remco
Acta oncologica (Stockholm, Sweden)
INTRODUCTION:Accurate assessment of cervical lymph node status is essential in patients with head and neck squamous cell carcinoma (HNSCC) as it influences prognosis and treatment decisions. During patient workup, lymph node status is often examined by ultrasound guided fine needle aspiration cytology (USgFNAC). F-Fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG PET-CT) is frequently used to assess primary tumor and distant metastases but provides information on lymph node status as well. It is possible that FDG PET-CT (if already made for abovementioned indications) can predict the results of USgFNAC in subgroups of lymph nodes based on FDG-uptake and size. The objective of this study is to identify maximum standardized uptake (SUVmax) and short axis diameter cutoff values of lymph nodes at which FDG PET-CT can reliably predict USgFNAC results. METHODS:One hundred and seventeen patients with HNSCC were retrospectively analyzed. Patients were included when FDG PET-CT and USgFNAC were available. SUVmax measurements were performed and compared to the USgFNAC results. RESULTS:Using USgFNAC as a reference standard, the area under the curve of the receiver operating curve was 0.91. At an SUVmax cutoff value of 4.9, the accuracy of FDG PET-CT was the highest (85%). Lymph nodes with short axis diameter ≥1.0 cm and SUVmax ≥4.9 were in 91% positive on USgFNAC. If SUVmax was below 2.2, no nodes were positive on USgFNAC. Of all lymph nodes 52% either had a short axis diameter ≥1.0 cm and SUVmax ≥4.9 or an SUVmax <2.2. FDG PET-CT and USgFNAC results were very similar in these nodes. CONCLUSIONS:By measuring SUVmax values and minimal axial diameters of lymph nodes and using appropriate cutoff values, FDG PET-CT can predict the results of USgFNAC examinations in half of the examined lymph nodes. This information may lead to a reduction of USgFNAC examinations in HNSCC patients if FDG PET-CT is already performed for other indications.
Computed tomography detection of extracapsular spread of squamous cell carcinoma of the head and neck in metastatic cervical lymph nodes.
Carlton Joshua A,Maxwell Adam W,Bauer Lyndsey B,McElroy Sara M,Layfield Lester J,Ahsan Humera,Agarwal Ajay
The neuroradiology journal
Background and purpose In patients with squamous cell carcinoma of the head and neck (HNSCC), extracapsular spread (ECS) of metastases in cervical lymph nodes affects prognosis and therapy. We assessed the accuracy of intravenous contrast-enhanced computed tomography (CT) and the utility of imaging criteria for preoperative detection of ECS in metastatic cervical lymph nodes in patients with HNSCC. Materials and methods Preoperative intravenous contrast-enhanced neck CT images of 93 patients with histopathological HNSCC metastatic nodes were retrospectively assessed by two neuroradiologists for ECS status and ECS imaging criteria. Radiological assessments were compared with histopathological assessments of neck dissection specimens, and interobserver agreement of ECS status and ECS imaging criteria were measured. Results Sensitivity, specificity, positive predictive value, and accuracy for overall ECS assessment were 57%, 81%, 82% and 67% for observer 1, and 66%, 76%, 80% and 70% for observer 2, respectively. Correlating three or more ECS imaging criteria with histopathological ECS increased specificity and positive predictive value, but decreased sensitivity and accuracy. Interobserver agreement for overall ECS assessment demonstrated a kappa of 0.59. Central necrosis had the highest kappa of 0.74. Conclusion CT has moderate specificity for ECS assessment in HNSCC metastatic cervical nodes. Identifying three or more ECS imaging criteria raises specificity and positive predictive value, therefore preoperative identification of multiple criteria may be clinically useful. Interobserver agreement is moderate for overall ECS assessment, substantial for central necrosis. Other ECS CT criteria had moderate agreement at best and therefore should not be used individually as criteria for detecting ECS by CT.
Shear Wave Elastography in Head and Neck Lymph Node Assessment: Image Quality and Diagnostic Impact Compared with B-Mode and Doppler Ultrasonography.
Desmots Florian,Fakhry Nicolas,Mancini Julien,Reyre Anthony,Vidal Vincent,Jacquier Alexis,Santini Laure,Moulin Guy,Varoquaux Arthur
Ultrasound in medicine & biology
The aim of this study was to assess the diagnostic performance of shear wave elastography (SWE) in comparison to B-mode and Doppler ultrasonography in differentiating benign from malignant head and neck lymph nodes (HNLNs). Sixty-two HNLNs from 56 patients were prospectively examined using B-mode, Doppler and SWE. The standard of reference was histopathology or cytology and follow-up. Qualitative malignant criteria (hilum infiltration, cortical hypo-echogenicity, irregular margins, abnormal vessels) were assessed on a five-point scale. Four quantitative parameters were obtained: long axis length, short axis length, short axis/long axis ratio, resistive index and maximum shear elasticity modulus (μmax). Diagnostic performance was analyzed with special emphasis on the sub-centimeter HNLN subgroup. Thirty HNLNs were malignant (48%). μmax intra-observer reproducibility was 0.899 (0.728 in sub-centimeter subgroup). Malignant HNLNs were stiffer (μmax = 72.4 ± 59.0 kPa) compared with benign nodes (μmax = 23.3 ± 25.3 kPa) (p < 0.001). Among the quantitative criteria, μmax had the highest diagnostic accuracy (area under the curve = 0.903 ± 0.042), especially in the sub-centimeter subgroup (area under the curve = 0.929 ± 0.045; p < 0.001) in which the area under the curve was significantly higher compared with the other quantitative criteria (p < 0.05). The additional use of SWE combined with B-mode tended to improve diagnostic accuracy (p > 0.05). SWE is a promising reproducible quantitative tool with which to predict malignant HNLNs, especially sub-centimeter nodes.
Diagnostic accuracy of ultrasonographic features for lymph node metastasis in papillary thyroid microcarcinoma: a single-center retrospective study.
Liu Zeming,Zeng Wen,Liu Chunping,Wang Shuntao,Xiong Yiquan,Guo Yawen,Li Xiaoyu,Sun Shiran,Chen Tianwen,Maimaiti Yusufu,Yu Pan,Huang Tao
World journal of surgical oncology
BACKGROUND:Whether sonography is an appropriate imaging modality for cervical lymph nodes in patients with papillary thyroid microcarcinoma (PTMC) remains unclear. Hence, this study aimed to evaluate the diagnostic value of ultrasonography (US) features for lymph node metastasis in PTMC. METHODS:Seven hundred twelve patients with PTMC who underwent conventional ultrasonography examinations of the cervical lymph nodes were included. All included cases underwent total thyroidectomy plus prophylactic central lymph node dissection. The included lymph nodes were marked superficially, and the corresponding lymph nodes were completely removed and sent for pathological examination. The US features of lymph nodes with and without metastasis were compared, and the odds ratios of the suspicious US features were determined with univariate and multivariate analyses. RESULTS:Round shape, loss of an echogenic fatty hilum, cystic change, calcification, and abnormal vascularity were significantly more common in metastatic than nonmetastatic lymph nodes, whereas the boundary and echo did not significantly differ. Multivariate logistic regression analysis showed that round shape, loss of echogenic fatty hilum, cystic change, calcification, and abnormal vascularity were independent predictive factors for the assessment of metastatic lymph nodes. Round shape had the highest sensitivity of all variables, while loss of an echogenic fatty hilum had the highest specificity and accuracy. The area under the receiver operating characteristic curve, which was calculated to verify the relationship between the various US features and metastatic lymph nodes, was 0.793. CONCLUSIONS:Our study found that the US features of round shape, cystic change, calcification, loss of echogenic fatty hilum, and abnormal vascularity were useful sonographic criteria for differentiating between cervical lymph nodes with and without metastasis.
Diagnostic value of lymph node metastasis by diffusion-weighted magnetic resonance imaging in cervical cancer.
He Xiang-Qin,Wei Li-Na
Journal of cancer research and therapeutics
INTRODUCTION:Diffusion.weighted imaging. (DWI) combined with its apparent diffusion coefficient. (ADC) value shows great significance in the differential diagnosis of human tumors. This meta.analysis is to determine whether ADC valued in DWI could contribute to the differential diagnosis of positive and negative lymph node. (LN) metastasis in cervical cancer. (CC) or not. MATERIALS AND METHODS:A series of types of computerized databases were used searching for eligible studies relied on a strict inclusion and exclusion criteria. Two investigators were involved in the process of selecting articles and extracting dataset. Standardized mean differences (SMD) for the assessment of ADC values in positive and negative LN metastasis in CC patients were calculated. RESULTS:Fifteen cohort studies composed of 687 cases diagnosed with cervical tumor were incorporated into the current meta-analysis. Statistical analysis showed that the ADC value in positive LN metastasis was significantly lower than that with negative LN metastasis [SMD = 1.02, 95% confidence interval (CI) =0.54~1.50, P < 0.001]. Stratified by country, a lower ADC value in tumor tissues with LN metastasis was detected in comparison to that of tumor tissues without LN metastasis among China (SMD = 1.28, 95# CI = 0.62~1.94, P < 0.001) and Korea subgroups (SMD = 1.09, 95% CI = 0.65~1.52, P < 0.001). CONCLUSION:The ADC values in CC tissues with LN metastasis were significantly lower than those without LN metastasis, suggesting that DWI appears to improve diagnostic performance and can be a useful adjunct imaging for identifying LN metastasis in CC patients.
Prediction model for para-aortic lymph node metastasis in patients with locally advanced cervical cancer.
Shim Seung-Hyuk,Kim Dae-Yeon,Lee Sun Joo,Kim Soo-Nyung,Kang Soon-Beom,Lee Shin-Wha,Park Jeong-Yeol,Suh Dae-Shik,Kim Jong-Hyeok,Kim Yong-Man,Kim Young-Tak,Nam Joo-Hyun
OBJECTIVE:Concurrent chemoradiotherapy is usually administered to patients with locally advanced cervical cancer (LACC). Extended-field chemoradiotherapy is required if para-aortic lymph node (PALN) metastasis is detected. This study aimed to construct a prediction model for PALN metastasis in patients with LACC before definitive treatment. METHODS:Between 2009 and 2016, all consecutive patients with LACC who underwent para-aortic lymphadenectomy at two tertiary centers were retrospectively analyzed. A multivariate logistic model was constructed, from which a prediction model for PALN metastasis was developed and internally validated. Before analysis, risk grouping was predefined based on the likelihood ratio. RESULTS:In total, 245 patients satisfied the eligibility criteria. Thirty-four patients (13.9%) had pathologically proven PALN metastases. Additionally, 16/222 (7.2%) patients with negative PALNs on positron emission tomography/computed tomography (PET/CT) had PALN metastasis. Moreover, 11/105 (10.5%) patients with both negative PALNs and positive pelvic lymph nodes on PET/CT had PALN metastasis. Tumor size on magnetic resonance imaging and PALN status on PET/CT were independent predictors of PALN metastasis. The model incorporating these two predictors displayed good discrimination and calibration (bootstrap-corrected concordance index=0.886; 95% confidence interval=0.825-0.947). The model categorized 169 (69%), 52 (22%), and 23 (9%) patients into low-, intermediate-, and high-risk groups, respectively. The predicted probabilities of PALN metastasis for these groups were 2.9, 20.8, and 76.2%, respectively. CONCLUSION:We constructed a robust model predicting PALN metastasis in patients with LACC that may improve clinical trial design and help clinicians determine whether nodal-staging surgery should be performed.