Staging of Cervical Lymph Nodes in Oral Squamous Cell Carcinoma: Adding Ultrasound in Clinically Lymph Node Negative Patients May Improve Diagnostic Work-Up

Abstract

IntroductionClinical staging of patients with oral squamous cell carcinoma (OSCC) is crucial for the choice of treatment. Computed tomography (CT) and/or magnetic resonance imaging (MRI) are typically recommended and used for staging of the cervical lymph nodes (LNs). Although ultrasonography (US) is a non-expensive, accessible and non-ionising imaging modality this method is not consistently used.This study aimed to investigate if addition of US of patients classified as clinically LN negative (cN0) by CT and/or MRI, increases the detection of LN metastases. Also, we aimed to identify which of the sonographic characteristics: echogenicity, border, shape, appearance of hilum and nodal blood-flow pattern best detect metastases in this patient group.MethodFifty-one patients with OSCC classified as cN0 by CT/MRI were consecutively included and prospectively examined with US prior to sentinel node biopsy or selective neck dissection. Localisation, size and sonographic characteristics were registered for each LN and compared with the pathological findings. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for different size measurements and sonographic characteristics.ResultsWe found that short axial diameter was the best size criterion for detection of metastases. However, the sonographic characteristics were better predictors than size and the presence at least four of the sonographic characteristics: hypo-echoic or heterogeneous appearance; irregular border; spherical shape; absence of nodal hilum; and peripheral nodal blood-flow resulted in a sensitivity of 43.8; specificity 91.4; PPV 70.0; and NPV 78.0. The number of patients with occult metastases decreased from 16 out of 51 (31%) to nine out of 51 (18%). Three patients (6%) were over-staged by US.ConclusionThe addition of US to the clinical work-up of patients with cN0 OSCC increases the detection of metastases, thus US potentially reduces the number of patients requiring a secondary neck surgery after sentinel node biopsy.

Staging of early lymph node metastases with the sentinel lymph node technique and predictive factors in T1/T2 oral cavity cancer: A retrospective single‐center study

“…Identifying small lymph node metastases in patients with early oral squamous cell carcinoma (OSCC) using traditional imaging (CT, positron emission tomography-CT, and/ or MRI) is known to be unreliable. 1,2 Thus, it has been estimated that approximately 20% to 30% of patients with a clinically N0 neck (cN0) will have occult neck disease after careful pathological examination of lymph nodes from an elective neck dissection (pN-positive). [3][4][5] An often cited dogma in the treatment of the cN0 neck in patients with OSCC states that if there is more than 20% risk of lymph node metastases, then elective neck dissection is warranted.…”

Measurable and Unmeasurable Features of Ultrasound Lymph Node Images in Detection of Malignant Infiltration

“…Diff erent studies used diff erent cut-off values for the short-axis diameter in order to better distinguish malignant from benign nodes. It has also been argued that a higher cut-off value reduces the sensitivity but increases the specifi city, and vice versa 4,5,19,22,23 . In addition, regional variations and agedependent histoarchitectural changes in human LNs have also been described.…”

“…For lymph node (LN) diagnosis, several methods are available including clinical examination, ultrasonography (US), computerized tomography (CT), magnetic resonance imaging, US-guided cytologic aspiration, and positron emission tomography (PET/CT) 4,5 .…”

“…None of these features or their alteration, taken as a single criterion, is reliable, sensitive or specifi c enough to suspect or refute malignancy. A combination of morphological features can more accurately characterize the nature of LN 4 ; however, the results often diff er by anatomic region, clinical settings, type of malignancy, golden standard, level of expertise and demographics. When combined with guided fi ne needle aspiration and cytologic analysis (FNAC), or with surgical removal and histopathology of the entire node, it is nevertheless considered a safe, reliable and widely accepted method of real-time evaluation of peripheral LNs, even in clinically silent nodes [9][10][11] .…”

Capabilities of contrast-enhanced ultrasound for preoperative assessment of regional lymphatic basin in patients with early oral cavity squamous cell cancer

“…УЗИ в режиме серой шкалы (B-mode), дополненное цветовым допплеровским кодированием, достигает чувствительности в 87% при диагностике метастатических поражений шейного лимфоаппарата [22]. Комбинированное применение УЗИ, КТ и МРТ для оценки регионарных лимфоузлов у пациентов, страдающих ПКР слизистой полости рта в N0 стадии, показало диагностическую специфичность 91,4% и общую чувствительность, не превышающую 43,8% [23]. Различные УЗИ-режимы могут применяться для решения клинических задач предоперационного обследования: стандартное УЗИ в режиме серой шкалы позволяет оценить общий вид лимфоузлов и их топографию; режим цветового допплеровского кодирования используется для визуализации интра-и экстранодальной васкуляризации [24,25]; УЗИ-эластография дает возможность количественного измерения жесткости лимфатического узла [26][27][28][29][30].…”