Scintigraphic search for metastases in patients with neoplasms of the head and neck

Pretherapeutic staging is essential for the management of head and neck cancer. The diagnostic value of liver, brain and bone scanning was estimated by a retrospective study of 281 patients. Bone and liver scans are useful for detecting distant metastases from head and neck cancer. Brain scanning should be replaced by computed tomography, if there is clinical suspicion of intracerebral metastases. Nowadays ultrasound examination of the liver is more useful than liver scans. Thus, bone scanning remains the only radioisotope method used in the routine pretherapeutic staging of head and neck cancer. Chest X-ray, abdominal ultrasound examination and bone scans are adequate methods for the detection of metastases. The management of malignant lymphoma needs a special and more detailed diagnostic approach.     

Diagnosis and treatment of deep neck abscess due to congenital piriform sinus fistula in children

IntroductionCongenital piriform sinus fistula is a relatively rare type of disease in clinical practice, most occurring during childhood, but doctors have insufficient knowledge regarding this disease, easily misdiagnosing it.ObjectivesThis study aimed to identify the characteristics of deep neck abscess due to congenital piriform sinus fistula in children.MethodsWe performed a retrospective study of 21 cases from January 2016 to August 2018 in our hospital. The onset age, clinical characteristics, auxiliary examination and clinical treatment of the patients was summarized to analyze the diagnosis, treatment characteristics and prognosis.ResultsChildren from 11 days to 12 years-old were enrolled, with an average age of 3.5 years. Twenty patients had left congenital piriform sinus fistula and 1 had right congenital piriform sinus fistula. Cervical enhanced computed tomography imaging showed gas-liquid equilibrium or air-shadow in the abscesses in 18 cases, and neck ultrasound demonstrated gas echo in the thyroid region in 10 cases. All patients underwent low temperature plasma to seal the internal fistula and returned to the hospital for electronic laryngoscope and neck ultrasound examination at 3 months, 6 months and 1 year after the surgery. No recurrence occurred in any patient.ConclusionCongenital piriform sinus fistula is an important cause of deep neck abscess in children. The presence of purulent gas-liquid equilibrium or air shadow in cervical-enhanced computed tomography or ultrasound suggests a high possibility of the presence of an internal fistula, and endoscopic low temperature ablation can be done at the same time as the diagnostic endoscopy.     

Efficacy of radiologic screening for distant metastases and second primaries in newly diagnosed patients with head and neck cancer

OBJECTIVES: Detection of distant metastases and second primary tumors in newly diagnosed patients with head and neck cancer has usually a major effect on prognosis but does not always influence clinical management. This must be considered when radiologic screening investigations are used. The present study particularly evaluates how often additional neoplastic lesions detected by screening had an impact on therapy. STUDY DESIGN: The authors conducted a single-institution retrospective analysis. METHODS: The medical records of 260 patients with newly diagnosed squamous cell carcinoma of the head and neck treated between 1999 and 2002 were retrospectively analyzed. Before therapy, all patients had undergone screening by computed tomography scan of the chest, abdominal ultrasound, and bone scintigraphy. RESULTS: Screening investigations identified 16 patients (6.2%) with distant metastases and six patients (2.3%) with simultaneous second primaries. Chest computed tomography scan detected 20 neoplastic lesions; abdominal ultrasound and bone scintigraphy each detected 2. Three findings of distant metastases proved to be false-positive during follow up. Of the 22 patients with positive screening results, clinical management was affected in 13 (59.1%). Twelve were originally scheduled for curative surgery and 10 had chest abnormalities. CONCLUSION: Chest computed tomography scan was the most effective screening investigation, which should be routinely used whenever curative surgery of head and neck cancer is planned. Abdominal ultrasound and bone scintigraphy may sometimes be valuable before extensive surgical treatment of far advanced disease. In patients scheduled for primary radiotherapy, radiologic screening had hardly any consequence and should be confined to conventional x-ray of the chest.     

Clinicopathological and radiological evaluation of cervical lymph node metastasis in head and neck malignancies

The cervical lymphadenopathy due to metastasis carry poor prognosis. The status of cervical nodes is of critical interest to surgical, radiation and medical oncologists who manage patients with head and neck cancers. We conducted a prospective randomized study to assess the role of palpation, ultrasound and CT in detection of cervical metastasis in 25 patients presented to us with head and neck malignancy irrespective of cervical nodal status. It was observed that clinical examination was least sensitive (73.33%) when compared with computerized tomography (80%) and ultrasound (93.93%). The computerized tomography was found to be most specific (90%) when compared to clinical examination or ultrasonography (70% each).     

Post-therapeutic surveillance strategies in head and neck squamous cell carcinoma

The management of head and neck squamous cell carcinomas does not end with the completion of ablative therapy. The oncologic objectives of post-treatment follow-up are to detect recurrences and second primary tumors; beyond that, follow-up should evaluate acute and chronic treatment-related side effects, guide the rehabilitation process, alleviate functional loss, manage pain, restore nutritional status and assess psychosocial factors. In this structured review, we address the questions of timing and the tools required to achieve a complete and coherent routine surveillance. Several guidelines and consensus statements recommend clinical examination as the cornerstone of follow-up which should be performed for at least 5 years, although there are no data in favor of any one particular follow-up program, and only low-level evidence suggests an improvement in oncologic outcomes by close follow-up. Baseline imaging (computed tomography and magnetic resonance imaging) should be obtained within 2–6 months after definitive therapy if used for treatment response evaluation. Metabolic response, if indicated, should be assessed preferably after 3 months in patients who undergo curative-intent therapy with (chemo)-radiotherapy. Chest computed tomography is more sensitive than plain radiography, if used in follow-up, but the benefit and cost-effectiveness of routine chest computed tomography has not been demonstrated. There are no current data supporting modifications specific to the surveillance plan of patients with human papillomavirus-associated disease.     

Diagnosis and treatment of the N0 neck in carcinomas of the upper aerodigestive tract: current status of diagnostic procedures

Summary Diagnostic procedures currently utilized for determining nodal status in patients with head and neck primary carcinomas are reviewed. Diagnostic procedures include clinical palpation, computed tomography, magnetic resonance imaging and ultrasound. Each technique is discussed on the basis of clinical experience at the Technical University of Munich.Based on a presentation at the International Symposium on the N0 neck: Göttingen, September 1992     

Magnetic resonance imaging in head and neck cancer

The scans of 120 patients with proven head and neck cancer who underwent magnetic resonance imaging (MRI) at Mt. Vernon hospital were reviewed and, where possible, compared with their clinical, computed tomography (CT) and histological findings. MRI was generally superior to both clinical examination and CT in the detection of cervical lymphadenopathy and in the assessment of primary tumour extent, particularly in the tongue base, nasopharynx and parotid gland. Small intracranial tumour extensions were more readily detected by MRI than CT. MRI was no better than CT in distinguishing between malignant and inflamed tissues and was generally inferior to CT in spatial resolution, patient acceptance and examination cost.     

A comparative diagnostic study of head and neck nodal metastases using positron emission tomography

A prospective study was conducted to compare the accuracy of clinical examination, computed tomography (CT), and positron emission tomography (PET) in identifying head and neck squamous cell carcinoma metastatic to cervical lymph nodes. The findings in the necks of 49 patients evaluated by clinical examination and CT were compared to the findings in the same necks by PET, a newly available metabolic imaging modality. Pathology specimens were available for 45 of the necks. The findings of PET and CT correlated in 84% of cases. In the cases that did not correlate, CT proved correct in four of five cases. PET (82%) and CT (84%) were comparable and were both better than clinical examination (71%) in correctly identifying the presence or absence of metastatic disease.     

Diagnostic role of ultrasound elastography on lymph node metastases in patients with head and neck cancer

IntroductionUltrasonography is the easiest non-invasive method to diagnose lymph node metastases in patients with head and neck cancer. However, since CT scans are often preferred in the evaluation of primary tumours of these patients, information about lymphatic metastases may also available in these patients. Therefore, ultrasound is not routinely employed in the evaluation of these patients. However, elastography technique, a recent development in ultrasound technology, could make use of ultrasonography in these patients even more widespread, even though it is still not widely used today.ObjectivesThe aim of this study was to evaluate the role of sonographic elastography in the diagnosis of lymph node metastasis of head and neck cancer.MethodsTwenty-three patients diagnosed with head and neck cancer and scheduled for surgical treatment including neck dissection were included in the study. All patients underwent neck examination by palpation, ultrasound elastography and computerized tomography with contrast. To compare the diagnostic performance of palpation, ultrasound elastography and computerized tomography, the findings of each examination method were compared with the histopathological examination results of neck specimens.Results15 (65.2%) patients had a primary tumour in the larynx; 7 (30.4%) in the oral cavity; and 1 (4.3%) in the parotid. 7 (30.4%) out of 23 patients underwent bilateral neck dissection. In total, 30 neck dissections were hereby taken into account during study. Ultrasound elastography showed higher accuracy (83.3%) and higher sensitivity (82.4%) than palpation and computerized tomography, but the specificity of ultrasound elastography was lower (84.6%) than palpation and computerized tomography.ConclusionsUltrasound elastography is helpful for the diagnosis of lymph node metastases in patients with head and neck cancer. Due to its non-invasive character, it can be used safety in combination with other radiological techniques to support or improve their diagnostic performance.     

Color duplex sonography in post-therapeutic neck evaluation

PURPOSE: Assessment of the clinical utility of color duplex sonography for post-therapeutic evaluation of the neck. PATIENTS AND METHODS: Eighty neck sides were evaluated in a prospective nonrandomized study during the post-therapeutic course. Of these, 74 previously had undergone surgery, and 60 subsequently had additional radiotherapy. The diagnostic procedures applied were clinical examination, computed tomography, positron emission tomography, and color duplex sonography. The mean observation period was 18.6 months. RESULTS: Seven of 80 (8.75%) neck sides exhibited recurrent disease, and 76.2% of the lymph nodes resected during the postoperative observation period showed malignancy. Color duplex echography could detect all lymph nodes. Sensitivity was 100%, and the specificity was 95.8%. The sensitivity and specificity of computed tomography and positron emission tomography were found to be 85.7% and 97.2%, respectively. Palpation had a sufficient specificity (95.8%) but only a very poor 14.2% sensitivity in the post-therapeutic neck. CONCLUSION: In complex tissue alterations of the post-therapeutic neck, color duplex echography is a highly sensitive and easily applied diagnostic procedure for the detection of recurrent disease. It allows a high-resolution depiction of intranodal vascularization and adjacent structures. Problems may occur in the evaluation of vessels in nodes with a diameter of 6 millimeters and below. This may impair specificity in some cases.     

Computed tomography versus ultrasound/fine needle aspiration biopsy in differential diagnosis of thyroid nodules: a retrospective analysis

IntroductionUltrasound sonography provides a quick method for determining which nodule to sample for fine needle aspiration biopsy in thyroid nodules. On the other hand, the computed tomography examination is not restricted by echo attenuation and distinguishes between benign and malignant nodules.ObjectiveTo compare computed tomography examinations against ultrasound/fine needle aspiration biopsy in the differential diagnosis of thyroid nodules.MethodsData regarding computed tomography examinations, sonographic finding following fine needle aspiration biopsy, and tumor histology of 953 nodules from 698 patients who underwent thyroidectomy were collected and analyzed. The beneficial score for detection of the malignant tumor for each adopted modality was evaluated.ResultsUltrasound images did not show a well-circumscribed solid mass in 89 nodules, and ultimately did not detect nodules in fine needle aspiration biopsies (false positive non-malignant nodules). Ultrasound images showed parenchymatous disease (false positive malignant nodules) in several nodules. Computed tomography examinations demonstrated higher difficulty in detection of malignant nodules of 1.0–2.0 cm size than ultrasound examination following fine needle aspiration biopsies; compared to tumor histological data, computed tomography examinations had a sensitivity of 0.879.ConclusionComputed tomography examinations are a more reliable method for differential diagnosis of thyroid nodules than ultrasound examinations followed by fine needle aspiration biopsy.Level of EvidenceIII.     

Rationale for elective neck dissection in 1990

Elective neck dissection has long been a subject of debate among surgeons. The proponents of elective neck dissection base their rationale on studies that show a 30% incidence of occult disease in those situations for which elective neck dissection is recommended. One hundred eighty-two patients with advanced stages of squamous cell carcinoma of the head and neck were studied. All patients had preoperative computed tomography or magnetic resonance imaging, and all patients had some form of radical neck dissection. The sensitivity of clinical exam was compared with the sensitivity of computed tomography or magnetic resonance imaging in ability to detect nodal disease. The sensitivity of clinical exam alone was 71.7%, while the sensitivity of computed tomography or magnetic resonance imaging was 91.1%. Based on physical exam alone, there would be a 39% rate of occult disease; if computed tomography or magnetic resonance imaging data is combined with physical exam, the occult disease rate would drop to 12%. All centers performing elective neck dissection must reassess their rationale or restudy their occult disease rate with computed tomography or magnetic resonance imaging.     

Examining the need for neck dissection in the era of chemoradiation therapy for advanced head and neck cancer

OBJECTIVES: To (1) determine clinical factors that predict pathologic complete response (pCR) on neck dissection after sequential chemoradiotherapy (SCRT) for advanced head and neck cancer and (2) compare survival parameters between those who underwent neck dissection and those who did not among those patients with a clinical complete response (cCR) in the neck after SCRT, thus assessing the benefit of neck dissection in patients with a cCR in the neck. DESIGN: Retrospective review with a mean follow-up of 3.5 years. SETTING: Regional cancer center. PATIENTS: The study population comprised 55 patients undergoing SCRT for advanced head and neck cancer with N2 or N3 neck disease. Three patients developed progressive disease and were excluded, and 28 patients underwent neck dissection. INTERVENTIONS: Patients were assessed by physical examination and radiographically after SCRT. MAIN OUTCOME MEASURES: Physical examination and radiographic assessments of residual neck disease were compared with pathologic findings in those patients who underwent neck dissection. Survival comparisons were made between patients with a cCR in the neck who underwent neck dissection and those who did not. RESULTS: Of 28 patients who underwent neck dissection, 8 had persistent pathologically positive nodal disease: 5 (45%) of 11 had N3 and 3 (18%) of 17 had N2 disease. Individual clinical neck assessments after SCRT were fairly predictive of a negative pathologic finding at neck dissection. The negative predictive values were physical examination (75%), computed tomography or magnetic resonance imaging (71%), and positron emission tomography (75%). However, when physical examination, imaging studies, and positron emission tomography all indicated a complete response, this accurately predicted a pCR on neck dissection. There appeared to be no improvement in survival parameters when a neck dissection was performed on patients with a cCR in the neck. CONCLUSIONS: Patients with N3 disease are at high risk for residual neck metastasis after SCRT. Patients with N2 disease can be assessed with physical examination, imaging studies, and positron emission tomography. If these all indicate a cCR, then neck dissection is likely not needed. Neck dissection did not appear to further improve survival parameters for patients with a cCR in the neck.     

Ability of positron emission tomography to detect residual neck node disease in patients with head and neck squamous cell carcinoma after definitive chemoradiotherapy

OBJECTIVE: To report our experience using the neck examination, computed tomography (CT), and positron emission tomography (PET) to clinically evaluate node-positive patients with head and neck squamous cell cancer for residual neck node disease after definitive chemoradiotherapy. DESIGN: Retrospective review of all Cleveland Clinic patients with head and neck squamous cell cancer and N2 or N3 neck node involvement at presentation who were treated with definitive concurrent chemoradiotherapy and who underwent clinical restaging after treatment using the neck examination, CT, and PET. SETTING: Tertiary care referral institution. PATIENTS: Forty-eight patients with 72 positive necks at diagnosis were followed up for a median of 20 months. MAIN OUTCOME MEASURES: Palpable nodes on examination, nodes larger than 1 cm, nodes with central necrosis on CT, or any hypermetabolic lymph nodes on PET were considered clinical evidence of residual nodal disease. The true rate of pathologic involvement was determined by histologic examination after planned neck dissection or if regional recurrence developed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for all 3 clinical assessment tools. RESULTS: Planned neck dissection was performed in 33 necks and was positive for residual neck node disease in 5 necks. A delayed neck dissection was performed in 5 necks and was positive in 3 necks. The positive predictive value was low for all 3 clinical assessment tools. The addition of PET did not significantly improve the negative predictive value or positive predictive value of CT and the clinical examination. CONCLUSIONS: Residual neck node disease after definitive chemoradiotherapy was infrequent and was not well predicted by PET. A positive PET finding in this setting is of little utility. Although a negative PET finding was highly predictive for control of neck disease after chemoradiotherapy, it added little to the clinical neck examination and CT.     

Proton spin tomography in HIV 1-induced diseases in head and neck region

Most HIV-infected patients present with associated diseases (inflammations, hyperplastic disorders of the lymphatic tissue and malignancies) in the head and neck region. Speculum, endoscopy, ultrasound and computed tomography are important tools in the diagnostic management of HIV presentations. Moreover, MR is known to be an excellent technique especially in the evaluation of soft tissue disorders. -A prospective study of 23 out of 161 HIV-seropositive patients was performed to determine the efficiency of magnetic resonance imaging in HIV-related disorders. T1- and T2-sequences, as well as the contrast medium uptake (Gd-DTPA), presentation in three planes and the morphology of the tissue were useful parameters to distinguish the different HIV-related diseases (lymphatic hyperplasia, inflammation, Kaposi's sarcoma, Hodgkin's und Non-Hodgkin lymphoma, lymphoepithelial cysts and carcinoma) in most cases even prior to histological examination. -MR proved to be a significant non-invasive diagnostic tool especially in HIV-associated soft tissue disorders in the head and neck.     

Regional lymph node metastases in malignant tumors of the head and neck: value of diagnostic procedures

Sonography and computed tomography are used in staging of lymph nodes of patients with head and neck cancer. The accuracy of sonography (90%) and computed tomography (85%) is comparable or better than the palpatory accuracy (85%). The better delineation of reactive swollen cervical nodes leads to a higher sensitivity of sonography (90%) and computed tomography (84%) versus palpation (74%), but a lower specifity (palpation 94%, sonography 90%, computed tomography 86%). A literature survey shows that sonography, computed tomography and magnetic resonance imaging of cervical lymph nodes are comparable good methods.     

Correlation between PET/CT and CT in the staging prior to the treatment of head and neck squamous cell carcinoma

IntroductionHead and neck squamous cell carcinoma is the seventh most common malignant tumor. The advances in treatment have improved the global survival rates in the past years, although the prognosis is still grave.ObjectiveThe aim of the present study is to evaluate the correlation between positron emission computed tomography and computed tomography at the time of staging a previously untreated head and neck squamous cell carcinoma, and to determine which of the two imaging techniques gives us more information at the time of initial diagnosis.MethodsData from all patients diagnosed in our hospital of head and neck squamous cell carcinoma by a biopsy of any location or unknown primary tumor was collected, between January 2012 and July 2017. In all cases, computed tomography and positron emission computed tomography were performed with a maximum of 30 days difference between them and patients had not received any prior treatment to staging. The stage given to each case was compared based solely on the physical examination, only on the computed tomography/positron emission computed tomography, with respect to the stage given by the tumor board, observing the concordance obtained through Cramer's V statistical test.ResultsWe performed a comparative analysis obtaining a correlation of 0.729 between the stage given by the tumor board and the one assigned based on the physical examination without imaging techniques. When only using computed tomography as an imaging method, the correlation was 0.848, whereas with only the use of positron emission computed tomography it was estimated at 0.957. When comparing the statistical association between staging using exclusively one of the two imaging techniques, correlation was 0.855.ConclusionPositron emission computed tomography is useful for the diagnosis of head and neck squamous cell carcinoma, improving the patient's staging especially when detecting cervical and distant metastases. Therefore, we consider that the use of positron emission computed tomography for the staging of patients with head and neck squamous cell carcinoma is a diagnostic test to be considered.     

Resolution of radiodiagnosis of pharyngeal tumors

The authors show informative value of radiomethods in diagnosis of pharyngeal tumors, analyse resolution of x-ray investigation, computed tomography and ultrasound, present roentgenological semiotics of patients with nasopharyngeal cancer (45 patients), analyse results of x-ray examination of 45 patients with primary laryngopharyngeal tumors. In diagnosis of metastases to the neck lymph nodes ultrasound investigation (159 patients) is used as a screening method and provides additional information about tumor relationships with the major vessels.     

A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections

OBJECTIVES/HYPOTHESIS: To determine whether there is a scientific basis for the routine use of contrast-enhanced computed tomography (CECT) in the evaluation of suspected deep neck infection (DNI). STUDY DESIGN: We conducted a prospective, blinded comparison of clinical examination and CECT in DNI. METHODS: Thirty-five consecutive patients with suspected DNI were prospectively assessed by clinical examination and CECT for the presence and extent of surgically drainable purulent collections. Before CECT a surgeon recorded clinical data and predicted the extent of infection. A head and neck neuroradiologist, blinded to the clinical evaluation, predicted the extent of infection based on CECT. Final outcome (the presence of a purulent collection) was determined at surgery or in long-term follow-up. The clinical and CECT findings were compared with the final outcome to determine the sensitivity, specificity, and accuracy of each modality. RESULTS: Twenty patients had purulent drainable collections. The accuracy of clinical examination alone in identifying a drainable collection was 63%, the sensitivity was 55%, and the specificity was 73%. The accuracy of CECT alone was 77%, the sensitivity was 95%, and the specificity 53%. When CECT and clinical examination were combined, the accuracy in identifying a drainable collection was 89%, the sensitivity was 95%, and the specificity 80%. If fluid collections with volumes of 2 mL or greater on CECT were considered, the accuracy of CECT would have been 85%, the sensitivity 89%, and the specificity 80%. CONCLUSION: CECT and clinical examination are both critical components in the evaluation of suspected DNI.     

The current status of positron-emission tomography scanning in the evaluation and follow-up of patients with head and neck cancer

PURPOSE OF REVIEW: Functional imaging has increasingly become an important diagnostic tool for head and neck cancer and as its availability increases so will its utilization. Positron-emission tomography using the radiotracer [18F]fluoro-2-deoxy--glucose is the most commonly used functional imaging technology and it has the potential to improve the staging and detection of head and neck tumors compared with conventional imaging techniques such as computed tomography or magnetic resonance imaging. RECENT FINDINGS: The combination of [18F]fluoro-2-deoxy--glucose and positron-emission tomography contributes valuable information in localizing a primary tumor in patients with an unknown primary and neck metastases, in the staging of primary head and neck cancer, in the detection of residual disease following definitive chemoradiation, and in the detection of recurrent disease. New technologies have been recently introduced using the combination of computed tomography and positron-emission tomography that allows exact anatomical correlation with areas of increased tracer uptake. In addition, new tracers may allow quantification of important cellular processes related to tumor proliferation or identification of tumors that may respond to certain targeted therapies. SUMMARY: [18F]Fluoro-2-deoxy--glucose and positron-emission tomography are increasingly being used as a clinical imaging modality in the complex management of head and neck cancer. In particular, its clinical value in the evaluation of the unknown primary, and the evaluation of recurrent or residual disease, is well established and has shown to be more accurate than conventional imaging modalities.