A clinical study of ultrasonography for lymph node metastases in head and neck cancer

Ultrasonography (US) is very useful in evaluating cervical lymph node swelling in head and neck cancers. We studied problems with US in evaluating lymph nodes. Cervical lymph nodes were removed by radical neck dissection or modified radical neck dissection from 79 patients with squamous cell carcinoma in the head and neck. We studied the correlation between preoperative US findings and the histopathological features. Preoperative lymph nodes were measured three-dimensionally. We diagnosed lymph nodes as metastases when they meet two criteria: One is the shortest diameter exceeding 7 mm in level I and II and 6 mm in level III, IV and V. The other is shortest to longest diameter ratio exceeding 0.5. A total of 2004 lymph nodes were removed by neck dissection, and 199 lymph nodes were diagnosed histopathologically as metastases. Of the 199 metastatic lymph nodes, 93 (46%) were diagnosed as metastases by preoperative US findings and 33 (17%) were false negative. Thirty-six cases were diagnosed preoperatively as N0 by US findings, but 15 of these were pN(+) histopathologically. In the 15 cases, 21 lymph nodes were metastases. Of the 21 metastatic lymph nodes, 10 nodes were not detected by US. Thirty-one cases were diagnosed preoperatively as N1 by US findings, but 20 of these were pN2b histopathologically. In the 20 cases, 66 lymph nodes were metastases. Of the 66 metastatic lymph nodes, 46 were not diagnosed as metastases. They often located distant level from the lymph node diagnosed correctly as a metastasis. US is very useful in evaluating cervical lymph node metastasis, but it has the limitations indicated above. If 1 metastatic lymph node is detected by US, there will be multiple metastatic lymph nodes and sometimes they are distant from the original level. Radical neck dissection should be done for positive lymph nodes detected by US findings. If a lymph node is not clearly a metastasis, fine-needle aspiration cytology (FNA) should be done, because it provides more accurate diagnosis for metastatic lymph nodes.     

脱氧葡萄糖-正电子发射计算机断层显像对颈淋巴结转移癌的诊断价值

目的：探讨脱氧葡萄糖-正电子发射计算机断层[^18F-FDG-PET／CT（PET／CT）]融合显像对颈淋巴结转移癌的诊断价值。方法：对照颈淋巴结清扫术后病理结果,回顾性对比分析20例头颈癌患者颈部正电子发射断层（PET）、CT及PET／CT资料。结果：PET对颈淋巴结转移癌的诊断敏感性、特异性及准确度分别为92.3％、85.7％、90.0％,CT分别为77.0％、57.1％、70.0％,PET／CT分别为92.3％、100.0％、95.0％,PET／CT的诊断准确度显著高于CT（P〈0．05）、略优于PET。13例鼻咽癌放疗后患者,CT诊断正确7例,PET／CT诊断正确12例。7例N。患者颈淋巴结清扫术后病理证实4例存在颈淋巴结转移,术前PET／CT均诊断正确。结论：PET／CT融合显像对颈淋巴结转移癌的诊断价值优于单独的PET及CT,尤其对于治疗后的患者,其诊断优势更加突出,有望作为是否需行颈淋巴结清扫术的指征。     

Ultrasound investigation of cervical lymph node metastases: conception and results of a histopathological exploration

BACKGROUND: Ultrasound (US) is one of the most important methods for detection of cervical lymph node metastases in malignancies of the head and neck. In our study, the specificity of ultrasound was explored by a special, histopathological exploration considering the anatomical regions of the neck. METHODS: Thirty-eight patients were studied (5 female, 33 male, age: 38-86 years) with different histology and incidence of metastatic spread of head and neck cancers. Forty-six neck dissections were performed (30 radical and 16 selective). Histological exploration was performed after pinning the neck soft tissue with needles to anatomical live drawings of the lymph node regions, a modification of the Medina procedure. This procedure allowed a correct topographical assignment of lymph node metastases and comparison of preoperative sonographical findings with histopathological results. RESULTS: We isolated 1333 lymph nodes, 137 of them infiltrated by metastases. These lymph node metastases were found in 28 of 46 neck dissections. The number of lymph nodes in radical neck dissections ranged from 21 to 60 (mean: 36), in selective neck dissection from 1 to 43 (mean: 16). Sensitivity, specificity, and accuracy of ultrasound reached 96%, 69%, and 78%, respectively. Seventy-two lymph node metastases (52%) of 12 neck dissections could not be evaluated by ultrasound. CONCLUSIONS: Our results confirm the reliability of ultrasound regarding sensitivity, specificity and accuracy of US-detectable cervical lymph nodes as reported in world literature. However, we were able to demonstrate in special histopathological explorations, that ultrasound did not detect more than 50% of present lymph node metastases in our series. We consider it essential to perform histopathological explorations of the soft tissue of the neck as described in our study to evaluate the efficacy and reliability of US, CT, and MRI in detecting lymph node metastases of head and neck malignancies.     

Simultaneous bilateral neck dissections

From April 1985 to December 1989, 65 patients with advanced head and neck squamous cell carcinoma, underwent simultaneous bilateral neck dissection (SBND) at Saitama Cancer Center. Three and five year survival percentages were 53 and 42%, respectively. In patients without histologic involvement of cervical nodes, five year survival rate was 83%, whereas in those with nodal involvement five year survival fell to 32% (p less than 0.005). The conclusion were the following: (1) Of 38 patients diagnosed to have lymph node involvements on one side of neck before operation, 8 patients (22%) were found to have bilateral lymph node metastasis in clinicopathological study. Of 13 patients having no clinical lymph node metastasis on both sides of neck, 7 patients (54%) were found to have unilateral lymph node metastasis. Of 16 patients diagnosed to have bilateral lymph nodes involvement, 10 patients were found to have bilateral neck metastasis and 2 had unilateral neck metastasis. (2) Of 35 cases of hypopharyngeal canners, 19 cases had clinically positive lymph nodes on one side of neck. Of these 19 cases, 5 cases (26%) had histologically positive nodes on the opposite side. 14 (40%) of 35 cases had metastasis on the opposite side. In conclusion, SBND is a proper treatment for metastatic cervical cancer from a primary lesion of the head and neck, especially in hypopharyngeal cancers, because the rate of recurrence seems to be related more to the difficulty in controlling lymph node metastasis than to the failure in treatment of the primary cancer.     

Histopathological features of occult metastasis detected by sentinel lymph node biopsy in oral and oropharyngeal squamous cell carcinoma.

OBJECTIVES: Sentinel lymph node biopsy has been introduced for head and neck cancer with promising results. Research in breast cancer has revealed different histopathological features of occult lymph node metastasis with possibly different clinical and prognostic implications. The aim of the study was to evaluate the histopathological features of occult metastasis detected by sentinel lymph node in oral and oropharyngeal squamous cell carcinoma. STUDY DESIGN: Prospective. METHODS: According to Hermanek (5), occult metastasis was differentiated into isolated tumor cells and infiltration of lymph node parenchyma smaller than 2 mm in diameter (micrometastasis) and larger than 2 mm in diameter (metastasis). RESULTS: Occult metastases were found in 6 of 19 (32%) sentinel lymph nodes. Three patients showed micrometastasis with a mean size of 1.4 mm (range, 1.2-1.5 mm), the first with three separate micrometastases within the same sentinel lymph node, the second with an additional cluster of isolated tumor cells within the same sentinel lymph node, and the third with an additional micrometastasis in one lymph node of the elective neck dissection. Two patients had macrometastasis (3.4 and 8 mm), both with multiple metastases in the elective neck dissection. One patient had two clusters of isolated tumor cells in the sentinel lymph node and an additional cluster of isolated tumor cells in one lymph node of the elective neck dissection. CONCLUSIONS: Occult metastasis can be subdivided histopathologically in isolated tumor cells, micrometastasis, and macrometastasis. We present the first study describing a great variety of these subtypes in sentinel lymph nodes from head and neck squamous cell carcinoma. Because the independent prognostic factor and clinical relevance of these subtypes is still unclear, we emphasize the importance of reporting these findings uniformly and according to well-established criteria.     

Strategy of neck dissection in parotid cancer

We conducted definitive surgery on 45 patients with untreated primary parotid cancer from 1975 to 1995, and evaluated methods of neck dissection and results of treatment. All 14 with clinical neck lymph node metastasis underwent ipsilateral radical neck dissection and only 1 developed neck lymph node recurrence at the peripheral dissected site. Of 31 patients without clinical neck lymph node metastasis, 27 of 19 of 36 with high-grade malignancy and 12 of 24 with T3 or T4 did not undergo prophylactic neck dissection and developed latent neck lymph node metastasis in 2 cases (7.4%). Whereas in most cases we achieved good control of the primary site but neck lymph node recurrences occurred, recurrent sites were observed all around the ipsilateral neck and prognosis were very poor if neck dissection was conducted as secondary treatment. Although histopathological diagnosis was considered feasible for predicting occult neck lymph node metastasis, correct diagnostic with fine needle aspiration cytology revealed only 21.8%. Pathological positive lymph nodes in 15 patients who underwent neck dissection were detected all over (level I to V) the ipsilateral neck and the recurrent positive rate at level II was 100%. Based on the above results, we conclude that (1) in cases with neck lymph node metastasis in preoperative evaluation, ipsilateral radical neck dissection is mandated, and (2) in cases without neck lymph node metastasis, prophylactic neck dissection is not usually needed. When pathological results of frozen section from intraoperative jugulodigastric nodal sampling are positive, ipsilateral radical neck dissection is mandated.     

Diagnosis of cervical lymph node metastases in head and neck cancer with ultrasonic measurement of lymph node volume

ObjectiveThe purpose of this study was to evaluate the usefulness of ultrasound (US) volume measurement of the cervical lymph nodes for diagnosing nodal metastasis in patients with head and neck cancer using a node-by-node comparison.MethodsThirty-four consecutive patients with head and neck cancer from one tertiary university hospital were prospectively enrolled from 2012 to 2017. Patients with histologically proven squamous cell primary tumors in the head and neck region scheduled to undergo a therapeutic neck dissection were eligible. For each patient, 1–4 target lymph nodes were selected from the planned neck dissection levels. Lymph nodes with thickness >20 mm or in a cluster were excluded. Node-by-node comparisons between the pre-operative US assessment, the post-operative actual measurements and histopathological results were performed for all target lymph nodes. Quantitative measurements, such as three diameters, ratios of the three diameters and volume were analyzed in this study. Lymph node volume was calculated using the ellipsoid formula.ResultsPatients comprised 28 men and 6 women with a mean age of 60.0 years (range, 29–80 years) at the time of surgery. In total, 67 target lymph nodes were analyzed in this study and the thickness ranged from 3.9 to 20.0 mm (mean 8.0 mm). There was a strong correlation between the US volume and post-operative actual volume (ρ = 0.87, p < 0.01). The US volume measured 2156 ± 2156 mm³ for the tumor positive nodes, which was significantly greater than the US volume of 512 ± 315 mm³ for tumor negative nodes (p < 0.01). Significant differences between tumor positive and tumor negative nodes were found in five variables (volume, thickness, major axis, minor axis and ratio of minor axis to thickness) for total lymph nodes. To identify predictors of lymph node metastasis, ROC curves of the US variables of target lymph nodes were compared, of which 4 variables were considered acceptable for predicting the lymph node metastasis: volume (AUC 0.86), thickness (AUC 0.86), major axis (AUC 0.79), and minor axis (AUC 0.79) for total lymph nodes. The optimal cut-off level for US volume in total lymph nodes was found to be 1242 mm³, whereby a 62% sensitivity and 98% specificity was reached (likelihood ratio: 25.2).ConclusionPre-operative ultrasonic volume measurement of the cervical lymph nodes was useful for early detection of cervical nodal metastasis in head and neck cancer.     

Usefulness and limitations in ultrasonography for diagnosing neck lymph node metastases in patients with hypopharyngeal squamous cell carcinoma: comparison with pathological findings following neck dissection

We evaluated the usefulness and limitations in ultrasonography (US) for diagnosing neck lymph node metastases in patients with hypopharyngeal cancer by comparing the results of preoperative US examinations with postoperative pathological findings following neck dissection. Seventy-five previously untreated patients with hypopharyngeal squamous cell carcinoma underwent a curative procedure that included neck dissection. Preoperatively, all patients were examined by palpation, computed tomography (CT), and US. Postoperatively, all dissected neck lymph nodes were submitted for pathological examination. Results of pre-and postoperative examinations were then compared. US accuracy for each lymph node was 93.9%, while sensitivity was 78.0%, since hypopharyngeal cancer metastasizes early and easily to the neck lymph nodes, and it is difficult to detect small, pathologically positive nodes. Nine of 75 cases showed latent neck recurrence, and two of these were underestimated by US. The major cause for neck recurrence was considered to be the high rate of metastases in such cases, rather than a reduced dissection field. It is not rare to find very small, pathologically positive lymph nodes that US cannot detect in hypopharyngeal cancer. Efforts must therefore be expanded to improve the accuracy of US diagnosis. Care must also be taken when selecting cases for no or limited neck dissection.     

Marginal branch of the facial nerve in submandibular dissection for T2 lingual carcinomas

Lingual carcinomas were found in the early stages. However, even with early detection carcinomas may show lymph node metastasis in the neck, and this may play an important role in their outcome. For this reason, neck dissection is the treatment of choice for T2 lingual carcinomas. A surgical technique of submandibular dissection preserving the mandibular branch of the facial nerve has been done in our department for the past 3 years. The effectiveness of this technique was studied by means of histopathological investigations of superficial nodes that were included in fatty tissues together with the mandibular branch. The conclusions are as follows; 1. No lymph node metastasis was observed histopathologically in superficial fatty tissues that contained the mandibular branch in any of the 26 cases of T2 lingual carcinomas. 2. In 8 cases of those 26, lymph node metastasis was found histopathologically in deep submandibular tissues resected during neck dissection. Even in these 8 cases, however, no metastasis was ditected in the superficial lymph nodes. 3. CH40(activated carbon particle) was injected into the lateral surface of the mobile tongue and its uptake into the submandibular lymph nodes were investigated in 10 cases of N(-) head and neck carcinomas. CH40 was detected in none of the superficial lymph node. 4. These results indicate that early lingual carcinomas localizing in the lateral surface of the tongue do not metastasize into the superficial lymph nodes of the submandibular region, and that our surgical technique of submandibular dissection is useful for T2 lingual carcinomas.     

Impact of preoperative ultrasonographic staging of the neck in papillary thyroid carcinoma

OBJECTIVE: To determine the frequency of occult macroscopic metastasis detected by preoperative US evaluation of the neck in patients with PTC. Papillary thyroid carcinoma (PTC) is a malignancy with a high rate of lymph node metastasis. The findings of routine thyroid ultrasonography (US) and physical examination may underestimate metastatic disease. Thus, we propose that patients diagnosed as having PTC undergo preoperative US staging of the neck. DESIGN: This prospective study included 60 patients diagnosed as having PTC from January 1 through June 30, 2006. Patients had undergone previous thyroid US evaluation with no palpable adenopathy. Lymph nodes were deemed suspicious by US findings with a minor axis greater than 10 mm, a minor axis greater than 50% of the major axis, or hyperechogenicity with or without microcalcifications. Metastasis was confirmed by fine-needle aspiration biopsy or frozen section analysis. Patients with confirmed metastasis underwent a neck dissection. The location of adenopathy reported by US was correlated with the pathological report. RESULTS: The US evaluation identified 12 of 60 patients (20%) with adenopathy suggestive of metastasis. Metastasis was confirmed in 11 of 12 patients (92%). Metastasis was found in 1 of 48 patients who had a negative US finding. Overall, sensitivity, specificity, and positive and negative predictive values were 92%, 98%, 92%, and 98%, respectively. All neck levels with suspicious adenopathy detected by US evaluation, with 1 exception, were confirmed by pathological findings. Nine patients had additional neck levels involved with microscopic disease undetected by the US evaluation. CONCLUSIONS: In patients with PTC, preoperative US evaluation of the neck is effective in detecting nonpalpable metastasis. Therefore, routine preoperative neck US evaluation is recommended to optimize primary surgical planning.     

Predictive ability of the CT to evaluate cervical lymph nodes in head and neck tumours

ObjectiveThe aim of this study was to determine the predictive value of computed tomography (CT) i.e., its sensitivity and specificity in detecting metastatic lymph nodes of head and neck tumours. We also studied the capacity of CT in correct nodal staging.Patients and methodsA CT was performed on 95 patients diagnosed with neoplastic disease of the pharynx and/or larynx. All patients subsequently underwent cervical lymph node dissections. In the imaging study, the following parameters were considered for suspected radiological nodal involvement: lymph node diameter greater than 10 mm, lesion margins poorly defined, capsule enhancement after contrast administration and lymph nodes that, despite their size, had signs of central necrosis.ResultsIn the dissections, 70.53% resulted N+ in the histological study. The sensitivity of CT was 82.09% and the specificity, 85.71%. The CT detected positivity in 55 of the 67 histologically pathological dissections, while the CT detected negativity in 24 of the 28 dissections histologically negative. The weighted kappa index value was 0.6408, indicating limited capacity for appropriate staging of the lymph nodes.ConclusionsWhile the ability of CT to detect metastatic lymph nodes in head and neck tumours is quite acceptable, it is less so for correctly staging them. It is therefore necessary to look for other imaging tests that provide greater accuracy to avoid unnecessary elective neck dissections and to reduce morbidity and mortality from them. We must now pay attention to new imaging techniques such as PET and PET/CT.     

甲状腺乳头状癌Ⅱ区淋巴结隐匿性转移的临床分析

目的 分析甲状腺乳头状癌Ⅱ区淋巴结隐匿性转移的相关因素。方法 回顾分析天津医科大学附属肿瘤医院头颈外科2003年1月至2009年12月收治的213例术前Ⅱ区淋巴结临床阴性,颈侧其他区阳性的初治甲状腺乳头状癌患者的临床资料。淋巴清扫标本经病理证实颈侧区（Ⅱ～Ⅴ）有淋巴转移。单因素和多因素分析分别采用卡方检验和二分类Logistic回归分析。结果 颈部Ⅵ区淋巴结转移率79.3％( 169/213),Ⅲ、Ⅳ、Ⅴ区淋巴结转移率分别为83.6％( 178/213)、75.1％ (160/213)、13.1％ (28/213),Ⅱ区隐匿性淋巴结转移率为16.0％(34/213)。单因素分析显示：术前颈侧区Ⅲ、Ⅳ区淋巴结同时阳性或者术前Ⅲ区淋巴结阳性,与Ⅱ区淋巴结隐匿性转移密切相关（x2值分别为11.120和5.614,P值均＜0.05）;多因素分析显示术前颈侧区Ⅲ、Ⅳ区淋巴结同时阳性是隐匿性Ⅱ区淋巴转移的独立危险因素(P=0.033,OR =3.846)。结论 甲状腺乳头状癌患者术前未发现Ⅱ区和Ⅲ区淋巴结阳性时,可以考虑暂时不进行预防性Ⅱ区颈淋巴清扫术。     

Diagnosis of lateral cervical lymph node metastasis of papillary carcinoma of the thyroid by ultrasonography

No consensus for papillary carcinoma of the thyroid exists on the preoperative diagnosis of lateral cervical lymph node metastasis, indications, or range of neck dissection, so we studied the usefulness and limits of ultrasonography and sufficient dissection by comparing preoperative ultrasonographic and postoperative histopathological diagnosis. Subjects were 45 patients (51 affected sides) with lateral cervical lymph node metastasis of papillary carcinoma of the thyroid who underwent modified neck dissection between July 1997 and July 2003. Preoperative ultrasonographic and postoperative histopathological diagnosis were compared. Specimens excised by neck dissection contained 1,325 lymph nodes. Of these, 198 (15%) detected by preoperative ultrasonography were selected for investigation of diagnostic criteria for metastasis-positive lymph nodes. The best criterion for the diagnosis of metastasis-positive lymph node was 0.5 or greater [minor axis/major axis] with 6 mm or greater minor axis at levels III, IV, or V (7 mm or greater at level II), and sensitivity, specificity, and accuracy were 78%, 100%, and 84% respectively. The lateral cervical lymph node metastasis rate obtained by this diagnostic criterion was 41%. Regional histopathological metastasis positivity was investigated in the lateral cervical region, and high positivity rates were obtained: 57% at level II, 71% at level III, and 84% at level IV. Considering these findings and the preoperative ultrasonographic diagnosis rate of 41%, sufficient dissection at levels II-IV may be necessary for patients in whom lateral cervical metastasis is observed before surgery. The metastasis rate was 10% at level V, but dissection should always be done in lateral cervical metastasis-positive patients because: 1) No trend was observed in age, gender, the number of metastatic lymph nodes, or regional metastasis rate; 2) no anatomical boundary is present between levels II, III, IV and level V; 3) no functional disorder due to preservation of the accessory nerve occurred; 4) the prognosis of patients with advancement to the accessory nerve was poor; and 5) improvement of the prognosis of papillary carcinoma of the thyroid by modified radical neck dissection has been reported.     

术前超声评估分化型甲状腺癌颈部淋巴结转移

目的 探讨术前超声诊断分化型甲状腺癌(DTC)颈中央区及颈侧区淋巴结转移的临床价值。 方法 回顾性分析2017年4月至2018年8月术后病理证实的186例DTC患者,所有患者均于山东大学齐鲁医院(青岛)超声科行术前超声检查,并于耳鼻咽喉头颈外科行颈中央区淋巴结清扫术,其中71例同时行颈侧区择区淋巴结清扫术。以石蜡切片病理结果为金标准,计算术前超声诊断颈中央区淋巴结转移及颈侧区淋巴结转移的敏感度、特异度、阳性预测值(PPV)和阴性预测值(NPV)。根据患者有无桥本甲状腺炎(CLT),将所有病例分为两组,A组合并CLT,B组不合并CLT;分别计算两组超声诊断中央区淋巴结转移的敏感度、特异度、PPV、NPV。 结果 术前超声诊断甲状腺癌颈中央区及颈侧区淋巴结转移的敏感度分别为:68.9%、95.3%,特异度分别为:56.3%、57.1%,PPV分别为:75.0%、95.3%,NPV分别为:48.6%、57.1%。A组(60例)与B组(126例),术前超声对颈中央区淋巴结转移诊断的敏感度分别为:85.0%、62.5%,特异度分别为:35.0%、67.4%,PPV分别为:72.3%、76.9%,NPV分别为:53.8%、50.8%。 结论 术前超声检查对DTC颈中央区及颈侧区淋巴结转移的诊断有价值,对颈侧区的诊断准确性高于中央区。合并CLT的DTC患者,超声对颈中央区淋巴结转移的诊断准确性低于不合并CLT的患者。     

Ultrasonographic evaluation of metastatic cervical lymph nodes in head and neck cancers

This study evaluates the use of ultrasonography (USG) to diagnose metastatic cervical lymph nodes. Three-hundred and one lymph nodes were removed from 58 patients with squamous cell carcinomas of the head and neck. None of the patients had received any preoperative treatments for cancer. The lymph nodes were then histopathologically examined: 139 metastatic lymph nodes and 162 non-metastatic nodes were found. USG was then used to evaluate the size, internal echo, and margin of each lymph node. Size was found to be the best criteria for distinguishing metastatic lymph nodes from non-metastatic lymph nodes in all cervical regions (78% accuracy). Superior internal jugular lymph nodes and submandibular lymph nodes larger than 7 mm and mid and inferior internal jugular lymph nodes larger than 6 mm were regarded as metastatic. Internal echoes were classified into five patterns: homogeneous hypoechoic, homogeneous hyperechoic, heterogeneous, eccentric hyperechoic, and centric hyperechoic. Homogeneous hyperechoic and heterogeneous patterns were characteristic of metastatic nodes, while eccentric hyperechoic patterns were characteristic of non-metastatic nodes. Homogeneous hypoechoic patterns were observed in both metastatic and non-metastatic nodes. Regular margins were found in 81% of the metastatic nodes. Of the 22 lymph nodes with irregular margins, however, 91% were metastatic. Evaluations using a combination of USG and clinical feature criteria were compared with evaluations using only thickness as a criterium. Although thickness is the single most important factor in diagnosing metastatic nodes, the combination of USG and clinical feature criteria improved the accuracy of diagnosis to 83%. Thus, diagnostic methods involving a combination of several criteria are more accurate than methods involving only a single criterium.     

Value of ultrasound in detecting central compartment lymph node metastases in differentiated thyroid carcinoma

The value of ultrasound in detecting central compartment lymph node metastasis in patients with well-differentiated thyroid carcinoma (WDTC) is unclear. Prospective patients with WDTC attending a university-affiliated tertiary medical center between July 2010 and June 2011 underwent neck ultrasound for detection of central compartment lymph node metastases prior to surgery. Central lymph node dissection was performed during the initial surgery regardless of ultrasound findings. The sensitivity and specificity of preoperative ultrasound in detecting central lymph node metastases were calculated according to the final histopathological results. Sixty-four patients met the study criteria. Twenty-four had pathologic central compartment lymph nodes according to preoperative ultrasound, 20 of which were confirmed by histological examination. One patient was found to have pathological central lymph nodes by histology which was not detected by US. Sensitivity of preoperative ultrasound was 95 %, specificity 90 %, and negative and positive predictive values 97 and 83 %, respectively. Preoperative ultrasound may serve as an accurate and important tool for deciding the extent of surgery in WDTC.     

B-image sonography in lymph node staging of the head and neck area. A comparison with palpation, computerized and magnetic resonance tomography

The results of palpation, CT and MRI and high resolution ultrasound were compared in 100 patients with malignancy of the head and neck. Ultrasound detected far more lymph nodes than the other methods. These diagnostic findings were compared with the operative and histological results in 62 patients. Ultrasound proved superior to the other methods: a lymph node metastasis was missed in only 2 patients by sonography, whereas in 20 patients metastases were overlooked by CT and MRI scans, and in 27 patients by palpation. High resolution ultrasound is at present the most reliable method for the detection of lymph nodes in the head and neck.     

Level IIb lymph node metastasis in neck dissection for papillary thyroid carcinoma

OBJECTIVE: To determine the patterns of lateral cervical metastasis and the incidence of level IIb lymph node metastasis in papillary thyroid carcinoma. DESIGN: Retrospective medical record review. SETTING: Academic medicine. PATIENTS: From March 1, 2000, to April 30, 2006, 46 consecutive patients (38 women and 8 men) with papillary thyroid carcinoma. INTERVENTIONS: Patients underwent 55 modified radical neck dissections for the management of lateral cervical metastasis. MAIN OUTCOME MEASURES: All patients had preoperative evidence of a metastatic cervical lymph node. All specimens were labeled and mapped by the operating surgeon to identify their levels. RESULTS: Among 55 specimens, 82% (45 specimens) exhibited nodal disease at multiple levels. The incidences of metastases at level II, III, IV, and V nodes were 60% (33 specimens), 82% (45 specimens), 75% (41 specimens), and 20% (11 specimens), respectively. Skip metastases were present at a low rate (6% [3 specimens]). Among 12 specimens (22%) with metastatic lymph nodes at level IIb, 92% (11 specimens) had disease at level IIa. The rate of level IIb lymph node involvement in patients with metastatic lymph nodes at level IIa was 34% (11 of 32). CONCLUSIONS: Tumor involvement at multiple nodal levels usually occurs when patients have lateral cervical lymph node metastasis. Neck dissection should include the level IIb lymph node whenever level IIa lymph node metastasis is found. Level IIb dissection is probably unnecessary when level IIa lymph nodes are uninvolved because the incidence of metastasis to level IIb is low if level IIa is not involved.     

Sono-morphologic criteria of metastatic and reactive modes in the neck

Real time high resolution ultrasonography (US) is thought to be the diagnostic tool of high sensitivity in detecting lymph nodes in patients diagnosed and follow-up for head and neck malignancies. Sensitivity and specificity of US are determined by quality of equipment, the kind of transducer and the experience of ultrasonographer. The diagnostic difficulties are met in small lymph nodes, less than 10 mm. Which sonographic picture is ambigious. It is very important in follow-up to avoid false-negative nodes and possibility of overtreatment of patient. The aim of the paper was to determine the sonomorphogic criteria which enable improving the specificity of neck ultrasonography especially in assessing the small, less then 10 mm lymph nodes. MATHERIAL AND METHOD: Ultrasonograph Aloka SSD 3500 and transducer 7.5 Mhz with 42 mm linear probe. The neck US was performed before the surgery. Maximal longitudinal diameter (L), maximal diameter (S), their ratio (S/L) which indicate the lymph node shape, echogenicity and internal echostructure were assessed. The features of the lymph node capsule, i.e. continuity, lost of echos were taken into consideration. The high echogenicity, the round shape of the node, lost of hilus central echo or it's marginal displacement correlate with malignant character of the node. Lost of echos in node capsule are not the indicator of the extracapsular spread. Using sonomorphologic criteria in assessment of small lymph nodes in the neck the authors stated the meaningful improving of US specificity.     

Ultrasonography-guided fine-needle aspiration for the assessment of cervical metastases

OBJECTIVE: To assess the value of ultrasonography (US) combined with fine-needle aspiration (FNA) cytology for the investigation of lymph node metastases in patients with head and neck cancer. DESIGN: Comparison of clinical examination (palpation) and preoperative US-FNA examination results of cervical nodes in a sample of patients with head and neck cancer. The histological features of the neck dissection specimens are used to validate these 2 variables. SETTING: A head and neck oncology service in a tertiary referral hospital. PATIENTS: A consecutive sample of 56 patients with head and neck squamous cell carcinoma, first seen between April 1, 1996, and July 30, 1998, who had neck dissections performed after the US-FNA examination. INTERVENTION: Cervical US-FNA preoperatively, followed by elective or therapeutic radical modified or selective neck dissection. MAIN OUTCOME MEASURES: The histological examination results of subsequent neck dissection specimens are used to determine the sensitivity, specificity, and accuracy of US-FNA for individual nodes. Second, the results of node staging by clinical examination and US-FNA examination are compared. RESULTS: The sensitivity was 89.2%; specificity, 98.1%; and accuracy, 94.5%. Correct node stages were obtained in 52 (93%) of the patients using US-FNA compared with 34 (61%) using palpation. CONCLUSIONS: Ultrasonography combined with FNA is a highly accurate technique for the investigation of cervical lymph node metastases. A more accurate diagnosis may result in more appropriate treatment, particularly in a setting with limited resources. Retropharyngeal nodes, micrometastases, and lymph nodes smaller than 4 mm are limitations of US-FNA. Ultrasonography combined with FNA is a useful technique for the staging of head and neck cancer.