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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 3  |  Page : 419-423
Role of ultrasound in detection of metastatic neck nodes in patients with oral cancer


1 Department of Oral and Maxillofacial Surgery, KSR Institute of Dental Science and Research Institute, Tiruchengode, India
2 Consultant Oral and Maxillofacial Surgeon, Vinayaka Missions Sankarachariyar Dental College, Salem, India
3 Department of Oral and Maxillofacial Surgery, Vinayaka Missions Sankarachariyar Dental College, Salem, Tamil Nadu, India

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Date of Submission22-Feb-2010
Date of Decision20-Jul-2010
Date of Acceptance14-Sep-2010
Date of Web Publication3-Nov-2011
 

   Abstract 

Introduction: Head and neck cancer is one of the most physically and emotionally devastating cancers and often leaves the patient disabled and disfigured. The presence of cervical metastasis is one of the factorsthat influence the outcome of the patients. Cervical lymph node metastasis plays an essential role in the treatment and prognosis of head and neck cancer patients. The assessment of the cervical lymph node status still remains an unsolved problem. We conducted a study to compare the diagnostic accuracy of clinical palpation and ultrasonogram (USG) in the detection of metastatic cervical nodes from oral squamous cell carcinoma patients.
Materials and Methods: Ten patients (age range, 45-63 years; mean age, 54 years) with squamous cell carcinoma in the head and neck region underwent clinical palpation and USG. The results of each modality were analyzed for sensitivity, specificity, positi ve predictive value, negative predictive value and accuracy. Pathologic analysis of the surgical resection served as the reference standard.
Results: USG yielded a sensitivity, specificity, positive, negative predictive value and accuracy as 85.7%, 90%, 92.3%, 81.8% and 87.5% whereas clinical palpation yielded a sensitivity, specificity, positive, negative predictive value and accuracy as 68.7%, 87.5%, 91.6%, 58.3% and 75%.
Conclusion: USG is a reliable and valuable tool for metastatic lymph node screening in head and neck cancer patients. It is a cheap, noninvasive, easy-to-handle and cost-effective diagnostic method. USG performed better than clinical palpation in detecting cervical metastatic nodes.

Keywords: Cervical metastasis, head and neck cancer, lymph nodes, oral cancer, ultrasonography

How to cite this article:
Sureshkannan P, Vijayprabhu, John R. Role of ultrasound in detection of metastatic neck nodes in patients with oral cancer. Indian J Dent Res 2011;22:419-23

How to cite this URL:
Sureshkannan P, Vijayprabhu, John R. Role of ultrasound in detection of metastatic neck nodes in patients with oral cancer. Indian J Dent Res [serial online] 2011 [cited 2019 Nov 22];22:419-23. Available from: http://www.ijdr.in/text.asp?2011/22/3/419/87064
These days, the world is afflicted with various types of non-communicable diseases, which are also known as modern epidemics. Cancer is one among them. Head and neck cancer (HNC) is the sixth most common malignancy reported worldwide and one with high mortality ratios among all malignancies. The Indian subcontinent accounts for one-third of the world's burden. [1] Head and neck cancer is the most physically and emotionally devastating cancers and often leaves the patient disabled and disfigured. Head and neck cancer refers to a group of biologically similar cancers originating from the upper aerodigestive tract. About 90% of head and neck cancers are of the squamous cell variety. [1] Early-stage head and neck cancers have high cure rates, but most of the patients present with advanced disease. Cure rates decrease in advanced cases, whose probability of cure is inversely related to tumor size and even more to the extent of regional node involvement.

Though oral cancer occurs at a site which is accessible for clinical examination and amenable to diagnosis, the crux of the problem is that the majority of the patients present with lymph node metastasis. The presence of ipsilateral metastatic node reduces the five-year survival rate to 50% [2],[3],[4] when compared to a patient without a metastatic node, and the presence of bilateral metastatic neck nodes reduces the survival rate even further to 25%. [5],[6] Although cervical lymph node metastasis plays an important role in the treatment and prognosis of patients with a cancer in the head and neck region, the assessment of the cervical lymph node status remains a problem. Clinical palpation is insufficient in determining the cause of nodal enlargement, nodal size, extra-capsular growth or vascular involvement. [6]

Clinical palpation for nodes has its obvious drawbacks of being unreliable and infallible, other investigations like computed tomography (CT), magnetic resonance imaging (MRI), and the newer positron emission tomography (PET) are expensive for the average-income patient in our country. US can be a solution for the problem. US has been studied adequately and has proved its efficiency for the detection of lymph node metastasis. There are many studies defining the role of numerous imaging modalities individually, but very few comparative studies. [7] In this study the efficiency of clinical palpation and US to detect metastatic lymph nodes was compared with histopathological examination (HPE) of neck dissection specimen which was taken as the gold standard.


   Materials and Methods Top


A cross-sectional observational study was conducted to evaluate the role of ultrasound in detecting metastatic lymph nodes of the neck in the department of oral surgery, Vinayaka Mission's Sankarachariyar Dental College and Hospital during the year 2007-8. The study was designed to compare the accuracy of determining metastatic neck nodes using USG with clinical palpation and both were compared for sensitivity, specificity, positive predictive value, negative predictive value and accuracy while keeping HPE as the gold standard. Patients with carcinoma from the buccal mucosa, maxilla, mandible and gingiva were included in the study.

The study sample consisted of ten patients. Out of which seven were male and three were female in the age range of 45-63 years. Patients who fulfilled the following inclusion criteria were enrolled in the study a) If the primary tumor is histopathologically proven squamous cell carcinoma of the oral cavity, b) presence of palpable neck node(s). The lymph node levels were assessed according to the American Joint Committee on Cancer Classification.

Clinical examination procedure

Clinically, lymph nodes were assessed for location, number, size, shape, consistency, and fixation of the lymph nodes. Nodes were considered to be malignant clinically if size greater than 1 cm; hard and fixed.

US examination procedure

US was performed on all the patients preoperatively. All scans were done with a Voluson 730 Pro ultrasound scanner (Austria, 2008), using a linear high-resolution transducer, 7.5-10 MHz. All the scans were done by the same radiologist who had eight years' experience in head and neck radiology. The radiologist was blinded to the patient's clinical lymph node status during the examination. The patient was positioned supine with the neck hyper-extended.The submental and submandibular region, internal jugular chain nodes, and supraclavicular nodes were assessed. All lymph node levels were assessed by a transverse scan [Figure 1]. The radiologist noted the number, size (longitudinal and transverse diameters), shape, nodal border, echogenicity, and calcification of the lymph nodes.
Figure 1: Transverse scan of neck nodes

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Interpretation of sonogram

The shape of the lymph node was determined by the short: long axis ratio (S: L). An S: L ratio of less than 0.5 indicates a long or oval node, whereas equal to or more than 0.5 indicates a round node. The internal architecture of lymph nodes was assessed for the presence or absence of calcification. The nodal border was assessed for its sharpness. Nodes were considered to be malignant if they fulfill the following criteria- size greater than 10 mm, round node(s), hypoechoic, contour irregularity and absence of calcification.

Surgical procedure

The surgical intervention was performed by the same surgeon who did the clinical examination. All patients were operated under general anesthesia through naso-endotracheal intubation. Primary tumor was resected with a 1.5-cm clearance margin [Figure 2]. Neck dissection was performed on the positive neck side. Apron incision was placed and Level I to Level V lymph node clearance was given [Figure 3] and [Figure 4]. Lymph nodes of each level were tagged and sent for histopathological examination along with the resected tumor specimen [Figure 5]. The primary reconstruction of the defect was done with local or distant flap according to the size and type of the defect.
Figure 2: Primary lesion with excision margins

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Figure 3: Apron incision

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Figure 4: Radical neck dissection

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Figure 5: Excised neck specimen

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Histopathological procedures

The histological examination was performed by an oral and maxillofacial pathologist. The histological examination of all cases was assessed by light microscopy. Paraffin-embedded tissue was cut in 4-mm thin slides and processed routinely with hematoxylin-eosin staining (H and E). Comparison of clinical palpation, USG with pathologic findings was done as shown in [Table 1].
Table 1: Comparison of palpation, ultrasound findings with histopathological examination

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Statistical analysis

The results were evaluated statistically, and the sensitivity, specificity, predictive values, and accuracy of the methods were estimated. Negative and positive predictive values were used to assess the performance of sonographic examinations in the detection of metastatic nodes. The negative predictive value (NPV) is the percentage of nodes interpreted on sonograms as negative for metastases that were histopathologically proved not to be metastatic node. The positive predictive value (PPV) is the percentage of nodes interpreted by sonography as positive for metastases that were histopathologically proved to be metastases. We calculated the sensitivity (true-positive results/ [true-positive results + false-negative results]), specificity (true-negative results/ [true-negative results + false-positive results]), PPV (true-positive results/ [true-positive results + false-positive results]), NPV (true-negative results/ [true-negative results + false-negative results]) and accuracy (true-positive results + true-negative results)/total number of nodes. McNemar 's statistical test was done to compare the diagnostic power of both palpation and US examination of lymph nodes taking HPE as gold standard.


   Results Top


Comparison of clinical palpation, USG with histopathology

On clinical examination, all the patients had palpable neck nodes. Clinically, 24 nodes were palpated out of which 12 were diagnosed as metastatic nodes and 12 as non-metastatic nodes. On comparing with the pathology reports, 16 of 24 nodes showed metastasis but the remaining eight nodes revealed no metastasis. Eleven were true-positive (45.8%), seven were true-negative (29.1%), one false-positive (4.2%) and five were false-negative (20.8%).

On USG examination nine patients had positive nodes and one patient had negative node. The radiologists gave results of 13 (54.2%) nodes as positive and the remaining 11 (45.8%) nodes as negative for metastasis. On comparing with the pathology reports 14 of the 24 nodes revealed metastasis but 10 nodes revealed no metastasis. Twelve were true-positive (50%), nine were true-negative (37.5%), one false-positive (4.2%) and two were false-negative (8.3%) [Table 1].

Efficiency of ultrasound vs. palpation

The efficiency of clinical palpation and USG to detect metastatic nodes was evaluated in terms of sensitivity, specificity, PPV, NPV and accuracy, with HPE as gold standard. USG showed a sensitivity of 85.7%, specificity of 90%, PPV of 92.3%, NPV of 81.8% and accuracy of 87.5% while clinical palpation yielded a sensitivity of 68.7%, a specificity of 87.5%, PPV of 91.6%, NPV of 58.3% and accuracy of 75%. The resue lts of each modality are given in [Table 2].
Table 2: Results of palpation and ultrasound

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McNemar's test was performed to find out the marginal homogeneity of both palpation and USG examination of lymph nodes taking HPE as gold standard. It was found that there was no statistically significant difference between USG and HPE with P value 1.41 [Table 3]. But when palpation and USG examination was associated US showed statistically significant difference than palpation method with P value <0.05 in diagnosing reactive node or the metastatic nodes [Table 4].
Table 3: Ultrasound vs. histopathological examination

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Table 4: Ultrasound vs. palpation

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Mean dimension of the lymph nodes measured with USG examination was 9.70±3.72 mm in the long axis and 4.58±2.64 mm in the short axis. In that the long axis dimension of the nodes which tested positive With USG and HPE was found to be statistically significant with P<0.05, but the short axis dimension was not significant [Table 5].
Table 5: Mean size of the lymph nodes measured with ultrasound examination

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   Discussion Top


Cervical metastasis by a tumor is a firm statement of its aggressive malignant nature. Nothing is more controversial than the management of cervical metastatic disease. It is well recognized that the presence of cervical metastasis is the most important prognostic factor in Head and Neck Squamous Cell Carcinoma, accounting for a 50% reduction in the five-year survival rate for ipsilateral cervical lymph node metastasis [2],[13],[14] and 75% reduction in case of bilateral metastasis. [5],[6] When the risk of metastasis exceeds 15-20%, neck dissection or radiation therapy is indicated. [7],[8] Therefore, evaluation of cervical lymphadenopathy is important for patients with HNSCC. Fortunately, great strides have been made in understanding the intricate processes related to metastatic disease. Most tumors have a predictable pattern of neck metastasis. The main routes of the cervical lymph node metastasis is through the first station nodes [9],[10] Level I and II, followed by the second station nodes which include the Level III, IV, and V. In our study as seen in previous studies, [9],[10] metastatic node was seen in Level I (70%) followed by Level II (66.7%) and Level III (33.3%). All the patients of this study had T4 lesions and the metastasis was confined to Levels I, II and III, we did not find metastasis at Levels IV and V. In most countries of the world, the neck is mainly staged by palpation. The smallest-sized nodes detected with palpation were approximately 0.5 cm for superficial nodes and 1 cm for deeper nodes. [11] Unfortunately, palpation of the neck demonstrates a large variation of findings among various examiners.

The incidence of false-negative (occult) nodes based on palpation varies in the literature from 27-38%. [6],[7],[12] The overall false-negative rate in our study on palpation is 20.8%. Reported figures for the accuracy of palpation for the detection of metastatic nodes range between 59-89% depending on the site of the primary tumor. [6] The sensitivity and specificity of palpation are in the range of 60-70%. Our study showed 75% accuracy, 68.7% sensitivity and 87.5% specificity by palpation which is similar to others. [7],[12] The inaccuracy of clinical palpation paved the way for further studies in search of other more accurate diagnostic means for detecting neck nodes. Debate persists over the relative merits of imaging in the evaluation of the neck for metastatic disease. Imaging techniques like CT and MRI have been popularized to detect metastatic neck nodes. It is not clear why USG is not popular in the field of oral cancer. Unlike other imaging modalities US needs an experienced radiologist. If USG is used properly it gives more valuable information than CT or MRI. USG is reported to be superior to palpation for detecting lymph node metastases. [7],[12],[13] USG is reported to detect small lesions, less than 1 cm more frequently [11] and our finding corelates to it. We found metastases in nodes smaller than 1 cm by USG, which was missed by palpation.

US is a useful imaging modality in the evaluation of cervical lymphadenopathy. [10],[13],[14],[15] In the literature USG shows a sensitivity ranging from 78-97%. In this study, USG yielded a sensitivity, specificity, PPV, NPV and accuracy of 85.7%, 90%, 92.3%, 81.8% and 87.5% whereas clinical palpation yielded a sensitivity, specificity, PPV, NPV and accuracy of 68.7%, 87.5%, 91.6%, 58.3% and 75%. US is deemed better than CT and MRI in many aspects including the affordability for the patients. CT and MRI are based on the size criteria to detect malignant nodes but USG can detect shape, echogenic pattern, peripheral vascularity and calcification of lymph nodes which is important to differentiate malignant nodes from benign nodes. [14] The detection of nodes in the submental and submandibular regions is found to be superior with USG whereas CT and MRI studies have occasionally been impaired by artefacts from bones and dental amalgam restorations. [15] Being less invasive than CT, USG is particularly indicated for follow-up studies aimed at assessing the efficacy of chemotherapy or radiotherapy.

Like any other noninvasive technique to assess metastatic lymph nodes, USG has got its own limitations. Even though the sensitivity, specificity and accuracy of detecting metastatic lymph nodes by USG is better, it is not yet proved to be 100% accurate. These drawbacks can be overcome with the application of US-fine needle aspiration cytology (FNAC). In the literature, the accuracy of USG-FNAC varies from 89-97%. [6] In addition to the good results, we found that USG is useful in detecting metastatic neck nodes. The advantages of US over other imaging modalities are its low cost, noninvasiveness and patient's compliance for follow-up. Hence ultrasound is a good means for assessing cervical metastases in head and neck cancers.

 
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Correspondence Address:
P Sureshkannan
Department of Oral and Maxillofacial Surgery, KSR Institute of Dental Science and Research Institute, Tiruchengode
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.87064

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