Review
Detection of lymph node metastases in head and neck cancer: A meta-analysis comparing US, USgFNAC, CT and MR imaging

https://doi.org/10.1016/j.ejrad.2007.02.037Get rights and content

Abstract

Purpose

To perform a meta-analysis comparing ultrasonography (US), US guided fine needle aspiration cytology (USgFNAC), computed tomography (CT), and magnetic resonance imaging (MRI) in the detection of lymph node metastases in head and neck cancer.

Methods

MEDLINE, EMBASE and Cochrane databases were searched (January 1990–January 2006) for studies reporting diagnostic performances of US, USgFNAC, CT, and MRI to detect cervical lymph node metastases. Two reviewers screened text and reference lists of potentially eligible articles. Criteria for study inclusion: (1) histopathology was the reference standard, (2) primary tumors and metastases were squamous cell carcinoma and (3) data were available to construct 2 × 2 contingency tables. Meta-analysis of pairs of sensitivity and specificity was performed using bivariate analysis. Summary estimates for diagnostic performance used were sensitivity, specificity, diagnostic odds ratios (DOR) (95% confidence intervals) and summary receiver operating characteristics (SROC) curves.

Results

From seventeen articles, 25 data sets could be retrieved. Eleven articles studied one modality: US (n = 4); USgFNAC (n = 1); CT (n = 3); MRI (n = 3). Six articles studied two or more modalities: US and CT (n = 2); USgFNAC and CT (n = 1); CT and MRI (n = 1); MRI and MRI-USPIO (Sinerem®) (n = 2); US, USgFNAC, CT and MRI (n = 1). USgFNAC (AUC = 0.98) and US (AUC = 0.95) showed the highest areas under the curve (AUC). MRI-USPIO (AUC = 0.89) and CT (AUC = 0.88) had similar results. MRI showed an AUC = 0.79. USgFNAC showed the highest DOR (DOR = 260) compared to US (DOR = 40), MRI-USPIO (DOR = 21), CT (DOR = 14) and MRI (DOR = 7).

Conclusion USgFNAC showed to be the most accurate imaging modality to detect cervical lymph node metastases.

Introduction

Of all head and neck tumors more than 90% are squamous cell carcinomas (SCC) [1]. The presence of one isolated lymph node metastasis (stage N1) decreases the prognosis with 50%, while multiple metastases decrease the prognosis even more dramatically; therefore, the lymph node status is one of the most important predictors of poor prognosis in head and neck tumors [2], [3], [4].

Management in patients presenting with lymph node metastases could consist of a neck dissection in which selected or all lymph node levels in the neck are removed. This could be followed by radiation therapy depending on histological findings like extra nodal spread or presence of multiple metastases. It has to be kept in mind that a neck dissection as well as radiation therapy have a considerable morbidity and mortality [5], [6], [7]. Therefore, accurate assessment of the lymph node status is important for the choice of treatment.

Radiological imaging modalities, like computed tomography (CT) and magnetic resonance imaging (MRI), can be used to support treatment decisions when an unexpected lymph node metastasis is detected on the opposite side in the neck or when it is detected on the ipsilateral side where it is not suspected. Alternative diagnostic modalities are ultrasonography (US) and ultrasonography guided fine needle aspiration cytology (USgFNAC). However, because of the high operator dependency of these latter modalities it generally remains restricted to expert referral centers. Important questions, whether these imaging techniques perform well enough and whether one modality is superior to others, need answers.

Regarding the literature, diagnostic performances of studies are difficult to compare due to a large variety in study designs, study populations, imaging modalities and techniques. Also, only few reports compared all radiological imaging modalities in one study. A meta-analysis of the literature is a tool for these problems as it provides in summarizing the results of individual radiological diagnostic studies.

Such a meta-analysis could provide answers to two relevant questions in the management of patients with a head and neck tumor. Firstly, what is the relative performance of these modalities and secondly, are these modalities accurate enough to further reduce the potential risk of occult lymph node metastases?

The aim of this study was to perform a meta-analysis of radiological imaging modalities for the detection of lymph node metastases in patients with SCC of the head and neck; US, USgFNAC, CT, and MR imaging were compared.

Section snippets

Literature search

A computerized systematic literature search was performed by one reader (RBJdB). Abstracts were selected of articles reporting the diagnostic performance of ultrasound (US), US guided fine needle aspiration cytology (USgFNAC), computed tomography (CT), and magnetic resonance imaging (MRI) in the detection of lymph node metastases in head and neck tumors. The MEDLINE database from January 1990 to January 2006 was searched with the following search terms as keywords: (a) “head and neck neoplasm”

Results

The computerized search revealed a total of 831 articles. After reading the abstracts, 88 articles were found to be relevant, of which 17 studies fulfilled the criteria for inclusion after reading the full text [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. There was no disagreement between the two readers in selecting articles. Reasons for exclusion of studies were as follows: (a) not sufficient or inconclusive information was presented on

Discussion

The current meta-analysis shows that ultrasound guided fine needle aspiration cytology (USgFNAC) has the best diagnostic performance for the detection of cervical lymph node metastases. Ultrasound alone is also associated with high DOR, whereas computed tomography (CT) and magnetic resonance imaging (MRI) perform less well.

The findings of this study are contrary to daily practice where CT and MRI are more commonly used to detect cervical lymph node metastases. The main advantage of CT and MRI

References (35)

  • R.L. Foote et al.

    Base of tongue carcinoma: patterns of failure and predictors of recurrence after surgery alone

    Head Neck

    (1993)
  • C.R. Leemans et al.

    Recurrence at the primary site in head and neck cancer and the significance of neck lymph node metastases as a prognostic factor

    Cancer

    (1994)
  • K.D. Olsen et al.

    Primary head and neck cancer. Histopathologic predictors of recurrence after neck dissection in patients with lump node involvement

    Arch Otolaryngol Head Neck Surg

    (1994)
  • R.M. Byers et al.

    Rationale for elective modified neck dissection

    Head Neck Surg

    (1988)
  • L.E. Moses et al.

    Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations

    Stat Med

    (1993)
  • M.W. van den Brekel et al.

    The size of lymph nodes in the neck on sonograms as a radiologic criterion for metastasis: how reliable is it?

    AJNR Am J Neuroradiol

    (1998)
  • R. Danninger et al.

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

    Laryngorhinootologie

    (1999)
  • Cited by (306)

    • Artificial Intelligence in Head and Neck Imaging

      2022, Seminars in Ultrasound, CT and MRI
    View all citing articles on Scopus
    1

    Tel.: +31 43 3874910.

    2

    Tel.: +32 50 452108.

    3

    Tel.: +31 43 387585.

    View full text