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