Head Michiel Wietse
W.M. van den Brekel, MD #{149} Jonas Luth, MD #{149} Jaap Valk, MD, PhD
Occult Metastatic and US-guided
Neck Fine-Needle
The
authors performed a prospective of the value of ultrasonography (US) and US-guided fine-needle aspiration cytology (FNAC) for assessment of NO lesions in the neck. Preoperative US was performed in 107 patients with squamous cell carcinoma of the head and neck, who underwent 132 elective neck disseclions. During the US examination of the last 54 patients, who underwent 70 elective neck dissections, USguided FNAC was performed. US alone was found to be an unreliable method for detecting occult lymph node metastasis; the accuracy never exceeded 70% (93 of 132), with a sensitivity of 60% (32 of 53) and a specificity of 77% (61 of 79). In contrast, US-guided FNAC had an accuracy of 89% (62 of 70), a sensitivity of 76% (25 of 33), and a specificity of 100% (37 of 37). Because of the high sensitivity and specificity of US-guided FNAC for the assessment of the NO neck, this modality may play an important role in directing treatment of these patients in the future. study
Index
terms: Head and neck neoplasms, 262.37, 271.37, 276.37, 28.314 #{149}Lymphatic systern, neoplasms, 20.37, 99.33, 99.82 #{149}Lymphatic system, US studies, 99.1298, 99.12985, 99.12986 Radiology
A. Castelijns, #{149} Isaac van
J.
1991;
180:457-461
I
(CT)
From the Departments of Otorhinolaryngoland Head and Neck Surgery (M.W.M.v.d.B., G.B.S.), Diagnostic Radiology (J.A.C., W.J.L., J.V.), Pathology and Cytology (H.V.S.), and Oral Pathology (I.v.d.W.), Free University Hospital, P0 Box 7057, 1007 MB Amsterdam, The Netherlands.
Received quested March
accepted from
the
January 30, 1991; revision re12; revision received March 28; April 8. Supported by grant IKA 88-19 Queen Wilhelmina Fund for Cancer Address reprint requests to
Research. M.W.M.v.d.B. 0
RSNA,
1991
and
magnetic
V. Stel, MD, PhD Gordon B. Snow,
remains.
nodes
(9-13).
This
can
be
explained by the fact that US does not reliably depict tumor cells in either lymphatic tissue or necrotic tumor tissue; neither does it reliably depict tumor keralinization. Therefore, the only criteria left for accurate differentialion between reactive and metastatic lymph nodes are size (minimal axial diameter) and grouping of three or more borderline lymph nodes (21). US-guided fine-needle aspiration (FNAC)
may
give
cytologic
evidence of tumor in a large percentage of metastatic nodes. Although some authors studied US-guided FNAC in patients with head and neck cancer (11,18,20), to our knowledge none of them has studied this technique in a homogeneous group of previously untreated patients who underwent elective neck dissection because results of palpation were negative. In this study, the value of US and US-guided FNAC for the detection of occult cervical lymph node metastasis
One hundred and
neck
is assessed.
seven
squamous
was previously examined with years.
PhD
US
These
METHODS
patients
with
head
cell carcinoma
that
untreated (Table US over a period
107 patients
1) were of 1’/
underwent
a to-
tal of 132 elective neck dissections that were either comprehensive or selective. contain
these
132 necks
were
no lymph
node
involvement
the decision to perform was made on the basis
At
found
to
(NO);
elective dissection of the site and
stage of the primary tumor. In principle, negative findings
at US and
FNAC had no influence on the of treatment of the neck. In four however, the finding of positive
US-guided
Most studies of ultrasonography (US) of the neck claim that US is superior to palpation for enabling deteclion and classification of cervical lymph node metastasis (9-20). Although some authors defined criteria for diagnosis of malignant or benign nodes at US (14-17), US alone does not enable differentiation between enlarged reactive nodes and enlarged metastatic
MD,
AND
MATERIALS
palpation,
resonance
(MR) imaging have enabled detection of 38%-67% of these occult lymph node metastases (6-8). Consequently, the need for a more sensitive technique
Radiology
Disease: Detection with Aspiration Cytology’
with primary squamous cell carcinoma of the head and neck, staging of neck lesions with palpation is reported to yield false-negalive results in O%-77% of cases (1,2), depending on the site (3), size (4), and other parameters (5) of the primary tumor. To date, computed tomography
Neck
#{149}
N patients
cytology
ogy
MD, PhD #{149} Herbert der Waal, DDS, PhD
and
direction lesions,
aspirate necessitated unanticipated neck specimens
performance of an dissection. Of the 132
obtained,
53 (40%)
contained
metastatic lymph nodes, whereas 79 (60%) were negative at histopathologic examinalion. Consequently, accuracy of palpation was 60%. In the second
part
the 107 patients neck dissections. 33 of the
ination,
found
to contain
whereas tumor.
37 (53%) US-guided
lesions All
of this
study,
54 of
underwent 70 elective At histopathologic exam70 specimens
metastatic
(47%)
lymph
were
nodes,
were found to be free of FNAC of 57 of these 70
was performed. specimens
obtained
at neck
dissec-
lion were thoroughly examined histopathologically; all nodes that were visible
on the radiograph of the specimen or were palpable in the specimen itself were documented by one physician (M.W.M. v.d.B.). Depending on the type of neck dissection, an average of 43 lymph nodes (range,
24-.87)
were
found
in comprehen-
sive specimens, whereas an average of 16 lymph nodes (range, 6-48) were found in specimens. The number of posilive lymph nodes varied from zero to five (mean, 1.8 in the specimens that were positive for tumor). Depending on the size of selective
the lymph ery
ined
node,
sections
were
made
ev-
and all sections were examhistopathologically, as described in
2-4
mm,
our previous
Abbreviation:
studies
FNAC
(6,21). Exact docu-
=
fine-needle
aspiration
cytology.
457
Table
1
of Patients
Number
Lesions
with
at Various
Sites
and T Stages
Stage
t..1. Primary
Tumor
Ti
T2
T3
T4
Total
2 1 1 0 0 0 0 0 0 0
7 12 5 0 5 2 3 4 2 4
8 7 0 3
0 4 1 1
17 24 7 4
4
2
11
3 4 4 7 0
1 0 4 6 0
6 7 12 15 4
4
44
40
19
107
-
Mobile tongue Floor of mouth I
Alveolar
process
Base of tongue Tonsil, soft palate
!‘-
Pharyngealwall Piriformsinus Supraglottic larynx (Trans)glottic larynx Figure
1.
US image
obtained
with
Lip,nose
a 7.5-
MHz,
linear array transducer during aspiration of a subdigastric node. Note the hyperechogenic spot inside the node (arrow), representing the needle tip.
Total
Table
2
Sensitivity,
mentation nodes that
of the size and were examined
site of all lymph in the speci-
Size
(mm)*
at US-guided FNAC with the lymph node that was resected in the great majority of specimens. Correlation among findings at histopathologic examination, US, or USFNAC
was
determined
for
each
was
were
(H.V.S.,
reviewed
650;
B-scan
Aloka,
US examinations
Tokyo)
were
by
89
33
55
85 81 60
44 59 77
61 68 70
8 9 10
42 26 15
85 95 97
67 67 64
transducer. sides of the
neck were
for the presence
lymph
mandibular
and
nodes
(level
submental,
I
lymph
nodes,
2, 3, 4
indicating
of the node
and the region
neck
imaged.
being
The
diameter
our
the
one =
size
previous
that the minimal
is the most
accurate
axial
criterion
for
size, we again used this criterion for evaluation of lesions depicted at US. For subdigastric
was that
minimal axial diameter to be 1 mm larger than nodes. In addition, a group-
nodes,
ing of three
or more
borderline
drainage
regions
malignant.
was
In this
also
study,
considered several
size
last 8 months
of the
all US-guided
the
FNACs
performed
one
physician
(M.W.M.v.d.B.).
458
#{149}
Radiology
were
nodes
(1 mm
larger Nodes
for subdigastric were
nodes)
and
not considered
for groups
to be grouped
punctured
lymph
per
Most
side.
punctured
twice
cient material After sterile was
was nodes
lymph
to ensure
was obtained. preparation,
performed
in
of three
if the diam-
was introduced
and
inside
was
gently
the
lymph
up
and
ethanol
and
of a
1)
obtain
additional
smears.
and
Papanico-
and stained solution.
to be
examined
(Fig
the needle
fixed by using with
revised
All
by one
with The nee-
(Ta-
guided
smears
FNAC,
sensitivity
necks
were
malignancy Necks
were
chance
a cytologic
of demonstrating
diag-
positive
findings with US or US-guided FNAC in a side of the neck that contained metastasis, whereas the specificity was the chance of demonstrating negative findings when no metastatic lymph nodes were present. Accuracy
was
positive by the
and true-negative results, total number of examinations.
were
estimated
as the
sum
of true-
divided
RESULTS US
a high
the
for
observer at US-
considered
be positive if one or more aspirates to be positive for tumor or suspicious
by
was
material
with CarboConn) to
(H.V.S.).
To obtain
at cyto-
that contained
nosis were considered to be negative. Sensitivity, specificity, and accuracy of US and US-guided FNAC were estimated by using the histopathologic findings in the neck dissection specimens as a standard of reference. Findings at US and histopathologic examination were compared for each side of the neck and not for each node or for each patient. The sensitivity
node
either stained
to be negative
Smears
(and, or if all
insufficient
down.
were
found
tumor
obtained)
nodes
use
by moving
were
was
suspi-
in the drain-
that suffi-
into the skin 0.5-
continued
of the primary
logic examination.
if no
visualized
aspirate
smears
1.0 cm from the transducer, at the middle of the long axis of the transducer. Aspiralion was started after the needle point was visualized
no
punc-
biopsy guide attached to the transducer, by using a syringe holder (Cameco, Taeby, Sweden) and a 0.6 x 25-mm needle. The
needle
thus,
examination
were
were
US-guided
without
FNAC
nodes
age regions
regions
of the neck
US-guided
cious
lymph
drainage
to three
axial
punctured.
(largest)
tumor
sides
One
in minimal
were
dle and syringe were washed wax (Union Carbide, Danbury,
study,
Lymph
or both
FNAC
mm
suspicious in the
were
3-12
than
na
ble2). During
of single
laou stain or air-dried May-GrUnwald-Giemsa
crite-
for lesions seen at US were compared to assess which was most accurate for evaluation of clinically negative necks
most
tured.
70%
nodes
(each of which was I or 2 mm smaller the size criterion chosen) in the tumor
were
The smears
the
considered of other
diameter
from 57 necks
node(s)
and side of the
Since
(21) showed
study
that
diameter
sub-
=
levels level 5
nodes
high-, mid-, low jugular, = supraclavicular). All nodes that were visible at US were measured on screen. The jugular chain nodes in levels 2-5 were examined craniocaudally in the axial plane. Only the nodes in level 1 were examined in the coronal and sagittal planes. Radiographic prints were made of all enlarged
axial
nodes that were each 1 or 2 mm smaller. eter of each was not at least 7 mm.
us-
ing a 7.5-MHz, linear array Levels I through 5 of both of enlarged
(%)
Accuracy
(SSD
performed
fully examined
at US
(%)
Specificity
or more
slides
by two physicians
I.v.d.W.). Real-time,
cm-
(%)
Sensitivity
Size Criteria
5 6 7
Minimal
*
specimen, as only this correlation ically relevant. All histopathologic
of Different
4
men enabled us to retrospectively correlate the lymph node that was punctured
guided
and Accuracy
Specificity,
at cytologic
examination.
considered
to be negative
to
proved for
at
Findings US
findings
were
compared
the histopathologic findings neck dissection specimens patients. All US examinations diagnostic.
Because
metastalic
with
in the of all 107 were lymph
August
1991
Table
-#{149}
3 at US-guided
Findings
Histopathologic
Positive
I
.J
25 8
0 37
45
Total
33
37
70
sis.
=
76%,
25
specificity
=
100%.
These
necks
were
considered
neg-
alive; however, three proved to be positive at histopathologic examina-
-
Total
at US examination, US-guided FNAC was not performed. Consequently, aspiration was not performed in 13 patients. The necks of these 13 palients were considered to be negative at US-guided FNAC and proved to be negative at histopathologic examinalion of the neck dissection specimen. In six necks, insufficient material was aspirated for a cytologic diagno-
‘.:
s;:d
,.:
Negative
Positive Negative
Note-Sensitivity
-
ye rsus
Pathologic Finding
Finding at US-guided FNAC
-,
FNAC
Examination
S-
lion. L
.#{149}
#{149}‘‘:
There
was
tween
d.
C.
Figure
2.
(a) US scan
of 57-year-old
man
with
a T4N1
mobile
tongue
carcinoma.
The
image
shows
a submandibular node (arrow), with a hyperechogenic area inside. M = mandible, H = hyoid muscle. (b) Histopathologic section of the same submandibular node shows that the hyperechogenic area was caused by fat tissue (F) in the hilar structure. L = preexisting lymphatic tissue. (c) Axial US image of a midjugular node (arrow) in a patient with a T2NO carcinoma of the floor of the mouth. Note the very similar hyperechogenic area inside the node. I = internaljugular vein, C = carotid artery, L = preexisting lymphatic tissue, S = sternocleidomastoid muscle. (d) Histopathologic section of the same midjugular node shows that this hyperechogenic area was caused by a metastatic keratinizing squamous cell carcinoma (K). L = preexisting lymphatic tissue, T = tumor tissue.
the
malignancy. neity were
US pattern and compared between
homogemeta-
static and reactively enlarged nodes. Although large metastatic nodes often exhibited an inhomogeneous pattern
crolic tumor,
at US-reflecting
tumor, fat,
cystic
lymphatic
tissue,
or keralinizing
these
inhomogeneous
were
less
or ne-
solid
tumor-
US patterns
frequently
encountered
hypoechogenic.
Furthermore,
areas of hyperechogenicity could represent fatty tissue or keratinizing tumor (Fig 2). Thus, we used only the criterion
of lesion
size
at US to predict
malignancy. Volume
180
#{149} Number
2
were tivity, these
minimal
axial
optimal
sion mm and
had
(70%)
(8 mm when
when
a minimal
in the each
axial
a single
subdigastric lesion
in a group
of 7
area) of at
least three borderline lesions was not more than 2 mm smaller in minimal axial diameter. The corresponding optimal sensitivity and specificity are 60% and 77%, respectively. Findings
at US-guided
benode
and
in 96%.
3 shows
that
25 aspirates
were considered to be positive at USguided FNAC; 19 were malignant and six were suspicious for malignancy.
Results
le-
diameter
lymph
chance to obtain a diagnostic smear for lymph nodes this size was 67%. Smears from larger nodes were diagTable
compared. In Table 2 the sensispecificity, and accuracy of criteria are shown. Accuracy
was
relationship
of the
than 5 mm in axial diameter. A total of 12 aspirates were obtained from lymph nodes that were not more than 5 mm in axial diameter; therefore, the
diameters
in
small nonpalpable lymph nodes. With use of a 7.5-MHz transducer, reaclively enlarged nodes, as well as small metastalic nodes, were often found to be well circumscribed and homogeneously
Several
size
the ability to obtain sufficient material for a diagnostic smear. Four of the six insufficient aspirates were obtained from lymph nodes that measured less
noslic
nodes often contain necrotic or keratinizing tissue, as well as preexisting lymphatic tissue, we looked for specific US features to serve as criteria for
a clear
#{149}
FNAC
Results of US-guided FNAC were available for 54 patients who underwent 70 elective neck dissections. A total of 57 lesions were aspirated. Lymph nodes were aspirated only if the minimal axial diameter was at least 3-4 mm, depending on the level of the node in the neck. If no lymph nodes exceeding this size were found
at US-guided
negative
in 32 cases
necks total
were
not
of 45 sides
FNAC and
were
13 sides
aspirated,
making
of necks
considered
of
a to
be negative. Eight of these 45 sides of necks were found to have false-negalive results. In five of the eight sides of necks with false-negative results, no malignant cells were aspirated, even though correlation between the US
and
histopathologic
reports
re-
garding the size and site of the punctured node indicated that the correct node had been punctured (Fig 3). In two of these five punctures, insufficient
material
was
obtained
for
a diag-
nosis, whereas in the other three punctures the aspirates were obtained from the wrong part of the node and only lymphatic the other three
cells were aspirations
found. with
Radiology
In false-
459
#{149}
negative
results,
the
wrong
nodes
were aspirated; at histopathologic examination it was found that
a reac-
tively enlarged node had been aspirated that was not in the same region as the smaller metastatic node. The sensitivity, specificity, and accuracy US-guided FNAC were 76%, 100%,
_.;-
-
-
-
of
-;
-r,
and
89%, respectively. If the six nondiagnostic smears (those with insufficient material) were left out of the study, the sensitivity, specificity, and accuracy of US-guided FNAC
would
be 83%,
100%,
and
92%,
respectively.
b. DISCUSSION Palpation
rate
is known
technique
neck
Figure
to be an
with
tastasis
in the
In selected phylactic
neck
and
neck
if an
exceeds
accurate
available
of occult
that
if
those
method
the
However,
the
risk
need for elective dissection can only be ruled out for patients in whom the neck does not have to be entered for excision of the primary tumor, such as patients
with
geal,
nasal,
glottic
and small (T1-T2) oral Elective dissection can out in the contralateral
mas.
ruled patients
with
extend these for
lip,
tumors
over patients
regular
approach
to re-stage
have
a lesion
of these
tastases
have
thermore,
both
disadvantages
CT and of being
70%, as any accompanied
rise
sary
to enable
between proved
nodes
lymph more 460
and
and
is in
of necks the opneces-
nodes. study
(21),
lymph Radiology
#{149}
As shown groupings
nodes
that
for
all other
in our are each
or
a
carcinoma
of the
from
size
ranging that are
small
of the
nodes
from more
96% than
all sides of necks in this NO, whereas patients in
previous
study
were
not
to any one stage; size of the metastatic
selected therefore, nodes
study was smaller. Second, as necrosis cannot be a criterion at
loss
of sensitivity
studied
has
and
to be com-
on
the
radio-
logic modality employed. Cytologic examination of lymph nodes detected with US enables a more accurate diagnosis of malig-
only
moderate
the accuracy In this study,
discomfort
to the
of the
aspiration needles carotid artery was in our
for lymph nodes 5 mm in minimal
of
pa-
rare and use of thin
matoma nor bleeding shown in the Results the chance of obtaining
neither
he-
occurred. As section herein, a diagnostic
to 67%
less
negative was
than
results;
present
in lymph
5 mm
nodes
in diameter.
In two aspithat were less the cytologic but gave false-
a micrometastasis
in these
nodes.
Selection of the correct pirate is very important.
node to asA thorough
knowledge of the lymph drainage pathways in the neck is necessary. As a simple guide, enlarged nodes in areas 3 (midjugular), 4 (low jugular),
5 (mid-,
clavicular) metastases. occur more
(23). Although the punctured in one
study,
are
as
decreases,
However, use of US-guided FNAC enabled detection of metastatic tumor cells in two nodes that measured 5
and
tient. Although seeding of tumor cells along the needle tract has been reported after use of Tm-Cut needles (Baxter Healthcare, Pharmaseal, Valencia, Calif) (22), to our knowledge such seeding is extremely has never occurred with
that
diameter
node
mm or less in diameter. rated metastatic nodes than 5 mm in diameter, report was diagnostic
the
floor
decreases
lymph
at palpation, study were
patient
previ-
of three
a T2NO
axial
US-guided FNAC proved to be a quick (10-20 minutes) and safe (no complications) technique that caused
distinction
7 mm
from in a
the
positive and negative lesions to be 8 mm for subdigastric
lymph ous
accurate
markedly
previously
nancy and increases the US examination.
in sensitivity by a decrease
(Table 2). For sides that are negative at palpation, timal minimal axial diameter
the
meFur-
expensive
with
smear
pensated for by a decrease in the size criterion. This illustrates that size criteria depend very much on the group
of sides results at 33%-
specificity
should
all
not readily accessible for repeated use in follow-up of patients. The results of this study show that the accuracy of US alone never exceeds always
differ
reported
of patients
MR have
smaller malignant.
US,
in a
occult lymph node not been detected.
man,
or
been
upward
of a 63-year-old
random study of a group of patients with various head and neck cancers with use of CT and MR (ie, 11 mm and 10 mm, respectively) (21). This difference has two major causes. First,
in this tumor
visits.
MR imaging
criteria we
according the mean
carcinoalso be neck of
large percentage (38%.-67%) of necks with false-negative palpation (6-8). Consequently, 62%
laryn-
midline. However, must agree to return
follow-up
CT and used
the
that
US scan
Image of a subdigastric node 6 x 9 mm area (arrow) that demonstrates appearance of lymph node. S = sternocleidomastoid muscle. (b) Detail of a histopathologic section the same subdigastric node shows a micrometastasis (arrow) that was not detected US-guided FNAC. L = preexisting lymphatic tissue.
These
of probe
minimized
(a) Axial
maximum of 2 mm also be considered
15%-20%.
staging
metastasis.
with
most advocate dissection node me-
cases, performance neck dissection could
avoided
were
of the
head
cancer (1-6). Consequently, head and neck surgeons performance of elective the risk of occult lymph
mouth. normal through
maccu-
for assessment
of patients
3.
low
mental and (subdigastric thermore,
midline
and
tumors
that
or extend
for nodes 1 (sub-
over (or
study,
approach
it may
2 Furthe
give
contralateral)
me-
false-negative
at US-guided FNAC were aspirating the wrong node cases), obtaining insufficient
(two cases), wrong part In six cases,
supra-
suspicious enlarged in areas
submandibular) and and high posterior).
rise to bilateral tastasis.
In this
posterior,
are always Reactively frequently
the
results result of
(three aspirate
or aspirating from the of the node (three cases). obtaining these false-neg-
alive results appeared to be inevitable because either the metastases inside
the lymph themselves
nodes were
or the lymph nodes too small to allow
sufficient aspiration of tumor cells 3). Thus, the sensitivity of US-guided FNAC could be only slightly in-
August
(Fig
1991
creased by aspirating more often. However, tastases
cannot
lion is indicated. Careful follow-up with US-guided FNAC should be performed in all such patients. #{149}
more nodes as microme-
be reliably
detected
with either US-guided FNAC or any other currently available technique, the sensitivity of US-guided FNAC will probably not rise much over 82% (27 of 33). The specificity of US-guided FNAC does not fall much under the 100% reported herein, as false-positive results at cytologic examination of squamous
cell
carcinoma
or suspicious
FNAC, as can study previously irradiated
results
and Dr.J.S. Lameris for giving us the opportunity to learn the US-guided FNAC technique
To our
knowledge,
and specificity FNAC in this
the
sensitivity of USare higher
than those reported for CT or MR in the literature (6-8); therefore, the technique described herein deserves an important role in enabling deteclion of occult metastatic neck disease. However, as one-fourth of the occult metastases are not detected at USguided FNAC, it is questionable whether this technique fully solves the problem of when to recommend elective neck treatment. We believe, however, that the need for elective (sometimes contralateral) neck treatment can be diminished by performance of US-guided FNAC. This is especially the case for the patient groups involved in this study, for whom elective neck treatment would mean the risk of increased morbidity. Such patients include the elderly or those in whom the neck does not have to be entered for primary tumor excision or in whom the need for a contralateral therapeutic neck dissec-
Volume
180
#{149} Number
2
W, HaelsJ,
13.
HospitaL
G.
14.
1.
2.
McGavran
MH, Bauer
The incidence
of
WC, Ogura
cervicallymph
me-
tastasis from epidermoid carcinoma of the larynx and their relationship to certain characteristics of the primary tumor. Can-
3.
4.
5.
6.
cer 1%1; 14:55-66. All 5, Tiwari RM, Snow GB. False positive and false negative neck nodes. Head Neck Surg 1985; 8:78-82. Byers RM, Wolf PF, Baliantyne AJ. Rationale for elective modified neck dissection. Head Neck Surg 1988; 10:160-167. Okamoto M, Ozeki 5, Watanabe T, lida Y, Tashiro H. Cervical lymph node metastasis in carcinoma of the tongue: correlation between dlinicaland histopathologic findings and metastasis. J Craniomaxillofac Surg 1988; 16:31-34. van den BrekelMWM, CastelijnsJA, Cmli GA, et al. Magnetic resonance versus pal-
pation of cervical
7.
8.
9.
lymph
node
MS. Helier KS. Computed tomography of the clinically negative neck. Head Neck 1990; 12:109-113. Close LG, Merkel M, Vuittch MF, ReischJ, Schaefer SD. Computed tomographic evaluation of regional lymph node involvement in cancer of the oral cavity and oropharynx. Head Neck 1989; 11:309-317. Koch T, Volirath M, Reimer P, Milbrath H. Die relevanz der sonographischen halslymphknotendiagnostik bei tumoren des kopf-und halsbereiches. HNO 1989; 37:144-147.
10.
11.
16.
17.
Leicher-Duber A, Thelen M, Bleier R. Palpation und sonographie von halslymphknotenmetastasen. Rontgenblatter 1989; 42:195-198. Baatenburg dejong RJ, Rongen RJ, Lam#{233}ris JS, Harthoorn M, Verwoerd CDA, Knegt P. Metastatic neck disease: palpation vs ultrasound examination. Arch Otolaryngol Head Neck Surg 1989; 115:689-690.
U, Ga-
beurteilung bei kopf-
JN, Roux
HNO 1988; 36:16-21. P, Caramella E, Demard
Chauvel P. Ear, nose, and ultrasound diagnosis of menodes.
Radiology
Grasl MC, Neuwirth RK, Gritzmann N, Schurawitzki H, Braun 0. Wertigkeit sonomorphologischer kriterien bei der identifikation regionarer metastasen von plattenepithelkarzinomen des iches. HNO 1989; 37:333-337.
HNO-bere-
Penn B, Gardellin G, Nisi E, Perini L, Lunghi F, Frasson P. Identificazione ecotomografica di area iperecogena centrale nei linfonodi: segno di linfoadenopatia benigna. Radiol Med 1987; 74:535-538. Bruneton JN, Normand F. Cervical lymph nodes. In Bruneton JN, ed. Ultrasonography of the neck Berlin: Springer-Verlag, 1987; 81-91.
18.
Siegert R, Schrader ultraschallgefuhrte
pathologigischer 19.
metastasis. Surg 1991;
Arch Otolaryngol Head Neck 117:667-673. Stern WBR, Silver CE, Zeifer BA, Persky
Bruneton
tastasis to cervicallymph 1984; 152:771-773.
15.
JH. node
T, Mende und
von halslymphknotenmetastasen hals-tumoren: ein methodenvergleich. Laryngol Rhinol Otol (Stuttg) 1989; 68:327332. Eichhorn T, Schroeder HG, Schwerk WB. Erfahrungen mit der B-scan sonographie ala bildgebendem diagnoseferfahren im
F, VallicioniJ, throat cancer:
Spiro RH, Strong EW. Epidermoid cardnoma of the mobile tongue: treatment by partial glossectomy alone. AmJ Surg 1971;
Lenartz
Nachweis
HNO-fachgebiet.
at
of aspirates from lymph nodes
(100%) study
University
References
(24). (76%) guided
in the Rotterdam
Heppt demann
Dr. R.J. Bonten-
burg-DeJong
122:707-710.
in cervical
lymph nodes are rare. However, study of aspirates obtained from salivary glands might result in inaccurate false-positive
We thank
Acknowledgments:
12.
B, Baretton G. feinnadelpunction
raumforderungen
kopf-hals-bereich. HNO Hajec PC, Salomonowitz Tscholakoff D, Kumpan
1990;
E, Turk R, W, Czembirek
22. 23.
24.
H. with
US. Radiology 1986; 158:739-742. Baatenburg dejong RJ, Rongen RJ, dejong PC, Lam#{233}risJS,Knegt P. Screening for lymph nodes in the neck with ultrasound. Clin
21.
im
38:287-291.
Lymph nodes of the neck: evaluation 20.
Die
Otolaryngol
1988;
13:5-9.
van den Brekel MWM, Stel HV, Castelijns JA, et a!. Cervical lymph node metastasis: assessment of radiologic criteria. Radiology 1990; 177:379-384. Frable WJ. Thin needle aspiration biopsy. AmJ Clin Pathol 1976; 65:168-181. Engzell V,Jakobsson PA, Sigurdson A, ZajicekJ. Aspiration biopsy of metastatic carcinoma in lymph nodes of the neck Acta Otolaryngol 1971; 72:138-147. Baatenburg dejong RJ, Rongen RJ. Ultrasound examination of the head and neck Thesis. Rotterdam University Hospital, Rotterdam, The Netherlands, 1990; 59-75.
Radiology
461
#{149}
W.M. van den Brekel, MD #{149} Jonas Luth, MD #{149} Jaap Valk, MD, PhD
Occult Metastatic and US-guided
Neck Fine-Needle
The
authors performed a prospective of the value of ultrasonography (US) and US-guided fine-needle aspiration cytology (FNAC) for assessment of NO lesions in the neck. Preoperative US was performed in 107 patients with squamous cell carcinoma of the head and neck, who underwent 132 elective neck disseclions. During the US examination of the last 54 patients, who underwent 70 elective neck dissections, USguided FNAC was performed. US alone was found to be an unreliable method for detecting occult lymph node metastasis; the accuracy never exceeded 70% (93 of 132), with a sensitivity of 60% (32 of 53) and a specificity of 77% (61 of 79). In contrast, US-guided FNAC had an accuracy of 89% (62 of 70), a sensitivity of 76% (25 of 33), and a specificity of 100% (37 of 37). Because of the high sensitivity and specificity of US-guided FNAC for the assessment of the NO neck, this modality may play an important role in directing treatment of these patients in the future. study
Index
terms: Head and neck neoplasms, 262.37, 271.37, 276.37, 28.314 #{149}Lymphatic systern, neoplasms, 20.37, 99.33, 99.82 #{149}Lymphatic system, US studies, 99.1298, 99.12985, 99.12986 Radiology
A. Castelijns, #{149} Isaac van
J.
1991;
180:457-461
I
(CT)
From the Departments of Otorhinolaryngoland Head and Neck Surgery (M.W.M.v.d.B., G.B.S.), Diagnostic Radiology (J.A.C., W.J.L., J.V.), Pathology and Cytology (H.V.S.), and Oral Pathology (I.v.d.W.), Free University Hospital, P0 Box 7057, 1007 MB Amsterdam, The Netherlands.
Received quested March
accepted from
the
January 30, 1991; revision re12; revision received March 28; April 8. Supported by grant IKA 88-19 Queen Wilhelmina Fund for Cancer Address reprint requests to
Research. M.W.M.v.d.B. 0
RSNA,
1991
and
magnetic
V. Stel, MD, PhD Gordon B. Snow,
remains.
nodes
(9-13).
This
can
be
explained by the fact that US does not reliably depict tumor cells in either lymphatic tissue or necrotic tumor tissue; neither does it reliably depict tumor keralinization. Therefore, the only criteria left for accurate differentialion between reactive and metastatic lymph nodes are size (minimal axial diameter) and grouping of three or more borderline lymph nodes (21). US-guided fine-needle aspiration (FNAC)
may
give
cytologic
evidence of tumor in a large percentage of metastatic nodes. Although some authors studied US-guided FNAC in patients with head and neck cancer (11,18,20), to our knowledge none of them has studied this technique in a homogeneous group of previously untreated patients who underwent elective neck dissection because results of palpation were negative. In this study, the value of US and US-guided FNAC for the detection of occult cervical lymph node metastasis
One hundred and
neck
is assessed.
seven
squamous
was previously examined with years.
PhD
US
These
METHODS
patients
with
head
cell carcinoma
that
untreated (Table US over a period
107 patients
1) were of 1’/
underwent
a to-
tal of 132 elective neck dissections that were either comprehensive or selective. contain
these
132 necks
were
no lymph
node
involvement
the decision to perform was made on the basis
At
found
to
(NO);
elective dissection of the site and
stage of the primary tumor. In principle, negative findings
at US and
FNAC had no influence on the of treatment of the neck. In four however, the finding of positive
US-guided
Most studies of ultrasonography (US) of the neck claim that US is superior to palpation for enabling deteclion and classification of cervical lymph node metastasis (9-20). Although some authors defined criteria for diagnosis of malignant or benign nodes at US (14-17), US alone does not enable differentiation between enlarged reactive nodes and enlarged metastatic
MD,
AND
MATERIALS
palpation,
resonance
(MR) imaging have enabled detection of 38%-67% of these occult lymph node metastases (6-8). Consequently, the need for a more sensitive technique
Radiology
Disease: Detection with Aspiration Cytology’
with primary squamous cell carcinoma of the head and neck, staging of neck lesions with palpation is reported to yield false-negalive results in O%-77% of cases (1,2), depending on the site (3), size (4), and other parameters (5) of the primary tumor. To date, computed tomography
Neck
#{149}
N patients
cytology
ogy
MD, PhD #{149} Herbert der Waal, DDS, PhD
and
direction lesions,
aspirate necessitated unanticipated neck specimens
performance of an dissection. Of the 132
obtained,
53 (40%)
contained
metastatic lymph nodes, whereas 79 (60%) were negative at histopathologic examinalion. Consequently, accuracy of palpation was 60%. In the second
part
the 107 patients neck dissections. 33 of the
ination,
found
to contain
whereas tumor.
37 (53%) US-guided
lesions All
of this
study,
54 of
underwent 70 elective At histopathologic exam70 specimens
metastatic
(47%)
lymph
were
nodes,
were found to be free of FNAC of 57 of these 70
was performed. specimens
obtained
at neck
dissec-
lion were thoroughly examined histopathologically; all nodes that were visible
on the radiograph of the specimen or were palpable in the specimen itself were documented by one physician (M.W.M. v.d.B.). Depending on the type of neck dissection, an average of 43 lymph nodes (range,
24-.87)
were
found
in comprehen-
sive specimens, whereas an average of 16 lymph nodes (range, 6-48) were found in specimens. The number of posilive lymph nodes varied from zero to five (mean, 1.8 in the specimens that were positive for tumor). Depending on the size of selective
the lymph ery
ined
node,
sections
were
made
ev-
and all sections were examhistopathologically, as described in
2-4
mm,
our previous
Abbreviation:
studies
FNAC
(6,21). Exact docu-
=
fine-needle
aspiration
cytology.
457
Table
1
of Patients
Number
Lesions
with
at Various
Sites
and T Stages
Stage
t..1. Primary
Tumor
Ti
T2
T3
T4
Total
2 1 1 0 0 0 0 0 0 0
7 12 5 0 5 2 3 4 2 4
8 7 0 3
0 4 1 1
17 24 7 4
4
2
11
3 4 4 7 0
1 0 4 6 0
6 7 12 15 4
4
44
40
19
107
-
Mobile tongue Floor of mouth I
Alveolar
process
Base of tongue Tonsil, soft palate
!‘-
Pharyngealwall Piriformsinus Supraglottic larynx (Trans)glottic larynx Figure
1.
US image
obtained
with
Lip,nose
a 7.5-
MHz,
linear array transducer during aspiration of a subdigastric node. Note the hyperechogenic spot inside the node (arrow), representing the needle tip.
Total
Table
2
Sensitivity,
mentation nodes that
of the size and were examined
site of all lymph in the speci-
Size
(mm)*
at US-guided FNAC with the lymph node that was resected in the great majority of specimens. Correlation among findings at histopathologic examination, US, or USFNAC
was
determined
for
each
was
were
(H.V.S.,
reviewed
650;
B-scan
Aloka,
US examinations
Tokyo)
were
by
89
33
55
85 81 60
44 59 77
61 68 70
8 9 10
42 26 15
85 95 97
67 67 64
transducer. sides of the
neck were
for the presence
lymph
mandibular
and
nodes
(level
submental,
I
lymph
nodes,
2, 3, 4
indicating
of the node
and the region
neck
imaged.
being
The
diameter
our
the
one =
size
previous
that the minimal
is the most
accurate
axial
criterion
for
size, we again used this criterion for evaluation of lesions depicted at US. For subdigastric
was that
minimal axial diameter to be 1 mm larger than nodes. In addition, a group-
nodes,
ing of three
or more
borderline
drainage
regions
malignant.
was
In this
also
study,
considered several
size
last 8 months
of the
all US-guided
the
FNACs
performed
one
physician
(M.W.M.v.d.B.).
458
#{149}
Radiology
were
nodes
(1 mm
larger Nodes
for subdigastric were
nodes)
and
not considered
for groups
to be grouped
punctured
lymph
per
Most
side.
punctured
twice
cient material After sterile was
was nodes
lymph
to ensure
was obtained. preparation,
performed
in
of three
if the diam-
was introduced
and
inside
was
gently
the
lymph
up
and
ethanol
and
of a
1)
obtain
additional
smears.
and
Papanico-
and stained solution.
to be
examined
(Fig
the needle
fixed by using with
revised
All
by one
with The nee-
(Ta-
guided
smears
FNAC,
sensitivity
necks
were
malignancy Necks
were
chance
a cytologic
of demonstrating
diag-
positive
findings with US or US-guided FNAC in a side of the neck that contained metastasis, whereas the specificity was the chance of demonstrating negative findings when no metastatic lymph nodes were present. Accuracy
was
positive by the
and true-negative results, total number of examinations.
were
estimated
as the
sum
of true-
divided
RESULTS US
a high
the
for
observer at US-
considered
be positive if one or more aspirates to be positive for tumor or suspicious
by
was
material
with CarboConn) to
(H.V.S.).
To obtain
at cyto-
that contained
nosis were considered to be negative. Sensitivity, specificity, and accuracy of US and US-guided FNAC were estimated by using the histopathologic findings in the neck dissection specimens as a standard of reference. Findings at US and histopathologic examination were compared for each side of the neck and not for each node or for each patient. The sensitivity
node
either stained
to be negative
Smears
(and, or if all
insufficient
down.
were
found
tumor
obtained)
nodes
use
by moving
were
was
suspi-
in the drain-
that suffi-
into the skin 0.5-
continued
of the primary
logic examination.
if no
visualized
aspirate
smears
1.0 cm from the transducer, at the middle of the long axis of the transducer. Aspiralion was started after the needle point was visualized
no
punc-
biopsy guide attached to the transducer, by using a syringe holder (Cameco, Taeby, Sweden) and a 0.6 x 25-mm needle. The
needle
thus,
examination
were
were
US-guided
without
FNAC
nodes
age regions
regions
of the neck
US-guided
cious
lymph
drainage
to three
axial
punctured.
(largest)
tumor
sides
One
in minimal
were
dle and syringe were washed wax (Union Carbide, Danbury,
study,
Lymph
or both
FNAC
mm
suspicious in the
were
3-12
than
na
ble2). During
of single
laou stain or air-dried May-GrUnwald-Giemsa
crite-
for lesions seen at US were compared to assess which was most accurate for evaluation of clinically negative necks
most
tured.
70%
nodes
(each of which was I or 2 mm smaller the size criterion chosen) in the tumor
were
The smears
the
considered of other
diameter
from 57 necks
node(s)
and side of the
Since
(21) showed
study
that
diameter
sub-
=
levels level 5
nodes
high-, mid-, low jugular, = supraclavicular). All nodes that were visible at US were measured on screen. The jugular chain nodes in levels 2-5 were examined craniocaudally in the axial plane. Only the nodes in level 1 were examined in the coronal and sagittal planes. Radiographic prints were made of all enlarged
axial
nodes that were each 1 or 2 mm smaller. eter of each was not at least 7 mm.
us-
ing a 7.5-MHz, linear array Levels I through 5 of both of enlarged
(%)
Accuracy
(SSD
performed
fully examined
at US
(%)
Specificity
or more
slides
by two physicians
I.v.d.W.). Real-time,
cm-
(%)
Sensitivity
Size Criteria
5 6 7
Minimal
*
specimen, as only this correlation ically relevant. All histopathologic
of Different
4
men enabled us to retrospectively correlate the lymph node that was punctured
guided
and Accuracy
Specificity,
at cytologic
examination.
considered
to be negative
to
proved for
at
Findings US
findings
were
compared
the histopathologic findings neck dissection specimens patients. All US examinations diagnostic.
Because
metastalic
with
in the of all 107 were lymph
August
1991
Table
-#{149}
3 at US-guided
Findings
Histopathologic
Positive
I
.J
25 8
0 37
45
Total
33
37
70
sis.
=
76%,
25
specificity
=
100%.
These
necks
were
considered
neg-
alive; however, three proved to be positive at histopathologic examina-
-
Total
at US examination, US-guided FNAC was not performed. Consequently, aspiration was not performed in 13 patients. The necks of these 13 palients were considered to be negative at US-guided FNAC and proved to be negative at histopathologic examinalion of the neck dissection specimen. In six necks, insufficient material was aspirated for a cytologic diagno-
‘.:
s;:d
,.:
Negative
Positive Negative
Note-Sensitivity
-
ye rsus
Pathologic Finding
Finding at US-guided FNAC
-,
FNAC
Examination
S-
lion. L
.#{149}
#{149}‘‘:
There
was
tween
d.
C.
Figure
2.
(a) US scan
of 57-year-old
man
with
a T4N1
mobile
tongue
carcinoma.
The
image
shows
a submandibular node (arrow), with a hyperechogenic area inside. M = mandible, H = hyoid muscle. (b) Histopathologic section of the same submandibular node shows that the hyperechogenic area was caused by fat tissue (F) in the hilar structure. L = preexisting lymphatic tissue. (c) Axial US image of a midjugular node (arrow) in a patient with a T2NO carcinoma of the floor of the mouth. Note the very similar hyperechogenic area inside the node. I = internaljugular vein, C = carotid artery, L = preexisting lymphatic tissue, S = sternocleidomastoid muscle. (d) Histopathologic section of the same midjugular node shows that this hyperechogenic area was caused by a metastatic keratinizing squamous cell carcinoma (K). L = preexisting lymphatic tissue, T = tumor tissue.
the
malignancy. neity were
US pattern and compared between
homogemeta-
static and reactively enlarged nodes. Although large metastatic nodes often exhibited an inhomogeneous pattern
crolic tumor,
at US-reflecting
tumor, fat,
cystic
lymphatic
tissue,
or keralinizing
these
inhomogeneous
were
less
or ne-
solid
tumor-
US patterns
frequently
encountered
hypoechogenic.
Furthermore,
areas of hyperechogenicity could represent fatty tissue or keratinizing tumor (Fig 2). Thus, we used only the criterion
of lesion
size
at US to predict
malignancy. Volume
180
#{149} Number
2
were tivity, these
minimal
axial
optimal
sion mm and
had
(70%)
(8 mm when
when
a minimal
in the each
axial
a single
subdigastric lesion
in a group
of 7
area) of at
least three borderline lesions was not more than 2 mm smaller in minimal axial diameter. The corresponding optimal sensitivity and specificity are 60% and 77%, respectively. Findings
at US-guided
benode
and
in 96%.
3 shows
that
25 aspirates
were considered to be positive at USguided FNAC; 19 were malignant and six were suspicious for malignancy.
Results
le-
diameter
lymph
chance to obtain a diagnostic smear for lymph nodes this size was 67%. Smears from larger nodes were diagTable
compared. In Table 2 the sensispecificity, and accuracy of criteria are shown. Accuracy
was
relationship
of the
than 5 mm in axial diameter. A total of 12 aspirates were obtained from lymph nodes that were not more than 5 mm in axial diameter; therefore, the
diameters
in
small nonpalpable lymph nodes. With use of a 7.5-MHz transducer, reaclively enlarged nodes, as well as small metastalic nodes, were often found to be well circumscribed and homogeneously
Several
size
the ability to obtain sufficient material for a diagnostic smear. Four of the six insufficient aspirates were obtained from lymph nodes that measured less
noslic
nodes often contain necrotic or keratinizing tissue, as well as preexisting lymphatic tissue, we looked for specific US features to serve as criteria for
a clear
#{149}
FNAC
Results of US-guided FNAC were available for 54 patients who underwent 70 elective neck dissections. A total of 57 lesions were aspirated. Lymph nodes were aspirated only if the minimal axial diameter was at least 3-4 mm, depending on the level of the node in the neck. If no lymph nodes exceeding this size were found
at US-guided
negative
in 32 cases
necks total
were
not
of 45 sides
FNAC and
were
13 sides
aspirated,
making
of necks
considered
of
a to
be negative. Eight of these 45 sides of necks were found to have false-negalive results. In five of the eight sides of necks with false-negative results, no malignant cells were aspirated, even though correlation between the US
and
histopathologic
reports
re-
garding the size and site of the punctured node indicated that the correct node had been punctured (Fig 3). In two of these five punctures, insufficient
material
was
obtained
for
a diag-
nosis, whereas in the other three punctures the aspirates were obtained from the wrong part of the node and only lymphatic the other three
cells were aspirations
found. with
Radiology
In false-
459
#{149}
negative
results,
the
wrong
nodes
were aspirated; at histopathologic examination it was found that
a reac-
tively enlarged node had been aspirated that was not in the same region as the smaller metastatic node. The sensitivity, specificity, and accuracy US-guided FNAC were 76%, 100%,
_.;-
-
-
-
of
-;
-r,
and
89%, respectively. If the six nondiagnostic smears (those with insufficient material) were left out of the study, the sensitivity, specificity, and accuracy of US-guided FNAC
would
be 83%,
100%,
and
92%,
respectively.
b. DISCUSSION Palpation
rate
is known
technique
neck
Figure
to be an
with
tastasis
in the
In selected phylactic
neck
and
neck
if an
exceeds
accurate
available
of occult
that
if
those
method
the
However,
the
risk
need for elective dissection can only be ruled out for patients in whom the neck does not have to be entered for excision of the primary tumor, such as patients
with
geal,
nasal,
glottic
and small (T1-T2) oral Elective dissection can out in the contralateral
mas.
ruled patients
with
extend these for
lip,
tumors
over patients
regular
approach
to re-stage
have
a lesion
of these
tastases
have
thermore,
both
disadvantages
CT and of being
70%, as any accompanied
rise
sary
to enable
between proved
nodes
lymph more 460
and
and
is in
of necks the opneces-
nodes. study
(21),
lymph Radiology
#{149}
As shown groupings
nodes
that
for
all other
in our are each
or
a
carcinoma
of the
from
size
ranging that are
small
of the
nodes
from more
96% than
all sides of necks in this NO, whereas patients in
previous
study
were
not
to any one stage; size of the metastatic
selected therefore, nodes
study was smaller. Second, as necrosis cannot be a criterion at
loss
of sensitivity
studied
has
and
to be com-
on
the
radio-
logic modality employed. Cytologic examination of lymph nodes detected with US enables a more accurate diagnosis of malig-
only
moderate
the accuracy In this study,
discomfort
to the
of the
aspiration needles carotid artery was in our
for lymph nodes 5 mm in minimal
of
pa-
rare and use of thin
matoma nor bleeding shown in the Results the chance of obtaining
neither
he-
occurred. As section herein, a diagnostic
to 67%
less
negative was
than
results;
present
in lymph
5 mm
nodes
in diameter.
In two aspithat were less the cytologic but gave false-
a micrometastasis
in these
nodes.
Selection of the correct pirate is very important.
node to asA thorough
knowledge of the lymph drainage pathways in the neck is necessary. As a simple guide, enlarged nodes in areas 3 (midjugular), 4 (low jugular),
5 (mid-,
clavicular) metastases. occur more
(23). Although the punctured in one
study,
are
as
decreases,
However, use of US-guided FNAC enabled detection of metastatic tumor cells in two nodes that measured 5
and
tient. Although seeding of tumor cells along the needle tract has been reported after use of Tm-Cut needles (Baxter Healthcare, Pharmaseal, Valencia, Calif) (22), to our knowledge such seeding is extremely has never occurred with
that
diameter
node
mm or less in diameter. rated metastatic nodes than 5 mm in diameter, report was diagnostic
the
floor
decreases
lymph
at palpation, study were
patient
previ-
of three
a T2NO
axial
US-guided FNAC proved to be a quick (10-20 minutes) and safe (no complications) technique that caused
distinction
7 mm
from in a
the
positive and negative lesions to be 8 mm for subdigastric
lymph ous
accurate
markedly
previously
nancy and increases the US examination.
in sensitivity by a decrease
(Table 2). For sides that are negative at palpation, timal minimal axial diameter
the
meFur-
expensive
with
smear
pensated for by a decrease in the size criterion. This illustrates that size criteria depend very much on the group
of sides results at 33%-
specificity
should
all
not readily accessible for repeated use in follow-up of patients. The results of this study show that the accuracy of US alone never exceeds always
differ
reported
of patients
MR have
smaller malignant.
US,
in a
occult lymph node not been detected.
man,
or
been
upward
of a 63-year-old
random study of a group of patients with various head and neck cancers with use of CT and MR (ie, 11 mm and 10 mm, respectively) (21). This difference has two major causes. First,
in this tumor
visits.
MR imaging
criteria we
according the mean
carcinoalso be neck of
large percentage (38%.-67%) of necks with false-negative palpation (6-8). Consequently, 62%
laryn-
midline. However, must agree to return
follow-up
CT and used
the
that
US scan
Image of a subdigastric node 6 x 9 mm area (arrow) that demonstrates appearance of lymph node. S = sternocleidomastoid muscle. (b) Detail of a histopathologic section the same subdigastric node shows a micrometastasis (arrow) that was not detected US-guided FNAC. L = preexisting lymphatic tissue.
These
of probe
minimized
(a) Axial
maximum of 2 mm also be considered
15%-20%.
staging
metastasis.
with
most advocate dissection node me-
cases, performance neck dissection could
avoided
were
of the
head
cancer (1-6). Consequently, head and neck surgeons performance of elective the risk of occult lymph
mouth. normal through
maccu-
for assessment
of patients
3.
low
mental and (subdigastric thermore,
midline
and
tumors
that
or extend
for nodes 1 (sub-
over (or
study,
approach
it may
2 Furthe
give
contralateral)
me-
false-negative
at US-guided FNAC were aspirating the wrong node cases), obtaining insufficient
(two cases), wrong part In six cases,
supra-
suspicious enlarged in areas
submandibular) and and high posterior).
rise to bilateral tastasis.
In this
posterior,
are always Reactively frequently
the
results result of
(three aspirate
or aspirating from the of the node (three cases). obtaining these false-neg-
alive results appeared to be inevitable because either the metastases inside
the lymph themselves
nodes were
or the lymph nodes too small to allow
sufficient aspiration of tumor cells 3). Thus, the sensitivity of US-guided FNAC could be only slightly in-
August
(Fig
1991
creased by aspirating more often. However, tastases
cannot
lion is indicated. Careful follow-up with US-guided FNAC should be performed in all such patients. #{149}
more nodes as microme-
be reliably
detected
with either US-guided FNAC or any other currently available technique, the sensitivity of US-guided FNAC will probably not rise much over 82% (27 of 33). The specificity of US-guided FNAC does not fall much under the 100% reported herein, as false-positive results at cytologic examination of squamous
cell
carcinoma
or suspicious
FNAC, as can study previously irradiated
results
and Dr.J.S. Lameris for giving us the opportunity to learn the US-guided FNAC technique
To our
knowledge,
and specificity FNAC in this
the
sensitivity of USare higher
than those reported for CT or MR in the literature (6-8); therefore, the technique described herein deserves an important role in enabling deteclion of occult metastatic neck disease. However, as one-fourth of the occult metastases are not detected at USguided FNAC, it is questionable whether this technique fully solves the problem of when to recommend elective neck treatment. We believe, however, that the need for elective (sometimes contralateral) neck treatment can be diminished by performance of US-guided FNAC. This is especially the case for the patient groups involved in this study, for whom elective neck treatment would mean the risk of increased morbidity. Such patients include the elderly or those in whom the neck does not have to be entered for primary tumor excision or in whom the need for a contralateral therapeutic neck dissec-
Volume
180
#{149} Number
2
W, HaelsJ,
13.
HospitaL
G.
14.
1.
2.
McGavran
MH, Bauer
The incidence
of
WC, Ogura
cervicallymph
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tastasis from epidermoid carcinoma of the larynx and their relationship to certain characteristics of the primary tumor. Can-
3.
4.
5.
6.
cer 1%1; 14:55-66. All 5, Tiwari RM, Snow GB. False positive and false negative neck nodes. Head Neck Surg 1985; 8:78-82. Byers RM, Wolf PF, Baliantyne AJ. Rationale for elective modified neck dissection. Head Neck Surg 1988; 10:160-167. Okamoto M, Ozeki 5, Watanabe T, lida Y, Tashiro H. Cervical lymph node metastasis in carcinoma of the tongue: correlation between dlinicaland histopathologic findings and metastasis. J Craniomaxillofac Surg 1988; 16:31-34. van den BrekelMWM, CastelijnsJA, Cmli GA, et al. Magnetic resonance versus pal-
pation of cervical
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MS. Helier KS. Computed tomography of the clinically negative neck. Head Neck 1990; 12:109-113. Close LG, Merkel M, Vuittch MF, ReischJ, Schaefer SD. Computed tomographic evaluation of regional lymph node involvement in cancer of the oral cavity and oropharynx. Head Neck 1989; 11:309-317. Koch T, Volirath M, Reimer P, Milbrath H. Die relevanz der sonographischen halslymphknotendiagnostik bei tumoren des kopf-und halsbereiches. HNO 1989; 37:144-147.
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Chauvel P. Ear, nose, and ultrasound diagnosis of menodes.
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Penn B, Gardellin G, Nisi E, Perini L, Lunghi F, Frasson P. Identificazione ecotomografica di area iperecogena centrale nei linfonodi: segno di linfoadenopatia benigna. Radiol Med 1987; 74:535-538. Bruneton JN, Normand F. Cervical lymph nodes. In Bruneton JN, ed. Ultrasonography of the neck Berlin: Springer-Verlag, 1987; 81-91.
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