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ORIGINAL RESEARCH
Sonography for Diagnosis of Benign and Malignant Tumors of the Nose and Paranasal Sinuses Jun-jie Liu, MD, Yong Gao, MD, Ya-Fei Wu, MS, Shang-Yong Zhu, MD Objectives—The purpose of this study was to demonstrate the reliability of sonography for diagnosis of nose and paranasal sinus tumors. Methods—Ninety-six consecutive patients with tumors underwent sonography and computed tomography (CT) before surgical treatment. Tumor detectability and imaging findings were evaluated independently and then compared with pathologic findings. Results—Of 96 tumors, 75 were detected by sonography, for a detectability rate of 78.1%; 93 tumors were detected by CT, for a detectability rate of 96.9%. By comparison, sonography showed a trend toward higher detectability of nasal vestibular tumors than CT (87.5% for sonography versus 50.0% for CT) and small lumps on the wing of the nose (78.8% for sonography versus 33.3% for CT). Among the sonographic features, boundary, shape, internal echo, calcification, bone invasion, vascular pattern, and cervical lymph node metastasis all had significantly positive correlations with malignancy (P < .05), but size did not (P = .324). In addition, the vascular resistive index for malignant tumors was significantly higher (mean ± SD, 0.66 ± 0.20) than the index for benign lesions (0.24 ± 0.30; P < .001). Moreover, the detection rate for grade 1–3 (small–large) blood flow in benign lesions was only 43.8%, whereas the rate for malignant tumors was 97.7% (P < .001). Conclusions—The vascular pattern may be a promising predictive indicator for distinguishing benign and malignant tumors of the nose and paranasal sinuses. Consequently, sonography has high value for diagnosis of benign and malignant tumors of the nose and paranasal sinuses, especially for nasal vestibular tumors and small lumps on the wing of the nose. Received November 11, 2013, from the Department of Diagnostic Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China. Revision requested January 3, 2014. Revised manuscript accepted for publication January 29, 2014. This study was supported by the Natural Science Foundation of Guangxi Province, China (grant 0832125). Address correspondence to Shang-Yong Zhu, MD, Department of Diagnostic Ultrasound, First Affiliated Hospital of Guangxi Medical University, 22 Shuang-Yong Rd, 530021 Nanning, Guangxi, China. E-mail: [email protected] Abbreviations
CT, computed tomography
Key Words—benign and malignant tumors; computed tomography; nose and paranasal sinuses; sonography
T
umors of the nose and paranasal sinuses, which arise from the head and neck, have complex anatomy and proximity to the eye, brain, and cranial nerves. Nowadays, computed tomography (CT), as one of the modern imaging techniques, has been accepted as the reference standard for pathologic anatomic evaluation and is considered an obligatory part of surgical planning for the nose and paranasal sinuses.1,2 Some studies have demonstrated that sonography is a very useful method for differential diagnosis of head and neck tumors3–5 and the cervical lymph nodes6–8 and is even regarded as the preferred imaging method routinely used to detect cervical lymph node metastasis of head and neck tumors.9 Moreover, previous studies have yielded promising results for
doi:10.7863/ultra.33.9.1627
©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:1627–1634 | 0278-4297 | www.aium.org
3309jum1531-1668online_Layout 1 8/21/14 8:33 AM Page 1628
Liu et al—Sonography for Diagnosis of Nose and Paranasal Sinus Tumors
sonography in the safe and noninvasive diagnosis of sinusitis and accurate evaluation of orbital and nasal fractures.10–14 However, it has rarely been used as an imaging technique for investigation of nose and paranasal sinus tumors. The purpose of our study was to evaluate the reliability of sonography for diagnosis of benign and malignant tumors of the nose and paranasal sinuses and to assess the concordance of sonography with CT, which is the current clinical mainstay.
Materials and Methods This study was performed with approval from the local Institutional Review Board. Patients received verbal information about the study and gave informed consent to participate. From April 2011 to August 2012, consecutive patients (58 male and 42 female; median age, 47.8 years; range, 2–82 years) with tumors of the nose and paranasal sinuses were enrolled randomly. Exclusion criteria were patients who had clinically suspected tumors, had a surgical history of nose and paranasal sinus tumors, or had undergone radiotherapy. Before surgery, all patients were investigated with sonography and CT within a time frame of 7 days. The evaluators were blinded to the patients’ clinical information and the corresponding sonographic and CT findings, and after comparison with postoperative histopathologic results, the sonographic results were contrasted with CT results to evaluate the possibility of sonography for diagnosis of nose and paranasal sinus tumors. Sonographic examinations were performed by 2 sonologists (J.L. and S.-Y.Z., with 11 and 24 years of experience in head and neck sonography, respectively). Any discrepancies were resolved by consensus. Sonography was performed with a Technos MPX scanner (Esaote SpA, Genoa, Italy) equipped with a 7.5–14.0-MHz linear transducer (transducer body, 1.9 cm wide and 6.5 cm long; 1.2 cm wide
and 5.4 cm long where the surface of the transducer contacted the skin) and a 3.5–5.0-MHz convex array transducer or an EUB-6500 scanner (Hitachi Medical Corporation, Tokyo, Japan) equipped with a 7.5–14.0-MHz linear transducer (dimensions as above) and a 3.5–5.0-MHz convex array transducer. All patients were in the supine position. The scan region was from the middle to anterolateral aspects of the face and from the upper frontal to alveolar margins, including surrounding structures. The examination was performed in transverse, oblique, and longitudinal planes (Figure 1). The frontal sinus, lower orbital border, ethmoidal sinus, nose, maxillary sinus, alveolar margin, and external cheekbone were delineated. The following sonographic features were assessed: tumor detectability, site, size, shape, internal echo, calcification, bone invasion, vascular pattern, and cervical lymph node metastasis. The size was defined as the maximum length of the tumor in centimeters. A normal image was defined as showing an acoustic shadow arising from the bone wall (Figure 2A, left); a pathologic image was defined as visualization of a hypoechoic nose and sinus cavity delineated by surrounding air (Figure 2A, right). Infiltration of the surrounding structures indicated a hypoechoic tumor spreading into the soft tissues of the face (Figure 2B). Bone invasion was defined as interruption of the inner and outer membranes, which normally appeared as hyperechoic lines (Figure 2C). We classified the vascular patterns of the tumors into 4 grades: grade 0, no blood flow signal inside the tumor; grade 1, a small amount of blood flow, with 1 or 2 pointed or fine rodlike blood vessels visible inside the tumor; grade 2, a moderate amount of blood flow, with 3 or 4 visible spotlike blood vessels or a long vessel across the lesion with a length close to or longer than the tumor radius; and grade 3, a larger amount of blood flow, with 5 or more visible spotlike blood vessels or 2 long vessels across the lesion (Figure 2D).
Figure 1. Probe locations in the transverse (left), oblique (center), and longitudinal (right) planes during the examination of the anterior paranasal regions.
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Liu et al—Sonography for Diagnosis of Nose and Paranasal Sinus Tumors
For comparison, CT images were obtained with a Somatom Sensation 16 CT system (Siemens AG, Erlangen, Germany). The patients were imaged in the supine position and were asked to breathe quietly and avoid swallowing during scanning. The section thickness was 5 mm, with a 5-mm intersection gap. Axial, coronal, and sagittal planes were obtained. Contrast material was not used routinely in this study because of the economic burden on the patients. A pathologic image was defined as abnormal increased density resembling soft tissues on low-density images of the nasal cavity and paranasal sinuses (Figure 2E). Infiltration of the surrounding structures indicated a highdensity tumor spreading into the adjacent soft tissues of the face. Bone invasion was defined as intermediate soft tissue density on normal bone images. These imaging interpretations were compared with postoperative histopathologic results.
The SPSS version 13.0 statistical software package (IBM Corporation, Armonk, NY) was used in this study. The tumor detectability accuracy of sonography and CT were calculated and compared by the Pearson χ2 test. Differences in major clinical and sonographic features between detectable benign and malignant tumors were determined by an independent samples t test, Pearson χ2, Fisher exact test, and Mann-Whitney U test. Statistical significance was set at P < .05.
Results In this study, we investigated 100 patients with tumors of the nose and paranasal sinuses. However, 4 patients left the hospital or were transferred without pathologic results. Therefore, the study included 96 tumors with pathologic results. The pathologic diagnoses of the 96 complex tumors
Figure 2. Squamous cell carcinoma of the right ethmoid sinus in an 81-year-old woman. A, Oblique sonograms showing a normal acoustic shadow (arrow) behind the bone wall in the left image and a hypoechoic tumor and many calcifications (arrow) in the right image. B, Longitudinal sonogram of the right ethmoid sinus (E) at the eye level was showing the tumor (T; arrow) extending to the right eye. C, Transverse sonogram showing obvious bony invasion of the sinus wall (arrow). D, Sonogram clearly showing a rich vascular pattern (grade 3 blood flow) in the tumor (arrow). E, Computed tomogram showing the tumor arising from the right ethmoid sinus with intermediate to high density (long arrow) and extending to the right eye (short arrows), corresponding to the sonographic findings.
J Ultrasound Med 2014; 33:1627–1634
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are shown in Table 1. Cysts (37.5% [18 of 48 patients]) and inflammatory polyps (35.4% [17 of 48 patients]) were most common in the benign group; squamous cell carcinoma (27.1% [13 of 48 patients]) was most common in the malignant group. Of the 96 tumors, 75 were detected by sonography, for a detectability rate of 78.1%; 93 tumors were detected by CT, for a detectability rate of 96.9% (including misdiagnosed cases). The accuracy of sonographic and CT detection compared with the pathologic results is summarized in Table 2 (excluding misdiagnosed cases). There was no significant difference between the tumor detectability of sonography and CT (P = .388). For the 75 detectable tumors (21 benign and 43 malignant) on sonography, the major clinical and sonographic features are displayed in Table 3. In terms of the major clinical features, age (P = .393) and sex (P = .665) were not associated with benignity or malignancy. In terms of the sonographic features, boundary (P < .001), shape (P
ORIGINAL RESEARCH
Sonography for Diagnosis of Benign and Malignant Tumors of the Nose and Paranasal Sinuses Jun-jie Liu, MD, Yong Gao, MD, Ya-Fei Wu, MS, Shang-Yong Zhu, MD Objectives—The purpose of this study was to demonstrate the reliability of sonography for diagnosis of nose and paranasal sinus tumors. Methods—Ninety-six consecutive patients with tumors underwent sonography and computed tomography (CT) before surgical treatment. Tumor detectability and imaging findings were evaluated independently and then compared with pathologic findings. Results—Of 96 tumors, 75 were detected by sonography, for a detectability rate of 78.1%; 93 tumors were detected by CT, for a detectability rate of 96.9%. By comparison, sonography showed a trend toward higher detectability of nasal vestibular tumors than CT (87.5% for sonography versus 50.0% for CT) and small lumps on the wing of the nose (78.8% for sonography versus 33.3% for CT). Among the sonographic features, boundary, shape, internal echo, calcification, bone invasion, vascular pattern, and cervical lymph node metastasis all had significantly positive correlations with malignancy (P < .05), but size did not (P = .324). In addition, the vascular resistive index for malignant tumors was significantly higher (mean ± SD, 0.66 ± 0.20) than the index for benign lesions (0.24 ± 0.30; P < .001). Moreover, the detection rate for grade 1–3 (small–large) blood flow in benign lesions was only 43.8%, whereas the rate for malignant tumors was 97.7% (P < .001). Conclusions—The vascular pattern may be a promising predictive indicator for distinguishing benign and malignant tumors of the nose and paranasal sinuses. Consequently, sonography has high value for diagnosis of benign and malignant tumors of the nose and paranasal sinuses, especially for nasal vestibular tumors and small lumps on the wing of the nose. Received November 11, 2013, from the Department of Diagnostic Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China. Revision requested January 3, 2014. Revised manuscript accepted for publication January 29, 2014. This study was supported by the Natural Science Foundation of Guangxi Province, China (grant 0832125). Address correspondence to Shang-Yong Zhu, MD, Department of Diagnostic Ultrasound, First Affiliated Hospital of Guangxi Medical University, 22 Shuang-Yong Rd, 530021 Nanning, Guangxi, China. E-mail: [email protected] Abbreviations
CT, computed tomography
Key Words—benign and malignant tumors; computed tomography; nose and paranasal sinuses; sonography
T
umors of the nose and paranasal sinuses, which arise from the head and neck, have complex anatomy and proximity to the eye, brain, and cranial nerves. Nowadays, computed tomography (CT), as one of the modern imaging techniques, has been accepted as the reference standard for pathologic anatomic evaluation and is considered an obligatory part of surgical planning for the nose and paranasal sinuses.1,2 Some studies have demonstrated that sonography is a very useful method for differential diagnosis of head and neck tumors3–5 and the cervical lymph nodes6–8 and is even regarded as the preferred imaging method routinely used to detect cervical lymph node metastasis of head and neck tumors.9 Moreover, previous studies have yielded promising results for
doi:10.7863/ultra.33.9.1627
©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:1627–1634 | 0278-4297 | www.aium.org
3309jum1531-1668online_Layout 1 8/21/14 8:33 AM Page 1628
Liu et al—Sonography for Diagnosis of Nose and Paranasal Sinus Tumors
sonography in the safe and noninvasive diagnosis of sinusitis and accurate evaluation of orbital and nasal fractures.10–14 However, it has rarely been used as an imaging technique for investigation of nose and paranasal sinus tumors. The purpose of our study was to evaluate the reliability of sonography for diagnosis of benign and malignant tumors of the nose and paranasal sinuses and to assess the concordance of sonography with CT, which is the current clinical mainstay.
Materials and Methods This study was performed with approval from the local Institutional Review Board. Patients received verbal information about the study and gave informed consent to participate. From April 2011 to August 2012, consecutive patients (58 male and 42 female; median age, 47.8 years; range, 2–82 years) with tumors of the nose and paranasal sinuses were enrolled randomly. Exclusion criteria were patients who had clinically suspected tumors, had a surgical history of nose and paranasal sinus tumors, or had undergone radiotherapy. Before surgery, all patients were investigated with sonography and CT within a time frame of 7 days. The evaluators were blinded to the patients’ clinical information and the corresponding sonographic and CT findings, and after comparison with postoperative histopathologic results, the sonographic results were contrasted with CT results to evaluate the possibility of sonography for diagnosis of nose and paranasal sinus tumors. Sonographic examinations were performed by 2 sonologists (J.L. and S.-Y.Z., with 11 and 24 years of experience in head and neck sonography, respectively). Any discrepancies were resolved by consensus. Sonography was performed with a Technos MPX scanner (Esaote SpA, Genoa, Italy) equipped with a 7.5–14.0-MHz linear transducer (transducer body, 1.9 cm wide and 6.5 cm long; 1.2 cm wide
and 5.4 cm long where the surface of the transducer contacted the skin) and a 3.5–5.0-MHz convex array transducer or an EUB-6500 scanner (Hitachi Medical Corporation, Tokyo, Japan) equipped with a 7.5–14.0-MHz linear transducer (dimensions as above) and a 3.5–5.0-MHz convex array transducer. All patients were in the supine position. The scan region was from the middle to anterolateral aspects of the face and from the upper frontal to alveolar margins, including surrounding structures. The examination was performed in transverse, oblique, and longitudinal planes (Figure 1). The frontal sinus, lower orbital border, ethmoidal sinus, nose, maxillary sinus, alveolar margin, and external cheekbone were delineated. The following sonographic features were assessed: tumor detectability, site, size, shape, internal echo, calcification, bone invasion, vascular pattern, and cervical lymph node metastasis. The size was defined as the maximum length of the tumor in centimeters. A normal image was defined as showing an acoustic shadow arising from the bone wall (Figure 2A, left); a pathologic image was defined as visualization of a hypoechoic nose and sinus cavity delineated by surrounding air (Figure 2A, right). Infiltration of the surrounding structures indicated a hypoechoic tumor spreading into the soft tissues of the face (Figure 2B). Bone invasion was defined as interruption of the inner and outer membranes, which normally appeared as hyperechoic lines (Figure 2C). We classified the vascular patterns of the tumors into 4 grades: grade 0, no blood flow signal inside the tumor; grade 1, a small amount of blood flow, with 1 or 2 pointed or fine rodlike blood vessels visible inside the tumor; grade 2, a moderate amount of blood flow, with 3 or 4 visible spotlike blood vessels or a long vessel across the lesion with a length close to or longer than the tumor radius; and grade 3, a larger amount of blood flow, with 5 or more visible spotlike blood vessels or 2 long vessels across the lesion (Figure 2D).
Figure 1. Probe locations in the transverse (left), oblique (center), and longitudinal (right) planes during the examination of the anterior paranasal regions.
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For comparison, CT images were obtained with a Somatom Sensation 16 CT system (Siemens AG, Erlangen, Germany). The patients were imaged in the supine position and were asked to breathe quietly and avoid swallowing during scanning. The section thickness was 5 mm, with a 5-mm intersection gap. Axial, coronal, and sagittal planes were obtained. Contrast material was not used routinely in this study because of the economic burden on the patients. A pathologic image was defined as abnormal increased density resembling soft tissues on low-density images of the nasal cavity and paranasal sinuses (Figure 2E). Infiltration of the surrounding structures indicated a highdensity tumor spreading into the adjacent soft tissues of the face. Bone invasion was defined as intermediate soft tissue density on normal bone images. These imaging interpretations were compared with postoperative histopathologic results.
The SPSS version 13.0 statistical software package (IBM Corporation, Armonk, NY) was used in this study. The tumor detectability accuracy of sonography and CT were calculated and compared by the Pearson χ2 test. Differences in major clinical and sonographic features between detectable benign and malignant tumors were determined by an independent samples t test, Pearson χ2, Fisher exact test, and Mann-Whitney U test. Statistical significance was set at P < .05.
Results In this study, we investigated 100 patients with tumors of the nose and paranasal sinuses. However, 4 patients left the hospital or were transferred without pathologic results. Therefore, the study included 96 tumors with pathologic results. The pathologic diagnoses of the 96 complex tumors
Figure 2. Squamous cell carcinoma of the right ethmoid sinus in an 81-year-old woman. A, Oblique sonograms showing a normal acoustic shadow (arrow) behind the bone wall in the left image and a hypoechoic tumor and many calcifications (arrow) in the right image. B, Longitudinal sonogram of the right ethmoid sinus (E) at the eye level was showing the tumor (T; arrow) extending to the right eye. C, Transverse sonogram showing obvious bony invasion of the sinus wall (arrow). D, Sonogram clearly showing a rich vascular pattern (grade 3 blood flow) in the tumor (arrow). E, Computed tomogram showing the tumor arising from the right ethmoid sinus with intermediate to high density (long arrow) and extending to the right eye (short arrows), corresponding to the sonographic findings.
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are shown in Table 1. Cysts (37.5% [18 of 48 patients]) and inflammatory polyps (35.4% [17 of 48 patients]) were most common in the benign group; squamous cell carcinoma (27.1% [13 of 48 patients]) was most common in the malignant group. Of the 96 tumors, 75 were detected by sonography, for a detectability rate of 78.1%; 93 tumors were detected by CT, for a detectability rate of 96.9% (including misdiagnosed cases). The accuracy of sonographic and CT detection compared with the pathologic results is summarized in Table 2 (excluding misdiagnosed cases). There was no significant difference between the tumor detectability of sonography and CT (P = .388). For the 75 detectable tumors (21 benign and 43 malignant) on sonography, the major clinical and sonographic features are displayed in Table 3. In terms of the major clinical features, age (P = .393) and sex (P = .665) were not associated with benignity or malignancy. In terms of the sonographic features, boundary (P < .001), shape (P
