Imaging and Management of the N0 Neck
Jatin ShahMichiel van den Brekel
Snehal PatelBaris Karakullukcu
Ian GanlyAbrahim Al-Mamgani
Symposium 2015 IAOOSao Paulo
MSKCC – NKI AVL
Options for the N0 Neck Observation
– Based on an estimated low risk of occult metastases: T1 larynx
Staging– CT / MRI / PET– Ultrasound (guided FNAC)– Sentinel node biopsy
Treatment– Elective ND– Elective Radiotherapy
Imaging of the N0 Neck Modalities and developments Sensitivity, Specificity and impact on the
risk of occult metastases What is the maximum accuracy
Imaging of the N0 Neck
Risk reduction might influence management– Imaging should be very sensitive for N0 neck
What risk is acceptable ??
In 1994 Weiss et al. created a decision analysis and demonstrated that when the probability of occult cervical metastasis is more than 20%, the neck should be electively treated.This risk cut-of (Rx) was calculated with three variables:
a = the cure rate with END and no neck recurrence b = the cure rate with observation and late neck metastasisc = the cure rate with observation and no neck metastasis
Rx = (c − 0.97a) ⁄ (0.00376 − 0.0776a − 0.94b + c) = 44.4%
MRI, US and CT
Rely on morphological features
- Nodal size- Central necrosis / irregular enhancement- Signal intensities / enhancement- Indistinct nodal margins- Gross extracapsular extension
Easy Cases
NegativePositive
13
PET-CT: very promising
BJ de Bondt: Diffusion weighted MRI (2009)
CT misdiagnosis
False Positive PT-CT
Accuracy CT and MRI N0 neck No Sensit Specif
Stern CT 53 40 92 Friedman CT 68 68 90
MRI 16 80 82 Moreau CT 32 50 86 Hillsamer CT 11 60 83
MRI 9 66 83 Yucel MRI 20 57 93 Vd Brekel CT 86 49 78
MRI 83 55 88 Rhigi CT 25 60 100 Okura CT 132 52 81
MRI 60 61 84
Total CT 407 53 82 MRI 188 60 85
PET (CT) in cN0 casesAuthor Neck
sN+ Sensitivity Specificity NPV
Myers 1998 14 30% 79% 100%
Civantes 2001 18 61% 30% 100% 45%
Hyde 2003 18 22% 0% 87% 77%
Brouwer 2003 15 67% 92%
Wensing 2006 30 30% 33% 76% 73%
Schroder 2006 36 25% 67% 85% 88%
Krabbe 2008 38 21% 50% 97% 88%
Ozer 2012 112 57% 82% 59%
Sohn 2015 49 51% 55%
Sensitivity US-FNAC N0 NeckAuthor Tumor Neck Sides Sensitivity Specificit
yvdBrekel (1993) HNSCC 43 73 100Righi (1997) HNSCC 33 50 100Takes (1998) HNSCC 64 48 100Nieuwenhuis (2002) Oral SCC (T3-4) 23 71 100
Nieuwenhuis (2002) Oral SCC (T1-2) 37 25 100
Hodder (2000) Oral SCC (T1-4) 33 58 100Borgemeester (2009)
Oral SCC (T1-2) 37 18 100
Borgemeester (2009)
HNSCC (T3-4) 128 39 100
Wensing (2010) Oral (T1-2) 224 78 100
Sensitivity versus radiologist
Radiologist
Neck sides examined HP positive
Sensitivity (%)
1 39 11 9
2 29 14 29
3 31 11 45
4 43 17 53
US-FNAC vs CT, MRI, US: meta-analysis
De Bondt et al. Eur. J. Radiol. 2007
Computed tomography versus magnetic resonance imaging for diagnosing cervical lymph node metastasis of head and neck cancer: a systematic review and meta-analysis. Sun J, Li B, Li CJ, Li Y, Su F, Gao QH, Wu FL, Yu T, Wu L, Li LJ. Onco Targets Ther. 2015;8:1291-313
Analysis of sentinel node biopsy combined with other diagnostic tools in staging cN0 head and neck cancer: A diagnostic meta-analysis. Liao LJ, Hsu WL, Wang CT, Lo WC, Lai MS. Head Neck 2015
Hypothetic 100 cN0 patients, 40 pN+
Sensitivity 56%, Specificity 100% (USgFNAC)– Neck treatment in 22 (4-9% recur !!)– Wait & See policy in 78
» Undertreatment in 18 (30-70% salvaged) Sensitivity 56%, Specificity 79% (MRI)
– Neck Treatment in 35» Overtreatment in 13
– Wait and See in 65» Undertreatment in 18 (30-70% salvaged)
Maximum Sensitivity of Imaging
Depends on imaging criteria, spatial resolution, contrast, uptake of tracers
BUT ALSO ON THE SIZE OF THE METASTASIS
The challenge is to detect metastases smaller than 3-4-5 mm
MICROMETASTASES IN 96 cN0 ND SPECIMENS
van den Brekel et al. Laryngoscope 1996
In 25% of pN+, cN0 necks only metastases smaller than 25% are present
Conclusions Imaging can detect 50-60% of occult
metastases according to literature As all studies used HP as gold standard,
the reported sensitivities are overestimated
So far USgFNAC has the highest accuracy in well trained and motivated doctors
At least 25-30% of occult metastases cannot be detected with imaging