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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 28  |  Issue : 4  |  Page : 364-369

Comparison between clinical examination, ultrasonography, and computed tomography in assessment of cervical lymph node metastasis in oral squamous cell carcinoma


1 Department of Oral Medicine and Radiology, Hazaribag College of Dental Sciences, Hazaribag, Jharkhand, India
2 Department of Oral Medicine and Radiology, Rama Dental College, Kanpur, Uttar Pradesh, India
3 Department of Conservative Dentistry and Endodontics, Mathrushri Ramabai Ambedkar Dental College and Hospital, Bengaluru, Karnataka, India
4 Department of Oral Medicine and Radiology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

Date of Submission27-Oct-2015
Date of Acceptance30-Nov-2016
Date of Web Publication21-Feb-2017

Correspondence Address:
Kamala Rawson
Department of Oral Medicine and Radiology, Rama Dental College, Lakhanpur, Kalyanpur, Kanpur - 208 024, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.200630

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   Abstract 

Introduction: The most important prognostic factor in oral squamous cell carcinoma (OSCC) is the presence or absence of clinically involved neck nodes. Appropriate diagnosis of the metastatic lymph node is very important for management of OSCC. Aim: The aim of the present study was to evaluate the diagnostic accuracy of metastatic cervical lymph nodes through clinical examination, ultrasonography (USG) and computed tomography (CT), and to compare them with each other. Materials and Methods: Twenty individuals with histologically proven OSCC were selected for the study. The selected individuals were clinically examined by a single trained investigator and further investigations were advised. USG and contrast enhanced CT was performed for each patient with cervical lymphadenopathy to evaluate the findings. The results of each modality were analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Pathological analysis of the surgical specimen served as the reference standard. Results: Considering pathological analysis of the surgical resection as the baseline, data obtained from clinical, USG and CT examinations were compared. We found that the cases which showed negative results in clinical evaluation showed positive results in both CT and USG; on comparing the specificity and sensitivity, USG had 93% specificity and 92% sensitivity whereas CT had 84% specificity and 81% sensitivity. Conclusion: This study concludes that one should not rely solely on clinical evaluation; other diagnostic methods should be evaluated. Although CT is better than clinical evaluation, USG was found to be superior to both clinical and CT examinations.

Keywords: Computed tomography, oral squamous cell carcinoma, ultrasonography


How to cite this article:
Kallalli BN, Rawson K, Kumari V, Patil S, Singh A, Sulaga S. Comparison between clinical examination, ultrasonography, and computed tomography in assessment of cervical lymph node metastasis in oral squamous cell carcinoma. J Indian Acad Oral Med Radiol 2016;28:364-9

How to cite this URL:
Kallalli BN, Rawson K, Kumari V, Patil S, Singh A, Sulaga S. Comparison between clinical examination, ultrasonography, and computed tomography in assessment of cervical lymph node metastasis in oral squamous cell carcinoma. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2017 Sep 26];28:364-9. Available from: http://www.jiaomr.in/text.asp?2016/28/4/364/200630


   Introduction Top


The world is afflicted with various types of noncommunicable diseases, which are also known as modern epidemics. Cancer is one among them. Cancers of the head and neck region are the sixth most common cancers worldwide, with high mortality ratios among all malignancies.[1],[2],[3] Head and neck cancer is the most physically and emotionally devastating cancers and often leaves the patient disabled and disfigured. Head and neck cancers refer to a group of biologically similar cancers originating from the oral cavity and upper aerodigestive tract. Approximately 95% of head and neck cancers are of the squamous cell variety.[1] The global incidence of cancers of the oral cavity and pharynx account for 363,000 annual new cases worldwide and almost 200,000 deaths.[3] The Indian subcontinent accounts for one-third of the world's burden. The most important prognostic factor in patients with oral cavity squamous cell carcinoma is the presence or absence of cervical metastases.[4]

The occurrence of nodal metastasis has a profound effect on the treatment, prognosis and survival of patients with head and neck cancer.[5],[6] Metastatic spread to one side decreases the survival by 50%, whereas bilateral metastasis decreases survival by a further 25%. Metastasis that is higher than 20% is the most important indicator for elective neck treatment.[3],[4] The risk of occult metastasis is related to the method by which the lymph nodes are evaluated.[3],[7] It is possible to reduce the risk of undiagnosed metastasis with accurate imaging techniques. Various tools for the staging of lymph nodes are palpation, fine needle aspiration cytology (FNAC), ultrasonography (USG), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET).[8],[9]

Clinical examination of cervical lymph nodes have many false negative and false positive results. It has been estimated to exist in 20–40% of all cases.[9],[10] Its low sensitivity and specificity paved the way toward further studies in search of other accurate diagnostic means for detecting neck nodes.[2],[11],[12],[13] CT has improved the accuracy of diagnosis of cervical metastasis. However, it has the disadvantages of being expensive and having a higher radiation exposure. Ultrasound scanning has improved the overall accuracy of diagnosis of cervical metastases. It is a cheap and highly reliable method without the hazards of radiation exposure.[10]


   Aim Top


The aim of the present study was to evaluate the diagnostic accuracy of metastatic cervical lymph nodes through clinical examination, USG and CT, and to compare them with each other.


   Materials and Methods Top


A cross-sectional observational study was conducted to evaluate the role of ultrasound in detecting metastatic lymph nodes of the neck in the Department of Oral Medicine and Radiology. The study was designed to compare the accuracy of determining metastatic neck nodes using USG with clinical palpation, and both were compared for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy while keeping histopathological examination (HPE) as the gold standard. Patients with carcinoma of the buccal mucosa, maxilla, mandible and gingiva were included in the study.

The study sample consisted of 20 patients. Out of which 15 were males and 5 were females in the age range of 45–63 years. Patients who fulfilled the following inclusion criteria were enrolled in the study: (a) If the primary tumor was histopathologically proven to be SCC of the oral cavity and (b) the presence of palpable neck node(s). Ethical committee clearance was obtained from institutional ethical committee; the study was explained to all the participants and informed consent was obtained. All the details were recorded by a single trained observer in a prescribed format. Oral cancer was diagnosed clinically and then all the patients were examined for metastatic lymph nodes in the neck preoperatively, The findings were recorded in terms of the presence or absence of lymph nodes, its number, site, size, as well as its apparent relation to the surrounding structures. The lymph node levels were assessed according to the American Joint Committee on Cancer Classification (TNM staging) [Figure 1].[14]
Figure 1: Squamous cell carcinoma on the left buccal mucosa

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After clinical examination of the positive findings of SCC, including lymph node evaluation, all the patients were sent for an ultrasound. Ultrasound sonograms were obtained with real time sector scanners with scan heads of 7.5 MHz frequency. The neck was examined longitudinally and transversely in a continuous sweep technique covering the neck region from the thoracic inlet and scalenus muscles to the submental and retroparotideal regions. The criteria for considering a node positive on ultrasound of the neck were [Figure 2] and [Figure 3]:
Figure 2: Ultrasound scan of the neck showing right level II metastatic lymph node

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Figure 3: Ultrasound scan of the same patient showing level II metastatic lymph node

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  • Size greater than 1 cm
  • Loss of normal outline, and
  • Heterogeneous with a mixed cystic/solid pattern of echogenicity.


The ultrasound findings documented were its site, number, internal architecture and relation to surrounding structures and vessels. After USG, all the patients were sent for contrast enhanced CT. Contrast enhanced CT was performed with a spiral CT scanner using a magnification, high milliampere second package. Axial sections were taken of 3 mm thickness from the primary lesion and regional nodal areas. The remainder of the area from the base of the skull to the thoracic inlet was scanned in 5 mm increments. A rapid drip infusion of 75 ml of iopromide injection at the rate 2.7 ml/s was administered to all, and scans were obtained only after the contrast material had been administered. The criteria selected for interpreting a node as malignant were [Figure 4] and [Figure 5]:
Figure 4: Axial computed tomography scan showing the left level II metastatic lymph node

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Figure 5: Axial computed tomography scan of the same patient with left buccal mucosa cancer showing no cervical metastases

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  • Size greater than 1cm
  • Rim enhancement following intravenous contrast
  • Central necrosis
  • Spherical shape
  • Three or more lymph nodes on the first drainage site, and
  • Extracapsular spread of disease.


All the patients in the study underwent surgical treatment for neck along with the excision of the primary. The neck dissection specimens were examined by the pathologists. The pathologist examining the specimens was also blindfolded regarding the results of the clinical examination, USG, or CT.

Statistical analysis

The results were evaluated statistically, and the sensitivity, specificity, PPV, NPV, and accuracy of the methods were estimated. PPV and NPV were used to assess the performance of USG examinations in the detection of metastatic nodes.[1]


   Results Top


All the results were obtained, analyzed and comparisons were made of the HPE findings with the clinical, USG and CT findings. The results of the comparison of clinical examination and HPE are shown in [Table 1]. It is clear from [Table 1] that, on palpation, 21 lymph nodes were diagnosed positive and 14 lymph nodes were diagnosed as negative for metastatic lymph nodes with sensitivity of 60%, specificity of 40%, PPV of 61.9%, NPV of 68.6%, and accuracy of 68.6%. On comparing with the pathology report, 21 lymph nodes showed metastatic disease.
Table 1: Comparison of clinical examination, ultrasonography, and computed tomography with histopathologic examination

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Regarding the 20 necks evaluated by CT, 30 were interpreted as positive for the disease and the remaining 5 as negative with sensitivity of 89.4%, specificity of 100%, PPV of 83.3%, NPV of 25%, and accuracy of 85.7%. On comparing with the pathology report, 30 lymph nodes showed metastatic disease.

On USG, the radiologists gave results of 32 necks as positive and the rest of the 3 necks as negative for metastasis with sensitivity of 94.1%, specificity of 40%, PPV of 94.4%, NPV of 33.3%, and accuracy of 91.4%. On comparing with the pathology report, 32 lymph nodes showed metastatic disease.

All the results of clinical examination, USG and CT were compared in terms of sensitivity, specificity, PPV, NPV, and accuracy, assuming that the HPE of the neck has pointed out all the possible metastatic deposits in the neck of the 35 necks examined; 35 necks were found to be positive on histopathologic analysis [Table 2].
Table 2: Comparison of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy between clinical examination, ultrasonography, and computed tomography

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   Discussion Top


Carcinoma of the oral cavity is very aggressive and usually infiltrates the surrounding tissue and lymph vessel, producing metastasis in the cervical region.[14] Cervical metastasis plays a major role in the staging and management of head and neck carcinomas.[2] The rate of metastasis probably reflects the aggressiveness of the primary tumor and is an important prognostic factor.[3],[10],[15],[16] Accurate radiologic imaging could potentially allow for a more conservative approach regarding management of the neck.[1]

Cervical metastasis plays a major role in the staging and management of head and neck carcinomas. Clinically, no nodal involvement is present, and the entire treatment rests on the excision of the primary. The indication for prophylactic neck dissection depends upon the possible chances of occult metastasis. If this is more than 15%, then a prophylactic dissection is indicated. To avoid unnecessary stress to the patient by performing a prophylactic neck dissection, an investigating modality with high specificity and accuracy is required to detect neck metastasis. This study was done in search of an appropriate modality to detect maximum possible metastatic lymph nodes in neck, and comparing the results of clinical examination, CT, and USG.

Clinical palpation is the first line method in evaluating metastatic cervical lymphadenopathy. In our study, palpation results reported a sensitivity of 60%. The sensitivity of palpation is attributable to the use of only physical characteristics such as size and consistency. The reactive lymph nodes can also achieve the same dimensions as metastatic nodes, and hence, false positive results are inevitable. The accuracy of 60% of palpation in our study can be compared to the previous studies, where it ranged from 60–86%. In 1993, John et al. reported a sensitivity of 62%, specificity of 80%, accuracy for palpation of 81%, whereas 44, 67, and 67% by using USG, respectively.[17] In 2011, Sureshkannan [1] presented a sensitivity of 85.7% and a specificity of 90% for USG, while the clinical examination presented sensitivity of 68.7% and specificity of 87.5%.

Geetha et al.,[2] in 2010, reported the sensitivity in the detection of cervical lymph nodes to be 83% for palpation and 100% for USG. In the present study, 20 patients had 34 lymph nodes on pathological investigation. The sensitivity, specificity, NPV, PPV, and accuracy of palpation were 60, 40, 38.1, 61.9, and 68.6%, respectively, whereas the values for USG examination were 94.1, 100, 33.3, 94.4, and 91.4%, respectively. In a study by Haberal et al.,[18] 22 patients had positive lymph nodes on pathologic investigation. The sensitivity, specificity, NPV, PPV, and accuracy of palpation were 64, 85, 74, 78, and 75%, respectively. The respective values for USG and CT for sensitivity, specificity, NPV, PPV and accuracy were 72, 96, 80, 94 and 85%, and 81, 96, 85, 90 and 87%, respectively.

CT has been used to determine neck metastasis in carcinoma of head and neck since 1981. In 2010, Geetha et al.[2] reported sensitivity of the CT scan to be 50% and specificity to be 100%, whereas they reported sensitivity of 83% and specificity of 50% for physical examination. In an earlier study by Sönmez et al.,[19] authors reported a sensitivity of 95% and specificity of 47% for CT scan, whereas a sensitivity of 86% and specificity of 84% were reported for physical examination. In the present study, the sensitivity, specificity, NPV, PPV and accuracy of palpation were 60, 40, 38.1, 61.9 and 68.6%, respectively, whereas the CT examination presented 89.4, 100, 25, 83.3 and 85.7%, respectively.

Anand et al.[3] conducted a study among 100 patients with a variety of head and neck cancers to examine metastatic lymph nodes and compare the findings of clinical examination, USG and CT, as well as HPE of the neck dissection specimen. Saafan et al.[10] conducted a study among 100 consecutive patients with a histologically proven noncutaneous head and neck SCC. Every patient was subjected to clinical examination of cervical lymph nodes, along with CT scans of the neck with intravenous contrast and gray scale ultrasound scanning of the neck. Clinical palpation for cervical lymph nodes had a sensitivity of 71.43%, specificity 75.86% and accuracy 72.7%. CT scan was found to be better than clinical palpation. The sensitivity for CT was 82.9%, whereas the specificity was 89.66% and the accuracy was 84.85%. USG was found to be the best modality in the assessment of metastases in cervical lymph nodes. The sensitivity was 97.1%, the specificity was 93%, and the accuracy was 95.96%. The PPV for USG was 97.1% and the NPV was 93%.

USG has an advantage of being a simple, noninvasive maneuver with no hazards of exposure to radiation.[20] Moreover, USG can detect lymphadenopathy in the presence of severe postoperative scarring or post-radiotherapy thickening of the soft tissues of the neck. USG appears to be the best modality for assessing carotid artery invasion. It can be considered a valuable diagnostic measurement for cancer of the tongue. By providing a three-dimensional view of the tumor, it is more accurate than palpation in detecting the spread of tumor across the midline to the base of the tongue and the floor of the mouth. The tumor is predominately hypoechoic. It is difficult to differentiate fibrosis from tumors as well as to detect very superficial lesions [Table 3].[10]
Table 3: Comparison of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy between the present study and the study by Geetha et al.

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   Conclusion Top


Imaging plays a major role in the management of oral cancers. A systematic approach to evaluating lymph node is required for head and neck cancer. From this study, it is concluded that we should not rely solely on clinical examination, and other diagnostic modalities should be considered. CT and USG increase the accuracy of lymph node detection. It is also considered that USG is superior in this aspect and is cheaper, with no hazards of radiation exposure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Sureshkannan P, Vijayprabhu, John R. Role of ultrasound in detection of metastatic neck nodes in patients with oral cancer. Indian J Dent Res 2011;22:419-23.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Geetha NT, Hallur N, Goudar G, Sikkerimath BC, Gudi SS. Cervical lymph node metastasis in oral squamous carcinoma preoperative assessment and histopathology after neck dissection. J Maxillofac Oral Surg 2010;9:42-7.  Back to cited text no. 2
    
3.
Anand N, Chaudhary N, Mittal MK, Prasad R. Comparison of the efficacy of clinical examination, ultrasound neck and computed tomography in detection and staging of cervical lymph node metastasis in head and neck cancers. Indian J Otolaryngol Head Neck Surg 2006;59:19-23.  Back to cited text no. 3
    
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Wensing BM, Merkx MA, De Wilde PC, Marres HA, Van den Hoogen FJ. Assessment of preoperative ultrasonography of the neck and elective neck dissection in patients with oral squamous cell carcinoma. Oral Oncol 2010;46:87-91.  Back to cited text no. 4
    
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Hoang JK, Vanka J, Ludwig BJ, Glastonbury CM. Evaluation of cervical lymph nodes in head and neck cancer with CT and MRI: Tips, traps, and a systematic approach. Am J Roentgenol 2013;200:W17-25.  Back to cited text no. 5
    
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Atula TS, Grenman R, Varpula MJ, Kurki TJ, Klemi PJ. Palpation, ultrasound and ultrasound-guided fine needle aspiration cytology in the assessment of cervical lymph node status in head and neck cancer patients. Head Neck 1996;18:545-51.  Back to cited text no. 7
    
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Liao LJ, Lo WC, Hsu WL, Wang CT, Lai MS. Detection of cervical lymph node metastasis in head and neck cancer patients with clinically N0 neck- a meta-analysis comparing different imaging modalities. BMC Cancer 2012;12:236.  Back to cited text no. 8
    
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Figueiredo PT, Leite AF, Freitas AC, Nascimento LA, Cavalcanti MG, Melo NS, et al. Comparison between computed tomography and clinical evaluation in tumor/node stage and follow up of oral cavity and oro-pharyngeal cancer. Dentomaxillofac Radiol 2010:39:140-8.  Back to cited text no. 9
    
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Saafan ME, Elguindy AS, Abdel–Aziz MF, Abdel-Rahman Younes A, Albirmawy OA, et al. Assessment of cervical lymph nodes in squamous cell carcinoma of the head and neck. Surgery Curr Res 2013;3:145.  Back to cited text no. 10
    
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Watkinson JC, Todd CE, Paskin L, Rankin S, Palmers T, Shaheen OH, et al. Metastatic carcinoma in the neck: A clinical, radiological, scintigraphic and pathological study. Clin Otolaryngol 1991;16:187-92.  Back to cited text no. 11
    
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Friedman M, Mafee MF, Pacella BL Jr, Strorigl TL, Dew LL, Toriumi DM. Rationale for elective neck dissection in 1990. Laryngoscope 1990;100:54-9.  Back to cited text no. 12
    
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Candela FC, Kothari K, Shah JP. Patterns of cervical node metastases from squamous carcinoma of the oropharynx and hypopharynx. Head Neck 1990;12:197-203.  Back to cited text no. 13
    
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Van den Brekel MW, Stel HV, Castelijns JA, Croll GJ, Snow GB. Lymph node staging in patients with clinically negative neck examinations by ultrasound and ultrasound-guided aspiraiton cytology. Am J Surg 1991;162:362-6.  Back to cited text no. 16
    
17.
John DG, Anaes FC, Williams SR, Ahuja A, Evans R, To KF, et al. Palpation compared with ultrasound in the assessment of malignant cervical lymph nodes. J Laryngol Otol 1993;107:821-3.  Back to cited text no. 17
    
18.
Haberal I, Celik H, Göçmen H, Akmansu H, Yörük M, Ozeri C. Which is important in the evaluation of metastatic lymph nodes in head and neck cancer: Palpation, ultrasonography, or computed tomography? Otolaryngol Head Neck Surg 2004;130:197-201.  Back to cited text no. 18
    
19.
Sönmez A, Oztürk N, Ersoy B, Bayramiçli M, Celebiler O, Numanoğlu A. Computed tomography in the management of cervical lymph node pathology. J Plast Reconstr Aesthet Surg 2008;61:61-4.  Back to cited text no. 19
    
20.
Supreeta A, Devendra C, Prathamesh P. Imaging in oral cancers. Indian J Radiol Imaging 2012;22:195-208.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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