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 Table of Contents  
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 170-173

Cervical lymphnode metastasis in oral squamous cell carcinoma: Correlation of manual palpation, ultrasonographic, and histopathological findings

1 Department of Oral Medicine and Radiology, District Hospital, Chamarajanagar, India
2 Department of Oral Medicine and Radiology, Daswani Dental College and Research Centre, Kota, Rajasthan, India
3 Department of Oral Medicine and Radiology, AME's Dental College, Raichur, Karnataka, India

Date of Submission03-Nov-2016
Date of Acceptance06-Nov-2017
Date of Web Publication20-Nov-2017

Correspondence Address:
Sathya P Dongade
#44, 13th cross, 5th main, Gokulam 2nd stage, Mysore - 570 002, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.JIAOMR_12_17

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Introduction: The staging of cervical lymphadenopathy is an important consideration in the management of oral cancer as it determines the patients' prognosis. Ultrasound is used to image the cervical lymph nodes for staging because it is noninvasive and there is no radiation exposure to the patient. Aim: To investigate the applicability and diagnostic relevance of sonography in staging cervical lymphnode metastases. Materials and Methods: Cervical lymphnodes of the patients were subjected to manual palpation and ultrasound evaluation for its size, number, shape, borders, internal echoes, echogenic hilus, and central necrosis. The manual palpation findings and ultrasound features of the lymphnodes were compared with the histological features for malignant and nonmalignant nodes. Results: When short axis of node is more than 10 mm, 86% were metastatic, nodes with irregular borders were metastatic in 84%, in the absence of the echogenic hilus, 93% were metastatic, 81% were metastatic with heterogeneous nodes, and nodes with central necrosis showed 90% metastasis. Conclusion: By using ultrasound no single parameter showed high sensitivity, specificity, and accuracy.

Keywords: Cervical lymph nodes, hilus, lymph nodes, oral squamous cell carcinoma, staging, ultrasound

How to cite this article:
Dongade SP, Meti M, Ramesh DN. Cervical lymphnode metastasis in oral squamous cell carcinoma: Correlation of manual palpation, ultrasonographic, and histopathological findings. J Indian Acad Oral Med Radiol 2017;29:170-3

How to cite this URL:
Dongade SP, Meti M, Ramesh DN. Cervical lymphnode metastasis in oral squamous cell carcinoma: Correlation of manual palpation, ultrasonographic, and histopathological findings. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2021 May 11];29:170-3. Available from: https://www.jiaomr.in/text.asp?2017/29/3/170/218708

   Introduction Top

Oral cancer is the sixth most common cancer in the world. It accounts for 4% of all cancers and 2% of all cancer deaths worldwide. In India, it is the most common malignant neoplasm, accounting for 20–30% of all cancers. The status of the cervical lymphnodes is the single most important prognostic indicator of survival for patients with oral cancer. The development of nodal metastases halves the 5-year survival rate.[1]

The difficulty in predicting the presence of metastatic disease in clinically negative necks has led to the widespread use of elective (prophylactic) treatment of the neck by either neck dissection or radiotherapy. At present, several methods are available for investigating the presence and extent of nodal metastasis, including physical palpation, radiologic imaging by computerized tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), and ultrasound with fine needle aspiration cytology (US-FNAC).[2] Each of these methods has their own diagnostic criteria, accuracy, and limitations.

Ultrasound is gaining popularity because of its high sensitivity. It has an advantage over other imaging modalities for its low price, low patient burden, and the possibility of on-screen nodal measurements. Furthermore, for frequent and routine follow-up, ultrasound is the only imaging technique available.[3] It is noninvasive and there is no radiation exposure to the patient. Ultrasound investigation shows characteristic echogram findings in cervical lymphnode metastases. Reliable palpatory findings may be difficult to obtain even for experienced investigators, especially when involved lymphnode groups are situated medially to the sternocleidomastoid muscle or there is a history of previous surgery or radiation therapy.[4] Ultrasound assessment of cervical lymph nodes has the benefit of rapidly demonstrating all three nodal dimensions without the need for ionizing radiation or intravenous contrast medium.[5]


This study was conducted to investigate the applicability and diagnostic relevance of sonography in staging cervical lymphnode metastasis.

   Materials and Methods Top

Fifty patients, diagnosed with squamous cell carcinoma in the gingivobuccal sulcus of the oral cavity, were included in the study. All patients were made aware of the procedure and informed consent taken from them; ethical approval was taken from the institutional ethical committee. All the patients were clinically examined and the palpation of cervical lymphnodes was documented. The lymphnodes were palpated for their size, number, consistency, fixity, and tenderness.

All 50 patients were subjected to ultrasonographic evaluation of the neck. Two-dimensional real time B-mode ultrasonographic examinations were performed using high frequency (7–11 MHz) linear transducer. The neck was examined longitudinally and transversely in a continuous sweep technique, covering the neck region.

Ultrasound findings were documented as mentioned below:

  1. Size of the lymphnodes (minimal and maximal diameter)
  2. Shape of the lymphnodes
  3. Borders of nodes (smooth borders/irregular borders)
  4. Internal echoes (homogeneous/heterogeneous), and
  5. Central necrosis.

For 50 patients, 52 neck dissections were performed (two cases were bilateral). Twenty-nine (29) underwent submandibular omohyoid neck dissection (SOND), eight submandibular node dissection (SND), and 15 radicular neck dissection (RND). The lymphnodes thus obtained were examined histopathologically for the presence of metastasis. The correlation between all sonographic parameters and histological findings was statistically analyzed for each lymphnode.

An un-paired t-test was used for comparison of the maximal diameter, minimum diameter, and shape index between metastatic and nonmetastatic nodes. Chi-square test was used for comparison of margin pattern, internal echo pattern, and existence of an echogenic hilus. Regression analysis was done for determining the presence of metastasis as well as the parameters with significant difference between metastatic and nonmetastatic nodes.

   Results Top

Of the 50 cases, 52 neck dissections were performed (two bilateral), and 590 lymph nodes were excised. Of the 590 nodes, 71 nodes were metastatic and 519 were nonmetastatic on histological examination. Of the 50 cases, three cases were N0 for manual palpation. Fifty-two (52) nodes were palpated by manual palpation. Of the 52 nodes, 22 nodes were proven histopathologically as nonmetastatic and 30 necks with metastatic cervical lymphnodes.

On manual palpation, 49 necks lymphnodes were detected and remaining three (3) necks were N0 (no lymphnodes detected). Only one N0 patient was correctly identified as having nonmetastatic nodes. The sensitivity of manual palpation was 91%, specificity was 37%, and accuracy was 68%. Ninety-six (96) nodes were identified by ultrasound, of which 55 were malignant and 41 benign (non-malignant) lymph nodes. All the ultrasound features (maximum diameter, minimum diameter, smooth or irregular borders, internal echoes, presence or absence of hilus, and central necrosis) of the nodes compared with histopathological features.

Minimal/short axis diameter

Of the lymphnodes less than 10 mm, 47% were malignant, 53% nonmalignant nodes, and those with nodal size 11–15 mm was 87% and 13%, respectively. Above 16 mm, 82% and 18% showed metastatic and nonmetastatic nodes, respectively. When the cut off point of 10 mm was used, it showed specificity of 90.24%, sensitivity of 40%, and accuracy of 61% [Table 1].
Table 1: Distribution of width/minimum diameter according to involvement of lymph nodes

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Smooth borders/Nodal border

84% of lymphnodes with irregular borders were found to be metastatic. Smooth borders were seen in 36% of metastatic nodes and 64% of nonmetastatic nodes, respectively [Table 2].
Table 2: Distribution of smooth border according to involvement of lymph nodes

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Internal echoes

Eighty-nine percent of heterogeneous nodes showed metastasis and 11% showed nonmetastasis. Thirty-one percent of homogeneous echo nodes showed metastasis and 69% showed nonmetastasis.

Echogenic hilus

Forty-one nodes (93.18%) and 3 nodes (6.82%) showed metastasis and nonmetastasis, respectively, in the absence of echogenic hilus [Table 3].
Table 3: Distribution of echogenic hilus according to involvement of lymph nodes

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Central necrosis

Nodes with central necrosis showed nine (90%) metastatic and one (10%) nonmetastatic nodes. Nodes without necrosis were 54% and 46% metastatic and nonmetastatic lymphnodes, respectively.

   Discussion Top

Before the era of imaging most clinicians performed elective neck treatment for the great majority of clinically N0 neck sides, overtreatment and the morbidity were well expected. On the other hand, undertreatment, leading to development of neck node metastasis was minimum. Consequently, high sensitivity is more important than high specificity.[3]

Head and neck squamous cell carcinoma neck lymphnodes are usually examined by manual palpation. This is, however, not a very reliable method as both sensitivity and specificity is less with figures around 60–80%.[6] Imaging techniques are more accurate being efficient enough to detect smaller tumor deposits; moreover, they can distinguish better between metastasis and other cause of masses (palpable) in the neck. With the use of imaging technique such as CT, MRI, PET, and US, better accuracy and sensitivity can be achieved.[7] In general, none of the currently available imaging technique can depict small tumor deposits inside lymphnodes, nor is any of them able to distinguish reactively enlarged lymphnodes from metastatic lymphnodes. Although very high-resolution CT and MRI with fewer artifacts, immunoimaging with SPECT and PET and more specific contrast agents are becoming available; either these techniques are too expensive and impractical for routine use or they still rely on known radiological criteria for metastases, such as nodal size and depiction of necrosis.[3]

In the present study, when the minimum diameter was less than 10 mm size of the node, we observed 47% and 53% were malignant and nonmalignant nodes, with sensitivity, specificity and accuracy of 40%, 90%, and 61%, respectively. Don Debra et al. obtained 83% sensitivity and specificity in 67% of metastatic nodes.[8] They also showed that the sensitivity reduced from 68% for minimum diameter of 5 mm to 5% in node size more than 20 mm and the specificity rose from 72% for 5 mm size nodes to 99.9% in nodes more than 20 mm.

Metastatic lymph nodes tend to have sharp borders, whereas reactive and normal nodes usually show unsharp borders. The sharp borders in malignant nodes is believed to be due to tumor infiltration and the reduced fatty deposition within the lymphnodes, which increase the acoustic impedance difference between the lymphnode and the surrounding tissues. Unsharp borders are common in tuberculous nodes and these are due to the edema and inflammation of the surrounding soft tissue (periadenitis). A malignant node with unsharp borders indicates extracapsular spread, which helps in the assessment of patient's prognosis.[9]

Considering lymphnode borders, smooth borders were seen in 53 nodes and irregular borders in 43 nodes. Smooth borders were seen in 36% of metastatic nodes and 64% of non-metastatic nodes. Specificity and sensitivity were 65% and 83%, respectively. Irregular borders showed 84% and 16% metastatic and nonmetastatic nodes, respectively. Ying et al.[10] observed nodal border to be the least accurate criterion for middle cervical and posterior triangle nodes with accuracy of 64% and 62%, respectively. Yusa et al.[11] observed 77% of metastatic nodes and 100% of nonmetastatic nodes having smooth borders.

The heterogeneity of lymphnodes found in carcinomas of oral cavity is the result of internodal coagulation necrosis and liquefication necrosis. In our study, 89% of the heterogeneous echo showed metastasis and 11% showed non-metastasis. A few previous studies [12],[13] observed similar results.

Echogenic hilus is a normal sonographic feature of most of the normal cervical lymphnodes and is commonly seen in larger nodes. Although metastatic nodes tend to have absent hilus, they may be present with an echogenic hilus in their early stage of involvement in which the medullary sinus has not been sufficiently disrupted to eradicate it.[9] The absence of echogenic hilus suggests an abnormal node.[14] Varying appearances of the echogenic lymphnode hilum and the surrounding hypoechoic cortex have shown to be helpful in distinguishing malignant from benign normal size nodes. However, this degree of spatial resolution is only possible with relatively superficial lymphnodes.

In our study, 52 nodes showed echogenic hilus and 44 nodes without hilus. Forty-one nodes (93.18%) and 3 nodes (6.82%) showed metastases and nonmetastases, respectively, in the absence of echogenic hilus. Fourteen nodes (27%) and 38 nodes (73%) that had echogenic hilus, showed metastatic and nonmetastatic nodes, respectively, with sensitivity of 75% and specificity of 93%. Yusa et al.[15] observed the absence of echogenic hilus in 97% of metastatic lymphnodes and presence in 73% of reactive nodes. For Jank et al.,[16] 91.5% of malignant nodes did not show the presence of echogenic hilus on grayscale sonography.

Lymphnodes with intranodal necrosis are considered to be pathologic.[9] Metastatic central necrosis is considered a biologically late event in the evolution of tumor within a lymphnode. Central necrosis occurred primarily, in lymphnodes approximating 20 mm or greater. It appears that central necrosis occurs characteristically after tumor infiltration has become massive.[8] In the present study, nodes with central necrosis showed nine (90%) metastatic and one (10%) non-metastatic node. Nodes without necrosis were 54% and 46% metastatic and non-metastatic respectively.

   Conclusion Top

Current imaging improves the clinical staging but does not detect the micrometastases reliably. Hence, our current modalities cannot alone dictate whether and how to operate, but should play a significant role in the multifactorial decisions concerning treatment. We consider that the current criterion obtained from our small sample is valuable in successfully treating neck node metastasis and in diminishing the possibility of unnecessary neck dissection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Burusapat C, Jarungroongruangchai W, Charoenpitakchai M. Prognostic factors of cervical node status in head and neck squamous cell carcinoma. World J Surg Oncol 2015;13:51.  Back to cited text no. 1
Woolgar JA, Beirne JC, Vaughan ED, Lewis-Jones HG, Scott J, Brown JS. Correlation of histopathologic findings with clinical and radiologic assessments of cervical lymph-node metastases in oral cancer. Int J Oral Maxillofac Surg 1995;24:30-7.  Back to cited text no. 2
Castelijns JA, van den Brekel MW. Imaging of lymphadenopathy in the neck. Eur Radiol 2002;12:727-38.  Back to cited text no. 3
Hessling KH, Schmelzeisen R, Reimer P, Milbradt H, Unverfehrt D. Use of sonography in the follow-up of preoperatively irradiated efferent lymphatics of the neck in oropharyngeal tumors. J Craniomaxillofac Surg 1991;19:128-30.  Back to cited text no. 4
Connor SE, Olliff JF. Review imaging of malignant cervical lymphadenopathy. Dentomaxillofac Radiol 2000;29:133-43.  Back to cited text no. 5
Baatenburg de Jong RJ, Rongen RJ, Laméris JS, Harthoorn M, Verwoerd CD, Knegt P. Metastatic neck disease palpation vs ultrasound examination. Arch Otolaryngol Head Neck Surg 1989;115:689-90.  Back to cited text no. 6
Takes RP. Staging of the neck in patients with head and neck squamous cell cancer: Imaging techniques and biomarkers. Oral Oncol 2004;40:656-67.  Back to cited text no. 7
Don DM, Anzai Y, Lufkin RB, Fu YS, Calcaterra TC. Evaluation of cervical lymph node metastases in squamous cell carcinoma of the head and neck. Laryngoscope 1995;105:669-74.  Back to cited text no. 8
Ahuja A, Ying M. An overview of neck node sonography. Invest Radiol 2002;37:333-42.  Back to cited text no. 9
Ying M, Ahuja A, Metreweli C. Diagnostic accuracy of sonographic criteria for evaluation of cervical lymphadenopathy. J Ultrasound Med 1998;17:437-45.  Back to cited text no. 10
Yusa H, Yoshida H, Ueno E. Ultrasonographic criteria for diagnosis of cervical lymph node metastasis of squamous cell carcinoma in the oral and maxillofacial region. J Oral Maxillofac Surg 1999;57:4l-8.  Back to cited text no. 11
Ahuja A, Ying M, Yang WT, Evans R, King W, Metreweli C. The use of sonography in differentiating cervical lymphomatous lymph nodes from cervical metastatic lymph nodes. Clin Radiol 1996;51:186-90.  Back to cited text no. 12
Toriyabe Y, Nishimura T, Kita S, Saito Y, Miyokawa N. Differentiation between benign and metastatic cervical lymph nodes with ultrasound. Clin Radiol 1997;52:927-32.  Back to cited text no. 13
Steinkamp HJ, Cornehl M, Hosten N, Pegios W, Vogl T, Felix R. Cervical lymphadenopathy: Ration of long- to short axis diameter as a predictor of malignancy. Br J Radiol 1995;68:266-70.  Back to cited text no. 14
Yuasa K, Kawazu T, Kunitake N, Uehara S, Omagari J, Yoshiura K, et al. Sonography for the detection of cervical lymphnode metastases among patients with tongue cancer: Criteria for early detection and assessment of follow-up examination intervals. AJNR Am J Neuroradiol 2000;21:1127-32.  Back to cited text no. 15
Jank S, Robatscher P, Emshoff R, Strobl H, Gojer G, Norer B. The diagnostic value of ultrasonography to detect occult lymphnode involvement at different levels in patients with squamous cell carcinoma in maxillofacial region. Int J Oral Maxillofac Surg 2003;32:39-42.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3]


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