USGFNAC Project

Projectbeschrijving:

Projectcode: NKIxxxxx

Project titel: Assessment of accuracy and prognostic impact of preoperative ultrasound guided fine needle cytology in patient with oral, oropharyngeal and supraglottic carcinoma.

Aantal weken: 20 weken
Aanvang stage: date

Naam student: Mister Xr
Telefoonnummer:
e-mail:

Naam begeleider: Dr. M. van den Brekel
Telefoonnummer: 020-5122550/2992
e-mail adres: m.vd.brekel@nki.nl

Naam 2e begeleider: Dr.F.Pameijer
Telefoonnummer: 020-5121500/1089
e-mail: f.pameijer@nki.nl

Adresgegevens: Het Nederlands Kanker Instituut - Antoni van Leeuwenhoek Ziekenhuis
Plesmanlaan 121
1066 CX Amsterdam

Introduction:

The vast majority of oral, oropharyngeal, and supraglottic cancers are squamous cell
carcinomas. They account for more than 90% of all malignant lesions. These lesions are thought to result from multiple genetic alterations that affect cell growth regulation. Other lesions that may occur are lymphomas, sarcomas and minor salivary gland tumours [ , ]. As a result of these malignant lesions metastases can occur. The lungs, the skeletal system, and the liver are the most frequent sites of distant metastases.

Lymphatic spread usually occurs in a predictable way. The presence of lymph node metastases determines to a great extent the chances of loco regional cure or the development of distant metastases[ ].
The lymph node status of the neck is the most important prognostic factor for patients with head and neck squamous cell carcinoma (HNSCC). There are several important prognostic features like the presence but also number of nodal metastases, level in the neck, size of the nodes, and presence of extranodal spread. If metastases in the neck are diagnosed, the neck should be treated. Because both sensitivity and specificity of palpation are in the range of 60% to 70% , a neck without palpable lymph nodes (N0) is still at risk of harboring occult metastases. Therefore, much effort has been devoted to increase the accuracy of assessment of the N0 neck[ ].
The outcome of the prognosis probably depends on the delay in treatment of the occult metastases, where time is of the essence[ ]. Therefore, it is important to detect lymphatic metastasis from an early point on.

Oral, oropharyngeal, and supraglottic cancers are treated with curative intent. The choice of therapy depends on the volume of the tumour. Small lesions (T1 and T2) are treated by either radiotherapy or surgery. Larger lesions (T3 or T4) are, if possible, surgically treated, with postoperative radiotherapy. Inoperable oropharyngeal cancer is treated by chemoradiotherapy[ ]. This emphasizes the need for an early diagnostic tool so the “damage” to the lesion area is minimized.

Both CT and MRI of the neck have been found to be superior to palpation in detecting cervical metastases, these modalities still have a relatively low accuracy for the N0 neck[ ].

The use of US-guided-fine-needle aspiration cytotology (US-guided FNAC) in the detection of neck metastases has already been assessed in previous studies, but the outcome of these studies vary widely.
The reported sensitivity of US-guided FNAC in the N0 neck ranges from 42% by Takes, and 50% by Righi, to 73% by van den Brekel et al. The specificity is almost 100%, this is because false-positive cytologic results of lymph nodes are very rare.
A sensitivity of 73% is significantly better than CT or MRI. A sensitivity of 48% or 50% is inferior to the 60% for CT[ ]. The cause of this variation is largely unknown.

Since 1992, the Netherlands Cancer Institute changed there policy for patients treated with transoral excisions without metastases detected with palpation or US-guided FNAC. In the past these patients would have received the elective therapy of surgery. These days the patients are followed at regular intervals with palpation and US-guided FNAC (wait-and-see-policy) [ ].

Because of the importance of diagnosing clinically occult N0 metastases in the neck this study wants to retrospectively assess the results of using US-guided FNAC as a routine in the Netherlands Cancer Institute over the last 10 years. Comparison of the accuracy with MRI and CT will be performed as well. Subpopulation analysis will hopefully lead to a more rational use of this technique.

Methods:
The charts of all patients with oral, oropharyngeal, and supraglottic cancer treated with primary surgery will be analyzed. Only sides of the neck, staged N0 by palpation initially are eligible for this study. The US guided FNAC findings, the MRI and/or CT results will be compared with the pathological findings in the neck dissection specimen or the outcome of the neck during follow-up. In patients not treated with a neck dissection, survival and neck recurrences will be analyzed.

Inclusion Criteria

Clinically T1-4N0 Oral Cavity, oropharynx and larynx carcinomas
Second primaries only if neck(side) not treated previously (either RT or ND)
Elective neck dissection or Wait and See of the neck (T1-T2 oral cavity and laryngeal carcinomas)

Exclusion

Primary RT of the neck (no elective ND)
Clinically N+

Items Scored:

Patient / Tumor

1. Site of tumor
2. Left / right / midline
3. T stage

Results US

1. Radiologist (numbered)
2. Date US
3. Size nodes
4. Level of nodes
5. Side nodes (ipsi/contralateral)
6. Other Characteristics (homogenous, duplex doppler, hilus)

Results US-FNAC

1. Cytology results
a. SCC
b. Reactive
c. Suspicious
d. Insufficient material

Results CT

1. Radiologist
2. Date
3. Size
4. Side
5. Level
6. Characteristics (necrosis, irregularities, etc)

Results MRI

1. Radiologist
2. Date
3. Size
4. Side
5. Level
6. Characteristics (necrosis, irregularities, etc)

Neck Dissection

1. Type of neck dissection (Modified Radical, Selective: levels removed)
2. Histopathology results per level: number, size, ENS
3. postoperative RT

Follow-UP

1. Last follow-up date
2. State at follow-up (NED, DOD, DOC, AWD)
3. Neck at follow-up: remained negative, developed metastasis, which level

Tasks of Student:

X stelt, aan de hand van de te scoren items en patiënten selectie een spreadsheet op en selecteert patiënten die in de studie geïncludeerd kunnen worden. Hij neemt de klinische gegeven over uit de statussen evenals de radiologische bevindingen en cytologie en voert deze in de database in. Hij verwerkt de resultaten en berekent de statische parameters. Van belang hierbij is dat de uitkomsten mogelijk varieren bij verschillende variabelen (T stadium, site tumor, radioloog, etc). Tevens stelt hij zich op de hoogt van de gebruikte technieken en patiënten populatie (poli meelopen, Echo-onderzoek, CT, MRI, operatie bijwonen). Naar aanleiding van de resultaten kan het huidige beleid worden bijgesteld. Hij besluit het onderzoek met het schrijven van een manuscript.

References
Vincent Chong. Oral cavity cancer. Cancer Imaging 2005; 5: S49-S52
Robert Hermans. Oropharyngeal cancer. Cancer Imaging 2005; 5: S52-S57
Michiel W.M. van den Brekel and Jonas A. Castelijns. What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck. Cancer Imaging 2005; 5: S41-S49
Eline J.C. Nieuwenhuis et al. Wait and see policy for the N0 neck in early-stage oral and oropharyngeal squamous cell carcinoma using ultrasonography-guided cytology: is there a role for identification of the sentinel node? Head and Neck 2002; 3; 282-289
Michiel W.M. van den Brekel and Jonas A. Castelijns. What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck. Cancer Imaging 2005; 5: S41-S49
Robert Hermans. Oropharyngeal cancer. Cancer Imaging 2005; 5: S52-S57
Eline J.C. Nieuwenhuis et al. Wait and see policy for the N0 neck in early-stage oral and oropharyngeal squamous cell carcinoma using ultrasonography-guided cytology: is there a role for identification of the sentinel node? Head and Neck 2002; 3; 282-289
Michiel W.M. van den Brekel, Laurens C. Reitsma et al. Sonographically guided aspiration cytology of neck nodes for selection of treatment and follow-up in patients with N0 head and neck cancer. AJNR Am J Neuroradiol 1999; 20: 1727-1731
Eline J.C. Nieuwenhuis et al. Wait and see policy for the N0 neck in early-stage oral and oropharyngeal squamous cell carcinoma using ultrasonography-guided cytology: is there a role for identification of the sentinel node? Head and Neck 2002; 3; 282-289




	USGFNAC Project		Projectbeschrijving: Projectcode: NKIxxxxx Project titel: Assessment of accuracy and prognostic impact of preoperative ultrasound guided fine needle cytology in patient with oral, oropharyngeal and supraglottic carcinoma. Aantal weken: 20 weken Aanvang stage: date Naam student: Mister Xr Telefoonnummer: e-mail: Naam begeleider: Dr. M. van den Brekel Telefoonnummer: 020-5122550/2992 e-mail adres: m.vd.brekel@nki.nl Naam 2e begeleider: Dr.F.Pameijer Telefoonnummer: 020-5121500/1089 e-mail: f.pameijer@nki.nl Adresgegevens: Het Nederlands Kanker Instituut - Antoni van Leeuwenhoek Ziekenhuis Plesmanlaan 121 1066 CX Amsterdam Introduction: The vast majority of oral, oropharyngeal, and supraglottic cancers are squamous cell carcinomas. They account for more than 90% of all malignant lesions. These lesions are thought to result from multiple genetic alterations that affect cell growth regulation. Other lesions that may occur are lymphomas, sarcomas and minor salivary gland tumours [ , ]. As a result of these malignant lesions metastases can occur. The lungs, the skeletal system, and the liver are the most frequent sites of distant metastases. Lymphatic spread usually occurs in a predictable way. The presence of lymph node metastases determines to a great extent the chances of loco regional cure or the development of distant metastases[ ]. The lymph node status of the neck is the most important prognostic factor for patients with head and neck squamous cell carcinoma (HNSCC). There are several important prognostic features like the presence but also number of nodal metastases, level in the neck, size of the nodes, and presence of extranodal spread. If metastases in the neck are diagnosed, the neck should be treated. Because both sensitivity and specificity of palpation are in the range of 60% to 70% , a neck without palpable lymph nodes (N0) is still at risk of harboring occult metastases. Therefore, much effort has been devoted to increase the accuracy of assessment of the N0 neck[ ]. The outcome of the prognosis probably depends on the delay in treatment of the occult metastases, where time is of the essence[ ]. Therefore, it is important to detect lymphatic metastasis from an early point on. Oral, oropharyngeal, and supraglottic cancers are treated with curative intent. The choice of therapy depends on the volume of the tumour. Small lesions (T1 and T2) are treated by either radiotherapy or surgery. Larger lesions (T3 or T4) are, if possible, surgically treated, with postoperative radiotherapy. Inoperable oropharyngeal cancer is treated by chemoradiotherapy[ ]. This emphasizes the need for an early diagnostic tool so the “damage” to the lesion area is minimized. Both CT and MRI of the neck have been found to be superior to palpation in detecting cervical metastases, these modalities still have a relatively low accuracy for the N0 neck[ ]. The use of US-guided-fine-needle aspiration cytotology (US-guided FNAC) in the detection of neck metastases has already been assessed in previous studies, but the outcome of these studies vary widely. The reported sensitivity of US-guided FNAC in the N0 neck ranges from 42% by Takes, and 50% by Righi, to 73% by van den Brekel et al. The specificity is almost 100%, this is because false-positive cytologic results of lymph nodes are very rare. A sensitivity of 73% is significantly better than CT or MRI. A sensitivity of 48% or 50% is inferior to the 60% for CT[ ]. The cause of this variation is largely unknown. Since 1992, the Netherlands Cancer Institute changed there policy for patients treated with transoral excisions without metastases detected with palpation or US-guided FNAC. In the past these patients would have received the elective therapy of surgery. These days the patients are followed at regular intervals with palpation and US-guided FNAC (wait-and-see-policy) [ ]. Because of the importance of diagnosing clinically occult N0 metastases in the neck this study wants to retrospectively assess the results of using US-guided FNAC as a routine in the Netherlands Cancer Institute over the last 10 years. Comparison of the accuracy with MRI and CT will be performed as well. Subpopulation analysis will hopefully lead to a more rational use of this technique. Methods: The charts of all patients with oral, oropharyngeal, and supraglottic cancer treated with primary surgery will be analyzed. Only sides of the neck, staged N0 by palpation initially are eligible for this study. The US guided FNAC findings, the MRI and/or CT results will be compared with the pathological findings in the neck dissection specimen or the outcome of the neck during follow-up. In patients not treated with a neck dissection, survival and neck recurrences will be analyzed. Inclusion Criteria Clinically T1-4N0 Oral Cavity, oropharynx and larynx carcinomas Second primaries only if neck(side) not treated previously (either RT or ND) Elective neck dissection or Wait and See of the neck (T1-T2 oral cavity and laryngeal carcinomas) Exclusion Primary RT of the neck (no elective ND) Clinically N+ Items Scored: Patient / Tumor 1. Site of tumor 2. Left / right / midline 3. T stage Results US 1. Radiologist (numbered) 2. Date US 3. Size nodes 4. Level of nodes 5. Side nodes (ipsi/contralateral) 6. Other Characteristics (homogenous, duplex doppler, hilus) Results US-FNAC 1. Cytology results a. SCC b. Reactive c. Suspicious d. Insufficient material Results CT 1. Radiologist 2. Date 3. Size 4. Side 5. Level 6. Characteristics (necrosis, irregularities, etc) Results MRI 1. Radiologist 2. Date 3. Size 4. Side 5. Level 6. Characteristics (necrosis, irregularities, etc) Neck Dissection 1. Type of neck dissection (Modified Radical, Selective: levels removed) 2. Histopathology results per level: number, size, ENS 3. postoperative RT Follow-UP 1. Last follow-up date 2. State at follow-up (NED, DOD, DOC, AWD) 3. Neck at follow-up: remained negative, developed metastasis, which level Tasks of Student: X stelt, aan de hand van de te scoren items en patiënten selectie een spreadsheet op en selecteert patiënten die in de studie geïncludeerd kunnen worden. Hij neemt de klinische gegeven over uit de statussen evenals de radiologische bevindingen en cytologie en voert deze in de database in. Hij verwerkt de resultaten en berekent de statische parameters. Van belang hierbij is dat de uitkomsten mogelijk varieren bij verschillende variabelen (T stadium, site tumor, radioloog, etc). Tevens stelt hij zich op de hoogt van de gebruikte technieken en patiënten populatie (poli meelopen, Echo-onderzoek, CT, MRI, operatie bijwonen). Naar aanleiding van de resultaten kan het huidige beleid worden bijgesteld. Hij besluit het onderzoek met het schrijven van een manuscript. References Vincent Chong. Oral cavity cancer. Cancer Imaging 2005; 5: S49-S52 Robert Hermans. Oropharyngeal cancer. Cancer Imaging 2005; 5: S52-S57 Michiel W.M. van den Brekel and Jonas A. Castelijns. What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck. Cancer Imaging 2005; 5: S41-S49 Eline J.C. Nieuwenhuis et al. Wait and see policy for the N0 neck in early-stage oral and oropharyngeal squamous cell carcinoma using ultrasonography-guided cytology: is there a role for identification of the sentinel node? Head and Neck 2002; 3; 282-289 Michiel W.M. van den Brekel and Jonas A. Castelijns. What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck. Cancer Imaging 2005; 5: S41-S49 Robert Hermans. Oropharyngeal cancer. Cancer Imaging 2005; 5: S52-S57 Eline J.C. Nieuwenhuis et al. Wait and see policy for the N0 neck in early-stage oral and oropharyngeal squamous cell carcinoma using ultrasonography-guided cytology: is there a role for identification of the sentinel node? Head and Neck 2002; 3; 282-289 Michiel W.M. van den Brekel, Laurens C. Reitsma et al. Sonographically guided aspiration cytology of neck nodes for selection of treatment and follow-up in patients with N0 head and neck cancer. AJNR Am J Neuroradiol 1999; 20: 1727-1731 Eline J.C. Nieuwenhuis et al. Wait and see policy for the N0 neck in early-stage oral and oropharyngeal squamous cell carcinoma using ultrasonography-guided cytology: is there a role for identification of the sentinel node? Head and Neck 2002; 3; 282-289