Computed tomography performance in predicting extranodal extension in HPV-positive oropharynx cancer.

OBJECTIVES: To evaluate the performance characteristics of seven predetermined imaging features on pretreatment computed tomography (CT) in identifying extranodal extension (ENE) in cervical lymph node metastases from human papillomavirus-positive oropharyngeal carcinoma (HPV-OPC). STUDY DESIGN: Retrospective study. METHODS: Seventy-three patients with HPV-OPC who underwent primary surgery and cervical lymph node dissection were included. Preoperative contrast-enhanced CT (cCT) imaging was evaluated by two radiologists blinded to pathological results. Each cCT was scored for seven imaging features of interest: 1) indistinct capsular contours, 2) irregular nodal margins, 3) perinodal fat stranding, 4) perinodal fat planes, 5) nodal necrosis, 6) intranodal cysts, and 7) nodal matting. Logistic regression was employed to determine radiologist-specific odds ratios (OR) of predicting ENE for each imaging feature and radiologist-specific receiver operating characteristics (sensitivity [Sn], specificity [Sp], area under the curve [AUC], positive predictive value [PPV], negative predictive value [NPV]) for each imaging feature. RESULTS: Thirty-two (44%) patients had ENE-positive lymph nodes. The presence of irregular margins (ORA = 12.3, 95% confidence interval [CI]A = 2.3-65.9; ORB = 7.0, 95% CIB = 1.4-36.3) and absence of perinodal fat plane (ORA = 6.8, 95% CIA = 2.0-23.3; ORB = 14.2, 95% CIB = 1.7-120.5) were significantly associated with ENE for each radiologist. Irregular nodal margin status was most specific for ENE (SnA = 45%, SpA = 94%, AUCA = 69%, PPVA = 82%, NPVA = 73%; SnB = 28%, SpB = 95%, AUCB = 61%, PPVB = 80%, NPVB = 64%). Absence of perinodal fat plane was most sensitive for ENE (SnA = 87%, SpA = 50%, AUCA = 69%, PPVA = 59%, NPVA = 62%; SnB = 96%, SpB = 34%, AUCB = 65%, PPVB = 53%, NPVB = 63%). CONCLUSIONS: Of the seven imaging features hypothesized to be associated with ENE-status, the presence of irregular nodal margins and absence of perinodal fat plane were the most specific and sensitive features, respectively. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1479-1486, 2020.

Evaluating oropharyngeal carcinoma with transcervical ultrasound, CT, and MRI.

OBJECTIVE: To compare transcervical ultrasonography (US) to standard cross-sectional imaging for the visualization of human papillomavirus-related oropharyngeal cancer (HPV-OPC). MATERIALS AND METHODS: Patients with HPV-OPC and available standard imaging (CT and/or MRI) were identified in clinic and prospectively enrolled. US was performed to visualize the oropharynx and lymph nodes. Tumor characteristics across imaging modalities were evaluated (CT versus MRI, and US versus standard imaging (SI)). RESULTS: Forty-three patients were included. The overall blinded detection rates for CT and MRI were 83% and 71%, respectively. The unblinded detection rate for US was 98%. Agreement of tumor anatomic subsite was moderate for both CT vs MRI (κ = 0.59) and US vs SI (κ = 0.47). Comparison of tumor size by CT and MRI showed statistically significant correlations in craniocaudal (CC), anteroposterior (AP), and mediolateral (ML) dimensions (RhoCC = 0.51, pCC = 0.038; RhoAP = 0.81, pAP < 0.0001; RhoML = 0.57, pML = 0.012). Tumor size estimates by US and SI showed statistically significant correlations in CC and AP, but not ML (RhoCC = 0.60, pCC = 0.003; RhoAP = 0.71, pAP < 0.0001; RhoML = 0.30, pML = 0.08). Tumor volume estimates improved correlations between US and SI (Rho = 0.66, p < 0.0001). Stratification of US patients into early and late imaging studies demonstrated an increase in correlation strength from early (Rho = 0.32, p = 0.32) to late groups (Rho = 0.77, p < 0.0001) demonstrating that ultrasound accuracy improved with experience. CONCLUSIONS: Our findings suggest that transcervical ultrasonography is a sensitive and relatively accurate adjunct to standard imaging for the evaluation of oropharyngeal tumors. Its cost, portability, and potential for in-clinic and serial imaging render US an attractive modality to further develop for imaging oropharyngeal tumors.

Liposarcoma metastases to the small bowel presenting as fat-density intraluminal lesions.

Metastatic disease to the small bowel is rare; however, it is important to recognize that when it does occurs a variety of complications are possible including obstruction, gastrointestinal bleeding, intussusception, and bowel perforation. We present here an unusual case of small bowel metastases in a patient with known metastatic liposarcoma in which the lesions manifested as rapidly evolving fat-density masses that necessitated segmental small bowel resection. Careful scrutiny of the small bowel in oncology patients is necessary to guide appropriate treatment and avoid potential catastrophic complications from small bowel metastases.

Association of Ultrasound Characteristics With Extranodal Extension in Metastatic Papillary Thyroid Carcinoma.

IMPORTANCE: The presence of extranodal extension (ENE) in metastatic papillary thyroid carcinoma (PTC) has emerged as an important prognostic factor, independently associated with tumor persistence after initial resection, decreased likelihood of complete biochemical response, and worse cause-specific survival. Therefore, the ability to determine ENE before surgery is desirable and advantageous but to date has not yet been evaluated. OBJECTIVE: To evaluate the use of preoperative ultrasound characteristics in predicting pathologic ENE in patients with metastatic PTC. DESIGN, SETTING, AND PARTICIPANTS: Single-institutional, retrospective analysis of patients with metastatic PTC between December 1, 2007, and May 31, 2012. The dates of the analysis were September 1, 2014, to July 31, 2015. Clinicodemographic and histopathologic data were extracted. Preoperative ultrasound images were scored for characteristics of interest by 2 independent radiologists masked to radiology and pathology reports. The setting was an academic tertiary care center. Patients were excluded if they were younger than 18 years, did not have clinical or imaging follow-up after surgery, were found to have histologic diagnoses other than PTC, or were being treated for recurrent disease. EXPOSURES: Preoperative ultrasound and neck dissection. MAIN OUTCOMES AND MEASURES: Association of ultrasound characteristics with ENE. RESULTS: Data from 29 patients with metastatic PTC and available preoperative ultrasound images and pathologic data from neck dissection were included. The patients had a median age at diagnosis of 47 years (age range, 19-85 years); and 76% (22 of 29) were female. Among 29 patients, 11 (38%) had ENE. There were no significant differences in distributions of clinicodemographic or histopathologic characteristics between patients with vs without ENE. The following ultrasound characteristics were significantly associated with ENE positivity: node matting (odds ratio [OR], 6.67; 95% CI, 1.01-44.10; P = .049), presence of node matting or cystic areas (OR, 11.70; 95% CI, 1.85-74.19; P = .009), composite score of 3 or more ultrasound characteristics (OR, 14.00; 95% CI, 2.06-95.09; P = .007), and presence of node matting, perinodal edema, unclear margins, or cystic areas (OR, 10.00; 95% CI, 1.05-95.24; P = .045), as well as presence of node matting, perinodal edema, or unclear margins (OR, 7.07; 95% CI, 1.17-42.85; P = .03). A composite score of 3 or more ultrasound characteristics had the highest accuracy (79.3%) for predicting ENE positivity. CONCLUSIONS AND RELEVANCE: This study identifies preoperative ultrasound characteristics of metastatic PTC that are significantly associated with pathologically determined ENE and supports prospective analyses to further evaluate this use of preoperative ultrasound.

Ultrasonography-guided fine-needle aspiration with concurrent small core biopsy of neck masses and lymph nodes yields adequate material for HPV testing in head and neck squamous cell carcinomas.

INTRODUCTION: Human papillomavirus (HPV)-associated head and neck squamous cell carcinoma (HNSCC) is a distinct epidemiologic and pathologic disease that is increasing in frequency. Currently, there is no clinical standard for obtaining diagnostic material or determining HPV status in the workup of these patients. The purpose of this study was to the determine the specimen adequacy for HPV testing on material obtained by ultrasonography-guided fine-needle aspiration and small core biopsy of neck masses and lymph nodes in patients with HNSCC. MATERIALS AND METHODS: Cases were reviewed for patients who (1) underwent ultrasonography-guided fine-needle aspiration with or without small core biopsy of neck masses and lymph nodes, (2) were diagnosed with HNSCC, and (3) were tested for HPV. Several HPV detection methods were used, including p16, HPV 16 and 18, and high-risk and wide spectrum HPV in situ hybridization. RESULTS: Of the 63 patients studied, 48 (76.2%) were male and 15 (23.8%) were female. The overall adequacy rate of cell block and small core biopsy material was 88%. Forty-five of 63 patients (73%) tested positive for HPV. Overall agreement was achieved in 92.9% of cases in which both p16 and HPV in situ hybridization were performed. On available surgical follow-up, histocytologic correlation for HPV-related testing was 100%. CONCLUSIONS: Ultrasonography-guided fine-needle aspiration with concurrent small core biopsy of neck masses and lymph nodes, along with on-site evaluation by a pathologist, yields adequate material for reliable HPV-related testing in HNSCC and should be incorporated into the routine pathologic evaluation for these patients.

Visualization of the Oropharynx With Transcervical Ultrasound.

OBJECTIVE: The purposes of this article are to illustrate the sonographic appearance of the oropharynx and to discuss the potential role of ultrasound in evaluation of the oropharynx. CONCLUSION: Ultrasound is not currently used in the standard clinical evaluation of the oropharynx, but it is a promising imaging modality for evaluating the base of the tongue and the palatine tonsils. Ultrasound is comparable and complementary to CT and MRI, which have recognized limitations.

Preliminary data using computed tomography texture analysis for the classification of hypervascular liver lesions: generation of a predictive model on the basis of quantitative spatial frequency measurements--a work in progress.

OBJECTIVE: Computed tomography texture analysis (CTTA) is a method of quantifying lesion heterogeneity based on distribution of pixel intensities within a region of interest. This study investigates the ability of CTTA to distinguish different hypervascular liver lesions and compares CTTA parameters by creating a proof-of-concept model to distinguish between different lesions. METHODS: Following institutional review board approval, CTTA software (TexRAD Ltd) was used to retrospectively analyze 17 cases of focal nodular hyperplasia, 19 hepatic adenomas, 25 hepatocellular carcinomas, and 19 cases of normal liver parenchyma using arterial phase scans. Two radiologists read the same image series used by the CTTA software and reported their best guess diagnosis. Computed tomography texture analysis parameters were computed from regions of interest using spatial band-pass filters to quantify heterogeneity. Random-forest method was used to construct a predictive model from these parameters, and a separate regression model was created using a subset of parameters. RESULTS: The random-forest model successfully distinguished the 3 lesion types and normal liver with predicted classification performance accuracy for 91.2% for adenoma, 94.4% for focal nodular hyperplasia, and 98.6% for hepatocellular carcinoma. This error prediction was generated using a subset of data points not used in generation of the model, but not on discrete prospective cases. In contrast, the 2 human readers using the same image series data analyzed by the CTTA software had lower accuracies, of 72.2% and 65.6%, respectively. The explicit regression model with a subset of image parameters had intermediate overall accuracy of 84.9%. CONCLUSIONS: Computed tomography texture analysis may prove valuable in lesion characterization. Differentiation between common hypervascular lesion types could be aided by the judicious incorporation of texture parameters into clinical analysis.

Ultrasonography evaluation of pelvic masses.

Ultrasonography is the primary imaging modality for evaluation of pelvic masses. Ultrasonography has the advantage of being inexpensive, widely available, and offering superior tissue characterization compared with computed tomography. The real-time imaging ability of ultrasonography and three-dimensional ultrasonography also has the advantage of being able to identify the organ of origin of the pelvic mass. Many pelvic masses have characteristic sonographic appearances that allow confident diagnosis and management. This article reviews the sonographic appearances and management of common pelvic masses encountered in nonpregnant women, and is organized based on anatomic location: uterus, cervix, ovaries, and fallopian tubes.

The role of sonography in thyroid cancer.

Sonography plays several important roles in the diagnosis and management of thyroid cancer. Ultrasound (US) is used for the detection and characterization of thyroid nodules as well as a guidance modality for fine-needle aspiration biopsy of indeterminate or suspicious nodules. US is also used to help stage thyroid cancer by identifying cervical lymph nodes suspicious for metastasis so they can be biopsied prior to subsequent neck dissection. Post-thyroidectomy, routine surveillance of the neck is performed with US to identify local recurrence and/or nodal metastatic disease so that focused and limited repeat neck dissection or alcohol ablation can be accomplished.

Intrapancreatic accessory spleen: possibilities of computed tomography in differentiation from nonfunctioning pancreatic neuroendocrine tumor.

OBJECTIVE: The aim of this study was to evaluate the ability of computed tomography (CT) in differentiating between intrapancreatic accessory spleen (IPAS) from pancreatic neuroendocrine tumor (PanNET). METHODS: Eight IPASs and 12 PanNETs in the pancreatic tail were retrospectively evaluated by 2 radiologists. Readers assigned a diagnosis to each examination and evaluated for the presence or absence of 9 CT findings that may aid in the diagnosis. RESULTS: Reader 1 had a sensitivity of 0.83 and a specificity of 1; reader 2 had a sensitivity of 0.78 and a specificity of 0.86. Three of the 9 CT findings were found to be statistically significant in IPASs: the lesion present along the pancreatic dorsal surface, the lesion demonstrating the same enhancement as the spleen on venous phase, and heterogeneous enhancement during arterial phase. CONCLUSIONS: CT can be used to differentiate between IPAS and PanNET with good specificity and sensitivity. The IPAS mirrors the spleen's enhancement and is usually located along the dorsal surface of the pancreas.

MDCT imaging following nephrectomy for renal cell carcinoma: Protocol optimization and patterns of tumor recurrence.

The purpose of this pictorial essay is to review the common and uncommon sites of renal cell carcinoma recurrence throughout the body by examining their appearances on computerized tomography (CT). CT imaging protocols will be discussed. The sites of recurrence have been categorized into 4 groups: chest and mediastinum, abdomen and pelvis, musculoskeletal, and neurological. For each site of recurrence, a representative CT image correlate with discussion is provided. The unique CT appearance of renal cell carcinoma recurrence and how it can be used in lesion detection will be discussed. Renal cell carcinoma recurrences are hypervascular like the primary tumor, which can aid in not only lesion detection but also in some cases, differentiation from other primary tumors. Through CT case review of various sites of recurrence, lesions are shown to be easily seen on arterial phase while sometimes being nearly inconspicuous on venous or delayed phases. Coronal and sagittal reconstructions can also improve diagnostic sensitivity. CT is the most commonly used imaging tool for surveillance of renal cell carcinoma recurrence after nephrectomy. Knowledge of sites of recurrence as well as the utility of arterial phase imaging and multiplanar reconstructions will aid in optimizing detection of disease recurrence.