Radiologic extranodal spread and matted nodes: Important predictive factors for development of distant metastases in patients with high-risk head and neck cancer.

BACKGROUND: Different clinical high-risk factors for the development of distant metastases have been identified but not tested in the same cohort of patients with head and neck squamous cell carcinoma (HNSCC). METHODS: In 145 patients with previously identified clinical high risk factors, the presence of extranodal spread (ENS) and matted node on pretreatment CT (n = 96) and/or MRI (n = 111) were determined. RESULTS: Of 145 patients, ENS was detected in 87 patients (60.0%) and matted nodes in 53 patients (36.6%). Kaplan-Meier curves for presence or absence of ENS (on CT and/or MRI) and matted nodes (on CT) differ significantly. In a Cox regression analysis, only ENS was a significant risk factor (hazard ratio [HR] = 3.3; 95% confidence interval [CI] = 2.0-5.5; p < .001). CONCLUSION: In patients with high-risk HNSCC with clinically (palpably or radiologically) ENS and matted nodes, both determined radiologically, are high risk factors for development of distant metastases. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1452-E1458, 2016.

Predictive value of diffusion-weighted imaging without and with including contrast-enhanced magnetic resonance imaging in image analysis of head and neck squamous cell carcinoma.

OBJECTIVES: To assess disease-free survival (DFS) in head and neck squamous cell carcinoma (HNSCC) treated with (chemo)radiotherapy ([C]RT). METHODS: Pretreatment MR-images of 78 patients were retrospectively studied. Apparent diffusion coefficients (ADC) were calculated with two sets of two b-values: 0-750s/mm(2) (ADC750) and 0-1000s/mm(2) (ADC1000). One observer assessed tumor volume on T1-WI. Two independent observers assessed ADC-values of primary tumor and largest lymph node in two sessions (i.e. without and with including CE-T1WI in image analysis). Interobserver and intersession agreement were assessed with intraclass correlation coefficients (ICC) separately for ADC750 and ADC1000. Lesion volumes and ADC-values were related to DFS using Cox regression analysis. RESULTS: Median follow-up was 18 months. Interobserver ICC was better without than with CE-T1WI (primary tumor: 0.92 and 0.75-0.83, respectively; lymph node: 0.81-0.83 and 0.61-0.64, respectively). Intersession ICC ranged from 0.84 to 0.89. With CE-T1WI, mean ADC-values of primary tumor and lymph node were higher at both b-values than without CE-T1WI (P<0.001). Tumor volume (sensitivity: 73%; specificity: 57%) and lymph node ADC1000 (sensitivity: 71-79%; specificity: 77-79%) were independent significant predictors of DFS without and with including CE-T1WI (P<0.05). CONCLUSIONS: Pretreatment primary tumor volume and lymph node ADC1000 were significant independent predictors of DFS in HNSCC treated with (C)RT. DFS could be predicted from ADC-values acquired without and with including CE-T1WI in image analysis. The inclusion of CE-T1WI did not result in significant improvements in the predictive value of DWI. DWI without including CE-T1WI was highly reproducible.

Diagnostic value of CT and MRI in the detection of paratracheal lymph node metastasis.

The presence of paratracheal lymph node (PTLN) metastasis harbours a worse prognosis. Uniform guidelines on PTLN dissection are missing, mainly because of the value of diagnostic techniques for the detection of PTLN metastasis are not clear. This study is performed to identify CT and MRI criteria for detection of PTLN metastasis. 149 patients who underwent laryngectomy and a PTLN dissection between 1990 and 2010 were included. Patient, tumour, treatment and follow up data were collected. On computed tomography (CT) and magnetic resonance imaging (MRI) different test criteria were examined. Considering PTLN with a maximal axial diameter of ≥5 mm as positive predicts PTLN metastasis best: sensitivity and specificity 70% and 36% (CT) and 50% and 71% (MRI). Other risk factors for PTLN metastasis were subglottic extension of the tumour (sensitivity is 45%) and clinical positive neck status (sensitivity is 59%). When at least one of these risk factors was present and the status of PTLN was considered positive, a high sensitivity (90% for CT and 100% for MRI) and a lower specificity (19% for CT and 32% for MRI) was found. If at least one of the risk factors such as subglottic extension, clinical positive neck and PTLN with a maximal axial diameter of ≥5 mm is present, sensitivity and negative predictive value for the prediction of PTLN metastasis are high, but the specificity is low. These risk factors can be used to select laryngectomy patients for PTLN dissection.

Pre- and post-radiotherapy MRI results as a predictive model for response in laryngeal carcinoma.

The purpose was to determine if pre-radiotherapy (RT) and/or post-radiotherapy magnetic resonance (MR) imaging can predict response in patients with laryngeal carcinoma treated with RT. Pre- and post-RT MR examinations of 80 patients were retrospectively reviewed and associated with regard to local control. Pre-RT MR imaging parameters such as tumor involvement of specific laryngeal anatomic subsites including laryngeal cartilages and post-RT changes, i.e., complete resolution of the tumor or focal mass/asymmetric obliteration of laryngeal tissue and signal pattern on T2-weighted images, were evaluated. Local control was defined as absence of a recurrence at the primary site for 2 years. Local control rates based on pretreatment MR findings were 73% for low pre-RT risk-profile and 29% for high pre-RT risk-profile patients (p=0.0001). Based on posttreatment MR findings, local control rates were 100% score 1, 64% score 2, and 4% score 3 (p<0.0001). Using post-RT T2-weighted images, significant association was found between differences in signal pattern and local control: 77% hypointense, 54% isointense and 15% hyperintense lesions (p<0.001). Differences between means of delay of post-MRI examination were significantly associated with regard to local control (p=0.003); recurrent tumors followed 5 months after RT were more easily detectable on MRI than recurrent tumors within 4 months after RT. Sensitivity, specificity, accuracy, negative and positive predictive values of post-RT score 3 were 96%, 76%, 83%, 98% and 66%. Pre- and post-RT MRI evaluation of the larynx can identify patients at high risk for developing local failure.

MR imaging predictors of local control of glottic squamous cell carcinoma treated with radiation alone.

PURPOSE: To retrospectively evaluate the prognostic significance of magnetic resonance (MR) imaging-determined tumor parameters, especially the presence of cartilage invasion, regarding local control of glottic squamous cell carcinoma treated with radiation therapy (RT) alone. MATERIALS AND METHODS: The study was performed with the approval of our institutional review board; direct patient consent was waived. Pretreatment MR images of 118 patients aged 41-86 years (110 men, eight women) with glottic carcinoma treated with RT alone were reviewed for tumor involvement of specific laryngeal anatomic subsites (including laryngeal cartilage), tumor volume, and extralaryngeal tumor spread; these findings were compared with local control. Local control was defined as absence of a recurrence at the primary site for 2 years. Statistical significance of differences between curves for local control estimated with the Kaplan-Meier method was tested with log-rank test. RESULTS: Results of univariate analysis showed all MR imaging-determined parameters to be significant predictors of local control rate, compared with clinical parameters where T classification and vocal cord mobility were the only significant parameters associated with local control. Multivariate analysis (Cox regression model) of clinical and radiologic parameters revealed that hypopharyngeal extension (P=.04) and intermediate T2 signal intensity (SI) in cartilage similar to tumor SI (P<.001) were independent prognostic factors with regard to local control. CONCLUSION: Intermediate T2 SI in cartilage, which may suggest cartilage invasion, and hypopharyngeal extension of tumor, predict greater likelihood of local failure, whereas high T2 SI, which may suggest inflammatory tissue in cartilage, predicts lower likelihood of local failure.

Distant metastases in head and neck carcinoma: identification of prognostic groups with MR imaging.

PURPOSE: To evaluate retrospectively the prognostic significance of lymph node parameters assessed on pretreatment magnetic resonance (MR) images for development of distant metastases in patients with head and neck squamous cell carcinomas. MATERIALS AND METHODS: Pretreatment MR images of 311 patients were retrospectively reviewed for the presence of lymph nodes at specific neck node levels as well as the size and the presence of a number of lymph node characteristics including extranodal spread, central necrosis and number and volume of ipsi- and contralateral nodes. Of these patients, 174 (56%) had MRI-positive nodes (defined as nodes with minimum axial diameter >8 and >4 mm for paratracheal level and retropharyngeal nodes). RESULTS: The 2-year distant-metastasis free survival rate (DMFSR) for patients without MRI-positive nodes was 94% compared to 75% for those patients with MRI-positive nodes. In patients with MRI-positive nodes, results of multivariate analysis with the Cox regression model yielded statistical significance for presence of extranodal spread (ENS), detected on MRI, as the only independent prognostic factor associated with the 2-year DMFSR (p=0.002). Based on the analysis, three risk groups regarding the DMFSR could be identified. Low-risk group (DMFSR:94%) consisted of patients without MRI-positive nodes. Intermediate-risk group (DMFSR:81%) consisted of patients with MRI-positive nodes without ENS. High-risk group (DMFSR:59%) consisted of patients with MRI-positive nodes and ENS as shown on MRI (p<0.0001). Statistical separation for different tumor locations showed MRI-determined ENS (larynx: p=0.05; oropharynx: p=0.04; oral cavity: p<0.001), lowjugular/posterior triangle nodes (oropharynx: p=0.02), paratracheal nodes (larynx: p=0.03), and contralateral node volume >5 cm3 (larynx: p=0.03; oral cavity: p=0.02) to be significant predictors with regard to DMFSR. CONCLUSION: Especially patients with on MRI demonstrating extranodal spread and with suspicious nodes at lowjugular/posterior triangle (oropharyngeal cancer) or paratracheal level (laryngeal cancer), or with contralateral enlarged nodes (laryngeal and oral cavity cancer) are at high risk for developing distant metastases and this subset of patients might benefit from supplementary imaging screening (CT-chest, PET-scan).

Supraglottic carcinoma treated with curative radiation therapy: identification of prognostic groups with MR imaging.

PURPOSE: To retrospectively assess the prognostic meaning of tumor characteristics depicted on pretreatment magnetic resonance (MR) images for local outcome in supraglottic squamous cell carcinoma treated with definitive radiation therapy. MATERIALS AND METHODS: Pretreatment MR images acquired in 84 patients with supraglottic carcinoma treated with curative radiation therapy were reviewed for tumor involvement of laryngeal sites including glottis, subglottis, pre-epiglottic space, laryngeal cartilages, and hypopharynx, and for extralaryngeal extension. The volume of each tumor was estimated, and mean tumor volume was calculated for the group of tumors in each T staging category. RESULTS: Results of univariate analysis showed MR imaging-determined primary tumor volume (P =.03), involvement of pre-epiglottic space (P =.008), abnormal signal intensity in thyroid cartilage (P =.04), and extralaryngeal extension beyond thyroid and/or cricoid cartilage (P =.02) to be significant predictors of local control rate. Results of multivariate analysis with the Cox regression model confirmed statistical significance for invasion of pre-epiglottic space (P =.004) and for abnormal signal intensities in thyroid cartilage adjacent to the anterior commissure (P =.04) and in cricoid cartilage (P =.01). Five-year local control rates were calculated from the regression coefficients of three independent MR imaging prognostic factors, and three prognostic groups were identified on the basis of these control rates. The 5-year local control rate in the high-risk group was 35%, significantly lower than the rates in the intermediate- and low-risk groups (60% and 89%, respectively; P =.002). CONCLUSION: MR imaging-determined pre-epiglottic space involvement and abnormal signal intensities in the thyroid cartilage adjacent to the anterior commissure and/or the cricoid cartilage are strong predictors of local outcome in supraglottic carcinoma treated with definitive radiation therapy.