Abstract
Simple SummaryPatients with cervical lymph node metastasis from squamous cell carcinoma undergo extensive irradiation or surgery of the head and neck with higher treatment morbidity, recurrence rate and lower overall survival than patients with overt primary tumor. In order to enhance treatment efficiency and morbidity reduction, the primary tumor detection accuracy was evaluated by using Ultrafast-Dynamic Contrast-Enhancement (DCE-)MRI in addition to Diffusion-Weighted (DW-)MRI and 18F-FDG-PET/CT imaging. Ultrafast-DCE, with a temporal resolution of 4 s, enabled capturing lesions with increased neoangiogenesis or perfusion compared to normal tissue. The use of Ultra-fast DCE resulted in higher confidence for suspicious locations and high observer agreement. Ultrafast-DCE showed potential to improve detection of unknown primary tumors in addition to DWI and 18F-FDG-PET/CT in patients with cervical squamous cell carcinoma lymph node metastasis. The combined use of ultrafast-DCE, DWI and 18F-FDG-PET/CT yielded highest sensitivity.To evaluate diagnostic accuracy of qualitative analysis and interobserver agreement of single ultrafast-DCE, DWI or 18F-FDG-PET and the combination of modalities for the detection of unknown primary tumor (UPT) in patients presenting with cervical lymph node metastasis from squamous cell carcinoma (SCC). Between 2014–2019, patients with histologically proven cervical lymph node metastasis of UPT SCC were prospectively included and underwent DWI, ultrafast-DCE, and 18F-FDG-PET/CT. Qualitative assessment was performed by two observers per modality. Interobserver agreement was calculated using the proportion specific agreement. Diagnostic accuracy of combined use of DWI, ultrafast-DCE and 18F-FDG-PET/CT was assessed. Twenty-nine patients were included (20 males. [68%], median age 60 years). Nine (31%) primary tumors remained occult. Ultrafast-DCE added reader confidence for suspicious locations (one additional true positive (5%), 2 decisive true malignant (10%). The per-location analysis showed highest specific positive agreement for ultrafast-DCE (77.6%). The per-location rating showed highest sensitivity (95%, 95%CI = 75.1–99.9, YI = 0.814) when either one of all modalities was scored positive, and 97.4% (95%CI = 93.5–99.3, YI = 0.774) specificity when co-detected on all. The per-patient analysis showed highest sensitivity (100%) for 18F-FDG-PET/CT (YI = 0.222) and either DWI or PET (YI = 0.111). Despite highest trends, no significant differences were found. The per-patient analysis showed highest specific positive agreement when co-detected on all modalities (55.6%, 95%CI = 21.2–86.3, YI = 0.456). Ultrafast-DCE showed potential to improve detection of unknown primary tumors in addition to DWI and 18F-FDG-PET/CT in patients with cervical squamous cell carcinoma lymph node metastasis. The combined use of ultrafast-DCE, DWI and 18F-FDG-PET/CT yielded highest sensitivity.
Highlights
Head and neck squamous cell carcinoma (HNSCC) presents with cervical lymph node metastasis of an unknown primary tumor (UPT) in up to 9% of patients [1,2,3]
The purpose of this study is to evaluate diagnostic accuracy of qualitative analysis and interobserver agreement of single ultrafast-DCE, DWI or 18 F-FDG-PET and the combination of modalities for the detection of UPT in patients presenting with cervical squamous cell carcinoma (SCC) lymph node metastasis
The performance of imaging and pathology resulted in 20 discovered primary tumor lesions (69%) and in 9 patients (31%) primary tumor remained occult at final diagnosis (Table S1)
Summary
Head and neck squamous cell carcinoma (HNSCC) presents with cervical lymph node metastasis of an unknown primary tumor (UPT) in up to 9% of patients [1,2,3]. Location of primary HNSCC remains occult in 60–80% of patients after extensive diagnostic workup including physical examination and assessment under anesthesia [4]. These UPT patients undergo (chemo)radiotherapy, generally including the whole mucosal area where potentially the occult primary tumor may be hidden, with or without neck dissection [5]. This (too) extensive irradiation results in higher treatment morbidity, recurrence rate and lower overall survival than patients with overt HNSCC [4,5,6]. In tonsillar carcinoma higher ADC values are reported compared with normal (lymphoid) tonsils, which can result in a diminished detection rate, especially in small primary tumors [1,9,10]
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