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10.5005/jp-journals-10011-1105
Ankur
Aggarwal ARTICLE
et al
ORIGINAL
Grayscale Ultrasonography in the Assessment
of Regional Lymph Nodes in Oral Cancer and
its Correlation with TNM Staging and FNAC
1
1
Ankur Aggarwal, 2M Jonathan Daniel, 3SV Srinivasan, 4Charles P Sargouname
Junior Resident, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of
Dental Sciences, Puducherry, India
2
Professor and Head, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of
Dental Sciences, Puducherry, India
3
Associate Professor, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of
Dental Sciences, Puducherry, India
4
Specialist Grade II Radiologist, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry, India
Correspondence: Ankur Aggarwal, Junior Resident, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate
Institute of Dental Sciences, Puducherry-605006, India, e-mail: [email protected]
ABSTRACT
Objectives: The purpose of the study was to evaluate the role of grayscale ultrasound (US) in differentiation of benign from malignant lymph
nodes in oral cancer patients and to correlate the ultrasonographic features with TNM staging and FNAC findings of cervicofacial lymph
nodes.
Methods: In the study, 34 patients with histopathologically proved oral cancer presenting with enlarged superficial cervicofacial
lymphadenopathy were included. The clinical, ultrasonographic and fine needle aspiration cytology (FNAC) findings were compared in
these patients. Patients were assessed for presence of nodes, their size, ratio of maximum longitudinal diameter to maximum transverse
diameter (L/T) and echogenicity. All patients then underwent fine needle aspiration cytology of the lymph nodes and the slides were
examined for the presence of malignant cells.
Results: It was found that ultrasonography had assessed the status of 28 nodes positively out of 34 nodes for metastasis when compared
with results of FNAC. Thus, ultrasonography had a sensitivity of 75% and specificity of 86% in detecting the metastatic nodes when
compared with FNAC taken as standard in the detection of metastatic nodes.
Conclusion: The lymph node status can be assessed successfully by ultrasonography preoperatively for the presence of metastasis in
majority of cases. Therefore, ultrasonography was found to be efficient and cost-effective preoperatively, in planning appropriate management
in oral cancer patients.
Keywords: Ultrasonography, Lymph node, Fine needle aspiration cytology.
INTRODUCTION
Regional lymph node status in oral cancer patients is of
paramount prognostic significance. Patients who present with
tumors localized at the primary site without dissemination to
regional lymph nodes have excellent prognosis. On the other
hand, once dissemination to regional lymph nodes takes place,
the probability of 5-year survivorship, regardless of the
treatment rendered, reduces to nearly half of that seen in early
staged patients.1,5,6 The inadequacy of physical palpation in
examination of regional lymph nodes is well-documented and
other investigations, like computed tomography, magnetic
resonance imaging and newer positron emission tomography
are expensive for the average income patient in our country.
Ultrasonography being a noninvasive and radiation free
modality can be used as a powerful tool in assessment of regional
lymph nodes in oral cancer.4,7 Hence, the study was undertaken
with the following aim and objective: (1) To evaluate the role
of grayscale ultrasonography in differentiation of benign from
104
malignant lymph nodes in oral cancer patients. (2) To correlate
the ultrasonographic features with TNM staging and FNAC
findings of cervicofacial lymph nodes.
MATERIALS AND METHODS
A total of 34 patients were included in the study. Patients with
histopathologically proved oral cancer and oral cancer
presenting with enlarged cervicofacial lymph nodes were
included in the study. Other known causes for cervicofacial
lymphadenopathy like oral infection, tuberculosis, sarcoidosis
etc. were excluded. Patients presenting with enlarged palpable
cervicofacial lymph node were subjected to clinical examination
and TNM staging was done. Clinical criteria used for
differentiating malignant nodes were: (i) Lymph node with
approximate size larger than 1 cm in diameter; (ii) a hard, stony
hard or indurated consistency; (iii) fixation to underlying
structures, implying that the tumor cells had invaded through
the capsule of the lymph node. The patients were subjected to
JAYPEE
JIAOMR
Grayscale Ultrasonography in the Assessment of Regional Lymph Nodes in Oral Cancer and its Correlation with TNM Staging and FNAC
ultrasonographic examination. If more than one node were
present then the node with largest diameter was subjected to
further investigation. The node was assessed for nodal diameter,
ratio of maximum longitudinal diameter to maximum transverse
diameter (L/T) and echogenicity of the lymph node. Based on
the echogenicity, the lymph node was classified as either
homogeneous (Fig. 1) or heterogeneous (Fig. 2).
Following the ultrasonographic examination, the lymph
nodes showing lower value of L/T (Fig. 3) (which tend to have
round shape) and heterogenecity were considered as probable
metastatic nodes and subjected to the fine needle aspiration
cytology test. Each lymph node was evaluated pathologically
with an emphasis on the presence or absence of malignant cells
in the smear by an experienced pathologist.
For comparison of nodal diameter, echogenicity of node
and ratio of maximum longitudinal to transverse diameter,
t-test was applied within each group and in order to correlate
the ultrasonographic features with TNM staging and FNAC
findings, Chi-square test was done within each group.
RESULTS
Since the p-value is less than 0.05, so the difference between
the two groups was found to be statistically significant. This
test leads to the conclusion that the heterogeneous lymph nodes
tend to have greater nodal diameter than the homogeneous group
of lymph nodes (Table 1).
Although the values in Table 2 show that the heterogeneous
group of lymph nodes is having L/T value lesser than the
homogeneous group, the difference between the two groups
was not found to be statistically significant with p-value > 0.05
(0.2076) (Table 2).
There was significant correlation between the findings of
clinical and ultrasonographic examination as both have detected
the N1 and N2 status equally and it was found to be statistically
significant with p < 0.05 (Table 3).
There was significant correlation between the findings of
ultrasonographic examination and FNAC results for detection
of metastasis (M) and it was found to be statistically significant
with p-value less than 0.05 (0.0007) (Table 4). Ultrasonography
had a sensitivity of 75% and specificity of 86% in detecting the
metastatic nodes when compared with FNAC taken as standard
for detection of metastatic nodes.
DISCUSSION
Fig. 1: Homogeneous node
Fig. 2: Heterogeneous node
For the evaluation of lymph nodes, ultrasound scanning has
one particular advantage over all other axial imaging methods,
in that it allows free rotation of the scanning plane and easy
identification of the largest diameter of a node, which has been
suggested to be an objective criterion for characterizing
malignant lymph nodes.2
Our study showed that there is significant correlation
between size of the node and heterogenecity of the lymph node
which has been found to be a good indicator of the involvement
of node by metastatic cells as it will alter the normal pattern of
echogenicity of the lymph node.8,9
In reactive nodal disease, the pathogen (microorganism or
cellular debris) initially reaches the nodal cortex and induces
lymphocyte proliferation within lymphoid follicles and
Fig. 3: AB–transverse diameter; CD–longitudinal diameter;
L/T = CD/AB
Journal of Indian Academy of Oral Medicine and Radiology, April-June 2011;23(2):104-107
105
Ankur Aggarwal et al
sinusoidal enlargement and margination of macrophages, which
lead to widening of the cortex. In malignant disease, however,
the changes occurring within the lymph node are somewhat
different in nature. The process involves infiltration of the node
by malignant tissue, which is more likely to result in early
distortion of internal nodal architecture showing as
heterogenecity on ultrasound.3,10 Out of total 11 metastatic
nodes in our study, eight were found to depict this feature on
ultrasonographic examination.
Our study has shown that the grayscale ultrasonography can
be used to assess the suspicious node. Out of 34 cases, grayscale
ultrasonography positively assessed the node in 28 cases (20
cases being nonmetastatic and 8 being metastatic) when
compared with FNAC findings. Thus, in our study ultrasonography was found to have a sensitivity of 75% and
specificity of 86% in detecting the metastatic nodes.
Although our study did not show statistically significant
correlation between L/T values as compared to echogenicity of
node, it showed that heterogeneous nodes tend to have lesser
value of L/T parameter. Luigi Solbiati et al (1992) concluded
that 71% of nodes with L/T smaller than 1.5 (roundish shape)
are malignant, whereas 84% of nodes with L/T value greater
than 2 (oval shape) are benign.
The best method and current reference standard for staging
lymph node metastases is histopathologic examination, which
is the gold standard. Ophelia Dsouza et al (2000) conducted
the clinical, ultrasonographic and histopathological examination
of cervical lymph nodes in head and neck cancer patients and
concluded that ultrasonography had a sensitivity of 47.6% and
specificity of 77.7%.11 However, this is an invasive surgical
procedure in which complications and morbidity may occur. In
our study we have used a combination of noninvasive
(ultrasonography) and a minimally invasive (FNAC) technique
causing minimal discomfort for the patient. To the best of our
knowledge, our study is the first of its kind correlating grayscale
ultrasonography with TNM staging and FNAC findings in the
assessment of metastatic node in oral cancer. Thus, the results
of our study may be considered to be valid in assessing the
metastatic lymph nodes by noninvasive grayscale ultrasonography in oral cancer patients.
One disadvantage of ultrasonography is that the changes in
internal architecture of the lymph nodes cannot be recognized
in deeper lymph nodes. The possible explanations for this can
be the decreasing contrast resolution because of signal
attenuation with increasing distance of the object of interest
from US probe and the poorer spatial resolution of US probes
used for analyzing deeper structure.
CONCLUSION
Our study led to the conclusion that there is a significant relation
between the size of the node and echogenicity of the node. Both
of these parameters may be used to assess the metastatic nodes.
Its significance lies in the fact that the lymph node status can be
assessed successfully by ultrasonography preoperatively, and
Table. 1: Comparison of mean nodal diameter of cases with homogeneous and heterogeneous findings
Findings
Mean ± SD
Homogeneous
9.65 ± 1.62
Heterogeneous
15.16 ± 4.52
t-value
p-value
– 5.16
0.0001
Table. 2: Comparison of mean L/T of cases with homogeneous and heterogeneous findings
Findings
Mean ± SD
Homogeneous
1.69 ± 0.43
Heterogeneous
1.48 ± 0.43
t-value
p-value
1.29
0.2076
Table. 3: Comparison of values of N after clinical and ultrasonographic examination
Clinical
Ultrasound
N1
N2
N1
19
0
N2
0
15
t-value
p-value
33
0.0001
Table. 4: Comparison of values of M after ultrasonographic examination and FNAC results
Ultrasound
FNAC results
Non-metastatic
106
t-value
p-value
11.52
0.0007
Metastatic
Non-metastatic
20
3
Metastatic
3
8
JAYPEE
JIAOMR
Grayscale Ultrasonography in the Assessment of Regional Lymph Nodes in Oral Cancer and its Correlation with TNM Staging and FNAC
the need for extensive surgeries like commando operation can
be obviated in some cases and the treatment can be rendered in
a more precise manner reducing the morbidity and improving
the prognosis.
With advances in technology now, other forms of
ultrasonography, such as contrast-enhanced grayscale
ultrasonography,12 color Doppler sonography, power Doppler
sonography and real time ultrasound elastography 13 are
available, which may be used for more accurate assessment of
metastatic nodes. Future studies with advanced forms of
ultrasonography need to be done as ultrasonography is a costeffective, radiation free modality which can be used easily at
the bed side of the patient and can be repeated at regular intervals
on patients without causing any radiation hazard.
REFERENCES
1. Shah Jatin p, Johnson Newell W, Batsakis John G. Book on
oral cancer (1st ed) 2003.
2. Pierre Vassalo, Karl Wernecke. Differentiation of benign from
malignant superficial lymphadenopathy: The role of high
resolution US. Radiology 1992;183:215-20.
3. Ahuja A, Ying M. The use of sonography in differentiating
cervical lymphomatous lymph nodes from cervical metastatic
lymph nodes. Clinical Radiology 1996;51:186-90.
4. Ahuja A, King Ann. Lymph node hilus: Grayscale and power
Doppler sonography of cervical nodes. J Ultrasound Med
2001;20:987-92.
5. Calabrese L, Bruschini R. Role of sentinel lymph node biopsy
in oral cancer. Acta Otorhinolaryngol Ital 2006;26:345-49.
6. Michael Ying, Anil Ahuja. Ultrasound evaluation of neck lymph
nodes. Asum ultrasound bulletin Aug 2003;6(3).
7. Ahuja Anil, Ying Michael. An overview of neck node
sonography. Investigative radiology June 2002;37(6):333-42.
8. Hayashi Takafumi, Ito Jusuke. The clinical significance of
follow-up sonography in the detection of cervical lymph node
metastases in patients with stage I or II squamous cell carcinoma
of the tongue. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2003;96:112-17.
9. Solbiati Luigi, Cioffi Vincenzo. Ultrasonography of the neck.
Radiologic Clinic of North America Sep 1992;30(5).
10. To EWH, Tsang WM. Is neck ultrasound necessary for early
stage oral tongue carcinoma with clinically no neck? Dentomaxillofacial Radiology 2003;32:156-59.
11. D’Souza Ophelia, Hasan Suhel. Cervical lymph node metastases
in head and neck malignancy: A clinical/ultrasonographic/
histopathological comparative study. Indian Journal of
Otolaryngology and Head and Neck Surgery 2003;55(2):
90-93.
12. Roberto Stramare, Elena Scagliori. The role of contrast-enhanced
grayscale. Ultrasonography in the differential diagnosis of
superficial lymph nodes. Ultrasound Quarterly Mar
2010;26(1):45-51.
13. Bhatia Kunwar SS, Carmen CM. Cho real-time qualitative
ultrasound elastography of cervical lymph nodes in routine
clinical practice: Interobserver agreement and correlation with
malignancy. Ultrasound in Medicine and Biology Dec
2010;36(12):1990-97.
Journal of Indian Academy of Oral Medicine and Radiology, April-June 2011;23(2):104-107
107
Ankur
Aggarwal ARTICLE
et al
ORIGINAL
Grayscale Ultrasonography in the Assessment
of Regional Lymph Nodes in Oral Cancer and
its Correlation with TNM Staging and FNAC
1
1
Ankur Aggarwal, 2M Jonathan Daniel, 3SV Srinivasan, 4Charles P Sargouname
Junior Resident, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of
Dental Sciences, Puducherry, India
2
Professor and Head, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of
Dental Sciences, Puducherry, India
3
Associate Professor, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of
Dental Sciences, Puducherry, India
4
Specialist Grade II Radiologist, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry, India
Correspondence: Ankur Aggarwal, Junior Resident, Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate
Institute of Dental Sciences, Puducherry-605006, India, e-mail: [email protected]
ABSTRACT
Objectives: The purpose of the study was to evaluate the role of grayscale ultrasound (US) in differentiation of benign from malignant lymph
nodes in oral cancer patients and to correlate the ultrasonographic features with TNM staging and FNAC findings of cervicofacial lymph
nodes.
Methods: In the study, 34 patients with histopathologically proved oral cancer presenting with enlarged superficial cervicofacial
lymphadenopathy were included. The clinical, ultrasonographic and fine needle aspiration cytology (FNAC) findings were compared in
these patients. Patients were assessed for presence of nodes, their size, ratio of maximum longitudinal diameter to maximum transverse
diameter (L/T) and echogenicity. All patients then underwent fine needle aspiration cytology of the lymph nodes and the slides were
examined for the presence of malignant cells.
Results: It was found that ultrasonography had assessed the status of 28 nodes positively out of 34 nodes for metastasis when compared
with results of FNAC. Thus, ultrasonography had a sensitivity of 75% and specificity of 86% in detecting the metastatic nodes when
compared with FNAC taken as standard in the detection of metastatic nodes.
Conclusion: The lymph node status can be assessed successfully by ultrasonography preoperatively for the presence of metastasis in
majority of cases. Therefore, ultrasonography was found to be efficient and cost-effective preoperatively, in planning appropriate management
in oral cancer patients.
Keywords: Ultrasonography, Lymph node, Fine needle aspiration cytology.
INTRODUCTION
Regional lymph node status in oral cancer patients is of
paramount prognostic significance. Patients who present with
tumors localized at the primary site without dissemination to
regional lymph nodes have excellent prognosis. On the other
hand, once dissemination to regional lymph nodes takes place,
the probability of 5-year survivorship, regardless of the
treatment rendered, reduces to nearly half of that seen in early
staged patients.1,5,6 The inadequacy of physical palpation in
examination of regional lymph nodes is well-documented and
other investigations, like computed tomography, magnetic
resonance imaging and newer positron emission tomography
are expensive for the average income patient in our country.
Ultrasonography being a noninvasive and radiation free
modality can be used as a powerful tool in assessment of regional
lymph nodes in oral cancer.4,7 Hence, the study was undertaken
with the following aim and objective: (1) To evaluate the role
of grayscale ultrasonography in differentiation of benign from
104
malignant lymph nodes in oral cancer patients. (2) To correlate
the ultrasonographic features with TNM staging and FNAC
findings of cervicofacial lymph nodes.
MATERIALS AND METHODS
A total of 34 patients were included in the study. Patients with
histopathologically proved oral cancer and oral cancer
presenting with enlarged cervicofacial lymph nodes were
included in the study. Other known causes for cervicofacial
lymphadenopathy like oral infection, tuberculosis, sarcoidosis
etc. were excluded. Patients presenting with enlarged palpable
cervicofacial lymph node were subjected to clinical examination
and TNM staging was done. Clinical criteria used for
differentiating malignant nodes were: (i) Lymph node with
approximate size larger than 1 cm in diameter; (ii) a hard, stony
hard or indurated consistency; (iii) fixation to underlying
structures, implying that the tumor cells had invaded through
the capsule of the lymph node. The patients were subjected to
JAYPEE
JIAOMR
Grayscale Ultrasonography in the Assessment of Regional Lymph Nodes in Oral Cancer and its Correlation with TNM Staging and FNAC
ultrasonographic examination. If more than one node were
present then the node with largest diameter was subjected to
further investigation. The node was assessed for nodal diameter,
ratio of maximum longitudinal diameter to maximum transverse
diameter (L/T) and echogenicity of the lymph node. Based on
the echogenicity, the lymph node was classified as either
homogeneous (Fig. 1) or heterogeneous (Fig. 2).
Following the ultrasonographic examination, the lymph
nodes showing lower value of L/T (Fig. 3) (which tend to have
round shape) and heterogenecity were considered as probable
metastatic nodes and subjected to the fine needle aspiration
cytology test. Each lymph node was evaluated pathologically
with an emphasis on the presence or absence of malignant cells
in the smear by an experienced pathologist.
For comparison of nodal diameter, echogenicity of node
and ratio of maximum longitudinal to transverse diameter,
t-test was applied within each group and in order to correlate
the ultrasonographic features with TNM staging and FNAC
findings, Chi-square test was done within each group.
RESULTS
Since the p-value is less than 0.05, so the difference between
the two groups was found to be statistically significant. This
test leads to the conclusion that the heterogeneous lymph nodes
tend to have greater nodal diameter than the homogeneous group
of lymph nodes (Table 1).
Although the values in Table 2 show that the heterogeneous
group of lymph nodes is having L/T value lesser than the
homogeneous group, the difference between the two groups
was not found to be statistically significant with p-value > 0.05
(0.2076) (Table 2).
There was significant correlation between the findings of
clinical and ultrasonographic examination as both have detected
the N1 and N2 status equally and it was found to be statistically
significant with p < 0.05 (Table 3).
There was significant correlation between the findings of
ultrasonographic examination and FNAC results for detection
of metastasis (M) and it was found to be statistically significant
with p-value less than 0.05 (0.0007) (Table 4). Ultrasonography
had a sensitivity of 75% and specificity of 86% in detecting the
metastatic nodes when compared with FNAC taken as standard
for detection of metastatic nodes.
DISCUSSION
Fig. 1: Homogeneous node
Fig. 2: Heterogeneous node
For the evaluation of lymph nodes, ultrasound scanning has
one particular advantage over all other axial imaging methods,
in that it allows free rotation of the scanning plane and easy
identification of the largest diameter of a node, which has been
suggested to be an objective criterion for characterizing
malignant lymph nodes.2
Our study showed that there is significant correlation
between size of the node and heterogenecity of the lymph node
which has been found to be a good indicator of the involvement
of node by metastatic cells as it will alter the normal pattern of
echogenicity of the lymph node.8,9
In reactive nodal disease, the pathogen (microorganism or
cellular debris) initially reaches the nodal cortex and induces
lymphocyte proliferation within lymphoid follicles and
Fig. 3: AB–transverse diameter; CD–longitudinal diameter;
L/T = CD/AB
Journal of Indian Academy of Oral Medicine and Radiology, April-June 2011;23(2):104-107
105
Ankur Aggarwal et al
sinusoidal enlargement and margination of macrophages, which
lead to widening of the cortex. In malignant disease, however,
the changes occurring within the lymph node are somewhat
different in nature. The process involves infiltration of the node
by malignant tissue, which is more likely to result in early
distortion of internal nodal architecture showing as
heterogenecity on ultrasound.3,10 Out of total 11 metastatic
nodes in our study, eight were found to depict this feature on
ultrasonographic examination.
Our study has shown that the grayscale ultrasonography can
be used to assess the suspicious node. Out of 34 cases, grayscale
ultrasonography positively assessed the node in 28 cases (20
cases being nonmetastatic and 8 being metastatic) when
compared with FNAC findings. Thus, in our study ultrasonography was found to have a sensitivity of 75% and
specificity of 86% in detecting the metastatic nodes.
Although our study did not show statistically significant
correlation between L/T values as compared to echogenicity of
node, it showed that heterogeneous nodes tend to have lesser
value of L/T parameter. Luigi Solbiati et al (1992) concluded
that 71% of nodes with L/T smaller than 1.5 (roundish shape)
are malignant, whereas 84% of nodes with L/T value greater
than 2 (oval shape) are benign.
The best method and current reference standard for staging
lymph node metastases is histopathologic examination, which
is the gold standard. Ophelia Dsouza et al (2000) conducted
the clinical, ultrasonographic and histopathological examination
of cervical lymph nodes in head and neck cancer patients and
concluded that ultrasonography had a sensitivity of 47.6% and
specificity of 77.7%.11 However, this is an invasive surgical
procedure in which complications and morbidity may occur. In
our study we have used a combination of noninvasive
(ultrasonography) and a minimally invasive (FNAC) technique
causing minimal discomfort for the patient. To the best of our
knowledge, our study is the first of its kind correlating grayscale
ultrasonography with TNM staging and FNAC findings in the
assessment of metastatic node in oral cancer. Thus, the results
of our study may be considered to be valid in assessing the
metastatic lymph nodes by noninvasive grayscale ultrasonography in oral cancer patients.
One disadvantage of ultrasonography is that the changes in
internal architecture of the lymph nodes cannot be recognized
in deeper lymph nodes. The possible explanations for this can
be the decreasing contrast resolution because of signal
attenuation with increasing distance of the object of interest
from US probe and the poorer spatial resolution of US probes
used for analyzing deeper structure.
CONCLUSION
Our study led to the conclusion that there is a significant relation
between the size of the node and echogenicity of the node. Both
of these parameters may be used to assess the metastatic nodes.
Its significance lies in the fact that the lymph node status can be
assessed successfully by ultrasonography preoperatively, and
Table. 1: Comparison of mean nodal diameter of cases with homogeneous and heterogeneous findings
Findings
Mean ± SD
Homogeneous
9.65 ± 1.62
Heterogeneous
15.16 ± 4.52
t-value
p-value
– 5.16
0.0001
Table. 2: Comparison of mean L/T of cases with homogeneous and heterogeneous findings
Findings
Mean ± SD
Homogeneous
1.69 ± 0.43
Heterogeneous
1.48 ± 0.43
t-value
p-value
1.29
0.2076
Table. 3: Comparison of values of N after clinical and ultrasonographic examination
Clinical
Ultrasound
N1
N2
N1
19
0
N2
0
15
t-value
p-value
33
0.0001
Table. 4: Comparison of values of M after ultrasonographic examination and FNAC results
Ultrasound
FNAC results
Non-metastatic
106
t-value
p-value
11.52
0.0007
Metastatic
Non-metastatic
20
3
Metastatic
3
8
JAYPEE
JIAOMR
Grayscale Ultrasonography in the Assessment of Regional Lymph Nodes in Oral Cancer and its Correlation with TNM Staging and FNAC
the need for extensive surgeries like commando operation can
be obviated in some cases and the treatment can be rendered in
a more precise manner reducing the morbidity and improving
the prognosis.
With advances in technology now, other forms of
ultrasonography, such as contrast-enhanced grayscale
ultrasonography,12 color Doppler sonography, power Doppler
sonography and real time ultrasound elastography 13 are
available, which may be used for more accurate assessment of
metastatic nodes. Future studies with advanced forms of
ultrasonography need to be done as ultrasonography is a costeffective, radiation free modality which can be used easily at
the bed side of the patient and can be repeated at regular intervals
on patients without causing any radiation hazard.
REFERENCES
1. Shah Jatin p, Johnson Newell W, Batsakis John G. Book on
oral cancer (1st ed) 2003.
2. Pierre Vassalo, Karl Wernecke. Differentiation of benign from
malignant superficial lymphadenopathy: The role of high
resolution US. Radiology 1992;183:215-20.
3. Ahuja A, Ying M. The use of sonography in differentiating
cervical lymphomatous lymph nodes from cervical metastatic
lymph nodes. Clinical Radiology 1996;51:186-90.
4. Ahuja A, King Ann. Lymph node hilus: Grayscale and power
Doppler sonography of cervical nodes. J Ultrasound Med
2001;20:987-92.
5. Calabrese L, Bruschini R. Role of sentinel lymph node biopsy
in oral cancer. Acta Otorhinolaryngol Ital 2006;26:345-49.
6. Michael Ying, Anil Ahuja. Ultrasound evaluation of neck lymph
nodes. Asum ultrasound bulletin Aug 2003;6(3).
7. Ahuja Anil, Ying Michael. An overview of neck node
sonography. Investigative radiology June 2002;37(6):333-42.
8. Hayashi Takafumi, Ito Jusuke. The clinical significance of
follow-up sonography in the detection of cervical lymph node
metastases in patients with stage I or II squamous cell carcinoma
of the tongue. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2003;96:112-17.
9. Solbiati Luigi, Cioffi Vincenzo. Ultrasonography of the neck.
Radiologic Clinic of North America Sep 1992;30(5).
10. To EWH, Tsang WM. Is neck ultrasound necessary for early
stage oral tongue carcinoma with clinically no neck? Dentomaxillofacial Radiology 2003;32:156-59.
11. D’Souza Ophelia, Hasan Suhel. Cervical lymph node metastases
in head and neck malignancy: A clinical/ultrasonographic/
histopathological comparative study. Indian Journal of
Otolaryngology and Head and Neck Surgery 2003;55(2):
90-93.
12. Roberto Stramare, Elena Scagliori. The role of contrast-enhanced
grayscale. Ultrasonography in the differential diagnosis of
superficial lymph nodes. Ultrasound Quarterly Mar
2010;26(1):45-51.
13. Bhatia Kunwar SS, Carmen CM. Cho real-time qualitative
ultrasound elastography of cervical lymph nodes in routine
clinical practice: Interobserver agreement and correlation with
malignancy. Ultrasound in Medicine and Biology Dec
2010;36(12):1990-97.
Journal of Indian Academy of Oral Medicine and Radiology, April-June 2011;23(2):104-107
107
