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Original Investigation |

Accuracy of Computed Tomography in the Prediction of Extracapsular Spread of Lymph Node Metastases in Squamous Cell Carcinoma of the Head and Neck

Raymond L. Chai, MD1; Tanya J. Rath, MD2; Jonas T. Johnson, MD1; Robert L. Ferris, MD, PhD1; Gregory J. Kubicek, MD3; Umamaheswar Duvvuri, MD, PhD1; Barton F. Branstetter IV, MD1,2
[+] Author Affiliations
1Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
2Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
3Department of Radiation Oncology, Cooper University Hospital, Camden, New Jersey
JAMA Otolaryngol Head Neck Surg. 2013;139(11):1187-1194. doi:10.1001/jamaoto.2013.4491.
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Importance  At many institutions, computed tomography with iodinated intravenous contrast medium is the preferred imaging modality for staging of the neck in squamous cell carcinoma of the head and neck. However, few studies have specifically assessed the diagnostic accuracy of computed tomography for determining the presence or absence of extracapsular spread (ECS).

Objective  To determine the accuracy of modern, contrast-enhanced, multidetector computed tomography in the diagnosis of ECS of cervical lymph node metastases from squamous cell carcinoma of the head and neck.

Design, Setting, and Participants  Retrospective observational study at an academic tertiary referral center among 100 consecutive patients between May 1, 2007, and February 1, 2012, who underwent a lateral cervical neck dissection for squamous cell carcinoma of the head and neck with neck metastases of at least 1 cm in diameter on pathologic assessment. Exclusion criteria included malignant neoplasms other than squamous cell carcinoma, a delay in surgery longer than 6 weeks from the time of staging computed tomography, and prior treatment of the neck or recurrent disease or a second primary.

Main Outcomes and Measures  Each patient was independently assigned a subjective score for the presence of ECS by 2 Certificate of Added Qualification–certified neuroradiologists according to a 5-point scale. Receiver operating characteristic curves were generated, and sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for each observer.

Results  The areas under the receiver operating characteristic curve for observers 1 and 2 are 0.678 (95% CI, 0.578-0.768) and 0.621 (95% CI, 0.518-0.716), respectively. For observer 1, the positive and negative predictive values for the detection of ECS were 84% (95% CI, 68%-93%) and 49% (95% CI, 36%-62%), respectively. For observer 2, the positive and negative predictive values for the detection of ECS were 71% (95% CI, 57%-82%) and 48% (95% CI, 32%-64%), respectively.

Conclusions and Relevance  Computed tomography cannot be used to reliably determine the presence of pathologic ECS. Radiologic findings suggestive of ECS should not be relied on for treatment planning in squamous cell carcinoma of the head and neck.

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Figure 1.
False-Positive Interpretation

Contrast-enhanced computed tomographic scan shows a metastatic enlarged right level IIA lymph node (arrow) with central low attenuation, irregular margins, and infiltration of surrounding fat that was incorrectly interpreted as probable extracapsular spread by both observers. No extracapsular spread was present on pathologic examination.

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Figure 2.
False-Negative Interpretation

Contrast-enhanced computed tomographic scan shows a nonenlarged enhancing right level IIA lymph node (arrow) with central low attenuation that was incorrectly interpreted as no extracapsular spread by both observers. Extracapsular spread was found on pathologic examination.

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Figure 3.
Receiver Operating Characteristic Curves Demonstrate Poor Accuracy of Computed Tomography for the Detection of Extracapsular Spread by Both Observers

The areas under the curve for observers 1 and 2 are 0.678 (95% CI, 0.578-0.768) and 0.621 (95% CI, 0.518-0.716), respectively.

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Figure 4.
Matted Lymph Nodes

Contrast-enhanced neck computed tomographic scan shows loss of intervening fat planes among a group of metastatic right level II lymph nodes (arrow) classified as matted. No extracapsular extension of tumor was present on pathologic examination.

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