Radiographic Imaging Does Not Reliably Predict Macroscopic Extranodal Extension in Human Papilloma Virus-Associated Oropharyngeal Cancer

Abstract

Background: Radiographic concern for lymphatic extranodal extension (ENE) impacts upfront management decisions for patients with human papilloma virus (HPV) oropharyngeal squamous cell carcinoma (OPSCC). Therefore, we set out to evaluate the accuracy of preoperative contrast-enhanced computed tomography (CECT) to predict major ENE (> 2 mm). Methods: Twenty-seven consecutive patients with HPV-associated OPSCC who presented at our institutional multidisciplinary tumor board were staged radiographically with positron emission tomography (PET/CT) and CECT, and underwent primary transoral robotic resection and neck dissection. CECT imaging results were correlated with pathologic ENE (pENE). Results: CECT specificity for all pENE was 69 and 75% for radiologist 1 and 2, respectively. For pENE > 2 mm, the sensitivities were 88 and 100%, but specificities were 52.6 and 63.2%. Positive predictive values (PPV) were 43.8 and 53.3%; negative predictive values were 90.9 and 100%. On logistic regression analysis, only size ≥3 cm (OR 4.7–5.4, p < 0.02, 95% CI 1.3–44.0) demonstrated significant correlation with major ENE > 2 mm. Conclusions: Preoperative imaging for HPV-associated OPSCC had a PPV for pENE > 2 mm of 44–55%, based on any interruption in the capsule or invasion into the perinodal fat. The PPV is low and equipoise in treatment decision making for patients with HPV-associated OPSCC may require other imaging characteristics.

Predictive value of computed tomography in identifying extracapsular spread of cervical lymph node metastases in p16 positive oropharyngeal squamous cell carcinoma

“…Multiple studies have investigated the accuracy of CT in identifying ECS, (Table ) however, only a limited number of studies have focused on ECS in P16 + OPSCC which has implications for accuracy due to the differing clinical and radiological features, and for how this knowledge is applied to clinical practice as other cancers, such as cutaneous SCC, are readily amenable to resection. Geltzeiler et al .…”

“…In a smaller cohort study of 27 patients, Patel et al . evaluated the accuracy of CT to predict macroscopic ECS (>2 mm) . For two radiologists, the sensitivities were 88% and 100% (PPV = 43.8 and 53.3%); however, specificities were 52.6% and 63.2% (NPV = 90.9 and 53.3%).…”

Computed tomography performance in predicting extranodal extension in HPV‐positive oropharynx cancer

“…These studies were performed using HNSCC from heterogenous or undefined anatomic subsites and did not account for the role of HPV status. To our knowledge, three studies have investigated the performance of cCT in predicting ENE . Geltzeiler et al found the presence of three or more radiologically suspicious lymph nodes to be strongly associated with ENE (positive predictive value [PPV] = 91%), whereas Patel et al found the interruption of the capsule and invasion into the perinodal fat to be poorly predictive of ENE (PPV = 44–55%).…”

Predictive value of computed tomography in identifying extranodal extension in human papillomavirus‐positive versus human papillomavirus‐negative head and neck cancer

“…Full text review of these articles identified seven studies to be used for qualitative and quantitative analysis. [22][23][24][25][26][27][28] A summary of the search process is shown in Figure 1. All seven studies were of level 2 evidence based on the Oxford Level of Evidence criteria.…”

“…In some cases, evaluating HPV-positive diseases with the same criteria used for HPV-negative disease may have led to inconsistencies among radiologists. 27 There is no standardized method to score rENE. However, commonly used assessment criteria include internal lymph node characteristics, perinodal stranding, irregular nodal margins, matted nodes, gross adjacent invasion, and nodal size.…”