Ultrasound examination of the head and neck

Structure of this thesis Part I deals with basic bio-physics and bio-effects of clinical ultrasound of the head and neck. Furthermore, the ultrasound anatomy of the head and neck is described and illustrated. In addition, the technique of ultrasound guided fine needle aspiration biopsy (UGFNAB) is outlined. In part H the significThe fallibility of palpation and current diagnostic tests to detect subclinical (occult) nodal disease in patients with upper aero-digestive tract cancer results in imperfect staging, improper treatment and delayed identification of recurrences in the neck. With continuous advances in imaging techniques (CT, MRI), the sensitivity for the detection of cervical lymph nodes is true enough increasing, while the specificity for detecting metastasis with these techniques remains low. An ideal diagnostic test should be suitable for screening, demonstrating and excluding cervical metastasis. In addition, the test should have no morbidity. The diagnostic work-up of patients with a head and neck mass is another important diagnostic problem. Although careful history taking and thorough ENT examination may be sufficiently characteristic to permit diagnosis, every clinical diagnosis will be associated with a certain degree of uncertainty. This uncertainty is mainly deterntined by the lintitations of clinical exantination in differentiating between solid and cystic lesions on one hand, and the establishment of exact anatontic properties on the other. In addition, there is a proportion of lesions which, despite thorough diagnostic work-up. remain elusive and are subjected to premature surgical exploration. CT may contribute to the pre-treatment work-up but is associated with several important drawbacks: high costs, lintited availability, radiation exposure and the need to use intravenous contrast. A simple, uniformly reliable, non-invasive and cost-effective test would be beneficial in these cases. The low accuracy of current diagnostic methods in the assessment of cervical nodal disease and the difficulties to evaluate head and neck masses actuated the present study, which started in 1984. By that time small-parts ultrasound transducers had been developed. These high-frequency transducers seemed better suited for examination of the superficial tissues in the head and neck region than earlier ultrasound equipment. In close cooperation between the departments of Radiology and Otorhinolaryngology and Head and Neck Surgery. a prospective study on the value of ultrasound examination of the head and neck was designed. The purpose of this study was to deterntine the values of palpation and ultrasound examination in the assessment of cervical metastatic disease in patients with upper aerodigestive tract cancer and in the evaluation of head and neck masses. An additional purpose of this study was to appraise the adjunctive value of cytologic exantination in the above mentioned clinical problem

Prediction of survival with alternative modeling techniques using pseudo values

Background: The use of alternative modeling techniques for predicting patient survival is complicated by the fact that some alternative techniques cannot readily deal with censoring, which is essential for analyzing survival data. In the current study, we aimed to demonstrate that pseudo values enable statistically appropriate analyses of survival outcomes when used in seven alternative modeling techniques. Methods: In this case study, we analyzed survival of 1282 Dutch patients with newly diagnosed Head and Neck Squamous Cell Carcinoma (HNSCC) with conventional Kaplan-Meier and Cox regression analysis. We subsequently calculated pseudo values to reflect the individual survival patterns. We used these pseudo values to compare recursive partitioning (RPART), neural nets (NNET), logistic regression (LR) general linear models (GLM) and three variants of support vector machines (SVM) with respect to dichotomous 60-month survival, and continuous pseudo values at 60 months or estimated survival time. We used the area under the ROC curve (AUC) and the root of the mean squared error (RMSE) to compare the performance of these models using bootstrap validation. Results: Of a total of 1282 patients, 986 patients died during a median follow-up of 66 months (60-month survival: 52% [95% CI: 50%-55%]). The L

Noncompliance to guidelines in head and neck cancer treatment; associated factors for both patient and physician

Background: Decisions on head and neck squamous cell carcinoma (HNSCC) treatment are widely recognized as being difficult, due to high morbidity, often involving vital functions. Some patients may therefore decline standard, curative treatment. In addition doctors may propose alternative, nonstandard treatments. Little attention is devoted, both in literature and in daily practice, to understanding why and when HNSCC patients or their physicians decline standard, curative treatment modalities. Our objective is to determine factors associated with noncompliance in head and neck cancer treatment for both patients and physicians and to assess the influence of patient compliance on prognosis. Methods: We did a retrospective study based on the medical records of 829 patients with primary HNSCC, who were eligible for curative treatment and referred to our hospital between 2010 and 2012. We analyzed treatment choice and reasons for nonstandard treatment decisions, survival, age, gender, social network, tumor site, cTNM classification, and comorbidity (ACE27). Multivariate analysis using logistic regression methods was performed to determine predictive factors associated with non-standard treatment following physician or patient decision. To gain insight in survival of the different groups of patients, we applied a Cox regression analysis. After checking the proportional hazards assumption for each variable, we adjusted the survival analysis for gender, age, tumor site, tumor stage, comorbidity and a history of having a prior tumor. Results: 17 % of all patients with a primary HNSCC did not receive standard curative treatment, either due to nonstandard treatment advice (10 %) or due to the patient choosing an alternative (7 %). A further 3 % of all patients refused any type of therapy, even though they were considered eligible for curative treatment. Elderliness, single marital status, female gender, high tumor stage and severe comorbidity are predictive factors. Patients declining standard treatment have a lower overall 3-year survival (34 % vs. 70 %). Conclusions: Predictive factors for nonstandard treatment decisions in head and neck cancer treatment differed between the treating physician and the patient. Patients who received nonstandard treatment had a lower overall 3-year survival. These findings should be taken into account when counselling patients in whom nonstandard treatment is considered

Head and neck cancer patients' preferences for individualized prognostic information: a focus group study

BACKGROUND: Head and Neck cancer (HNC) is characterized by significant mortality and morbidity. Treatment is often invasive and interferes with vital functions, resulting in a delicate balance between survival benefit and deterioration in quality of life (QoL). Therefore, including prognostic information during patient counseling can be of great importance. The first aim of this study was to explore HNC patients' preferences for receiving prognostic information: both qualitative (general terms like "curable cancer"), and quantitative information (numbers, percentages). The second aim of this study was to explore patients' views on "OncologIQ", a prognostic model developed to estimate overall survival in newly diagnosed HNC patients. METHODS: We conducted a single center qualitative study by organizing five focus groups with HNC patients (n = 21) and their caregivers (n = 19), categorized in: 1) small laryngeal carcinomas treated with radiotherapy or laser, 2) extensive oral cavity procedures, 3) total laryngectomy, 4) chemoradiation, 5) other treatments. The patients' perspective was the main focus. The interview guide consiste

Development and validation of Raman spectroscopic classification models to discriminate tongue squamous cell carcinoma from non-tumorous tissue

Background Currently, up to 85% of the oral resection specimens have inadequate resection margins, of which the majority is located in the deeper soft tissue layers. The prognosis of patients with oral cavity squamous cell carcinoma (OCSCC) of the tongue is negatively affected by these inadequate surgical resections. Raman spectroscopy, an optical technique, can potentially be used for intra-operative evaluation of resection margins. Objective To develop in vitro Raman spectroscopy-based tissue classification models that discriminate OCSCC of the tongue from (subepithelial) non-tumorous tissue. Materials and methods Tissue classification models were developed using Principal Components Analysis (PCA) followed by (hierarchical) Linear Discriminant Analysis ((h)LDA). The models were based on a training set of 720 histopathologically annotated Raman spectra, obtained from 25 tongue samples (11 OCSCC and 14 normal) of 10 patients, and were validated by means of an independent validation set of 367 spectra, obtained from 19 tongue samples (6 OCSCC and 13 normal) of 11 patients. Results A PCA-LDA tissue classification model ‘tumor’ versus ‘non-tumorous tissue’ (i.e. surface squamous epithelium, connective tissue, muscle, adipose tissue, gland and nerve) showed an accuracy of 86% (sensitivity: 100%, specificity: 66%). A two-step PCA-hLDA tissue classification model ‘tumor’ versus ‘non-tumorous tissue’ showed an accuracy of 91%

Assessing hearing loss in older adults with a single question and person characteristics; Comparison with pure tone audiometry in the Rotterdam Study

INTRODUCTION: Hearing loss (HL) is a frequent problem among the elderly and has been studied in many cohort studies. However, pure tone audiometry-the gold standard-is rather time-consuming and costly for large population-based studies. We have investigated if self-reported hearing loss, using a multiple choice question, can be used to assess HL in absence of pure tone audiometry. METHODS: This study was performed within 4,906 participants of the Rotterdam Study. The question (in Dutch) that was investigated was: 'Do you have any difficulty with your hearing (without hearing aids)?'. The answer options were: 'never', 'sometimes', 'often' and 'daily'. Mild hearing loss or worse was defined as PTA0.5-4(Pure Tone Average 0.5, 1, 2 & 4 kHz) ≥20dBHL and moderate HL or worse as ≥35dBHL. A univariable linear regression model was fitted with the PTA0.5-4 and the answer to the question. Subsequently, sex, age and education were added in a multivariable linear regression model. The ability of the question to classify HL, accounting for sex, age and education, was explored through logistic regression models creating prediction estimates, which were plotted in ROC curves. RESULTS: The variance explained (R2) by the univariable regression was 0.37, which increased substantially after adding age (R2 = 0.60). The addition of sex and educational level, however, did not alter the R2 (0.61). The ability of the question to classify hearing loss, reflec

Progression of Hearing Loss in the Aging Population: Repeated Auditory Measurements in the Rotterdam Study

We quantified changes in the auditory acuity of 675 aging adults (mean age 71.1 years, 52.0% female, mean follow-up 4.4 years ± 0.2) of an ongoing cohort study with a pure-tone audiogram and a speech-in-noise test. Generalized estimating equation models were used to study the association between hearing loss and the progression with age, sex, education, cognition, BMI, blood pressure, having type 2 diabetes mellitus, cholesterol ratio, smoking and alcohol consumption. The mean progression of hearing loss was 0.29 and 1.35 dB/year (low and high frequencies). Progression of hearing loss was associated with baseline hearing thresholds. Besides, the presence of type 2 diabetes, smoking, age, sex and time were associated with worse hearing at baseline, but there was no statistical evidence that the tested determinants were associated with progression of hearing loss. This finding indicates that the 4-year progression of hearing loss in older adults in this study is not influenced by the measured determinants. More research with multiple follow-up rounds is desired

Treatments and costs for recurrent and/or metastatic squamous cell carcinoma of the head and neck in the Netherlands

__Abstract__ For patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN), chemotherapy can prolong life and alleviate symptoms. However, expected gains may be small, not necessarily outweighing considerable toxicity and high costs. Treatment choice is to a large extent dependent on preferences of doctors and patients and data on these choices are scarce. The purpose of this study is to obtain real-world information on palliative systemic treatment and costs of R/M SCCHN in the Netherlands. In six Dutch head and neck treatment centers, data were collected on patient and tumor characteristics, treatment patterns, disease progression, survival, adverse events, and resource use for R/M SCCHN, between 2006 and 2013. 125 (14 %) out of 893 R/M SCCHN patients received palliative, non-trial first-line systemic treatment, mainly platinum + 5FU + cetuximab (32 %), other platinum-based combination therapy (13 %), methotrexate monotherapy (27 %) and capecitabine monotherapy (14 %). Median progression-free survival and overall survival were 3.4 and 6.0 months, respectively. 34 (27 %) patients experienced severe adverse events. Mean total hospital costs ranged from €10,075 (±€9,891) (methotrexate monotherapy) to €39,459 (±€21,149) (platinum + 5FU + cetuximab). Primary cost drivers were hospital stays and anticancer drug treatments. Major health care utilization and costs are involved in systemically treating R/M SCCHN patients with a limited survival

Corrigendum: Hearing impairment is associated with smaller brain volume in aging

In the original article, Roshchupkin et al. (2016) was not cited in the article. The citation has now been inserted in Materials and Methods, subsection Brain MRI Acquisition and Processing, second paragraph and should read: Voxel based morphometry (VBM) was performed according to an optimized VBM protocol (Good et al., 2001) and was previously described (Roshchupkin et al., 2016). FSL software (Smith et al., 2004) was used for VBM data processing, all GM and WM density maps were non-linearly registered to the standard ICBM MNI152 GM and WM template (Montreal Neurological Institute) with a 1 mm × 1 mm × 1 mm voxel resolution. Subsequently, a spatial modulation and smoothing procedure with 3 mm (FWHM 8 mm) isotropic Gaussian kernel were applied to all images. The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

Optical detection of field cancerization in the buccal mucosa of patients with esophageal cancer

Introduction: Esophageal cancer is an increasingly common type of neoplasm with a very poor prognosis. This prognosis could improve with more early tumor detection. We have previously shown that we can use an optical spectroscopy to detect field cancerization in the buccal mucosa of patients with laryngeal cancer. The aim of this prospective study was to investigate whether we could detect field cancerization of buccal mucosa of patients with esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC). Methods: Optical measurements were performed in vivo using a novel optical technique: multidiameter single-fiber reflectance (MDSFR) spectroscopy. MDSFR spectra were acquired by a handheld probe incorporating three fiber diameters. Multiple absorption and scattering parameters that are related to the physiological and ultrastructural properties of the buccal mucosa were derived from these spectra. A linear discriminant analysis of the parameters was performed to create a combined biomarker σ to discriminate oncologic from non-oncologic patients. Results: Twelve ESCC, 12 EAC, and 24 control patients were included in the study. The median value of our biomarker σ was significantly higher in patients with ESCC (2.07 [1.93-2.10]) than control patients (1.86 [1.73-1.95], p = 0.022). After cross-validation σ was able to identify ESCC patients with a sensitivity of 66.7% and a specificity of 70.8%. There were no significant differences between the EAC group and the control group. Conclusion: Field cancerization in the buccal mucosa can be detected using optical spectroscopy in ESCC patients. This may be the first step towards non-invasive ESCC cancer screening