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Original Investigation
December 29, 2021

Assessment of the Diagnostic Accuracy of Baseline Clinical Examination and Ultrasonographic Imaging for the Detection of Lymph Node Metastasis in Patients With High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck

Author Affiliations
  • 1Department of Dermatology, Erasmus Medical Center Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
  • 2Department of Otolaryngology and Head and Neck Surgery, Erasmus University Medical Center, Rotterdam, Rotterdam, the Netherlands
  • 3Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
  • 4Department of Pathology, Erasmus University Medical Center, Rotterdam, the Netherlands
  • 5Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
JAMA Dermatol. Published online December 29, 2021. doi:10.1001/jamadermatol.2021.4990
Key Points

Question  What is the diagnostic accuracy of clinical examination and baseline ultrasonography for the detection of regional lymph node metastasis in patients with high-risk cutaneous squamous cell carcinoma (SCC) of the head and neck, and what is the diagnostic accuracy of ultrasonography among patients with negative results at clinical examination?

Findings  In this diagnostic study of 246 high-risk cutaneous SCC tumors of the head and neck involving 233 patients, among 22 cytologically confirmed metastases (9%), ultrasonography correctly detected 20 metastases (91%), and clinical examination detected only 11 metastases (50%). In the group of 226 patients with negative results at clinical examination, ultrasonography detected 9 of 11 metastases (82%).

Meaning  This study found that ultrasonography had higher sensitivity than clinical examination for the detection of metastasis among patients with high-risk cutaneous SCC of the head and neck; however, ultrasonography also had a high rate of false-positive results.

Abstract

Importance  Patients with cutaneous squamous cell carcinoma (SCC) of the head and neck may develop lymph node metastasis; therefore, additional workup of the regional lymph nodes in these patients should be considered. However, there is uncertainty regarding the value of baseline ultrasonographic imaging in addition to clinical examination for the detection of metastasis.

Objective  To assess the diagnostic accuracy of clinical examination and baseline ultrasonography for the detection of metastasis among patients with high-risk cutaneous SCC of the head and neck and to assess the accuracy of ultrasonography when baseline clinical examination produces negative results.

Design, Setting, and Participants  This diagnostic study was conducted among a retrospective cohort of 233 patients with 246 high-risk cutaneous SCC tumors of the head and neck. The study included all patients with high-risk cutaneous SCC of the head and neck who received clinical examination and baseline ultrasonographic imaging of their lymph nodes at the Erasmus Medical Center Cancer Institute, a tertiary referral hospital for patients with skin cancer in Rotterdam, the Netherlands, between January 1, 2015, and December 31, 2017. Data were analyzed from October 13, 2020, to September 29, 2021.

Main Outcomes and Measures  Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Fine-needle aspiration cytologic biopsy and 6 months of follow-up per patient were used as the reference standards.

Results  Among 233 patients (176 men [75.5%]; median age, 79.1 years [IQR, 71.5-83.7 years]; data on race and ethnicity were not collected) with 246 high-risk cutaneous SCC tumors of the head and neck, 20 metastases were cytologically confirmed at baseline, and 2 metastases were detected during 6 months of follow-up, yielding a 9% metastasis rate. The sensitivity of clinical examination was 50% (95% CI, 28%-72%), and the specificity was 96% (95% CI, 93%-98%). The PPV and NPV were 55% (95% CI, 36%-72%) and 95% (95% CI, 93%-97%), respectively. In the total cohort, ultrasonography had a sensitivity of 91% (95% CI, 71%-99%) and a specificity of 78% (95% CI, 72%-83%), with a PPV of 29% (95% CI, 23%-35%) and an NPV of 99% (95% CI, 96%-100%). In the group of patients with negative results at baseline clinical examination, 9 of 11 metastases were detected by ultrasonography, with 82% sensitivity (95% CI, 48%-98%); specificity was 79% (95% CI, 73%-84%), PPV was 17% (95% CI, 12%-23%), and NPV was 99% (95% CI, 96%-100%).

Conclusions and Relevance  In this diagnostic study, among a cohort of patients with high-risk cutaneous SCC of the head and neck, baseline ultrasonography was more sensitive than clinical examination alone for the detection of lymph node metastasis. In the setting of a negative result at baseline clinical examination, ultrasonography had high sensitivity for detecting nodal metastases, but this sensitivity should be evaluated against the high rate of false-positive findings.

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