Reinterpretation of cross-sectional images in patients with head and neck cancer in the setting of a multidisciplinary cancer center

Abstract

Background and purpose: Patients referred to tertiary care centers frequently arrive with images obtained at outside institutions; these images require reinterpretation. We assessed the clinical value of reinterpreting cross-sectional imaging studies of patients with head and neck cancer, in the setting of a multidisciplinary cancer center.

Methods: Outside CT and MR images of 136 patients with known or presumed head and neck cancer were reinterpreted by a neuroradiologist. Clinical history and findings on physical examination were available. Reinterpretation was performed before review of outside reports, which were subsequently compared with those generated at the cancer center. Changes in interpretation were noted, and their effects on TNM staging, patient care, and prognosis were assessed. Reliability and statistical significance of rates of change in diagnosis were analyzed with 95% confidence intervals (CIs) and the sign test, respectively. Verification of change in diagnosis was confirmed by pathologic analysis (75%), characteristic radiologic findings (18%), or clinical and imaging follow-up (7%).

Results: Change in interpretation occurred in 56 patients (41%) (95% CI: 33-49%, P <.001). Forty-six patients (34%) had a change in T, N, and/or M staging (26-42%, P <.001). Change in T stage occurred in 27 cases (20%) (13-27%, P <.001) (upstaged in 22, downstaged in five), and a change in N stage in 26 cases (19%) (12-26%, P <.001) (upstaged in 20, downstaged in six). Two patients (1.5%) had missed systemic metastases. Three patients with an initial diagnosis of cancer were found to be cancer-free, and six patients had a diagnosis of new second primary cancers that were missed at original interpretation. One patient had a missed middle cerebral artery aneurysm. Changes in image interpretation altered treatment in 55 (98%) of 56 patients and affected prognosis in 53 patients (95%) (P <.001).

Conclusion: Reinterpretation of cross-sectional images in the setting of a multidisciplinary cancer center has a significant effect on staging, management, and prognosis in patients with head and neck cancer.

Fig 1.

57-year-old woman with a history of squamous cell carcinoma of the left side of the tongue. Enhanced CT image shows a necrotic regional nodal metastasis (arrows) in the contralateral neck that was detected on reinterpretation in the cancer center, but missed on the initial read. This was pathologically proved following neck dissection.

Fig 2.

49-year-old woman with known cancer of the right side of the tongue and a second primary cancer of the nasopharynx detected at the time of image reinterpretation. A, Nonenhanced axial CT image shows asymmetry of the nasopharynx, with increased tissue on the left (arrow) and obliteration of the fat along the deep musculature (levator and tensor veli palatini muscles). B, Nonenhanced coronal CT image again shows increased tissue at the left nasopharynx (arrows). Subsequent biopsy revealed carcinoma.

Fig 3.

80-year-old woman with primary pharyngeal cancer. A normal-sized, fat-replaced left jugulogastric lymph node was interpreted as abnormal because of inhomogeneous signal intensity. A, Axial nonenhanced T1-weighted (600/17/1 [repetition time/echo time/excitations]) MR image shows intrinsic high signal intensity in the lymph node (arrows) consistent with fat. B, Axial fat-suppressed T2-weighted (4000/80/1) MR image obtained at the same level as that in A shows hypointensity in the hilum of this node (arrow) consistent with suppressed fat.