Sentinel Node Biopsy Combined other Diagnostic Tools in the Evaluation of cN0 Head & Neck Cancer--a Diagnostic Accuracy and Outcome Study
Date Issued
2014
Date
2014
Author(s)
Liao, Li-Jen
Abstract
Background: The optimum management over the neck of clinical negative (cN0) head and neck cancer has been a debate for a long time. In the past, most head and neck surgeons did prophylactic neck dissection and potentially leaded to over-treatment. Since more and more modern diagnostic technologies are developing, the possibility of conservative treatment is increasing. The aim of this dissertation is to comprehensively assess multiple diagnostic tests, including traditional CT, MRI image, high resolution ultrasound (US), ultrasound guided fine needle aspiration(US-FNA), positron emission tomography (PET) and sentinel node biopsy (SNB).
Materials and Methods: While the first part focuses on systematic review of individual diagnostic test, meta-analysis is also done to assess the diagnostic performance of each test. The second part uses hypothetical estimation of serial tests, which compares multiple diagnostic strategies, to evaluate the negative predictive value, over- and under treatment of each strategy. The third part uses decision modeling, which is under view point of patient and health care system, to assess the efficiency of the proposed diagnostic strategies. At the end, a feasibility study of sentinel node navigation surgery (SNNS) in Taiwan is presented.
Results: In systematic review, total 73 studies were recruited. Ten studies fulfilled all inclusion criteria for CT, 7 studies for MRI, 12 studies for PET, 9 studies for US, 5 studies for US-FNA, 55 studies for SNB. In meta-analysis, the pooled estimates for sensitivity are 56% (95% confidence interval [CI], 45%~67%) and 85% (82~87%) for US-FNA and SNB respectively. The pooled estimates for sensitivity were 47% (95% confidence interval [CI], 38.2%~56.0%), 56.6% (39.8~71.9%), 63.3% (54.0~71.7%), 48.3% and (30.9~66.1%) for CT, MRI, US and PET respectively. The pooled estimates for specificity were 88.9% (82.0%~93.3%), 82.5% (39.8~71.9%), 79.1% (73.4~83.8%) and 86.2 % (76.9~92.1%) for CT, MRI, US and PET respectively. The AUC are 0.81(0.56~1), 0.79(0.66~0.93), 0.83(0.69~0.96), 0.81(0.74~0.87), 0.97(0.85~1) and 0.98(0.96~0.99) for CT, MRI, PET, US, US-FNA and SNB respectively. For hypothetical estimation, the NPV of CT/MRI then SNB strategies will still be higher than 85%, even the pre-test occult rate up to 60%. In decision analysis, without considering the cost, combined CT-SNB or MRI-SNB will have a higher expected utility if the pre-test occult metastasis rate is greater than10%. In cost-effectiveness analysis, the strategy of CT followed by US-FNA had the lowest price. The strategy of CT followed by SNB would be the most cost-effectiveness strategies. In feasibility study, between June 2013 and March 2014, eleven patients were recruited. At least one sentinel lymph node was identified in all patients (100%). All sentinel nodes were located at level I~ level III. The sensitivity of SNNS is 80% (4/5).
Conclusions: SNB is reliable in evaluation of cN0 neck. SNNS could be a promising diagnostic and management strategy for cN0 HN cancer patients.
Subjects
統合分析
成本效益分析
頸部轉移零期
頭頸癌
前哨淋巴結切片
SDGs
Type
thesis
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