Original Research. Pre-operative staging of carcinoma of tongue using ultrasonography and magnetic resonance imaging

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1 Originl Reserch Americn Journl of Dignostic Imging DOI: /jdi Pre-opertive stging of crcinom of tongue using ultrsonogrphy nd mgnetic resonnce imging Nilu Mlpni Dhoot 1, Sumn Hzrik 2, Binoy Choudhury 3, Aml Chndr Ktki 4, Hridynnd Goswmi 2, Rnjn Bruh 2, Rji Shrm 2 1 Deprtment of Rdiology, Dr. B. Borooh Cncer Institute, Interntionl Hospitl, Guwhti, Assm, Indi, 2 Deprtment of Rdiology, Interntionl Hospitl, Guwhti, Assm, Indi, 3 Deprtment of Rdiology, Dr. B. Borooh Cncer Institute, Guwhti, Assm, Indi, 4 Deprtment of Rdiology, Dr. B. Borooh Cncer Hospitl, Guwhti, Assm, Indi ABSTRACT Purpose: To ssess the ccurcy of stging tongue cncer using ultrsound (US) nd mgnetic resonnce imging (MRI) when compred to histopthology (HPE). Method: Biopsy confirmed, 28 cses of crcinom of tongue were prospectively studied. A tumor, node, metstsis stge ws ssigned to ech ptient using MRI nd US in this doule-lind study. The gold stndrd stge on HPE ws then correlted with MRI/US stge. Sttisticl nlysis ws performed. Results: Most of the ptients 75% (21/28) t presenttion were stge II or more. MRI stging hd n overll ccurcy of 82.1% (23/28) while US hd 57.1% (16/28) overll ccurcy. The difference in stging ws not sttisticlly significnt on Fischer s exct test. US ws more ccurte in evluting lrger tumors. For stge 1, II nd III MRI ws 83.3% ccurte. US chieved n ccurcy of 16.6% for stge I nd n ccurcy of 66.6% for stge II nd III. For stge IV, oth MRI nd US ttined 100% ccurcy. Conclusion: US hs n ccurcy of 57.1% in stging tongue cncer, while MRI ttins 82.1% ccurcy. The difference is not significnt sttisticlly. US chieves high ccurcy in evluting dvnced cncers. It cn e used where MRI is unville or contrindicted. Address for correspondence: Dr. Nilu Mlpni Dhoot, Dr. B. Borooh Cncer Institute, Interntionl Hospitl, Guwhti, Assm, Indi. E-mil: drniludhoot@ gmil.com Received: Octoer 12, 2016 Accepted: Decemer 13, 2016 Pulished: Decemer 27, 2016 KEY WORDS: Cncer, mgnetic resonnce imging, stging, tongue, ultrsound INTRODUCTION An ccurte nlysis of the stge of tongue tumor is vitl in deciding the therpy offered to the ptient [1]. Even though tongue is n orgn, which is visile to the eye, clinicl exmintion is difficult s most of the ptients with crcinom of tongue cnnot open their mouth wide nd mny cnnot tolerte plption. Furthermore, these tumors re infiltrtive, nd if they cross the rrier of lingul poneurosis, they will grow eneth it extensively involving the musculture while the mucosl surfce shows smll or even no normlity [2]. Hence pre-therpy imging nd stging of the tongue cncer is indispensile. Computed tomogrphy (CT), mgnetic resonnce imging (MRI) nd ultrsound (US) re the ville imging modlities for cncer of tongue. MRI llows good visuliztion of orl cncer nd is the imging technique of choice for studying hed nd neck tumors [3]. The normlities detected on MRI re well correlted pthologiclly [4]. MRI imprts detiled view of the tongue tumor nd its nodl extensions. Although, CT cn e used for imging the tongue ut MRI is superior owing to its etter soft tissue resolution nd hence it is preferred. However, MRI is generlly expensive nd sometimes unville. Aprt from tht, clustrophoi, incomptiility with metllic implnts, nd the long durtion of the procedure re dditionl issues restricting MRI use in mny situtions. Even though the 8 A J Dign Imging 2017 Vol 2 Issue 1

2 Dhoot, et l.: Stging of tongue cncer, ultrsonogrphy nd mgnetic risk of contrst gent rections in MRI is less thn tht of CT, they re known to occur [5]. MRI contrst gents re to e voided in ptients with renl insufficiency [6,7]. US is sustntil investigtive tool in hed nd neck pthologies due to its high resolution, convenience, nd dptility [8]. It cn e done edside nd cn e performed repetedly s it is reltively sfe, is universlly ville, nd generlly less expensive. There is no solute requirement of contrst gents in US. In ddition to ll this, it cn e performed in clustrophoic, restless, uncoopertive ptients nd lso in ptients with metllic implnts. In our study, we hve used US in ssessing the stge of tongue cncer in ptients who were posted for surgery on the sis of MRI findings nd clinicl evlution. We compred the US ssigned tongue cncer stge with MRI stge nd histopthology. METHODS We selected 43 tongue cncer ptients for our prospective study who were referred to our institute from April 2013 to Mrch Following institutionl ethicl committee pprovl nd written informed consent from ech ptient, these 43 iopsyproven cses of squmous cell crcinom of the nterior tongue were included in our study. Cses with cncer in the se of the tongue or uccl mucos without nterior tongue involvement were excluded. The ptients who were considered cliniclly inoperle sed on ge, generl condition, ssocited medicl conditions, nd dvnced disese were excluded. This study ws performed over period of 1 yer in our deprtments of rdiology nd imging. Ech ptient ws evluted in detil y dedicted hed nd neck oncosurgeon hving more thn 10 yers of experience. A cliniclly ssessed tumor, node, metstsis (TNM) [9] stge ws ssigned to ech ptient. Further MRI of orl cvity ws performed within dy or two of clinicl exmintion. A MRI sed TNM [9] stge of tongue cncer ws ssigned to ech ptient y two rdiologists working in consensus nd hving more thn 5-yer experience in hed nd neck rdiology. If there ws discrepncy etween clinicl nd MRI stge, MRI stge ws considered superior nd ssigned to the ptient. Surgicl tretment ws offered to ll these ptients depending on MRI stge, generl helth fctors such s ge, physicl fitness, nd other coexisting medicl conditions. After explining the risks nd the enefits of the surgery to the ptients, 6 ptients opted out of surgicl therpy. The contrst enhnced MRI exmintions of the orl cvity ws performed on 1.5-T mgnet (Achiev Level 5; Philips Helthcre, Best, the Netherlnds) with the use of ody coil. The imging protocol consisted of T1- nd T2-weighted fst spin echo imges in xil nd coronl plnes nd short-tu inversion recovery (STIR) sequences in xil, sgittl, nd coronl plnes. T1-weighted post contrst (gdopenttte dimeglumine, dose 0.2 ml/kg) ft-suppressed imges were otined in ll three plnes. The imging prmeters were s follows - T1-weighted imging: Repetition time/echo time, 400/8 milliseconds; field of view, 20 cm; mtrix size, ; T2-weighed imging: Repetition time/echo time, 2341/50 milliseconds; field of view, 20 cm; mtrix size, ; nd STIR: Repetition time/echo time, shortest/80 milliseconds; field of view, 20 cm; mtrix size, The verge scn time ws out 35 min. A slice thickness of 5 mm covered the re of interest from the floor of the orit to the cricoid crtilge. The sme protocol ws followed in ll ptients. The MRI exmintions were red in consensus y two hed nd neck rdiologists. The rdiologists were wre tht ll ptients hd confirmed tongue cncer ut were linded to ptient identities nd clinicl exmintion results. Nine cses were either T4 or N2/N3 or oth on MRI, these were surgiclly irresectle due to dvnced disese. There were 28 ptients out of 43 (6 ptients opted out of surgery nd 9 ptients hd extensive locl nd nodl disese on MRI) cses who consented for surgery nd were found surgiclly resectle on MRI. These ptients were evluted on US y sonologist with more thn 5 yers of experience in hed nd neck US. The sonologist ws linded to clinicl/mri stge, ut ws wre of the proven dignosis of tongue cncer. Using systemtic US technique, the sonologist ssigned US sed TNM stge for ech ptient. The ptient ws plced in supine position with the neck extended. The systemtic sonogrphic technique ws done using high resolution proe (7-12 mhz) of high-resolution US mchine (Nemio 30 SSA-550A; Toshi Medicl Systems Co, Ltd, Tokyo, Jpn). Strting from the sumentl region, with the proe in trnsverse orienttion, the neck ws scnned to the hyoid one. The mylohyoid muscle, intrinsic tongue muscles, sulingul spce, sulingul neurovsculr undle, se of the tongue, nd lingul septum were identified nd exmined in this plne. The proe ws then moved to longitudinl orienttion, with the long xis prllel to the midline in the sumentl region nd tilted on either side to view the genioglossus muscle, mylohyoid muscle, sumndiulr glnds, nd sumndiulr duct. The neck ws scnned lter for detection of the neck nodes. A US sed TNM stge ws ssigned to ech of the 28 tongue cncer ptients. All these ptients were operted within 15 dys of US nd MRI exmintions. A TNM stge ssigned on histopthology (HPE) for ech ptient ws considered the gold stndrd. Comprisons were mde etween the TNM stge on MRI nd US with HPE gold stndrd stge. The ccurcy of ech modlity ws clculted. Fischer s exct test ws used to evlute ny sttisticlly significnt difference etween US nd MRI stge. P < 0.05 ws considered sttisticlly significnt. RESULTS In our cohort of 28 ptients, there were 17 mles nd 11 femles. The ge rnge of this study group ws etween 30 nd 55 yers. Most of the ptients (75%, 21/28) t presenttion were stge II or more. MRI stging hd n overll ccurcy of 82.1% (23/28) while US stging hd n overll ccurcy of 57.1% (16/28) when compred to gold stndrd HPE stging. On Fischer s exct test, the P vlue otined ws Thus, the difference in stging of tongue cncer on MRI nd US ws not quite sttisticlly significnt. US ws more ccurte in evluting lrger tumors nd less ccurte in ssessing smller A J Dign Imging 2017 Vol 2 Issue 1 9

3 Dhoot, et l.: Stging of tongue cncer, ultrsonogrphy nd mgnetic Tle: 1 Stge wise ccurcy on MRI nd US when compred to HPE Stge of the disese Numer of ptients stged on HPE (gold stndrd stge) Numer of ptients correctly stged on MRI Stge wise ccurcy in MRI when compred with HPE (%) Numer of ptients correctly stged on US Stge wise ccurcy in US when compred with HPE (%) Stge 0 TIS 1 0 0/1, 0 0 0/1, 0 Stge /6, /6, 16.6 Stge /12, /12, 66.6 Stge /6, /6, 66.6 Stge /3, /3,100 Totl /28, /28, 57.1 HPE: Histopthology, MRI: Mgnetic resonnce imging, CIS: Crcinom in situ, US: Ultrsound tumors. The stge wise ccurcy is shown in [Tle 1]. Both MRI nd US were unle to detect one cse of crcinom in situ (CIS) in our cohort. This ptient hd speckled leukoplki with ulcertion. One ptient ws downstged on MRI nd 4 ptients were upstged [Tle 2]. On US 7 ptients were downstged, while 5 ptients were upstged s depicted in [Tle 3]. If stge 0 nd stge 1 diseses were to e excluded, US would chieve n ccurcy of 71% (15/21) wheres MRI would e 85% (18/21) ccurte. This suggests tht US is more ccurte for dvnced disese nd most of our ptients t presenttion were stge II or more. DISCUSSION A definite dignosis of tongue cncer is otined primrily y iopsy. The principl role of imging is for stging the disese to provide n ccurte stging work-up for the plnning of therpy. MRI is indispensile for stging tongue cncer is well-known fct. Contrst enhnced MRI hs ecome the cornerstone in the pretretment evlution of tongue cncers nd provides ccurte informtion out the extent nd depth of disese tht cn help decide the pproprite mngement strtegy nd indicte prognosis. There re multiple ppers proving the worth of MRI in tongue cncer time nd gin [4,10-13]. The reported ccurcy of MRI in evlution of tongue crcinom y Zeng et l. [14] ws %. We chieved n ccurcy of 82.1% in our study. Sonogrphy is not modlity of choice for defining tongue pthology. It is excting, s ony mndile outlines the orl cvity llowing only limited field of view. It is fundmentlly used in neck for evluting neck nodes nd guiding fine needle spirtions nd iopsies [15,16] However, there re ccessile sites tht cn e used for trnsmission of the US em to the tongue lesion, for exmple, the sumentl region nd introrl ccess. The introrl pproch provides limited view nd is more useful for tumor thickness ssessment. A few studies hve indicted the usefulness of introrl sonogrphy while evluting tumor thickness in orl cncers [17,18]. Sumentl ccess hs lso een successfully used ttining sensitivity of 61% [19]. Wksugi-Sto et l. [20] evluted the usefulness of introrl nd intropertive sonogrphy in tumor thickness ssessment nd tumor mrgin clernce during surgery. Even in the lrynx nd hypophrynx, US hs een ttempted with encourging results [21]. Mngement of the tongue cncer is primrily decided on stge of the disese, [22] likewise t our institutes. Stge I nd II cncers (T1-T2, N0) re treted with single modlity therpy t our institutes. Surgery or rdiotherpy (RT) is dvised for the primry t erly stges, the former eing fvored. Loclly dvnced cncers (stge III nd IV) re treted with comintion of surgery, RT nd chemotherpy for oth the primry nd the neck. Distnt tumor metstsis is well ssessed y CT nd Positron emission tomogrphy (PET) CT. If distnt tumor spred is detected, the mngement chnges even if there is minor regionl spred. USG hs limited role in ssessing distl tumor spred prt from spred to the neck nodes. PET CT nd/or CT re indispensile modlities with regrds to confirming or ruling out distnt metstsis. In study of 50 tongue cncer cses, Fruehwld et l. [23] could stge ll ut 1 cse correctly using US. In our study group of 28 ptients, we could perfectly stge 16 ptients using US. In nother study y Bruneton et l., [24] sonogrphy did not visulize tumors in 9 of 42 cses of tongue cncer (7 stge T1 nd 2 nterior stge T2 tumors). We could not correctly recognize the stge of 12 tongue tumors out of 28 (6 stge 1 nd 4 stge 2). One of our ptients ws CIS, where oth MRI nd US filed. This ptient hd speckled leukoplki with ulcertion, hving high suspicion of mlignncy cliniclly. This ptient ws iopsied which ws positive for cncer. US nd MRI were done to know the extent of the disese s well s the nodl sttus. US ws more ccurte in detecting dvnced disese, stge II nd more. In cses of stge 1 disese, sonogrphy filed to identify ll except one [Figures 1 nd, 2 nd ] smll intrinsic tongue muscle tumor, primrily ecuse of the depth. The high frequency proe we used through sumentl pproch provided coronl nd sgittl sections of the tongue. The intrinsic tongue muscle eing locted frthest from the proe hd the lest resolution. Similrly, involvement of the mylohyoid muscle y the tumor ws difficult to detect due to depth. However, in our study, we could identify ll three cses of mylohyoid invsion [Figure 3] correctly. Genioglossus is fn-shped muscle [Figure 4], esy to identify on US, therefore, tumor involving the fn-shped genioglossus [Figure 4 nd 5] is simple to locte. The hypoechoic tumors extending to sulingul spce could not e overlooked due to striking contrst with the hyperechoic sulingul glnds. The use of Doppler could tell us the encsement of the lingul neurovsculr undle y the tumor [Figure 5 nd ]. Doppler lso llowed differentition etween the lingul rtery nd sumndiulr 10 A J Dign Imging 2017 Vol 2 Issue 1

4 Dhoot, et l.: Stging of tongue cncer, ultrsonogrphy nd mgnetic Tle 2: Demonstrtes numer of ptients upstged or down stged or correctly stged on MRI when compred with HPE Numer of ptients in ech stge on HPE (gold stndrd) Numer of ptients in ech stge on MRI CIS Stge 1 Stge 2 Stge 3 Stge 4 Totl Norml 1 1 CIS 0 Stge Stge Stge Stge Totl HPE: Histopthology, MRI: Mgnetic resonnce imging, CIS: Crcinom in situ Tle 3: Demonstrtes numer of ptients upstged or downstged or correctly stged on US when compred with HPE Numer of ptients in ech stge on HPE (gold stndrd) Numer of ptients in ech stge on US CIS Stge 1 Stge 2 Stge 3 Stge 4 Totl Figure 1: () A 42-yer-old mle ptient hving tongue ulcer, coronl T2 ft sturted section of mgnetic resonnce imging of the tongue shows smll intrinsic muscle T2 hyperintense lesion on the left side. () Coronl section ultrsound of tongue of the sme ptient shows smll hypoechoic growth on the left side intrinsic muscles mrked s M. The strs shows the genioglossus muscles. The hyperechoic sulingul glnds re mrked s S. The rrows show mylohyoid muscles on oth sides Norml CIS 0 Stge Stge Stge Stge Totl HPE: Histopthology, MRI: Mgnetic resonnce imging, CIS: Crcinom in situ, US: Ultrsound glnd duct encsement y the tongue mss [Figure 6 nd ]. In ll, lrge growths [Figure 7 nd ] cn e ssessed resonly well on US, wheres it is not very sensitive for smll tumors. One of the fundmentl dvntges of using sonogrphy is the high resolution it ffords [8]. In ddition, sonogrphy is inexpensive, does not involve ionizing rdition, cn e performed in ptients with metllic implnts, t the edside, in ptients with renl filure, nd is suitle for restless, clustrophoic, or uncoopertive ptients. The mny frilties of sonogrphy would restrict it from ecoming the sole imging modlity for evlution of tongue mlignncies. We used sonogrphy despite the fct tht MRI is the modlity of choice in this study to evlute this option in cse MRI is unville or contrindicted. There re severl situtions were MRI my not e fesile. Aprt from clustrophoi, the contrst gents used in MRI re lso contrindicted in certin situtions. In restless ptients, MRI is extremely limited for evlution of tumor invsion. Therefore, in the ptient popultion in which MRI is contrindicted, unffordle, nd unville, sonogrphy cn e used s n lterntive modlity nd for posttretment follow-up. There re multiple limittions of this study. The first nd min limittion of this study is its smll smple size tht descries our first routine use of US in tongue. For wider cceptnce of US, further study with lrger study group would e needed. Second, we included operle cses of cncer involving the nterior c Figure 2: () A 54-yer-old mle ptient hving pin nd tongue lesion, sgittl short-tu inversion recovery mgnetic resonnce imging (MRI) imges show smll hyperintense growth involving only the intrinsic muscles of the tongue on the left. The right side is norml on MRI. () Sme ptient s in Figure 2, sgittl section on ultrsound shows hypoechoic growth in intrinsic muscles on the left mrked y rrows. The intrinsic muscles re mrked s T on oth sides. SMG is sumndiulr glnd. Str sign is on the hypoechoic norml mylohyoid muscle tongue, inoperle tumors nd those infiltrting the se of tongue were excluded mounting to selection is. Third, we did not use contrst-enhnced sonogrphy to ssess the tumors. The use of contrst in US of tongue cncer could e n venue for further reserch. Fourth, we hve used high frequency proe for our study, which hs limited depth resolution nd intrinsic tongue muscles were the frthest from sumentl d A J Dign Imging 2017 Vol 2 Issue 1 11

5 Dhoot, et l.: Stging of tongue cncer, ultrsonogrphy nd mgnetic Figure 5: () Sme ptient of Figure 4/, hs liner hypoechoic structure mrked y rrows on ultrsound could e lingul rtery, which is encsed y the hypoechoic mss infiltrting the genioglossus muscle, mrked y str. () Use of Doppler signl in Figure 5, confirms tht the lingul rtery is encsed y the tongue mss Figure 3: Ptient hving lrge tongue mss since 4 months, trnsverse section through the sumentl window on ultrsound shows lrge heterogeneously hypoechoic growth mrked y solid str, it infiltrtes the mylohyoid muscle shown y the solid rrow Figure 6: () A 38-yer-old mle ptient, sgittl ultrsound (US) shows the sumndiulr glnd duct shown y rrowheds. The str mrks the genioglossus muscle nd rrow mrks the mylohyoid muscle. The circle is in the sumndiulr glnd. () Sme ptient on the other side sgittl US imge shows, hypoechoic mss (mrked y str), rrows point the sumndiulr glnd duct (there is no flow on Doppler) encsed y the mss. Solid circle is the echogenic sumndiulr glnd Figure 4: () A 34-yer-old ldy hving tongue tumor, the sgittl section of tongue on ultrsound shows the norml fn-shped genioglossus muscle mrked y str. The rrow mrks the norml mylohyoid muscle on the right side. () Sme ptient on the left side hs hypoechoic mss (M) on ultrsound sgittl section infiltrting the genioglossus mrked y str. The rrow shows the mylohyoid muscle pproch. Thus, reducing the ility of US to interpret only intrinsic muscle growth. Lower frequency proe usge through the sumentl window cn lso e n re of further reserch. Fifth, ll of our cses were iopsy-proven tongue cncers, nd we evluted role of sonogrphy for detection of extension of the disese ut not for detection of the disese itself. Finlly, the use of US in tongue itself hs severl inherent limittions. These include poor visuliztion of the posterior regions, such s intrinsic tongue muscle growths (missed in ll, ut one cses in our study), the unproven role of sonogrphy, nd the difficulty in showing smll tumors on sonogrphy. CONCLUSION To conclude, we reched n ccurcy of 57.1% in the evlution of tongue cncer using US, which ws sttisticlly not significntly different when compred with MRI, which ttined 82.1% ccurcy. Although smll tumors were inccessile on Figure 7: () A 30-yer-old femle ptient hs lrge tongue ulcer, coronl short-tu inversion recovery mgnetic resonnce imging shows lrge hyperintense tongue growth going cross the lingul septum. () Sme ptient ultrsound imge, coronl section shows lrge hypoechoic mss mrked y solid circles going cross the midline. The rrow point to the lingul septum sonogrphy, we think tht it cn ply significnt role in the stging of tongue tumor for dvnced disese. REFERENCES 1. Fletcher GH. Textook of Rdiotherpy. 3 rd ed. Phildelphi, PA: Le & Feiger; Mncuso AA, Hnfee WN. Computed Tomogrphy of the Hed nd Neck. Bltimore: Willims nd Wilkins; Lufkin RB, Worthm DG, Dietrich RB, Hoover LA, Lrsson SG, Kngrloo H, et l. Tongue nd orophrynx: Findings on MR imging. 12 A J Dign Imging 2017 Vol 2 Issue 1

6 Dhoot, et l.: Stging of tongue cncer, ultrsonogrphy nd mgnetic Rdiology 1986;161: Arkw A, Tsurut J, Nishimur R, Skmoto Y, Korogi Y, B Y, et l. Lingul crcinom. Correltion of MR imging with histopthologicl findings. Act Rdiol 1996;37: Hseroock KM, Serkov NJ. Toxicity of MRI nd CT contrst gents. Expert Opin Drug Met Toxicol 2009;5: Mrckmnn P, Skov L, Rossen K, Dupont A, Dmholt MB, Hef JG, et l. Nephrogenic systemic firosis: Suspected custive role of gdodimide used for contrst-enhnced mgnetic resonnce imging. J Am Soc Nephrol 2006;17: Perzell MA. Current sttus of gdolinium toxicity in ptients with kidney disese. Clin J Am Soc Nephrol 2009;4: Lovedy EJ. Ultrsound of the lrynx. Imging 2003;15: Edge SB, Compton CC. The Americn Joint Committee on Cncer: The 7 th edition of the AJCC cncer stging mnul nd the future of TNM. Ann Surg Oncol 2010;17: Ong CK, Chong VF. Imging of tongue crcinom. Cncer Imging 2006;6: Ary S, Chukr D, Pi P. Imging in orl cncers. Indin J Rdiol Imging 2012;22: Iwi H, Kyomoto R, H-Kw SK, Lee S, Ymshit T. Mgnetic resonnce determintion of tumor thickness s predictive fctor of cervicl metstsis in orl tongue crcinom. Lryngoscope 2002;112: Lm P, Au-Yeung KM, Cheng PW, Wei WI, Yuen AP, Trendell-Smith N, et l. Correlting MRI nd histologic tumor thickness in the ssessment of orl tongue cncer. AJR Am J Roentgenol 2004;182: Zeng H, Ling CH, Zhou ZG, Zheng JH, Zeng QX. Study of preopertive MRI stging of tongue crcinom in reltion to pthologicl findings. Di Yi Jun Yi D Xue Xue Bo 2003;23: Di Muzio B, Gllird F. Squmous cell crcinom of the tongue. Rdiopedi. Aville from: squmous-cell-crcinom-of-the-tongue. [Lst ccessed on 2015 Jul 17]. 16. de Bondt RB, Nelemns PJ, Hofmn PA, Csselmn JW, Kremer B, vn Engelshoven JM, et l. Detection of lymph node metstses in hed nd neck cncer: A met-nlysis compring US, USgFNAC, CT nd MR imging. Eur J Rdiol 2007;64: Shintni S, Yoshihm Y, Ueym Y, Terkdo N, Kmei S, Fijimoto Y, et l. The usefulness of introrl ultrsonogrphy in the evlution of orl cncer. Int J Orl Mxillofc Surg 2001;30: Lodder WL, Teertstr HJ, Tn IB, Pmeijer FA, vn Smeele LE. Tumour thickness in orl cncer using n intr-orl ultrsound proe. Eur Rdiol 2011;21: Dhoot NM, Hzrik S, Choudhury B, Ktki AC, Bruh R, Goswmi H. Evlution of tongue cncer using high-resolution sonogrphy: Comprison with mgnetic resonnce imging. J Ultrsound Med 2015;34: Wksugi-Sto N, Kodm M, Mtsuo K, Ymmoto N, Od M, Ishikw A, et l. Advnced clinicl usefulness of ultrsonogrphy for diseses in orl nd mxillofcil regions. Int J Dent 2010;2010: Dhoot NM, Singh S, Choudhury B, Ktki AC, Klit NK, Bhttchryy M, et l. Evlution of hypophryngel crcinom using high-resolution ultrsound: Comprison with CT. J Clin Ultrsound 2014;42: Shh JP, Gil Z. Current concepts in mngement of orl cncer Surgery. Orl Oncol 2009;45: Fruehwld F, Slomonowitz E, Neuhold A, Pvelk R, Milth G. Tongue cncer. Sonogrphic ssessment of tumor stge. J Ultrsound Med 1987;6: Bruneton JN, Roux P, Crmell E, Mnzino JJ, Vllicioni J, Demrd F. Tongue nd tonsil cncer: Stging with US. Rdiology 1986;158: EJMnger. This is n open ccess rticle licensed under the terms of the Cretive Commons Attriution Non-Commercil License ( cretivecommons.org/licenses/y-nc/3.0/) which permits unrestricted, noncommercil use, distriution nd reproduction in ny medium, provided the work is properly cited. Source of Support: Nil, Conflict of Interest: None declred. A J Dign Imging 2017 Vol 2 Issue 1 13