Survey of Head and Neck Practice
================================

* D.M. Yousem

I read with curiosity the article by Ko et al1 regarding the survey of TNM staging by radiologists.

Two statements were made that I believe need clarification.

1.  The claim is made in the “Results” that “Subspecialization in head and neck radiology was reported by 72.1% of respondents.”1 How is this defined? Obviously, the survey results may reflect the bias of the respondents. Selecting only members of the American Society of Head and Neck Radiology is a bias. Does “subspecialization in head and neck radiology” refer to a neuroradiology fellowship? If so, the results may be believable. Otherwise, I am skeptical that that many people are practicing head and neck radiology exclusively as a subspecialist.

2.  In the “Discussion,” the authors state, “It has been reported that the short axial diameter of lymph nodes is the most accurate indicator of metastatic versus normal or reactive nodes.”1 These data are cited from sonography2 and postmortem examination3 studies, not studies of CT and MR imaging, with which most American radiologists examine head and neck cancers. In his seminal review, Peter M. Som4 wrote in 1987, “It should be noted that most cervical lymph nodes are ovoid or lima bean shaped, and the determination of nodal size is based on the greatest nodal diameter.” Similarly, in the largest multi-institutional study written in the radiology literature looking at head and neck lymph nodes, Curtin et al5 state in their methodology, “On axial images, the readers noted the largest dimension of the largest node in each zone of the neck” for their data.

It is true that there is no consensus regarding what dimension is best to assess whether a node is pathologic or not. It is also true that size criteria alone are flawed as guidelines. However, I thought that having statement number 2 above in the literature without at least some caveats would not be appropriate.

## Footnotes

*   Disclosures: David Yousem—*UNRELATED*: *Payment for Lectures (including service on Speakers Bureaus)*: ACR Educational Center; *Royalties*: Elsevier; *Payment for Development of Educational Presentations*: CMEInfo.com.* *Money paid to the institution.

## References

1.  1. Ko B, Parvathaneni U, Hudgins PA, et al. Do radiologists report the TNM staging in radiology reports for head and neck cancers? A national survey study. AJNR Am J Neuroradiol 2016;37:1504–09 doi:10.3174/ajnr.A4742 pmid:27032970
    
    [Abstract/FREE Full Text](http://www.ajnr.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo5OiIzNy84LzE1MDQiO3M6NDoiYXRvbSI7czoxODoiL2FqbnIvMzgvMS9FOS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. van den Brekel MW, Castelijns JA, Snow GB. The size of lymph nodes in the neck on sonograms as a radiologic criterion for metastasis: how reliable is it? AJNR Am J Neuroradiol 1998;19:695–700 pmid:9576657
    
    [Abstract](http://www.ajnr.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIxOS80LzY5NSI7czo0OiJhdG9tIjtzOjE4OiIvYWpuci8zOC8xL0U5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  3. van den Brekel MW, Stel HV, Castelijns JA, et al. Cervical lymph node metastasis: assessment of radiologic criteria. Radiology 1990;177:379–84 doi:10.1148/radiology.177.2.2217772 pmid:2217772
    
    [CrossRef](http://www.ajnr.org/lookup/external-ref?access_num=10.1148/radiology.177.2.2217772&link_type=DOI) 
    
    [PubMed](http://www.ajnr.org/lookup/external-ref?access_num=2217772&link_type=MED&atom=%2Fajnr%2F38%2F1%2FE9.atom) 
    
    [Web of Science](http://www.ajnr.org/lookup/external-ref?access_num=A1990EE79900016&link_type=ISI) 

4.  4. Som PM. Lymph nodes of the neck. Radiology 1987;165:593–600 doi:10.1148/radiology.165.3.3317494 pmid:3317494
    
    [CrossRef](http://www.ajnr.org/lookup/external-ref?access_num=10.1148/radiology.165.3.3317494&link_type=DOI) 
    
    [PubMed](http://www.ajnr.org/lookup/external-ref?access_num=3317494&link_type=MED&atom=%2Fajnr%2F38%2F1%2FE9.atom) 
    
    [Web of Science](http://www.ajnr.org/lookup/external-ref?access_num=A1987K986100001&link_type=ISI) 

5.  5. Curtin HD, Ishwaran H, Mancuso AA, et al. Comparison of CT and MR imaging in staging of neck metastases. Radiology 1998;207:123–30 doi:10.1148/radiology.207.1.9530307 pmid:9530307
    
    [CrossRef](http://www.ajnr.org/lookup/external-ref?access_num=10.1148/radiology.207.1.9530307&link_type=DOI) 
    
    [PubMed](http://www.ajnr.org/lookup/external-ref?access_num=9530307&link_type=MED&atom=%2Fajnr%2F38%2F1%2FE9.atom) 
    
    [Web of Science](http://www.ajnr.org/lookup/external-ref?access_num=000072662500019&link_type=ISI) 

*   © 2017 by American Journal of Neuroradiology