Title	In Patients with Head and Neck Cancer, CBCT Is the Highest Priority Modality for Detecting Mandibular Bone Invasion Compared to Other Modalities
Clinical Question	For patients with head and neck cancer, is cone-beam computed tomography (CBCT) the best modality to diagnose mandibular invasion of the malignancy compared to other modalities, such as single-photon emission computed tomography (SPECT), CT, magnetic resonance imaging (MRI), panoramic radiography (PR), positron emission tomography-computed tomography (PET-CT), and bone scintigraphy (BS)?
Clinical Bottom Line	CBCT is a highly accurate modality diagnostically, and it is “the top priority modality to detect bone invasion.” CT and MRI can be used as confirmation of the diagnosis while SPECT is recommended as the first modality for exclusion. The involvement of mandibular bone marrow in cases of head and neck cancer requires further investigation.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 30409295 Qiao/2018 49 studies, 2575 patients tested, 1180 found positive for mandibular invasion Systematic Review with Meta-analysis Key results The study found in conclusion that CBCT has very high sensitivity and specificity (0.90 and 0.85, respectively), compared to: CT (0.73 and 0.91) MRI (0.88 and 0.90) PR (0.75 and 0.83) PET-CT (0.90 and 0.89) SPECT (0.97 and 0.69) BS (0.92 and 0.79) The positive likelihood ratios (LR+) for CT, MRI, PR, CBCT, PET-CT, SPECT, and BS are 8.23, 8.44, 4.40, 6.02, 8.53, 3.10, and 4.29, respectively. The negative likelihood ratios (LR-) for these modalities are 0.29, 0.13, 0.30, 0.12, 0.11, 0.04, and 0.10, respectively. The diagnostic odds ratios (DOR) for the modalities are 28.26, 64.77, 14.82, 51.02, 74.77, 80.51, and 43.01, respectively.
Evidence Search	"cbct"[All Fields] AND ("head and neck neoplasms"[MeSH Terms] OR ("head"[All Fields] AND "neck"[All Fields] AND "neoplasms"[All Fields]) OR "head and neck neoplasms"[All Fields] OR ("head"[All Fields] AND "neck"[All Fields] AND "cancer"[All Fields]) OR "head and neck cancer"[All Fields]) AND (("bone and bones"[MeSH Terms] OR ("bone"[All Fields]AND "bones"[All Fields]) OR "bone and bones"[All Fields] OR "bone"[All Fields]) AND ("invasibility"[All Fields] OR "invasible"[All Fields] OR "invasion"[All Fields] OR "invasions"[All Fields] OR "invasive"[All Fields] OR "invasively"[All Fields] OR "invasiveness"[All Fields] OR "invasives"[All Fields] OR "invasivity"[All Fields]))
Comments on The Evidence	Validity: The authors did a very thorough review of the literature. They provided the statistical analysis, as well as the inclusion and exclusion criteria. The statistical analysis is very meticulous with all the details included in the published paper. All the papers include either prospective or retrospective studies with the pathological examination as the gold standard. Perspective: The article has weaknesses. First of all, some of the included studies used a low number of patients, affecting the statistical power. Secondly, the included studies had an unclear or high risk of bias. Furthermore, some of these papers exhibited heterogeneity in the methodology used. Finally, the term “Head and Neck Cancer” can be used to describe a significant variety of pathologies. A systematic review of a more specific pathology might be more clinically significant (e.g., for squamous cell carcinoma).
Applicability	Head and neck malignancies are amongst the most common malignancies in humans. They are invasive, and the diagnosis often occurs in a late stage of the tumor, increasing the mortality rates. Tumor invasion into adjacent bony structures such as the mandible is common, and the detection of it is crucial since it affects the preoperative evaluation, which results in different treatment of the patients. For the detection of bone invasion, the most widely used modalities are CT and MRI, which are also used for tumor staging. However, CBCT offers a very accurate and reliable alternative. CBCT has many advantages over the current modalities used, such as a much lower dose of radiation compared to CT, and a lower scan time compared to MRI. Finally, CBCT is able to achieve high quality images with small voxel size.
Specialty	(Oral Medicine/Pathology/Radiology)
Keywords	CBCT; head and neck cancer; bone invasion/infiltration; diagnosis
ID#	3444
Date of submission	12/03/2020
E-mail	shinas@livemail.uthscsa.edu
Author	Nikolaos Shinas, DDS
Co-author(s)	Yahia Khubrani, BDS
Co-author(s) e-mail	khubrani@uthscsa.edu
Faculty mentor	Hassem Geha, DDS, MDS
Faculty mentor e-mail	geha@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available