2007 47 3130 146 12 2007 10 19 20 Landmarks for Imaging of Head Neck Cancer Hugh D. Curtin, MD Department of Radiology Massachusetts Eye and Ear Infirmary Head and neck carcinoma is almost always diagnosed clinically before the patient comes to be imaged. Imaging determines the deeper extent of the lesion. The major types of spread are direct encroachment, submucosal spread, perineural extension, lymphatic metastasis. The specific landmarks that must be checked depend on location of the primary. Certain important landmarks can illustrate the basic principles of cancer imaging and are the focus of this lecture. Anterior oral cavity/floor of mouth: The inner cortex of the mandible is the key landmark. CT evaluates direct extension into bone. Is the bone normal? Is there minimal cortical erosion or has the tumor reached the medullary space? These findings determine the feasibility of marginal vs. segmental mandibulectomy. Retromolar trigone/tonsillar pillar/posterior floor of mouth: In this complex anatomic region, submucosal spread can carry tumor along the tonsillar pillar from soft palate to the underside of the tongue. The posterior floor of mouth is immediately adjacent to a gap in the sheet-like musculature. Tumor encounters less resistence in spreading into the soft tissues close to the submandibular gland. Roof of mouth : Perineural spread is particularly important in this location. Tumor can grow along the palatine nerves to the pterygopalatine fossa. The status of the fat in the fossa is an important indicator of the presence or absence of perineural spread. The entire course of the second division of the trigeminal nerve must be examined. The important structures include the infraorbial canal and the fat at the infraorbital foramen, the foramen rotundum and gasserian ganglion. The trigeminal fat pad just medial to the lateral pterygoid muscle and just inferior to foramen ovale is a key landmark for tumor spreading along the trigeminal or auriculotemporal nerves. The fat in the stylomastoid foramen is the key landmark for tumor extension along the facial nerve into the temporal bone. Lymph nodes : Nodal metastasis is a major determinant of prognosis. CT, MRI, Ultrasound and PET scanning can all assess the nodes. The best examination would have a low false negative rate. The key statistic is the error rate of the negative finding. This percentage indicates the number of patients that have insidious tumor though the imaging is negative. 1 CT MRI 2 preslyloid retrostyloid CT MRI 2 CT multi-detector row CT MDCT 10 CT MDCT 1 0.5 300 3 130
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ALPHARD ALPHARD VEGA 2 PSR9000N CT CT CT CT CT 41mm 40mm CT CT CT ALPHARD ALPHARD ALPHARD VEGA 2 ALPHARD 3 VEGA 4 VEGA 200mm 179mm CT 3 2 X CT CB MercuRay CB Throne XR X X X CT CT 1 1 10 2 3 4 3 3D CT Veraviewepocs 3D 2 CT CT 1992 1997 12 X CT 2001 3DX CT CT 3 2 line pair/mm X CT 3 5 CT X I.I FPD 2007 3 IDS CT X 3D CT X Veraviewepocs 3D 3 3DX Veraviewepocs 3D 4 CBCT 1 CT 2 FOV 81.0mm H75.2mm 147 m FOV 55.7mm H51.7mm 101 m FOV 512 19 CT 2 1024 37 CCD CT 133
3 3D DICOM Work in progress 2 MRI 1 3 MRMAGNETOM Trio, A Tim System MR 3 MR MAGNETOM Trio A Tim System SPACE 1 mm 1 1 mm SPACE T1 T2 FLAIR 180 3 MR SAR SPACE SAR SE 3T 3D S/N 3T 3 MR 1.5 MR BLADE BLADE blade k-space k-space BLADE Tl T2 FLAIR 2 Work in progress MRI MRI MRI 25 T1 MRI Atlas SPEEDER MRA FBI 10 Time-SLIP 3 MRI MRI MRI MRI 3.0T MRI MRI MRI MRI MRI MRI MRI 1987 MRI MRI MRI MRI 1 1.4 134
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2 3 7.8 0.86cm 0.08 0.95 CT CT 5 CT-arthorography CT M.A. CT CTarthrography multi detector CT MDCT 2 cone beam CT CBCT 0.128mm 0.5mm 8 350 Iohexol 350mgI/ml 5 50 MDCT Sensation64 CBCT 3DX FineCube MDCT FOV 50mm 50mm 0.6mm 3DX FOV 4 cm 3 cm 0.5mm FineCube FOV 56.5mm 51.7mm 0.5mm 4 12 0.5mm 40 50 MDCT 2 CBCT 0.405mm 30 50 CT 80MDCT 0.33mm 3DX 0.235mm FineCube 0.205mm 50 3DX Fine- Cube 3DX 30 50 100 180mgI/ml FineCube 3DX MDCT 0.4mm 3 6 CT 1 2 2 3 1 2 3 CT 15 CT X X 7 MR 1 ADC ADC 2 ADC ADC MRI 1 ADC 2 Time-signal intensity curve TIC 2003 MR ADC TIC ADC TIC ADC TIC TIC 137
8 CT MRI CT MRI CT MRI 2005 2007 CT MRI 70 CT MRI 7 CT Light Speed QX/i MRI Signa LX T1 T2 T1 Analyze 7 CT 4027.85mm 3 T1 3033.56mm 3 T2 5148.49mm 3 T1 3923.1mm 3 T1 T2 MRI T2 7 4 T2 T1 T1 CT MRI T1 T2 9 CT MR 1 2 1 2 CT MR 62 2 1 2 class MRI T1W T2W STIR T1W 5 CT low density 10MRI CT X CT CT MRI CT MRI 1997 4 2007 3 CT MRI 6 2 4 59.5 CT 3 MRI 5 CT T1 T2 6 MRI 15 CT 12 T1 15 T2 13 CT 22.9 51.5HU 38.2HUCT 5 MRI MRI MRI CT 138
11 MRI MRI MRI 43 2007 4 27 3 14 10mm 4 3 4 10 24mm 39mm 4 16 14mm 18mm 5 10 MRI T2wI 7 10 42mm I T2wI 12 Neuroendocrine tumor 1 2 1 2 Neuroendocrine tumor chromatin Neuroendocrine tumor Neuroendocrine tumor 1 39 17 3 3 7 4 sarcoma CT 30 28 40mm MRI T1WI T2WI FS 7 28 5FU Total 4100mg8 1 Total 30Gy8 25 Neuroendocrine tumor carcinoid tumor 2 13 1 Hodgkin Waldeyer 1 78 2005 4 5 1997 2004 40 35mm X CT MRI T1 T2 STIR T1 Hodgkin diffuse large B cell type 1997 67 Ga 139
1 14 9 16 11 17 1 6 18 8 24 31 25 20mm 6 CT MRI T1 T2 T1 US 19 1 3 T2 15 CT MRI 47 1 X X CT MRI T1 T2 16 MRI MRI 2002 4 2007 7 MRI 7 open lock 2 1 1 1 1 1 MRI 1 MRI 140
open lock 17 MRI 2 1 1 2 2 2 1 1 2 CT MRI MRI 2 1 72 6 3 4 10 15mm 7 mm US MRI T1 T2 T1 2 26 4 US CT MRI T1 1 2 MRI T1 1 Mucoepidermoid carcinoma 2 Pleomorphic adenoma 18 3 3 1 70 2 X 1 MR 3 2 68 20 6 X 10 MR 6 3 31 15 1 MR 2 2 1 2 3 19 15 95 503 15 4 4 1 4 45 56Gy 141
4 48 70Gy 2 5 60Gy 20Gy 68Gy 1 57Gy 2 75Gy 4 61Gy 3 50Gy 5 44Gy 20 Real-Time Tissue Elastography Real-Time Tissue Elastography 17 8 18 11 15 4 11 20 87 62.6 Real-time tissue elastography EUB-8500 Tsukuba Elastography Score 5 26 92 86 88PPV 85NPV 92 0.5cm 21 1 1 1 1 1 2 CT 2 Synapse FUJI FILM Japan 6 5 1 59.410.7/18 79.414.3/18 2 54.210.3/19 76.314.5/19 22 2002 4 4 retrospective 1 2002 7 2006 6 3 11 MRI retrospective 1 59 18 30.5 41 69.560 27 45.8 70 13 142
22 40 7 62.17 30 82 2 59 45 76.2 2 1 3 30 50.8 27 45.8 2 4 39 20 MRI MRA 23 focal defect focal defect focal defect focal defect apparent diffusion coefficient ADC Gyroscan Intera 1.5T Master ADC b 0,500 1,000 ADC focal defect ADC 24 MR US MR US MR US MR US 1 MR US 2 3 4 MR US MR US 25 ADC ADC ADC ADC ADC 40Gy MR Intera 1.5T Master Philips 1 4 MR T1 T2 T1 T2 ADC MR ADC ADC ADC MR 26 1 1 1 1 143
1999 1 2007 7 9 2 7 56.9 Retrospective 2 8 5 4 CT MRI 27 MR sialography 48 MR sialography Dynamic MR sialography Dynamic MR sialography 30 Dynamic MR sialography 30 MR MIP Dynamic MR sialography 23 Pearson r 0.448 P 0.013 Pearson r 0.418 P 0.047 Dynamic MR sialography Dynamic MR sialography 28 pulse Doppler 1 1 1 pulse Doppler Sjögren 67 US pulse Doppler 10 0.5ml Vmax Vmax Vmax 10 Vmax Vmax Vmax Vmax Vmax Vmax 29 76 40 144
CT High Density Area CT ECG 30 Madelung disease 1 Madelung disease 1 77 30 18 20 CT US CT CT 100 X US 10 18mm CT CT Madelung disease Madelung disease 31 1 1 2 1 2 74 H18 10 19 2 8 X 24 32 69 X CT 32 1 1 1 1 30 1 1 28 10mm CT 145
MRI T2WI T1WI 15mm PET 18FDG 11C-Choline SUV 18FDG 4.80 11C-Choline 6.82 33 WHO X X X X 20 30 32 2006 7 2006 9 X X X CT 2006 11 CT 34 1 72 20 39 2 30 2006 11 28 34 65 CT 10 9 8 mm osteolytic lesion lesion MR lesion T1WI isointense T2WI isointense hyperintense dynamic study lesion wash out lesion contamination ameloblastoma follow-up 146