Objectives - NYP
Transcript of Objectives - NYP
C. Douglas Phillips, MD FACRDirector of Head and Neck ImagingWeill Cornell Medical CenterNewYork‐Presbyterian Hospital
Objectives
Review basics of head and neck imagingDiscuss our spatial approach to head and neck imagingDescribe appearance of tumors and normal and abnormal lymph nodesReview some basic of imaging pitfalls and limitations for CT and MR
CT or MR?
Basic question is always same: What information do we hope to gain?
Presence or absence of tumorPresence or absence of nodal diseaseExtent of neoplasm
Our tools in this eraCTMRPET and/or PET‐CT (PET‐MR)
Basics of H&N Imaging
Use easiest, most reliable and reproducible technique Know patient’s limitationsCT usually wins
Quick, accessible, inexpensive, reproducible, reliable
MR may provide additional/confirmatory evidence and may be more sensitive for some disease or disease spread
Spatial Approach to H&N Imaging
Cross‐sectional imaging revolutionized our approach to diagnosesSegmentation of anatomic regions by layers of deep cervical fasciaOther anatomic divisions still of importance, but spatial approach narrows differential
Traditional Anatomic Regions
NasopharynxOropharynxOral cavityHypopharynxLarynxSuprahyoid and infrahyoid neckSinonasal cavity
Traditional thinking
Spatial approach: Ideal for
cross‐sectional imaging
Spatial Approach
Pharyngeal mucosal spaceCarotid spaceParapharyngeal spaceMasticator spaceParotid spaceBuccal spacePrevertebral, perivertebral spaceRetropharyngeal space
CT of H&N Tumors
Lesions depicted by 2 major mechanismsDistortion of normal anatomy (morphology)Differential enhancement
Typical SCCa appearanceCombination of infiltrative and exophytic massHeterogeneous enhancementUniform enhancement is atypical, and suggests other diagnoses
Oral Tongue SCCa with Bilateral Nodal Disease
MR of H&N Tumors
Similar depiction to CT, but with key advantage of MR in depicting signal changes of tumorTypical SCCa appearance
Hypointense but heterogeneous on T2Hypointense on T1Other characteristics (mass and enhancement) as seen on CT
T2 T2
T1 T1 C+
CT of Nodal Disease
Three key elements of identifying pathologic lymph nodes
SizeMultiple systems are utilizedLevels 1 and 2 ‐ > 1.5 cm axial diameterAll other internal jugular chain nodes ‐ > 1 cmRetropharyngeal nodes ‐ >5 mm
Enhancement characteristicsEvidence of extracapsular disease (capsular penetration)
MR of Nodal Disease
System is not as well studiedSize as per CT criteriaEnhancement is poorly understoodNormal nodes may heterogeneously enhanceCorrelate non‐enhancing areas with T2 signal
Central nodal T2 hyperintensityExtracapsular disease often overestimated
IBIB
IIA IIA
IB IB
IIA IIA
IIBIIB
Level III Nodes
Level IV Nodes
IB IB
IIA IIA
IIBIIB
VV
Pathologic Level V Node
Level VI Node
Pathologic Level VI Node
PET‐CT
Adds dimension of physiologic information (“molecular imaging”)Metabolic activity of tissue on standardized scale
SUV or standardized uptake valueMany use cut‐off of 2.5 for malignancyCan be much higher in metabolically active muscles and some other tissuesNOT A BE‐ALL, END‐ALL VALUE
SCCa Oral Tongue
Residual Disease Following Chemo‐RT
SCCa of Tongue: Less Significance of Artifact
PET‐CT in H&N Cancer
Has proven useful in most SCCa initial evaluation and in follow upVery useful in lymphoma evaluationLess useful for several other malignancies
Still being studiedNotorious undercall of AdCysticCaThyroid disease is very topical, and new developments are now showing greater promise
False positives must always be considered
Fake‐Out: Melanoma Primary, Dental Abscess
Layers of Deep Cervical Fascia Defines Spaces
Named Spaces of Suprahyoid Neck
PPS: PleomorphicAdenomaPostero‐ lateral flattening ‐
parotid
RPS: Anterior Displacement of PPS
MS: Odontogenic Lesions (Abscess)
PS: Mucoepidermoid Carcinoma
PS: Benign Lesions ‐ Warthin’s Tumor
INFRAHYOID NECK: Major Fascial Spaces
VisceralThyroid, parathyoids, aerodigestive tract, paratracheal nodes
CarotidRetropharyngealPerivertebralPosterior cervical
CT
CT
Hyoid Bone Level
High Supraglottic Level
Mid‐Supraglottic Level
Low Supraglottic Level
Glottic Level
Subglottic Level
GlotticSCCa
TransglotticSCCa
CN V2 – Adenoid Cystic Ca
of Palate
Important Imaging Points
Radiology dictum is describe full extent of primary disease and evaluate scanned volume for metastasisIn H&N cancer, this should include review of cervical lymph nodesGreat undiagnosed condition is PNS of H&N malignancies
Critical prognostic informationFailure to see almost guarantees undertreatment
Conclusions
Cross sectional imaging is best evaluated by a spatial approachKnowledge of spaces can narrow differential diagnosesCT, MR and PET‐CT can contribute to initial evaluation and play key roles in follow up of patients with H&N cancer