Head and Neck Cancer Imaging

Preface
Contents
Epidemiology, Risk Factors, Pathology, and Natural History of Head and Neck Neoplasms
	1	 Epidemiology: Frequency Measures and Risk Factors
		1.1	 Frequency Measure: Incidence
		1.2	 Risk Factors for the Development of Head and Neck Malignancies
			1.2.1	 Risk Factors for Development of HNSCC
			1.2.2	 Risk Factors for Development of Glandular Neoplasms
	2 Pathology and Natural History of Frequent Benign and Malignant Head and Neck Neoplasms
		2.1	 Epithelial Neoplasms of the Mucous Membranes
			2.1.1	 Tumour Typing and Clinical Behaviour
				2.1.1.1 Benign Lesions
				2.1.1.2 Premalignant Lesions
				2.1.1.3 Malignant Lesions
				2.1.1.4 Natural History Before and at Diagnosis
				2.1.1.5 Natural History Following Diagnosis and Successful Treatment of Malignant HNSCC
				2.1.1.6 Microscopical Negative Prognostic Findings
		2.2	 Glandular Neoplasms
			2.2.1	 Thyroid Neoplasia
				2.2.1.1 Benign Disease: Multinodular Enlargement
				2.2.1.2 Benign Disease: Uninodular Enlargement—The Solitary Thyroid Nodule
				2.2.1.3 Malignant Disease
				2.2.1.4 Papillary Thyroid Cancer (PTC)
				2.2.1.5 Follicular Thyroid Cancer (FTC)
				2.2.1.6 Hürthle Cell Carcinoma
				2.2.1.7 Medullary Carcinoma
				2.2.1.8 Anaplastic Carcinoma
			2.2.2	 Salivary Gland Neoplasia
				2.2.2.1 Tumour Typing and Clinical Behaviour
				2.2.2.2 Benign Tumours
					Pleomorphic Adenoma
					Warthin’s Tumour
			2.2.3	 Malignant Tumours
				2.2.3.1 Mucoepidermoid Carcinoma
				2.2.3.2 Adenoid Cystic Carcinoma
				2.2.3.3 Acinic Cell Carcinoma
				2.2.3.4 Adenocarcinoma Not Otherwise Specified (NOS)
	References
Clinical and Endoscopic Examination of the Head and Neck
	1 Introduction
	2 Neck
	3 Nose and Paranasal Sinuses
	4 Nasopharynx
	5 Oral Cavity
	6 Oropharynx
	7 Larynx
	8 Hypopharynx and Cervical Oesophagus
	9 Salivary Glands
	10 Thyroid Gland
	11 Role of Imaging Studies
	References
Imaging Techniques
	1 Introduction
	2 Plain Radiography
	3 Ultrasonography
	4 Computed Tomography and Magnetic Resonance Imaging
		4.1 Computed Tomography
			4.1.1 Patient Positioning
			4.1.2 Contrast Agent Injection
			4.1.3 Data Acquisition and Image Reconstruction
				4.1.3.1 General Comments
				4.1.3.2 Dose Reduction
				4.1.3.3 Multidetector Spiral CT
				4.1.3.4 Dual Energy CT
			4.1.4 Dynamic Maneuvers
			4.1.5 Three-Dimensional Image Reformatting
		4.2 Magnetic Resonance Imaging
			4.2.1 Patient Positioning
			4.2.2 Coils
			4.2.3 Standard Sequences
			4.2.4 Contrast Agents
			4.2.5 Additional MRI Techniques
				4.2.5.1 Dynamic Contrast-Enhanced Magnetic Resonance Imaging
				4.2.5.2 Diffusion-Weighted Magnetic Resonance Imaging
	5 Positron Emission Tomography
		5.1 Physical Aspects
		5.2 Radiopharmaceuticals
			5.2.1 Imaging of Glucose Metabolism: 18Fluorodeoxyglucose
			5.2.2 Imaging of Tumor Proliferation: 18Fluorothymidine
			5.2.3 Imaging of Amino Acid Metabolism: 18FET and 11C-MET
			5.2.4 Imaging of Hypoxia
			5.2.5 Imaging of Molecular Targets
		5.3 Technical Aspects of FDG-PET and Integrated FDG-PET/CT in Head and Neck Cancer
		5.4 PET/MRI
	References
Laryngeal Neoplasms
	1 Introduction
	2 Normal Laryngeal Anatomy
		2.1 Laryngeal Skeleton
		2.2 Mucosal Layer and Deeper Laryngeal Spaces
		2.3 Normal Radiological Anatomy
	3 Squamous Cell Carcinoma
		3.1 General Imaging Findings
		3.2	 Neoplastic Extension Patterns of Laryngeal Cancer
			3.2.1	 Glottic Cancer
				3.2.1.1 Local Tumor Spread
				3.2.1.2 Lymphatic Spread
			3.2.2	 Supraglottic Cancer
				3.2.2.1 Suprahyoid Epiglottis
				3.2.2.2 Infrahyoid Epiglottis
				3.2.2.3 Aryepiglottic Fold and Arytenoid
				3.2.2.4 False Vocal Cords
				3.2.2.5 Lymphatic Spread
			3.2.3	 Subglottic Cancer
	4 Prognostic Factors for Local Outcome of Laryngeal Cancer
		4.1 Treatment Options
			4.1.1	 Glottic Cancer
			4.1.2	 Supraglottic Cancer
		4.2 Impact of Imaging on Treatment Choice and Prognostic Accuracy
		4.3 Use of Imaging Parameters as Prognostic Factors for Local Outcome Independently from the TN-Classification
			4.3.1	 Predicting Local Outcome After Radiotherapy
				4.3.1.1 Tumor Volume and Deep Tissue Infiltration
				4.3.1.2 Cartilage Involvement
				4.3.1.3 Imaging of the Tumoral Micro-Environment
			4.3.2	 Predicting Local Outcome After Surgery
			4.3.3	 Towards Risk Profiles Incorporating Imaging Findings
	5 Posttreatment Imaging in Laryngeal Cancer
		5.1 Expected Findings After Treatment
			5.1.1	 Expected Tissue Changes After Radiotherapy
			5.1.2	 Expected Findings After Laryngeal Surgery
				5.1.2.1 Laser Resection
				5.1.2.2 Partial Laryngectomy
				5.1.2.3 Total Laryngectomy
		5.2	 Persistent or Recurrent Cancer
			5.2.1	 Imaging Strategies and Findings
			5.2.2	 Potential Value of Imaging Surveillance
		5.3	 Treatment Complications
			5.3.1	 Complications After Surgery
			5.3.2	 Complications After Radiotherapy
				5.3.2.1 Laryngeal Necrosis
				5.3.2.2 Other Complications After Radiotherapy
	6 Non-squamous Cell Laryngeal Neoplasms
		6.1 Minor Salivary Gland Neoplasms
		6.2	 Mesenchymal Malignancies
			6.2.1	 Chondrosarcoma
			6.2.2	 Other Mesenchymal Malignancies
		6.3	 Hematopoietic Malignancies
			6.3.1	 Lymphoma
			6.3.2	 Plasma Cell Neoplasms
			6.3.3	 Metastasis
	References
Neoplasms of the Hypopharynx and Proximal Esophagus
	1 Introduction
	2	 Anatomy
		2.1	 Descriptive Anatomy
		2.2	 Imaging Anatomy
	3 Pathology
		3.1	 Non-squamous Cell Malignancies
		3.2	 Squamous Cell Malignancies
			3.2.1	 Risk Factors
			3.2.2	 Clinical Presentation
			3.2.3	 Growth Pattern
			3.2.4	 Nodal Chain Involvement
			3.2.5	 Detection of Distant Metastasis
			3.2.6	 TNM Classification
		3.3	 Secondary Involvement by Other Tumors
	4 Cross-Sectional Imaging
	5 Radiologist’s Role
		5.1	 Pretreatment
			5.1.1	 Submucosal Spread
			5.1.2	 Cartilage Involvement
			5.1.3	 Tumor Volume
		5.2	 During Treatment
		5.3	 Posttreatment
			5.3.1	 Post Surgery
			5.3.2	 Postradiation Therapy
		5.4	 Detection of Second Primary Tumors
	References
Neoplasms of the Oral Cavity
	1	 How to Assess a Tumor in the Oral Cavity
		1.1	 Modalities
		1.2	 Tumor Localization
		1.3	 Tumor Measurements
		1.4	 Infiltration of Adjacent Structures
			1.4.1	 Lip Cancer
			1.4.2	 Gingival and Buccal Cancer
			1.4.3	 Retromolar Trigone Cancer
			1.4.4	 Hard Palate Cancer
			1.4.5	 Tongue Cancer
			1.4.6	 Floor of Mouth Cancer
			1.4.7	 Advanced Tumor Spread (T4a and T4b Stages)
		1.5	 Perineural Spread
		1.6	 Lymph Nodes
		1.7	 TNM, Eighth Edition
	2	 How to Report an MRI or CT of an Oral Cavity Malignancy
		2.1	 New Malignancies
		2.2	 Posttreatment Follow-Up
			2.2.1	 Radiotherapy Changes Versus Residual/Recurrent Tumor
			2.2.2	 Radionecrosis Versus Residual/Recurrent Tumor
	3	 The Black Swans: Diagnoses Other Than SCC
		3.1	 Infection or Inflammation
		3.2	 Osteoradionecrosis
		3.3	 Lymphoma
		3.4	 Salivary Gland Tumors
			3.4.1	 Sublingual Gland Tumors
			3.4.2	 Minor Salivary Gland Tumors
		3.5	 Other Differential Diagnoses
	4	 Useful Anatomical Landmarks
		4.1	 Buccal Mucosa Anatomy
		4.2	 Floor of Mouth
		4.3	 Extrinsic Tongue Muscles
	References
Neoplasms of the Oropharynx
	1	 Introduction
	2	 Normal Anatomy
	3	 Squamous Cell Carcinoma
		3.1	 Tonsillar Cancer
		3.2	 Tongue Base Cancer
		3.3	 Soft Palate Cancer
		3.4	 Posterior Oropharyngeal Wall Cancer
		3.5	 Lymphatic Spread
	4	 Treatment
	5	 Post-treatment Imaging
	6	 Other Neoplastic Disease
		6.1	 Non-Hodgkin Lymphoma
		6.2	 Salivary Gland Tumours
		6.3	 Other
	References
Nasopharyngeal Neoplasms
	1 Introduction
		1.1 Histologic Subtypes
		1.2 Risk Factors
	2 Nasopharyngeal Imaging Anatomy
	3 Clinical Features and Pathologic Anatomy of the Nasopharynx
		3.1 Clinical Presentation and Evaluation
		3.2 Imaging Evaluation
			3.2.1 Normal Appearance
		3.3 Local Extension and Patterns of Spread
			3.3.1 Anterior Spread
			3.3.2 Lateral Spread
			3.3.3 Posterior Spread
			3.3.4 Superior Spread
			3.3.5 Orbital and Paranasal Sinus Involvement
			3.3.6 Perineural Tumour Spread and Intracranial Extension
			3.3.7 Carotid Artery Encasement
		3.4 T-Staging
	4 Metastatic Disease
		4.1 Nodal Metastases
			4.1.1 Imaging Evaluation
		4.2 Distant Metastases
			4.2.1 Metastatic Workup
	5 Staging and Treatment
	6 Post-treatment Changes and Follow-Up
		6.1 Post-treatment Changes
			6.1.1 Resolution
			6.1.2 Residual and Recurrent Tumour
		6.2 Post-treatment Changes
			6.2.1 Skull Base Osteoradionecrosis
			6.2.2 Radiation-Induced Brain Necrosis
			6.2.3 Radiation-Induced Tumours
			6.2.4 Brain Stem and Spinal Cord Encephalomyelopathy
			6.2.5 Radiation-Induced Cranial Neuropathy
			6.2.6 Vascular Complications
			6.2.7 Xerostomia and Trismus
			6.2.8 Radiation-Induced Lung Disease
	7 Future Directions?
	8 Other Nasopharyngeal Neoplasms and Infections
		8.1 Pleomorphic Adenoma
		8.2 Inflammatory Pseudotumour
		8.3 Lymphoma
		8.4 Adenoid Cystic Carcinoma (ACC)
	References
Parapharyngeal Space Neoplasms
	1	 Introduction
	2	 Anatomy
		2.1	 Fascial Layers and Compartments
		2.2	 Radiological Anatomy
	3	 Imaging Findings in Parapharyngeal Space Lesions
		3.1	 Primary Lesions of the Parapharyngeal Space
			3.1.1	 Prestyloid Lesions
			3.1.2	 Retrostyloid Lesions
		3.2	 Secondary Lesions of the Parapharyngeal Space
	4	 Conclusion
	References
Malignant Lesions of the Masticator Space
	1 Introduction
	2 Imaging Techniques
	3 General Imaging Features of MS Masses
	4 Specific Imaging Features of Primary MS Malignancies
	5 Specific Imaging Features of Secondary MS Malignancies
	6 Post-treatment Imaging
	7 Benign Lesions Mimicking MS Malignancies
	8 Conclusion
	References
Neoplasms of the Sinonasal Cavities
	1 Introduction
	2 Normal Radiological Anatomy
	3 Indications for Imaging Studies
	4 Imaging Appearance and Extension Patterns of Sinonasal Neoplasms
		4.1 Appearance of the Tumor Mass on CT and MRI
		4.2 Extension Toward Surrounding Structures
			4.2.1 Nasoethmoidal Pattern
			4.2.2 Maxillary Sinus Pattern
	5 Tumor Types
		5.1 Epithelial Tumors
			5.1.1 Benign Epithelial Tumors
				5.1.1.1 Sinonasal Papillomas
				5.1.1.2 Sinonasal Ameloblastoma
				5.1.1.3 Salivary Gland Adenomas
				5.1.1.4 Respiratory Epithelial Adenomatoid Hamartoma (REAH) and Seromucinous Hamartoma (SH)
			5.1.2 Malignant Epithelial Tumors
				5.1.2.1 Squamous Cell Carcinoma
				5.1.2.2 Sinonasal Undifferentiated Carcinoma and Neuroendocrine Carcinoma
				5.1.2.3 Adenocarcinoma
				5.1.2.4 Salivary Gland-Type Carcinomas
				5.1.2.5 Nuclear Protein in Testis Midline Carcinoma (NUT) Carcinoma and Teratocarcinosarcoma
				5.1.2.6 Staging of Sinonasal Carcinomas
		5.2 Non-epithelial Tumors
			5.2.1 Neuroectodermal Tumors
				5.2.1.1 Olfactory Neuroblastoma
				5.2.1.2 Ewing Sarcoma (ES)/Peripheral Neuroectodermal Tumor (PNET)
				5.2.1.3 Mucosal Melanoma
			5.2.2 Soft Tissue Tumors
				5.2.2.1 Benign Soft Tissue Tumors
				5.2.2.2 Malignant Soft Tissue Tumors
				5.2.2.3 Borderline/Low-Grade Soft Tissue Tumors
			5.2.3 Osseous and Cartilaginous Tumors
				5.2.3.1 Benign Fibro-osseous Tumors
				5.2.3.2 Osteosarcoma
				5.2.3.3 Chondrosarcoma
			5.2.4 Hematolymphoid Tumors
				5.2.4.1 Lymphoma
				5.2.4.2 Extramedullary Plasmacytoma
			5.2.5 Metastasis
	6 Treatment Monitoring
	References
Parotid Gland and Other Salivary Glands Tumors
	1	 Introduction
	2	 Anatomy
	3	 Imaging Issues
	4	 Parotid Benign Tumors
		4.1	 Pleomorphic Adenoma or Benign Mixed Tumor
			4.1.1	 General Description
			4.1.2	 Histologically
			4.1.3	 Imaging Findings
			4.1.4	 Differential Diagnosis (See Sect. 6)
		4.2	 Warthin Tumor (Adenolymphoma)
			4.2.1	 General Description
			4.2.2	 Histologically
			4.2.3	 Imaging Findings
			4.2.4	 Differential Diagnosis
		4.3	 Other Benign Tumors
			4.3.1	 Lipoma
			4.3.2	 Facial Nerve Schwannoma
				4.3.2.1 Differential Diagnosis
			4.3.3	 Oncocytoma
		4.4	 Congenital Tumors
			4.4.1	 Lymphangioma
			4.4.2	 Infantile Hemangioma
		4.5	 Cystic Tumors
			4.5.1	 Solitary Cystic Lesion
			4.5.2	 Dermoid Cysts
			4.5.3	 Epidermoid Cysts
			4.5.4	 Multiple Intraparotid Cystic Lesions
	5	 Parotid Malignant Tumors
		5.1	 Histologic Classification
		5.2	 Imaging Findings
			5.2.1	 Parotid Cancer
			5.2.2	 Non-Hodgkin Lymphoma
	6	 Strategy in Difficult Cases
	7	 Pseudo-Tumors of the Parotid Gland
		7.1	 Sjögren’s Syndrome
		7.2	 Sarcoidosis
		7.3	 Intraparotid Lymph Nodes
	8	 Tumors of the Other Salivary Glands
		8.1	 Minor Salivary Glands Tumor
		8.2	 Submandibular Gland Tumors
		8.3	 Sublingual Gland Tumor
	9	 Conclusion
	References
Malignant Lesion of the Central and Posterior Skull Base
	1 Introduction
	2 Anatomy
		2.1 Central Skull Base
		2.2 Posterior Skull Base
	3 Clinical Presentation
	4 Normal Anatomical Variations
	5 Pathology
		5.1 Malignant Lesions Causing Diffuse or Multi-focal Skull Base Involvement
		5.2 Mimics of Malignant Lesions Causing Diffuse or Multi-focal Skull Base Involvement
		5.3 Non-region Specific, Localized Malignant Skull Base Lesions
		5.4 Mimics of Non-region Specific, Localized Malignant Skull Base Lesions
		5.5 Malignant Central Skull Base Lesions
		5.6 Mimics of Malignant Central Skull Base Lesions
		5.7 Malignant Lesions at the Junction of Central to Posterior Skull Base
		5.8 Malignant Posterior Skull Base Lesions
		5.9 Mimics of Malignant Posterior Skull Base Lesions
	6 Imaging Protocol
	7 Radiologist’s Role
	References
Thyroid and Parathyroid Neoplasms
	1	 Introduction
	2	 Thyroid Anatomy
	3	 Thyroid Gland Imaging Modalities
	4	 Thyroid Nodules
	5	 Thyroid Cancer
		5.1	 Papillary Thyroid Cancer
		5.2	 Follicular Adenoma and Follicular Thyroid Cancer
		5.3	 Anaplastic Thyroid Carcinoma
		5.4	 Medullary Thyroid Cancer
		5.5	 Thyroid Lymphoma
		5.6	 Thyroid Metastases
	6	 Imaging of Papillary Microcarcinoma
	7	 Post-operative Thyroid Cancer Imaging
	8	 Parathyroid Imaging Modalities
	9	 Parathyroid Adenoma
	10	 Parathyroid Carcinoma
	References
Neck Nodal Disease
	1	 Introduction
	2	 Nodal Group Classification and Pathways of Lymphatic Drainage
	3	 Imaging Modalities
		3.1	 CT and MRI
		3.2	 US and US-Guided Fine-Needle Aspiration Cytology (US-FNAC)
		3.3	 FDG-PET Imaging
		3.4	 Lymphoscintigraphy for Sentinel Node Localisation
	4	 Imaging Criteria for Malignant Nodes
		4.1	 Size and Nodal Clustering
		4.2	 Shape
		4.3	 Hilum
		4.4	 Vascular Pattern
		4.5	 Internal Heterogeneity
		4.6	 Border Irregularity
		4.7	 FDG-PET Uptake
	5	 Advanced Techniques
	6	 Micrometastases
	7	 Nodal Staging
	8	 Impact of Nodal Imaging on Patient Management
		8.1	 Detection of Metastatic Nodes
		8.2	 Extranodal Extension and Infiltration of Adjacent Structures
		8.3	 Identification of Patients at High Risk for Distant Metastases
	9	 Treatment Assessment
		9.1	 Prediction of Treatment Response to (Chemo)Radiotherapy
		9.2	 Post-treatment Assessment
		9.3	 Post-treatment Surveillance
	10	 Brief Overview of Non-HNSCC Lymphadenopathies
		10.1	 Lymphoma
		10.2	 Thyroid Cancer
		10.3	 Salivary Gland Carcinoma
		10.4	 Nasopharyngeal Carcinoma
		10.5	 Skin Cancer
	11	 Squamous Cell Carcinoma of Unknown Primary
	12	 Non-malignant Lymphadenopathy
	13	 Conclusion
	References
Neck Lymphoma
	1 Introduction
		1.1 Epidemiology
		1.2 Etiology
		1.3 Pathology and Classifications
	2 Hodgkin’s Lymphoma
	3 Non-Hodgkin’s Lymphomas (NHL) and Specific Entities
		3.1 B Cell Neoplasms
		3.2 T Cell and Natural Killer (NK)-Cell Neoplasms
		3.3 Hodgkin’s Lymphoma (Hodgkin’s Disease)
	4 Workup
		4.1 Diagnosis
		4.2 Initial Imaging
		4.3 Staging
	5 Treatment
	6 Response Assessment
	7 Nodal Disease
		7.1 The Common Sites
		7.2 The Uncommon Sites
	8 Extranodal Disease
		8.1 Waldeyer’s Ring and the Upper Aerodigestive Tract
			8.1.1 Nasopharynx
			8.1.2 Tonsillar Fossa
			8.1.3 Base of Tongue
			8.1.4 Larynx
		8.2 Orbit
			8.2.1 Conjunctiva
			8.2.2 Intra-orbital Lymphoma
			8.2.3 Lacrimal Gland
		8.3 Salivary Glands
			8.3.1 Parotid Gland
		8.4 Sinonasal Cavities
		8.5 Thyroid
		8.6 Bone
			8.6.1 Primary Lymphoma of Bone
			8.6.2 Multiple Myeloma (Kahlers’ Disease)
			8.6.3 Extramedullary Plasmacytoma
		8.7 Skin
	9 Conclusion
	References
Positron Emission Tomography in Head and Neck Cancer
	1	 Introduction
	2	 Clinical Applications
		2.1 Pretreatment
			2.1.1	 Primary Tumor Staging
			2.1.2	 Nodal Staging
			2.1.3	 Detection of Distant Metastasis and Second Primary Tumors
			2.1.4	 Detection of Unknown Primary Tumors
		2.2 Treatment Planning
		2.3 Treatment Surveillance
			2.3.1	 Posttreatment Evaluation of the Primary Site
			2.3.2	 Posttreatment Evaluation of Nodal Disease
			2.3.3	 Posttreatment Evaluation of Distant Metastases
		2.4 Special Considerations for Some Histological Tumor Types
			2.4.1	 Salivary Gland Tumors
			2.4.2	 Bone Lesions
			2.4.3	 Neuroendocrine Tumors
	References
Use of Imaging in Radiotherapy for Head and Neck Cancer
	1 Introduction
	2 General Principles of Radiotherapy for Head and Neck Cancer
		2.1 Evolution of Treatment Fields
		2.2 Photon Versus Proton Therapy
	3 Overview of Imaging Modalities Used in Radiotherapy
		3.1 CT
			3.1.1 Use
			3.1.2 Advantages
			3.1.3 Limitations
		3.2 MRI
			3.2.1 Use
			3.2.2 Advantages
			3.2.3 Limitations
		3.3 PET
			3.3.1 Use
			3.3.2 Advantages
			3.3.3 Limitations
	4 Applications of Imaging Data in Radiation Oncology
		4.1 Diagnosis and Staging
		4.2 Radiotherapy Planning
			4.2.1 Anatomic Imaging
			4.2.2 Functional Imaging
				4.2.2.1 Dose Painting
				4.2.2.2 Proliferation
				4.2.2.3 Hypoxia
				4.2.2.4 Apoptosis
				4.2.2.5 Receptor Status
		4.3 Treatment Verification
		4.4 Response Prediction
		4.5 Follow-Up
	5 Conclusion and Challenges
	References