SURGICAL ONCOLOGY POINT OF VIEW

1. DR DHARA PANDYA
DNB SURGICAL ONCOLOGY

5. NECK RADIOGRAPHS
ULTRASONOGRAPHY
COMPUTED TOMOGRAPHY
MRI
RADIO ISOTOPE STUDIES
PET CT/ PET MR.
INTERVENTIONAL RADIOLOGY.

6. ORTHOPANTAMOGRAM
 OPG for involvement of mandible & maxilla
 Assessment of the entire dentition and evaluation of
erosions
 Mentum & lingual cortex difficult to assess

7. IMAGING IN HEAD AND NECK
 Highly operator dependent
 Sensitive in picking up nodes in clinical N0 disease
 Useful for image guided biopsy
 High frequency linear probe is excellent for superficial structures
 Ultrasound criteria:
Size
Roundness index ratio of transverse to longitudinal diameters
Absence of an echogenic hilus
Presence of necrosis – coagulative or cystic within a node
Extracapsular spread
Colour doppler- disorganised peripheral flow pattern

8. Coagulative necrosis Cystic
necrosis
Extracapsular disease Disorganised
peripheral flow

9. CT SCAN
 Standard practise now
 Evaluates site and location of primary
 Assessment of Metastatic adenopathy
 Scans done prior to biopsy to avoid confusion by changes from biopsy
Indications for CT:
 For evaluation of primary situated adjacent to bone
 Evaluation of extent of spread in large primaries
 Evaluation of neck
ADVANTAGES:
 Increased speed
 Bony framework – better evaluated
 Small calcifications more apparent
DISADVANTAGES:
 Requires ionizing radiation
 iodinated contrast agents

10. MRI –
 Better Soft tissue contrast
 Multiplanar – better assessment of Primary
 Useful additional information in previously treated patients
(recurrence and residues) and in lesions with skull base
involvement
 No dental amalgam artifact
Indications for MRI:
 In primaries with possible perineural spread
 For evaluation of possible skull base involvement
 To evaluate exact soft tisue spread of the tumor

11. NUCLEAR SCANS:
 Iodine scans for thyroid.
 MIBG scans for parathyroid.
PET CT/ PET MR
 Residual VS recurrence.
 Radiation Scar vs recurrence.
 Occult primaries.
 Guiding endoscopic biopsies.

12. BASICS OF IMAGING IN HEAD
AND NECK CANCER
 CT and MRI - assess the interface of tumor with bone, fat, muscles
and other soft tissues, air, blood vessels, dura, and brain
 intravenous (IV) administration of iodinated contrast medium,
tumors enhance to varying degrees
 Foci of necrosis or prior hemorrhage are dark (hypodense) on CT
 Lacking a blood supply, necrotic foci do not enhance after contrast
administration.
 MRI, tumor signal is quite variable - Many head and neck neoplasms
are
 isointense to (ie, have the same signal as) soft tissues (brain, muscle) on
nonenhanced T1-weighted images
 isointense to hyperintense (have the same or brighter signal) on T2-
weighted images
 enhance at least somewhat after IV gadolinium.
 Very cellular or fibrous neoplasms that contain little free water may
be hypointense (dark) on T2-weighted image
 Necrosis produces a fluid signal on MRI; this is hypointense on T1-
weighted images and hyperintense on T2-weighted images

13. Hounsfield unit

14. T1- TE- < 90 msecs
TR- < 1600 msecs
water-black,
fat- bright
T2- TE- >90 msecs
TR- > 1600 msecs
water- bright(white)
fat- black
Longitudinal or spin-lattice relaxation T1: gives the anatomic details
Transverse or spin-spin relaxation T2: gives the details of the pathologic proces
STIR (Short Time Inversion Recovery)
FLAIR (Fluid Attenuated Inversion Recovery)
T1 T2

15.  Tumor and muscle may have similar appearances on
both CT and MRI studies
 Tumor usually enhances more than any structures,
except mucosa and the extraocular muscles
 Scar tissue has a variety of appearances, depending
on its age
 Granulation tissue enhances intensely
 fibrous tissue usually enhances less but cannot
always be differentiated from tumor on CT or MRI
 Consecutive studies are extremely helpful: With
time, tumor grows (or occasionally remains stable),
but scar tissue tends to contract and, thus, decrease
in size

17. Calcifications within a tumor are white on CT and
usually a signal void (black) on MRI.
These may represent residual normal bone or tumor
matrix.

18.  Cortical bone is a dense white line on CT
 Its density is much greater than that of tumor, making CT
an ideal modality for the evaluation of erosion of bone
 Even subtle erosion of thin cortical bone, such as tegmen
tympani cribriform plate, and lamina papyracea, is easily
detected on CT bone algorithms
 MRI - cortical bone is a signal void
 subtle erosion of a signal void is difficult to detect, making
MRI less useful than CT for evaluating cortical bone
erosion by tumor
 MRI - excellent imaging modality for the evaluation of
medullary bone and bone marrow
 Fat-suppression pulse sequences are special image
acquisitions that decrease the high signal of fat without

20.  The appearance of the cartilage of the normal adult
larynx is quite variable
 Cartilage may mineralize and even ossify
 Mineralized laryngeal cartilage is dense (white) on CT
and hypointense on MRI.
 normal laryngeal cartilage ossifies irregularly and
discontinuously;
 CT images - may be impossible to determine whether a
defect in the cartilage is erosion by tumor or a normal
discontinuity
 tumor extension to the extralaryngeal surface of the
cartilage, invading or displacing strap muscles -
presumed to be erosion
 MRI - by contrast, is an ideal imaging modality for
evaluating ossified laryngeal cartilage, as even small

21. LARYNX

22.  On CT, fat is lucent (hypodense,
dark) with respect to tumor
 only air is more lucent than fat
 On T1-weighted MRI sequences,
fat is hyperintense (white).
 To differentiate tumor from fat on
MRI, nonenhanced T1-weighted
images are useful
 Fat-suppression techniques
darken the high signal of fat
without altering the high signal of
enhancing tumor
 nonenhanced T2-weighted images
and fat-suppressed enhanced
images are essential to the
evaluation of neoplasms that abut
fat

23.  beneath the skull base at the neural foramina:
 stylomastoid foramen for the facial nerve (parotid tumors) and
 foramen ovale for the mandibular division
 foramen rotundum for the maxillary division of the trigeminal nerve
 Replacement of perineural fat, on CT or MRI, by soft tissue strongly
suggests perineural extension of tumor along cranial nerves
 On CT perineural tumor causes enlargement and erosion of the skull
base foramina and canals that transmit the affected cranial nerves
 On MRI the corresponding abnormalities are intense enhancement
and enlargement of the nerves
 MRI is a more sensitive test for the detection of perineural tumor
growth

25.  Dural enhancement may indicate tumor invasion or dural
inflammation secondary to adjacent tumor or prior surgery
 Enhancement of dura is often evidence of intracranial extension of
tumors arising in the paranasal sinuses, nasal cavity, skull base,
nasopharynx, and temporal bone
 Subtle dural enhancement is not detected on CT
 Coronal images often provide important information about dura
along the floor of the anterior and middle cranial fossae and the
roof of the temporal bone
 Both CT and MRI (especially T2-weighted pulse sequences) show
white matter edema; MRI is superior for the detection of subtle
edema

27.  On nonenhanced CT studies, blood vessels are isodense to other
soft tissues
 After IV iodinated contrast administration, however, blood vessels
become hyperdense (white) and can be easily differentiated from
other soft tissues
 Tumor invading a blood vessel is usually a different density from
the opacified blood in the remaining vessel lumen
 On spin echo pulse MRI sequences (T1- and T2-weighted images,
for example), rapidly flowing blood generates a signal void (black)
 This appearance does not change significantly after IV gadolinium
administration; rapidly flowing blood is a signal void whether or
not it contains gadolinium
 More slowly flowing blood vessels, such as smaller veins and
arteries and the cavernous sinus are an important exception; these
vessels may enhance after contrast administration
 The carotid arteries, jugular veins, and large dural venous sinuses
are all black.

29. Air is black on CT and on all MR pulse sequences
Dense tumor calcifications are black (signal voids) on MRI, but
calcified foci are usually scattered within the soft tissue mass of a
tumor
PUFFED-CHEEK TECHNIQUE

36. The sternocleidomastoid muscle divides the
neck into the anterior and posterior cervical
triangles.
The hyoid bone further divides the anterior
triangle into SUPRAHYOID &
INFRAHYOID portions.

38. An alternative to the traditional cervical triangle
method of organizing anatomy of the neck is to divide
the neck into spaces created by the deep cervical
fascia .
The deep cervical fascia consists of three layers:
 a superficial investing layer,
 a middle visceral layer,
and deep prevertebral layer.

39. Investing fascia
Prevertebral fascia
Carotid sheath
Pretracheal fascia *
Buccopharyngeal fascia *
Common carotid a.
Internal jugular v.
Vagus n.
* = Component of visceral fascia
Retropharyngeal space

40. SUPRAHYOID NECK:
 Buccal space
 Masticator space.
 Parotid space.
 Para pharyngeal space
 Pharyngeal mucosal space.
 Sub mandibular space
 Sublingual space
INFRAHYOID NECK
Visceral space.
Anterior cervical space.
Posterior cervical space
SUPRA & INFRAHYOID
NECK
Carotid space
Retropharyngeal space.
Danger space.
Perivertebral space.

41. Buccopharyngeal fascia
Prevertebral fascia
Retropharyngeal space
Base of skull
Mediastinum

44. BOS...

45. BOS...

46. HIGH SUPRAHYOID LEVEL

49. The paired sublingual spaces are located in the floor of the mouth and are
defined by
the mandible anteriorly and laterally,
the hyoid bone posteriorly,
 the oral mucosa superiorly,
and the mylohyoid muscle inferiorly
Sublingual Space
The fan-shaped mylohyoid muscle separates the floor of the mouth
from the soft tissues of the neck.
It originates along the inner surface of the mandible and inserts on
the hyoid bone.
The posterior lateral edges of the muscle permit the sublingual
space to freely communicate with the submandibular space.

52. Also contained within each sublingual space are
 hyoglossus and styloglossus muscles
 lingual arteries,
 deep lobes of the submandibular salivary glands,
the glossopharyngeal & hypoglossal nerves.
The hyoglossus muscle is the surgical landmark separating the
superficially located submandibular duct from the lingual artery located
deep to the muscle.

55. Submandibular space
The submandibular space is posterolateral to the sublingual space
contains the superficial lobe of the submandibular salivary gland and
lymph nodes.
It communicates freely with the sublingual space because of the lack of
limiting fascial boundaries
 SUBMANDIBULAR SPACE

58. PAROTPIPPD SPACE
The PAROTID SPACE is located posterior to the masseter muscle.
Contents of the parotid space include the
parotid gland,
 Stenson's duct,
 the facial nerve,
 intraparotid lymph nodes,
and blood vessels.

59. Evaluation of masses within the parotid region begins with determination
of the lesion as intra-parotid or extra-parotid.
Lesions are considered intra-parotid if 50% or greater of the circumference
is surrounded by parotid tissue and the epicenter is lateral to the
parapharyngeal space.
Intraparotid masses displace the parapharyngeal fat medially.
Large lesions of the deep parotid lobe may be difficult to distinguish from
primary parapharyngeal masses.
Identification of a fat plane between the lesion and the parotid indicates a
parapharyngeal space site of origin, whereas direct contiguity of mass to
gland indicates a deep parotid lobe origin .

61. Intraparotid lesions must then be localized to either the superficial or
deep parotid lobes.
The facial nerve divides these two lobes.
 Because the facial nerve is not reliably demonstrated on scans, the
retromandibular vein is chosen as an alternative landmark for
demarcation.
 Superficial lesions may only need a superficial parotidectomy; however,
deep lesions usually require a total parotidectomy.

64. The parapharyngeal space is shaped like an inverted pyramid and extends
from the skull base to the hyoid bone.
This space is triangular on axial images with the apex pointing towards
the nasopharynx.
At the level of the nasopharynx, this space is subdivided into prestyloid
and poststyloid compartments by the fascia of the tensor veli palatini.

65.  Medially: buccopharyngeal fascia
over superior constrictors
 Laterally: fascia overlying medial
pterygoid muscle, ramus of
mandible, and fascia overlying
retromandibular parotid
 Anterior: pterygomandibular raphe
 Posterior: dorsal layer of fascia of
the carotid sheath
 Inferior: junction of posterior belly
of the digastric and greater cornu
of hyoid

67. Prestyloid
 Fat
 Retromandibular parotid
 lymphnodes
Retrostyloid
 Internal carotid artery
 Jugular vein
 Sympathetic chain
 Cranial nerves IX-XII
 Lymphnodes
 Key anatomical division of PPS
 Tensor-vascular styloid fascia divides into prestyloid and
retrostyloid spaces
 Anterolateral prestyloid/posteriormedial retrostyloid
 Used to make differential diagnosis based on imaging

68. The prestyloid compartment contains
 branches of the internal maxillary and ascending pharyngeal arteries,
fat,
and minor salivary glands.

69. Intrinsic parapharyngeal lesions have a surrounding halo of
parapharyngeal fat, whereas deep parotid lesions extending into the
parapharyngeal space are inseparable from the parotid gland tissue.
 This differentiation is important in that surgeons prefer to approach
primary parapharyngeal masses from the oral or submandibular regions
and deep parotid lobe lesions through a parotid approach in order to
conserve the facial nerve.

70. The cylindrical CAROTID SPACE extends from the base of the skull to the
aortic arch.
 In the suprahyoid neck, the carotid space as the poststyloid
parapharyngeal space.
The carotid space contains
 the carotid artery,
 internal jugular vein,
 glossopharyngeal nerve,
 vagus nerve,
 spinal accessory nerve,
 hypoglossal nerve,
 sympathetic chain,
 and the internal jugular nodes of the deep cervical chain

72.  paired supra-hyoid cervical spaces
 extend from the angle of the mandible to
the parietal calvarium
 lineated by a superficial layer of the deep
cervical fascia in two layers: an inner and
outer or superficial layer
 fuse along the anterior and posterior
borders of the mandibular ramus,
enveloping the space
 contains
 mastication muscles,
 posterior mandible, and
 mandibular nerve
 Maxillary artery

73. MASTICATORY SPACE
potential space present
around the muscle of
mastication with four
separate compartments
1.Submassetric (G)
2.Pterygomandibular (H)
3.Superficial temporal (E)
4.Deep temporal space (F)

74. MASTICATORY SPACE-
IMAGING
 Clinical examination of the masticator space is difficult
 Imaging techniques - essential to detect and characterise the
pathology of this space
 CT and MRI imagings are the preferred techniques and are both
equally reliable in detecting lesions
 CT is better than MR in detecting subtle erosions of the cortex of
the mandible and provides excellent detection and
characterisation of the tumour matrix mineralisation
 MR has higher soft tissue contrast resolution than CT and better
depicts muscle invasion by tumours
 provides better assessment of mandibular medullary disease and
is more sensitive for detecting perineural tumour spread
 Imaging findings of extrinsic tumour involvement include
effacement of the surrounding fat planes, deformity or a soft tissue
mass in the space, and erosion or destruction of the mandibular
ramus

79. The mandibular branch of the trigeminal nerve exits the skull through the
foramen ovale, which is located above the masticator space and has been
termed the "chimney of the masticator space".
 Lesions within the masticator space can invade the middle cranial fossa
by this route and intracranial processes, such as meningiomas, can
descend into the masticator space and become extracranial.

80. INFRATEMPORAL FOSSA
Cranial cavity (through foramen ovale and spinosum)
Temporal fossa (deep to zygomatic arch)
pterygopalatine fossa (through pterygomaxillary fissure)
Orbit (through inferior orbital fissure)
parapharyngeal space

81. MANDIBULAR NERVE & ITS BRANCHES SEEN IN
INFRA TEMPORAL FOSSA
CONTENTS

83. Pterygoid venous plexus
 Lies around and within the lateral pterygoid muscles.

84. Pterygopalatine fossa
 inverted 'tear-drop' shaped space between bones on the
lateral side of the skull immediately posterior to the
maxilla.

86. 7 foramina and fissures provide apertures through which structures enter and
leave the pterygopalatine fossa:
foramen rotundum & pterygoid canal middle cranial fossa
palatovaginal canal nasopharynx
palatine canal leads oral cavity (hard palate)
sphenopalatine foramen nasal cavity
pterygomaxillary fissure infratemporal fossa
inferior orbital fissure orbit

88. It includes the mucosal surfaces and
immediate submucosa of the
nasopharynx, oropharynx, oral cavity,
and hypopharynx .
Included in this space are
lymphoid tissue,
minor salivary glands,
pharyngeal constrictor muscles,
and the salpingopharyngeus muscle.

89. Mucosal space lesions usually are well seen by the clinician; however,
imaging evaluates deep invasion and assesses lymph node metastases.
imaging results in upstaging almost 25% of advanced pharyngeal mucosal
space cancers by demonstrating clinically silent submucosal disease.
 On CT or MRI the mucosa may be thickened and asymmetric.
Nasopharyngeal cancers typically blunt the fossa of Rosenmuller and
displace the parapharyngeal fat

91. VISCERAL SPACE
The midline VISCERAL SPACE is enclosed by the middle layer of deep
cervical fascia and extends from the hyoid bone to the mediastinum .
It contains
the larynx and hypopharynx,
the thyroid and parathyroid glands,
 the trachea and esophagus,
 paratracheal lymph nodes,
and the recurrent laryngeal nerves.

92. Both MRI and CT demonstrate the larynx
and hypo pharynx well.
 Computed tomography better depicts
calcified cartilage compared with MRI, but
MRI better defines soft-tissue planes.
Swallowing and vascular pulsations may
degrade MRI images.

105. The hypopharynx is that portion of the foregut that lies
between the oropharynx and larynx, extending from the hyoid
bone to the cricopharyngeus muscle.
The hypopharynx consists of three regions:
the paired pyriform sinuses,
 the postcricoid region (pharyngoesophageal junction),
 and the posterior hypopharyngeal wall.

106. The RETROPHARYNGEAL SPACE lies posterior to
the visceral space. The retropharyngeal space
extends from the base of the skull to the
mediastinum and serves as a potential conduit for
spread of neck pathology into the chest.
The retropharyngeal space is divided into
suprahyoid and infrahyoid compartments.
The suprahyoid compartment contains lymph nodes
and fat, whereas the infrahyoid compartment only
contains fat
The lymph nodes of the suprahyoid component of the
retropharyngeal space form paired medial and
lateral chains. The lateral chain is also known as the
nodes of Rouvier.

107. Therefore, retropharyngeal lymphadenopathy only occurs above the hyoid
and tends to remain unilateral or bilateral, sparing the midline .
 In contradistinction, infections and direct invasion of cancer may involve
both the suprahyoid and infrahyoid portions and the midline.
A "DANGER SPACE" posterior to the retropharyngeal space has been
described. The danger space cannot be reliably differentiated from the
retropharyngeal space on imaging and is therefore combined with the
retropharyngeal space for discussion.

109. POSTERIOR CERVICAL SPACE
The posterior cervical space corresponds to the occipital and subclavian
divisions of the posterior cervical triangle.
The primary components of this space are
 fat,
 the spinal accessory and dorsal scapular nerves,
and the spinal accessory lymph nodes of the deep cervical chain.

110. The PREVERTEBRAL SPACE is formed by the deep cervical fascia.
Fascia attaches to the transverse processes of the cervical vertebra
dividing this space into anterior and posterior compartments.
The anterior compartment contains
the vertebral bodies and spinal cord,
the vertebral arteries,
and prevertebral and scalene muscles.
The posterior compartment contains
the posterior vertebral elements
 and paraspinous muscles.
Prevertebral space lesions usually arise in the vertebral body,
intervertebral disc spaces, or prevertebral or paraspinous muscles.
 Examples include vertebral osteomyelitis and metastases, and rarer
lesions such as chordoma and nerve sheath tumors.

112. BOS...

115. Enhancement of Lymph Nodes
 Normal lymph nodes are the same CT density as muscle and are
isointense to muscle on T1-weighted MR images.
 Normal nodes are usually slightly hyperintense (white) on T2-
weighted images and enhance slightly and homogeneously after
contrast administration.
 normal the criterion of 1 cm in greatest axial diameter for
cervical lymph nodes / 1.5 cm for jugulodigastric (zone II) nodes
that drain much of the upper aerodigestive tract.
 Homogeneous density or signal, an oval shape, and intact
surrounding fat are also normal
 A heterogeneous appearance, enhancement and/or frank central
necrosis strongly suggest the presence of metastatic tumor in the
appropriate clinical context

117. The American Joint Committee on Cancer (AJCC) has established
guidelines using a terminology that divides the lymph node groups into a
series of levels that have prognostic importance
Level I consists of the submental and submandibular nodes.
 Level II includes the internal jugular chain extending from the base
of skull to the carotid bifurcation (hyoid bone).

118. Level III corresponds to the internal jugular nodes
from the carotid bifurcation to the omohyoid muscle
(cricoid cartilage).
Level IV refers to all nodes in the internal jugular
group from the omohyoid muscle to the clavicle.
Level V consists of spinal accessory and transverse
cervical nodes.
Level VI contains the pretracheal, prelaryngeal, and
paratracheal nodes.
level VII includes the nodes in the
tracheoesophageal groove and upper mediastinum.