1. Imaging plays an important role in head and neck cancer for tumor detection, characterization, staging, treatment planning, and monitoring treatment response and recurrence. MRI is often the preferred initial imaging modality, while CT and PET are also used. 2. Ultrasound is useful for imaging neck lymph nodes and salivary glands. CT is better for evaluating bone involvement. PET is used for detecting distant metastases. 3. Imaging also guides biopsies and interventions such as embolization prior to surgery. Advances include functional MRI, PET/CT, and intra-arterial chemotherapy.

1. IMAGING IN
HEAD & NECK CANCER
Dr. Amol M. Lahoti
Senior Resident
Dept. Of Radio-Diagnosis
NKPSIMS, Nagpur

2. ROLE OF IMAGING
• Clinical examination and endoscopy can visualise
tumours in the mucosa of the upper AE tract.
• However, not all areas are well visualised and
submucosal and deeper tumours cannot be seen.

3. Role of
Imaging
To see
which
structures
are
involved
and spared
Characteri-
sation of
tumours
Detection or
Exclusion of
tumors
Delineate
it’s Size
and Extent

4. Imaging in
Management
Follow
patients
under
Therapy
Planning
Therapy
Image
guided
Biopsies
Evaluate
Response
&
Recurrence

5. Imaging
Modalities
MRI
CT
USG
PET-CT

6. USG
Assessment of-
• Blood vessels and thus tumour vascularity
• in real time without contrast media.

7. • Ultrasound can evaluate the morphology of lymph nodes and Doppler sonography
can be used to assess the vascular pattern.
• Monitoring the lymph node size is also useful in the assessment of treatment
response.
Lymph node metastasis
a. In a patient with known multifocal papillary carcinoma of the thyroid showing a
small area of necrosis (arrow).
b. Color doppler image showing pathological peripheral vascularity

8. Ultrasound is ideal for guiding interventions
FNAC/Biopsy where the lesion is well visualized.

9. CT Scan
• Thin slice, high resolution image acquisition allows high quality
Multiplanar Reconstructions
• CT is readily accessible ,faster image acquisition

10. • Superior evaluation of bony structures and calcifications.
• The study can be extended to the rest of the body for
staging purposes, mainly CHEST and upper abdomen.
• Fast image acquisition
 Advantages

11. Lymph node
Stations

13. MRI
• Excellent soft tissue contrast

14. MRI
• Better evaluation of blood vessels with or without giving
contrast media.
• No radiation exposure, no iodinated contrast.
• Functional imaging like diffusion-weighted imaging, perfusion
and dynamic enhancement

15. MRI v/s CT

16. Normal oral cavity structures and
spaces

18. Positron emission tomography-computed
tomography with fluorine-18-Deoxy-D-Glucose
(18FDG PET-CT)
• Evaluation of the whole body ,lymph node involvement when they
are normal in size,
• Detection and exclusion of distant metastases
• The high sensitivity of detection of glucose uptake.

19. • Mass of soft tissue density on CT which enhances
according to its vascularity

20. Cases At a Glance

21. Left buccal mucosa
Squamous cell carcinoma

22. Fig. 4
Oral and Maxillofacial Surgery Clinics 2010 22, 107-115DOI: (10.1016/j.coms.2009.10.002)

23. Fig. 7
Oral and Maxillofacial Surgery Clinics 2010 22, 107-115DOI: (10.1016/j.coms.2009.10.002)

24. Fig. 6
Oral and Maxillofacial Surgery Clinics 2010 22, 107-115DOI: (10.1016/j.coms.2009.10.002)

25. A small tumour is seen arising from
the buccal surface of the gingiva

26. Buccal SCC

27. Clear Cell Mucoepidermoid
Carcinoma in the Retromolar Trigone

28. Primary imaging (before therapy)
• The ideal initial study is one which is safe and provides all the
information required for proper management.
• This depends on the site of origin of the tumor and known
patterns of spread.
• The next study, if required should be able to answer questions
not clarified by the first study.
• Furthermore, distant metastases or concomitant tumors
which can be present due to common risk factors should be
excluded. This is usually done either by performing a CT or
MRI.

29. Imaging appearance (after therapy)
• The expected changes after radiotherapy include
1. Edema and
2. Inflammation
3. Thickening, swelling and induration of all the structures in the
radiation field,
Followed by atrophy, calcification.

30. Tumor Recurrence
• Tumor recurrences appear as a soft tissue mass at the primary
site on CT or MRI and after major surgery with reconstruction,
recurrence is usually seen at the edge of the resection or the
soft tissue flaps.
• It can be very difficult to distinguish between tumor
recurrence and post-therapeutic changes in the early stages.
 PET-CT is accurate -after 1-3 months

31. Modality Prescribing
The modality prescribed depends primarily on availability.
• MRI is best for evaluation of the oral cavity and oropharynx
and for evaluation of perineural tumour spread.
• For evaluation of the PNS, nasal cavity and larynx, where soft
tissue and bony details are important, both CT and MRI are
commonly used and provide complementary information.

32. • Ultrasound is used widely for evaluation of the thyroid gland,
neck lymph nodes and salivary glands and in soft tissue mass
evaluation and in the paediatric population
• PET-CT is useful for detection of the primary tumour, known
or unknown, nodal metastases, second tumours or distant
metastases. It has a role in restaging and long term
surveillance to detect recurrence.

33. Fig. 10
Oral and Maxillofacial Surgery Clinics 2010 22, 107-115DOI: (10.1016/j.coms.2009.10.002)
RECENT ADVANCES

35. Management of vascular lesions
Interventinal Radiology

39. • Intra-Arterial Chemotherapy, for Head and Neck Carcinoma.
• Preoperative embolization of ECHN tumors is frequently
performed by transarterial route.
• Pre-operative embolization helps to prevent blood loss during
surgery and provides a clean field for the surgical resection

41. In a nutshell-Summary
• MRI - Modality of choice in head and neck cancer (Tongue,oral cavity
Oropharynx, nasopharynx and salivary gland) and to diagnose
recurrence.
• CT is indicated when-
– Bony involvement, skull base
– Patient is uncooperative .
– Respiratory difficulty due to mass in naso-pharynx .
– Claustrophobic patients .
• PET is not routinely indicated in the follow up due to cost and high
false positive rate and non-specificity

44. References
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