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Parsaei M, Sanjari Moghaddam H, Mazaheri P. The clinical utility of diffusion-weighted imaging in diagnosing and predicting treatment response of laryngeal and hypopharyngeal carcinoma: A systematic review and meta-analysis. Eur J Radiol 2024; 177:111550. [PMID: 38878501 DOI: 10.1016/j.ejrad.2024.111550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/24/2024] [Accepted: 06/02/2024] [Indexed: 07/24/2024]
Abstract
PURPOSE Laryngeal and Hypopharyngeal Carcinomas (LC/HPC) constitute about 24 % of head and neck cancers, causing more than 90,000 annual deaths worldwide. Diffusion-Weighted Imaging (DWI), is currently widely studied in oncologic imaging and can aid in distinguishing cellular tumors from other tissues. Our objective was to review the effectiveness of DWI in three areas: diagnosing, predicting prognosis, and predicting treatment response in patients with LC/HPC. METHODS A systematic search was conducted in PubMed, Web of Science, and Embase. A meta-analysis by calculating Standardized Mean Difference (SMD) and 95 % Confidence Interval (CI) was conducted on diagnostic studies. RESULTS A total of 16 studies were included. All diagnostic studies (n = 9) were able to differentiate between the LC/HPC and other benign laryngeal/hypopharyngeal lesions. These studies found that LC/HPC had lower Apparent Diffusion Coefficient (ADC) values than non-cancerous lesions. Our meta-analysis of 7 diagnostic studies, that provided ADC values of malignant and non-malignant tissues, demonstrated significantly lower ADC values in LC/HPC compared to non-malignant lesions (SMD = -1.71, 95 %CI: [-2.00, -1.42], ADC cut-off = 1.2 × 103 mm2/s). Furthermore, among the studies predicting prognosis, 67 % (4/6) accurately predicted outcomes based on pretreatment ADC values. Similarly, among studies predicting treatment response, 50 % (2/4) successfully predicted outcomes based on pretreatment ADC values. Overall, the studies that looked at prognosis or treatment response in LC/HPC found a positive correlation between pretreatment ADC values in larynx/hypopharynx and favorable outcomes. CONCLUSION DWI aids significantly in the LC/HPC diagnosis. However, further research is needed to establish DWI's reliability in predicting prognosis and treatment response in patients with LC/HPC.
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Affiliation(s)
| | - Hossein Sanjari Moghaddam
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Mazaheri
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA.
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2
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Ravanelli M, Rondi P, Ferrari M, Lancini D, Buffoli B, Borghesi A, Maroldi R, Farina D. CT and MR anatomy of the larynx and hypopharynx. Neuroradiology 2024; 66:883-896. [PMID: 38418594 DOI: 10.1007/s00234-024-03320-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
Imaging of the larynx and hypopharynx is frequently requested to assess the extent of neoplasms beyond the field of view of endoscopic evaluation. The combination of optical and cross-sectional imaging allows tumors to be classified according to AJCC/UICC guidelines. A thorough understanding of laryngeal and hypopharyngeal anatomy is crucial to guide the radiological eye along the possible pathways of the spread of diseases and to guide differential diagnoses. Computed tomography (CT) has been the first cross-sectional imaging technique used to evaluate the larynx and hypopharynx; its spatial resolution combined with volumetric capability and the use of injectable contrast medium made CT the working horse in the assessment of neoplastic and inflammatory diseases. In the last two decades, magnetic resonance (MR) supported CT in the most challenging cases, when the optimal contrast resolution due to the multisequence portfolio is needed to assess the neoplastic involvement of laryngeal cartilages, paraglottic space(s), and extra laryngeal spread. The aim of this paper is to give a comprehensive radiological overview of larynx and hypopharynx complex anatomy, combining in vivo images, anatomical sections, and images of ex vivo specimens.
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Affiliation(s)
- Marco Ravanelli
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Paolo Rondi
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedaliera Di Padova, University of Padua, Padua, Italy
| | - Davide Lancini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ENT Unit, University of Brescia, Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Andrea Borghesi
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Roberto Maroldi
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Davide Farina
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
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3
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Cunha B, Lancini D, Rondi P, Ravanelli M, Maroldi R, Paderno A, Zigliani G, Bertotto I, Piazza C, Farina D. Magnetic resonance diagnosis of laryngeal chondritis after transoral laser microsurgery for laryngeal cancer. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:32-41. [PMID: 36860148 PMCID: PMC9978306 DOI: 10.14639/0392-100x-n2262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/06/2022] [Indexed: 03/03/2023]
Abstract
Objective Laryngeal chondritis (LC) is a rare complication of carbon dioxide transoral laser microsurgery (CO2 TOLMS) for laryngeal tumours and can pose a diagnostic challenge. Its magnetic resonance (MR) features have not been previously described. This study aims to characterise a cohort of patients who developed LC after CO2 TOLMS and describe its clinical and MR findings. Methods Clinical records and MR images of all patients presenting with LC after CO2 TOLMS between 2008 and 2022 were reviewed. Results Seven patients were analysed. Timing of LC diagnosis ranged from 1 to 8 months after CO2 TOLMS. Four patients were symptomatic. Abnormal endoscopic findings included suspected tumour recurrence in 4 patients. MR documented focal or extensive signal changes involving the thyroid lamina and para-laryngeal space with T2 hyperintensity, T1 hypointensity and intense contrast enhancement (n = 7), and minimally reduced mean apparent diffusion coefficient (ADC) values (1.0-1.5 x 10-3 mm2/s) (n = 6). A favourable clinical outcome was achieved in all patients. Conclusions LC after CO2 TOLMS has a distinctive MR pattern. When tumour recurrence cannot be confidently excluded based on imaging, antibiotic therapy, close clinical and radiological follow-up and/or biopsy are recommended.
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Affiliation(s)
- Bruno Cunha
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal,Correspondence Bruno Cunha Neuroradiology Department, Hospital São José, Centro Hospitalar Universitário de Lisboa Central, R. José António Serrano, 1150-199 Lisboa, Portugal Tel. +35 1218841000. Fax +35 1218841023 E-mail:
| | - Davide Lancini
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Paolo Rondi
- Department of Radiology, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Department of Radiology, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Department of Radiology, University of Brescia, Brescia, Italy
| | - Alberto Paderno
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Gabriele Zigliani
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Ilaria Bertotto
- Radiology Unit, Surgery Department, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Cesare Piazza
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Davide Farina
- Department of Radiology, University of Brescia, Brescia, Italy
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4
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Ravanelli M, Lancini D, Maroldi R, Paderno A, Rondi P, Battocchio S, Ardighieri L, Vezzoli M, Del Bon F, Farina D, Piazza C. Magnetic resonance imaging to assess cartilage invasion in recurrent laryngeal carcinoma after transoral laser microsurgery. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2022; 42:531-537. [PMID: 36654519 PMCID: PMC9853105 DOI: 10.14639/0392-100x-n2090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 10/20/2022] [Indexed: 01/19/2023]
Abstract
Objective To evaluate the diagnostic performance of magnetic resonance (MR) with surface coils in assessing cartilage invasion in recurrent laryngeal carcinoma after carbon dioxide transoral laser microsurgery (CO2 TOLMS). Methods Two expert head and neck radiologists assessed cartilage invasion (infiltrated or non-infiltrated) in submucosal recurrences of laryngeal carcinoma after CO2 TOLMS: results were compared with histopathological report after salvage laryngectomy. Results Thirty patients met the inclusion criteria and 90 cartilages were assessed. Overall sensitivity, specificity, and positive and negative predictive values for cartilage infiltration were 76, 93, 72 and 94%, respectively; for thyroid cartilage, the values were 82, 79, 69 and 88% respectively; for cricoid cartilage, all values were 100%; and for arytenoids, the values were 33, 96, 56 and 93% respectively. Conclusions MR with surface coils was able to detect most thyroid and cricoid infiltration in the complex setting of post-CO2 TOLMS laryngeal carcinoma recurrence. In particular, the optimal performance in assessing cricoid invasion can be valuable in choosing the most appropriate treatment among total laryngectomy, open partial horizontal laryngectomies and non-surgical strategies.
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Affiliation(s)
- Marco Ravanelli
- Unit of Radiology, ASST Spedali Civili of Brescia, Brescia, Italy, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Davide Lancini
- Unit of Otorhinolaryngology, Head and Neck Cancer, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, ASST Spedali Civili of Brescia, Brescia, Italy, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Alberto Paderno
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy, Unit of Otorhinolaryngology, Head and Neck Cancer, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Paolo Rondi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy,Correspondence Paolo Rondi Unit of Radiology, University of Brescia, Spedali Civili di Brescia, piazzale Spedali Civili 1, 25123 Brescia, Italy E-mail:
| | - Simonetta Battocchio
- Unit of Pathology, Department of Molecular and Translational Medicine, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Laura Ardighieri
- Unit of Pathology, Department of Molecular and Translational Medicine, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Marika Vezzoli
- Biostatistics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Francesca Del Bon
- Unit of Otorhinolaryngology, Head and Neck Cancer, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Davide Farina
- Unit of Radiology, ASST Spedali Civili of Brescia, Brescia, Italy, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Cesare Piazza
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy, Unit of Otorhinolaryngology, Head and Neck Cancer, ASST Spedali Civili of Brescia, Brescia, Italy
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5
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D'Arco F, Mertiri L, de Graaf P, De Foer B, Popovič KS, Argyropoulou MI, Mankad K, Brisse HJ, Juliano A, Severino M, Van Cauter S, Ho ML, Robson CD, Siddiqui A, Connor S, Bisdas S. Guidelines for magnetic resonance imaging in pediatric head and neck pathologies: a multicentre international consensus paper. Neuroradiology 2022; 64:1081-1100. [PMID: 35460348 DOI: 10.1007/s00234-022-02950-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
Abstract
The use of standardized imaging protocols is paramount in order to facilitate comparable, reproducible images and, consequently, to optimize patient care. Standardized MR protocols are lacking when studying head and neck pathologies in the pediatric population. We propose an international, multicenter consensus paper focused on providing the best combination of acquisition time/technical requirements and image quality. Distinct protocols for different regions of the head and neck and, in some cases, for specific pathologies or clinical indications are recommended. This white paper is endorsed by several international scientific societies and it is the result of discussion, in consensus, among experts in pediatric head and neck imaging.
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Affiliation(s)
- Felice D'Arco
- Radiology Department, Great Ormond Street Hospital for Children, London, UK.,Radiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Livja Mertiri
- Radiology Department, Great Ormond Street Hospital for Children, London, UK. .,Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome, Italy.
| | - Pim de Graaf
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bert De Foer
- Radiology Department, GZA Hospitals, Antwerp, Belgium
| | - Katarina S Popovič
- Neuroradiology Department, Clinical Institute of Radiology, University Medical Center Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Maria I Argyropoulou
- Department of Clinical Radiology and Imaging, Medical School, University of Ioannina, Ioannina, Greece
| | - Kshitij Mankad
- Radiology Department, Great Ormond Street Hospital for Children, London, UK
| | - Hervé J Brisse
- Imaging Department, Institut Curie, Paris, France.,Institut Curie, Paris Sciences Et Lettres (PSL) Research University, Paris, France
| | - Amy Juliano
- Department of Radiology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | | | - Sofie Van Cauter
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Genk, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Mai-Lan Ho
- Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University, Columbus, OH, USA
| | - Caroline D Robson
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ata Siddiqui
- Radiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Steve Connor
- Radiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College, London, UK
| | - Sotirios Bisdas
- Lysholm Department of Neuroradiology, The National Hospital for Neurology & Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
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Abstract
State-of-the-art MR imaging of the larynx and hypopharynx with high-resolution surface coils, parallel imaging techniques, and DWI has several advantages over CT for assessing submucosal tumor spread, in particular neoplastic involvement of the paraglottic space, laryngeal cartilages, and extralaryngeal soft tissues. Current diagnostic MR imaging criteria based on a combination of distinct imaging features on morphologic sequences combined with DWI allow improved discrimination between tumor, peritumoral inflammation, and fibrosis and, ultimately, an increased precision for submucosal tumor delineation, which is a key prerequisite for tailored treatment options. Multiparametric MR imaging with DWI has a higher diagnostic performance than CT.
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Affiliation(s)
- Minerva Becker
- Diagnostic Department, Division of Radiology, Unit of Head and Neck and Maxillo-facial Radiology, Geneva University Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva 14, Geneva 1211, Switzerland.
| | - Yann Monnier
- Department of Clinical Neurosciences, Clinic of Otorhinolaryngology, Head and Neck Surgery, Unit of Cervicofacial Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 14, Geneva 1211, Switzerland
| | - Claudio de Vito
- Diagnostic Department, Division of Clinical Pathology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 14, Geneva 1211, Switzerland
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Connor SEJ, Burd C, Sivarasan N, Goh V. MRI in head and neck cancer following chemoradiotherapy: what is the optimal delay to demonstrate maximal response? Eur Radiol 2021; 31:9273-9286. [PMID: 34009413 PMCID: PMC8589821 DOI: 10.1007/s00330-021-07913-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/23/2021] [Accepted: 03/18/2021] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To investigate the optimal timing for post-chemoradiotherapy (CRT) reference magnetic resonance imaging (MRI) in head and neck cancer, so as to demonstrate a maximal treatment response. To assess whether this differs in human papillomavirus-related oropharyngeal cancer (HPV-OPC) and whether the MRI timing impacts on the ability to predict treatment success. METHODS Following ethical approval and informed consent, 45 patients (40 male, mean age 59.7 ± 7.9 years, 33 HPV-OPC) with stage 3 and 4 HNSCC underwent pre-treatment, 6- and 12-week post-CRT MRIs in this prospective cohort study. Primary tumour (n = 39) size, T2w morphology and diffusion weight imaging (DWI) scores, together with nodal (n = 42) size and necrotic/cystic change, were recorded. Interval imaging changes were analysed for all patients and according to HPV-OPC status. MRI descriptors and their interval changes were also compared with 2-year progression-free survival (PFS). RESULTS All MRI descriptors significantly changed between pre-treatment and 6-week post-treatment MRI studies (p < .001). Primary tumour and nodal volume decreased between 6- and 12-week studies; however, interval changes in linear dimensions were only evident for HPV-OPC lymph nodes. Nodal necrosis scores also evolved after 6 weeks but other descriptors were stable. The 6-week nodal necrosis score and the 6- and 12-week nodal volume were predictive of 2-year PFS. CONCLUSION Apart from HPV-OPC patients with nodal disease, the 6-week post-CRT MRI demonstrates maximal reduction in the linear dimensions of head and neck cancer; however, a later reference study should be considered if volumetric analysis is applied. KEY POINTS • This study provides guidance on when early post-treatment imaging should be performed in head and neck cancer following chemoradiotherapy, in order to aid subsequent detection of recurrent tumour. • Lymph nodes in HPV-related oropharyngeal cancer patients clearly reduced in size from 6 to 12 weeks post-treatment. However, other lymph node disease and all primary tumours showed only a minor reduction in size beyond 6 weeks, and this required a detailed volumetric analysis for demonstration. • Timing of the reference MRI following chemoradiotherapy for head and neck cancer depends on whether the patient has HPV-related oropharyngeal cancer and whether there is nodal disease. MRI as early as 6 weeks post-treatment may be performed unless volumetric analysis is routinely performed.
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Affiliation(s)
- S E J Connor
- School of Biomedical Engineering & Imaging Sciences Clinical Academic Group, King's College London, London, UK. .,Department of Radiology, Guy's and St Thomas' Hospital, London, UK. .,Department of Neuroradiology, King's College Hospital, London, UK.
| | - C Burd
- Department of Radiology, Guy's and St Thomas' Hospital, London, UK
| | - N Sivarasan
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - V Goh
- School of Biomedical Engineering & Imaging Sciences Clinical Academic Group, King's College London, London, UK.,Department of Radiology, Guy's and St Thomas' Hospital, London, UK
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8
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Lionello M, Bertolin A, Nardello E, Giacomelli L, Canal F, Rizzotto G, Marioni G, Lucioni M. Could the infiltration of the thyroarytenoid muscle define the pT2 glottic carcinoma? Head Neck 2019; 41:3639-3646. [PMID: 31385412 DOI: 10.1002/hed.25893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/05/2019] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The involvement of the thyroarytenoid (TA) muscle by glottic cancer may be related to an impaired vocal cord mobility, which is classified as cT2 disease. The primary endpoint was to evaluate the prognostic significance of TA muscle involvement in early glottic cancer treated with transoral laser microsurgery (TLM). METHODS A review was conducted on a cohort of 209 patients consecutively treated with TLM for early glottic carcinoma. Univariate analysis was used to examine the prognostic meaning of clinical and pathological parameters. RESULTS The statistical analysis showed that TA muscle infiltration correlated significantly with a worse prognosis in terms of recurrence rate and disease-free survival, and this was confirmed even in the subcohort with pT1a glottic cancer. CONCLUSIONS Our preliminary findings suggest that it could be considered as a criterion for upstaging a glottic cancer from pT1 to pT2.
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Affiliation(s)
- Marco Lionello
- Otolaryngology Unit, Vittorio Veneto Hospital, Treviso, Italy
| | - Andy Bertolin
- Otolaryngology Unit, Vittorio Veneto Hospital, Treviso, Italy
| | - Ennio Nardello
- Department of Neuroscience DNS, Otolaryngology Section, University of Padova, Padova, Italy
| | | | - Fabio Canal
- Pathology Unit, Vittorio Veneto - Conegliano Hospital, Treviso, Italy
| | | | - Gino Marioni
- Department of Neuroscience DNS, Otolaryngology Section, University of Padova, Padova, Italy
| | - Marco Lucioni
- Otolaryngology Unit, Vittorio Veneto Hospital, Treviso, Italy
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9
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Ruytenberg T, Verbist BM, Vonk-Van Oosten J, Astreinidou E, Sjögren EV, Webb AG. Improvements in High Resolution Laryngeal Magnetic Resonance Imaging for Preoperative Transoral Laser Microsurgery and Radiotherapy Considerations in Early Lesions. Front Oncol 2018; 8:216. [PMID: 29928638 PMCID: PMC5997776 DOI: 10.3389/fonc.2018.00216] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/25/2018] [Indexed: 12/13/2022] Open
Abstract
As the benefits, limitations, and contraindications of transoral laser microsurgery (TLM) in glottic carcinoma treatments become better defined, pretreatment imaging has become more important to assess the case-specific suitability of TLM and to predict functional outcomes both for treatment consideration and patient counseling. Magnetic resonance imaging (MRI) is the preferred modality to image such laryngeal tumors, even though imaging the larynx using MRI can be difficult. The first challenge is that there are no commercial radiofrequency (RF) coils that are specifically designed for imaging the larynx, and performance in terms of coverage and signal-to-noise ratio is compromised using general-purpose RF coils. Second, motion in the neck region induced by breathing, swallowing, and vessel pulsation can induce severe image artifacts, sometimes rendering the images unusable. In this paper, we design a dedicated RF coil array, which allows high quality high-resolution imaging of the larynx. In addition, we show that introducing respiratory-triggered acquisition improves the diagnostic quality of the images by minimizing breathing and swallowing artifacts. Together, these developments enable robust, essentially artifact-free images of the full larynx with an isotropic resolution of 1 mm to be acquired within a few minutes.
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Affiliation(s)
- Thomas Ruytenberg
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Berit M Verbist
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Elisabeth V Sjögren
- Department of ENT - Head and Neck Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Andrew G Webb
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
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10
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Piazza C, Filauro M, Paderno A, Marchi F, Perotti P, Morello R, Taboni S, Parrinello G, Incandela F, Iandelli A, Missale F, Peretti G. Three-Dimensional Map of Isoprognostic Zones in Glottic Cancer Treated by Transoral Laser Microsurgery as a Unimodal Treatment Strategy. Front Oncol 2018; 8:175. [PMID: 29872643 PMCID: PMC5972218 DOI: 10.3389/fonc.2018.00175] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/04/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction The Union for International Cancer Control–American Joint Committee on Cancer TNM staging system for glottic squamous cell carcinoma (SCC) includes different types of lesions defined by the involvement of specific subsites in each T category. Our study aims to identify different subcategories according to tumor local extension and determine oncologic outcomes after treatment by transoral laser microsurgery (TLM) alone. Methods We retrospectively evaluated 410 patients affected by previously untreated pT1-pT3 glottic SCC treated by TLM alone from January 2005 to December 2015 at the Departments of Otorhinolaryngology—Head and Neck Surgery, Universities of Genoa and Brescia, Italy. All patients had at least 2 years of follow-up. Clinical, radiological, surgical, and histopathological data were reviewed and tumors divided into six subcategories: I, pT1a not involving the anterior commissure (AC); II, pT1b involving the AC; III, pT2 extending superficially to the supraglottis or the subglottis; IV, pT2 infiltrating the vocal muscle; V, pT3 involving the anterior paraglottic space; VI, pT2 or pT3 with vertical extension across the AC with/without involvement of the pre-epiglottic space. Recurrence-free survival (RFS), local control with laser alone (LCL), and organ preservation (OP) were defined as the primary oncologic outcomes. Results The 2, 5, and 10-year RFS for the entire series were 85.7, 80.3, and 73.8%, LCL rates 93.8, 92.1, and 89.6%, and OP rates 96.8, 95.9, and 93.5%, respectively. However, when comparing the rates of RFS, LCL, and OP for each subcategory, important differences emerged. In particular, subcategories V and VI showed a significantly increased risk of local recurrence [hazard ratio (HR) = 9.2 and 13.3, respectively]. These subcategories also had a significantly reduced probability to achieve LCL (HR: 73.6 and 93.5, respectively) and OP (HR: 6.4 and 8.1, respectively). Conclusion The present classification in subcategories allows introducing the concept of a three-dimensional map of isoprognostic zones in glottic SCC treated by TLM alone as a useful tool in its management by a multidisciplinary tumor board.
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Affiliation(s)
- Cesare Piazza
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Marta Filauro
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Alberto Paderno
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy.,Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Filippo Marchi
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Pietro Perotti
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Riccardo Morello
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Stefano Taboni
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Giampiero Parrinello
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Fabiola Incandela
- Department of Otorhinolaryngology - Head and Neck Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy.,Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Andrea Iandelli
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Francesco Missale
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Giorgio Peretti
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Genoa, Genoa, Italy
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11
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Carta F, Bandino F, Olla AM, Chuchueva N, Gerosa C, Puxeddu R. Prognostic value of age, subglottic, and anterior commissure involvement for early glottic carcinoma treated with CO2 laser transoral microsurgery: a retrospective, single-center cohort study of 261 patients. Eur Arch Otorhinolaryngol 2018; 275:1199-1210. [DOI: 10.1007/s00405-018-4890-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 01/27/2018] [Indexed: 12/18/2022]
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12
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Kuno H, Sakamaki K, Fujii S, Sekiya K, Otani K, Hayashi R, Yamanaka T, Sakai O, Kusumoto M. Comparison of MR Imaging and Dual-Energy CT for the Evaluation of Cartilage Invasion by Laryngeal and Hypopharyngeal Squamous Cell Carcinoma. AJNR Am J Neuroradiol 2018; 39:524-531. [PMID: 29371253 DOI: 10.3174/ajnr.a5530] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 11/10/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Dual-energy CT can distinguish iodine-enhanced tumors from nonossified cartilage and has been investigated for evaluating cartilage invasion in patients with laryngeal and hypopharyngeal squamous cell carcinomas. In this study, we compared the diagnostic accuracy of MR imaging and of a combination of weighted-average and iodine overlay dual-energy CT images in detecting cartilage invasion by laryngeal and hypopharyngeal squamous cell carcinomas, in particular thyroid cartilage invasion. MATERIALS AND METHODS Fifty-five consecutive patients who underwent 3T MR imaging and 128-slice dual-energy CT for preoperative initial staging of laryngeal or hypopharyngeal squamous cell carcinomas were included. Two blinded observers evaluated laryngeal cartilage invasion on MR imaging and dual-energy CT using a combination of weighted-average and iodine-overlay images. Pathologic findings of surgically resected specimens were used as the reference standard for evaluating sensitivity, specificity, and the areas under the receiver operating characteristic curve of both modalities for cartilage invasion by each type of cartilage and for all cartilages together. Sensitivity and specificity were compared using the McNemar test and generalized linear mixed models. RESULTS Dual-energy CT showed higher specificity than MR imaging for diagnosing all cartilage together (84% for MR imaging versus 98% for dual-energy CT, P < .004) and for thyroid cartilage (64% versus 100%, P < .001), with a similar average area under the curve (0.94 versus 0.95, P = .70). The sensitivity did not differ significantly for all cartilages together (97% versus 81%, P = .16) and for thyroid cartilage (100% versus 89%, P = .50), though there was a trend toward increased sensitivity with MR imaging. CONCLUSIONS Dual-energy CT showed higher specificity and acceptable sensitivity in diagnosing laryngeal cartilage invasion compared with MR imaging.
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Affiliation(s)
- H Kuno
- From the Departments of Diagnostic Radiology (H.K., K.S., M.K.) .,Departments of Radiology (H.K., O.S.)
| | - K Sakamaki
- From the Departments of Diagnostic Radiology (H.K., K.S., M.K.).,Department of Biostatistics (K.S., T.Y.), Yokohama City University, Yokohama, Kanagawa, Japan
| | - S Fujii
- Division of Pathology (S.F.), Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Chiba, Japan
| | - K Sekiya
- From the Departments of Diagnostic Radiology (H.K., K.S., M.K.)
| | - K Otani
- Advanced Therapies Innovation Department (K.O.), Siemens Healthcare K.K., Shinagawa-ku, Tokyo, Japan
| | - R Hayashi
- Head and Neck Surgery (R.H.), National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - T Yamanaka
- Department of Biostatistics (K.S., T.Y.), Yokohama City University, Yokohama, Kanagawa, Japan
| | - O Sakai
- Departments of Radiology (H.K., O.S.).,Otolaryngology-Head and Neck Surgery (O.S.).,Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - M Kusumoto
- From the Departments of Diagnostic Radiology (H.K., K.S., M.K.)
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13
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Nooij RP, Hof JJ, van Laar PJ, van der Hoorn A. Functional MRI for Treatment Evaluation in Patients with Head and Neck Squamous Cell Carcinoma: A Review of the Literature from a Radiologist Perspective. CURRENT RADIOLOGY REPORTS 2018; 6:2. [PMID: 29416951 PMCID: PMC5778171 DOI: 10.1007/s40134-018-0262-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To show the role of functional MRI in patients treated for head and neck squamous cell carcinoma. RECENT FINDINGS MRI is commonly used for treatment evaluation in patients with head and neck tumors. However, anatomical MRI has its limits in differentiating between post-treatment effects and tumor recurrence. Recent studies showed promising results of functional MRI for response evaluation. SUMMARY This review analyzes possibilities and limitations of functional MRI sequences separately to obtain insight in the post-therapy setting. Diffusion, perfusion and spectroscopy show promise, especially when utilized complimentary to each other. These functional MRI sequences aid in the early detection which might improve survival by increasing effectiveness of salvage therapy. Future multicenter longitudinal prospective studies are needed to provide standardized guidelines for the use of functional MRI in daily clinical practice.
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Affiliation(s)
- Roland P. Nooij
- Department of Radiology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Jan J. Hof
- Department of Radiology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Peter Jan van Laar
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P. O. Box 30.001, 9700 RB Groningen, The Netherlands
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anouk van der Hoorn
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P. O. Box 30.001, 9700 RB Groningen, The Netherlands
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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14
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State of the art MRI in head and neck cancer. Clin Radiol 2017; 73:45-59. [PMID: 28655406 DOI: 10.1016/j.crad.2017.05.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/26/2017] [Indexed: 12/17/2022]
Abstract
Head and neck cancer affects more than 11,000 new patients per year in the UK1 and imaging has an important role in the diagnosis, treatment planning, and assessment, and post-treatment surveillance of these patients. The anatomical detail produced by magnetic resonance imaging (MRI) is ideally suited to staging and follow-up of primary tumours and cervical nodal metastases in the head and neck; however, anatomical images have limitations in cancer imaging and so increasingly functional-based MRI techniques, which provide molecular, metabolic, and physiological information, are being incorporated into MRI protocols. This article reviews the state of the art of these functional MRI techniques with emphasis on those that are most relevant to the current management of patients with head and neck cancer.
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15
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Role of imaging in the follow-up of T2–T3 glottic cancer treated by transoral laser microsurgery. Eur Arch Otorhinolaryngol 2017. [DOI: 10.1007/s00405-017-4642-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Preda L, Conte G, Bonello L, Giannitto C, Tagliabue E, Raimondi S, Ansarin M, De Benedetto L, Cattaneo A, Maffini F, Bellomi M. Diagnostic accuracy of surface coil MRI in assessing cartilaginous invasion in laryngeal tumours: Do we need contrast-agent administration? Eur Radiol 2017; 27:4690-4698. [PMID: 28477165 DOI: 10.1007/s00330-017-4840-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/20/2017] [Accepted: 04/03/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the diagnostic accuracy of MRI performed using surface coils, with and without contrast medium, in predicting thyroid and cricoid cartilage infiltration in laryngeal tumours, and to investigate whether the radiologist's experience influences diagnostic accuracy. METHODS We retrospectively enrolled patients with biopsy-proven laryngeal cancer who had undergone preoperative staging MRI and open surgery. Two radiologists with different experience (senior vs. junior) reviewed the MR images without (session A1) and with contrast medium (session A2) separately. We calculated the accuracy of MRI with and without contrast medium in detecting infiltration of the thyroid and cricoid cartilages. Interobserver agreement was calculated by Cohen's Kappa (k). RESULTS Forty-two patients were enrolled, for a total of 62 cartilages. In session A1 the senior and junior radiologists showed an accuracy of 85% and 71%, respectively, with k = 0.53 (0.33-0.72). In session A2 the senior and junior radiologists showed an accuracy of 84% and 77%, respectively, with k = 0.68 (0.49-0.86). CONCLUSIONS Staging of laryngeal tumours with surface coil MRI showed good diagnostic accuracy in assessing cartilaginous infiltration. We observed similar values of diagnostic accuracy for the analysis performed with and without contrast medium for the senior radiologist. KEY POINTS • Surface coil MRI demonstrated good accuracy in assessing laryngeal cartilage invasion. • The radiologist's experience can influence the diagnostic accuracy. • Gadolinium administration may increase interobserver concordance.
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Affiliation(s)
- Lorenzo Preda
- Department of Clinical-Surgical Diagnostic and Pediatric Sciences, Università degli Studi di Pavia, Pavia, Italy
- Division of Radiology, National Center of Oncological Hadrontherapy (CNAO Foundation), Pavia, Italy
| | - Giorgio Conte
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy.
| | - Luke Bonello
- Division of Radiology, Poliambulanza Hospital, Brescia, Italy
| | | | - Elena Tagliabue
- Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
| | - Sara Raimondi
- Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
| | - Mohssen Ansarin
- Division of Head and Neck Surgery, European Institute of Oncology, Milan, Italy
| | - Luigi De Benedetto
- Division of Head and Neck Surgery, European Institute of Oncology, Milan, Italy
| | - Augusto Cattaneo
- Division of Head and Neck Surgery, European Institute of Oncology, Milan, Italy
| | - Fausto Maffini
- Division of Pathology, European Institute of Oncology, Milan, Italy
| | - Massimo Bellomi
- Division of Radiology, European Institute of Oncology, Milan, Italy
- Oncology and Haematology/Oncology Department, Università degli Studi di Milano, Milan, Italy
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17
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New Developments in Imaging of Laryngeal Cancer. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017. [DOI: 10.1007/s40136-017-0145-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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De Fiori E, Conte G, Ansarin M, De Benedetto L, Bonello L, Alterio D, Maffini F, Bellomi M, Preda L. The role of ultrasound-guided transcutaneous tru-cut biopsy in diagnosing untreated and recurrent laryngo-hypopharyngeal masses. Eur J Radiol 2015; 85:158-163. [PMID: 26724661 DOI: 10.1016/j.ejrad.2015.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 09/13/2015] [Accepted: 10/25/2015] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate the diagnostic performance of Ultrasound-guided Transcutaneous Tru-Cut biopsy (USGTCB) of laryngo-hypopharyngeal masses suspicious for malignancy. Furthermore we investigated whether USGTCB is accurate for both untreated masses and suspected recurrences. MATERIALS AND METHODS From August 2004 to July 2014 we prospectively enrolled 66 patients for a total of 68 USGTCBs: 38 USGTCB were performed for a suspicious untreated mass and in 30 for a suspected recurrence. We calculated the sensitivity, specificity, positive predictive value and negative predictive value for all procedures and separately for untreated masses and suspected recurrences. RESULTS USGTCB diagnosed 57 malignancies (51 squamous cell carcinomas, 6 other tumors) and 11 benign lesions. There were no false positives reported, whereas five false negatives were observed: two in patients with an untreated mass, three in patients with a suspected recurrence. Overall, the sensitivity of the technique was 91.9% (95% confidence interval [CI]: 82.2-97.3%); the specificity was 100% (95% CI: 54.1-100%); positive and negative predictive values were 100% (95% CI: 93.7-100%) and 54.5% (95% CI: 23.5-83.1%) respectively, with similar performances in untreated masses and suspected recurrences of SCC. CONCLUSION USGTCB is an effective procedure for the histological diagnosis of laryngo-hypopharyngeal masses suspicious for malignancy in patients showing contraindications to biopsy via microlaryngoscopy under general, with similar performances for untreated masses and suspected recurrences.
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Affiliation(s)
- Elvio De Fiori
- Division of Radiology, European Institute of Oncology, Milan, Italy.
| | - Giorgio Conte
- Department of Health Sciences, University of Milan, Milan, Italy.
| | - Mohssen Ansarin
- Department of Head and Neck Surgery, European Institute of Oncology, Milan, Italy.
| | - Luigi De Benedetto
- Department of Head and Neck Surgery, European Institute of Oncology, Milan, Italy.
| | - Luke Bonello
- Department of Health Sciences, University of Milan, Milan, Italy.
| | - Daniela Alterio
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy.
| | - Fausto Maffini
- Division of Pathology, European Institute of Oncology, Milan, Italy.
| | - Massimo Bellomi
- Division of Radiology, European Institute of Oncology, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy.
| | - Lorenzo Preda
- Division of Radiology, European Institute of Oncology, Milan, Italy.
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19
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Abstract
PURPOSE OF REVIEW This review summarizes the most recent experiences on the integration of magnetic resonance in assessing the local extent of laryngeal cancer and detecting submucosal recurrences. RECENT FINDINGS Advances in magnetic resonance have been characterized by the development of technical solutions that shorten the acquisition time, thereby reducing motion artifacts, and increase the spatial resolution. Phased-array surface coils, directly applied to the neck, enable the use of parallel-imaging techniques, which greatly reduce the acquisition time, and amplify the signal intensity, being closer to the larynx. One of the most important drawbacks of this technique is the small field-of-view, restricting the imaged area to the larynx. Furthermore, diffusion-weighted imaging (DWI) has increased the set of magnetic resonance sequences. Differently from computed tomography (CT), which has only two variables (precontrast/postcontrast), magnetic resonance is based on a multiparameter analysis (T2-weighting and T1-weighting, DWI, and postcontrast acquisition). This multiparameter approach amplifies the contrast resolution. It has, also, permitted to differentiate scar tissue (after laser resection) from submucosal recurrent disease. In addition, DWI sequences have the potential of a more precise discrimination of peritumoral edema from neoplastic tissue, which may lead to improve the assessment of paraglottic space invasion. SUMMARY Magnetic resonance of the larynx is technically challenging. The use of surface coils and motion-reducing techniques is critical to achieve adequate image quality. The intrinsic high-contrast resolution is further increased by the integration of information from different sequences. When CT has not been conclusive, magnetic resonance is indicated in the pretreatment local assessment and in the suspicion of submucosal recurrence.
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