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Role of Cross-Sectonal
Imaging in the
Preoperative Evalution of
Laryngeal Cancer
Ajinkya Desai MD, Asha Bhatt MD, Parul Patel MD, Sarah Ifthikharuddin MD
ASNR 2016
eEde-135
Disclosures
None
Introduction
• Laryngeal cancer is one of the most common cancers of the head
and neck
• Approximately 90% of laryngeal malignancy is due to squamous cell
carcinoma, with lymphoma being the second most frequent
diagnosis
• The incidence of laryngeal cancer is highly associated with a history
of smoking
• Patients commonly present with hoarseness, however other clinical
presentations include:
– neck mass, dysphagia, stridor and hemoptysis
Laryngeal Cancer:
Diagnosis and Staging
•
Laryngoscopy is the gold standard to evaluate mucosal tumor burden and assess
for vocal cord mobility
•
Cross sectional imaging is however critical for pre-operative staging
•
Cross sectional imaging allows the evaluation of
– Extent of submucosal extension
– Invasion of adjacent structures
•
Both CT and MRI are appropriate for the evaluation of laryngeal cancer. Choice of
modality depends on availability, as well as radiologist and clinician
preference/experience. This presentation will review the role of CT imaging in
staging laryngeal cancer.
•
It is imperative that radiologists who interpret cross sectional imaging studies in
laryngeal cancer patients have an understanding of:
–
–
–
–
Laryngeal anatomy
Patterns of tumor spread
Laryngeal cancer staging and associated imaging findings
How imaging findings and staging affects treatment
Laryngeal Cancer Treatment
•
Therapeutic options for laryngeal cancer include:
– surgery, radiotherapy and chemotherapy (alone or in combination)
•
•
•
Low volume T1/T2 supraglottic and glottic tumors may be treated with radiotherapy alone
Advanced tumors typically require a combination of surgical and radiotherapy
Goal of surgical treatment is to treat the tumor while preserving the three primary
functions of the larynx as much as possible:
– breathing, swallowing and phonation
•
Surgical treatment options:
– Partial, conservative excision, such as cordectomy partial laryngetomy or near total
laryngectomy
•
Preservation of a portion of the larynx so vocal function is preserved as well as respiration (without
tracheostomy) and swallowing
– Total laryngectomy
•
•
Results in total loss of vocal function
Treatment decisions depend on
– Tumor location
– Disease stage
– Patient needs and preferences
Review of Laryngeal Anatomy
• The larynx is subdivided into three segments
– Supraglottis
• Epiglottis, aryepiglottic folds and false vocal cords
• Preglottic space (fat density space between the hyoid bone anteriorly and epiglottis
posteriorly)
• Paraglottic space: paired fatty areas deep to the false vocal cords
– Glottis
• Consists of the true vocal cords and anterior and posterior commissures
– Subglottis
• Extends from the inferior portion of the true vocal cords to the inferior portion of the
cricoid cartilage
• Major laryngeal cartilages
– Thyroid cartilage: largest laryngeal cartilage
– Cricoid cartilage: at the level of the subglottis, the only complete ring of
cartilage
– Arytenoid cartilage: paired pyramid shape cartilages at the level of the glottis
Vallecula
Hyoid Bone
Paraglottic Space
Supraglottis
False Cords
Glottis
True Cords
Subglottis
Normal Laryngeal Anatomy:
Supraglottis
Hyoid Bone
Valleculae
Paraglottic Space
Paraglottic Space
Epiglottis
Aryepiglottic Folds
Preglottic Space
Thyroid Cartilage
Paraglottic Space
Paraglottic Space
False Vocal Cords
Piriform Sinus
Normal Laryngeal Anatomy:
Glottis and Subglottis
Anterior Commissure
True Vocal Cords
Thyroid Cartilage
Posterior Commisure
Arytenoid Cartilage
Glottis
Cricoid Cartilage
Cricoid Cartilage
Thyroid Gland
Subglottis
CT Staging of Laryngeal Cancer
• Cross sectional imaging is critical in the pre-operative
staging of laryngeal cancer
• T staging of laryngeal cancer is crucial in selecting the
appropriate treatment options
• Accurate staging depends on specific imaging
findings and guides management of laryngeal staging
T Stage
Supraglottic
Glottic
Subglottic
T Stage
Tumor extent and vocal cord (VC) mobility
T1
Tumor limited to one supraglottic subsite with normal VC mobility
T2
Tumor involves mucosa of more than one supraglottic subsite or glottis or
extralaryngeal spread, with normal VC mobility
T3
Tumor limited to larynx with VC fixation and/or invasion of postcricoid space,
preglottic space, paraglottic space and/or minor thyroid cartilage erosion (inner
cortex)
T4
T4a: Tumor invades tissues beyond the larynx and/or laryngeal cartilage (trachea,
tongue muscles, strap muscles, strap muscles or esophagus)
T4b: Tumor invades prevertebral space, encases carotid artery or invades mediastinal
structures
T1
T1a: Tumor limited to one VC with normal mobility
T1b: Tumor involves both VC with normal mobility
T2
Tumor extends to supraglottic and/or subglottic larynx or to region outside the
supraglottis (with or without impaired VC mobility)
T3
Tumor limited to the larynx with VC fixation and/or invades the paraglottic space
and/or minor thyroid cartilage erosion (inner cortex)
T4
T4a and T4b: Same as in supraglottic CA (see above)
T1
Tumor limited to the subglottis
T2
Tumor extends to the VCs with normal or impaired mobility
T3
Tumor limited to the larynx with VC fixation
T4
T4a and T4b: Same as in supraglottic CA (see above)
American Joint Committee on Cancer. Cancer staging manual. 6th ed. New York, NY: Springer-Verlag, 2002.
N Stage
N Stage
Regional lymph node (LN) findings
NX
Regional nodes cannot be assessed
N0
No regional LN metastasis
N1
Metastasis in a single ipsilateral LN, ≤ 3 cm in greatest dimension
N2
N2a: Metastasis in a single ipsilateral lymph node, > 3 cm but < 6 cm in
greatest dimension
N2b: Multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension (N2b)
N2c: Bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N3
Metastasis in a lymph node > 6 cm in greatest dimension
M Stage
M Stage
Findings
MX
Distant metastases cannot be assessed
M0
No distant metastases
M1
Distant metastases
American Joint Committee on Cancer. Cancer staging manual. 6th ed. New York, NY: Springer-Verlag, 2002.
Imaging Features
• The following specific imaging features should be evaluated
when staging laryngeal cancer on cross sectional imaging
– Spread of tumor across the anatomic divisions of the larynx
– Spread into the preglottic and paraglottic spaces
• assessed by effacement of the normal fat in these spaces
– Erosive changes or transmural spread through a laryngeal
cartilage
• most commonly the thyroid cartilage
– Extralaryngeal spread
– Nodal involvement
– Distant metastasis
• most commonly lungs
Thyroid Cartilage Erosion
• Minor erosion of the thyroid
cartilage:
– invasion involving the inner
cortex but not extending to
the outer cortex
• Lysis of the thyroid cartilage:
– when the tumor invades the
inner cortex and just reaches
the outer cortex without
invading it
• Transmural spread:
– When the tumor invades the
thyroid cartilage and spreads
to the extra-laryngeal tissue
Extralaryngeal Spread
• Laryngeal cancer most commonly spreads outside the larynx through
one of the following areas of inherent weakness within the larynx:
•
Thyrohyoid membrane
•
Inferior pharyngeal constrictor muscle
•
Cricothyroid membrane
Case Based Review
Case 1: 66 y/o male with long history of smoking presenting with
right neck mass and throat pain for months
A
B
C
(A) There is a large right supraglottic mass (red arrow), involving the right paraglottic fat but sparing
the preglottic fat. There is also extralaryngeal spread, noted by soft tissue density extending past
the thyroid cartilage boundary (purple arrow).
(B) Bone window shows extensive erosive changes involving the thyroid cartilage (yellow arrows).
(C) There was no definite evidence for glottic or subglottic involvement; however, there was a
palpable, enlarged metastatic node (blue arrow) marked by BB marker.
Case 1 Summary
•
T Stage
–
•
N stage:
–
•
Right supraglottic cancer with transmural extralaryngeal
spread through the thyroid cartilage and without evidence for
supraglottic or subglottic spread  T4
Metastatic disease in a 3.3 cm ipsilateral level III
jugulodiagastirc lymph node  N2
M stage:
–
No distant metastasis
•
TNM : T4, N2, M0
•
Patient underwent tracheostomy (due to airway
compromise) and chemoradiation
•
Follow up imaging in 3 months status post chemoradiation
showed decrease in tumor burden (red oval)
Case 2: 63 y/o male presents to the ED with difficulty breathing. He had also noted
hoarse voice and throat fullness in recent months. There was a history of laryngeal CA
in the past and patient elected not to undergo total laryngectomy
A
E
B
C
(A) There is a right glottic mass with extension to
the anterior and posterior commissures and
marked airway narrowing (red oval).
(B) On bone window, there is multifocal
transmural erosive change involving the
thyroid cartilage (yellow arrows).
(C) Supraglottic spread involving the right
aryepiglottic fold is present (blue arrow),
there is no preglottic or paraglottic fat
involvement.
(D) and (E) Additionally, there is inferior
extension to the subglottis (purple arrows).
D
Case 2 Summary
•
T stage:
–
–
–
Right glottic tumor with transglottic spread, involvement
of the anterior and posterior commissures and transmural
extension through the thyroid cartilage
On laryngoscopy, there was fixation of the vocal cords.
 T4
•
Tracheostomy was performed due to marked airway
obstruction
•
N stage: No nodal metastases  N0
•
M Stage: No distant metastasis  M0
•
TNM : T4, N0, M0
•
The patient refused surgery and underwent
chemoradiation
•
Follow up CT scan performed 6 months after
chemoradiation shows significant decrease in tumor
burden at the level of the glottis (D) and subglottis (E)
D
E
Case 3: 76 y/o male with 50 year history of smoking, now
presenting with hoarse voice (initial scan on 6/20/2011)
A
D
B
C
(A) There is a right supraglottic mass (red arrow) with
involvement of the right paraglottic fat as well as
partial effacement of the preglottic fat (yellow
arrows). Note the preserved left paraglottic fat
(purple arrow).
(B) On bone window, there was no definite erosive
change involving the right thyroid cartilage.
(C) There was inferior extension to the right glottis
(blue arrow).
(D) Note the supraglottic (red arrow) and glottic (blue
arrow) involvement on the coronal reformats.
Case 3: Patient underwent chemoradiation
Follow up scan on 10/1/2013 shows recurrent disease
A
B
C
(A) There is progression with new involvement of the left vocal cord (red
arrow) and anterior commissure (purple arrow).
(B) There was new erosive change of the thyroid cartilage, especially
anteriorly (blue arrows) .
(C) Note the extralaryngeal spread of the tumor through the thyroid
cartilage anteriorly (yellow arrow).
Case 3 Summary
• T Stage:
– Initial scan showed a right supraglottic and glottic mass with
involvement of the right paraglottic and preglottic fat. No
involvement of the thyroid cartilage or evidence for transmural
spread  T3
– The patient underwent chemoradiation, but 2 years later, there
was progression of disease with new transmural laryngeal
spread causing upstaging of the tumor  T4
• No nodal or distant metastases were present on both studies
• TNM: (T3, N0, M0)  (T4, N0, M0)
Case 4: Patient presenting with hoarseness
A
B
C
(A) There is a left glottic mass (yellow arrow).
(B) There is extension to the supraglottis (red arrow) with infiltration of the left
paraglottic fat posteriorly (blue arrow) and sparing of the preglottic fat (purple arrow).
(C) There is also subglottic extension (red circle).
Additional findings: There was no definite evidence for thyroid cartilage
involvement. An enlarged left supraclavicular node was also noted.
Case 4 Summary
• T Stage:
– Left glottic cancer with supraglottic and subglottic extension. The tumor
involves the left paraglottic fat (T3)
• N Stage:
– There was a prominent left supraclavicular node measuring < 3.0 cm 
N1
• M Stage:
– There were no distant metastasis  M0
• TNM: T3, N1, M0
• Patient underwent chemoradiation. Subsequent scans demonstrated
post radiation change but not evidence for recurrent tumor
Case 5: 71 year old male with history of laryngeal cancer
several years ago status post radiation therapy, now
presenting with hoarseness
A
D
B
C
(A) There is a midline anterior and right sided glottic/subglottic mass
(red arrows).
(B) On bone window, there is periosteal reaction (blue arrows)
involving the inner and outer cortex of the left anterior aspect of
the thyroid cartilage (suggestive of transmural extension) and
slight erosive change involving the left anterior aspect of the
thyroid cartilage (yellow arrow).
(C) There is involvement of the glottis noted as a subtle asymmetric
prominence of the right true vocal cord (red arrow).
(D) There is also more inferior extension into the subglottis (purple
arrow).
Case 5 Summary
• T Stage:
– Left glottic and subglottic cancer and probable transmural
extension through the thyroid cartilage  T4
• No lymph node involvement or distant metastasis
• TNM: T4, N0, M0
• Pathology demonstrated transmural extension through the
thyroid cartilage.
• The patient underwent radiation therapy and total
laryngectomy
Case 6: Long history of smoking, now presenting with
stridor
A
B
C
(A) There is a large subglottic mass (blue arrows). There is extension into the soft
tissues surrounding the cricoid and no clear fat plane between mass and
esophagus (red oval).
(B) On bone window, there is marked transmural erosive change involving the
cricoid cartilage posteriorly and on the left (yellow arrows).
(C) There is no evidence for extension to the glottis.
Case 6 Summary
• T Stage:
– Right subglottic cancer with extralaryngeal spread
through the cricothyroid membrane and loss of
normal fat plane around the esophagus  T4
• No lymph node involvement or distant metastasis
• TNM : T4, N0, M0
• Patient underwent total laryngectomy with
postoperative chemoradiation
Case 7: Patient with history of laryngeal cancer treatment many
years ago, now presenting with hypoxia and respiratory distress
A
B
C
D
(A) There is a glottic mass
involving both vocal cords,
left greater than right (blue
arrows).
(B) On bone window there is
erosive change involving the
arytenoid cartilage (red
arrows).
(C) There was subglottic
extension with erosive
change seen at the central
posterior aspect of the
cricoid cartilage (yellow
arrows).
(D) There was also supragottic
extension with involvement
of both aryepiglottic folds
(purple arrows).
Case 7 Continued
E
(E) There was further inferior extension of the mass
with invasion of the left thyroid lobe (yellow
arrow). An enlarged right supraclavicular node
was also present (red arrow).
(F) In addition, there was more inferior and
posterior extension of the mass to involve
superior mediastinum.
F
Case 7 Summary
• T Stage:
– Tumor involving both vocal cords and eroding the cricoid and arytenoid
cartilages
– There is supraglottic and subglottic extension of the tumor as well as
involvement of the left thyroid lobe and superior mediastinum  T4
• N Stage:
– Metastatic disease in a single supraclavicular lymph node which
measures 1.7 cm  N2
• M stage: No distant metastasis
• TNM : T4b, N2c, M0
• Non surgical candidate, no chemoradiation, patient was referred for
palliative care
Case 8: 84 y/o male presenting with hoarseness of voice.
Laryngoscopy demonstrated a right laryngeal lesion
A
B
C
D
(A) There is a right glottic mass
with translaryngeal spread
through the right thyroid
cartilage (yellow arrows).
(B) Bone windows demonstrate
the extensive erosive change
involving the right thyroid
cartilage (red oval).
(C) The mass extends superiorly to
the supraglottic larynx (blue
arrows).
(D) Additionally, there is subglottic
extension with asymmetric
right anterolateral soft tissue
thickening and extralaryngeal
spread on the right (purple
arrows).
Case 8 Summary
• T stage:
– Right glottic cancer with transglottic spread,
transmural extralaryngeal spread through the
right thyroid cartilage and infiltration of
surrounding soft tissue structures  T4
• No lymph node involvement or distant
metastasis
• TNM : T4a, N0, M0
Case 9: 72 y/o male with history of smoking, now
presenting with 3-4 months of hoarseness
A
B
C
D
(A) There is a right glottic mass
(yellow arrow) with
extension to the anterior
commissure (blue arrow).
(B) Bone windows at the same
level demonstrate erosion of
the thyroid (red arrows)
cartilage compatible with
transmural extension.
(C) There is supraglottic
extension with asymmetric
soft tissue density in the
right paralaglottic fat (red
oval).
(D) Bone windows at the same
level demonstrate erosion of
the right thyroid cartilage
(purple arrow).
Case 9 Summary
• T Stage:
– Right glottic cancer with involvement of the left vocal cord, anterior
commissure and extralaryngeal spread through the thyroid cartilage 
T4
• No enlarged nodes or distant metastasis
• Patient underwent a total laryngectomy
Case 10: 69 y/o male with neck/throat pain
A
C
B
D
(A) There is a right
supraglottic mass at the
level of the false VC with
invasion of the preglottic
and right paraglottic fat
(red arrows). Note the
normal appearance of
the left paraglottic fat
(yellow arrow).
(B) There was also
involvement of the right
piriform sinus (red oval).
(C) and (D) There was no
subglottic or glottic
involvement.
Case 10 Summary
• T Stage
– Right supraglottic mass at the level of the false VC
with invasion of the preglottic and right paraglottic
fat, No subglottic or glottic involvement  T3
• No nodal or distant metastasis
• T3 N0 M0
• Patient underwent chemoradiation
Take Away Points
•
Cross sectional imaging plays a key role in the preoperative staging of laryngeal
cancer
•
Imaging findings in combination with laryngoscopy findings are used to determine
the optimal treatment for the patient
•
Radiologists interpreting CT exams in laryngeal cancer patients should be aware of
laryngeal anatomy, as well key imaging features which affect staging in order to
provide detailed and clinically relevant reports to clinicians
•
Key imaging features to evaluate in laryngeal cancer patients include:
–
–
–
–
–
–
Spread of tumor across the anatomic divisions of the larynx
Spread into the preglottic and paraglottic spaces
Erosive changes or transmural spread through a laryngeal cartilage
Extralaryngeal spread
Nodal involvement
Distant metastasis
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