CT MRI PET ORAL CANCERS

1. Role Of Imaging & Normal Radiological
Anatomy Of Head & Neck
With Emphasis On
Oral Cavity
Presenter :Dr Isha Jaiswal
Senior Resident Radiotherapy
Date 10th September 2018

2. ROLE OF IMAGING IN HEAD & NECK CANCER
• For Diagnosis & Staging
• For Treatment Planning (both surgery & radiotherapy)
• For Response Evaluation
• For Detection Of Recurrences

3. TYPES OF IMAGING
XRAY
• Panoramic Xray oral cavity
• Paranasal sinus
• X ray lateral Face And Neck
USG Neck
CECT Face And Neck
MRI Face And Neck
Whole body PET-CT Scan

4. Panoramic Xray oral cavity
Indication
• for determining bone invasion
• for planning dental treatment of oral cavity prior to chemotherapy and radiation to reduce
subsequent complications
• for early detection of maxillofacial complications of cancer therapy when they do occur;
• for detection of recurrent tumors within the maxillofacial complex.

5. characteristic features of malignant lesions in plain radiographs include
• atrophy of cortical lamina
• osteolytic defects
• in later stages, teeth lose their bony support at the site of infiltration
bone defect in the left mandibular body. The osteolytic lesion reaches the alveolus of
the lower left canine that had lost bony support
Discrete radiolucency in
mandible on right side.

6. Xray paranasal sinus
• PARANASAL SINUS:
 Paired structure
 Frontal sinus located between inner & outer table of skull bone
posterior to glabella
 Ethmoid sinus in labyrinth of ethmoid bone
 Maxillary sinus within body of maxilla
 Sphenoid sinus in body of sphenoid bone behind shella turcica
• XRAY PNS
 Standard views include the Water’s, Caldwell, lateral and basal
views.
 Usually filled with air
 Abnormal Xray may show fluid or mass

7. Water’s (occipitomental)
Extend neck, nose & chin of pt. touches film/table
OML will be 37 degree from table
Structures seen
• Maxillary sinus (seen best)
• Frontal sinus
• Sphenoid sinus (if mouth open )

8. Caldwell’s (occipitofrontal) view
Pt. place nose & forehead against upright table with
neck extended to elevate OML 15 degree from
horizontal
Structures seen
• Frontal sinus (seen best)
• Ethmoid sinus
• Maxillary sinus

9. Lateral view
Structures seen
• Ant.& post extent of sphenoid, frontal,& maxillary sinus
• Ethmoid sinus

10. Pt. raise chin, hyperextend neck
until OML is parallel to film, head rests on
vertex. Vertex near film .Xray taken from sub
mental area
Structures seen
• Sphenoid sinus (seen best)
• Post Ethmoid sinus
• Maxillary sinus
Basal (submentovertical) view

11. XRAY lateral soft tissue neck
Indication
• Useful in assessing patients with potential pathology of upper aerodigestive tract.
• Detects foreign bodies ,airway compromise, trauma and infections such as croup, epiglottitis deep neck
infections such as retropharyngeal abscesses
• determination of the distribution of detected malignancies in vertebra
Advantages
• cheap, non invasive, readily available investigation tool
• Useful in planning for conventional radiotherapy
Drawbacks
• Poor visualisation of oral cavity and oropharynx
• Limited use in oncology

12. XRAY LATERAL NECK
1. Hard Palate
2. Soft Palate
3. Nasopharynx
4. Oropharynx
N
O

13. XRAY LATERAL NECK
1. Calcified tracheal cartilage rings
2. Hyoid bone
3. Epiglottis
4. Thyroid cartilage
5. Cricoid cartilage
T
C
H
E

14. Ultrasound
Advantages
• Availability
• Cheap
• No radiation
• Differentiate solid vs cystic
• Real time
• Colour Doppler vascularity identified
Disadvantages
• Cannot be used for deep seated tumors
• Air and acoustic window interference
• Interobserver variability
• Lack of reproducibility
• Cannot be incorporated into TPS
Indications
• used to evaluate superficial lesions
• For clinically occult nodal evaluation
• For evaluation of Thyroid gland
• for image guided fnac & biopsy

15. USG FEATURE OF MALIGNANT L.N
• increase in size
• Nodal parenchyma exhibited inhomogeneous low or mixed echogenicity.
• Irregular margin with round shape.
• Sharp borders.
• Loss of normal hilar echogenicity.
• Doppler sonograms, has peripheral or mixed vascular pattern

16. • usually the first modality used because it is widely available, relatively cheap, quick and easy to
perform and reproducible.
• The examination time is short with less motion artefacts than an MR scan.
• Thin slice, high resolution image acquisition allows high quality Multiplanar reconstructions with
superior evaluation of bony structures and calcifications.
• Evaluation of CT images is also easier than evaluation of MR images.
CECT Face & Neck Scan

17. CECT SCAN
Feature Of Malignancy
• Tumours appear as asymmetrical
thickening of the mucosa (a)
• can show areas of necrosis (b)
• enhances according to its
vascularity (a star)
Patient with cancer of the right pyriform sinus.
CECT scan a showing asymmetrical thickening of the pyriform sinus (arrow) on the right.(a;above)
slight thickening of the posterolateral hypopharyngeal wall (b;arrowhead)
lymph node with central necrosis (b;arrow) indicating metastasis

18. • More than 1cm size except jugulodigastric(1.5 cm) (short axis)
• Shape: spherical rather than ellipsoidal; Heterogeneous enhancing pattern
• Eccentric cortical hypertrophy.
• Necrotic center: hypo-dense
• Cluster of 3 or more borderline nodes
• Margin :ill defined
CT FEATURES OF MALIGNANT LYMPH NODE

19. CECT Scan Face & Neck
Advantages
• Widely available
• Fast imaging
• Detail crossectional images
• Good bony details
• Detect clinically occult metastatic L.N
• multiplanar reconstructions
• Aids in RT planning
• Gives electron density information
• less motion artefacts
Disadvantages
• Radiation exposure
• Relatively expensive
• Poor Soft tissue contrast
• Artifact due to dental fillings
• Underestimating ulcerative and infiltrative lesions
• overestimating tumor extent due to inflammation/
oedema & distortion of adjacent normal structures
• Contraindicated in allergy to contrast media,
kidney failure

20. MRI FACE AND NECK: features of malignancy
• On MRI, the tumour is usually hyperintense to muscle on T2-
weighting and hypointense or isointense to muscle on T1-
weighting.
• The plain T1-weighted images are particularly useful in
differentiating tumour from surrounding fat, detecting
neurovascular bundle and bone marrow involvement.
• Patient with Ca pleomorphic adenoma of submandibular
gland on left with invasion of mandible.
• In T2-MR image lesion is heterogenously hyperintense to
muscle and there is loss of the cortical hypointense line
indicating bone invasion (arrow). (a)
• In T1-weighted image lesion is hypointense to muscle
and there is replacement of the normal marrow fat by the
tumour. (b)
• The contrast T1-weighted image shows some
enhancement of the lesion. (c)

21. CT SCAN & PET SCAN FOR SAME CASE
• Contrast enhanced CT scan at the same level d shows the heterogenously enhancing mass which extends into the
mandible.
• The cortical bone erosion (arrow) is seen better in the bone window setting e.
• The PET-CT scan at the same level showing the increased glucose uptake by the tumour with extension into the
mandible

22. (B,C ) Coronal T1-weighted image through the hard palate and soft palate, respectively
MRI Anatomy Of Oral Cavity :coronal images at level of hard & soft palate
( A ) Coronal illustration through the hard
palate. Note the mylohyoid muscle forming the
inferior and lateral borders of the OC,, and the
extrinsic tongue muscles (hyoglossus and
genioglossus).

23. (C) Axial illustration at level of tongue
demonstrating tongue & RMT.
PMR, pterygomandibular raphe (facial
band connecting buccinator & sup.
constrictor ).
MRI Anatomy Of Oral Cavity :coronal at level of FOM &Tongue
( A ) Axial illustration at level of FOM
demonstrating extrinsic muscles
( B ) Axial T2wt image at the level of the FOM (D)Axial T2-wt image at the level of oral tongue.

24. Advantages
• Multiplanar scanning
• better soft tissue contrast
• can determine the involvement of local soft tissues, as
well as vessels and nerves.
• Better for perineural infiltration & intracranial extension,
bone marrow involvement
• May differentiate recurrent tumor and post treatment
fibrosis and radiation necrosis
• less artifact from dental fillings.
Disadvantages
• higher costs
• longer acquisition time
• No electron density information
• Contraindicated in pts with pacemaker
and implants
• Poor bone visualisation
• potential artefacts (motion artefacts, flow
artefacts, field distortion artefacts due to
metal or at air bone interfaces or with
blood products
MRI Face & Neck

25. 18 FDG PET
Features of malignancy
• On PET-CT, the morphological changes due to the tumour are seen as in CT with increased uptake of glucose
in those tumours which are FDG avid ,
• other processes resulting in glucose uptake like infection, inflammation show false positive results
• It is a nuclear medicine functional imaging technique used to observe metabolic processes in the body
detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide, most commonly FDG
• the concentrations of tracer imaged will indicate tissue metabolic activity

26. 18FDG PET-CT
Indications
Advantages
• Functional imaging
• In detection of unknown /small primary tumor
• In evaluating clinically occult nodal
involvement
• To detect distant mets
• In follow up to differentiate between
recurrent tumor and post treatment fibrosis
and radiation necrosis
Disadvantages
• Limited availability
• Costly
• False Positive uptake in inflammation and
infections

27. 18FDG PET-CT

28. Oral Cavity Radiological Anatomy & Presentation
Of Cancer
• Lip
• Buccal Mucosa
• Anterior Tongue
• Floor Of Mouth
• Alveolus
• Hard Palate
• Retromolar trigone

29. Axial CECT Neck
At Level Of C4
Bone
Muscles: Tongue, SCM, Trapezius
Gland
Vessels
Vallecula
Epiglottis
pharynx

30. • CT is complemented by the puffed cheek technique (PCT), when oral cavity lesion suspected.
• PCT involves voluntary blowing of the oral cavity with air during the CT. Compliance with the technique is variable,
Puffed Cheek Technique
T
ALV
HP
BM
FOM

32. Retromolar trigone
Triangular region bounded
• ant: post surface of last molar
• Post: ant tonsillar pillar
• Lat:buccal mucosa
• Apex: pterygoid hamulus

34. FLOOR OF MOUTH
• Floor of the mouth is a U-shaped area formed by 2 mylohyoid muscle & hyoglossus
• Anteriorly is bounded by the gingiva of the mandible and posteriorly by the anterior faucial pillar.
• Contains sublingual space: fatty connective tissue space within the floor of mouth, contains sublingual salivary
glands, submandibular duct ( warthon duct), lingual artery, vein and nerve and hypoglossal nerve (XII C.N.)

35. ORAL CAVITY CANCERS
• Tongue
• Buccal mucosa
• Floor of mouth
• Retromolar trigone
• Lips

36. Tongue

37. Presentation
ulcer along the lateral border of the Lt tongue.
• CE CT demonstrates an enhancing mass located on the lateral aspect of anterior tongue on left.
• does not cross the midline and is limited to the intrinsic muscle of the tongue.
• no extension to the gingival mucosa or involvement of the adjacent mandibular bone.
• No enlarged lymph nodes are identified

38. Carcinoma tongue: CT axial ,coronal & bone window
Ulcerated lesion involving the left posterolateral tongue No enlarged submental or submandibular lymph nodes.
Edentulous mandible and maxilla. No osseous destruction

39. Carcinoma Tongue: MRI
large oral tongue lesion is seen arising from left half. involves the entire extent of the left tongue from tip to level of
circumvallate papillae, predominantly involves ventral aspect with deep invasion into the intrinsic muscles. Anteriorly
crossing the midline with involvement of the right tongue

40. CARCINOMA BUCCAL MUCOSA
CT image showing a malignant
lesion in the left buccal mucosa.
CT image showing a mass from the Lt
buccal mucosa extending to the RMT
and involving submandibular region
Advanced lesion infiltrating mandible

41. Presentation
Swelling and pain in right cheek. Chronic tobacco chewerCARCINOMA BUCCAL MUCOSA
Serial section of CECT neck showing heterogenously enhancing mass lesion in the right buccal mucosa with multiple
enlarged right Level Ib lymph nodes

42. CARCINOMA BUCCAL MUCOSA: advanced

43. CARCINOMA FLOOR OF MOUTH
• patient presented with a large ulcer at the left floor of the mouth
CT showed an infiltrating tumour with irregular borders at the anterior left floor of the mouth and gingivo-buccal
sulcus, that crossed the midline and eroded the mandibular bone.
There was a centrally necrotic lymph node metastasis at the anterior border of the left sternocleidomastoid muscle.

44. Retromolar trigone cancer
Axial contrast enhanced CT right retromolar trigone mass (arrows)

45. HARD PALATE TUMORS
Right hard palate mass with invasion of the upper alveolar ridge(arrows)

46. LIP CANCER
UPPER LIP LOWER LIP
Extensive carcinoma of the lip

47. Oropharynx Radiological Anatomy & Presentation Of Cancer
Soft Palate
Base of tongue
Tonsil

48. CT (sagittal) image showing a base of tongue growth.

49. CARCINOMA BASE OF TONGUE
(A)axial: ulcerated contrast enhancing soft tissue mass in BOT (arrowheads)lesion crosses midline with large level II
L.N. lingual artery involved (curved arrow)
(B)Sagittal image: ant. Spread in FOM(white arrowhead)lesion extend into vallecula (black arrowhead);preepiglottic
space (asterisk) not involved

51. Ca Tonsil
Clinical picture CECT scan MRI

52. CA Rt. TONSIL

53. An MRI image showing right tonsillar growth
associated with Rt cervical adenopathy.
PET CT of the same patient
CARCINOMA TONSIL

54. CA SOFT PALATE

55. CANCER POST. PHARYNGEAL WALL

56. Nasopharynx Radiological Anatomy &
Presentation Of Nasopharyngeal Cancer

57. • Roof: Formed By Basiocciput & Basispenoid
• Floor: Formed By Soft Palate Anteriorly; Deficient Posterior Communicates With Oropharynx .
• Anterior :Nose
• Posterior: Atlas Axis Vertebra, Retropharyngeal Space, Prevertebral Fascia
• Lateral Wall: Contain Openings Of Eustachian Tube

58. • Lateral wall: contain openings of
eustachian tube bounded by
elevation called as torus tubarius

59. NASOPHARYNGEAL CANCERS
Usually originate in lateral wall from
fossa of Rosenmüller
Anterior Spread into nasal cavity

60. Posterior spread:
into retropharyngeal lymph node
Post. Lateral spread &
involvement of prevertebral muscles

61. nasopharyngeal tumor with infratemporal
fossa extension
Inferior Spread: to oropharynx

62. Superior spread: infilteration of orbital cavity via inferior Orbital fissure

63. Nose & Paranasal Sinus Radiological
Anatomy & Presentation Of Cancer

64. 64
An CT face axial 7 coronal section showing the nasal cavity with the paranasal sinuses.

66. • Sagittal CT scans showing the frontal, ethmoidal
and sphenoidal sinuses.
• Arrows indicate the hiatus semilunaris
66

67. The Ohngren line.
Sagittal CT shows a squamous cell carcinoma with the origin in the posterior maxillary sinus.
The white line refers to the Ohngren line, where cancer posterior to this line was previously considered
unresectable.
The posterior black line is the border between a T4a and a T4b cancer (AJCC 7th edition).
This tumour erodes the posterior maxillary wall and bulges into the orbital apex
• line that connects the medial canthus of the eye to the angle
of the mandible.
• divides the maxillary sinus into (1) an anterior-inferior part,
and (2) a superior-posterior part.
• Tumours that arise in the anterior-inferior part, i.e. below
Ohngren's line, generally have a better prognosis than those
in the other group

68. 68
CT of a nasal vestibule carcinoma that has spread by direct invasion of the upper lip and gingivolabial sulcus.
CARCINOMA NASAL VESTIBULE

69. Maxillary sinus squamous cell carcinoma.
(a) Axial CT shows erosion of the lateral nasal wall and lacrimal duct (arrow) and growth into the middle meatus (asterisk)
(b) Coronal CT in another patient with a carcinoma mimicking a nasal polyp, however, the lateral nasal wall is eroded
(arrow)

70. (a) Axial CT and (b) T2-weighted MR imaging demonstrate a tumour (black arrowheads)
• extending to the skin of the cheek (white arrowhead) bony erosion of the lateral maxillary sinus wall and the
pterygoid plates (arrows) are better visualized using CT;
• extension of the tumour and distinction from obstructed fluid-filled sinuses and surrounding oedematous soft tissue
are best evaluated using MR imagin

71. Maxillary Sinus Cancers: suprastructure with pattern of spread
Advanced tumor: alveolar process destruction with loosening of a tooth (E) and abutment of the orbital floor

72. Ethmoid sinus adenocarcinoma
(b) Contrast-enhanced coronal CT shows an intracranial component
(arrowheads) verified at
(c) coronal contrast-enhanced T1-weighted MR imaging. There is no
meningeal enhancement due to the dural barrier. The tumour also respects
the orbit and was classified as a T3 cancer.
(a) Coronal CT shows opacification of the
left nasal cavity, anterior ethmoid sinus
and frontal recess. The clue to a malignant
process is the erosion of the lateral
lamella (arrow).

73. • Extends from the level of Hyoid Bone to lower border of Cricoid cartilage.
• Corresponds to C4 - C6 vertebral bodies.
• Subsites-
• Pyriform sinus
• Post cricoid region
• Posterior pharyngeal wall
Hypopharynx Radiological Anatomy & Presentation Of Cancer

74. Hypopharynx Radiological Anatomy

75. CARCINOMA HYPOPHARYNX

76. CARCINOMA HYPOPHARYNX
• abnormal enhancing mass centred upon the right larynx/hypopharynx with large cervical lymph node
• superior extent of the lesion extends from the right aryepiglottic fold, involving the paraglottic right space (without
crossing the midline) and extending into the supraglottic larynx.
• Inferior extent extends to right true cord with likely subglottic spread.

77. Larynx Radiological Anatomy & Presentation Of
Cancer

83. RADIOLOGICAL ANATOMY OF LYMPH NODE

86. Radiological Anatomy

87. Enlarged sub mental lymph nodeBounded by 2 ant. Belly of digastric

89. Bounded by ant. & post Belly of digastric
Ant belly digastric
Post belly digastric
Mandible

91. Cranial border: caudal C1 Caudal border: caudal edge of hyoid

93. Cranial border: caudal edge of hyoid Caudal border: caudal edge of cricoid

95. Caudal border: 2cm cranial to cranial
edge of sternoclavicular joint
Cranial border: caudal edge of cricoid

96. Cranial border: cranial edge of hyoid

99. THANKYOU