91 MR IMAGING OF LARYNGEAL CANCER SERIES IN RADIOLOGY Volume 23 MR Imaging of Laryngeal Cancer by J .A. CASTELIJNS Department of Radiology G.B. SNOW Department of Otolaryngology/Head and Neck Surgery and J. VALK Department of Radiology Free University Hospital, Amsterdam, The Netherlands With contributions by G.J. GERRITSEN Department of Otolaryngology, Dijkzigt Hospital, Rotterdam, The Netherlands and W.N. HANAFEE Department of Radiodiagnostics, University of California, Los Angeles, USA SPRINGER SCIENCE+BUSINESS MEDIA, B.V. Library of Congress Cataloging-in-Publication Data CIP CasteliJns. Jon~s A. MR illlaging of laryngeal cancer! by J.A. Castelijns. G.B. Snow. and J. Valk : with contributions by G.J. Gerritsen and W.N. Hanafee. p. CIII. -- (Series in radiology : v. 23) Inc ludes index. ISBN 978-94-010-5451-5 ISBN 978-94-011-3286-2 (eBook) DOI 10.1007/978-94-011-3286-2 1. Larynx--Cancer--Magnetic resonance imaging. 1. Snow. G.B. II. Valk. J. III. Title. IV. Series: Series in radiology : 23. RC280.T5C37 1991 616.99'42207548--dc20 90-27135 ISBN 978-94-010-5451-5 Printed an acid free paper AII rights reserved © 1991 by Springer Science+Business Media Dordrecht Origina11y published by Kluwer Academic Publishers in 1991 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner. Table of contents Foreword by W.N. Hanafee xi Introduction Xlll Acknowledgements XVll CHAPTER 1: GENERAL ASPECTS OF LARYNGEAL CANCER by J.A. Castelijns, G.B. Snow 1 1. Introduction 1 1.1. Incidence 1 1.2. Predisposing factors 1 2. TNM staging 2 2.1. Introduction 2 2.2. Clinical classification 2 3. Diagnostic aspects 3 3.1. History 3 3.2. External examination 4 3.3. Laryngoscopy 4 4. Therapeutic options 4 4.1. Radiotherapeutic options 4 4.1.1. Technique 4 4.1.2. Prognostic factors of irradiation treatment 5 4.1.3. Complications due to radiation therapy 5 4.2. Surgical options 5 4.2.1. Laser therapy and microsurgical stripping 5 4.2.2. Laryngofissure and cordectomy 6 4.2.3. Vertical partial laryngectomy 6 4.2.4. Antero-frontallaryngectomy for excision of the anterior commissure 6 4.2.5. Supraglottic laryngectomy 7 4.2.6. (Wide-field) total laryngectomy 7 4.3. Chemotherapeutic options 7 5. Therapeutic management 7 T1- and T2-glottic carcinomas 8 T1- and T2-subglottic carcinomas 8 TI- and T2-supraglottic carcinomas 8 T3- and T4-laryngeal cancer 8 Nodal metastasis 9 References 9 VI CHAPTER 2: THE PATTERNS OF GROWTH AND SPREAD OF LARYNGEAL CANCER by G.l. Gerritsen, G.B. Snow 11 1. Introduction 11 2. Spread of cancer in various regions 11 2.1. Cancer of the supraglottic region 11 2.2. Cancer of the glottic region 14 2.3. Cancer of the subglottic region 18 3. Cartilage invasion 19 4. Lymphatic spread 20 5. Vascular and perineural invasion 21 References 21 CHAPTER 3: THE RADIOLOGICAL EXAMINATION OF THE LARYNX by 1.A. Castelijns 23 1. Introduction 23 2. Phonation manoeuvers 23 3. Frontal tomography 24 4. Contrast laryngography 24 5. Computed tomography 25 6. CT versus conventional radiological techniques 25 6.1. CT versus conventional tomography 25 6.2. CT versus contrast laryngography 26 References 26 CHAPTER 4: GENERAL ASPECTS OF MR IMAGING by 1.A. Castelijns 29 1. Introduction 29 2. Technical principles 29 2.1. Properties of atomic nuclei 29 2.2. Resonance 30 2.3. Behaviour of a sample of nuclei 31 2.4. Proton density, tissue characteristics 32 2.5. Spin echo technique 33 3. The equipment 34 3.1. Magnet 35 3.2. Gradient system 35 3.3. Coils 35 3.4. Computer 36 vii 4. Disadvantages of MR imaging 36 4.1. Claustrophobia 36 4.2. Contra-indications 36 References 37 CHAPTER 5: MR IMAGING TECHNIQUES OF THE LARYNX by J.A. Castelijns 39 1. Surface coils 39 1.1. Coil selection 39 2. Parameters 42 2.1. Pulse sequences 42 2.2. Slice thickness 43 2.3. Slice direction 43 2.4. Matrix size 44 2.5. Number of signal measurements 45 3. Artifacts 46 3.1. Motion artifacts 46 3.2. System artifacts 49 3.3. Chemical shift artifacts 51 3.4. Artifacts due to ferromagnetic implants 52 4. Performance of the laryngeal examination 52 References 53 CHAPTER 6: MR IMAGING OF THE NORMAL LARYNX by J .A. Castelijns 55 1. Introduction 55 2. MR imaging of laryngeal structures 55 2.1. Laryngeal skeleton 55 2.2. Laryngeal compartments 59 3. Landmarks 60 3.1. Hyoid bone 60 3.2. Aryepiglottic fold 60 3.3. False vocal cords 60 3.4. True vocal cords 62 3.5. Subglottic level 62 References 62 Appendix 62 viii CHAPTER 7: MR IMAGING OF LARYNGEAL CANCER by J.A. Castelijns, M.C. Kaiser, J. Valk, G.J. Gerritsen, A.H. van Hattum, and G.B. Snow 65 Abstract 66 1. Introduction 66 2. Materials and methods 67 3. Case reports 67 Case 1 67 Case 2 69 Case 3 70 Case 4 70 Case 5 73 Case 6 74 Case 7 74 4. Discussion 75 5. Conclusions 77 References 78 CHAPTER 8: MR IMAGING OF NORMAL AND CANCEROUS LARYNGEAL CARTILAGES. HISTOPATHOLOGICAL CORRELATION by J.A. Castelijns, G.J. Gerritsen, M.C. Kaiser, J. Valk, W. Jansen, C.J.L.M. Meyer, and G.B. Snow 81 Abstract 82 1. Introduction 82 2. Materials and methods 83 3. Results 84 3.1. Epiglottic cartilage 84 3.2. Thyroid cartilage 84 3.3. Cricoid cartilage 89 3.4. Arytenoid cartilage 90 4. Discussion 90 5. Conclusions 99 References 99 CHAPTER 9: DIAGNOSIS OF LARYNGEAL CARTILAGE INVASION BY CANCER. COMPARISON OF CT AND MR IMAGING by J.A. Castelijns, G.J. Gerritsen, M.C. Kaiser, J. Valk, T.E.G. van Zanten, R.P. Golding, C.J.L.M. Meyer, A.H. van Hattum, M. Sprenger, P.D. Bezemer, and G.B. Snow 101 ix Abstract 102 1. Introduction 102 2. Materials and methods 103 2.1. Imaging techniques 104 2.2. Image interpretation 104 2.3. Pathological findings 106 3. Results 106 3.1. Epiglottic cartilage 106 3.2. Thyroid cartilage 109 3.3. Arytenoid cartilage 113 3.4. Cricoid cartilage 113 3.5. Group of patients for which no pathologic correlation was available 116 3.6. Movement artifacts 117 4. Discussion 4.1. Elastic cartilage: epiglottic cartilage 119 4.2. Hyaline cartilage: thyroid, cricoid and arytenoid cartilages 119 5. Summary 121 References 121 CHAPTER 10: MR FINDINGS OF CARTILAGE INVASION BY LARYNGEAL CANCER. VALUE IN PREDICTING OUTCOME OF RADIATION THERAPY by I.A. Castelijns, R.P. Golding, C. van Schaik, I. Valk, and G.B. Snow 123 Abstract 124 1. Introduction 124 2. Materials and methods 125 3. Results 127 4. Discussion 131 References 133 CHAPTER 11: GENERAL DISCUSSION 135 References 139 Index 141 Foreword MRI is assuming a dominant role in imaging of the larynx. Its superior soft tissue contrast resolution makes it ideal for differentiating invasion of tumors of the larynx from normal or more sharply circumscribed configuration of most of the benign lesions. Over ten years ago CT made a major impact on laryngeal examination because it was the first time that Radiologists were beginning to look at submucosal disease. All of the previous examinations duplicated the infor mation that was available to the clinician via direct and in-direct laryngo scopy. With the advent of rigid and flexible endoscopes, clinical examination became sufficiently precise that there was little need to perform studies such as laryngography which merely showed surface anatomy. The status of deep structures by these techniques was implied based on function. Fortunately laryngography is now behind us together with all of the gagging and contrast reactions which we would all like to forget. CT is still an excellent method of examining the larynx but it is unfortunately limited to the axial plane. With presently available CT techniques motion deteriorates any reformatting in sagittal or coronal projections. The latter two planes are extremely helpful in delineating the vertical extent of submucosal spreads. MRI has proven extremely valuable by producing all three basic projections, plus superior soft tissue contrast. Although motion artifacts still degrade the images in some patients, newer pulsing sequences that permit faster scanning are elimi nating most of these problems. The details of the larynx are becoming so clear that one can now see the intrinsic musculature of the larynx and identify the causes of any dysfunction. Dr. Castelijns has analyzed his results covering 44 consecutive patients examined with MRI, 12 of whom had surgery with specimen/MRI corre lation. All patients had histological verification of malignancy. The 32 pati ents who received radiation therapy had extensive clinical examinations which were compared to the radiological imaging studies. This book will playa vital role in this series in Radiology because it comes from one of the leading institutions of Europe and combines the best of the American and European ideas regarding laryngeal cancer. In Europe, the treatment emphasis is on radiation therapy while in the USA, surgery is usually the treatment of choice. The authors are from the Netherlands and combine the expertise of Dr. J.A. Castelijns in the Department of Radiology and Dr. J. Valk from the Department of Radiology with the Departments of Head and Neck Surgery, under Dr. G.B. Snow and Dr. G.J. Gerritsen. Dr. Castelijns has a long xi