Учебники / Head_and_Neck_Cancer_Imaging

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CONTENTS

14.1Imaging Modalities 271

14.1.1Plain X-Ray 271

14.1.2Ultrasound 271 14.1.2.1 Thyroid Gland 272 14.1.2.2 Parathyroid Gland 273

14.1.2.3 Fine Needle Aspiration Biopsy 274

14.1.3Computed Tomography 275

14.1.4 Magnetic Resonance Imaging 276

14.1.5Nuclear Medicine 276

14.2Thyroid Gland 281

14.2.1Embryology 281

14.2.2Anatomy 281

14.2.4.1Benign Disease 282

14.2.4.2Malignant Neoplasms 283

14.3Parathyroid Gland 287

14.3.1 Embryology, Anatomy and Physiology 287

14.3.2Pathology 287

14.1

Imaging Modalities

14.1.1 Plain X-Ray

X-rays of the neck, the chest or barium swallows can give hints mainly regarding thyroid disease, such as narrowing of tracheal, hypopharyngeal or oesophageal lumen, their shifting away from the midline, and coarse calcifications (Fig. 14.1). Their importance has remarkably decreased since the

S. Robinson, MD

Department of Radiology,Helsinki University Central Hospital, Haartmaninkatu 4, POB 340, 00029 HUS Helsinki, Finland

development and refinement of modern cross-sec- tional techniques. Reports on radiographically visible calcified parathyroid adenomas are anecdotal (Polga and Balikian 1971; Warter et al. 1975;

Randel et al. 1987).

Despite its much lower sensitivity to detect pulmonary metastases than CT, chest X-ray is still part of the routine follow-up program after removal of primary tumours (Lorenzen et al. 1998) (Fig. 14.2).

Bony changes of hyperparathyroidism can be easily visible on plain X-rays.

14.1.2 Ultrasound

High-resolution ultrasound is performed with frequencies between 7.5–12.5 MHz. Its role in the preand postoperative management of thyroid and parathyroid lesions is regarded controversial in the literature. There is agreement that it can prove the presence or absence of thyroid nodules and assess their texture (solid versus cystic), number and location, which eases the interpretation of nuclear medicine studies for both organs.

Apart from gaining information about the morphology of a lesion, ultrasound is also used for guidance of fine needle aspiration biopsy (see Sect. 14.1.2.3), percutaneous laser thermal ablation and ethanol injection (Baskin 2004). While the latter seeps into the surrounding tissue and can cause excessive scarring, which makes subsequent surgery difficult, US-guided percutaneous laser ablation has been used successfully in patients at poor surgical risk for debulking of hypofunctioning masses for amelioration of local compression symptoms, where radioablation does not work (Pacella et al. 2004). Although it has been used for palliation in anaplastic carcinoma, caution is needed because of the friability of neoplastic tissue, where the extent of therapy is difficult to predict and the proximity of the big cervical vessels a danger.

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Fig. 14.1. Chest X-ray: huge struma shifting the trachea to the right and narrowing its transverse diameter by half

S. Robinson

Fig. 14.2. Chest X-ray: disseminated pulmonary metastases from medullary carcinoma

14.1.2.1 Thyroid Gland

The thyroid lobes lie fairly symmetric on either side of the trachea, connected by the isthmus of variable width and display homogenous, glandular structures with interspersed branches from the upper and lower thyroid vessels. Neck ultrasound performed for other indications yields 40%–50% of thyroid incidentalomas: non-palpable thyroid nodules, which were hitherto clinically silent (Iannuccilli et al. 2004). But only 5%–6.5% of those will be malignant. To reduce morbidity and costs of unnecessary thyroid surgery, many authors have tried to establish criteria for benign, indeterminate, and malignant looking nodules.

Coarse calcifications are typical for colloid cysts, which do not require further management in the absence of other manifestations.

Microcalcifications (too numerous to count), extracapsular invasion or lymphadenopathy are considered to be definite signs of malignancy (Iannuccilli et al. 2004) (Fig. 14.3).

Size criteria for metastatic thyroid nodes have not yet been established. They tend to loose their spindle shape and become rounder and inhomogeneous (Figs. 14.4, 14.5). More lymph nodes than normal are visible, especially in the lower jugular and accessory group (level 4, 5). Internal calcifications are frequently seen with or without posterior shadowing (Fig. 14.6). Adenopathies, as well as local tumour recurrences may be partly or purely cystic (Fig. 14.7).

Although some groups have published additional suspicious criteria, such as marked hypoechogenicity,

irregular, or microlobulated borders, a shape that is more tall than wide, and penetrating vessels in colour flow mapping and a pulsatility index of ≥ 1, most agree that including indeterminate signs in the malignant group increases the sensitivity at the cost of losing specificity and does not avoid overlap of benign and malignant disease (Iannuccilli et al. 2004; Fukunari et al. 2004).

Indeterminate findings are indistinct borders, dense nodules and incomplete hypoechoic halos (Figs. 14.8, 14.9).

Fig. 14.3. Ultrasound: ill-defined, hypoechoic mass in the right thyroid lobe with microcalcifications and slight posterior shadowing from papillary carcinoma

Thyroid and Parathyroid Neoplasms

Fig. 14.4. Ultrasound: round, heterogeneously hyperechoic lymph node metastasis from papillary carcinoma

Fig. 14.6. Ultrasound: enlarged, heterogeneous, partly calcified lymph node metastasis from papillary carcinoma

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Fig. 14.5. Ultrasound: ovoid, but inhomogeneous lymph node metastasis from papillary carcinoma

Fig. 14.7. Ultrasound: purely cystic local recurrence after radioablation of papillary carcinoma

Most carcinomas are hypoechoic, which do not accumulate radioiodine (cold nodule).

14.1.2.2 Parathyroid Gland

Normal parathyroid glands are only exceptionally visualized. Enlarged glands can be found behind

the lower and upper pole of the thyroid glands. Delineating the cleavage plane between the two organs is noteworthy. At times, depiction is eased, when the patient is swallowing (Simeone et al. 1981).

Abnormal parathyroid glands are typically round to ovoid, hypoechoic and show increased vascularity (Prager et al. 1999) (Fig. 14.10). Cystic degeneration and completely anechoic avascular findings are rare

The abundant cellularity of thyroid neoplastic lesions makes them ideal targets for aspiration biopsy. With appropriate US guidance of the needle tip the risk of missing a neoplastic lesion is low.

Fine needle aspiration biopsy (FNAB) is performed with fine needles (0.4–0.7 mm outer diameter) using needle movements in the lesion for detachment and suction for retrieval. The amplitude of the needle movement should be at least 0.5 cm (Kreula 1990a).

The suction force is produced with vacuum in a syringe that is attached to the needle either directly or with a connecting tube. A vacuum of 2 ml is enough to produce maximal suction force (Kreula 1990b).

The material can be prepared either as air dried smears or fixed, for example, in 50% ethanol for later centrifugation and staining. The choice of the technique is dependent on the training of the pathologist.

Histology from material obtained by core-needle biopsy (0.9- to 1.4-mm thick needles are attached to a spring-loaded device ) has also been applied for the diagnosis of thyroid lesions, especially for lymphomas (Quinn et al. 1994; Screaton et al. 2003).

The technique is a safe outpatient procedure,where occasional minimal intrathyroidal bleeding causing slight discomfort is mentioned as a rare complication. Bleeding may worsen the sample quality. The needle thickness should therefore be kept as small as possible. In fibrotic goitre nodules it may be difficult to aspirate diagnostic material.

Unfortunately, cytology cannot differentiate between follicular adenoma and follicular carcinoma.

In patients with hyperparathyroidism biopsies do not play a central role.

It is also appropriate to confirm the character of the target cytologically before ablation of the gland with ethanol injection. In addition, fluid aspiration of a lower neck cyst and laboratory assessment of its parathormone content can establish the diagnosis of a rare parathyroid cyst, which occurs more often on the left side (Ginsberg et al. 1978).

14.1.3

Computed Tomography

Computed tomography (CT) of the neck is nowadays usually performed in multi-slice mode, which pro-

vides higher spatial resolution than conventional CT scanners (Ishigaki et al. 2004).

Many contrast enhanced CT examinations performed for other indications will reveal incidental thyroid pathology (Fig. 14.12). If a patient has thyroid disease of unknown origin, one should rather perform MRI. On average, a dose of 100 ml of iodine containing contrast agent will deliver a dose of 20– 30 g iodine and will block the thyroid gland for subsequent scintigraphy or radioablation for 6–8 weeks (Laurie et al. 1992). Rarely, it may provoke a thyrotoxic crisis, which may be prevented by premedication with 500 mg oral perchlorate 2–4 h before and after iodine application and 3×300 mg perchlorate over the next week (Hehrmann et al. 1996).

Otherwise, the examination should be done from the skull base to the mediastinum down to the carina to exclude lymphadenopathy or ectopic parathyroid adenomas (Harnsberger 2004). At 30 s after intravenous administration of 100 ml non-ionic contrast medium the scan is performed in thin sections (e.g. slice thickness 1 mm, pitch 3, reconstruction increment 1 mm).

Evaluation includes size of thyroid lobes and isthmus, their density, homogeneity, and calcifications (Figs. 14.13, 14.14). In case of masses their borders and effect on larynx/trachea, hypopharynx/oesophagus, prevertebral fascia, big vessels and their relationship to the sternum, as well as possible lymphadenopathy, are assessed (Fig. 14.15).

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a

Fig. 14.12a,b. CT: lingual thyroid

Fig. 14.13. CT: large, retropharyngeal struma

In hyperparathyroidism, enhancing round or ovoid lesions behind the thyroid gland or in ectopic position anywhere from the carotid bifurcation to the mediastinum are sough.

CT can be applied in malignant thyroid tumors, for example to rule out associated disease in multiple endocrine neoplasia (MEN) syndromes, or metastatic disease (Figs. 14.16, Fig. 14.17).

14.1.4

Magnetic Resonance Imaging

S. Robinson

b

mediastinum (Czerny et al. 2003). The latter profits from cardiac gating. A matrix of 512×512, FOV of 20–25 cm and slice thickness of 2–3 mm have proven to be most useful. Commonly applied section planes are axial and coronal. Precontrast SE-T1, fat-suppressed T2-weighted (turbo)SE and postcontrast T1-weighted fat-suppressed SE sequences help delineation of disease.

Evaluation criteria are similar to the ones applied for CT. It is worth mentioning that haemorrhage into thyroid nodules, a high protein content of colloid, but also malignant primary tumour and lymph nodes may appear hyperintense on T1 before contrast administration (Figs. 14.18, 14.19). Partly or purely cystic recurrences or lymph node metastases are not uncommon (Figs. 14.20, 14.21). Coarse calcifications are hypointense on all sequences, microcalifications may go undetected.

Enlarged parathyroid glands are slightly hypointense to muscle, hyperintense on T2 and strongly enhance with contrast agent. While 99mTc-SestaMIBI with or without SPECT is more sensitive in the detection of (mediastinal) parathyroid disease, MRI is superior in evaluating the topographic relations on which the therapeutic decision (e.g. transsternal versus transthoracic approach) is based.

Furthermore, MRI has proven superior in the evaluation of distant metastases, especially of brain and bone marrow (Mirallié et al. 2005) (Fig. 14.22).

14.1.5

Nuclear Medicine

MRI is performed with a circular-polarized neck coil for the neck and a phased-array body coil for the

Nuclear medicine is indispensable in the management of thyroid and parathyroid neoplasms.

Fig. 14.15. CT: calcified lymph node metastasis in the left upper jugular group (level II) from medullary carcinoma

Fig. 14.16. CT: left paraaortal paraganglioma in patient with medullary thyroid carcinoma

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Fig. 14.17. CT: calcified liver metastases from medullary carcinoma

Fig. 14.19. Precontrast T1-weighted MR image: slightly hyperintense lymph node metastases from papillary carcinoma in the right submandibular (level I, white arrow) and in the left upper jugular group (level II, black arrow) behind the vessels

S. Robinson

Fig. 14.18. Precontrast T1-weighted MR image: hyperintense recurrence from papillary carcinoma in left thyroid bed (arrow)

Fig. 14.20. Precontrast T1-weighted MR image: slightly hyperintense recurrence in right thyroid bed 2 months after radioablation (arrow)

If tracer accumulation in the thyroid gland is not homogenous, it can either be “hot”, if an area is increased compared to the surrounding gland, or “cold”, if it accumulates less than the gland. The latter is associated with an up to 20% risk of malignancy. After thyroidectomy tumour cell remnants can be ablated with internal radiotherapy. In the fol- low-up, tracer accumulation can highlight recurrent and metastatic disease, especially, if thyroglobulin is elevated over 10 ng/ml.

99mTc pertechnetate, 123I and 131I scintigraphy are used for diagnosis of thyroid disorders. Technetium is applied intravenously and imaging performed 20 min later, or iodine is given orally and the patient scanned after 4–24 h. Diagnostic 131I scans can be performed post thyroidectomy to detect local and metastatic disease. If positive, therapeutic ablation with 131I follows. In other centres, in all differentiated T2 tumours, in cases with extension beyond the thyroid capsule or with lymph node metastases, radio-