Intrapulmonary lymph nodes: computed tomography findings with histopathologic correlations

We retrospectively assessed the computed tomography (CT) features of 31 intrapulmonary lymph nodes (IPLNs) with histopathologic correlations. CT scans revealed that the IPLNs are located in the subpleural region, frequently below the level of the carina, and angular in shape. Most of the IPLNs are solid in texture but occasionally present with a ground-glass appearance. For pleura-attached and pleura-separated IPLNs, one or more and 3 or more linear opacities extending from the nodules can be identified, respectively. Histologically, the IPLNs are located either at the junction of the pleura and lung lobules or at the junction of adjacent lung lobules.     

Imaging of the larynx and hypopharynx

The purpose of this article is to review currently used imaging protocols for the evaluation of pathologic conditions of the larynx and hypopharynx, to describe key anatomic structures in the larynx and hypopharynx that are relevant to tumor spread and to discuss the clinical role of Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and PET CT in the pretherapeutic workup and posttherapeutic follow-up of patients with squamous cell carcinoma of this region. A detailed discussion of the characteristic neoplastic submucosal invasion patterns, including extension to the preepiglottic space, paraglottic space and laryngeal cartilages and the implications of imaging for tumor staging and treatment planning is provided. The present article also reviews less common tumors of this region, such as chondrosarcoma, lymphoma, minor salivary gland tumors and lipoma. As the majority of non-neoplastic conditions do not require imaging the role of CT and MRI is discussed in some particular situations, such as to delineate cysts and laryngoceles, abscess formation in inflammatory conditions, to evaluate laryngeal and hypopharyngeal involvement in granulomatous and autoimmune diseases, and to evaluate the extent of laryngeal fractures due to severe blunt trauma.     

Imaging of tumors of the larynx and hypopharynx

Evaluation of patients with laryngeal and hypopharyngeal tumors is based on multidetector CT imaging. The cervicomediastinal CT protocol and general guidelines with regards to planning and acquisition will be detailed. The primary role of imaging is accurate tumor staging but also detection of possible tumor extension to the superior aerodigestive tract and nodal areas. Therefore, images are acquired from the skull base to the cervicomediastinal junction. A chest CT must also be performed to look for distant metastases or other primary tumor. Deep tumor extension, detected only by imaging, is very important to consider for therapeutic planning: surgery or chemoradiotherapy. In case of surgery, accurate evaluation of tumor extension is of great importance to determine whether to perform partial or total surgery. Cervical nodal metastases are very common with laryngeal and hypopharyngeal carcinomas, and accurate staging of nodal disease is important.     

MRI of the hypopharynx,larynx and neck

Correspondence to: T. J. Vogl     

Carcinoma of the hypopharynx: CT staging

The CT examinations of 42 patients with carcinoma of the hypopharynx were analyzed. Tumor site of origin and detailed patterns of extent and spread were noted and a T and N classification attempted. The results were compared to findings achieved by palpation, mirror examination, laryngoscopy, and hypopharyngoscopy. Computed tomography yielded valuable information concerning submucous tumor extension and cartilage involvement. The additional information obtained by CT led to upstaging 29% of the cases to a higher T level and 36% of the cases to a higher N level.     

MRI with Gd-DTPA in tumours of larynx and hypopharynx

Twenty-eight patients with tumours of the larynx, divided into supraglottic, glottic, and subglottic lesions, and of the hypopharynx were examined by different MRI techniques using the paramagnetic contrast medium Gd-DTPA. The results of preoperative MRI were compared with clinical laryngoscopy and the pathological tumour classification. The examinations were carried out using plain T1-wand T2-weighted and Gd-DTPA enhanced T1-weighted sequences. Most studies included three slice orientations for optimal assessment of different tumour locations. The most accurate diagnostic information was given by Gd-DTPA-enhanced sequences. The combination of plain images, contrast-enhanced images and subtraction enabled precise assessment of deep infiltration. T2-weighted and proton density sequences conveyed more information about cartilage invasion and liquid-filled structures, but gave more artefacts than T1-weighted images. Laryngoscopy had advantages in T1-classified tumors, as the extent of the tumor could be seen, and offered histological information via biopsy. Diagnostic findings of MRI correlated in 85.7% with the pathologist's report, and laryngoscopy provided exact classification in only 64.3% of patients. Gd-DTPA-enhanced MRI is an important adjunct to non-contrast MR studies, and forms an ideal diagnostic supplement to laryngoscopy. Offprint requests to: T. Vogl     

螺旋CT在喉及下咽部的临床应用价值(兼与传统CT比较)

目的探讨螺旋ＣＴ在喉及下咽部的临床应用价值。方法喉及下咽癌５７例，１９例螺旋ＣＴ扫描与３８例传统ＣＴ扫描行对比分析，８例多平面重建图像与轴位图像对比；８例（另有４例正常喉及１例声带息肉）螺旋ＣＴ扫描后经软件处理行仿真内窥镜成像，并与纤维喉镜对照研究。结果⑴１９例螺旋ＣＴ轴位图像在显示粘膜表面病变，估计深部浸润范围，喉软骨破坏，以及颈部淋巴结方面均与手术所见相符；而３８例普通ＣＴ中有３例对侧声带表面病变、１例喉软骨破坏及１例颈部淋巴结转移漏诊。⑵８例螺旋ＣＴ多平面重建中７例从不同角度、不同方位显示了喉内解剖、肿瘤及其浸润范围及血管、气道的情况。⑶４例正常喉、１例双侧声带息肉及８例喉癌ＣＴ仿真内窥镜从头端入路显示喉内解剖及病变位置、形态、大小范围与纤维喉镜所见一致，且２例从足端入路显示了纤维喉镜不能显示的声门下及气道狭窄远端情况。结论螺旋ＣＴ较传统ＣＴ敏感度及准确率高；多平面重建可更好地显示喉室、颈部血管及气道情况，是轴位图像的很好补充；ＣＴ仿真内窥镜成像可以分别从头端或从足端入路显示喉腔结构，是纤维喉镜的补充手段     

Squamous cell cancer of hypopharynx and larynx - evaluation of metastatic nodal disease based on computed tomography perfusion studies

Background and purpose

In patients with squamous cell cancer metastatic disease in lymph nodes still remains the single most important negative predicting factor and when detected, it reduces overall 5-year survival by 50%.The aim of the study was to evaluate contrast-enhanced computed tomography (CECT) with computed tomography perfusion (CTP) examination in order to differentiate malignant from non-malignant cervical lymph nodes in patients with squamous cell cancer of hypopharynx and larynx.

Material/Methods

This was a prospective three-center study. From November 2007 until March 2010 33 consecutive patients with squamous cell cancer of the hypopharynx and 27 patients with laryngeal cancer underwent computed tomography (CT) examination followed by CTP. During first part of examination 80 ml of contrast was administered, with flow rate 1 ml/s and 100 s delay; standard head and neck examination was performed. Next, perfusion images were acquired with the coverage of 8 cm and different groups of lymph nodes were evaluated – groups II, III, IV and V. Perfusion maps for basic parameters (blood flow [BF], blood volume [BV], mean transit time [MTT] and permeability surface [PS]) were reconstructed for all patients using dedicated software. The long and short axis diameters, the density of the node before and after contrast medium administration and average values of each perfusion parameter were calculated for every node separately. Results were compared with histologic analysis of resected nodes.

Results

Out of the total number of 293 nodes evaluated on CECT and CTP it was possible to correlate 208 resected nodes with histologic findings. 125 of them were proven to be malignant and 83 were benign.Malignant nodes showed remarkably higher density and hyperperfusion, comparing to benign ones. The average density values in Hounsfield units (HU) for cervical nodes were: 91.9 HU for metastatic comparing to 72.3 HU for non-metastatic, but this difference did not show statistical significance. The average value of BF in malignant nodes was 136.4 ml/100 g/min, BV was 7.7 ml/100 g, MTT was 4.4 s and PS was 19.4 ml/100 g/min. The average values for benign nodes were: BF was 80.7 ml/100 g/min, BV was 4.7 ml/100 g, MTT was 5.6 s and PS was 12.8 ml/100 g/min. Comparing to non-malignant nodes, malignant ones showed significantly higher BF, BV and PS values (p < 0.05).

Conclusions

Although CECT findings may draw our attention, pointing at abnormal morphology of the node, CTP seems to provide additional functional information regarding its possible malignancy. CTP may be useful in differentiation between malignant and benign lymph nodes, based on evaluation of the value of BF, BV and PS.     

Atypical squamous cell carcinoma of the larynx and hypopharynx: radiologic features and pathologic correlation

The objective of this study was to analyze the radiologic features of atypical forms of squamous cell cancer and correlate them with clinical, endoscopic, and histopathologic findings. The CT and MRI images of 31 patients with atypical forms of squamous cell carcinoma were reviewed retrospectively and the radiologic findings were correlated with clinical, endoscopic, and histopathologic findings. Histopathologic diagnoses included undifferentiated carcinoma of nasopharyngeal type (n = 8), verrucous carcinoma (n = 18), spindle cell carcinoma (n = 3), and basaloid cell carcinoma (n = 2). Undifferentiated carcinoma of nasopharyngeal type was located in the supraglottis or piriform sinus beneath an intact mucosa and initial endoscopic biopsy was most often negative. The discrepancy between an intact mucosa at endoscopy and a solid mass with homogenous enhancement at CT or MRI was characteristic for these tumors and warranted further investigations to obtain the definitive histologic diagnosis. Verrucous carcinoma displayed characteristic clinical, radiologic, and pathologic features, namely, an exophytic tumor arising from the glottic level displaying a rugged surface with finger-like projections but with only minor submucosal infiltration. Spindle cell carcinoma appeared as a polypoid mass with a thin stalk arising from the supraglottis. Basaloid cell carcinoma displayed a distinct lobulated enhancement pattern which was observed on contrast-enhanced T1-weighted SE images. Although the MR and CT features of atypical forms of squamous cell carcinoma cannot be considered pathognomonic they should raise the differential diagnosis even if endoscopic biopsy has been negative. The radiologist's awareness of the appearance of these unusual tumors on CT and MR images may greatly facilitate the diagnostic work-up and helps to guide the endoscopist to the adequate biopsy site in order to establish the correct diagnosis. Received 30 April 1998; Revision received 3 June 1998; Accepted 5 June 1998     

Multiplanar functional imaging of the larynx and hypopharynx with multislice spiral CT

The purpose of this study is to evaluate multislice spiral CT (MSCT) in multiplanar functional imaging of the larynx and hypopharynx and to define the optimal image planes for the delineation of the tumor and specific anatomical structures. Forty patients with suspected tumors of the larynx or hypopharynx were examined with MSCT during quiet breathing (QB), E-phonation (EP) and modified Valsalva maneuver (VM). Images were read in the axial, coronal and sagittal planes. Overall image quality, delineation of the tumor and anatomic structures for different conditions and orientations were graded using a three-point scale; the conditional permutation test was applied to detect quality differences. Differences between image types were statistically significant. The axial plane was superior in overall image quality and the delineation of the tumor, pyriform sinus, vocal cords and fat within the parapharyngeal/visceral space. The coronal plane was best for delineating the ventricle and the paraglottic space, the sagittal plane for the retropharyngeal and the preepiglottic space. For tumor detection, sensitivity, specificity and accuracy were 0.92, 1.0 and 0.93 for QB.ax, 0.94, 0.8 and 0.92 for EP.ax and 0.85, 1.0 and 0.87 for VM.ax, respectively. Examination during QB should be the standard procedure; additional scanning with EP improved tumor assessment.     

喉及下咽部CT仿真内窥镜成像技术及其初步临床应用

目的　探讨正常和异常喉及下咽部的CT仿真内窥镜 (CTVE)成像技术及其初步临床应用。方法　采用层厚 3 0mm、螺距 1 0、间隔 1 0mm对 10例正常和 2 0例经病理证实的喉及下咽部病变的患者进行CTVE成像 ,并与纤维喉镜、手术所见对照分析。结果　CTVE能清楚显示正常喉及下咽部的腔内结构。 19例头端CTVE上显示的病变部位、大小和形态与纤维喉镜所见基本一致 ,1例声带息肉显示明显不如后者 ;2例从足侧观察肿瘤与声带和前联合的关系 ,弥补了纤维喉镜的不足。CTVE不能显示组织的颜色变化 ,不易观察病变的表面状况 ,难以判断病变的性质 ,以及不能观察喉内结构的活动情况。结论　CTVE是一种新的、非侵袭性的方法 ,能清楚显示正常和异常喉及下咽部的腔内结构 ,是纤维喉镜的很好补充手段。     

A technique for postoperative irradiation of carcinomas of the larynx and hypopharynx.

Postoperative radiation is commonly employed for advanced lesions of the larynx and hypopharynx which have undergone a laryngectomy. It is technically difficult to achieve a homogeneous distribution of irradiation throughout the treatment volume because of the marked variation in contour across the treated area. We have described a technique which employs a 15 degrees lateral kick-out of the treatment table and a 15 degrees gantry angle above the horizontal for each of two lateral fields. This technique has certain advantages over other techniques previously described in the literature. By adding a gantry angle of 15 degrees above the horizontal to the kick-out lateral position of the table, we have found that we were able to decrease the amount of irradiation to the shoulder, to improve the dose to the posterior superior mediastinum, to lower the applied dose, and to avoid a hot spot overlying the spinal cord in the superior posterior portion of the field. This technique is particularly useful in patients who lack the flexibility to move their shoulders posteriorly and inferiorly.     

Carcinoma of the supraglottic larynx.

Retrospective review of 160 patients with carcinoma of the supraglottic larynx was accomplished for the period 1964 to 1974. The majority were treated by low dose preoperative radiation and conservation surgery and the rest by preoperative radiation and total laryngectomy or radiation alone. Relapse-free and actuarial 5 year survival for all patients was 71% and 45%, respectively. Of primary and neck failures, 85% occurred within 2 years. Primary, nodal, and distant failures occurred in 11%, 21%, and 14% of all patients, respectively. Of 40 T and/or N failures, 33 (83%) occurred in the neck and three T and six N failures (23%) were surgically salvaged. Voice was preserved in 71% of the patients. Major complications were noted in 16% and minor complications in 26% of surgically managed patients; operative mortality was 4%. The presence of microscopic lymph node metastases best predicted those who would later develop T and/or N failure and distant metastases. Second primary tumors occurred in 26% and the leading cause of death was tumor.     

CT diagnosis of retinoblastoma with histopathologic correlations

The authors correlated the radiologic and histopathologic characteristics of 108 retinoblastomas in 98 patients. Calcifications were demonstrable bu CT scans in 92.6% of the cases, whereas only 82% wer evident upon routine histologic study. Cases of severe invasion of the optic nerve beyond the lamina cribrosa and up to the surgical margin of the nerve were detected by CT scans. Lesser degrees of invasion could not be determined by the same method. Orbital extension was also demonstrable, whereas invasion limited to the sclera was rarely accessible to CT diagnosis. Choroidal invasion was not detectable. Computerized tomography detected enlargement of the ipsilateral lacrimal gland in 17.5% of patients. This phenomenon correlates with invasion of the choroid and the optic nerve.     

Supratentorial ependymomas: computed tomographic and pathologic correlations

Of a total of 52 cases of ependymomas, 38 were intracranial, with 15 being supratentorial and 23 infratentorial. Pre- and postoperative computed tomographic scans were correlated with surgical pathologic findings in four cases of supratentorial ependymomas. Pathologic specimens were analyzed from another four cases for which only postoperative scans were available. Seven cases had no computed tomographic studies, but pathology reports were available. Common computed tomography findings for these tumors included para- or intraventricular location, one or more cystic areas within the tumor, and calcifications within the lesion or around its periphery. Proven subependymal spread of tumor was evident by computed tomography in one case. Mixing of ependymoma with oligodendroglioma was present in four cases and with both oligodendroglioma and astrocytoma in two cases. Microscopic calcifications were more frequently seen in ependymomas that were mixed with oligodendroglioma.