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Abstract
Squamous cell carcinoma is the most common head and neck cancer. This review describes the state-of-the-art compu-
terised tomography and magnetic resonance imaging protocols of the neck and the normal larynx anatomy, and provides a
practical approach for the diagnosis and staging of laryngeal squamous cell carcinoma.
Keywords
Computerised tomography, magnetic resonance imaging, squamous cell carcinoma
adequate enhancement of primary tumour and an accu- The use of a 3D fat-suppressed T1-weighted gradient
rate differentiation of cervical lymph nodes from ves- echo (GRE) sequence (VIBE (Siemens Healthcare),
sels.9 Demonstration of sufficient attenuation of neck LAVA (GE Healthcare) and THRIVE (Philips
vessels suggests good image quality.10 Unenhanced Healthcare)) taking approximately 30 s reduces the
images are not routinely acquired to reduce patient long acquisition times of traditional spin echo (SE) or
exposure to ionising radiations. At our hospital, unen- fast SE sequences (several minutes) without degrading
hanced images are acquired only during the first CT image quality, and motion artifacts.15
examination.
A correct reformation plane orientation is crucial for
avoiding misinterpretation. Axial images must be par-
Anatomy of the larynx
allel to the true vocal cords or the hyoid bone, while Familiarity with the anatomy of the larynx, and the
coronal images must be parallel to the airways and routes of spread of SCC is crucial in assigning the cor-
orthogonal to the true vocal cords. Recognition of the rect stage.
true vocal cords is facilitated by the identification of the The larynx is anatomically divided into three parts:
arythenoid cartilages. the supraglottis, glottis and subglottis (Figure 1).
Images are viewed using both soft-tissue (window The glottis and supraglottis are the most common
width, 250–350 HU; window centre, 50 HU) and sites of origin of SCC, and account for approximately
bone window-settings (window width, 2000 HU; 60% and 35% of cases, respectively. The remaining
window centre, 600 HU), the latter helps to evaluate origins are in the subglottis or involve more than one
cartilage invasion. Slice thickness is 2 mm with an over- area.1 In the latter case, the tumour is classified as
lapping reconstruction interval of 1 mm. transglottic.
Multiplanar-reformatted (MPR) images in coronal The supraglottis is the upper part of the larynx,
and sagittal planes allow a more confident evaluation and extends from the tip of the epiglottis to the
of the anatomic relationship between the tumour and laryngeal ventricles. Above the tip of the epiglottis
the surrounding structures. is the oropharinx. The supraglottis includes the epi-
glottis, aryepiglottic folds, false vocal cords, and lar-
MRI. Magnetic resonance (MR) images are acquired yngeal ventricles. The glottis is located between the
using an anterior surface head and neck coil. Scan supraglottis and subglottis. It is bordered superiorly
extent and patient position are similar to CT. The by the upper margin of the true vocal cords, and
basic MRI protocol consists of axial and sagittal unen- inferiorly by a plane 1 cm below the ventricles.
hanced T1 turbo spin echo (TSE) weighted sequences, The supraglottis contains the true vocal cord, and
axial fat-suppressed T2-weighted TSE sequence, axial anterior and posterior commissures. The arytenoids
diffusion-weighted sequence, and axial and coronal fat- cartilages are an useful anatomic landmark to differ-
suppressed T1-weighted TSE sequences obtained before entiate the glottis from the supraglottis. Indeed, the
and after gadolinium injection. Slice thickness is 2– superior board lies at the level of the false vocal
4 mm, with no interslice gap. Similarly to CT, axial cords, while the vocal process lies at the level of
images must be parallel to the true vocal cords. To the true vocal cords.
obtain the correct orientation, MR examination The subglottis is the lower part of the larynx, and is
should start with the acquisition of an unenhanced separated by the trachea from the lower margin of the
sagittal T1-weighted sequence, which helps identify cricoid cartilage, which is easy to identify because it is
the larynx and the plane of the true vocal cords. Since the only laryngeal cartilage that forms a complete ring.
fat shows bright signal intensity, unenhanced T1-
weighted images also help delineate tumoral invasion
Diagnosis of SCC
of fat planes.
T2-weighted sequences are used to detect intratu- The normal larynx wall is usually thin and
moral cystic areas and evaluate deeper tumour spread. symmetric. Any asymmetric thickening of the
DWI sequences are useful in detecting and charac- laryngeal wall should raise the suspicion of SCC
terising laryngeal mass, and in differentiating malignant (Figure 2 and 3).
from benign cervical lymph nodes.11 Moreover, DWI At CT, SCCs usually show slight to moderate
seems to be promising in differentiating benign post- enhancement, which helps delineate tumour margins
treatment changes and residual or recurrent and evaluate deep tumour extension.9
tumour.12,13 At MR, SCCs show a characteristic T2-hyperinten-
Intravenous contrast material administration is sity and T1-hypointensity. The former helps differenti-
strongly recommended because it increases tumour ate the tumour from hypointense muscle, while the
conspicuity, helps differentiate necrotic and cystic latter helps differentiate the tumour from hyperintense
areas from viable tumour, and improves the evaluation fat.14 Hyperintensity on high-b-value diffusion-
of soft tissue and perineural invasion.14 Fat saturation weighted images, and hypointensity on the apparent
is essential in differentiating enhancing tumour from diffusion coefficient (ADC) map help detect the
surrounding fat. tumour, and confirm its solid nature.16
Agnello et al. 3
Figure 1. Anatomy of the larynx. AEF: aryepiglottic fold; CC: cricoid cartilage; E: epiglottis; HB: hyoid bone; LV: laryngeal ventricle; TVC:
true vocal cords; TC: thyroid cartilage; V: vallecula.
Figure 2. Axial contrast-enhanced computerised tomography (CT) image obtained in a 56-year-old man with glottic squamous cell
carcinoma (SCC) shows asymmetric thickening of the left true vocal cordal (arrowhead).
Local tumour spread. In addition to diagnosing an SCC, show variable signal intensity on T1- and T2-weighted
the radiologist should define its relationship to sub- images, depending on the degree of cartilage minerali-
mucosal spaces, laryngeal cartilages and extra-laryngeal sation, and no enhancement.18,19 Invaded cartilage
soft-tissues, because their involvement can preclude show intermediate T2-signal intensity and variable
conservative surgery and radiation therapy. enhancement.18,19
The submucosal pre-epiglottic and paraglottic A similar cartilage MRI appearance, however, can
spaces are critical structures for the spread of SCC. be due to peri-tumoral inflammation and reduces MRI
Invasion of these spaces upstages SCC to T3 stage, specificity.18,19 Comparison with signal intensity of the
thus influencing treatment choice. primary tumour helps in the differential diagnosis:
The pre-epiglottic space is a triangular, fat-filled area invaded cartilage shows T2-signal intensity and
located between the epiglottis (posteriorly) and the enhancement similar to that of the primary tumour,
hyoid bone (anteriorly). The paraglottic spaces are while inflamed cartilage shows T2-signal intensity and
located lateral to the true and false vocal cords, and enhancement higher than that of the primary tumour.19
contain fat and muscle. Of note, pre-epiglottic and
paraglottic spaces cannot be visualised at laryngoscopy. Lymphatic spread. Cervical lymph node metastasis is the
The primary sign of submucosal invasion at CT and main mechanism of the spread of SCC. Cervical nodes
MRI is an enhancing tumour within the submucosal are located according to the classification of the
spaces (Figure 4). Demonstration of replacement of American Head and Neck Society and the American
T1-hypentense fat from hypo-intense tumour usually Academy of Otolaryngology-Head and Neck
corroborates the diagnosis. Surgery.20 This classification divides cervical nodes
The presence of cartilage invasion indicates a T4 into six levels on the basis of the primary lymphatic
stage.17 The imaging appearance of the laryngeal carti- drainage of each cervical tumour. Knowledge of
lages depends on the degree of mineralisation. At CT, nodal drainage patterns helps radiologists to correctly
cortical ossified cartilage shows bone attenuation, while characterise enlarged nodes, and to accurately evaluate
medullary fat and non-ossified cartilage show low the most likely sites of metastasis.21 Indeed, the supra-
attenuation. Tumour invasion can be suspected only in glottis drains primarily into the upper jugular lymph
the presence of tumour proximity to the cartilage and nodes, while the glottis and subglottis have a sparse
asymmetric sclerosis of the cartilage surface18 (Figure 5). lymphatic drainage.21 These differences are due to the
MRI shows higher sensitivity than CT in the detec- different embryologic origins of the supraglottis with
tion of cartilage tumour invasion.18 Normal cartilages respect to those of the glottis and subglottis.21
Agnello et al. 5
Figure 3. Coronal contrast-enhanced computerised tomography (CT) image obtained in a 65-year-old man shows a trans-glottic squa-
mous cell carcinoma (SCC) (arrow) involving the true and false right vocal cord.
CT and MRI show higher accuracy than clinical pathologic cervical nodes have been reported in the
examination in the detection of cervical lymph node literature, and range between 5–30 mm.21 For instance,
metastasis. the Response Evaluation Criteria in Solid Tumors
The presence, number, site, and size of lymph node (RECIST) version 1.1 criteria use the node short-axis
metastasis reflect tumour aggressiveness, and influence diameter on axial CT and MR images. Nodes with
treatment choices. short-axis diameter of <10 mm are considered benign,
Traditional criteria to differentiate normal and while those with a short-axis diameter of >15 mm are
pathologic nodes include size, shape, margins and considered malignant.22 An optimal size cut-off, how-
enhancement. Diffusion-weighted imaging is a promis- ever, does not exist. Indeed, reactive lymph nodes can
ing technique to detect metastatic cervical node. be enlarged due to hyperplasia and inflammation, and
An enlarged cervical node should always raise the small lymph nodes can be pathologic due to micro-
suspicion of metastasis (Figure 6). As a general rule, scopic metastatic deposits.23 At our hospital, a cut-off
the smaller the size, the higher the likelihood of benig- short-axis diameter of 10 mm is used as suggested by
nity. Several size cut-offs to differentiate normal from Van den Brekel et al.23
6 The Neuroradiology Journal 0(00)
Figure 4. Axial contrast-enhanced computerised tomography (CT) image obtained in a 55-year-old man with supra-glottic squamous cell
carcinoma (SCC) shows tumour invasion of the pre-epiglottic space (arrow).
Figure 5. Axial contrast-enhanced computerised tomography (CT) images ((a) soft-tissue window, (b) bone window) obtained in a 76-
year-old man with squamous cell carcinoma (SCC) of the right true vocal cord shows asymmetric sclerosis of the vocal process of the
arytenoid cartilage (arrow) due to invasion of the tumour (arrowhead).
Agnello et al. 7
Figure 6. Axial magnetic resonance images obtained in a 66-year-old man with subglottic squamous cell carcinoma (SCC) and enlarged
lymph node metastases in the level IIa and b on the right side. (a) On T2-weighted turbo spin echo (TSE) image, lymph node metastases
(arrows) show heterogeneous hyperintesity. (b) On b800 diffusion-weighted image lymph node metastases show strong hyperintesity. (c)
On contrast-enhanced T1-gradient echo (GRE) image lymph node metastases show heterogeneous enhancement.
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