catholic university of louvain, st-luc university hospital ... · coronal se t1-weighted sequence...

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June 2002

Catholic University of Louvain, St-Luc University HospitalHead and Neck Oncology Program

Imaging of the head and neck neoplasms

Guidelines: last update 01 June 2002

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June 2002


Imaging H&N neoplasms: sectionsForeword: specific definition of the evidence levels applied to the imaging work-up

• T staging. The primitive tumors of:• the nasopharynx• the oral cavity - oropharynx• the hypopharynx-larynx• the sinonasal cavities• the salivary glands

• N staging. The metastatic lymph nodes• M staging. The distant metastases• The unknown primary tumor• The second primitive tumor• The loco-regional tumor recurrence

Appendix: references

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June 2002


Foreword:Levels of evidence as described in the introduction of the present work are not

suited for the evaluation of imaging modalities (see Valk PE*)since randomized controlled trials are not appropriate in thepurpose. Most studies consist in direct comparisons ofmodalities with the patient being its own control.

To establish the present guidelines, we used a “litterature-based consensus” and defined three levels of application :“standard” for techniques to be routinely used in all patients“individual” for techniques useful in a selected subset of patients

presenting with a peculiar clinical problem to be solved“investigational” for techniques of which benefit still remains

unsupported by sufficient scientific evidence but needing aclinical trial to be evaluated

*Valk PE. Clinical trials of cost effectiveness in technology evaluation. Q. J. Nucl. Med. 2000;44:197-203.

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June 2002


T Staging: 1. The nasopharynx

Spiral CT scanCT has lower performance than MRI in imaging soft tissue but remains a

valuable alternative technique (contra-indications to MRI/uncooperative patients)

CT best depicts the status of bone structures

Technique:Profile scout view

100 cc contrast medium

Biphasic injection (50 cc, 1 cc/sec-delay 150 s; 60 cc, 1.5 cc/s)

120 kV-300 mAs

Acquisition starting 35 s after the 2nd inj. 4 x 2.5 mm - Matrix: 512x512

Post processing and options:Soft tissue display + bone window setting

MPR if necessary

4 X 1 mm unenhanced CT to assess the skull base

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June 2002


MRI StandardMRI has two major advantages on CT: better soft tissue depiction and better accuracy in assessing endocranial involvement. It therefore appears as the best suited imaging modality.

Standardized examination protocol1. Sagittal FSE T2-weighted sequence (scout view)2. Coronal SE T1-weighted sequence / 15 slices 4 mm with a large FOV (30 cms) focussed on both the primitive and the nodal areas

If lesion located posteriorly on 1.3. Sagittal T1-weighted 15 slices 3mm0.34. Transverse T1-weighted 15 slices 4mm0.4 (both focussed on the primitive lesion)

If lesion located cranially on 1.3. Sagittal SE-T1-weighted 15 slices 3mm0.34. Coronal SE T1-weighted sequence 15 slices 4mm0.4 (both focussed on the primitive lesion) Paramagnetic contrast agent perfusion� Transverse or coronal FSE T2-weighted sequence with FS option 15 slices 4mm0.4 (transverse if posterior lesion; coronal if cranial lesion) 6. Similar as 3, but with FS option7. Similar as 4, but with FS option

Optional additional sequences 8. standard Transverse SE T1-weighted sequence covering the whole brain with 24 slices 5mm/0.5 if cerebral meningeal involvement is suspected

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June 2002


Ultrasound: Ø

Bone scanning : individual(locally advanced tumor with suspicion of involvementof the skull base)

FDG-PET scan : investigational

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June 2002


T Staging: 2. The oral cavity - oropharynxSpiral CTCT has lower performance than MRI in soft tissue depiction but

may be a valuable alternative technique (dental artifacts!!)

CT best performs in depicting bone structures but could be less

sensitive than MR in the purpose.

Technique:100 cc contrast medium

Biphasic injection (50 cc, 1 cc/s-delay 150 s; 60 cc, 1.5 cc/s)

120 kV-225 mAs

4 x 2.5 mm after a delay of 35 s - Matrix: 512 x 512

Post-processing and options:Soft tissue display + bone window setting

MPR if necessary

4 X 1 mm unenhanced CT images to assess the involvement of the

mandible by the tumoral process

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June 2002


Bone scanning : individual (locally advancedtumors, when mandibular invasion is suspected)FDG-PET scan : investigational

MRI standard primary imaging modality adressing both local tumor and nodal metastases Standardized examination protocol� Sagittal FSE T2-weighted sequence (scout-view)2. Coronal SE T1-weighted sequence with large FOV(covering primary and nodes)� Transverse SE T1-weighted sequence/ 20 slices 4.5mm/1� Coronal SE-T1-weighted sequence/ 20 slices 4.5mm/1 Paramagnetic contrast agent perfusion5. Transverse FSE T2-weighted sequence with FS option/ 20 slices 4.5 mm/16. Transverse SE T1-weighted sequence with FS option/ 20 slices 4.5mm/1

Optional additional sequence7. Thin FSE T2-weighted coronal slices on the pelvic-buccal floor if involvement of the muscles is insufficiently depicted by 4 and others.

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June 2002


Standardized examination protocol� Sagittal FSE T2-weighted sequence (scout-view)2. Coronal SE T1-weighted sequence with large FOV(covering primary and nodes)� Transverse SE T1-weighted sequence/ 20 slices 4.5mm/1� Coronal SE-T1-weighted sequence/ 20 slices 4.5mm/1 Paramagnetic contrast agent perfusion5. Coronal FSE T2-weighted sequence with FS option/ 20 slices 4.5 mm/1� Coronal SE T1-weighted sequence with FS option/ 20 slices 4.5mm/1 � Transverse SE T1-weighted sequence with FS option/ 20 slices 4.5mm/1

� Addendum: MRI protocol dedicated to pelvic-buccal tumors

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June 2002


T Staging: 4. The hypopharynx-larynx

Spiral CT StandardCT appears as the best imaging modality to assess the hypo-pharynx andlarynx in routine.MR seems promising in focussed purposes such as the tumoral involvement ofthe cartilages and of the anterior commissure, but needs further validation.Technique:Profil scout view including skull base and shouldersQuiet breathingIodinated contrast medium with bi-phasic injection (50 cc, 1 cc/s-delay 150 s;60 cc, 1.5 cc/s)4 x 2.5 mm, 35 sec after 2nd injection, from skull base down to the clavicles,Pitch: 1.25 / Matrix: 512 x 512Post-processing and options:4x1mm on laryngeal cartilages if suspicion of cartilage invasion.Valsalva manoeuver if asymmetry of the pyriform sinusesPhonation to assess the mobility of vocal cordsMPR reconstructions on sagittal plane to show the pre-epiglottic space,epiglottis, …

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June 2002


MRIStandardized protocol for the hypopharynx Individual • Sagittal FSE T2-weighted sequence (scout-view)• Coronal SE-T1-weighted sequence with large FOV including the

primitive and the nodal areas• Transverse SE T1-weighted sequence/ 20 slices 4.5 mm/14. Coronal SE T1-weighted sequence focussed on the primitive 4.5mm/1

Paramagnetic contrast agent perfusion5. Transverse FSE T2-weighted sequence with FS option 4.5 mm/16. Transverse SE T1-weighted sequence with FS option 4.5 mm/1

Experimental MR protocol for the larynx investigational1. Sagittal FSE T2-weighted sequence 21 slices 5mm/0.5 (scout view)2. Transverse SE T1-weighted sequence 15 slices3 mm/0.33. Transverse FSE T2-weighted sequence 15 slices 3 mm/0.34. Coronal FSE T2-weighted sequence 15 slices 3 mm/0.3Additional optional sequence Paramagnetic contrast agent perfusion5.Transverse SE T1-weighted sequence with FS option 15 slices 3 mm/0.3 (similar slice location as 2.)

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Ultrasound: Ø

Bone scanning: not performed (unless symptoms)

FDG-PET scan: investigational

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T Staging: 5. The sino-nasal cavities

Spiral CT- appropriate in the tumoral work-up with unsurpassed bone depiction- MRI must be preferred in cases of endocranial/orbital involvement

Technique:Patient in decubitus120 kV; 30 mAs (some authors advocate 10 mAs!)1.3 mm collimation0.6 mm interval of reconstructionPitch: 0.75FOV: 250 mm

Post-processing and optionsIV contrast medium injection if tumor is supected

MPR in sagittal and frontal planes

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June 2002


MRIBoth CT and MR are suited with similar accuracy.CT better depicts bone destructionMR better depicts meningeal/endo-orbital involvement

Standardized MR examination standard1.Sagittal FSE T2-weighted sequence 21 slices 5mm/0.5 (scout-view)2.Coronal SE T1-weighted sequence with large FOV for nodal areas work-up3.Coronal SE T1-weighted sequence focussed on the primitive/ 20 slices 4mm/.4 Paramagnetic contrast agent perfusion 4. Coronal FSE T2-weighted sequence with FS option 20 slices 4 mm/0.45. Coronal SE T1-weighted sequence with FS option 20 slices 4 mm/0.46. Transverse SE T1-weighted sequence with FS options 20 slices 4 mm/0.4Optional additional sequences7. Transverse SE T1-weighted sequence covering the whole brain 24 slices 5

mm/0.5 for meningeal involvement depiction

Bone scanning: individualFDG-PET scan : not applicable

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June 2002


T Staging: 6. The salivary glands

Spiral CTCT is the first-line imaging modality in the inflammatory painful

gland in which a neoplastic process seems poorly probable.

Technique:Profil scout view including skull base and shoulders

Unenhanced and enhanced CT images, biphasic injection (50 cc, 1

cc/s-delay 150 s; 60 cc, 1.5 cc/s)

4 x 2.5 mm from skull base down to the clavicles, pitch: 1.25

120 kV, 150 mAs

Quiet breathing

Post-processing and options:Soft tissue and bone window setting if bone contact or intra-tumoral

calcifications

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June 2002


MRI standardfirst line imaging modality of the indolent gland potentiallyharboring a neoplastic processStandardized examination protocol1. Sagittal FSE T2-weighted sequence 21 slices 5 mm/0.5 (scout)2. Transverse SE T1-weighted sequence 24 slices 4 mm/0.43. Coronal SE T1-weighted sequence 24 slices 4 mm/0.4 including salivary glands and nodal areas Paramagnetic contrast agent perfusion4. Transverse FSE T2-weighted sequence 24 slices 4 mm/0.45. Transverse SE T1-weighted sequence with FS option 24 slices 4 mm/0.46. Coronal SE T1-weighted sequence with FS option 24 slices 4 mm/0.4Additional optional sequences7. MR sialography using 3D T2 FSE sequence with very long echo time(lower interest than in the benign gland)

UltrasoundBone scanning : not applicable (unless symptoms)

FDG-PET scan : investigational

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June 2002


N Staging: the lymph nodes metastases

CT scan and MRI

* CT and MRI have similar accuracy in depicting metastatic nodes* both suffer significant - unsensitivity to micro-metastases - unspecificity in discriminating benign from malignant adenomegalies* lymph node size remains the main criterion for maligancy using MSAD

measurements* central necrosis is the second significant criterion, others being ancillary

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June 2002


Spiral CTThe use of IV contrast medium injection is mandatory to differentiate lymphnodes from adjacent soft tissue structures and for better characterization

Technique:Profil scout view including skull base and shoulders

Quiet breathing

Iodinated contrast medium with bi-phasic injection (50 cc, 1 cc/s-delay 150 s;60 cc, 1.5 cc/s)

4 x 2.5 mm, 35 s after 2nd injection, from skull base down to the clavicles,Pitch: 1.25 Matrix: 512 x 512

Post-processing and options:-Classification of lymph nodes in levels (1-6) using the internationalclassification

-Co-registration with PET

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June 2002


N Staging: the lymph nodes metastases

MRI

MRI is never performed as solely node-targeted examination. Nodal areas arefrequently included into the FOV of the images depicting the primary tumor,therefore yielding extra-information on the nodes.An additional large FOV T1-weighted sequence in the coronal plane before IVcontrast agent perfusion is often performed to cover the major nodal areas at theinitial phase of the procedure.

PET scan: investigational

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June 2002


Ultrasound and FNAUltrasound is an easy and inexpensive imaging modality to assess lymph nodes.

It can be used to guide a Fine Needle Aspiration (FNA) procedure.

FNA is operator-dependant and should be performed by the same trained radiologist

Colour Doppler Ultrasound improves the diagnostic performance by highlighting

specific vascular patterns of the neoplastic nodes.

Technique:High frequency probe.

Short axis registration with internal structure

(hypoechoic nodes are more suspicious)

Recommandations:If FNA is planned, do stop aspirin 3 days before the procedure

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June 2002


M Staging The distant metastases: lungs

The lungs appear to be the first site of extra cervical dissemination

Patients at risk to develop lung metastases are e.g., patients with three or moremetastatic lymph nodes, and/or with residual tumor above the clavicles, and/orwith recurrent tumor

TechniqueSpiral CT is by far the best imaging modality, surpassing the chest plain film

Scout view including the entire chest

No contrast medium injection

Deep inspiration and thereafter holding breath

5 mm slice thickness, pitch: 1.5

Mediastinal and lung window setting

Post-processing and optionsLow dose CT (15 mAs) in cases of young patients

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June 2002


M Staging: the distant metastases: the liver

There is no perfect imaging modality to detect liver metastases. Thefirst line modality should be selected regarding the local expertise, theavailability of the different techniques, and the patient’s status. Therisk for liver metastases seems strongly correlated to the presence oflung metastases.

If lung CT (+) for metastases � liver imaging

If lung CT (-) for metastases � stop

TechniquesUltrasound: best contributive when performed in thin cooperative patients byan experienced radiologist

Spiral CT: standardized using 4 x 2.5 mm, post-contrast slices, from theupper aspect of the liver down to the iliac crestsMR: restricted as additional technique because of high costs

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M Staging: the distant mestastases

PET-scan : Investigational. Published data supportthe use of PET-FDG as a staging procedure for Nand M evaluation but the impact of the technique onthe patient’s management and outcome is not fullydetermined. Further studies are subsequently neededbefore definite validation.

A major advantage of the technique is that it coverscomprehensively the whole boby in a one sessionprocedure.

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June 2002


The second primary

CT Scan Investigational in pulmonary lesionsLung cancer:

Low dose CT (15 mAs) of the lungs to detect the second primary is being evaluated.

Abdominal lesions:

In colonic and esophageal tumors, routine abdominal CT is not advocated.

CT may be helpful in characterizing abnormalities detected by other modalities (PET)

PET-scan : investigational. See Metastatic staging.

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June 2002


PET-scan: standard

The recommended initial routine work-up includes:

1. chest X-ray

2. panendoscopy

3. ultrasound.

If uncontributive : perform a FDG-PET scan.

If PET is positive, than perform additional imaginginvestigations (CT, MR, endoscopy) focussed onthe abnormal PET findings.

The unknown primary

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The second primitive

PET-scan: investigational. See Metastatic staging.

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June 2002


The locoregional tumor recurrence

PET-scan standard

Therefore considered as the first-line imaging procedure in the patientsuspected of tumoral recurrence, mainly if the primary site is notaccessible to the clinical examination (i.e. all sites except the oralcavity).

Best performed before panendoscopy so that PET information canguide biopsies.

Co-registration of CT-MR and PET information is beneficial bysuperimposing anatomical and metabolic information.

CT scan and MRI:

have yielded disappointing results in the purpose of detecting local recurrence and failed to reach an acceptable level in accuracy in spite of technical/semiological refinments

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June 2002


FDG-PET scan Limitations :State-of-the-art PET scanners have a maximal spatial resolution of 5-mm, whichmeans that micrometastatic lymph nodes/primitives may be overlooked by PET.High uptake of FDG can be seen in benign inflammatory lymph nodes.Usual recommendations for diabetic patients are: optimized glycemic control at thethe time of PET, early in the morning procedure scheduling, and adequate informationof the NM physician. Technique :patient must be fasting for at least 6 hours (12 hours is better). Premedication withdiazepam 10 mg orally is systematic 30 minutes before the injection of FDG.Injected dose is 10 mCi/70 kg. Imaging cannot be started less than 60 minutes aftertracer injection. Acquisition centered on the ENT region is performed using the 3-Dmode (increased sensitivity) and longer scanning time tin order to increase the imagequality. This MUST be followed by a whole-body acquisition to detect distantmetastases or synchronous tumors. Reconstruction of the data is performed using theiterative algorithm. The interpretation is based on the intensity and the symmetry ofthe uptake. PET should be performed BEFORE any surgical or (deep) samplingprocedure to avoid local reactive changes and thus local artificial increase in FDGuptake.

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June 2002


T staging – Oral cavity/Oropharynx� Sigal et al. CT and MRI of the SCC of the tongue and floor of the mouth.Radiographics 1996;16:787-810� Leslie et al. Staging of the SCC of the OC and oroP: a comparison of MRI and CT in T- and N-staging. JCAT 1999;23:43-9� Yousem et al. OC and pharynx. Radiol clin North Am 1998;36:967-81� Mukherji et al. SCC of the OroP and OC: how imaging makes the difference.Semin Ultrasound CT MR 1998;19:463-75�� Chan Chan KK, , Merrick Merrick MM, , Mitchell Mitchell RR.. Bone SPECT to assess Bone SPECT to assess mandibularmandibular invasion by invasion by intraoral squamousintraoral squamous-cell-cell carcinomas. carcinomas. J J--NuclNucl-Med. 1996-Med. 1996;;37:42-537:42-5..

T staging – nasopharynx

� Ng et al. NPC: MRI and CT assessment. Neuroradiology 1997;39:741-6� Chong et al. C. of the NP. Semin Ultrasound CT MR 1998;19:449-62� Ng et al. MRI in recurrent NPC. Neuroradiology 1999;41:855-62� Chong et al. NPC: review of how imaging affects staging. JCAT 1999;23:984-93

Appendix: references

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June 2002


T staging – Hypopharynx-larynx (a)

�� Baum U, Baum U, GreessGreess H, H, LellLell M, M, NomayrNomayr A, Lenz M . A, Lenz M . ImagingImaging of head andof head and neck neck tumorstumors----methodsmethods: CT,: CT,

spiral-CT, spiral-CT, multislicemultislice-spiral-CT. -spiral-CT. EurEur J J RadiolRadiol 2000 Mar; 33(3):153-60 2000 Mar; 33(3):153-60

�� KorkmazKorkmaz H, H, CerezciCerezci NG, NG, AkmansuAkmansu H, H, DursunDursun E . A E . A comparisoncomparison ofof spiral spiral and conventionaland conventionalcomputerized tomography methodscomputerized tomography methods in in diagnosing various laryngeal lesionsdiagnosing various laryngeal lesions. . Eur Arch OtorhinolaryngolEur Arch Otorhinolaryngol1998;255(3):149-541998;255(3):149-54

�� H H Ric HansbergerRic Hansberger. . HandbookHandbook of head andof head and neck neck imagingimaging. . MosbyMosby 1995. St Louis 1995. St Louis

�� HermansHermans, , OpOp de de BeeckBeeck K, K, DelaereDelaere PR, Marchal G. PR, Marchal G. Computed tomography and magnetic resonanceComputed tomography and magnetic resonanceimagingimaging of laryngeal tumorsof laryngeal tumors. Acta . Acta OtorhinolaryngolOtorhinolaryngol Bel 1999 ; 53:79-86 Bel 1999 ; 53:79-86

�� ZbarenZbaren P, Becker M, Lang H P, Becker M, Lang H. . Pretherapeutic stagingPretherapeutic staging of laryngeal carcinomaof laryngeal carcinoma. . Clinical findingsClinical findings,,computed tomographycomputed tomography, , and magnetic resonance imaging compared with histopathologyand magnetic resonance imaging compared with histopathology. Cancer 1996. Cancer 1996AprApr 1;77(7):1263-73 1;77(7):1263-73

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T staging – Hypopharynx-larynx (b)

�� Becker M, Becker M, ZbarenZbaren P, P, LaengLaeng H, H, StoupisStoupis C, C, PorcelliniPorcellini B, B, VockVock P P NeoplasticNeoplastic invasion invasion of the laryngealof the laryngeal

cartilage: cartilage: comparisoncomparison ofof MR MR imaging andimaging and CT CT with histopathologic correlationwith histopathologic correlation. . RadiologyRadiology 1995 1995

Mar;194(3):661-9. `Mar;194(3):661-9. `

�� ZbarenZbaren P, Becker M, Lang H . P, Becker M, Lang H . Pretherapeutic stagingPretherapeutic staging of hypopharyngeal carcinomaof hypopharyngeal carcinoma. . Clinical findingsClinical findings,,

computed tomographycomputed tomography, , and magnetic resonance imaging compared with histopathologic evaluationand magnetic resonance imaging compared with histopathologic evaluation..

Arch OtolaryngolArch Otolaryngol Head Neck Head Neck SurgSurg 1997 Sep;123(9):908-13 1997 Sep;123(9):908-13

�� Becker M. Becker M. NeoplasticNeoplastic invasion invasion of laryngealof laryngeal cartilage: cartilage: radiologic diagnosis and therapeuticradiologic diagnosis and therapeutic

implications. implications. EurEur J J RadiolRadiol 2000; 33:216-29 2000; 33:216-29

�� Becker M, Becker M, ZbärenZbären, , DelavelleDelavelle J, et J, et al al . . NeoplasticNeoplastic invasion invasion of the laryngeal of the laryngeal cartilage: cartilage: rreassessmenteassessment ofof

criteriacriteria for for diagnosis atdiagnosis at CT. CT. RadiologyRadiology 1997;203:521-532 1997;203:521-532

�� LoevnerLoevner LA, LA, YousemYousem DM, DM, MontoneMontone KT, Weber R, KT, Weber R, ChalianChalian AA, AA, WeinsteinWeinstein GS Can GS Can radiologistsradiologists

accurately predict preepiglottic spaceaccurately predict preepiglottic space invasion invasion withwith MR MR imagingimaging? ? AmAm J J R Roentgenoloentgenol 1997 1997

DecDec;169(6):1681-7;169(6):1681-7

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�� Braams J et al. Braams J et al. (1995) Detection of lymph node metastases of (1995) Detection of lymph node metastases of squamoussquamous-cell cancer of-cell cancer ofthe head and neck with FDG-PET and MRI J. the head and neck with FDG-PET and MRI J. NuclNucl. Med. 36:211-216. Med. 36:211-216

�� LaubenbacherLaubenbacher C et al. (1995) Comparison of fluorine-18- C et al. (1995) Comparison of fluorine-18-fluorodeoxyglucosefluorodeoxyglucose PET, MRI PET, MRIand and endoscopyendoscopy for staging head and neck for staging head and neck squamoussquamous-cell carcinomas. J. -cell carcinomas. J. NuclNucl. Med. Med36:1747-175736:1747-1757

�� Stokkel M et al. Stokkel M et al. (2000) Preoperative evaluation of patients with primary head and neck(2000) Preoperative evaluation of patients with primary head and neckcancer using dual-head 18fluorodeoxyglucose positron emission cancer using dual-head 18fluorodeoxyglucose positron emission tomographytomography. Ann . Ann SurgSurg231:229-234231:229-234

�� Adams S et al. (1998) Prospective comparison of 18F-FDG PET with conventionalAdams S et al. (1998) Prospective comparison of 18F-FDG PET with conventionalimaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer. imaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer. EurEur..J. J. NuclNucl. Med. 25:1255-1260. Med. 25:1255-1260

�� MyersMyers L et al. L et al. (1998) Positron emission(1998) Positron emission tomography tomography in the evaluation of the N0 neck. in the evaluation of the N0 neck.Laryngoscope 108:232-236Laryngoscope 108:232-236

�� BenchaouBenchaou et al. (1996) The role of FDG-PET in the preoperative assessment of N- et al. (1996) The role of FDG-PET in the preoperative assessment of N-staging in head and neck cancer.staging in head and neck cancer. Acta Otolaryngol Acta Otolaryngol. 116:332-335. 116:332-335

�� DiMartinoDiMartino E et al. (2000) Diagnosis and E et al. (2000) Diagnosis and staging staging of of head head and neck and neck caner caner. Arch.. Arch.OtolaryngolOtolaryngol.. Head Head Neck Neck Surg Surg. 126:1457-1461. 126:1457-1461

�� PaulusPaulus P et al. (1998) 18FDG-PET for the assessment of primary head and neck tumors: P et al. (1998) 18FDG-PET for the assessment of primary head and neck tumors:clinical, computedclinical, computed tomography tomography and and histopathological histopathological correlation in 38 patients. correlation in 38 patients.Laryngoscope 108:1578-1583Laryngoscope 108:1578-1583

N Staging

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�� De Bree R, De Bree R, DeurloDeurlo EE, EE, SnowSnow GB, GB, LeemansLeemans CR CR ScreeningScreening for distant for distant metastasesmetastases in patients in patients with headwith head

andand neck cancer. neck cancer. TheThe Laryngoscope 2000 110: 397-401 Laryngoscope 2000 110: 397-401

�� TroellTroell RJ, Terris DJ RJ, Terris DJ DetectionDetection ofof metastases from head andmetastases from head and neck cancers. neck cancers. TheThe Laryngoscope 105; Laryngoscope 105;

247-250247-250

�� Shah SI, Shah SI, ApplebaumApplebaum EL . EL . LungLung cancer cancer after head andafter head and neck cancer: neck cancer: rolerole of chest radiographyof chest radiography..

Laryngoscope 2000 Laryngoscope 2000 DecDec;110(12):2033-6;110(12):2033-6

�� Ong TK, Ong TK, KerawalaKerawala CJ, Martin IC, Stafford FW. CJ, Martin IC, Stafford FW. The roleThe role ofof thorax thorax imagingimaging in in staging head andstaging head and neck necksquamous cell carcinomasquamous cell carcinoma. J . J Craniomaxillofac SurgCraniomaxillofac Surg 1999; 27 (6) 339-44) 1999; 27 (6) 339-44)

�� KanekoKaneko M, M, EguchiEguchi K, K, OhmatsuOhmatsu H, et H, et alal Peripheral lung Peripheral lung cancer:cancer: screening and detection with low screening and detection with low--dose spiral CT versusdose spiral CT versus radiography radiography. . RadiologyRadiology 1996;201:798-802 1996;201:798-802

�� WedmanWedman J, J, Balm Balm AJ, Hart A A, et al Value of AJ, Hart A A, et al Value of resection resection of of pulmonary metastases pulmonary metastases in in head andhead and neck neckcancer patients. Headcancer patients. Head and and neck 1996;18:311-316 neck 1996;18:311-316

M Staging

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� Aasar et al, Radiology 1999;210:177-181

� Muhherji et al, Radiology 1996;199:761-766

� Greven et al, Cancer 1999;86:114-118.

� Lassen et al, EUR J Cancer 1999;35:1076-1082

� Braams et al, J Oral Maxill Surg 1997;26:112-15

� Stokkel et al, Oral Oncology 1999;35:390-394

� Hawasono et al, Laryngoscope 1999;109:880-885

� Bohuslavizki et al, JNM 200;41:816-822

� Jungehulsing et al, Otolaryng H Neck Surg 2000;123:294-301

The unknown primary

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� Stokkel et al, Cancer 1999;86:2370-2377

� Keyes et al, AJR 1997;169:1663-1669

The second primary

The recurrence

� Lowe et al, J Clin Oncol 2000;18:651-658

� Anzai et al, Radiology 1996;200:135-141

� McGuirt et al, Ann Otol Laryngol 1998;107:293-296

� Lapela et al, Eur J Cancer 2000;36:858-867� Farber et al, Laryngoscope 1999;109:970-975� Lonneux et al, Laryngoscope 2000;110:1493-1497.� Kresnik E, Mikosh P, Gallowitsch H et al. Evaluation of head and neck cancer with 18-F-FDG PET: a comparison with conventional methods.Eur.J.Nucl.Med. 2001;28:816-821.

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