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Shaaban Rezvani Chapman

SECOND EDITION

AkramM.Shaaban,MBBCh

Professor

DepartmentofRadiologyandImagingSciences UniversityofUtah SaltLakeCity,Utah

MaryamRezvani,MD

AssociateProfessorofRadiology

DepartmentofRadiologyandImagingSciences UniversityofUtah SaltLakeCity,Utah

PhilipR.Chapman,MD

AssociateProfessor ChiefofNeuroradiologySection TheUniversityofAlabamaatBirmingham Birmingham,Alabama

Elsevier

1600JohnF.KennedyBlvd. Ste1800 Philadelphia,PA19103-2899

DIAGNOSTICIMAGING:ONCOLOGY,SECONDEDITION

ISBN:978-0-323-66112-6

Nopartofthispublicationmaybereproducedortransmittedinanyformorbyanymeans,electronicormechanical, includingphotocopying,recording,oranyinformationstorageandretrievalsystem,withoutpermissioninwritingfrom thepublisher.Detailsonhowtoseekpermission,furtherinformationaboutthePublisher’spermissionspoliciesandour arrangementswithorganizationssuchastheCopyrightClearanceCenterandtheCopyrightLicensingAgency,canbe foundatourwebsite:www.elsevier.com/permissions.

ThisbookandtheindividualcontributionscontainedinitareprotectedundercopyrightbythePublisher(otherthanas maybenotedherein).

Notices

Practitionersandresearchersmustalwaysrelyontheirownexperienceandknowledgein evaluatingandusinganyinformation,methods,compoundsorexperimentsdescribedherein. Becauseofrapidadvancesinthemedicalsciences,inparticular,independentverificationof diagnosesanddrugdosagesshouldbemade.Tothefullestextentofthelaw,noresponsibilityis assumedbyElsevier,authors,editorsorcontributorsforanyinjuryand/ordamagetopersonsor propertyasamatterofproductsliability,negligenceorotherwise,orfromanyuseoroperationof anymethods,products,instructions,orideascontainedinthematerialherein.

Previouseditioncopyrighted2011.

LibraryofCongressControlNumber:2019941286

PrintedinCanadabyFriesens,Altona,Manitoba,Canada

Contributing Authors

JuliaR.Crim,MD

ChiefofMusculoskeletalRadiology ProfessorofRadiology UniversityofMissouriatColumbia Columbia,Missouri

AhmedEbadaSalem,MD

ClinicalFellow

DepartmentofRadiologyandImagingSciences UniversityofUtah SaltLakeCity,Utah AssistantLecturer AlexandriaUniversitySchoolofMedicine Alexandria,Egypt

ChrisHanrahan,MD,PhD

AdjunctAssociateProfessor DepartmentofRheumatology DepartmentofRadiologyandImagingSciences UniversityofUtahSchoolofMedicine SaltLakeCity,Utah

LeifJensen,MD

AssociateProfessor

DepartmentofRadiologyandImagingSciences UniversityofUtah SaltLakeCity,Utah

MatthewB.Morgan,MD,MS

AssociateProfessorofRadiology DepartmentofRadiologyandImagingSciences UniversityofUtah SaltLakeCity,Utah

JeffreyOlpin,MD

ProfessorofRadiology

DepartmentofRadiologyandImagingSciences UniversityofUtah

SaltLakeCity,Utah

DouglasRogers,MD

AssistantProfessor

DepartmentofRadiologyandImagingSciences UniversityofUtah SaltLakeCity,Utah

SherryS.Wang,MBBS AssistantProfessor

DepartmentofRadiologyandImagingSciences UniversityofUtah SaltLakeCity,Utah

Additional Contributing Authors

WendieA.Berg,MD,PhD,FACR,FSBI

Preface

In2018,theAmericanJointCommissiononCancer(AJCC)publishedthe8theditionoftheAJCCCancer StagingManual Immediatelyafterpublication,wequicklygottoworkonthe2ndeditionofDiagnostic Imaging:Oncology,thesinglemostup-to-dateandcomprehensivetextbookonradiologictumorstaging.

The8theditionbringsamultitudeofchangesthatdirectlyaffectradiologicimageevaluationandtumor staging.Almosteveryorgansystemhasseenwidespreadmodifications,andmoststagingschemes basedonthe7theditionarenowoutdatedandincorrect.Thiseditionfeatures7entirelynewstaging systemsandawiderangeofchangedornewstagingdefinitions.Changesincludesplittingofsome chaptersandmergingofothers.A“SummaryofChanges”tablehasbeenaddedtochaptersdetailing whatchangedbetweenthe7thand8theditions.

Eachlavishlyillustratedchapteroffersmultiplewaystoquicklyreviewaparticularcancer.Bulletedtext distillspertinentinformationtotheessentials.Referencetablesprovidequickaccesstodefinitionsfor TNMandAJCCprognosticgroupswithdetailedgraphicsforavisualreference.Over105updatedand newillustrationsfornewstagingclassificationshavebeenadded.High-qualityimagesdemonstratethe radiologicappearanceofpracticallyeverystageofeverytumor.Over2,000updatedimageswereadded, andallofthesevividimagesarefullycaptionedandannotatedtomaximizetheirillustrativepotential. Whether you are looking for routes of spread, imaging techniques for local staging, or treatment options,youwillfinditquicklyinthiseasy-to-useyetcomprehensivereference.Itisa“must-have”forany radiologistinvolvedintumorimaging.

AkramM.Shaaban,MBBCh Professor DepartmentofRadiologyandImagingSciences

UniversityofUtah

SaltLakeCity,Utah

Acknowledgments

LEADEDITOR

NinaI.Bennett,BA

TEXTEDITORS

ArthurG.Gelsinger,MA

RebeccaL.Bluth,BA

TerryW.Ferrell,MS

MeggMorin,BA

IMAGEEDITORS

JeffreyJ.Marmorstone,BS

LisaA.M.Steadman,BS

MEDICALEDITORS

DouglasRogers,MD

AhmedEbadaSalem,MD

ILLUSTRATIONS

RichardCoombs,MS

LaneR.Bennion,MS

LauraC.Wissler,MA

ARTDIRECTIONANDDESIGN

TomM.Olson,BA

PRODUCTIONCOORDINATORS

EmilyC.Fassett,BA

JohnPecorelli,BS

Sections

SECTION1: Head&Neck

SECTION2: Thorax

SECTION3: Breast

SECTION4: GastrointestinalSites

SECTION5: GenitourinarySites

SECTION6: GynecologicSites

SECTION7: MusculoskeletalSites

SECTION8: SystemicMalignancies

Shaaban Rezvani Chapman

Head & Neck

LipandOralCavityCarcinoma

T|DefinitionofPrimaryTumor

TCategory TCriteria

TX Primarytumorcannotbeassessed

Tis

T4a

T4b

Carcinomainsitu

Tumor≤2cm,≤5mmDOI;DOIisnottumorthickness

Tumor≤2cm,DOI>5mmand≤10mm; ortumor>2cmbut≤4cm,andDOI≤10mm

Tumor>4cmortumor≥10mmDOI,but<20mm

Moderatelyadvancedorveryadvancedlocaldisease

Moderatelyadvancedlocaldisease;T4aisdefinedasmoderatelyadvancedlocaldisease,tumorinvading adjacentstructuresonly(e.g.,throughcorticalboneofmandibleormaxilla,orinvolvesmaxillarysinusorskinof face)orextensivetumorwithbilateraltongueinvolvement&/orDOIlargerthan20mm

Veryadvancedlocaldisease;tumorinvadesmasticatorspace,pterygoidplates,orskullbase&/orencasesICA DOI=depthofinvasion;ICA=internalcarotidartery.

N|DefinitionofRegionalLymphNode:Clinical(cN)andPathological(pN)

Regionallymphnodescannotbeassessed

Noregionallymphnodemetastasis

N2a

N2b

N2c

N3a

N3b

PathologicalN(pN)

Metastasisinsingleipsilateralnode≤3cmandENE(-)

Metastasisinsingleipsilateralnodelargerthan3cmbutnotlargerthan6cmingreatestdimensionandENE(-); ormetastasesinmultipleipsilaterallymphnodes,nonelargerthan6cmingreatestdimensionandENE(-); orinbilateralorcontralaterallymphnodes,nonelargerthan6cmingreatestdimensionandENE(-)

Metastasisinsingleipsilaterallymphnodelargerthan3cmbutnotlargerthan6cmingreatestdimension,and ENE(-)

Metastasisinmultipleipsilaterallymphnodes,nonelargerthan6cmingreatestdimension,andENE(-)

Metastasisinbilateralorcontralaterallymphnodes,nonelargerthan6cmingreatestdimension,andENE(-)

Metastasisinlymphnodelargerthan6cmingreatestdimensionandENE(-); ormetastasisinanynode(s)andclinicallyovertENE(+)

Metastasisinlymphnodelargerthan6cmingreatestdimensionandENE(-)

Metastasisinanynode(s)andclinicallyovertENE(+)

NX Regionallymphnodescannotbeassessed

N0 Noregionallymphnodemetastasis

N2a

N2b

N2c

N3a

N3b

Metastasisinsingleipsilaterallymphnode,3cmorsmalleringreatestdimensionENE(-)

Metastasisinsingleipsilaterallymphnode,3cmorsmalleringreatestdimensionandENE(+); or largerthan3cmbutnotlargerthan6cmingreatestdimensionandENE(-); or metastasesinmultipleipsilaterallymphnodes,nonelargerthan6cmingreatestdimensionandENE(-); orinbilateralorcontralaterallymphnodes,nonelargerthan6cmingreatestdimension,ENE(-)

Metastasisinsingleipsilateralorcontralaterallymphnode3cmorsmalleringreatestdimensionandENE(+); or singleipsilateralnodelargerthan3cmbutnotlargerthan6cmingreatestdimensionandENE(-)

Metastasisinmultipleipsilateralnodes,nonelargerthan6cmingreatestdimensionandENE(-)

Metastasisinbilateralorcontralaterallymphnodes,nonelargerthan6cmingreatestdimensionandENE(-)

Metastasisinlymphnodelargerthan6cmingreatestdimensionandENE(-); or insingleipsilateralnodelargerthan3cmingreatestdimensionandENE(+); or multipleipsilateral,contralateral,orbilateralnodesanywithENE(+)

Metastasisinlymphnodelargerthan6cmingreatestdimensionandENE(-)

Metastasisinsingleipsilateralnodelargerthan3cmingreatestdimensionandENE(+); or multipleipsilateral,contralateral,orbilateralnodesanywithENE(+)

Adesignationof U or L maybeusedforanyNcategorytoindicatemetastasisabovethelowerborderofthecricoid(U)orbelowthelowerborderofthe cricoid(L).Similarly,clinicalandpathologicalENEshouldberecordedasENE(-)andENE(+).

LipandOralCavityCarcinoma

M|DefinitionofDistantMetastasis

MCategory MCriteria

M0 Nodistantmetastasis

M1 Distantmetastasis

AJCC|PrognosticStageGroups

WhenTis… AndNis… AndM

G|HistologicGrade

GCategory

GDefinition

GX Cannotbeassessed

G1 Welldifferentiated

G2 Moderatelydifferentiated

G3 Poorlydifferentiated

AlltablesusedwiththepermissionoftheAmericanCollegeofSurgeons.Amin,M.B.,Edge,S.B.,Greene,F.L.,etal.(Eds.)AJCCCancerStaging Manual.8thEd.SpringerNewYork,2017.

SummaryofChanges

Change

Mucosalportionoflipnowseparatedfromcutaneous (external)lip

Extrinsictonguemusculatureinvolvementnolongerused forT4

Detailsofchange

Externalportionsoflipsnowconsideredcutaneousstructuresforpurposesof classificationandstaging

ClinicalandpathologicalDOInowusedtoincreaseTcategory

Extranodalextensionisaddedasqualifierforupstaging disease ENEdefinestumorthathasmetastasizedtolymphnodeandthenprogressedwithin nodetopointatwhichnodecapsuleisbreached,andtumorextendsintosurrounding tissue;ENEcarrieshigherlikelihoodoflocalregionalrecurrenceanddistantmetastasis andcarriesworseprognosis

DOI=depthofinvasion;ENE=extranodaltumorextension.

LipandOralCavityCarcinoma

GraphicillustratesT1diseaseoftheoraltongueandmucosallip asatumorﬅthatis≤2cmanddepthofinvasion(DOI)≤5mm.

GraphicillustratesT3diseaseoftheoraltongueandlipasa tumorﬅthatis>4cmingreatestdimensionoranytumorwith DOI>10but≤20mm.Imagingisgenerallymorehelpfulin patientswithlargerlesionsforevaluatingthicknessofthelesion andpossibleinvasionofunderlyingstructures.

GraphicillustratesclinicalT2diseaseoftheoraltongueandlip asatumorﬅ.T2isdefinedasatumor≤2cmwithDOI>5mm and≤10mmortumor>2cmbut≤4cm,withDOI≤10mm.

Sagittalgraphicillustratesadeeplyinvasivetumorﬅinvading themandibleﬆ.Frontaldrawingshowsthetumorinvadingthe skin﬇oftheface.Eitherfindingissufficienttoclassifya carcinomaofthelipasT4a.

T4a:Lip

LipandOralCavityCarcinoma

T4a:OralCavity

Axialgraphicillustratesmoderatelyadvancedlocaldiseaseﬅ withalargeoraltonguecancerinvadingadjacentstructures.The tumorextendslaterallyandinvadesthemandible﬇.Thereis alsodeepinvasionwithDOI>20mm(blackline).

Metastases,OrganFrequency

Coronalgraphicillustratesveryadvancedlocaldiseasewiththe tumorinvadingthemasticatorspaceﬅ,pterygoidplates,and skullbaseﬆ.T4btumorsmayalsoencasetheinternalcarotid artery.

T4b

LipandOralCavityCarcinoma

OVERVIEW

GeneralComments

• AmericanJointCommitteeonCancer(AJCC)staging systemisusedtostageepithelialandminorsalivarygland cancersoforalcavity(OC)

•Thisclassificationis not usedforothertypesof malignanciesoforalcancer

○Nonepithelialtumorsoflymphoidtissue

○Nonepithelialtumorsofsofttissue,suchassarcoma

○Nonepithelialtumorsofbone/cartilage

○MucosalmelanomaofOC

○Cutaneouslipcarcinoma

•OCsquamouscellcarcinoma(SCCa)iscloselyassociated withexposuretotobaccoandalcohol

•ImaginginOCcarcinomasperformedmainlytoassesslocal extensionandregionalspread

○Clinicalexaminationisgenerallybetterthanradiological imagingforscreeningformucosallesionsandmore accurateforevaluationofmucosallesionsize

○Majorityofcarcinomasareimagedafterdiagnosishas beenmade

•Treatmentisgenerallyaimedatsurgicalresectionof primarylesion ±postoperativeadjuvanttherapy

Classification

•VastmajorityofOCmalignancies(90-95%)areSCCa

•MalignantsubtypesofOCSCCatumors

○BasaloidSCCa

○Spindlecellcarcinoma

○Adenosquamouscarcinoma

○Carcinomacuniculatum

○Verrucouscarcinoma

○Lymphoepithelialcarcinoma

○PapillarySCCa

○AcantholyticSCCa

•OCanatomicallybeginsatmucosal-linedportionsoflips andextendstooropharynx

○PosteriormarginofOCisdefinedbyjunctionofhardand softpalatesuperiorly,anteriortonsillarpillarslaterally, andcircumvallatepapillaeoftongueinferiorly

○Anatomicsubsitesincludemucosal-linedportionsoflips, alveolarridges,buccalmucosa,floorofmouth(FOM), oraltongue,hardpalate,andretromolartrigoneregions

PATHOLOGY

RoutesofSpread

• Macroscopiclocaltumorextensionlargelydependent on siteoforiginoftumor

○Mucosallip

–Tumorinvadessubmucosa,adjacentgingivalmucosa, skin,andadjacentmandibleormaxilla

○Buccalmucosa

–Tumorinvadessubmucosa,buccinatormuscle,and ultimately,buccalspace

–Tumorcanextendlaterallyintodeepsubcutaneous fatofcheek

–Canextendtogingivaandinvolvemaxillaormandible

–Largetumorscanextendtomasticatorspace

○Loweralveolarridge

–Extendssubmucosally,invadescortex,andthen invadesmarrowspaceofmandible

–Marrowspaceinvolvementcanleadtoinvasionof perineuriumofalveolarnerve

○Upperalveolarridge

–Invademaxillaryalveolarridge;caninvadehardpalate, maxillarysinus

○Retromolartrigone(orretromolargingiva)

–Tumorcanspreadlaterallyintobuccalspaceand masticatorspace

–Canspreadsuperiorlyalongpterygomandibularraphe

–Invadesmandibularbone

–Caninvolveinferioralveolarnerveandlingualnerve withperineuraltumorspread(PNTS)

○FOM

–Tumorcanspreaddeepintomusculatureoftongue, acrossmidline,laterallyintomandible,inferiorlyto hyoidbone

○Hardpalate

–Canextendlaterallytogingivalmucosa,deepthrough corticalboneofhardpalateintoinferiornasalcavityor maxillarysinus

–Perineuralextensionalongpalatinenervestopalatine groove

○Anterior2/3oftongue(oraltongue)

–Tendtoinvadetonguemusculatureprimarily(intrinsic andthenextrinsic)

–Canextendposteriorlytoglossotonsillarjunctionand laterallyoranteriorlyintoFOM

• Regionallymphaticspread

○Lymphnodemetastasesgenerallyfollowpredictable andorderlypatternofspread

○Ingeneral,spreadgoesfromuppertomiddletolower cervicalnodes

○Canceroflip(lowpotentialformetastases)

–Submental(levelIA)andsubmandibular(levelIB) nodes

○Cancerofalveolarridgeorhardpalate(lowpotentialfor metastases)

–Submandibular(levelIB)

–Jugular(levelsII-IV)

–Retropharyngeal(lesscommonly)

○Primarysiteclosertomidlineincreasesriskofbilateral spreadtocervicalnodes

○Anteriorsuperiormediastinalnodesconsideredregional nodes(levelVII);othermediastinalnodesconsidered distantmetastases

• Metastaticdisease

○Pulmonarymetastasis

○Skeletalandhepaticmetastasesarelesscommon

GeneralFeatures

•Comments

○>90%ofcancersinOCareSCCa,mostaremoderatelyor welldifferentiated

○MostcommonsubsitesofOCcancer:Tongue,FOM,and gingiva

•Genetics

○Oralcancershowsrelativelysmalleffectofgeneticand familialpredisposition

○MostSCCaofOChavemutationsinTP53gene

LipandOralCavityCarcinoma

○MostOCSCCaareconsideredgeneticallyunstable

•Etiology

○Tobaccouseconsideredmostcommonetiology

○Alcoholusage

○Alcoholandtobaccoactsynergistically

○Betelquidchewing

○Sunlightexposure

○Humanpapillomavirus(HPV)infectionlikelyplaysrolein smallpercentageofOCcancers

•Epidemiologycancer

○23,880estimatednewcasesinUSAin2010

○5,470estimateddeathsinUSAin2010

○OCSCCaismorecommoninmen

○OCcarcinomaismoreprevalentinelderly

–Meanageatpresentation:60years

○Overalldecreaseinincidencefrom1970sinUSA

–Largelyattributedtodecreasesinsmoking

○MoreprevalentinpartsofAsia

–Duetovariousformsoftobaccouse

–Consumptionofbetel-containingsubstances

•Associateddiseases

○Therearevarietyofpotentiallymalignant(premalignant) disordersofOCmucosa,includingleukoplakiaand erythroplakia

–Leukoplakiadefinedclinicallyas"whitepatch"or plaqueofmucosathatisnototherwisecharacterized clinicallyorpathologicallyasanyotherdisease

–Erythroplakiaisred,"velvety"patchofmucosathat cannotbeotherwisecharacterizedclinicallyor pathologicallyasbeingcausedbyanyothercondition

GrossPathology&SurgicalFeatures

•Resectionofprimarytumorallowsforpathologic evaluation,includingextentoflocalspread,depthof invasion(DOI),andpTdesignation

•Lymphnodedissectionallowsforpathologicevaluationof lymphnodes,evaluationforextranodalextension(ENE), andpNclassification

○Surgicallyresectednodesshouldbeinspectedfor presenceofENE

○ENErepresentsextensionofmetastatictumorwithin lymphnodesthroughlymphnodecapsuleintoadjacent tissue

–ENEmaybemicroscopic,≤2mmbeyondcapsule

–ENEmaybemajor,>2mmorgrossENE

•Pathologicstaging,whileimportant,doesnotsupersede clinicalstagingasprimarystagingtool

•Classicgrosspathology

○Centralmucosalulceration

○Tumorstendtobefirmandinfiltratedwithtanorwhite cutsurface

•Tumorcanbeendophytic,exophytic,orulcerated

MicroscopicPathology

•H&E

○MostOCSCCamoderatelytowelldifferentiated

○Well-differentiatedtumors

–Exhibitwell-differentiatedsquamouscells,generally polyhedral-shapedwithconspicuousintercellular bridges,andappearinginnests,cords,andislandsof cellswithpinkcytoplasmandroundnuclei

–Dyskeratoticcellsandkeratinpearlsareprominent

○Moderatelydifferentiatedtumor

–Composedofcordsorislandsofneoplasticatypical

epithelialcells,oblongoroval-shaped,which infiltratedtumoralstroma

–Nucleiofneoplasticcellshavevariousshapesand sizes,mosthypochromicwithlargenucleoli

•Specialstains

○p16andHPV

–Upto1/3ofOCSCCap16(+)

–However,insituhybridization(moresensitiveforhighriskHPV)indicates<10%arepositiveforHPV

–Asopposedtooropharynx,studieshaveshownno definitesurvivaladvantageinp16(+)OCSCCa comparedtop16(-)OCSCCa

•OtherhistologicfactorstobeconsideredincludeENE,DOI, PNTS,andlymphovascularinvasion

IMAGINGFINDINGS

Detection

•Clinicalassessmentusuallymoreaccuratethanimagingfor mucosallesion(T1-T3)

•Imagingimportantfordeepextentandlymphnodes

• CT

○ApposedmucosalsurfacescanlimitabilitytoidentifyOC lesions

○Typically,primarylesionwillappearasnodularormasslikeareaofenhancementinvolvingmucosalsurface

–Enhancingtissuemaybepredominantlyinvasive, exophytic(protrudingintoOC),orcombinationof bothpatterns

–Largerlesionscanshowareasofnecrosis

○Occasionally,lesionsareulceratedanddemonstrate excavationofmucosawithlocalizedtissueloss

○Appearanceofprimarytumorwilldependonsiteof originoftumor,size,andextentoflocalinvasion

–Locationsincludelip,buccalmucosa,alveolarridges, FOM,hardpalate,anterior2/3tongue(oraltongue), retromolartrigone

○Coronalandsagittalreformattedimageshelpful

○Puffed-cheektechniqueisoftenusefulforevaluating buccalandbuccal-gingivalsulcallesions

○LimitationsofCECT

–Smalllesionsmaybeobviousclinicallybutmaybe difficulttoseparatefromnormalmucosaonCECT

–Apposedmucosalsurfacescanlimitabilitytoidentify OClesions

–DentalamalgamstreakartifactcanobscureOC anatomyandpathology

• MR

○MRisidealimagingmodalityinOC

–Multiplanarcapabilities+bettercontrastforprimary evaluation

–DentalamalgamartifactlessseverethanwithCT

–Superiormodalityinevaluatinghardpalatetumors

–Superiorillustrationoftumor-muscleinterfaceand perineuralextension

○T1WI

–Isointensetomuscle

–Lowsignalintensityofprimarytumor

Diagnostic imaging oncology 2nd edition akram m. shaaban - Quickly download the ebook to explore the

Organic

Shaaban Rezvani Chapman

SECOND EDITION

AkramM.Shaaban,MBBCh

Notices

Contributing Authors

Additional Contributing Authors

Preface

Acknowledgments

Sections

TABLEOFCONTENTS

TABLEOFCONTENTS

Shaaban Rezvani Chapman

Head & Neck

LipandOralCavityCarcinoma

T|DefinitionofPrimaryTumor

N|DefinitionofRegionalLymphNode:Clinical(cN)andPathological(pN)

LipandOralCavityCarcinoma

M|DefinitionofDistantMetastasis

AJCC|PrognosticStageGroups

G|HistologicGrade

SummaryofChanges

LipandOralCavityCarcinoma

LipandOralCavityCarcinoma

Metastases,OrganFrequency

LipandOralCavityCarcinoma

OVERVIEW

LipandOralCavityCarcinoma

IMAGINGFINDINGS