Movement Disorders and Neurodegenerative Diseases. Ioflupane SPECT/CT Brain I-123 ioflupane SPECT/CT is a valuable test used to differentiate Parkinsonian syndromes (PD, MSA, PSP, CBD) from essential tremor and drug-induced tremor, demonstrating abnormality early in the disease course compared with anatomic imaging such as standard CT or MRI [32]. A normal I-123 ioflupane SPECT/CT essentially excludes Parkinsonian syndromes. I-123 ioflupane binds to the dopamine transporters and can be used to demonstrate the loss of presynaptic dopaminergic neurons in PD. It can demonstrate decreased radiotracer uptake in the striatum, usually in a posterior to anterior direction from the putamen to the caudate nuclei. I-123 ioflupane SPECT would demonstrate abnormal patterns of dopaminergic depletion for patients with PD, MSA, PSP, and CBD [33-39].


Movement Disorders and Neurodegenerative Diseases. Note is made of a steady emergence of new nuclear medicine tracers, which are yet to be approved by the US FDA for clinical use, designed to target the postsynaptic dopamine receptors (D1 and D2), including 11C-raclopride-PET and I-123-iodobenzamide SPECT scans. These radiotracers compete with endogenous dopamine to bind to the postsynaptic D2 receptors and show increased uptake within the putamen and, to a lesser extent, the caudate in patients with PD when compared with normal controls. The role of these tracers in the evaluation of patients with suspected PD may grow in the future.


Movement Disorders and Neurodegenerative Diseases. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy of the brain in the initial imaging evaluation of a patient with Parkinsonian syndrome.


Movement Disorders and Neurodegenerative Diseases. MRI Functional (fMRI) Head There is no relevant literature to support the use of fMRI of the brain in the initial imaging evaluation of a patient with Parkinsonian syndrome.


Movement Disorders and Neurodegenerative Diseases. MRI Head In patients with Parkinsonian syndrome, MRI of the brain without IV contrast is the optimal imaging modality because of its soft-tissue characterization and sensitivity to iron deposition [40-44]. Although IV contrast is not typically needed for the evaluation of Parkinsonian syndromes, it may be helpful for excluding additional differential considerations.


Movement Disorders and Neurodegenerative Diseases. Movement Disorders and Neurodegenerative Diseases In patients with CBD, MRI shows asymmetric atrophy of the frontal and parietal lobes, typically contralateral to the more affected side, as well as the striatum [42,57-60]. Faint T2/FLAIR hyperintensity can also be seen in the subcortical white matter in the atrophic regions, likely related to neuronal loss and gliosis [42,57,59,60].


Movement Disorders and Neurodegenerative Diseases. In contrast to conventional MRI, advanced MRI may offer more meaningful and earlier diagnostic opportunities for patients with suspected PD and other Parkinsonian syndromes. For instance, 7-T MRI has shown promise in accurately differentiating healthy subjects from PD patients because it can demonstrate increased susceptibility in the substantia nigra and thinning of the pars compacta with blurring of the borders between the substantia nigra and red nucleus [66]. Additionally, recent studies in patients with PD have shown decreased magnetization transfer ratio and functional anisotropy within the substantia nigra (particularly caudally) when compared with normal controls [67].


Movement Disorders and Neurodegenerative Diseases. HMPAO SPECT or SPECT/CT Brain There is no relevant literature to support the use of Tc-99m HMPAO SPECT/CT of the brain in the initial imaging evaluation of a patient with Parkinsonian syndrome.


Movement Disorders and Neurodegenerative Diseases. Variant 4: Suspected neurodegeneration with brain iron accumulation. Initial imaging. Although some iron accumulation within the basal ganglia and dentate nuclei can normally be seen as we age, NBIA is a distinct group of conditions characterized by excess iron deposition in the basal ganglia with progressive neuronal degeneration. Four subtypes have been defined, the most common of which is NBIA type 1, also known as pantothenate kinase-associated neurodegeneration and formerly known as Hallervorden-Spatz disease. NBIA type 1 is a rare autosomal recessive disease (annual incidence of 1/1,000,000), which classically presents in the first decade with slowly progressive gait disturbances, dystonia, dysarthria, spasticity, and pyramidal tract signs [68].


Movement Disorders and Neurodegenerative Diseases. FDG-PET/CT Brain There is no relevant literature to support the use of FDG-PET/CT of the brain in the initial imaging evaluation of a patient with suspected NBIA.


Movement Disorders and Neurodegenerative Diseases. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy of the brain in the initial imaging evaluation of a patient with suspected NBIA.


Movement Disorders and Neurodegenerative Diseases. MRI Functional (fMRI) Head There is no relevant literature to support the use of fMRI of the brain in the initial imaging evaluation of a patient with suspected NBIA.


Movement Disorders and Neurodegenerative Diseases. Movement Disorders and Neurodegenerative Diseases


Movement Disorders and Neurodegenerative Diseases. associated enhancement or restricted diffusion in these areas of iron deposition, although diffusion tensor imaging has shown increased fractional anisotropy in both the globus pallidus and substantia nigra in patients with NBIA [74]. The white matter and cortex are spared in NBIA type 1. MRI may also be helpful in distinguishing the other less common subtypes of NBIA [69,71,72]. IV contrast may be useful in the initial evaluation of suspected NBIA, considering the presence of limited inflammatory etiologies among the differential diagnoses.


Movement Disorders and Neurodegenerative Diseases. HMPAO SPECT or SPECT/CT Brain There is no relevant literature to support the use of Tc-99m HMPAO SPECT/CT of the brain in the initial imaging evaluation of a patient with suspected NBIA.


Movement Disorders and Neurodegenerative Diseases. Variant 5: Suspected motor neuron disease. Initial imaging. ALS is a progressive neurodegenerative disorder characterized by degeneration of the upper and lower motor neurons in the brain and spinal cord along the corticospinal tracts and is the most common motor neuron disease, representing ~85% of all cases [75]. The majority of cases are sporadic (85% to 90%) with an overall annual incidence of 1 to 2/100,000 and a median survival of 3 to 4 years after symptom onset [75]. Typically, patients present with hypertonicity and hyperreflexia (upper motor neuron degeneration) and muscle fasciculations, weakness, and atrophy (lower motor neuron degeneration). Electromyography and nerve conduction velocity are key tests in diagnosing ALS, with imaging relied upon mainly to exclude other conditions with similar clinical presentations rather than confirm or facilitate the diagnosis of ALS.


Movement Disorders and Neurodegenerative Diseases. CT Spine CT of the spine (either with, without, or without and with IV contrast) is not useful in making the diagnosis of ALS because of its limited soft-tissue characterization.


Movement Disorders and Neurodegenerative Diseases. FDG-PET/CT Brain There is no relevant literature to support the use of FDG-PET/CT of the brain in the initial imaging evaluation of a patient with suspected motor neuron disease.


Movement Disorders and Neurodegenerative Diseases. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy of the brain in the initial imaging evaluation of a patient with suspected motor neuron disease.


Movement Disorders and Neurodegenerative Diseases. MRI Functional (fMRI) Head There is no relevant literature to support the use of fMRI of the brain in the initial imaging evaluation of a patient with suspected motor neuron disease.


Movement Disorders and Neurodegenerative Diseases. MRI Head In patients with suspected motor neuron disease involving upper motor neurons, MRI of the brain without IV contrast is the optimal imaging modality [76]. Contrast is typically not needed for the evaluation of suspected motor neuron disease, but it may be helpful in excluding other infectious, inflammatory, or neoplastic differential considerations.


Movement Disorders and Neurodegenerative Diseases. MRI Spine MRI of the spine without IV contrast is often normal early in the disease course of ALS, but may be useful in certain clinical circumstances to exclude structural, infectious, or neoplastic etiologies of the spine that can mimic motor


Movement Disorders and Neurodegenerative Diseases. Movement Disorders and Neurodegenerative Diseases neuron disease [86-88]. To this end, the addition of IV contrast may add utility in patients who are at increased risk for infection or neoplastic mimics.


Movement Disorders and Neurodegenerative Diseases. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Movement Disorders and Neurodegenerative Diseases. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Staging and Post Therapy Assessment of Head and Neck Cancer. Introduction/Background Head and neck cancer comprises a heterogeneous group of malignancies that together represents the seventh most common cancer worldwide and ninth most common cancer in the United States [1]. Several anatomic sites are encompassed, including the oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, paranasal sinuses, nasal cavity, and salivary glands. There is heterogeneity in histopathology; although, the majority of the cancers are squamous cell carcinomas. Head and neck cancers are clearly associated with alcohol and tobacco consumption, with human papillomavirus (HPV) and Epstein-Barr virus (EBV) linked to oropharynx cancer and nasopharynx cancer, respectively [2].


Staging and Post Therapy Assessment of Head and Neck Cancer. Special Imaging Considerations For the purposes of distinguishing between CT and CT angiography (CTA), ACR Appropriateness Criteria topics use the definition in the ACR-NASCI-SIR-SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [7]:


Staging and Post Therapy Assessment of Head and Neck Cancer. Reprint requests to: publications@acr.org


Assessment of Head and Neck Cancer

Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer


Staging and Post Therapy Assessment of Head and Neck Cancer. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with IV contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. PET/CT imaging of head and neck cancers is frequently extended beyond the skull-base to the vertex to ensure inclusion of the entirety of the tumor.


Staging and Post Therapy Assessment of Head and Neck Cancer. Squamous cell carcinoma of the head and neck preferentially spreads to regional lymph nodes, with nodal disease conferring decreased survival rates. Presence of distant metastatic disease at the time of diagnosis has been reported in 10% to 18% of patients [10], and its occurrence is directly linked to the stage of tumor [11-13]. The lungs are the most frequent site for distant metastatic disease, and when other sites of distant metastatic disease are present, pulmonary nodules are almost always present [11,14]. Skeletal metastases, most frequently of ribs and vertebrae, confers morbidity, including pain and symptoms of hypercalcemia [11]. Detection of distant metastatic disease at initial staging is crucial because it will change prognosis and typically change the management strategy toward more systemic options. An increased rate of second primary malignancy and concurrent lung malignancy among head and neck cancer patients has been linked to the intake of tobacco and alcohol [15,16].


Staging and Post Therapy Assessment of Head and Neck Cancer. Cancer of unknown primary of the head and neck represents 1% to 4% of patients with malignant tumors of the head and neck and is diagnosed after identification of metastatic cervical lymphadenopathy in which no primary is evident [9]. When the pathology is consistent with HPV-related squamous cell carcinoma, the primary site is presumed to localize to the oropharynx. Initial staging should include every attempt at identifying the site of primary because this impacts prognosis and treatment planning, and it is important to document the extent of nodal disease in the neck. Despite multimodality imaging and endoscopic evaluation, 2% to 9% of primary sites remain undetected [17].


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Chest Chest radiography (CXR) is not useful for the evaluation of pulmonary metastatic disease in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck. Chest CT is far more sensitive in detecting pulmonary metastatic disease when compared to radiography [15], with the sensitivity of CXR to detect pulmonary metastatic disease reported as low as 28% when compared to chest CT [11]. The low sensitivity may in part be due to the small size of pulmonary nodules at presentation or peripheral location, in which CXR tends to be less reliable [11]. The use of CXR for detection of metastases has not been shown to improve prognosis because metastatic pulmonary nodules detectable on CXR tend to be associated with late-stage disease when it is not as amenable to treatment [18].


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the evaluation of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head With IV Contrast There is no relevant literature to support the use of CT head with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without and With IV Contrast There is no relevant literature to support the use of CT head without and with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without IV Contrast There is no relevant literature to support the use of CT head without IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial With IV Contrast There is no relevant literature to support the use of CT maxillofacial with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck. CT maxillofacial may not include the primary site in the hypopharynx or larynx and typically will not include the entire neck soft tissues, making it inadequate for the staging of regional lymphadenopathy.


Assessment of Head and Neck Cancer


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without and With IV Contrast There is no relevant literature to support the use of CT maxillofacial without and with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without IV Contrast There is no relevant literature to support the use of CT maxillofacial without IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck With IV Contrast Although protocols vary across institutions, for the purposes of this document, CT of the neck includes coverage from the top of the frontal sinuses down to the level of the aortic arch, with thin slices, multiplanar reformats, and both soft tissue and bony algorithms. Contrast-enhanced CT (CECT) of the neck has the advantage of detailed anatomic delineation of the primary tumor site, aiding in the correct T staging as well as providing regional nodal staging of the neck. In oral cavity cancer, CECT has been shown to provide an accurate estimation of depth of invasion and tumor thickness in lesions >5 mm when compared to histopathologic findings, an important upstaging feature of oral cavity cancers [22-25], performing similar to MRI [26]. CT imaging also gives excellent delineation of osseous anatomy, including bony destruction by tumor with high sensitivity and specificity for osseous [27-29] and cartilage involvement [30], which are upstaging features. When compared to MRI, CECT of the neck performs similar or slightly better in correctly identifying osseous involvement [29,31,32]. Conversely, MRI has been reported to have higher sensitivity than CT in detecting cartilage invasion but similar specificity, an upstaging feature of larynx and hypopharyngeal malignancies [33,34]. In comparing the ability of CECT to fluorine-18-2- fluoro-2-deoxy-D-glucose (FDG)-PET/CT to accurately diagnose regional nodal disease, CECT performs similar or slightly inferior to FDG-PET/CT [35-39]. Contrast enhancement is imperative in order to correctly identify and outline the primary site, and distinguishing it from the surrounding normal soft tissues. The puffed-cheek technique, consisting of requesting that the patient inflate their cheeks with pursed lips while undergoing CT examination, allows for a greater delineation of oral cavity tumors, particularly those along the gingiva and buccal mucosa. The maneuver allows for the separation of tumor from normal mucosa and provides a clearer picture of the size and extent of disease [40].


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without and With IV Contrast There is no relevant literature to support the use of CT neck without and with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without IV Contrast There is no relevant literature to support the use of CT neck without IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CTA Neck With IV Contrast There is no relevant literature to support the use of CTA of the neck with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck. CTA of the neck can be used to identify patients at high risk of bleeding in the instance of locally advanced disease with involvement encroaching on the carotid arteries [41].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT allows for the detection and localization of primary tumor site, identification of regional nodal disease, and distant metastases. FDG-PET/CT is recommended by the National Comprehensive Cancer Network for stage III and IV cancer [42]. FDG-PET/CT alone is not considered sufficient for initial staging because it may not provide detailed anatomic delineation of the primary site or detection of upstaging features needed for correct staging [43,44]. FDG-PET/CT will typically be used in conjunction with CECT or MRI of the neck. One advantage of FDG-PET/CT is that the whole body can be imaged, and FDG-PET is more sensitive in the detection of distant metastasis and synchronous tumors over radiography, CT, and MRI [10,42,45]. Although FDG-PET/CT is sensitive (72%-96%), there are some variations in the reported specificity rate for cervical nodal metastases [36,45-48], likely due to reactive lymph nodes resulting in false-positive findings on PET.


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer The utility of FDG-PET in lower-stage cancer is more controversial. There are conflicting results when evaluating the ability of FDG-PET/CT to accurately detect occult nodal disease in clinical node-negative cancer. A range of sensitivities and specificities and contradictory results when compared to CECT and MRI are reported, either performing similar to or outperforming these modalities [35-39]. This controversy led to the American College of Radiology Imaging Network 6685 multicenter trial, which conclusively demonstrated that FDG-PET/CT confers a high negative predictive value (NPV) of 87% (visual analysis) and 94% (standardized uptake value max analysis) for lymph node metastasis in N0 cancer, with moderate to substantial reader agreement and 99% for distant metastatic disease [37,42,49]. In addition, it changed surgical management in the 20% of the study population.


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT is considered standard of care for the evaluation of metastatic cervical adenopathy with no primary evident on clinical examination or other imaging modalities [17]. FDG-PET/CT has been demonstrated to be superior in detecting the primary site (69%) at the time of diagnosis versus 15% on CECT alone and 41% when using the combination of CECT and MRI [17]. FDG-PET/CT has been demonstrated to have a higher diagnostic accuracy than MRI and CT for the detection of small tumors [50,51].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/MRI Skull Base to Mid-Thigh FDG-PET/MRI is a new imaging modality with a growing body of evidence demonstrating the feasibility of use for routine clinical imaging, including the initial staging of head and neck tumors, with FDG-PET/MRI performing similar to FDG-PET/CT [42,44,52-57]. One study found that FDG-PET/MRI outperforms FDG-PET/CT in the diagnosis of primary site in the evaluation of unknown primary [58].


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck With IV Contrast There is no relevant literature to support the use of MR angiography (MRA) with IV contrast of the neck in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without and With IV Contrast There is no relevant literature to support the use of MRA of the neck without and with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without IV Contrast There is no relevant literature to support the use of MRA of the neck without IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head With IV Contrast There is no relevant literature to support the use of MRI of the head with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without and With IV Contrast There is no relevant literature to support the use of MRI of the head without and with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without IV Contrast There is no relevant literature to support the use of MRI of the head without IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck With IV Contrast There is no relevant literature to support the use of MRI of the orbits, face, and neck with IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without and With IV Contrast MRI orbits, face, and neck without and with IV contrast has superior soft tissue resolution compared to CT and with this an improved ability to delineate the soft tissue extent of the tumor, which is a key component in the T staging of disease and essential for surgical planning. The superior soft tissue contrast resolution allows for improved


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer detection of perineural spread of disease. MRI is less susceptible to metal artifact and may perform better in the oral cavity where there can be significant artifact from dental implants. Conversely, MRI offers decreased spatial resolution compared to CT and is more susceptible to motion artifact due to longer scan times. When compared to CECT, MRI neck performs similarly in correctly identifying osseous involvement, with MRI better delineating marrow involvement and CT better depicting erosive cortical change [29,31]. MRI and CT achieve similar capability in the detection of extranodal extension of tumor [59] and depth of invasion in oral tongue cancer [26]. Conversely, when compared to CT, MRI has been reported to have a higher sensitivity but a similar specificity in detecting cartilage invasion, an upstaging feature of larynx and hypopharyngeal malignancies [33,34]. Accuracy of local staging of larynx cancer has been reported to be higher with MRI than CECT (80% versus 70%) [60]. MRI performs similarly to CECT in the detection of nodal metastatic disease with sensitivity ranging from 64% to 92% and specificity from 40% to 81% [61]. Most studies show superiority of FDG-PET/CT compared to MRI for detection of nodal disease [61]. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary tumor, distinguishing it from surrounding normal soft tissues.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without IV Contrast There is no relevant literature to specifically support the use of MRI orbits, face, and neck without IV contrast in the initial staging of suspected or diagnosed cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary site, distinguishing it from the surrounding normal soft tissues. The absence of IV contrast limits the ability to accurately delineate margin and the soft tissue extent of the tumor, which is a key component in the T staging of disease and essential for treatment planning. However, noncontrast MR sequences are routinely used to identify the primary tumor, define tumor extent, in particular marrow involvement, and are used in nodal staging.


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Paranasal Sinuses There is no relevant literature to support the use of radiography of the sinuses in the initial staging of suspected or diagnosed cancer the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. US Neck Ultrasound (US) can be a useful adjunct to cross-sectional imaging, in particular for nodal staging of head and neck cancer. Coupled with fine-needle aspiration and/or core-needle biopsy, nodal evaluation with US is a reliable tool and correlates well with staging following neck dissection [62]. A range of sensitivities and specificities for detection of nodal disease are found in the literature, likely reflecting the highly operator-dependent nature of this technique. US alone has been shown to very sensitive (77.8%-96.8%) and specific (68.75%-97%) in detecting cervical nodal metastases [47,63-65].


Staging and Post Therapy Assessment of Head and Neck Cancer. US is not typically used to stage the primary site, although there is a growing body of research demonstrating the utility of US in delineating primary tumors of the oral cavity, oropharynx, hypopharynx, and larynx. Recent studies comparing transcervical US to CT and FDG-PET/CT and US to CT and MRI demonstrated increased accuracy of US in detecting primary site in patients with HPV-related oropharyngeal carcinoma [51,66]. Intraoral US of the tongue has been proven to be accurate in the evaluation of depth of invasion, which is an important staging feature of oral cavity cancers that has prognostic and therapeutic implications [67,68]. A few studies demonstrated the utility of US in the delineation of oral cavity primary in patients in which the tumor was obscured by metal on cross- sectional imaging [25,69]. In a study comparing US to CECT for the staging of hypopharyngeal cancer, US failed to detect significant findings seen on CT in 22.5% of cases, although US proved accurate in diagnosing cartilage invasion and vocal cord immobility [70]. Conversely, US was found to approach the accuracy of CECT and MRI in the evaluation of larynx primary site with 80% to 83.3% accuracy in delineating the correct T stage versus 88.8% for CECT and 76.7% for MRI [71-73].


Staging and Post Therapy Assessment of Head and Neck Cancer. Variant 2: Suspected or diagnosed nasopharynx cancer or EBV-associated unknown primary of the head and neck. Initial staging. Nasopharyngeal carcinoma (NPC) is a relatively rare cancer with a worldwide incidence of 0.5 to 1.0/100,00 per year [74], with higher endemic rates in Southeast Asian countries. NPC arising from the nasopharyngeal epithelium represents at least 70% of tumors of the nasopharynx and, for this reason, will be the focus of the upcoming discussion [74]. Other histologies, including nasopharyngeal lymphoma, constitute a minority of nasopharyngeal malignancies and will therefore not be emphasized in this section. The World Health Organization classifies


Assessment of Head and Neck Cancer

Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer


Staging and Post Therapy Assessment of Head and Neck Cancer. squamous cell carcinoma of the nasopharynx based on histopathologic features into keratinizing squamous cell carcinoma, nonkeratinizing squamous cell carcinoma, which is further subdivided into differentiated and undifferentiated type, and basaloid squamous cell carcinoma. Alcohol and smoking are associated with NPC, with the strongest link to keratinizing squamous cell carcinoma, which carries the worst prognosis [75]. Almost all nonkeratinizing squamous cell carcinoma and basaloid squamous cell carcinomas are associated with EBV infection with a slightly weaker association of EBV to keratinizing squamous cell carcinoma [18]. The undifferentiated subtype is most common in endemic areas, representing as many as 93% of all cases [75].


Staging and Post Therapy Assessment of Head and Neck Cancer. In addition to the epithelial tumors of the nasopharynx, cancers of the nasopharynx can also originate from minor salivary glands, most commonly adenoid cystic and mucoepidermoid carcinomas. Cancer of unknown primary of the head and neck represents 1% to 4% of patients with malignant tumors of the head and neck and is diagnosed after identification of metastatic lymphadenopathy in which no primary is evident [9]. When the pathology is positive for EBV, the primary site is presumed to localize to the nasopharynx.


Staging and Post Therapy Assessment of Head and Neck Cancer. Patients often present with a neck mass or findings secondary to local invasion of structures, with symptoms such as epistaxis or nasal blockage, hearing loss secondary to Eustachian tube dysfunction, or findings of cranial nerve involvement [76]. Advanced local disease in NPC is common at presentation with skull base involvement in 25% to 35% of cases and intracranial invasion in 3% to 12% of cases [77]. Accurate staging of the primary tumor includes evaluation of involvement of osseous structures, including the skull base and extension into the adjacent soft issues such as the pterygoid musculature, which are upstaging features. NPC has a high rate of regional nodal disease at presentation, including retropharyngeal and cervical lymph nodes, with as many as 75.8% of patients presenting with nodal mass at initial presentation [78]. Identification of nodal disease is critical in staging because it confers decreased survival, and the presence of nodal disease or advanced local disease is associated with increased risk for distant metastases. NPC also has a relatively high rate of distant metastases compared with other head and neck cancers, and distant metastases are found in 5% to 11% of patients at the time of diagnosis. The most common sites of metastasis are bone (20%), lung (13%), and liver (9%) [79,80]. Detection of distant metastatic disease at initial staging is crucial because it will change prognosis and typically convert the management strategy toward more systemic options.


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Chest CXR is not considered the imaging modality of choice for evaluation of pulmonary metastatic disease in suspected or diagnosed nasopharynx cancer or EBV-associated unknown primary of the head and neck. Chest CT is far more sensitive in detecting pulmonary metastatic disease compared to radiography [15], with the sensitivity of CXR to detect pulmonary metastatic disease reported to be as low as 28% compared to chest CT [11]. The low sensitivity may in part be due to the small size of pulmonary nodules at presentation or peripheral location, in which CXR tends to be less reliable [11]. The use of CXR for detection of metastases has not been shown to improve prognosis, because pulmonary metastatic disease detected on CXR tends to be diagnosed at a late stage when it is not as amenable to treatment [18].


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest With IV Contrast CT chest with IV contrast can accurately identify pulmonary metastases and be used to detect thoracic nodal and skeletal metastases to ribs or vertebrae. NPC has a relatively high rate of distant metastases with the lung being the second most common site of distant disease after osseous metastases. Although FDG-PET/CT is preferred for the staging of advanced stage NPC because it allows for simultaneous detection of metastatic disease outside the thorax, CT chest may be considered for screening of pulmonary metastatic disease. CT chest confers superior spatial localization and contrast resolution compared to radiography, allowing for the detection of small pulmonary nodules [15]. CT chest may also be useful in patients with NPC associated with smoking and alcohol intake, given the risk for synchronous lung cancer. The use of IV contrast may improve detection of mediastinal and hilar adenopathy, distinguishing nodes from mediastinal vessels and aid in delineation of soft tissue extension of skeletal metastatic disease. There is a paucity of relevant supportive literature specifically comparing the diagnostic performance of CT chest with IV contrast and CT chest without IV contrast.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the evaluation of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Assessment of Head and Neck Cancer


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest Without IV Contrast CT chest without IV contrast can accurately identify pulmonary metastasis and be used to detect thoracic nodal and skeletal metastases to the ribs or vertebrae. NPC has a relatively high rate of distant metastases with the lung being the second most common site of distant disease after osseous metastases. Although FDG-PET/CT is preferred for the staging of advanced stage NPC because it allows for simultaneous detection of metastatic disease outside the thorax, CT chest may be considered for screening of pulmonary metastatic disease. CT chest confers a superior spatial localization and contrast resolution compared to radiography, allowing for the detection of small pulmonary nodules [15]. CT chest may also be useful in patients with NPC associated with smoking and alcohol intake, increasing the risk for synchronous lung cancer. The use of IV contrast may improve detection of mediastinal and hilar adenopathy, distinguishing nodes from mediastinal vessels and aiding in delineation of soft tissue extension of skeletal metastatic disease. Noncontrast CT chest may be considered as an alternative and is part of routine clinical practice, although there is paucity of relevant supportive literature evaluating the use of CT chest without IV contrast.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head With IV Contrast There is no relevant literature to support the use of CT head with IV contrast in treated cancer of nasopharynx or EBV-associated cancer of unknown primary of the head and neck. Although CT head may be able to delineate skull base and intracranial involvement, inclusion of the neck is useful to evaluate for cervical adenopathy for staging purposes.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without and With IV Contrast There is no relevant literature to support the use of CT head without and with IV contrast in treated cancer of the nasopharynx or EBV-associated cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without IV Contrast There is no relevant literature to support the use of CT head without IV contrast in treated cancer of the nasopharynx or EBV-associated cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial With IV Contrast There is no relevant literature to support the use of CT maxillofacial with IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated cancer of unknown primary of the head and neck. CT maxillofacial with IV contrast may provide sufficient evaluation of the primary site and can be particularly helpful for the evaluation of osseous erosion. However, CT maxillofacial will typically not include evaluation of the neck and would therefore be inadequate for the staging of regional lymphadenopathy when performed alone and may best be used in combination with MRI or FDG-PET/CT.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without and With IV Contrast There is no relevant literature to support the use of CT maxillofacial without and with IV contrast in the initial staging of suspected or diagnosed nasopharynx cancer or EBV-associated cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without IV Contrast There is no relevant literature to support the use of CT maxillofacial without IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated cancer of unknown primary of the head and neck. CT maxillofacial without IV contrast would not provide sufficient evaluation of the soft tissue extent of disease but may be complementary in the anatomic evaluation of the primary site, in particular for the evaluation of osseous erosion. CT maxillofacial will typically not include evaluation of the neck and would therefore be inadequate for the staging of regional lymphadenopathy when performed alone and may best be used in combination with MRI or FDG- PET/CT.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck With IV Contrast Although protocols vary across institutions, for the purposes of this document, CT of the neck includes coverage from the top of the frontal sinuses down to the level of the aortic arch, with thin slices, multiplanar reformats, and both soft tissue and bony algorithms. CECT of the neck allows for the detection and localization of nasopharyngeal tumors as well as regional nodal staging. CT imaging is excellent for the delineation of osseous anatomy and in the detection of subtle cortical erosion. However, because of improved soft tissue contrast resolution, MRI is considered superior to CT in outlining the extent of soft tissue disease, including involvement of neighboring structures, findings that are necessary for the correct T staging of disease. Although MRI has largely surpassed the use of CECT for NPC staging with high sensitivity and specificity for correctly identifying the primary site [81,82], CT


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer has a complementary role in staging and is often used for radiation planning purposes. FDG-PET/CT is considered the imaging modality of choice for detecting cervical and distant metastases in patients with NPC [83] and demonstrates high sensitivity and specificity, when compared to CECT, in detecting nodal metastasis [82,84,85]. When CT is performed, IV contrast is recommended to better outline the soft tissue extent of the primary tumor.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without and With IV Contrast There is no relevant literature to support the use of CT neck without and with IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without IV Contrast There is no relevant literature to support the use of CT neck without IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated cancer of unknown primary of the head and neck. CT neck without IV contrast would not provide sufficient evaluation of the soft tissue extent of disease but may be complementary in the anatomic evaluation of the primary site in particular for the evaluation of osseous erosion.


Staging and Post Therapy Assessment of Head and Neck Cancer. CTA Neck With IV Contrast There is no relevant literature to support the use of CTA neck with IV contrast for the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck. CTA of the neck can be used to identify patients at high risk of bleeding in the instance of locally advanced disease encroaching on the carotid arteries [41].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT allows for the detection and localization of primary tumor site and identification of regional nodal disease and distant metastases. FDG-PET/CT alone is not considered sufficient in the initial staging of NPC because it does not provide detailed anatomic delineation of the primary site or detection of upstaging features needed for correct staging, including a tendency to underestimate the involvement of the skull base, brain, cavernous sinuses, and orbits compared to MRI [74,85,86]. FDG-PET/CT has also been found to have a higher false-negative rate than MRI for detection of retropharyngeal nodal disease [82].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT is useful for detecting cervical and distant metastases in patients with NPC [83] and demonstrates high sensitivity and specificity, when compared to CECT or MRI alone, in detecting nodal metastasis [82,84,85]. Furthermore FDG-PET/CT has a high sensitivity and accuracy in detecting distant metastases, including osseous and pulmonary metastases [82,87,88], the most common sites for distant metastatic disease in NPC. Studies have shown that for early stage (I-II) disease, FDG-PET/CT may not confer additional benefit [74].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT is useful for the evaluation of metastatic cervical adenopathy with no primary evident on clinical examination or other imaging [17]. Comparison between FDG-PET/CT, CECT neck alone, or in combination with IV contrast-enhanced MRI, showed FDG-PET to be superior in detecting the primary site (69%) of the time versus 15% on CT alone and 41% when using the combination of CT and MRI [17].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/MRI Skull Base to Mid-Thigh FDG-PET/MRI is a new imaging modality with a growing body of evidence demonstrating the feasibility of use for routine clinical imaging, including the initial staging of NPC with similar results to FDG PET/CT [53,86]. A study found that this imaging modality may provide more accurate staging than the combination of FDG-PET/CT and MRI [89].


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck With IV Contrast There is no relevant literature to support the use of MRA neck with IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without and With IV Contrast There is no relevant literature to support the use of MRA neck without and with IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without IV Contrast There is no relevant literature to support the use of MRA neck without IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head with IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Assessment of Head and Neck Cancer

Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without and With IV Contrast There is no relevant literature to support the use of MRI head without and with IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck. The coverage of an MRI of the head and MRI sequences tailored for assessment of the brain may be insufficient to completely evaluate the primary site in the nasopharynx and will not include regional nodal staging. MRI head without and with IV contrast may be used to further delineate advanced intracranial extension of disease if it is suspected based on clinical examination or other imaging modalities.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without IV Contrast There is no relevant literature to support the use of MRI head without IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck With IV Contrast There is no relevant literature to support the use of MRI of the orbits, face, and neck with IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without and With IV Contrast MRI of the orbits, face, and neck without and with IV contrast has superior soft tissue contrast resolution and with this an improved ability to delineate the soft tissue extent of the tumor at the primary site. MRI provides high sensitivity and specificity for correctly identifying the primary site [81,82], and the superior soft tissue contrast resolution allows for accurate evaluation of local extent of disease, including identification of subtle skull base marrow involvement, intracranial extension, and detection of perineural spread of disease [90,91]. Furthermore, MRI has been found to correctly identify the site of the tumor in endoscopically occult disease [81,92]. MRI has demonstrated a mildly lower sensitivity than FDG-PET/CT in detecting cervical nodal disease [82] but is considered superior in detecting retropharyngeal lymph node metastases [74,82]. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary site, distinguishing it from the surrounding soft tissues. This includes the evaluation of tumor size and local extent of disease, including the invasion of surrounding structures.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without IV Contrast There is no relevant literature to support the use of MRI of the orbits, face, and neck without IV contrast in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary site, distinguishing it from the surrounding normal soft tissues. The absence of IV contrast limits the ability to accurately delineate margin and the soft tissue extent of the tumor, which is a key component in the T staging of disease and essential for treatment planning. However, noncontrast MR sequences are routinely used to identify the primary tumor and define tumor extent, in particular marrow involvement, and are used in nodal staging.


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Paranasal Sinuses There is no relevant literature to support the use of radiography of the sinuses in the initial staging of suspected or diagnosed NPC or EBV-associated unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. US Neck US can be a useful adjunct to cross-sectional imaging, in particular for nodal staging in NPC or EBV-associated unknown primary of the head and neck. Coupled with fine-needle aspiration and/or core-needle biopsy, nodal evaluation with US is a reliable tool and correlates well with staging following neck dissection [62]. A range of sensitivities and specificities for detection of nodal disease are found in the literature, likely reflecting the highly operator dependent nature of this technique. US alone has been shown to be very sensitive (77.8%-96.8%) and specific (68.75%-97%) in detecting cervical nodal metastases [47,63-65]. One study has shown similar accuracy of US to MRI in the detection of the primary site in patients with suspected NPC, which suggests that US may have a role as a screening tool [93].


Staging and Post Therapy Assessment of Head and Neck Cancer. Variant 3: Suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. Initial staging. Sinonasal tumors are rare neoplasms and make up only 3% of head and neck carcinomas and approximately 0.5% to 1% of all malignancies [94,95]. Despite its relatively small anatomic confine, a wide range of malignancies can arise from the sinonasal cavity. Neoplasms can be classified as either epithelial or nonepithelial. Of the epithelial tumors, squamous cell carcinoma is by far the most common malignancy and accounts for up to 80% of sinonasal cancers and, for this reason, will be the focus of the upcoming discussion. The maxillary sinus and nasal cavity


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer constitute the most common sites of origin [95,96]. The most frequent nonepithelial malignancies are malignant lymphomas, which comprise approximately 6% to 13% of extranodal lymphomas of the head and neck [95]. Additional malignancies encountered in this region include adenocarcinoma, salivary gland tumors, olfactory neuroblastoma, and melanoma, among others. Olfactory neuroblastomas are rare and constitute only around 2% of sinonasal tumors. They arise from the olfactory epithelium found at the roof of the ethmoid sinuses, cribriform plate, upper nasal septum, and superior turbinates. Because of its site of origin, olfactory neuroblastomas have a propensity to invade the anterior cranial fossa [96,97]. Paranasal sinus cancers differ from other squamous cell cancers of the upper aerodigestive tract in their risk factors, such as occupational exposures (ie, adenocarcinoma linked to wood dust exposure), and in the presence of premalignant lesions such as Schneiderian papillomas [98].


Staging and Post Therapy Assessment of Head and Neck Cancer. Patients most commonly present with nasal obstruction, rhinorrhea, and/or epistaxis. Symptoms can oftentimes be unilateral and can frequently be overlooked because of their overlap with more common benign etiologies [98]. Furthermore, pain is generally absent until there is associated skull base or nerve involvement. For these reasons, sinonasal tumors are commonly large at presentation [55,98]. Additionally, the sinonasal cavity has close proximity to complex skull base anatomy, the orbits, and the pterygopalatine fossae, which facilitates early disease extension.


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Chest CXR is not useful in the evaluation of pulmonary metastatic disease in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. Chest CT is far more sensitive in detecting pulmonary metastatic disease compared to radiography [15], with the sensitivity of CXR to detect pulmonary metastatic disease reported as low as 28% compared to chest CT [11]. The low sensitivity may in part be due to the small size of pulmonary nodules at presentation or peripheral location, in which CXR tends to be less reliable [11]. The use of CXR for detection of metastases has not been shown to improve prognosis, because pulmonary metastatic disease detected on CXR tends to be diagnosed at a late stage when it is not as amenable to treatment [18].


Staging and Post Therapy Assessment of Head and Neck Cancer. A heavy smoking history may also be a separate indication for CT chest imaging at initial staging, because tobacco use is a risk factor not only for squamous cell carcinoma of the head and neck but also for primary lung cancer [15,20]. Studies have shown that 7% to 14% of patients have as second lung primary at the time of initial staging of head and neck squamous cell carcinoma [15,21]. This patient population may also qualify for annual chest imaging as per the U.S. Preventative Services Task Force guidelines for annual lung cancer screening with low- dose CT in well-defined groups of high-risk smokers [20]. The use of IV contrast may improve detection of mediastinal and hilar adenopathy, distinguishing nodes from mediastinal vessels and aid in delineation of soft-tissue extension of skeletal metastatic disease. There is a paucity of relevant supportive literature specifically comparing the diagnostic performance of CT chest with IV contrast and CT chest without IV contrast.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the evaluation of suspected or diagnosed initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. A heavy smoking history may also be a separate indication for CT chest imaging at initial staging, because tobacco use is a risk factor not only for squamous cell carcinoma of the head and neck but also for primary lung cancer [15,20]. Studies have shown that 7% to 14% of patients have as second lung primary at the time of initial staging of head and neck squamous cell carcinoma [15,21]. This patient population may also qualify for annual chest


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer imaging as per the U.S. Preventative Services Task Force guidelines for annual lung cancer screening with low- dose CT in well-defined groups of high-risk smokers [20]. The use of IV contrast may improve detection of mediastinal and hilar adenopathy, distinguishing nodes from mediastinal vessels and aid in delineation of soft tissue extension of skeletal metastatic disease. Noncontrast CT chest may be considered as an alternative and is part of routine clinical practice, although there is paucity of relevant supportive literature evaluating the use of CT chest without IV contrast.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head With IV Contrast There is no relevant literature to support the use of CT of the head with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. CT head may provide sufficient coverage for the anatomic evaluation of the primary tumor site in the sinonasal cavity; however, inclusion of the neck is recommended to evaluate for cervical adenopathy for staging purposes.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without and With IV Contrast There is no relevant literature to support the use of CT of the head without and with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without IV Contrast There is no relevant literature to support the use of CT of the head without IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial With IV Contrast There is no relevant literature to support the use of CT maxillofacial with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. CT maxillofacial may be complementary in the anatomic evaluation of the primary site, in particular for the evaluation of osseous erosion. However, CT maxillofacial will typically not include evaluation of the neck and would therefore be inadequate for the staging of regional lymphadenopathy when performed alone and may best be used in combination with MRI or FDG-PET/CT.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without and With IV Contrast There is no relevant literature to support the use of CT maxillofacial without and with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without IV Contrast There is no relevant literature to support the use of CT maxillofacial without IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. CT maxillofacial without IV contrast would not provide sufficient evaluation of the soft tissue extent of disease but may be complementary in the anatomic evaluation of the primary site, in particular for the evaluation of osseous erosion. CT maxillofacial will typically not include evaluation of the neck and would therefore be inadequate for the staging of regional lymphadenopathy when performed alone and may best be used in combination with MRI or FDG-PET/CT.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck With IV Contrast Although protocols vary across institutions, for the purposes of this document, CT of the neck includes coverage from the top of the frontal sinuses down to the level of the aortic arch, with thin slices, multiplanar reformats, and both soft tissue and bony algorithms. CECT of the neck allows for the detection and localization of sinonasal tumors as well as regional nodal staging. CT provides excellent delineation of the sinonasal skeleton and is superior to MRI in the depiction of osseous anatomy [96]. The presence of skull base foraminal widening, which can be detected on thin-section CT and reconstructions, may alert to perineural tumor spread [96], and the precise determination of bony destruction or remodeling may prove useful in the characterization of slow-growing versus aggressive sinonasal tumors [99]. MRI is considered superior to CT in the delineation of the soft tissue extent of disease, including involvement of neighboring structures, findings that are necessary for the correct T staging of disease. Contrast-enhanced imaging is imperative to correctly identify and outline the primary tumor, distinguishing it from the surrounding normal soft tissues.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without and With IV Contrast There is no relevant literature to support the use of CT neck without and with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without IV Contrast There is no relevant literature to support the use of CT neck without IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. CT neck without IV contrast would not provide


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer sufficient evaluation of the soft tissue extent of disease but may be complementary in the anatomic evaluation of the primary site in particular for the evaluation of osseous erosion.


Staging and Post Therapy Assessment of Head and Neck Cancer. CTA Neck With IV Contrast There is no relevant literature to support the use of CTA with IV contrast of the head and neck in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. CTA of the neck can be used to identify patients at high risk of bleeding in the instance of locally advanced disease encroaching on the carotid arteries [41].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT allows for the detection and localization of primary tumor site and identification of regional nodal disease and distant metastases. FDG-PET/CT alone is not considered sufficient in initial staging because it may not provide detailed anatomic delineation of the primary site or detection of upstaging features needed for correct staging, surgical, and treatment planning [100]. Furthermore, previous authors have suggested that PET/CT may in fact overestimate the extension of the tumor [101]. However, FDG-PET/CT is recommended by the National Comprehensive Cancer Network as an adjunct in the workup of stage III and IV cancers [42]. FDG-PET/CT has shown increased sensitivity for detection of regional nodal disease, distant metastasis, and synchronous tumors over radiography and cross-sectional imaging with CT and MRI [42]. At initial staging, one study showed that distant metastases or a secondary cancer was discovered in 22% of patients, which in turn led to adjustments in planned therapy [102]. The utility of FDG-PET in lower-stage cancer is more controversial. However, FDG-PET/CT does confer a high NPV of 87% for lymph node metastasis in N0 cancer and 99% for distant metastatic disease [37,49,85], which is valuable in directing therapy.


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/MRI Skull Base to Mid-Thigh FDG-PET/MRI is a new imaging modality with a growing body of evidence demonstrating the feasibility of use in routine clinical evaluation of head and neck tumors with FDG-PET/MRI shown to have similar results to FDG- PET/CT [42,52-54,56,57].


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck With IV Contrast There is no relevant literature to support the use of MRA neck with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without and With IV Contrast There is no relevant literature to support the use of MRA neck without and with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without IV Contrast There is no relevant literature to support the use of MRA neck without IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without and With IV Contrast There is no relevant literature to support the use of MRI head without and with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. The coverage of an MRI of the head and the sequences used may be insufficient to completely evaluate the primary site in the paranasal sinuses or nasal cavity and will not include regional nodal staging. MRI head without and with IV contrast may be a useful adjunct to further delineate advanced intracranial extension of disease when suspected based on clinical grounds or prior imaging.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without IV Contrast There is no relevant literature to support the use of MRI head without IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck With IV Contrast There is no relevant literature to support the use of MRI orbits, face, and neck with IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Assessment of Head and Neck Cancer

Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without and With IV Contrast MRI orbits, face, and neck without and with IV contrast has superior soft tissue contrast resolution and with this an improved ability to delineate the soft tissue extent of the tumor [96], which is a key component in the T staging of disease and essential for surgical planning. Perineural tumor spread is more easily recognized with MRI compared to CT, as is the regional extension to neighboring structures such as the orbits, dura, and brain, and subtle marrow involvement [96]. Furthermore, the superior soft tissue contrast resolution of MRI can better distinguish tumors from sinus inflammatory changes and retain secretions compared to CT. Advanced tools, including higher- resolution imaging, diffusion-weighted and diffusion-tensor sequences, and MR perfusion techniques such as dynamic-contrast-enhanced MRI show promise in improving anatomic and functional imaging [103-105]. These tools may help to distinguish between benign and malignant disease, however, as of now they are not consistently used in routine clinical practice. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary site, distinguishing it from the surrounding normal soft tissues.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without IV Contrast There is no relevant literature to support the use of MRI orbits, face, and neck without IV contrast in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary site, distinguishing it from the surrounding normal soft tissues. The absence of IV contrast limits the ability to accurately delineate margin and the soft tissue extent of the tumor, which is a key component in the T staging of disease and essential for treatment planning. However, noncontrast MRI sequences are routinely used to identify the primary tumor and to define tumor extent, in particular marrow involvement, and are used in nodal staging.


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Paranasal Sinuses There is no relevant literature to support the use of radiography of the paranasal sinuses in the initial staging of suspected or diagnosed cancer of the paranasal sinuses or nasal cavity.


Staging and Post Therapy Assessment of Head and Neck Cancer. US Neck US can be a useful adjunct to cross-sectional imaging, in particular for nodal staging of head and neck cancer. Coupled with fine-needle aspiration and/or core-needle biopsy, nodal evaluation with US is a reliable tool and correlates well with staging, following neck dissection [62]. A range of sensitivities and specificities for detection of nodal disease are found in the literature, likely reflecting the highly operator-dependent nature of this technique. US alone has been shown to very sensitive (77.8%-96.8%) and specific (68.75%-97%) in detecting cervical nodal metastases [47,63-65].


Staging and Post Therapy Assessment of Head and Neck Cancer. Variant 4: Suspected or diagnosed cancer of a major salivary gland (parotid, submandibular, and sublingual glands). Initial staging. The salivary glands are classified into major and minor. The major salivary glands are paired bilateral parotid, submandibular, and sublingual glands. The minor salivary glands are located along the mucosa of the aerodigestive tract, including the oral cavity, nasal cavity, and pharynx, and tumors of the minor salivary glands occurring in various sites are included in the discussion of Variants 1, 2, and 3 above. Tumors of the major salivary glands are considered rare and account for 3% to 5% of all head and neck neoplasms and only 0.5% of all malignancies [106,107]. The most common site is the parotid gland, with about 70% arising from this site [108], followed by the submandibular gland, and lastly the sublingual gland. In general, the risk of malignancy is inversely proportional to the size of the gland. Therefore, the risk of cancer is greater in a sublingual gland lesion as opposed to a lesion in the parotid gland. The majority, approximately 70% to 80%, of these tumors are benign, with the most common benign tumor being pleomorphic adenoma (60%-70%) and Warthin tumor (5%-12%) [107]. A smaller percentage are malignant tumors, of which mucoepidermoid carcinoma, adenoid cystic carcinoma, lymphoma, and acinic cell carcinoma are the most common subtypes [107,109]. Furthermore, intraglandular lymphatic tissue predisposes the parotid glands to metastatic disease from locoregional cancers of the head and neck, as well as from distant tumors including the thyroid, breast, and lung [110]. Patients typically present with a palpable abnormality or pain. When there is perineural spread of disease, the patient may experience weakness of the facial muscles.


Staging and Post Therapy Assessment of Head and Neck Cancer. Surgery is considered the primary treatment in the majority of salivary gland tumors and imaging is obtained in large part to determine feasibility of resection [108]. Imaging plays a crucial role in the characterization of these lesions and is aimed at determining anatomic location, relation to surrounding structures, size, multiplicity, presence of perineural spread, and internal features. In turn, this information in conjunction with histologic type serves to define treatment approach and management. The appropriate imaging technique is generally determined by the site


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer of origin [108]. Fine-needle aspiration remains the most definitive tool to determine the benign or malignant nature of salivary gland masses [106]. US, cross-sectional imaging (CT, MRI), and functional imaging with FDG-PET/CT may be used independently or in combination to enhance the diagnostic strength and reduce the deficiency of each modality [106]. Furthermore, imaging characteristics are particularly helpful when fine-needle aspiration cannot be performed because of inaccessible location or patient preference. In established malignancy, staging to include nodal disease and distant metastases may be warranted. Locoregional metastatic adenopathy is seen in approximately 10% to 15% of malignant salivary gland tumors and is more common in high-grade than in low- grade cancer [108]. Distant metastatic disease is identified in 10% to 50% of patients at initial staging, and both lymph node and distant metastases are more common in the setting of tumor recurrence [108]. Perineural tumor spread is especially prevalent in adenoid cystic carcinoma and is reported in >50% of patients [108].


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Chest CXR is not considered useful in the evaluation of pulmonary metastatic disease in the initial staging of suspected or diagnosed cancer of a major salivary gland. Chest CT is far more sensitive in detecting pulmonary metastatic disease compared to radiography [15], with the sensitivity of CXR to detect pulmonary metastatic disease reported as low as 28% compared to chest CT [11]. The low sensitivity may in part be due to the small size of pulmonary nodules at presentation or peripheral location, in which CXR tends to be less reliable [11]. The use of CXR for detection of metastases has not been shown to improve prognosis because pulmonary metastatic disease detected on CXR tends to be diagnosed at a late stage when it is not as amenable to treatment [18].


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest With IV Contrast CT chest with IV contrast can accurately identify pulmonary metastasis and can be used to detect thoracic nodal and skeletal metastases to the ribs or vertebrae. The most common site of metastatic involvement beyond the head and neck in up to 90% of cases is to the lungs. A distant second are the bones followed by the liver, brain, and other sites [108]. For this reason, CT of the chest may be considered in cases of increased risk of metastatic disease, in particular in patients with high-grade malignant tumors. CT chest confers a superior spatial and contrast resolution when compared to radiography, allowing for the detection of small pulmonary nodules [15]. The use of IV contrast may improve detection of mediastinal and hilar adenopathy, distinguishing nodes from mediastinal vessels and aid in delineation of soft tissue extension of skeletal metastatic disease. There is a paucity of relevant supportive literature specifically comparing the diagnostic performance of CT chest with IV contrast and CT chest without IV contrast.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the evaluation of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest Without IV Contrast CT chest without IV contrast can accurately identify pulmonary metastasis and be used to detect thoracic nodal and skeletal metastases to the ribs or vertebrae. The most common site of metastatic involvement beyond the head and neck in up to 90% of cases is to the lungs. A distant second are the bones followed by the liver, brain, and other sites [108]. For this reason, CT of the chest may be considered in cases of increased risk of metastatic disease, in particular in patients with high-grade malignant tumors. CT chest confers a superior spatial localization and contrast resolution compared to radiography, allowing for the detection of small pulmonary nodules [15]. The use of IV contrast may improve detection of mediastinal and hilar adenopathy and aid in delineation of the soft tissue extension of skeletal metastatic disease. Noncontrast CT chest may be considered as an alternative and is part of routine clinical practice, although there is paucity of relevant supportive literature evaluating the use of CT chest without IV contrast.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head With IV Contrast There is no relevant literature to support the routine use of CT of the head with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without and With IV Contrast There is no relevant literature to support the routine use of CT of the head without and with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without IV Contrast There is no relevant literature to support the routine use of CT of the head without IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer CT Maxillofacial With IV Contrast There is no relevant literature to support the routine use of CT maxillofacial with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland. CT of the maxillofacial region may provide sufficient coverage for the anatomic evaluation of the primary tumor site. However, CT maxillofacial will typically not include evaluation of the neck and would therefore be inadequate for the staging of regional lymphadenopathy when performed alone and may best be used in combination with MRI or FDG-PET/CT.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without and With IV Contrast There is no relevant literature to support the routine use of CT maxillofacial without and with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without IV Contrast There is no relevant literature to support the routine use of CT maxillofacial without IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland. CT maxillofacial without IV contrast would not provide sufficient evaluation of the soft tissue extent of disease but may be complementary in the anatomic evaluation of the primary site in particular for the evaluation of osseous erosion. However, CT maxillofacial will typically not include evaluation of the neck and would therefore be inadequate for the staging of regional lymphadenopathy when performed alone and may best be used in combination with MRI or FDG-PET/CT.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck With IV Contrast Although protocols vary across institutions, for the purposes of this document, CT of the neck includes coverage from the top of the frontal sinuses down to the level of the aortic arch, with thin slices, multiplanar reformats, and both soft tissue and bony algorithms. CECT of the neck can give detailed anatomic delineation of the primary tumor site and adjacent anatomy, as well as provide regional nodal staging of the neck. Soft tissue resolution of CT is considered inferior to that of MRI [108], and certain cancers such as adenoid cystic carcinoma, mucoepidermoid carcinoma, and acinic cell carcinomas may lack significant contrast enhancement on CT, making their detection difficult by this modality [111]. Furthermore, MRI is considered superior in the detection of perineural spread and the soft tissue extent of disease [107,108], which are features needed for accurate T staging. Generally, CT is reserved for patients when there are indeterminate findings on MRI regarding osseous invasion [107,108]. CT may prove to be especially useful in the setting of suspected bone involvement because of its improved detection of cortical erosion [112]. Furthermore, CT is superior to MRI in the detection of calculus disease resulting in sialadenitis, which may behave as a tumor mimic [112]. Both CT and MRI are capable of assessing internal tumor features, extraglandular extension, enhancement, and in detecting regional adenopathy [112]. Conflicting results have been published regarding the ability of imaging to distinguish benign from malignant salivary gland tumors. Some studies suggest no statistically significant difference in diagnostic accuracy between US, CT, MRI, and PET/CT [106,113], whereas others have reported that CT is less accurate than MRI in the prediction of malignancy [107]. The use of IV contrast is recommended to better outline the extent of the primary site.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without and With IV Contrast There is no relevant literature to support the routine use of CT neck without and with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Neck Without IV Contrast There is no relevant literature to support the routine use of CT neck without IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland. CT neck without IV contrast would not provide sufficient evaluation of the soft tissue extent of disease but may be complementary in the anatomic evaluation of the primary site in particular for the evaluation of osseous erosion.


Staging and Post Therapy Assessment of Head and Neck Cancer. CTA Neck With IV Contrast There is no relevant literature to support the use of CTA neck with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland. CTA of the neck can be used to identify patients at high risk of bleeding in the instance of locally advanced disease encroaching on the carotid arteries [41].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT allows for the detection and localization of primary tumor site and identification of regional nodal disease and distant metastases. The utility of FDG-PET/CT depends on the tumor grade because low-grade salivary gland tumors have relatively low metabolism and may be occult on FDG-PET/CT. FDG-PET/CT is therefore not routinely recommended for initial staging of low-grade salivary gland tumors [108]. FDG-PET/CT has been shown to correctly identify the site of the primary tumor at a similar rate as MRI [114]. FDG-PET/CT alone is not


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer considered sufficient in the initial staging of salivary gland cancer because it does not provide detailed anatomic delineation of the primary site and detection of upstaging features needed. FDG-PET/CT is inferior to MRI for the diagnosis of perineural tumor spread because the small volume of disease and the limited spatial resolution of PET [42,115].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/CT in the initial staging of salivary gland tumors remains a controversial subject [108]. FDG-PET/CT may be superior to conventional cross-sectional imaging in staging of regional neck nodal disease and preoperative planning for neck dissection [114]. One study showed an increased detection rate of regional nodal metastases calculated at 100% with FDG-PET/CT versus 50% with MRI in combination with CXR [114]. Furthermore, FDG- PET/CT may be recommended in the setting of high-grade malignancy because of the increased frequency of distant metastases [108,114]. Other studies have shown that PET/CT provides additional information regarding cervical lymph nodes and distant disease in particular in patients with high-grade carcinomas [114]. The rate of change in treatment plan based on detection of regional and/or distant metastases in patients with salivary gland carcinoma with PET or PET/CT has been calculated at 15% to 47% [114].


Staging and Post Therapy Assessment of Head and Neck Cancer. FDG-PET/MRI Skull Base to Mid-Thigh FDG-PET/MRI is new imaging modality with a growing body of evidence demonstrating the feasibility of use for routine clinical imaging. A potential application of FDG-PET/MRI has been studied in the setting of suspected perineural tumor spread. Combining the soft tissue resolution of MRI and the functional evaluation of FDG-PET may be an attractive tool for diagnosis of the perineural spread in major salivary gland tumors [110].


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck With IV Contrast There is no relevant literature to support the use of MRA neck with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without and With IV Contrast There is no relevant literature to support the use of MRA neck without and with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRA Neck Without IV Contrast There is no relevant literature to support the use of MRA neck without IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head With IV Contrast There is no relevant literature to support the routine use of MRI of the head with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without and With IV Contrast There is no relevant literature to support the routine use of MRI of the head without and with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Head Without IV Contrast There is no relevant literature to support the routine use of MRI of the head without IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck With IV Contrast There is no relevant literature to support the routine use of MRI orbits, face, and neck with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without and With IV Contrast MRI orbits, face, and neck without and with IV contrast has superior soft tissue contrast resolution and with this an improved ability to delineate the soft tissue extent of tumor including the extraglandular extension of disease and perineural spread, which are key components in the T staging of disease and essential for treatment planning. Because of its superior soft tissue contrast resolution, MRI is considered the modality of choice for initial staging of major salivary gland cancer [108,112] relative to CECT. MRI overcomes many of the limitations encountered


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer by US by providing extended cross-sectional anatomic view of the area of interest and allowing for the detection of perineural tumor spread, deep-tissue extension, and marrow involvement [107]. Additionally, MRI may identify signal change and signs of extranodal extension in regional lymph nodes [112]. In the setting of sublingual and submandibular gland tumors, MRI accurately depicts the anatomy of the floor of the mouth, which is imperative in preoperative staging [107]. Because of the increased risk of malignancy of sublingual gland lesions, MRI is the imaging modality of choice [112].


Staging and Post Therapy Assessment of Head and Neck Cancer. Studies have reported no statistically significant difference in diagnostic accuracy between US, CT, MRI, and PET/CT to distinguish benign from malignant salivary gland tumors [106,113]. However, one meta-analysis showed MRI to have a higher sensitivity and specificity for differentiating between benign and malignant tumors [113]. The addition of advanced MRI techniques including diffusion-weighted imaging and perfusion imaging, such as dynamic contrast-enhanced, may improve the ability of MRI to distinguish benign from malignant salivary gland tumor with reported similar results to fine-needle aspiration [107], although these tools are not consistently used in routine clinical practice. Furthermore, preprocedural assessment with advanced MRI techniques may serve to identify internal sites of greater cellularity as a target for fine-needle aspiration [107]. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary site. Contrast administration aids in detecting of subtle mass extension and invasion of surrounding structures and in identifying perineural tumor spread [108].


Staging and Post Therapy Assessment of Head and Neck Cancer. MRI Orbits, Face, and Neck Without IV Contrast There is no relevant literature to support the routine use of MRI orbits, face, and neck with IV contrast in the initial staging of suspected or diagnosed cancer of a major salivary gland. Combined pre- and postcontrast imaging provides the best opportunity to correctly identify and delineate the primary site. The absence of IV contrast limits the ability to accurately delineate the margin and the soft tissue extent of the tumor, which is a key component in the T staging of disease and essential for surgical planning. However, noncontrast MR sequences are routinely used to identify the primary tumor, define tumor extent, in particular marrow involvement, and are used in nodal staging.


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Paranasal Sinuses There is no relevant literature to support the use of radiography of the paranasal sinuses in the initial staging of suspected or diagnosed cancer of a major salivary gland.


Staging and Post Therapy Assessment of Head and Neck Cancer. US Neck US allows for the detection and localization of major salivary gland tumors as well as regional nodal staging. US is often considered an appropriate first-line examination in the characterization of accessible salivary masses, in particular for submandibular gland tumors and masses of the superficial lobe of the parotid gland [107,108,112]. The superficial location of the major salivary glands renders their evaluation with high-resolution US an effective and safe modality for initial assessment [112,116]. US provides information regarding tissue characterization, anatomic delineation, and intralesional vascular pattern via Doppler technique. Additionally, nodal involvement may also be established by US, and this modality may serve as guidance for fine-needle aspiration. However, some caveats exist. US may be insufficient in the detection and characterization of masses located in the deep lobe of the parotid gland [107,112]. Additional limitations of US include the inability to appropriately assess deep compartment extension, perineural tumor spread, bone invasion, and oropharyngeal/retropharyngeal nodal involvement [112].


Staging and Post Therapy Assessment of Head and Neck Cancer. Variant 5: Treated cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck. Surveillance imaging or follow-up imaging for suspected or known recurrence. Tumors of the oral cavity, oropharynx, hypopharynx, and larynx as well as tumors in which a primary site is not identified but the patient presents with metastatic cervical adenopathy are generally treated with a combination of surgery, chemotherapy, and/or radiation therapy [117]. This represents a heterogeneous group of tumors with posttreatment prognosis dependent on the site of origin and histology, although the majority of tumors are squamous cell carcinomas. As many as 40% of patients suffer recurrence after therapy, and up to 25% of patients will develop distant metastases [118,119], with the majority of recurrences occurring in the first 2 years following treatment [16]. Rate of recurrence and distant metastatic disease is directly linked to advanced stage of disease before treatment. The early detection of residual disease and recurrence, diagnosis of distant metastases, and differentiation from posttreatment changes is vital in the follow-up imaging in order to offer salvage therapy and improved survival. The exact delineation of recurrence is crucial in determining the type of salvage therapy offered. Cross-sectional imaging remains the mainstay of posttreatment surveillance. Additionally, imaging in the posttreatment setting may be geared to detecting complications secondary to therapy, which include but are not limited to osteoradionecrosis,


Assessment of Head and Neck Cancer

Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer


Staging and Post Therapy Assessment of Head and Neck Cancer. infection, and flap failure. The appropriate imaging modality to evaluate each potential suspected complication will depend on the clinical scenario and is beyond the scope of this document.


Staging and Post Therapy Assessment of Head and Neck Cancer. Radiography Chest CXR is not considered useful for the evaluation of pulmonary metastatic disease in treated cancer of the oral cavity or oropharynx or hypopharynx, or larynx or cancer of unknown primary of the head and neck. Chest CT is far more sensitive in detecting pulmonary metastatic disease compared to radiography [15], with the sensitivity of CXR to detect pulmonary metastatic disease reported as low as 28% compared to chest CT [11]. The low sensitivity may in part be due to the small size of pulmonary nodules at presentation or peripheral location, in which CXR tends to be less reliable [11]. The use of CXR for detection of metastases has not been shown to improve prognosis because pulmonary metastatic disease detected on CXR tends to be diagnosed at a late stage when it is not as amenable to treatment [18].


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the evaluation of treated cancer of the oral cavity or oropharynx or hypopharynx or larynx or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head With IV Contrast There is no relevant literature to support the use of CT head with IV contrast as follow-up imaging or evaluation of suspected or known recurrence of treated cancer of the oral cavity, oropharynx, hypopharynx, larynx, or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. Assessment of Head and Neck Cancer CT Head Without and with IV Contrast There is no relevant literature to support the use of CT head without and with IV contrast as follow-up imaging or evaluation of suspected or known recurrence of treated cancer of the oral cavity, oropharynx, hypopharynx, larynx, or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Head Without IV Contrast There is no relevant literature to support the use of CT head without IV contrast as follow-up imaging or evaluation of suspected or known recurrence of treated cancer of the oral cavity, oropharynx, hypopharynx, larynx, or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial With IV Contrast There is no relevant literature to support the use of CT maxillofacial with IV contrast for the evaluation of known recurrence of treated cancer of the oral cavity, oropharynx, hypopharynx, larynx, or cancer of unknown primary of the head and neck. CT maxillofacial will typically not include the neck and therefore would be inadequate for the staging of regional lymphadenopathy and may not include the primary site in the hypopharynx or larynx.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without and With IV Contrast There is no relevant literature to support the use of CT maxillofacial without and with IV contrast for the evaluation of known recurrence of treated cancer of the oral cavity, oropharynx, hypopharynx, larynx, or cancer of unknown primary of the head and neck.


Staging and Post Therapy Assessment of Head and Neck Cancer. CT Maxillofacial Without IV Contrast There is no relevant literature to support the use of CT maxillofacial without IV contrast for the evaluation of known recurrence of treated cancer of the oral cavity, oropharynx, hypopharynx, larynx, or cancer of unknown primary of the head and neck.