Laryngeal Cancer Imaging
Laryngeal Cancer Imaging
Laryngeal Cancer Imaging
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Abstract
Imaging plays an important complementary role to clinical examination and endoscopic biopsy in the evaluation of laryngeal cancers.
Avast majority of these cancers are squamous cell carcinomas(SCC). Crosssectional imaging with contrastenhanced computed
tomography(CT) and magnetic resonance(MR) imaging allows excellent depiction of the intricate anatomy of the larynx and the
characteristic patterns of submucosal tumor extension. CT, MRI and more recently PETCT, also provide vital information about
the status of cervical nodal disease, systemic metastases and any synchronous malignancies. Additionally, certain imagingbased
parameters like tumor volume and cartilaginous abnormalities have been used to predict the success of primary radiotherapy or
surgery in these patients. Integration of radiological findings with endoscopic evaluation greatly improves the pretherapeutic staging
accuracy of laryngeal cancers, and significantly impacts the choice of management strategies in these patients. Imaging studies
also help in the posttherapeutic surveillance and followup of patients with laryngeal cancers. In this article, we review the currently
used laryngeal imaging techniques and protocols, the key anatomic structures relevant to tumor spread and the characteristic
patterns of submucosal extension and invasion of laryngeal cancer. The role of CT, MRI and PETCT in the evaluation of patients
with laryngeal SCC and the impact of imaging findings on prognosis and clinical management is also discussed.
Key words: CT; imaging; laryngeal cancer; MRI; posttreatment; staging
Introduction
Cancers of the larynx constitute about 25% of all head
and neck malignancies. They commonly present in
adults between 50 and 70 years and show a strong male
predominance.[1] Over90% of these cancers are squamous
cell carcinomas (SCC). Tobacco smoking and alcohol
consumption are important risk factors for laryngeal
SCC.[1,2] Patients with laryngeal SCC have a higher risk for
synchronous malignancies arising from the lung and upper
aerodigestive tract.[3]
Majority of these SCCs are readily identified at endoscopy.
Integration of endoscopic findings with crosssectional
imaging to assess the submucosal and locoregional extent
of the SCC improves the T staging accuracy and influences
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DOI:
10.4103/0971-3026.107183
Imaging Protocols
CT
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Laryngeal cartilages
Figure 1C: Normal anatomy of larynx. Lateral view with one thyroid
lamina removed
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Figure 2A: Normal anatomy of larynx on axial contrast CT images supraglottis. Axial contrast CT image shows the tip of the epiglottis in
the midline (thin arrow)
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Figure 3B: Sagittal T1W MR image through the larynx. Sagittal T1W
MRI shows the epiglottis (thin arrow) and the preepiglottic fat space
(thick arrow). Note the close relationship of the base of tongue (elbow
arrow) with the epiglottis
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Extent
Contents
Supraglottis
Epiglottis
False cords
Aryepiglottic
folds
Arytenoid
cartilages
Preepiglottic
space
Paraglottic
space
Vestibule
Glottis
True vocal
cords
Anterior
commissure
Posterior
commissure
Subglottis
Figure 4A: Coronal image though the larynx. Line diagram shows
complete extent of the paraglottic space and the laryngeal ventricle
complex in the coronal plane. Note the laryngeal subdivisions
Tumor confined to one supraglottic subsite with normal vocal cord mobility
T2
T3
Tumor limited to the larynx, with vocal cord fixation and/or invasion of
postcricoid area or preepiglottic space
T4A Resectable: Tumor invading through the thyroid cartilage and/or other
extralaryngeal tissues(trachea, cervical soft tissues, strap muscles,
thyroid, esophagus)
T4B Unresectable: Tumor invading prevertebral space, encasing the carotid
artery, or invading mediastinal structures
Glottic SCC
T1
T3
Tumor limited to the larynx, with vocal cord fixation and/or invasion of
paraglottic space and/or inner cortex of thyroid cartilage
T4A Resectable: Tumor invading through the thyroid cartilage and/or other
extralaryngeal tissues(trachea, cervical soft tissues, deep extrinsic
muscles of tongue, strap muscles, thyroid, esophagus)
T4B Very advanced local disease: Tumor invading prevertebral space,
encasing the carotid artery, or invading mediastinal structures
Subglottic SCC
T1
T2
T3
a. Epiglottic SCC
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Figure 5B: Supraglottic mass arising from the epiglottis. Axial line
diagram shows the pathways of spread (thick black arrows) of epiglottic
mass (red colour)
Figure 5A: Supraglottic mass arising from the epiglottis. Sagittal line
diagram shows the pathways of spread (thick black arrows) of epiglottic
mass (red colour)
into the PES [Figures 5 and 6]. While the SCCs arising
from the mobile portion of the epiglottis may spread from
the PES further into the base of tongue and laterally into
the PGS, those arising from the stem often invade the low
PES and via the anterior commissure, reach the glottis or
subglottis [Figure 5]. The primary sign of PES invasion
at imaging is replacement of the normal fat by abnormal
enhancing soft tissue [Figures 6,7,9,18A and 19B]. The
sensitivity of CT and MRI to detect invasion of the PES
is 100% and the corresponding specificities are 93% and
8490%.[9,13]
b. Aryepiglottic fold(AE fold) SCC
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Subglottic SCC
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Figure 10: Supraglottic mass arising from the false cord. Line diagram
shows a section through the false cord in the axial plane. The mass in
the false cord is seen in red with pathways of spread in black curved
arrows
Figure 12B: Glottic mass. Axial line diagram shows the pathways of
spread (thick black arrows) of glottic SCC (red mass lesion)
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Figure 17C: Transglottic mass. Coronal line diagram shows the spread
of transglottic cancer in the paraglottic space
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PostTreatment Evaluation
Posttreatment followup is critical in detecting the response
to treatment and also for assessment of early recurrent
disease. Surveillance is especially crucial in the first 23years
because twothirds of local recurrence and nodal metastases
occur in this period.
A baseline pretreatment FDG PET CT has been recommended
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Figure 20B: Cartilage invasion on MRI. T2 axial image shows the large
mass with cartilage destruction. The intracartilage signal is similar to
the adjacent mass (thin arrow)
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Conclusions
CT and MRI play a significant complementary role to
clinical endoscopy in pretherapeutic staging of laryngeal
SCC. Determination of the precise extent of cancer spread
within the larynx(T staging) is the singlemost critical factor
guiding treatment decisions in patients with localised
laryngeal cancer. Additionally, imaging studies are routinely
used to assess associated nodal disease (Nstaging) and
systemic metastases(M staging), presence of synchronous
cancers and also posttherapeutic tumor recurrence in
these patients. Aclear understanding of the standard
imaging techniques and protocols for imaging the larynx,
and familiarity with the key anatomical features and
characteristic patterns of tumor spread within the different
regions of the larynx, are fundamental to the interpretation
of CT and MRI scans of these patients.
Acknowledgments
The authors would like to thank Tutu Behera and Rachnoutsav
Events for their help in making the schematic illustrations.
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