Elsevier

Clinical Radiology

Volume 66, Issue 1, January 2011, Pages 13-24
Clinical Radiology

Review
Post-treatment imaging appearances in head and neck cancer patients

https://doi.org/10.1016/j.crad.2010.09.004Get rights and content

Surgery and radiotherapy (with or without chemotherapy) for head and neck cancer can create a daunting array of radiological appearances post-treatment. The role of the radiologist lies not only in detecting recurrent neoplastic disease, but also identifying non-neoplastic changes that may account for clinical presentation and symptoms in this patient group. There are a number of non-neoplastic as well as neoplastic changes and disease entities that can present on surveillance imaging, such as primary resection and reconstructive surgical change, surgical neck dissection changes, radionecrosis, post-treatment denervation change, and radiotherapy-related secondary tumours. Some of these require conservative management, while others require more active treatment. Awareness and recognition of the imaging appearances of these post-treatment changes is therefore critical for the radiologist involved in the multidisciplinary care of the head and neck cancer patient.

Introduction

The radiological appearances of the post-treatment neck using computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound can present a daunting array of changes that may hinder the identification and evaluation of important complicating factors in the head and neck cancer patient, most notably in relation to residual or recurrent neoplastic disease. Nevertheless, recurrent tumour is not the only change that warrants early detection in this particular patient group following surgical and chemo-radiotherapy management. Surgical neck dissection, as well as tissue reconstruction, can yield frequent false-positive clinical signs of recurrent disease as a result of asymmetrical soft-tissue bulk and rather complex cross-sectional imaging appearances. Both acute and chronic inflammatory post-treatment changes can masquerade as potential recurrent disease symptoms. In addition, secondary tumours can arise as a direct consequence of the treatment that cured the original tumour.

The present review aims to provide some guidance on potential changes that may arise in the post-treatment neck and the relevant radiological appearances.

Section snippets

Neck dissection

En bloc surgical removal of cervical lymph nodes at risk of harbouring metastatic disease in head and neck malignancy is aimed at controlling metastatic disease as well as providing tissue for histopathological staging of the neoplastic disease. The cervical lymph nodes are closely related to a number of functionally important structures, including the internal jugular vein (IJV), the spinal accessory nerve, and the sternocleidomastoid muscle. The technique first described by Crile in 19061, 2,

Reconstructive surgery

Following tumour resection of the upper aerodigestive tract and neck dissection, sizeable defects may be left that require reconstruction. Various types of surgical tissue flaps have been created to reconstruct such defects. A flap is tissue transferred from one part of the body to another for reconstruction providing protective, cosmetic, and functional correction. Numerous classifications exist for flaps in the head and neck region. One is based on the type of primary tissue used: cutaneous,

Laser resection in the larynx

The carbon dioxide laser is frequently used for curative excision of early low volume T1 squamous cell carcinoma (SCC) of the larynx as well as benign lesions.3

Sclerosis of the arytenoid cartilage or cricoid cartilage adjacent to abnormal soft-tissue change in the larynx on CT (or MRI) imaging has long been used as a secondary sign of tumour with possible cartilage invasion.1, 19, 20, 21 However, similar non-neoplastic appearance on imaging can occur following laser resection of low volume

Soft-tissue changes

Within 2 weeks of radiotherapy, patho-physiologically, an acute inflammatory reaction within the deep tissues occurs and interstitial oedema develops, and fibrosis ensues. Macroscopically, the changes identified on CT and MR assessment are: thickening of the skin and platysma muscle; reticulation of the subcutaneous and deep tissue fat layers; retropharyngeal space oedema and effusion; increased enhancement of the major salivary glands; thickening and enhancement of the mucosa of the upper

Radiation-induced cerebral necrosis

Neurotoxicity is a well-recognized complication of high-dose radiotherapy. The radiation portals for tumours at or extending to the skull base may incorporate a certain volume of brain parenchyma. As a result, the irradiation of such tumours may result in damage to the adjacent brain parenchyma. The commonest examples include irradiation for NPC, which may result in collateral damage to the medial and inferior parts of the temporal lobes, or radiotherapy for aesthesioneuroblastoma where frontal

Sarcoma

Cahan et al. originally described the following criteria for post-radiation sarcoma: histological or radiological proof that there was no previous tumour in the involved tissue; development of sarcoma in an irradiated area; a sufficiently long interval or latent period between irradiation and the development of sarcoma of at least 5 years; histological proof of sarcoma.55, 56 Arlen et al. subsequently modified these criteria reducing allowable latent period to 3 to 4 years and also allowing the

Traumatic neuroma

Traumatic neuromas develop due to exaggerated response to nerve injury resulting in reactive hyperplasia and are not neoplastic; they indicate a thwarted attempt by the nerve injured or transected by trauma or surgery to regenerate resulting in tangle of neural fibres and connective tissue. Following neck dissection (or surgery such as parotidectomy), traumatic neuromas may arise from injury to peripheral sensory nerves usually from superficial branches of the sensory cervical plexus, the

Radiation-induced arteriopathy

Accelerated atherosclerosis is well recognized in head and neck cancer patients who have received radiotherapy.29, 68, 69, 70 Predisposing factors include elevated serum cholesterol and lipid levels and smoking; findings not uncommon in this particular patient group anyway. In addition, hypothyroidism, which may develop secondary to radiotherapy to this region, also favours degenerative arteriopathy. Changes include occlusive and subocclusive atheromatous plaque formation, mural thrombus, and

Conclusion

With improved survival following surgical and radiotherapy treatment for head and neck cancer, knowledge and recognition of the imaging appearances of post-treatment changes becomes increasingly important for the radiologist, particularly when attempting to distinguish these changes from tumour recurrence.

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