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Research ArticleHead and Neck Imaging

MRI with DWI for the Detection of Posttreatment Head and Neck Squamous Cell Carcinoma: Why Morphologic MRI Criteria Matter

A. Ailianou, P. Mundada, T. De Perrot, M. Pusztaszieri, P.-A. Poletti and M. Becker
American Journal of Neuroradiology April 2018, 39 (4) 748-755; DOI: https://doi.org/10.3174/ajnr.A5548
A. Ailianou
aFrom the Division of Radiology (A.A., P.M., T.D.P., P.-A.P., M.B.), Department of Imaging and Medical Informatics
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P. Mundada
aFrom the Division of Radiology (A.A., P.M., T.D.P., P.-A.P., M.B.), Department of Imaging and Medical Informatics
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T. De Perrot
aFrom the Division of Radiology (A.A., P.M., T.D.P., P.-A.P., M.B.), Department of Imaging and Medical Informatics
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M. Pusztaszieri
bDivision of Clinical Pathology (M.P.), Department of Laboratory and Genetics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.
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P.-A. Poletti
aFrom the Division of Radiology (A.A., P.M., T.D.P., P.-A.P., M.B.), Department of Imaging and Medical Informatics
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M. Becker
aFrom the Division of Radiology (A.A., P.M., T.D.P., P.-A.P., M.B.), Department of Imaging and Medical Informatics
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  • Fig 1.
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    Fig 1.

    DWIMRI obtained 23 months after RTH for laryngeal squamous cell carcinoma and increasing hoarseness. Axial T2 (A), T1 (B), and contrast-enhanced T1 (C) show an oval lesion (arrows) in the left false cord and left paraglottic space with intermediate signal intensity on T2, low signal intensity on T1, and moderate contrast enhancement highly suspicious for rHNSCC. The b=1000 image (D) shows high signal intensity in the lesion. ADC map (E) reveals low signal intensity compatible with restricted diffusion (arrow), further suggesting recurrence (ADCmean = 0.798 × 10−3 mm2/s). Endoscopic biopsy confirmed rHNSCC. F, Histology (H&E, original magnification ×100) shows squamous cell carcinoma with areas of densely packed and loosely packed squamous cells of variable size with keratin pearls (asterisk).

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    Fig 2.

    DWIMRI obtained 13 months after RTH and neck dissection for squamous cell carcinoma of the larynx and oropharynx. The patient had massive weight loss, malnutrition, and recurrent aspiration pneumonia. Endoscopy showed intact mucosa and fixed vocal cords bilaterally. Axial T2 (A), T1 (B), and contrast-enhanced T1 (C) show a triangular lesion (arrows) in the left true vocal cord with very low signal intensity on T2, low signal intensity on T1, and faint contrast enhancement suggesting post-RTH late fibrosis. In contrast, the right vocal cord (dashed arrows) displays high signal intensity on T2, low signal on T1, and enhancement. Findings on the right were interpreted as suggesting inflammatory edema. The b=1000 image (D) and ADC map (E) reveal no restricted diffusion in the right vocal cord (ADCmean = 1.643 × 10−3 mm2/s) and restricted diffusion with low ADC in the left vocal cord (ADCmean = 1.006 × 10−3 mm2/s). Because the nonfunctional larynx was the cause of malnutrition and recurrent aspiration pneumonia, laryngectomy was performed. F, Corresponding whole-organ histologic slice (H&E) shows extensive muscle fibrosis on the left (arrows) and inflammatory edema with denervation on the right (dashed arrows).

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    Fig 3.

    DWIMRI obtained 3 months after RTH and bucopharyngectomy for squamous cell carcinoma of the retromolar trigone. The patient had right reflex otalgia and progressing trismus. Endoscopy could not be performed. Axial T2 (A) and coronal STIR (B) images show a triangular, elongated, strongly hypointense lesion (arrows) on the right. There was no contrast enhancement (not shown). The diagnosis of benign post-RTH late fibrosis was made. The b=1000 image (C) reveals low signal. ADC map (D) likewise shows low signal (ADCmean = 0.731 × 10−3 mm2/s). Follow-up at 38 months (not shown) showed no recurrence but progressive scar retraction on MRI.

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    Fig 4.

    Box-and-whisker plots of ADCmean values in patients with post-RTH changes and post-RTH tumors. The horizontal lines represent the median values, and the bottom and the top of the box represent the 25th and 75th quartiles, respectively. Median ADCmean (25th–75th quartiles) for rHNSCC/sHNSCC = 1.061 (0.907–1.191) × 10−3 mm2/s. Median ADCmean (25th–75th quartiles) for post-RTH changes (late fibrosis and inflammatory edema together) = 1.671 (1.3355–1.915) × 10−3 mm2/s.

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    Fig 5.

    Box-and-whisker plots of ADCmean values in patients with post-RTH inflammatory edema, late fibrosis, and post-RTH HNSCCs. The horizontal lines represent the median values; the bottom and the top of the box represent the 25th and 75th quartiles, respectively. Median ADCmean (25th–75th quartiles) for rHNSCC/sHNSCC = 1.061 (0.907–1.191) × 10−3 mm2/s. Median ADCmean (25th–75th quartiles) for post-RTH inflammatory edema = 1.764 (1.575–1.938) × 10−3 mm2/s. Median ADCmean (25th–75th quartiles) for late fibrosis/mature scar post-RTH = 1.068 (0.939–1.152) × 10−3 mm2/s. There was no statistically significant difference between ADCmean in late fibrosis and rHNSCC/sHNSCC (P > .05). However, there was a significant difference between ADCmean in inflammatory post-RTH edema and late fibrosis (P < .05).

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    Fig 6.

    Receiver operating characteristic curve for the quantitative analysis of ADCmean values showing the area under the curve of 0.8678. A threshold of ADC = 1.222 × 10−3 mm2/s was found (see description in the text). This threshold yielded a sensitivity of 78.9%, a specificity of 86.2%, and an accuracy of 83.5%.

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    Table 1:

    Patient and tumor characteristics

    Primary HNSCCrHNSCC and sHNSSC after Treatment
    Total No. of patients100
    Total No. of tumors10338a
    Female (No.) (%)22 (22%)
    Male (No.) (%)78 (78%)
    Mean age (yr)59.3 ± 11.361.5 ± 11.1
    Treatment modalities in pHNSCC (No. of patients)NA
        RTH alone52
        Operation followed by RTH48
        Median interval (quartile 1–quartile 3) between end of RTH and rHNSCC/sHNSCC (mo)NA14 (4.5–51)
    Tumor location (No. of tumor sites) (%)
        Nasopharynx7 (6.8%)1 (2.6%)
        Oral cavity22 (21.3%)13 (34.2%)
        Oropharynx38 (36.9%)8 (21.1%)
        Hypopharynx12 (11.6%)5 (13.1%)
        Larynx19 (18.5%)6 (15.8%)
        Paranasal sinuses4 (3.9%)2 (5.3%)
        Base of the skull0 (0%)3 (7.9%)
        Unknown primary tumor1 (1%)0 (0%)
    T classificationb
        Tx1 (1%)0 (0%)
        Tis1 (1%)1 (2.6%)
        T114 (13.6%)3 (7.9%)
        T230 (29.1%)7 (18.4%)
        T325 (24.3%)6 (15.8%)
        T432 (31.0%)21 (55.3%)
    N classificationb
        N031 (30.1%)26 (68.4%)
        N120 (19.4%)5 (13.2%)
        N245 (43.7%)6 (15.8%)
        N36 (5.8%)1 (2.6%)
        Nx1 (1%)0 (0%)
    M classificationb
        Mx7 (6.8%)0 (0%)
        M094 (91.3%)36 (94.7%)
        M12 (1.9%)2 (5.3%)
    • Note:—NA indicates not applicable.

    • ↵a Thirty-three rHNSCCs and 5 sHNSCCs.

    • ↵b Tumor, Node, Metastasis (TNM) classification according to Union for International Cancer Control 2016.28

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    Table 2:

    Diagnostic performance of morphologic MRI alone, quantitative DWI alone, qualitative DWIMRI, and quantitative DWIMRI with ADCmean < 1.22 × 10−3 mm2/s

    Morphologic MRIQuantitative DWI with ADCmean < 1.22Morphologic MRI with Qualitative DWIMorphologic MRI with Quantitative DWI (ADCmean < 1.22)
    TP (No.)30303435
    TN (No.)52565962
    FP (No.)13963
    FN (No.)8843
    Sensitivity (%)a78.978.989.492.1
        (95% CI)(65.9–91.9)(65.9–91.9)(79.7–99.2)(83.5–100.0)
    Specificity (%)b80.086.190.895.4
        (95% CI)(70.3–89.7)(74.8–93.1)(83.7–97.8)(90.3–100.0)
    PPV (%)69.776.985.092.1
        (95% CI)(56.1–83.5)(60.3–88.3)(73.9–96.1)(83.5–100.0)
    NPV (%)86.687.593.695.4
        (95% CI)(78.1–95.3)(76.3–94.1)(87.6–99.6)(90.2–100.0)
    LR+c3.945.709.6919.9
        (95% CI)(2.36–6.59)(3.04–10.68)(4.48–20.9)(6.58–60.5)
    LR−d0.260.240.110.08
        (95% CI)(0.14–0.49)(0.13–0.45)(0.04–0.29)(0.03–0.24)
    • Note:—TP indicates true-positive; TN, true-negative; FP, false-positive; FN, false-negative; PPV, positive predictive value; NPV, negative predictive value.

    • ↵a Comparison of sensitivities: MRI vs DWI: P = 1; MRI vs qualitative DWIMRI: P = .10; MRI vs quantitative DWIMRI: P = .025; qualitative DWIMRI vs quantitative DWIMRI: P = .31; DWI vs quantitative DWIMRI: P = .05.

    • ↵b Comparison of specificities: MRI vs DWI: P = .34; MRI vs qualitative DWIMRI: P = .05; MRI vs quantitative DWIMRI: P = .004; qualitative DWIMRI vs quantitative DWIMRI: P = .18; DWI vs quantitative DWIMRI: P = .03.

    • ↵c Comparison of LR+: MRI vs DWI: P = .36; MRI vs qualitative DWIMRI: P = .03; MRI vs quantitative DWIMRI: P = .004; qualitative DWIMRI vs quantitative DWIMRI: P = .17; DWI vs quantitative DWIMRI: P = .02.

    • ↵d Comparison of LR−: MRI vs DWI: P = .85; MRI vs qualitative DWIMRI: P = .06; MRI vs quantitative DWIMRI: P = .01; qualitative DWIMRI vs quantitative DWIMRI: P = .24; DWI vs quantitative DWIMRI: P = .04.

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American Journal of Neuroradiology: 39 (4)
American Journal of Neuroradiology
Vol. 39, Issue 4
1 Apr 2018
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A. Ailianou, P. Mundada, T. De Perrot, M. Pusztaszieri, P.-A. Poletti, M. Becker
MRI with DWI for the Detection of Posttreatment Head and Neck Squamous Cell Carcinoma: Why Morphologic MRI Criteria Matter
American Journal of Neuroradiology Apr 2018, 39 (4) 748-755; DOI: 10.3174/ajnr.A5548

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MRI with DWI for the Detection of Posttreatment Head and Neck Squamous Cell Carcinoma: Why Morphologic MRI Criteria Matter
A. Ailianou, P. Mundada, T. De Perrot, M. Pusztaszieri, P.-A. Poletti, M. Becker
American Journal of Neuroradiology Apr 2018, 39 (4) 748-755; DOI: 10.3174/ajnr.A5548
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