Ultrasound assessment of T1 Squamous Cell Carcinomas of the Tongue.

Ultrasound assessment of T1 Squamous Cell Carcinomas of the Tongue. Poster No.: C-2014 Congress: ECR 2015 Type: Educational Exhibit Authors: S. R. Rice, G. Price, L. Firmin, S. Morley, T. Beale; London/UK Keywords: Neoplasia, Cancer, Staging, Ultrasound, Oncology, Ear / Nose / Throat DOI: 10.1594/ecr2015/C-2014 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 38

Learning objectives The purpose of this educational exhibit is: To present an overview of the tumour staging of squamous cell carcinoma (SCC) of the tongue; To demonstrate the value of ultrasound in the comprehensive imaging staging of T1 tongue lesions; To demonstrate the technique of intra-oral ultrasound of the tongue; To outline potential difficulties with multi-modality radiological assessment in this patient cohort. Background The European age-standardised incidence rates of oral cancer have increased by 82% in 1 the UK between 1975 and 2011. There are likely to be several reasons for this, including changes in the prevalence of oral cancer risk factors such as smoking and alcohol use and co-infection with human papilloma virus (HPV). Definitive management of T1 tongue tumours (those under 2cm - Fig. 1 on page 6) remains controversial. Tumour thickness is related to depth of invasion and predictive of nodal metastasis development. 2 In T1 tumours the incidence of occult metastases is relatively high, with up to 33% staged N0 having metastases. 3 Where the depth of invasion exceeds 4 mm, 38-70% of patients will have occult spread. However, in early disease it is often difficult for the radiologist to accurately stage tumour depth, even using high-resolution MRI, the current gold standard. A further difficulty in this patient population is the effect of adjacent dental restoration, particularly dental amalgam. Both CT and MRI are prone to considerable 'star artefact' (Fig. 2 on page 7, Fig. 3 on page 8). Page 2 of 38

Fig. 2: Dental amalgam 'star' artefact References: University College Hospital - London/UK Page 3 of 38

Fig. 3: Dental amalgam artefact on T2-weighted MR image References: University College Hospital - London/UK Intra-oral ultrasound with a high frequency (18MHz) linear hockey-stick probe (Fig. 4 on page 9) facilitates accessible, rapid and reproducible assessment of the tongue (Fig. 6 on page 10). It has been demonstrated as accurate to up to 1mm and well tolerated 4 by patients. Page 4 of 38

Fig. 4: 18MHz 'Hockey Stick' probe References: University College Hospital - London/UK Page 5 of 38

Fig. 5: Intra-oral ultrasound of the tongue References: University College Hospital - London/UK Images for this section: Page 6 of 38

Fig. 1: T Staging for Tumors of the Oral Cavity Page 7 of 38

Fig. 2: Dental amalgam 'star' artefact Page 8 of 38

Fig. 3: Dental amalgam artefact on T2-weighted MR image Page 9 of 38

Fig. 4: 18MHz 'Hockey Stick' probe Page 10 of 38

Fig. 6: Ultrasound image of tongue lesion using 18MHz probe Page 11 of 38

Findings and procedure details All patients with suspected squamous cell carcinoma (SCC) of the tongue undergo triple modality assessment as part of the London Head & Neck cancer network using the following protocols: CT: Post contrast (90sec) 1mm axial imaging neck and chest. MRI: Pre and post contrast T1 and T2 PROPELLER sequences in the axial and coronal planes with post contrast fat-saturation sequencing. Diffusion Weighted imaging and ADC mapping. US: US bilateral neck +/- FNAC. Focused ultrasound assessment of the tongue may be achieved both directly -intra-orally on the tongue surface, or indirectly, through the buccal structures with the patient pressing the tongue against the cheek. Procedure: Intra oral US is achieved as follows: 18MHz probe Universal cross infection control Ask patient to lubricate tongue with water (a glass of water may be required) Hold tongue gently in extension with dry gauze Gently place probe on area of interest - care should be taken not to distort the tissues. ( Fig. 7 on page 21, Fig. 8 on page 22 ) Page 12 of 38

Fig. 7: Ultrasound assessment of the tongue using a covered 18MHz probe References: University College Hospital - London/UK Page 13 of 38

Fig. 8: Ultrasound assessment of the tongue using a covered 18MHz probe References: University College Hospital - London/UK Ultrasound versus MRI 1. Dental artefact - dental amalgam can significant artefact on both CT and MR which may completely obscure the area of interest when investigating superficial tongue lesions. Ultrasound allows accurate assessment of the tongue in these cases. 2. Spatial resolution - the spatial resolution of ultrasound is significantly higher than MR, enabling a much more accurate assessment of tumour depth. Page 14 of 38

3. Swallowing artefact [pain] - this can cause problems for MR assessment which can take 30-40 minutes. When in pain it can be particularly difficult for the patient to keep the tongue still, resulting in movement artefact and poor visualisation the tumour, or miscalculation of the tumour depth. 4. Position of the lesion - For lesions that are very posterior at the tongue base it is not possible to visualise the lesion from an intra-oral ultrasound approach, however, it may be possible to assess externally using a curvilinear probe. Case Example: 1 This is a case based demonstration where CT and/or MRI did not demonstrate the primary lesion, despite it being clinically evident. A small ulcerated lesion was visible on the right lateral surface of the tongue, which was visualised with ultrasound, Fig. 9 on page 23, measuring up to 3mm in depth. No corresponding abnormality could be identified on the MR images, Fig. 10 on page 24, Fig. 11 on page 25, Fig. 12 on page 26. Page 15 of 38

Fig. 9: Case 1 - intra-oral ultrasound assessment of the tongue demonstrating a lesion 3mm in depth References: University College Hospital - London/UK Page 16 of 38

Fig. 11: Case 1 - coronal contrast enhanced fat saturated T1-weighted MR image of the tongue. No lesion demonstrated. References: University College Hospital - London/UK Case Example: 2 This is a case based demonstration where CT and/or MRI did not demonstrate the primary lesion due to local artefact. Page 17 of 38

A small ulcerated lesion was identified on the left lateral surface of the tongue which was visualised using intra-oral ultrasound Fig. 13 on page 27, measuring up to 4mm in depth. On the corresponding MR images there is significant dental amalgam artefact which completely obscures the area of interest Fig. 14 on page 28, Fig. 15 on page 29, Fig. 16 on page 30. Fig. 13: Case 2 - Intra-oral ultrasound of the tongue demonstrating a lesion 4mm in depth and 10mm wide. References: University College Hospital - London/UK Page 18 of 38

Fig. 15: Case 2 - Axial fat-saturated contrast enhanced MR image of the tongue demonstrating significant dental amalgam artefact which obscures the tongue lesion. References: University College Hospital - London/UK Case Example: 3 This is a case based demonstration where CT and/or MRI demonstrated the primary lesions but was discordant with the assessment of tumour depth. Page 19 of 38

A lesion is visualised on intra-oral ultrasound measuring up to 7mm in depth Fig. 17 on page 31. On MR images a lesion can be seen in the left side of the tongue, measuring up to 11mm on the contrast enhanced images, Fig. 18 on page 32, Fig. 19 on page 33, Fig. 20 on page 34, Fig. 21 on page 35. Fig. 17: Case 3 - Intra-oral ultrasound image of the left lateral tongue demonstrating a lesion 7mm in depth References: University College Hospital - London/UK Page 20 of 38

Fig. 21: Case 3 - Coronal fat saturated, contrast enhanced T1 weighted image of the tongue, a lesion can be seen in the left lateral tongue measuring up to 11mm in depth. References: University College Hospital - London/UK Images for this section: Page 21 of 38

Fig. 7: Ultrasound assessment of the tongue using a covered 18MHz probe Page 22 of 38

Fig. 8: Ultrasound assessment of the tongue using a covered 18MHz probe Page 23 of 38

Fig. 9: Case 1 - intra-oral ultrasound assessment of the tongue demonstrating a lesion 3mm in depth Page 24 of 38

Fig. 10: Case 1 - Coronal T1 weighted image of the tongue. No lesion demonstrated. Page 25 of 38

Fig. 11: Case 1 - coronal contrast enhanced fat saturated T1-weighted MR image of the tongue. No lesion demonstrated. Page 26 of 38

Fig. 12: Case 1 - Axial T2-weighted image of the tongue. No lesion demonstrated. Page 27 of 38

Fig. 13: Case 2 - Intra-oral ultrasound of the tongue demonstrating a lesion 4mm in depth and 10mm wide. Page 28 of 38

Fig. 14: Case 2 - Coronal T1 weighted MR image of the tongue with significant dental amalgam artefact obscuring the lesion. Page 29 of 38

Fig. 15: Case 2 - Axial fat-saturated contrast enhanced MR image of the tongue demonstrating significant dental amalgam artefact which obscures the tongue lesion. Page 30 of 38

Fig. 16: Case 2 - Coronal fat-saturated contrast enhanced MR image of the tongue demonstrating significant dental amalgam artefact which obscures the tongue lesion. Page 31 of 38

Fig. 17: Case 3 - Intra-oral ultrasound image of the left lateral tongue demonstrating a lesion 7mm in depth Page 32 of 38

Fig. 18: Case 3 - Coronal T1 weighted image of the tongue, a lesion can be seen in the left lateral tongue. Page 33 of 38

Fig. 19: Case 3 - axial T1 weighted image of the tongue, a lesion can be seen in the left lateral tongue. Page 34 of 38

Fig. 20: Case 3 - Axial fat saturated, contrast enhanced T1 weighted image of the tongue, a lesion can be seen in the left lateral tongue. Page 35 of 38

Fig. 21: Case 3 - Coronal fat saturated, contrast enhanced T1 weighted image of the tongue, a lesion can be seen in the left lateral tongue measuring up to 11mm in depth. Page 36 of 38

Conclusion Ultrasound can provide high-resolution detail in the staging of T1 squamous cell lesions of the tongue that cannot be demonstrated on cross-sectional imaging. It is non-ionising, relatively inexpensive and reproducible. It is particularly valuble in early lesions or where cross sectional imaging is degraded by dental artifact. This can have important clinical implications in the accuate staging of squamous cell carcinoma of the tongue. Personal information Dr Scott Rice: UCL Centre for Medical Imaging, 3rd Floor East, 250 Euston Road, London NW1 2PG. scott.rice@ucl.ac.uk Dr Gemma Price: UCLH Foundation NHS Trust, 235 Euston Road, London NW1 2BU. Dr Louisa Firmin: UCLH Foundation NHS Trust, 235 Euston Road, London NW1 2BU. Dr Simon Morley: UCLH Foundation NHS Trust, 235 Euston Road, London NW1 2BU. Dr Timothy Beale: UCLH Foundation NHS Trust, 235 Euston Road, London NW1 2BU. References Page 37 of 38

1. 2. 3. 4. Cancer Research UK. Oral Cancer (C00-C06, C09-C10, C12-C14), European Age-Standardised Incidence Rates, Great Britain, 1975-2011. 2014 Pentenero M, Gandolfo S, Carrozzo M. Importance of tumor thickness and depth of invasion in nodal involvement and prognosis of oral squamous cell carcinoma: a review of the literature. Head Neck. 2005:27;1080-1091. Keski-Säntti H, Atula T, Törnwall j, Koivunen P, Mäkitie A. Elective neck treatment versus observation in patients with T1/T2 N0 squamous cell carcinoma of oral tongue. Oral Oncology. 2006: 42; 95-100. Shintani S, Nakayama B, Matsuura H, Hasegawa Y. Intraoral ultrasonography is useful to evaluate tumor thickness in tongue carcinoma. Am J Surg 1997;173: 345-347. Page 38 of 38