An approach to trans-spatial and multi-spatial processes
in the head and neck RemyLobo,MDNeuroradiology
UniversityofMichiganUniversityofUtah
No disclosures
• Specialthanks:• AshokSrinivasan• KristineMosier• EdwardP.Quigley• RichardWiggins
Up front definitions
• Transspatiallesionsoccupyorinvolvemultiplecontiguousspaces
• Multispatiallesionsinvolvemultiplespaces,thoughinaNON-contiguousfashion
Transspatial categories
• Congenital• Formpriortofascialclosure(e.g.veno/lymphaticmalformation)
• Inflammatory/Infectious• Cellulitis/phlegmon/abscesscanaffectsurgicalmanagement
• Benigntumors• Nerveorigin(schwannoma)orvascular(hemangioma)
• Malignanttumors• Pharyngealmucosalsurfacesquamouscellcarcinoma(SCCa)caninvademultiplecontiguousspaces(bewareperineuraltumorspread)
Multispatial categories
• Congenital• Syndromicpresentations(PHACES,NF,etc…)
• Infectious/Inflammatory• Suppurativeortuberculousnodes
• Malignanttumors• SCCaorlymphomaoftheaerodigestivetract,andnodalburden
Case 1
• 24yoMwithfacialswelling
Transspatial or Multispatial?
Transspatial
• T2hyperintensefromsubmucosalsurfaceoforopharynxtothesublingualandsubmandibularspace• Extensiontothemasseter(masticatorspace)andelevationoftheSMAS• SMAS=superficialmusculatureaponeurosissystem,facialexpression
T2 hyperintense
• Initiallybelievetobealymphatic(orvenolymphatic)malformation
• U/Sguidedaspirationwasperformedinclinic
What biochemical or cytological analysis can be performed upon aspiration of the lesion to prove it is a ranula (i.e. salivary in origin)?
• Lipase• Amylase• Protein• Cellcount• alpha-fetoprotein
What biochemical or cytological analysis can be performed upon aspiration of the lesion to prove it is a ranula (i.e. salivary in origin)?
• Lipase• Amylase• Protein• Cellcount• alpha-fetoprotein
Ranula
• Sublingualspace/glandmucousretentioncyst• Simple–unilocularsublingualspacecyst• Unilateral=oval• Bilateral=horseshoe
• Diving–ruptureintothesubmandibularspace
Ranula
• OftenmatchesCSF(T2FSbestsequence)• Peripherymayenhance
• DDx:lymphaticmalformation,dermoid(fat),epidermoid(DWI),BCC,nodes,abscess,mucocele(SMG)orsialocele(true/false)
• Treatmentiscontroversial
Case 2
• 3yoMwithneckmass
Transspatial or Multispatial? Transspatial
• Fatattenuating/intensitysignalfrompleuralmarginintoneuralforamina,superiorlyontovisceralspace,parapharyngealspaceandposteriorcervicalspace• Vascularandneuronalencasement• Minimalseptaeassociated
What is the most likely diagnosis for this transspatial fat mass in a 3 year old male?
• Lipoblastoma• Liposarcoma• Lymphangioma• Ganglioneuroma• Rhabdomyosarcoma
What is the most likely diagnosis for this transspatial fat mass in a 3 year old male?
• Lipoblastoma• Liposarcoma• Lymphangioma• Ganglioneuroma• Rhabdomyosarcoma
Lipoblatoma/Lipoblastomatosis
• Raretumorofinfancy/childhood• Postnatallipoblastproliferation(whitefat)• 80-90%diagnosedby3years,rapidlygrowingneckmassinamale(3:1)• Lipoblastoma–focal/circumscribedclassicallysuperficial• Lipoblastomatosis–diffuseinfiltrativeformindeepertissue(pronetorecur)
Lipoblatoma/Lipoblastomatosis
• DDx:liposarcoma(uncommon),lymphangioma(vascular/lymphatic),ganglioneuroma(neuronaltissue),rhabdomyosarcoma(mesoderm)
• Someproposethatlipoblastomamaydifferentiateintomaturelipoma(ifgiventhechance)
Lipoblatoma/Lipoblastomatosis
• Variableadipocytes,mesenchymalcells,myxoidmatrix,welldefinedseptaeandfinevascularnetwork• Keytodistinguishfrommyxoidvariantliposarcoma,uncommonindemographic
• Completeexcisionisideal• 12-25%canrecur
Case 3
• 56yoFwithfaceswelling
Transspatial or Multispatial?
Transspatial
• MixedgasandfluidattenuationthroughtheSMAS,SMS,SLS,MS,PS,PPS,RPSontotheCS
• Lotsofspaces!!Buttheyalltouch
• Infectioncanspreadquickly
What is the most likely cause of this transspatial infectous process?
• Trauma• Dental• Hematogenous• Iatrogenic• Neoplastic
What is the most likely cause of this transspatial infectous process?
• Trauma• Dental• Hematogenous• Iatrogenic• Neoplastic
Dental infection
• 1-4%ofERvisits(non-traumaticdental)• Oftenuninsured,untreated(preventable)chronicinfections
• Apicallucency,disruptsadjacentcortex,directrouteofspreadalongmuscleandfascialplanes
Dental infection
• Over700differentbacteriamakeuptheoralmicrobiome• 100millionorganisms/mLsaliva
• “themouthisadirtyplace”
• Lookfordrainablefluidcollections• Treatmentissurgical,antimicrobial
Case 4
• 56yoFwithgeneticdisorder(unspecified)
Transspatial or Multispatial?
Multispatial
• RightorbitalperipherallyT2hyperintense,centrallyhypointensetarget-likelesion• Additionallesionontheleftscalp
• Enhancingleftbrachialplexuslesionwithsimilarcharacteristics
Which chromosome is abnormal in this patient?
• 3• 9• 16• 17• 22
Which chromosome is abnormal in this patient?
• 3• 9• 16• 17• 22
Neurofibromatosis (type I)
• Autosomaldominant,mutatedtumorsuppressorprotein(neurofibromin),leadstouncontrolledproliferation
• Plexiformneurofibroma(transspatial)isanNF-1defininglesion
• Historyishelpful!
Multiple additional NF-1 associations
• FASI–dentatenuclei,GP,brainstem,thalamus,HF• Lambdoidsuturedefectandsphenoiddysplasia• ICAstenosis,Moyamoya• Pheo,PTadenomas• Thoracicmeningoceles• Pseudoarthroses(longbones)
Case 5
• 28yoMwithALL,febrileneutropenia
• d
Transspatial or Multispatial?
• d
Transspatial
• Ethmoidopacification,nonenhancingmucosa,directextensionintothemedialrightorbit• Extensiveinflammatorystranding• MayhavehypointenseT2signal
What is the most common causative organism in neutropenic patients like the one shown?
• Aspergillus• Rhizopus• Mucor• Absidia• Staphaureus
What is the most common causative organism in neutropenic patients like the one shown?
• Aspergillus• Rhizopus• Mucor• Absidia• Staphaureus
AIFRS (Acute Invasive Fungal RhinoSinusitis)
• Rapidlyprogressivetransmucosalfungalinfection,perivascularspreadcommon• Canbehyperattenuating(mineralization)• VariableT1signal,oftenlowonT2(possiblyrelatedtoMn,othermetalliccompounds)• Nonenhancingmucosa=blacknecroticeschar
• Mortalitycanbe50-80%• Treatmentissurgical,antimicrobial,andaddressunderlyingcause(PMNLs!)
AIFRS
• Neutropenic=Aspergillus• DMpatients=Zygomycetes
• Poorpredictorsincludeorbitalorintracranialspread,inabilitytoaddresstheunderlyingcause
• Checklist:cavernoussinus,vasculature,cranialnerves,brainparenchyma
Case 6
• 75yoMwithhoarseness
Transspatial or Multispatial?
Transspatial
• Relativelyhyperattenuatingmasscenteredinthesupraglotticlarynx• Aryepiglotticfoldthickening,invasionofthepostcricoidspaceandpiriform• Paraglotticinfiltrationandextensionthroughthethyroidcartilageintotheoverlyingstrapmusculature
What is the most common laryngeal site for squamous cell cancer to present?
• Supraglottis• Glottis• Subglottis• Allareequal
What is the most common laryngeal site for squamous cell cancer to present?
• Supraglottis• Glottis• Subglottis• Allareequal
Which laryngeal site rarely has positive (metastatic) nodes at presentation?
• Supraglottis• Glottis• Subglottis• Allareequal
Which laryngeal site rarely has positive (metastatic) nodes at presentation?
• Supraglottis• Glottis• Subglottis• Allareequal
Squamous cell carcinoma (larynx)
• Glotticismostcommon(thiscaseisasupraglotticprimaryhowever)• Glotticisleastlikelytohavenodalinvolvement(limitedlymphatics)• Supraglottic/subglotticcommonlyhavenodalspreadofdisease
• SmokingandEtOHaremajorriskfactors,leadto“fieldcancerization”
Squamous cell carcinoma (larynx)
• Accuratestagingrequiresknowledgeofvocalcordfunction(cordparesisheraldsatLEASTaT3category)• InvasionbeyondthethyroidcartilageindicatesaT4acategory• T4breservedformediastinal,prevertebralorcarotidinvolvement
• FeaturesofENE:infiltrativefatplanes,irregularnodalborder,tetheringoftheadjacenttissues
Thank you for your time
• [email protected],commentsorfeedback
An approach to trans-spatial and multi-spatial processes
in the head and neck RemyLobo,MD