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Assessment of Metastatic Cervical Adenopathy Using Dynamic Contrast-Enhanced MR Imaging

Nancy J. Fischbeina, Susan M. Noworolskia, Roland G. Henrya, Michael J. Kaplanb, William P. Dillona and Sarah J. Nelsona

a Department of Radiology, University of California, San Francisco, San Francisco, CA
b Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA



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  		FIG 1. Patient 21, a 62-year-old man who was previously treated for squamous cell carcinoma of the floor of the mouth with primary and level I lymph node resection at an outside institution.

A, Coil-corrected axial view fast spin-echo T2-weighted image with fat saturation (4000/90/4) shows pathologically enlarged left neck nodes in level IIA and superficial to the sternocleidomastoid muscle (white arrows). The level IIA node shows internal areas of irregular low signal intensity (arrowheads), an appearance we would describe as nodal heterogeneity but not nodal necrosis. Note that it would be impossible to exclude these small, irregular areas from region of interest analysis. Also note the soft tissue deformity and absence of the ipsilateral submandibular gland due to previous resection.

B, Coil-corrected axial view contrast-enhanced T1-weighted image with fat saturation (600/20/2), obtained at the same level as that shown in A, shows slightly irregular enhancement of both nodes, with the irregularity clearly more pronounced in the level IIA node. Both nodes were pathologically confirmed to be tumor-involved.



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  		FIG 2. Patient 16, an 83-year-old woman with newly diagnosed squamous cell carcinoma of the lateral tongue.

A, Axial view fast spoiled gradient recalled image (10.4/2.3; flip angle, 30 degrees), obtained during bolus administration of contrast agent, shows a normal appearing left level IIA lymph node (arrow). SMG, submandibular gland.

B, Same image as that shown in A, magnified to emphasize the area of interest and with a region of interest indicator placed over the level IIA node. Pathologic analysis showed that this lymph node was not a tumor-involved node.

C, Plot of signal intensity versus time generated from the region of interest placed around the cervical lymph node shown in B. Derivation of peak time, peak enhancement, maximum up-slope, and washout slope are illustrated.



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  		FIG 3. Patient 6, a 57-year-old man with right oropharyngeal cancer and multiple palpable nodes who underwent pharyngectomy, right modified radical neck dissection, and left supraomohyoid neck dissection.

A, Coil-corrected fast spin-echo T2-weighted image with fat saturation (4000/90/4) shows the primary tumor (P), a dominant tumor-involved right level IIA node (white arrow), and two smaller tumor-involved level IIA lymph nodes (white arrowheads) on the right and left sides of the neck.

B, Baseline image (10.4/2.3; flip angle, 30 degrees) from the dynamic sequence shows the same tumor-involved nodes 117 seconds after contrast medium injection.

C, Enhanced dynamic image (10.4/2.3; flip angle, 30 degrees) shows the same tumor-involved nodes.

D, Plot of signal intensity versus time after injection of contrast agent, generated from regions of interest placed on the right level IIA tumor-involved node, a left level III non-tumor-involved node (not included on these images), the submandibular gland (SMG), and the sternocleidomastoid muscle (SCM). The different curve morphologies generated from these different tissues can be appreciated as shown by this comparison plot.



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  		FIG 4. Patient 7, a 52-year-old man who had previously undergone partial glossectomy for squamous cell carcinoma of the tongue, received no additional therapy, and then presented with a palpable right neck mass. Fine needle aspiration confirmed recurrent squamous cell carcinoma in the neck, and MR imaging revealed right cervical necrotic lymphadenopathy. The patient then underwent re-excision of the primary site and a right radical neck dissection.

A, Coil-corrected axial view enhanced dynamic image (10.4/2.3; flip angle, 30 degrees), acquired 195 s into the acquisition, shows a large, centrally necrotic, right level IIA lymph node.

B, Same image as that shown in A, with the region of interest encompassing the whole node shown.

C, Same image as that shown in A, with the region of interest encompassing only the rim shown.

D, Same image as that shown in A, with the region of interest encompassing only the necrotic core shown.

E, Plot of signal intensity versus time from this node, with curves generated from regions of interest placed on the whole node, the rim only, and the necrotic core only. Note that the "rim" curve is very similar to the "whole" curve but appears reduced in magnitude by a scaling factor related to the necrotic core. All these curves appear very different from the average non-tumor curve that is shown for comparison, but a statistically significant comparison was not possible because of the small number of grossly necrotic nodes.





Copyright © 2008 by the American Society of Neuroradiology. Print ISSN: 0195-6108 Online ISSN: 1936-959X