This guideline is endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper summarises the current imaging modalities in use for head and neck cancer evaluation. It highlights their role in the management with recommendations on modality choice for each cancer subsite.</p

Al-Booz, Hoda

Colley, S

Dunn, Janet

Gibson, D

Hall, Peter

Hartley, Andrew G.J.

Hulme, Claire

Junor, Elizabeth

McConkey, Christopher C.

Mehanna, Hisham

Nutting, Christopher

Powell, Ned

Rahman, Joy K.

Rizwanullah, Mohammed

Robinson, Martin

Robinson, Max

Smith, Alison F.

V. von Zeidler, Sandra

Wieshmann, Hulya

Wong, Wai-Lup

English

University of Birmingham Research Portal

  Imaging in head and neck cancerColley, S; Gibson, D; Mehanna, Hesham; Wong, Wai-Lup; McConkey, Christopher; Rahman,Joy; Robinson, Max; Hartley, Andrew; Nutting, Christopher; Powell, Ned; Al-Booz, Hoda;Robinson, Martin; Junor, Elizabeth; Rizwanullah, Mohammed; V. von Zeidler, Sandra;Wieshmann, Hulya; Hulme, Claire; Smith, Alison F.; Hall, Peter; Dunn, JanetDOI:10.1017/S0022215116000396License:Creative Commons: Attribution (CC BY)Document VersionPublisher's PDF, also known as Version of recordCitation for published version (Harvard):Colley, S, Gibson, D, Mehanna, H, Wong, W-L, McConkey, CC, Rahman, JK, Robinson, M, Hartley, AGJ,Nutting, C, Powell, N, Al-Booz, H, Robinson, M, Junor, E, Rizwanullah, M, V. von Zeidler, S, Wieshmann, H,Hulme, C, Smith, AF, Hall, P & Dunn, J 2016, 'Imaging in head and neck cancer: United Kingdom nationalmultidisciplinary guidelines', The Journal of laryngology and otology, vol. 130, no. S2, pp. S28-S31.https://doi.org/10.1017/S0022215116000396Link to publication on Research at Birmingham portalGeneral rightsUnless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or thecopyright holders. The express permission of the copyright holder must be obtained for any use of this material other than for purposespermitted by law.•	Users may freely distribute the URL that is used to identify this publication.•	Users may download and/or print one copy of the publication from the University of Birmingham research portal for the purpose of privatestudy or non-commercial research.•	User may use extracts from the document in line with the concept of ‘fair dealing’ under the Copyright, Designs and Patents Act 1988 (?)•	Users may not further distribute the material nor use it for the purposes of commercial gain.Where a licence is displayed above, please note the terms and conditions of the licence govern your use of this document.When citing, please reference the published version.Take down policyWhile the University of Birmingham exercises care and attention in making items available there are rare occasions when an item has beenuploaded in error or has been deemed to be commercially or otherwise sensitive.If you believe that this is the case for this document, please contact UBIRA@lists.bham.ac.uk providing details and we will remove access tothe work immediately and investigate.Download date: 01. Feb. 2019Imaging in head and neck cancer: United KingdomNational Multidisciplinary GuidelinesH LEWIS-JONES1, S COLLEY2, D GIBSON31Department of Radiology, University Hospital Aintree, Liverpool, 2Department of Radiology, University HospitalBirmingham NHS Trust, Birmingham, UK, and 3Fiona Stanley Hospital, Murdoch, Perth, WA, AustraliaAbstractThis guideline is endorsed by the specialty associations involved in the care of head and neck cancer patients in theUK. This paper summarises the current imaging modalities in use for head and neck cancer evaluation. It highlightstheir role in the management with recommendations on modality choice for each cancer subsite.Recommendations• Offer appropriate radiological imaging, based on tumour extent, site and local expertise, to stage tumours andplan treatment for patients diagnosed with head and neck cancer. (G)• Consider positron emission tomography combined with computed tomography (PET–CT) imaging ifconventional cross-sectional imaging identifies no primary site. (R)• Offer PET–CT imaging 12 weeks after non-surgical treatment to detect residual disease. (R)IntroductionImaging in head and neck cancer has developedenormously over the last few decades. Advancedcross-sectional imaging modalities allow accuratestaging of disease and contribute significantly to man-agement decisions and prognosis. As a core member ofa multidisciplinary team, the radiologist has a key rolein presenting relevant multi-modality findings thatdefine disease extent, help with surveillance and high-light pertinent co-morbidities.1 This approach also aidspre-treatment counselling and patient consent.Prior to imaging, the primary site and the presenceor absence of neck metastases of a head and neckcancer has often been established clinically and it isnot unusual for a histological diagnosis to have beensecured from a representative biopsy. Therefore, theprimary role of radiology is in accurately stagingthe full extent and distant spread of disease with thecurrent tumour–node–metastasis (TNM) system, withan emphasis on features that will influence surgical ornon-surgical treatment options.The areas that radiological assessment should focuson are:• Local extent of the primary tumour• Spread to locoregional cervical lymph nodes• Detection of metastatic disease precluding cureand synchronous primary tumours of the lungand upper aero-digestive tract.Imaging modalitiesComputed tomography (CT)Contrast-enhanced CT is the mainstay for imagingprimary disease. It is widely available and establishedin practice. It incurs a significant radiation penaltyand iodinated contrast medium is contraindicated inthose with severe renal impairment. Conventionally,centres would image the neck and chest at presentationfrom the skull base to below the diaphragm.Spatially good but at a radiation cost, CT provideslimited soft tissue resolution. Bone detail such aswith mandibular or skull base involvement is a majorstrength. Modern multislice, slip-ring CT detector tech-nology rapidly acquires images without movementartefact as potential head and neck cancer patientsmay have difficulty with breathing, swallowing secre-tions and lying flat. Multiplanar and volume renderedimages are easily reconstructed. Contrast-enhancedCT allows opacification of vascular structures whilsttumours generally tend to be slower to enhance witha reduced wash out.Magnetic resonance imaging (MRI)Magnetic resonance imaging reflects biochemicaltissue characteristics and is largely influenced byproton density and other in situ paramagnetic sub-stances such as blood products and melanin content.Alongside the permanent bore magnet, additionalThe Journal of Laryngology & Otology (2016), 130 (Suppl. S2), S28–S31. GUIDELINE©JLO (1984) Limited, 2016. This is an Open Access article, distributed under the terms of the Creative CommonsAttribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, andreproduction in any medium, provided the original work is properly cited.doi:10.1017/S0022215116000396http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.transient magnetic gradients allow the development ofan ever increasing array of sequences that are able toreflect pathological processes from normal surroundingtissues. Multiple manufacturers may have differingterms for sometimes similar sequence parameters.T1-weighted ‘anatomical’ images have excellentspatial resolution, whilst T2-weighted images preferen-tially highlight oedema and therefore pathology. Ashort tau inversion-recovery (STIR) sequence retainsthe positive attributes of a T2-weighted image and sup-presses surrounding fat signal in normal or invadedtissues to best depict abnormal tissue as a bright,high signal. Magnetic resonance imaging has theability to dramatically improve tissue contrast reso-lution when compared with CT and, in compliantpatients without contraindications, it is the imagingmodality of choice for defining the primary extent oforal and oropharyngeal cancers. Detrimentally, whencompared with CT, scan times are much longer andcan vary from about 2–10 minutes for each sequence,during which the patient must keep relatively still.Intravenous gadolinium contrast agents allow staticand dynamic vascular assessments of a tumour and,when combined with fat suppression techniques, thiscan increase the conspicuity of occult pathology.Dental amalgam can reduce the image quality bothfor CT and MR imaging that makes interpretationmore challenging.Positron emission tomography combined with CT(PET–CT)Positron emission tomography combined with CTwhole-body imaging uses various labelled tracers tofuse conventional, anatomical CT images with a func-tional ‘map’ of the disease process. This is conductedon a single gantry at a single appointment. The com-monest tracer is 18 fluoro-deoxyglucose, which is pref-erentially transported and trapped into hypermetaboliccancerous or inflamed tissues. It is detected with agamma camera array. The patient’s fasted baselineglucose level should be measured and the isotope isinjected intravenously approximately 1 hour beforeimaging. The patient refrains from talking or chewing.Actual image acquisition takes about 30–45 minutes.Modern scanner design accurately co-registersmetabolic tissue activity with its precise anatomicallocation.In 2013, the Royal College of Radiologists publishedevidence-based guidelines for PET–CT use in headand neck cancer. Evaluating the patient with malignantcervical adenopathy from an unknown primary is oneof the main, up-front indications. Positron emissiontomography will detect an occult primary in approxi-mately one third of cases. Positron emission tomog-raphy combined with CT is also valuable in theassessment of suspected recurrence of head and neckcancer when there are extensive, confounding post-treatment changes on conventional imaging modalities.Its added benefit in routine surveillance following treat-ment is still being assessed. Along with other modal-ities, it has a role in staging malignant thyroid diseaseincluding medullary thyroid carcinoma.UltrasoundOffered as part of a modern one-stop service, ultra-sound, alongside fine needle aspiration cytology,allows rapid imaging assessments for those with anundiagnosed neck lump or suspected metastaticdisease in the neck. This technique can be notoriouslyoperator dependent, but has no detrimental patienteffects. Following slide preparation, best cytologicalpractice recommends prompt adequacy assessmentsand, ideally, the cytologist should be onsite for diag-nostic advice. In reality, a shortage of radiology andhistopathological input makes such universal servicedevelopments difficult.Ultrasonography comfortably delineates thyroidpathology and can detect occult pathological nodes(necrosis, microcalcification, etc.) that may feel clinic-ally normal in size. A normal node should remain ovoidin shape with a short axis diameter less than 10 mmwith a preserved echogenic hilum. Retropharyngealand superior mediastinal nodes cannot be assessedwith this modality.Current doctrine dictates that clinically and radio-logically N0 disease from high-risk primary sites ispresumed to have small volume nodal micrometastasisthat routinely requires prophylactic first-line treatmentas no available tests can guarantee a true pathologicalN0 status.FluoroscopyThere are a variety of scenarios when contrast swallowsand fluoroscopy are used in head and neck cancer,although the availability of local expertise can be vari-able. Contrast swallows can be used to assess the lengthof a malignant proximal oesophageal stricture, whilethe risk of airway aspiration or penetration is dynamic-ally assessed by videofluoroscopy. Alternative, non-oncological causes for dysphagia such as a pharyngealpouch may be diagnosed. Water soluble contraststudies are advised when the risk of aspiration ishigh, for instance, following recurrent chest infectionsor diminished pharyngeal sensory/motor functionafter surgery or radiation. The integrity of a surgicalanastomosis or the tract of an entero-cutaneous fistulacan also be well evaluated. These studies are oftenjointly performed with a speech and language therapistto facilitate decision making and may improve func-tional outcomes.Chest imagingWith common aetiological factors, patients with headand neck cancer have higher incidences of synchronousand metachronous primary lung tumours that may beIMAGING IN HEAD AND NECK CANCER: UK GUIDELINES S29http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.disseminated at presentation. At staging, CT imaging ofthe thorax is routinely advised.The most common protocol for patients with a headand neck cancer will therefore be to image the primarysite by either contrast-enhanced CT or magnetic reson-ance imaging (MRI), perform CT imaging of the chestand PET–CT for the unknown primaries.Specific tumour sitesThis section deals with specific tumour sites and high-lights areas where radiological evaluation is particular-ly important and often difficult.Oral cavityPreferred imaging modality: MRITongue tumours are routinely evaluated with MRI toaid treatment choices and prognosis. Early or advancedcancers of the buccal mucosa, retromolar trigone, palataland floor of mouth are more difficult to evaluate reliablyby imaging alone and good clinical correlation is essen-tial. Perineural and marrow involvement is best definedat MRI.In an attempt to avoid osteoradionecrosis, orthopan-tomograms are still requested to proactively treat dentalcaries and peri-apical disease.OropharynxPreferred imaging modality: MRISmall or subclinical primaries in the tonsil andtongue base that often present with cervical lymph-adenopathy can be difficult to identify with all formsof imaging including PET–CT. These tumours areoften best evaluated at MRI with STIR sequences andoften, may only be localised retrospectively after exam-ination and biopsy under anaesthesia. Extension ofmucosal tumours into the adjacent structures andneck spaces is well depicted with MR imaging.NasopharynxPreferred imaging modality: MRINasopharyngeal tumours commonly present at anadvanced stage with palpable nodal neck disease.Magnetic resonance imaging allows accurate classifica-tion of the primary site and nodal disease as per theTNM classification, based on disease extent.HypopharynxPreferred imaging modality: MRIIn those patients who have difficulty with swallow-ing, aspiration or breathing when supine, a CT scanwill need to be strongly considered.LarynxPreferred imaging modality: MRIDisease at the level of the vocal cords presentsearly with dysphonia and is well localised. Imaging isoften unnecessary for T1 disease unless extralaryngealdisease, cartilage involvement, nodal metastasis orchest pathology is suspected. MRI with contrast is thegold standard for depiction of cartilage involvement.Recommendations• Offer appropriate radiological imaging, basedon tumour extent, site and local expertise, tostage tumours and plan treatment for patientsdiagnosed with head and neck cancer (G)• Consider PET–CT imaging if conventionalcross-sectional imaging identifies no primarysite (R)• Offer PET–CT imaging 12 weeks afternon-surgical treatment to detect residualdisease (R)Salivary glandsMalignant salivary glands neoplasms are a veryheterogenous group of tumours, where tumour behav-iour and prognosis is dictated by the histology.Ultrasound techniques have a significant role to playin assessing the parenchymal mass, local adenopathyand guiding biopsies. Perineural or skull base involve-ment often requires a combined multi-modality CTand MR approach. The best imaging modality maybe guided by site-specific characteristics such asrespiratory motion artefact.SinusesMRI with contrast is the modality of choice to assesssurgical resectability issues around intracranial andorbital disease spread. Skull base involvement usuallyrequires a complementary CT study.Post-operative imagingThe choice of imaging in the post-operative scenario isdetermined by the specific clinical question posed.Complications are frequent with difficult head andneck resections. When the specific question is overpotential residual or recurrent disease, followingeither surgery or chemoradiotherapy, the choice forbaseline imaging mainly falls between a contrast CTof the neck and chest and a timely PET–CT study.As an exception, MRI has a large role to play specific-ally for nasopharyngeal, sinonasal and skull basetumour follow up.2 Early detection of residual diseaseis vital to planning further curative attempts. Thetiming of the scan is important. Dedicated CT givesbetter resolution and anatomical detail at the primarysite as well as detecting subcentrimetre early metastaticdisease in the lungs. Obliteration of fat planes and ana-tomical distortions makes interpretation difficult. Anegative, normal PET–CT 12 weeks post-treatmentlikely offers the best prognostic reassurance currently.3PET–CT fails to reliably distinguish inflammatoryH LEWIS-JONES, S COLLEY, D GIBSONS30http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.elements from malignant foci. Ultrasound guided pro-cedures still have a role to play in sampling in-determinate, persistent enlarged cervical nodes.Key points• Accurate image interpretation and staging heavilyinfluences optimal treatment strategies• Contrast-enhanced computed tomography of theskull base, neck and chest is ubiquitous in nature,readily available and the workhorse for routinetumour–node–metastasis staging of head and neckcancers• Positron emission tomography combined with com-puted tomography is of proven diagnostic benefitwhen searching for the unknown primaries, whenconventional imaging is non-informative• In compatible patients, magnetic resonance imaginghas superior soft tissue characterisation at severalprimary sites including oropharynx, nasopharynx/skull base and sinuses that greatly aid surgical plan-ning and resections• Ultrasound image guided diagnostic fine needle andcore biopsies are well established and cost-effectivein the context of good cytological/histological support• In certain instances, multi-modality approaches arecomplementary to each other but should not adverse-ly impact on the speed of the diagnostic pathway.References1 Olliff J, Richards P, Connor S, Wong WL, Beale T, Madani G.Head and neck cancers. In: Nicholson T, ed. Recommendationsfor Cross-Sectional Imaging in Cancer Management, 2nd edn.London: The Royal College of Radiologists, 2014. pp 3–192 Hermans R, ed. Head and Neck Cancer Imaging. New York:Springer, 20123 Mehanna H, Wong WL, McConkey CC, Rahman J, Robinson M,Hartley A et al. PETCT Surveillance versus Neck Dissection inAdvanced Head and Neck Cancer, N Engl J Med 2016;374:1444–54Address for correspondence:Daren Gibson,Fiona Stanley Hospital,Murdoch, Perth, WA, AustraliaE-mail: gibsondaren9@googlemail.comIMAGING IN HEAD AND NECK CANCER: UK GUIDELINES S31http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.

Imaging in head and neck cancer:United Kingdom national multidisciplinary guidelines

  University of BirminghamImaging in head and neck cancerColley, S; Gibson, D; Mehanna, Hisham; Wong, Wai-Lup; McConkey, Christopher C.;Rahman, Joy K.; Robinson, Max; Hartley, Andrew G.J.; Nutting, Christopher; Powell, Ned; Al-Booz, Hoda; Robinson, Martin; Junor, Elizabeth; Rizwanullah, Mohammed; V. von Zeidler,Sandra; Wieshmann, Hulya; Hulme, Claire; Smith, Alison F.; Hall, Peter; Dunn, JanetDOI:10.1017/S0022215116000396License:Creative Commons: Attribution (CC BY)Document VersionPublisher's PDF, also known as Version of recordCitation for published version (Harvard):Colley, S, Gibson, D, Mehanna, H, Wong, W-L, McConkey, CC, Rahman, JK, Robinson, M, Hartley, AGJ,Nutting, C, Powell, N, Al-Booz, H, Robinson, M, Junor, E, Rizwanullah, M, V. von Zeidler, S, Wieshmann, H,Hulme, C, Smith, AF, Hall, P & Dunn, J 2016, 'Imaging in head and neck cancer: United Kingdom nationalmultidisciplinary guidelines', The Journal of laryngology and otology, vol. 130, no. S2, pp. S28-S31.https://doi.org/10.1017/S0022215116000396Link to publication on Research at Birmingham portalGeneral rightsUnless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or thecopyright holders. The express permission of the copyright holder must be obtained for any use of this material other than for purposespermitted by law.•Users may freely distribute the URL that is used to identify this publication.•Users may download and/or print one copy of the publication from the University of Birmingham research portal for the purpose of privatestudy or non-commercial research.•User may use extracts from the document in line with the concept of ‘fair dealing’ under the Copyright, Designs and Patents Act 1988 (?)•Users may not further distribute the material nor use it for the purposes of commercial gain.Where a licence is displayed above, please note the terms and conditions of the licence govern your use of this document.When citing, please reference the published version.Take down policyWhile the University of Birmingham exercises care and attention in making items available there are rare occasions when an item has beenuploaded in error or has been deemed to be commercially or otherwise sensitive.If you believe that this is the case for this document, please contact UBIRA@lists.bham.ac.uk providing details and we will remove access tothe work immediately and investigate.Download date: 26. Dec. 2025Imaging in head and neck cancer: United KingdomNational Multidisciplinary GuidelinesH LEWIS-JONES1, S COLLEY2, D GIBSON31Department of Radiology, University Hospital Aintree, Liverpool, 2Department of Radiology, University HospitalBirmingham NHS Trust, Birmingham, UK, and 3Fiona Stanley Hospital, Murdoch, Perth, WA, AustraliaAbstractThis guideline is endorsed by the specialty associations involved in the care of head and neck cancer patients in theUK. This paper summarises the current imaging modalities in use for head and neck cancer evaluation. It highlightstheir role in the management with recommendations on modality choice for each cancer subsite.Recommendations• Offer appropriate radiological imaging, based on tumour extent, site and local expertise, to stage tumours andplan treatment for patients diagnosed with head and neck cancer. (G)• Consider positron emission tomography combined with computed tomography (PET–CT) imaging ifconventional cross-sectional imaging identifies no primary site. (R)• Offer PET–CT imaging 12 weeks after non-surgical treatment to detect residual disease. (R)IntroductionImaging in head and neck cancer has developedenormously over the last few decades. Advancedcross-sectional imaging modalities allow accuratestaging of disease and contribute significantly to man-agement decisions and prognosis. As a core member ofa multidisciplinary team, the radiologist has a key rolein presenting relevant multi-modality findings thatdefine disease extent, help with surveillance and high-light pertinent co-morbidities.1 This approach also aidspre-treatment counselling and patient consent.Prior to imaging, the primary site and the presenceor absence of neck metastases of a head and neckcancer has often been established clinically and it isnot unusual for a histological diagnosis to have beensecured from a representative biopsy. Therefore, theprimary role of radiology is in accurately stagingthe full extent and distant spread of disease with thecurrent tumour–node–metastasis (TNM) system, withan emphasis on features that will influence surgical ornon-surgical treatment options.The areas that radiological assessment should focuson are:• Local extent of the primary tumour• Spread to locoregional cervical lymph nodes• Detection of metastatic disease precluding cureand synchronous primary tumours of the lungand upper aero-digestive tract.Imaging modalitiesComputed tomography (CT)Contrast-enhanced CT is the mainstay for imagingprimary disease. It is widely available and establishedin practice. It incurs a significant radiation penaltyand iodinated contrast medium is contraindicated inthose with severe renal impairment. Conventionally,centres would image the neck and chest at presentationfrom the skull base to below the diaphragm.Spatially good but at a radiation cost, CT provideslimited soft tissue resolution. Bone detail such aswith mandibular or skull base involvement is a majorstrength. Modern multislice, slip-ring CT detector tech-nology rapidly acquires images without movementartefact as potential head and neck cancer patientsmay have difficulty with breathing, swallowing secre-tions and lying flat. Multiplanar and volume renderedimages are easily reconstructed. Contrast-enhancedCT allows opacification of vascular structures whilsttumours generally tend to be slower to enhance witha reduced wash out.Magnetic resonance imaging (MRI)Magnetic resonance imaging reflects biochemicaltissue characteristics and is largely influenced byproton density and other in situ paramagnetic sub-stances such as blood products and melanin content.Alongside the permanent bore magnet, additionalThe Journal of Laryngology & Otology (2016), 130 (Suppl. S2), S28–S31. GUIDELINE©JLO (1984) Limited, 2016. This is an Open Access article, distributed under the terms of the Creative CommonsAttribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, andreproduction in any medium, provided the original work is properly cited.doi:10.1017/S0022215116000396http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.transient magnetic gradients allow the development ofan ever increasing array of sequences that are able toreflect pathological processes from normal surroundingtissues. Multiple manufacturers may have differingterms for sometimes similar sequence parameters.T1-weighted ‘anatomical’ images have excellentspatial resolution, whilst T2-weighted images preferen-tially highlight oedema and therefore pathology. Ashort tau inversion-recovery (STIR) sequence retainsthe positive attributes of a T2-weighted image and sup-presses surrounding fat signal in normal or invadedtissues to best depict abnormal tissue as a bright,high signal. Magnetic resonance imaging has theability to dramatically improve tissue contrast reso-lution when compared with CT and, in compliantpatients without contraindications, it is the imagingmodality of choice for defining the primary extent oforal and oropharyngeal cancers. Detrimentally, whencompared with CT, scan times are much longer andcan vary from about 2–10 minutes for each sequence,during which the patient must keep relatively still.Intravenous gadolinium contrast agents allow staticand dynamic vascular assessments of a tumour and,when combined with fat suppression techniques, thiscan increase the conspicuity of occult pathology.Dental amalgam can reduce the image quality bothfor CT and MR imaging that makes interpretationmore challenging.Positron emission tomography combined with CT(PET–CT)Positron emission tomography combined with CTwhole-body imaging uses various labelled tracers tofuse conventional, anatomical CT images with a func-tional ‘map’ of the disease process. This is conductedon a single gantry at a single appointment. The com-monest tracer is 18 fluoro-deoxyglucose, which is pref-erentially transported and trapped into hypermetaboliccancerous or inflamed tissues. It is detected with agamma camera array. The patient’s fasted baselineglucose level should be measured and the isotope isinjected intravenously approximately 1 hour beforeimaging. The patient refrains from talking or chewing.Actual image acquisition takes about 30–45 minutes.Modern scanner design accurately co-registersmetabolic tissue activity with its precise anatomicallocation.In 2013, the Royal College of Radiologists publishedevidence-based guidelines for PET–CT use in headand neck cancer. Evaluating the patient with malignantcervical adenopathy from an unknown primary is oneof the main, up-front indications. Positron emissiontomography will detect an occult primary in approxi-mately one third of cases. Positron emission tomog-raphy combined with CT is also valuable in theassessment of suspected recurrence of head and neckcancer when there are extensive, confounding post-treatment changes on conventional imaging modalities.Its added benefit in routine surveillance following treat-ment is still being assessed. Along with other modal-ities, it has a role in staging malignant thyroid diseaseincluding medullary thyroid carcinoma.UltrasoundOffered as part of a modern one-stop service, ultra-sound, alongside fine needle aspiration cytology,allows rapid imaging assessments for those with anundiagnosed neck lump or suspected metastaticdisease in the neck. This technique can be notoriouslyoperator dependent, but has no detrimental patienteffects. Following slide preparation, best cytologicalpractice recommends prompt adequacy assessmentsand, ideally, the cytologist should be onsite for diag-nostic advice. In reality, a shortage of radiology andhistopathological input makes such universal servicedevelopments difficult.Ultrasonography comfortably delineates thyroidpathology and can detect occult pathological nodes(necrosis, microcalcification, etc.) that may feel clinic-ally normal in size. A normal node should remain ovoidin shape with a short axis diameter less than 10 mmwith a preserved echogenic hilum. Retropharyngealand superior mediastinal nodes cannot be assessedwith this modality.Current doctrine dictates that clinically and radio-logically N0 disease from high-risk primary sites ispresumed to have small volume nodal micrometastasisthat routinely requires prophylactic first-line treatmentas no available tests can guarantee a true pathologicalN0 status.FluoroscopyThere are a variety of scenarios when contrast swallowsand fluoroscopy are used in head and neck cancer,although the availability of local expertise can be vari-able. Contrast swallows can be used to assess the lengthof a malignant proximal oesophageal stricture, whilethe risk of airway aspiration or penetration is dynamic-ally assessed by videofluoroscopy. Alternative, non-oncological causes for dysphagia such as a pharyngealpouch may be diagnosed. Water soluble contraststudies are advised when the risk of aspiration ishigh, for instance, following recurrent chest infectionsor diminished pharyngeal sensory/motor functionafter surgery or radiation. The integrity of a surgicalanastomosis or the tract of an entero-cutaneous fistulacan also be well evaluated. These studies are oftenjointly performed with a speech and language therapistto facilitate decision making and may improve func-tional outcomes.Chest imagingWith common aetiological factors, patients with headand neck cancer have higher incidences of synchronousand metachronous primary lung tumours that may beIMAGING IN HEAD AND NECK CANCER: UK GUIDELINES S29http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.disseminated at presentation. At staging, CT imaging ofthe thorax is routinely advised.The most common protocol for patients with a headand neck cancer will therefore be to image the primarysite by either contrast-enhanced CT or magnetic reson-ance imaging (MRI), perform CT imaging of the chestand PET–CT for the unknown primaries.Specific tumour sitesThis section deals with specific tumour sites and high-lights areas where radiological evaluation is particular-ly important and often difficult.Oral cavityPreferred imaging modality: MRITongue tumours are routinely evaluated with MRI toaid treatment choices and prognosis. Early or advancedcancers of the buccal mucosa, retromolar trigone, palataland floor of mouth are more difficult to evaluate reliablyby imaging alone and good clinical correlation is essen-tial. Perineural and marrow involvement is best definedat MRI.In an attempt to avoid osteoradionecrosis, orthopan-tomograms are still requested to proactively treat dentalcaries and peri-apical disease.OropharynxPreferred imaging modality: MRISmall or subclinical primaries in the tonsil andtongue base that often present with cervical lymph-adenopathy can be difficult to identify with all formsof imaging including PET–CT. These tumours areoften best evaluated at MRI with STIR sequences andoften, may only be localised retrospectively after exam-ination and biopsy under anaesthesia. Extension ofmucosal tumours into the adjacent structures andneck spaces is well depicted with MR imaging.NasopharynxPreferred imaging modality: MRINasopharyngeal tumours commonly present at anadvanced stage with palpable nodal neck disease.Magnetic resonance imaging allows accurate classifica-tion of the primary site and nodal disease as per theTNM classification, based on disease extent.HypopharynxPreferred imaging modality: MRIIn those patients who have difficulty with swallow-ing, aspiration or breathing when supine, a CT scanwill need to be strongly considered.LarynxPreferred imaging modality: MRIDisease at the level of the vocal cords presentsearly with dysphonia and is well localised. Imaging isoften unnecessary for T1 disease unless extralaryngealdisease, cartilage involvement, nodal metastasis orchest pathology is suspected. MRI with contrast is thegold standard for depiction of cartilage involvement.Recommendations• Offer appropriate radiological imaging, basedon tumour extent, site and local expertise, tostage tumours and plan treatment for patientsdiagnosed with head and neck cancer (G)• Consider PET–CT imaging if conventionalcross-sectional imaging identifies no primarysite (R)• Offer PET–CT imaging 12 weeks afternon-surgical treatment to detect residualdisease (R)Salivary glandsMalignant salivary glands neoplasms are a veryheterogenous group of tumours, where tumour behav-iour and prognosis is dictated by the histology.Ultrasound techniques have a significant role to playin assessing the parenchymal mass, local adenopathyand guiding biopsies. Perineural or skull base involve-ment often requires a combined multi-modality CTand MR approach. The best imaging modality maybe guided by site-specific characteristics such asrespiratory motion artefact.SinusesMRI with contrast is the modality of choice to assesssurgical resectability issues around intracranial andorbital disease spread. Skull base involvement usuallyrequires a complementary CT study.Post-operative imagingThe choice of imaging in the post-operative scenario isdetermined by the specific clinical question posed.Complications are frequent with difficult head andneck resections. When the specific question is overpotential residual or recurrent disease, followingeither surgery or chemoradiotherapy, the choice forbaseline imaging mainly falls between a contrast CTof the neck and chest and a timely PET–CT study.As an exception, MRI has a large role to play specific-ally for nasopharyngeal, sinonasal and skull basetumour follow up.2 Early detection of residual diseaseis vital to planning further curative attempts. Thetiming of the scan is important. Dedicated CT givesbetter resolution and anatomical detail at the primarysite as well as detecting subcentrimetre early metastaticdisease in the lungs. Obliteration of fat planes and ana-tomical distortions makes interpretation difficult. Anegative, normal PET–CT 12 weeks post-treatmentlikely offers the best prognostic reassurance currently.3PET–CT fails to reliably distinguish inflammatoryH LEWIS-JONES, S COLLEY, D GIBSONS30http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.elements from malignant foci. Ultrasound guided pro-cedures still have a role to play in sampling in-determinate, persistent enlarged cervical nodes.Key points• Accurate image interpretation and staging heavilyinfluences optimal treatment strategies• Contrast-enhanced computed tomography of theskull base, neck and chest is ubiquitous in nature,readily available and the workhorse for routinetumour–node–metastasis staging of head and neckcancers• Positron emission tomography combined with com-puted tomography is of proven diagnostic benefitwhen searching for the unknown primaries, whenconventional imaging is non-informative• In compatible patients, magnetic resonance imaginghas superior soft tissue characterisation at severalprimary sites including oropharynx, nasopharynx/skull base and sinuses that greatly aid surgical plan-ning and resections• Ultrasound image guided diagnostic fine needle andcore biopsies are well established and cost-effectivein the context of good cytological/histological support• In certain instances, multi-modality approaches arecomplementary to each other but should not adverse-ly impact on the speed of the diagnostic pathway.References1 Olliff J, Richards P, Connor S, Wong WL, Beale T, Madani G.Head and neck cancers. In: Nicholson T, ed. Recommendationsfor Cross-Sectional Imaging in Cancer Management, 2nd edn.London: The Royal College of Radiologists, 2014. pp 3–192 Hermans R, ed. Head and Neck Cancer Imaging. New York:Springer, 20123 Mehanna H, Wong WL, McConkey CC, Rahman J, Robinson M,Hartley A et al. PETCT Surveillance versus Neck Dissection inAdvanced Head and Neck Cancer, N Engl J Med 2016;374:1444–54Address for correspondence:Daren Gibson,Fiona Stanley Hospital,Murdoch, Perth, WA, AustraliaE-mail: gibsondaren9@googlemail.comIMAGING IN HEAD AND NECK CANCER: UK GUIDELINES S31http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.

  University of BirminghamImaging in head and neck cancerColley, S; Gibson, D; Mehanna, Hisham; Wong, Wai-Lup; McConkey, Christopher C.;Rahman, Joy K.; Robinson, Max; Hartley, Andrew G.J.; Nutting, Christopher; Powell, Ned; Al-Booz, Hoda; Robinson, Martin; Junor, Elizabeth; Rizwanullah, Mohammed; V. von Zeidler,Sandra; Wieshmann, Hulya; Hulme, Claire; Smith, Alison F.; Hall, Peter; Dunn, JanetDOI:10.1017/S0022215116000396License:Creative Commons: Attribution (CC BY)Document VersionPublisher's PDF, also known as Version of recordCitation for published version (Harvard):Colley, S, Gibson, D, Mehanna, H, Wong, W-L, McConkey, CC, Rahman, JK, Robinson, M, Hartley, AGJ,Nutting, C, Powell, N, Al-Booz, H, Robinson, M, Junor, E, Rizwanullah, M, V. von Zeidler, S, Wieshmann, H,Hulme, C, Smith, AF, Hall, P & Dunn, J 2016, 'Imaging in head and neck cancer: United Kingdom nationalmultidisciplinary guidelines', The Journal of laryngology and otology, vol. 130, no. S2, pp. S28-S31.https://doi.org/10.1017/S0022215116000396Link to publication on Research at Birmingham portalGeneral rightsUnless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or thecopyright holders. 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Mar. 2020Imaging in head and neck cancer: United KingdomNational Multidisciplinary GuidelinesH LEWIS-JONES1, S COLLEY2, D GIBSON31Department of Radiology, University Hospital Aintree, Liverpool, 2Department of Radiology, University HospitalBirmingham NHS Trust, Birmingham, UK, and 3Fiona Stanley Hospital, Murdoch, Perth, WA, AustraliaAbstractThis guideline is endorsed by the specialty associations involved in the care of head and neck cancer patients in theUK. This paper summarises the current imaging modalities in use for head and neck cancer evaluation. It highlightstheir role in the management with recommendations on modality choice for each cancer subsite.Recommendations• Offer appropriate radiological imaging, based on tumour extent, site and local expertise, to stage tumours andplan treatment for patients diagnosed with head and neck cancer. (G)• Consider positron emission tomography combined with computed tomography (PET–CT) imaging ifconventional cross-sectional imaging identifies no primary site. (R)• Offer PET–CT imaging 12 weeks after non-surgical treatment to detect residual disease. (R)IntroductionImaging in head and neck cancer has developedenormously over the last few decades. Advancedcross-sectional imaging modalities allow accuratestaging of disease and contribute significantly to man-agement decisions and prognosis. As a core member ofa multidisciplinary team, the radiologist has a key rolein presenting relevant multi-modality findings thatdefine disease extent, help with surveillance and high-light pertinent co-morbidities.1 This approach also aidspre-treatment counselling and patient consent.Prior to imaging, the primary site and the presenceor absence of neck metastases of a head and neckcancer has often been established clinically and it isnot unusual for a histological diagnosis to have beensecured from a representative biopsy. Therefore, theprimary role of radiology is in accurately stagingthe full extent and distant spread of disease with thecurrent tumour–node–metastasis (TNM) system, withan emphasis on features that will influence surgical ornon-surgical treatment options.The areas that radiological assessment should focuson are:• Local extent of the primary tumour• Spread to locoregional cervical lymph nodes• Detection of metastatic disease precluding cureand synchronous primary tumours of the lungand upper aero-digestive tract.Imaging modalitiesComputed tomography (CT)Contrast-enhanced CT is the mainstay for imagingprimary disease. It is widely available and establishedin practice. It incurs a significant radiation penaltyand iodinated contrast medium is contraindicated inthose with severe renal impairment. Conventionally,centres would image the neck and chest at presentationfrom the skull base to below the diaphragm.Spatially good but at a radiation cost, CT provideslimited soft tissue resolution. Bone detail such aswith mandibular or skull base involvement is a majorstrength. Modern multislice, slip-ring CT detector tech-nology rapidly acquires images without movementartefact as potential head and neck cancer patientsmay have difficulty with breathing, swallowing secre-tions and lying flat. Multiplanar and volume renderedimages are easily reconstructed. Contrast-enhancedCT allows opacification of vascular structures whilsttumours generally tend to be slower to enhance witha reduced wash out.Magnetic resonance imaging (MRI)Magnetic resonance imaging reflects biochemicaltissue characteristics and is largely influenced byproton density and other in situ paramagnetic sub-stances such as blood products and melanin content.Alongside the permanent bore magnet, additionalThe Journal of Laryngology & Otology (2016), 130 (Suppl. S2), S28–S31. GUIDELINE©JLO (1984) Limited, 2016. This is an Open Access article, distributed under the terms of the Creative CommonsAttribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, andreproduction in any medium, provided the original work is properly cited.doi:10.1017/S0022215116000396http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.transient magnetic gradients allow the development ofan ever increasing array of sequences that are able toreflect pathological processes from normal surroundingtissues. Multiple manufacturers may have differingterms for sometimes similar sequence parameters.T1-weighted ‘anatomical’ images have excellentspatial resolution, whilst T2-weighted images preferen-tially highlight oedema and therefore pathology. Ashort tau inversion-recovery (STIR) sequence retainsthe positive attributes of a T2-weighted image and sup-presses surrounding fat signal in normal or invadedtissues to best depict abnormal tissue as a bright,high signal. Magnetic resonance imaging has theability to dramatically improve tissue contrast reso-lution when compared with CT and, in compliantpatients without contraindications, it is the imagingmodality of choice for defining the primary extent oforal and oropharyngeal cancers. Detrimentally, whencompared with CT, scan times are much longer andcan vary from about 2–10 minutes for each sequence,during which the patient must keep relatively still.Intravenous gadolinium contrast agents allow staticand dynamic vascular assessments of a tumour and,when combined with fat suppression techniques, thiscan increase the conspicuity of occult pathology.Dental amalgam can reduce the image quality bothfor CT and MR imaging that makes interpretationmore challenging.Positron emission tomography combined with CT(PET–CT)Positron emission tomography combined with CTwhole-body imaging uses various labelled tracers tofuse conventional, anatomical CT images with a func-tional ‘map’ of the disease process. This is conductedon a single gantry at a single appointment. The com-monest tracer is 18 fluoro-deoxyglucose, which is pref-erentially transported and trapped into hypermetaboliccancerous or inflamed tissues. It is detected with agamma camera array. The patient’s fasted baselineglucose level should be measured and the isotope isinjected intravenously approximately 1 hour beforeimaging. The patient refrains from talking or chewing.Actual image acquisition takes about 30–45 minutes.Modern scanner design accurately co-registersmetabolic tissue activity with its precise anatomicallocation.In 2013, the Royal College of Radiologists publishedevidence-based guidelines for PET–CT use in headand neck cancer. Evaluating the patient with malignantcervical adenopathy from an unknown primary is oneof the main, up-front indications. Positron emissiontomography will detect an occult primary in approxi-mately one third of cases. Positron emission tomog-raphy combined with CT is also valuable in theassessment of suspected recurrence of head and neckcancer when there are extensive, confounding post-treatment changes on conventional imaging modalities.Its added benefit in routine surveillance following treat-ment is still being assessed. Along with other modal-ities, it has a role in staging malignant thyroid diseaseincluding medullary thyroid carcinoma.UltrasoundOffered as part of a modern one-stop service, ultra-sound, alongside fine needle aspiration cytology,allows rapid imaging assessments for those with anundiagnosed neck lump or suspected metastaticdisease in the neck. This technique can be notoriouslyoperator dependent, but has no detrimental patienteffects. Following slide preparation, best cytologicalpractice recommends prompt adequacy assessmentsand, ideally, the cytologist should be onsite for diag-nostic advice. In reality, a shortage of radiology andhistopathological input makes such universal servicedevelopments difficult.Ultrasonography comfortably delineates thyroidpathology and can detect occult pathological nodes(necrosis, microcalcification, etc.) that may feel clinic-ally normal in size. A normal node should remain ovoidin shape with a short axis diameter less than 10 mmwith a preserved echogenic hilum. Retropharyngealand superior mediastinal nodes cannot be assessedwith this modality.Current doctrine dictates that clinically and radio-logically N0 disease from high-risk primary sites ispresumed to have small volume nodal micrometastasisthat routinely requires prophylactic first-line treatmentas no available tests can guarantee a true pathologicalN0 status.FluoroscopyThere are a variety of scenarios when contrast swallowsand fluoroscopy are used in head and neck cancer,although the availability of local expertise can be vari-able. Contrast swallows can be used to assess the lengthof a malignant proximal oesophageal stricture, whilethe risk of airway aspiration or penetration is dynamic-ally assessed by videofluoroscopy. Alternative, non-oncological causes for dysphagia such as a pharyngealpouch may be diagnosed. Water soluble contraststudies are advised when the risk of aspiration ishigh, for instance, following recurrent chest infectionsor diminished pharyngeal sensory/motor functionafter surgery or radiation. The integrity of a surgicalanastomosis or the tract of an entero-cutaneous fistulacan also be well evaluated. These studies are oftenjointly performed with a speech and language therapistto facilitate decision making and may improve func-tional outcomes.Chest imagingWith common aetiological factors, patients with headand neck cancer have higher incidences of synchronousand metachronous primary lung tumours that may beIMAGING IN HEAD AND NECK CANCER: UK GUIDELINES S29http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.disseminated at presentation. At staging, CT imaging ofthe thorax is routinely advised.The most common protocol for patients with a headand neck cancer will therefore be to image the primarysite by either contrast-enhanced CT or magnetic reson-ance imaging (MRI), perform CT imaging of the chestand PET–CT for the unknown primaries.Specific tumour sitesThis section deals with specific tumour sites and high-lights areas where radiological evaluation is particular-ly important and often difficult.Oral cavityPreferred imaging modality: MRITongue tumours are routinely evaluated with MRI toaid treatment choices and prognosis. Early or advancedcancers of the buccal mucosa, retromolar trigone, palataland floor of mouth are more difficult to evaluate reliablyby imaging alone and good clinical correlation is essen-tial. Perineural and marrow involvement is best definedat MRI.In an attempt to avoid osteoradionecrosis, orthopan-tomograms are still requested to proactively treat dentalcaries and peri-apical disease.OropharynxPreferred imaging modality: MRISmall or subclinical primaries in the tonsil andtongue base that often present with cervical lymph-adenopathy can be difficult to identify with all formsof imaging including PET–CT. These tumours areoften best evaluated at MRI with STIR sequences andoften, may only be localised retrospectively after exam-ination and biopsy under anaesthesia. Extension ofmucosal tumours into the adjacent structures andneck spaces is well depicted with MR imaging.NasopharynxPreferred imaging modality: MRINasopharyngeal tumours commonly present at anadvanced stage with palpable nodal neck disease.Magnetic resonance imaging allows accurate classifica-tion of the primary site and nodal disease as per theTNM classification, based on disease extent.HypopharynxPreferred imaging modality: MRIIn those patients who have difficulty with swallow-ing, aspiration or breathing when supine, a CT scanwill need to be strongly considered.LarynxPreferred imaging modality: MRIDisease at the level of the vocal cords presentsearly with dysphonia and is well localised. Imaging isoften unnecessary for T1 disease unless extralaryngealdisease, cartilage involvement, nodal metastasis orchest pathology is suspected. MRI with contrast is thegold standard for depiction of cartilage involvement.Recommendations• Offer appropriate radiological imaging, basedon tumour extent, site and local expertise, tostage tumours and plan treatment for patientsdiagnosed with head and neck cancer (G)• Consider PET–CT imaging if conventionalcross-sectional imaging identifies no primarysite (R)• Offer PET–CT imaging 12 weeks afternon-surgical treatment to detect residualdisease (R)Salivary glandsMalignant salivary glands neoplasms are a veryheterogenous group of tumours, where tumour behav-iour and prognosis is dictated by the histology.Ultrasound techniques have a significant role to playin assessing the parenchymal mass, local adenopathyand guiding biopsies. Perineural or skull base involve-ment often requires a combined multi-modality CTand MR approach. The best imaging modality maybe guided by site-specific characteristics such asrespiratory motion artefact.SinusesMRI with contrast is the modality of choice to assesssurgical resectability issues around intracranial andorbital disease spread. Skull base involvement usuallyrequires a complementary CT study.Post-operative imagingThe choice of imaging in the post-operative scenario isdetermined by the specific clinical question posed.Complications are frequent with difficult head andneck resections. When the specific question is overpotential residual or recurrent disease, followingeither surgery or chemoradiotherapy, the choice forbaseline imaging mainly falls between a contrast CTof the neck and chest and a timely PET–CT study.As an exception, MRI has a large role to play specific-ally for nasopharyngeal, sinonasal and skull basetumour follow up.2 Early detection of residual diseaseis vital to planning further curative attempts. Thetiming of the scan is important. Dedicated CT givesbetter resolution and anatomical detail at the primarysite as well as detecting subcentrimetre early metastaticdisease in the lungs. Obliteration of fat planes and ana-tomical distortions makes interpretation difficult. Anegative, normal PET–CT 12 weeks post-treatmentlikely offers the best prognostic reassurance currently.3PET–CT fails to reliably distinguish inflammatoryH LEWIS-JONES, S COLLEY, D GIBSONS30http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.elements from malignant foci. Ultrasound guided pro-cedures still have a role to play in sampling in-determinate, persistent enlarged cervical nodes.Key points• Accurate image interpretation and staging heavilyinfluences optimal treatment strategies• Contrast-enhanced computed tomography of theskull base, neck and chest is ubiquitous in nature,readily available and the workhorse for routinetumour–node–metastasis staging of head and neckcancers• Positron emission tomography combined with com-puted tomography is of proven diagnostic benefitwhen searching for the unknown primaries, whenconventional imaging is non-informative• In compatible patients, magnetic resonance imaginghas superior soft tissue characterisation at severalprimary sites including oropharynx, nasopharynx/skull base and sinuses that greatly aid surgical plan-ning and resections• Ultrasound image guided diagnostic fine needle andcore biopsies are well established and cost-effectivein the context of good cytological/histological support• In certain instances, multi-modality approaches arecomplementary to each other but should not adverse-ly impact on the speed of the diagnostic pathway.References1 Olliff J, Richards P, Connor S, Wong WL, Beale T, Madani G.Head and neck cancers. In: Nicholson T, ed. Recommendationsfor Cross-Sectional Imaging in Cancer Management, 2nd edn.London: The Royal College of Radiologists, 2014. pp 3–192 Hermans R, ed. Head and Neck Cancer Imaging. New York:Springer, 20123 Mehanna H, Wong WL, McConkey CC, Rahman J, Robinson M,Hartley A et al. PETCT Surveillance versus Neck Dissection inAdvanced Head and Neck Cancer, N Engl J Med 2016;374:1444–54Address for correspondence:Daren Gibson,Fiona Stanley Hospital,Murdoch, Perth, WA, AustraliaE-mail: gibsondaren9@googlemail.comIMAGING IN HEAD AND NECK CANCER: UK GUIDELINES S31http://dx.doi.org/10.1017/S0022215116000396Downloaded from http:/www.cambridge.org/core. University of Birmingham, on 12 Oct 2016 at 15:01:32, subject to the Cambridge Core terms of use, available at http:/www.cambridge.org/core/terms.

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Imaging in head and neck cancer:United Kingdom national multidisciplinary guidelines

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