Giovanni Simonetti, MD

A variety of neoplasms, derived from a multitude of tissue types, can develop in the sinonasal tract. Sinonasal neoplasms are classified as epithelial or mesenchymal. Epithelial tumors occur in the epithelial lining of the nasal and sinus cavities, accessory salivary tissue, neuroendocrine tissue, and the olfactory mucosa. Mesenchymal tumors are found in supporting tissues.

Neoplasms affecting the paranasal sinuses and nasal cavities are rare in comparison with sinonasal inflammatory disease. Carcinomas are by far the most common neoplasm, yet they account for only 0.2% to 0.8% of all malignant tumors and about 3% of all head and neck malignant tumors.

 Sinonasal carcinoma comprises two distinct types: squamous cell carcinomas and adenocarcinomas. Unlike other cancers of the oral cavity, oropharynx, larynx, and hypopharynx, these tumors are not linked to tobacco use or alcohol consumption. Adenocarcinomas are related to prolonged exposure to exotic woods and are often found in carpenters.

Treatment of sinonasal tumors is complex, involving combined therapy and multidisciplinary teams. Although surgery remains the primary treatment, combined chemotherapy and radiotherapy now play a significant role for these patients,

 especially those with advanced disease. The region's complex anatomy, combined with the possibility of facial deformity, prolonged morbidity, and gross dysfunction, often limits the extent of surgical resection.

Sinonasal tumors can remain clinically silent for some time. Coexisting infection can disguise clinical signs and symptoms, further delaying diagnosis. Patients with maxillary tumors may present with trismus, epiphora, orbital pain, or proptosis accompanied by gum or tooth pain. Those with ethmoid tumors may have diplopia, proptosis, nasal stuffiness, anosmia, epistaxis, and headache. Frontal sinus tumors can deform the face and extend into the orbits or intracranially, while sphenoid tumors extend into the nasopharynx.

A multidisciplinary team approach is often required for accurate tumor assessment. Improved imaging technology enables superior tumor mapping and staging, aiding "cure versus palliation" treatment decisions.

 Surgical techniques have also improved, and tumor extirpation is less likely to lead to morbidity or facial deformity. The evolution of numerous approaches to the skull base has extended earlier operative indications, allowing treatment of cancers that were previously considered unresectable.

 Multiple factors, including tumor histopathology, age, patient health, and extent of disease, determine the method of treatment. Otolaryngologists and head and neck surgeons treat the majority of cases, but neurosurgeons should participate if the anterior cranial fossa is involved. Radiologists play a critical role in determining the most appropriate clinicians to conduct the treatment.

Tumor biology and anatomic location have prognostic significance.

 A lesion confined to the antrum generally has a better prognosis than one located in the pterygopalatine fossa or central skull base. Certain tumors, however, are highly aggressive regardless of location and despite a noninfiltrating appearance on imaging.

The TNM carcinoma classification is used only for tumors of the ethmoid complex and the maxillary antrum, the most common site of primary tumors. The maxillary antrum is bounded superiorly by the orbit and ethmoid air cells and posteriorly by the pterygoid plates and pterygopalatine fossa. The inferior and medial margins of the maxillary sinus are more easily resected, and tumors in these areas have a better prognosis. Ethmoid sinuses are bounded laterally by the lamina papyracea. Tumors in this region can extend into the orbit, requiring orbital exenteration. Involvement of the cribriform plate and intracranial spread also mandate craniofacial resection. Sphenoid sinus tumors are difficult to resect completely, due to their central position.

MRI is superior to CT for assessing the extent of tumor involvement. MRI provides multiplanar reconstruction and better contrast resolution than CT. Postcontrast scans can help distinguish tumor from secretions and evaluate extent and brain involvement.

Most tumors are hypointense or isointense on T1-weighted MRI. They show slightly above average signal intensity on T2-weighted images and enhance with a solid pattern after contrast administration, compared with muscle and brain.

Secretions are hypointense on T1-weighted MRI and exhibit higher signal intensity than tumors on T2-weighted images. Inflammatory mucosal disease shows similar characteristics, with peripheral enhancement after contrast administration.

Because the T2 relaxation of secretions depends on their water content, signal characteristics change as they become desiccated and the protein content increases. Secretions are more hyperintense on T1-weighted MRI. Small tumors are often indistinguishable from adjacent secretions and may

be missed. Larger tumors are usually associated with bony changes, which may be helpful in diagnosis. Radiologists are often reluctant to diagnose a tumor in the absence of adjacent bone involvement.

The involvement of fine bone structures is best evaluated with CT because of its excellent spatial resolution (Figure 1).

 Multislice CT scanners greatly reduce acquisition time and, thus, movement artifacts. MSCT data can be used for multiplanar reformatting, 3D reconstruction, and virtual rhinosinus endoscopy, providing a more precise measurement of mass size, better presurgical evaluation, and a virtual assessment of the likely surgical outcome.

Aggressive changes caused by bone involvement are commonly seen in squamous cell carcinoma but may also be observed in lymphoma and metastases and in benign lesions such as sarcoidosis. Imaging reveals invasion and irregular destruction of the bone with only small fragments remaining. Slow tumor appears as bony remodeling, which typically occurs in inflammatory lesions such as mucoceles and polyps but may also occur with melanoma, plasmocytoma, or olfactory neuroblastoma. The third characteristic pattern, sclerosis of marginal bone, usually occurs in chronic relapsing infection such us obstructive sinusitis or osteomyelitis, which is uncommon. It may also be found in breast or prostate metastases, however.

Tumoral calcifications in the sinonasal cavities are uncommon. Discrete solitary or multiple calcifications within a mass usually signify a chronic bacterial or fungal inflammatory process. Calcifications may also be found in osteoblastoma, osteosarcoma, chondrosarcoma, and olfactory neuroblastoma.

Orbital invasion is an extremely important parameter because it radically alters surgical planning. Involvement of the periosteum requires orbital exenteration, whereas the eye can be preserved and local recurrence reduced if the periosteum is intact.

 The presence of bony destruction and involvement of orbital fat confirms orbital invasion (Figure 2). In the absence of these signs, CT and MRI can exclude invasion with positive predictive values of 86% and 80%, respectively.

Carcinoma, lymphoma, and olfactory neuroblastoma frequently invade the skull base. MRI surpasses CT in identifying perineural spread and intracranial extension. Contrast-enhanced T1-weighted coronal and sagittal MR images show destruction of the cribriform plate and enhancement of the dural envelope, confirming intracranial invasion (Figure 3).

Childhood infections often obliterate the retropharyngeal nodes, which are the primary lymph nodes draining the paranasal sinuses and nasal cavities. Consequently, sinonasal malignancies in adults frequently metastasize to the secondary nodes in submental, submandibular, superficial, and deep laterocervical stations. These nodal metastases occur in approximately 15% of patients. The presence and extension of locoregional nodal metastases in these patients strongly influences prognosis; the five-year survival rate is less than 30% if lymph nodes are positive. Correct preoperative evaluation with imaging thus provides important prognostic information.

Nodal status also has a direct impact on therapeutic planning.

 Color Doppler ultrasound, CT, and MRI all provide relevant morphological data on lymph node enlargement, while PET contributes metabolic data. Lymphadenopathy can be diagnosed on imaging if a node is larger than 10 mm, has a round appearance, and is accompanied by intranodal necrosis and extracapsular diffusion. CT has a negative predictive value of 84% and a positive predictive value of 50%, according to these criteria. Comparable values for MRI are 79% and 52%, respectively.

 The use of superparamagnetic iron oxide particles increases the sensitivity and specificity for MR-based detection of metastatic nodes.

Ultrasound is more accurate than CT and MR in assessing lymphadenopathy, but Doppler signal is not always detectable in metastatic lymph nodes. Contrast-enhanced ultrasound can enhance the signal in perfused vessels and improve the differential diagnosis of inflammatory and metastatic enlarged lymph nodes.

PET has a high sensitivity for identifying the primary tumor and locoregional lymph node metastases in patients with sinonasal tumors. Reported sensitivity for nodal detection using FDG-PET is 80% to 96%, while specificity is 90% to 94%. FDG-PET is superior to both CT and MRI for detection of cervical nodal metastases.

 All methods can miss micrometastases, which occur in a significant number of patients. The presence of cervical node disease is predictive of distant metastases. Cervical lymph node metastases have been discovered in 34% of autopsied patients but are found in only 10% of patients at presentation. Cervical lymph node metastases should prompt a chest CT as part of the staging process.

Recurrence rates following tumor resection depend on tumor biology and treatment planning. Patients with sinonasal tumors tend to undergo therapies that produce significant anatomic alterations. This complicates evaluation of disease persistence or recurrence with conventional imaging approaches. FDG-PET can map functional and metabolic activity before structural changes have occurred, differentiating malignant from normal tissue. The modality also shows active infection or inflammation as increased uptake.

PET can be used for primary tumor staging, including assessment of nodal involvement and distant metastases. The diagnostic potential of PET, however, is particularly evident in the follow-up phase. PET adds significantly to the accuracy of differential diagnoses of disease recurrence and hypervascular fibrosis, yielding sensitivity and specificity rates of 94% and 85%, compared with rates of 54% and 46% for conventional imaging. PET can also be used to monitor the efficacy of radiotherapy (Figure 4).

The ideal diagnostic test for malignant sinonasal tumors would have high sensitivity, high specificity, local staging capabilities (primary mass extension, bone involvement, soft-tissue invasion, and perineural spread), distant staging capabilities (assessment of lymphadenopathies and metastases), and the ability to predict the likelihood of recurrence. Because no diagnostic examination meets all of these criteria, assessment of sinonasal malignancies requires a multidisciplinary team approach.

Advances in diagnostic imaging have contributed substantially to the management of sinonasal tumors.

 In order for radiologists to provide appropriate tumor mapping to aid decisions about resectability and prognosis, they must know the critical areas of tumor extension that will alter a surgical or irradiation treatment plan. These areas include the floor of the anterior and middle cranial fossae, the pterygopalatine fossae, the orbits, and the palate.

 A radiological report should include details of the sinus and the precise areas in which the neoplasm is developing.

Newer software can use raw imaging data to help prepare treatment plans. But CT and MR data are rarely specifically pathognomonic. Features on cross-sectional imaging can be used to differentiate benign from malignant disease, but radiologists' primary role is to produce accurate and anatomically informed tumor maps. Final treatment planning must await pathological diagnosis.

PROF. FANUCCI is a professor of radiology, DR. DI COSTANZO is a radiology resident, and PROF. SIMONETTI is head of diagnostic imaging and interventional radiology, all at the University of Rome Tor Vergata.

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Articles

Sinonasal tumors require team-based approach

Vascular imaging has benefited enormously from the increased speed and enhanced image acquisition capabilities of both single-slice spiral CT and multislice CT.

 The ability of 16-slice scanners to acquire images 40 times faster than conventional spiral scanners has revolutionized vascular imaging.

Faster scanning means a reduction in breath-holding, shorter examination times, and fewer motion artifacts, all of which enable examination of the entire thoracic and abdominal aorta in a single scan with high spatial resolution. Acquisition of large volumes with thinner slices generates nearly isotropic data that can be reconstructed in any imaging plane to yield the same resolution as the original axial images. Radiologists are not only adapting imaging protocols to patients' specific diagnostic needs but are also seeking new strategies with MSCT to reduce patient radiation exposure.

Use of 16-slice CT has many advantages for evaluating the abdominal vascular system in normal and pathological conditions. At the University Tor Vergata, we generally use a low-dose acquisition for precontrast scanning on our MSCT system (Light Speed 16, GE Healthcare). Such precontrast scans are advisable when bleeding is suspected, as they can evaluate wall calcifications and intramural hematomas or dissections. We use a 2.5-mm slice collimation for abdominal aorta or stent-graft imaging and 1.25-mm slice collimation for the study of visceral arteries, with a table feed of 13.75 mm/sec for both. Optimal anatomic coverage should range from 1 cm above the diaphragm to the iliac artery bifurcation.

Obtaining valid arterial enhancement is crucial in contrast-enhanced imaging. Optimal synchronization between data acquisition and peak vascular enhancement improves image quality. Because the fast speed of 16-slice CT scanners substantially reduces the time window for this synchronization, we use our scanner's "smart prep" function to calculate timing. This automated bolus triggering technique detects arrival of contrast in the artery of interest. The abdominal aorta at the diaphragmatic level is designated a region of interest. Contrast injection starts simultaneously with a low-dose dynamic monitoring scan. MSCT acquisition begins automatically once intensity measurements at the ROI rise above 180 HU.

Acquisition volume and table feed are identical to those used in the precontrast scan. We use slice collimations of 2.5 mm for the aorta and 1.25 mm for visceral arteries, with incremental reconstructions of 1.25 mm and 0.625 mm, respectively.

The switch to a 16-slice CT scanner with its faster acquisition has enabled us to reduce the volume of contrast used. Injection duration should match acquisition time. High-concentration contrast media (370 to 400 mg/mL iodine) requires injection flow rates between 3 and 4 mL/sec. We usually inject 100 to 120 mL of 370 mg/mL iodine contrast with a flow rate of 4 mL/sec. Flushing the vein with 60 mL saline solution following contrast bolus injection is always advisable.

A delayed scan is preferable for following up a stent-graft or studying a possible aortic dissection. Acquisition begins 60 to 80 seconds after the end of the contrast phase. The presence of leakage in the aneurysmatic sac during evaluation of stent-grafts can be better demonstrated in the delayed scan. True and false lumens that usually present with a slow washout can be differentiated easily.

Many real-time viewing and reformatting options exist for analyzing vascular 16-slice CT studies. We can acquire large volumes of body imaging data in a short time with near-isotropic spatial resolution, allowing us to create high-quality 2D and 3D images on a dedicated workstation (Advantage 4.2, GE Healthcare).

Axial source images remain the basis for diagnostic decision making. Curved planar reformatting, 2D multiplanar reformatting (MPR), and advantage vessel analysis (AVA) are particularly useful in evaluating the vessel diameter and measuring the degree of arterial stenosis. The arterial lumen and thrombus can be displayed simultaneously within the aneurysm. Three-D postprocessing options such as maximum intensity projection (MIP) and volume rendering, which provide angiography-like images, offer excellent demonstration of vascular anatomy. We always choose to reconstruct different projection angles.

Identification of all possible artifacts is an important part of image interpretation. Short acquisition times of 10 to 15 seconds reduce the likelihood of respiratory artifacts and make it feasible to perform the examination in uncooperative patients.

The presence of calcifications and metallic endovascular stents with higher attenuation than opacified vascular lumen can cause blurring artifacts, which may lead to overestimation of the stenosis. Better visualization is obtained with wide window settings. Image noise in 3D reconstructions can cause irregularities of object surfaces or even obscure underlying pathology, and it may produce a veil-like shadowing of structures deeper inside the displayed volume. Intravascular lesions such as mural thrombi or soft plaques sometimes cannot be visualized directly using 3D volume rendering or MIP when a thicker slab is used.

The main advantages of using 16-slice CT to assess abdominal vasculature are improved spatial resolution and increased coverage. MSCT scanners can examine a range of vascular pathologies involving the aorta and abdominal vessels.

A 16-slice scanner can cover the entire abdominal aorta within a single breath-hold and still yield isotropic resolution. Aortic aneurysms are more commonly found in the infrarenal portion of the aorta associated with a high grade of atherosclerosis. At our university and in many radiology departments, CT angiography is established as the first-line modality for diagnosis of patients with aneurysm dilatations. CTA enables evaluation of the aneurysm's extension and real diameter as well as vessel calcifications and thrombotic wall apposition (Figure 1). Accurate postprocessing makes it possible to judge the involvement of abdominal vessels such as the celiac trunk, upper mesenteric artery, and renal arteries.

Data from 16-slice CT also aid perioperative surveillance of the aneurysm and surgical planning. Curved or AVA reconstructions can be used to gain measurements of the aneurysmal sac diameters and the caliber and angle of the iliac arteries. These reconstructions also help in selecting the best endoprosthesis to exclude the dilatation. Images acquired for follow-up of surgical or endovascular procedures show the correct position and integrity of the prosthesis or stents. Any leakage due to residual perfusion of the aneurysmatic sac from a lumbar or hypogastric artery or caused by damage to the device mesh can be demonstrated (Figure 2). Sac regression can also be monitored.

Images of an aortic dissection acquired with 16-slice CT allow evaluation of true and false channels, the presence and extension of the intimal flap, primary entry and possible distal reentry, and the thrombotic process of the false lumen. MPR reconstructions and AVA protocols may help determine whether surgery or endovascular procedure would be the correct therapeutic workup (Figure 3).

Sixteen-slice CT can also prove useful for evaluating visceral arteries. The modality is regarded as a reference technique for noninvasive imaging of renal arteries. It can assess stenosis and occlusions with high accuracy: 90% sensitivity and 98% specificity compared with digital subtraction angiography (DSA).

 It depicts delayed parenchymal enhancement and decreased size of the involved kidney well. The images can also be used to grade stenoses and poststenotic dilatations. Two-D and 3D reconstructions allow assessment of the aneurysmatic dilatation, suspected dissection, and thrombosis or trauma of renal arteries.

Additionally, we can evaluate the suitability of potential renal donors, demonstrating their entire vascular map with all possible anatomical variations (Figure 4). We also use this technology to evaluate other splanchnic vessels such as the celiac trunk and its branches and the mesenteric arteries in aneurysmatic dilatation, dissection, and vasculitis.

We can map abdominal vasculature before and after embolization of liver lesions. Abdominal mesenteric arteries can be evaluated in cases of abdominal angina and in patients presenting with acute or chronic ischemia. MSCT images of acutely ill patients may reveal embolic occlusions of cardiac origin (30% to 50%), thromboses due to an atherosclerotic process (15% to 30%), nonocclusive vasospastic mesenteric ischemia (20% to 30%), acute mesenteric thromboses (5% to 10%), or spontaneous dissection.

 (These figures indicate the causes of abdominal ischemia.) Scans of patients with chronic abdominal angina will show any significant hemodynamic stenoses involving the superior or inferior mesenteric arteries (Figure 5).

Sixteen-slice CT can help in identifying stenoses to the anastomoses of hepatic arteries or portal veins in liver transplant patients and in assessing the encasement of superior mesenteric arteries and vein in patients with pancreatic carcinoma.

We investigated the utility of angiograms obtained on our 16-slice CT scanner between April and November 2003, using DSA as a gold standard. Axial MSCT angiograms were compared with DSA results in all 96 patients. Our study included 22 cases of abdominal aortic aneurysm, 14 aortic dissections, 10 stent-grafts, six renal artery aneurysms, 12 renal stenoses, 10 celiac trunk aneurysms, nine celiac trunk stenoses, 16 splenic artery aneurysms, and 12 superior mesenteric artery aneurysms.

We found that the MSCT angiograms provided additional clinical information not seen on DSA. Sixteen-slice CT also proved more accurate than DSA in measuring the real size of aneurysmatic dilatations and in demonstrating the presence of wall calcifications, mural thrombi inside the aneurysmal sac, and bleeding within self-contained ruptures.

Two-D and 3D postprocessed images depict the aneurysmal neck well. Sixteen-slice CT can also establish intimal flap extension into the aortic branches in cases of chronic or acute aortic dissection. It is our modality of choice in the follow-up of endovascular repair, due to its high accuracy in detecting endoleaks. A delayed scan is necessary to detect slow-flowing leaks that may otherwise be missed during the arterial phase. MSCT angiography shows renal artery stenosis clearly

 and is also useful in evaluation of renal artery aneurysms and dissections.

The move from single-slice spiral to multislice CT scanning is changing radiologists' role in the evaluation of vascular structures. Emergence of faster workstations with increasingly sophisticated reconstruction algorithms, more user-friendly interfaces, and smarter investigative tools will further enhance this technology.

PROF. SQUILLACI is a professor of radiology, DR. SPERANDIO is a fellow, and PROF. SIMONETTI is department head, all in the department of diagnostic imaging and interventional radiology at the University Tor Vergata in Rome.

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Giovanni Simonetti, MD

Articles

Sinonasal tumors require team-based approach

MSCT evaluates upper abdominal vessels