Synoptic reporting in head and neck cancers— Head and Neck Cancer Imaging Reporting and Data Systems (HN-CIRADS): The journey ahead for standardization of imaging in head and neck cancer staging : Cancer Research, Statistics, and Treatment

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Synoptic reporting in head and neck cancers— Head and Neck Cancer Imaging Reporting and Data Systems (HN-CIRADS)

The journey ahead for standardization of imaging in head and neck cancer staging

Mahajan, Abhishek*,; Agarwal, Ujjwal; Gupta, Anurag; Shukla, Shreya; Ashtekar, Renuka; Shah, Pritesh; Sable, Nilesh; Ankathi, Suman Kumar; Ahuja, Ankita; Noronha, Vanita1; Prabhash, Kumar1; Menon, Nandini1; Patil, Vijay1; Vaish, Richa2; D' CRUZ, Anil K

Author Information
Cancer Research, Statistics, and Treatment: Apr–Jun 2022 - Volume 5 - Issue 2 - p 322-330
doi: 10.4103/crst.crst_304_21
  • Open


Head and neck cancers are a major health burden in India due to the widespread use of tobacco in various forms. For proper care, clinical evaluation is required at the time of diagnosis and local staging of the disease. Characterization of tumor imaging, on the other hand, is critical for staging of deep-seated tumors. In the current era, reporting in head and neck cancers is mainly in free-text form. Therefore, the quality and structure of the report depend on the experience.[1]

Poor documentation of lesions and lack of communication has led to inadequate staging and suboptimal management. Hence, there is a need for synoptic reporting to standardize reports, reduce hassle, and better understand the disease status. Here, we propose the use of Head and Neck Imaging-Reporting and Data System (HNI-RADS) for synoptic reporting in head and neck cancers.


Reporting is a means of communication to physicians and patients. Therefore, it undoubtedly needs to be precise and should not miss any vital information.[2] Synoptic reporting involves reporting specific data elements in a particular format. This provides standardized information in lesser time than random reporting.[3]

Certain key elements that are common to all synoptic reporting formats has been described in Supplementary Figure 1.


  1. It allows for more detailed reporting and ensures nothing is missed. It ensures better surgical planning and communication by clinicians for treatment decision-making.
  2. Templates are regularly updated as per recent guidelines and clinician requirements.
  3. Synoptic reporting systems also generate reminders and alerts that help to carry out patient care tasks on schedule.
  4. Synoptic reporting facilitates data analysis, as one can analyze all data elements separately and more easily. Hence, it helps to understand patient outcomes with different therapies. Structured reports are recommended for any research activity involving radiology reporting, and databases have been generated over which automated informatics can be run.[3]
  5. Tumor response evaluation becomes efficient and effective as unnecessary data are excluded.


  1. Increasing volume, and a variety of data variables and poor formatting can result in information overload.
  2. It has been shown that increased clerical errors may occur with an increased number of required elements in synoptic reporting.[1]


Superficial and easily accessible structures are best evaluated by clinical examination and endoscopy. However, deep structure involvement, depth of invasion, bony erosion, and perineural spread are only assessed via imaging [Table 1].

Table 1:
Techniques for acquisition of head and neck imaging

Various techniques have been highlighted to delineate structures on computed tomography (CT) images, which are as follows [Table 2][4]:

Table 2:
Imaging protocol in head and neck cancers
  1. Puffed cheek technique: The patient is instructed to blow through pursed lips consistently while moving the tongue away from the hard palate and teeth. The retromolar trigone, buccinator, pterygomandibular raphe, and cheek are all clearly defined.[45]
  2. Modified Valsalva maneuver: Expiration is performed against pursed nose for nasopharynx, and against pursed lips for hypopharyngeal lesions (opposed to closed glottis in Valsalva maneuver).[6]
  3. Phonation: The patient is asked to say “eee” uniformly for at least 10 seconds and a scan is acquired.
  4. Open mouth technique: A device (50 cc syringe) is placed between the teeth to immobilize the open mouth position.[7]


Head and neck squamous cell carcinomas (HNSCCs) can be categorized into the following groups based on the anatomical subsite:

  1. Oral cavity and lips: Consist of buccal mucosa-buccinator complex along with upper and lower gingivobuccal sulcus, upper and lower alveolar region, retromolar trigone, hard palate, floor of the mouth, and anterior part of the tongue, i.e., anterior to the circumvallate papillae. The oropharynx consists of the soft palate and base of the tongue including the uvula, tonsils, and pharyngeal walls.[89]
  2. Hypopharynx: Consists of the bilateral pyriform sinuses, post cricoid region, and posterior hypopharyngeal wall.
  3. Nasopharynx
  4. Larynx
    • Supraglottic portion (suprahyoid epiglottis with both lingual and laryngeal surfaces, aryepiglottic folds, arytenoid cartilages, the false vocal cords, and the ventricles),
    • Glottis (true vocal cords and the anterior and posterior commissures), and
    • Sub glottis (from true vocal cords to the inferior margin of the cricoid).

Lips, oral cavity, and oropharynx

American Joint Committee on Cancer (AJCC) 8th edition changes[1011]:

  • Depth of invasion (DOI) is a critical criterion for T staging and prognostication (measured as perpendicular distance from the surface).
  • Extranodal extension (ENE) is an independent prognostic sign (imaging characteristics such as perinodal fat stranding, infiltration into neighboring fat or muscle, and necrosis have a high specificity for predicting ENE).[12]
  • Human papillomavirus (HPV) p16-positive tumors have a better prognosis and are staged separately. Primary tumors in p16-positive patients tend to have lower apparent diffusion coefficient (ADC) values and higher kurtosis and skewness and large, multiple, and/or bilateral cystic nodes.[13]

Implications of key imaging findings in various head and neck cancers are shown in Table 3.

Table 3:
Key imaging findings and their implications on management

Gingivobuccal, alveolus and retromolar trigone squamous cell carcinoma (SCC) [Figure 1]:

Figure 1:
Reporting format used in our department for staging of oral cancers
  • Most prevalent in Asian patients
  • Stages I and II cancers (T1-T2, N0) can be treated with single-modality treatment like surgery or radiotherapy (RT) for the primary tumor, which varies from patient to patient. Radiologists must be well-versed with the terms masticator space, infratemporal fossa (ITF), supranotch, and infranotch disease on the basis of the structures involved.[30]

According to 8th edition of the AJCC, disease involving masticator space is labelled as advanced T4b disease and deemed unresectable. However, Liao et al.[33] have reported that supranotch or high ITF disease has a poor outcome, whereas low ITF disease has a reasonably good outcome.

Key imaging features with implications on management and surgical planning:

  • Extranodal extension[31]
  • Depth of invasion[32]
  • High vs low ITF involvement[33]
  • Bone erosion[34]
  • Perineural spread[35]

More than 1.5 cm residual mandibular vertical height is required for mandible preservation surgery, whereas para-mandibular soft tissue, inferior alveolar canal involvement, and edentulous mandible are contraindications for marginal mandibulectomy.[3637]

For early detection of perineural dissemination, dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is the method of choice. There is an increased enhancement along the relevant nerve due to a disruption of the blood-nerve barrier.[3839]


These are better evaluated clinically. Advanced cancers are imaged to look for bony erosion and nodal disease.

SCC of the tongue and floor of the mouth

  • SCCs of the tongue usually occur along the ventral/lateral surface.
  • Depth of invasion is crucial in disease staging.[40]
  • The pattern of lymphatic spread of SCCs of the oral tongue, lip, and floor of the mouth is predominantly to levels I and II nodes.[41]
  • Imaging protocol includes coronal short tau inversion recovery (STIR) and T1-weighted images, axial T1-weighted and T2-weighted images, sagittal T2-weighted images, diffusion-weighted images in the axial plane for nodal assessment, and post-contrast images in all three planes [Figure 2].
Figure 2:
Reporting format used in our department for staging of tongue cancers

Nasopharyngeal SCC (NSCC)

  • It is prevalent in northeast Asia.[42]
  • The primary treatment is external beam radiation to the nasopharyngeal bed and primary draining lymph node, although in advanced illness, concomitant cisplatin-based chemotherapy is administered.[43]
  • Direct visualization with flexible endoscopy is the most sensitive modality for demonstrating mucosal nasopharyngeal SCCs; however, deep-seated lesions require magnetic resonance imaging (MRI) [Figure 3].
  • Imaging protocol:
    1. T1 axial and sagittal for skull base involvement
    2. T2 axial for peripheral nervous system involvement
    3. T1 post-contrast axial for perineural spread
    4. Diffusion-weighted imaging
Figure 3:
Reporting format used in our department for staging of nasopharyngeal cancers

Laryngeal SCCs

SCCs accounts for 90% of laryngeal cancer cases with lymphoma being the second-most common diagnosis. Hoarseness is the most common symptom of laryngeal cancer, but other symptoms include a neck lump, dysphagia, stridor, and hemoptysis. Speaking, breathing, and swallowing are all affected by impaired laryngeal function caused by cancer and its treatment [Figure 4].

Figure 4:
Reporting format used in our department for staging of laryngeal cancers

Neck node imaging

Nodal stations:

  1. Gingivobuccal and retromolar trigone malignancies drain to levels IB, II, and III.
  2. Oral and tongue malignancies drain to levels I, II, and III (contralateral adenopathy is also seen in tongue malignancies as a result of the disease crossing the midline).
  3. Nasopharyngeal malignancies drain to levels II and V.
    • The survival rates are reduced by 50% with a solitary lymph node metastasis from HNSCC, which is further reduced to 33% with contralateral node metastasis.
    • Morphological indicators of nodal metastasis include loss of fatty hilum, rounded appearance, necrosis, and cystic changes.


  1. For surveillance imaging (adopted from NI-RADS): It is performed in a manner similar to Breast Imaging-Reporting and Data System (BI-RADS) [Table 4 and Figure 5][44]
  2. Post-neoadjuvant chemotherapy evaluation: It is performed for response assessment. Reporting template is similar to primary staging with documentation of change in the size and appearance of any new lesions.
  3. Post-palliative chemotherapy/Metronomic therapy
Table 4:
Neck Imaging-Reporting and Data System (NI-RADS) surveillance imaging
Figure 5:
Reporting format used in our department for post-treatment evaluation of head and neck cancers


The quality of the report and clear communication of findings to treating physicians play an essential role in patient management. Synoptic reporting provides standardized information in shorter time and ensures detailed reports without missing significant findings, thereby affecting overall patient management.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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Head and neck cancers; imaging findings; radiologist; radiology; synoptic reporting

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