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    <div class="highwire-article-citation highwire-citation-type-highwire-article node62139--5" data-node-nid="62139" id="top-node-62139--6675696991" data-pisa="ajnr;39/8/E98" data-pisa-master="ajnr;ajnr.A5756" data-apath="/ajnr/39/8/E98.atom" data-hw-author-tooltip-instance="highwire_author_tooltip"><div class="highwire-cite highwire-cite-highwire-article highwire-citation-jcore-article-title-complete clearfix has-author-tooltip highwire-citation-highwire-article-top-a">
  
  
      <div class="highwire-cite-overline"><span  class="highwire-cite-metadata-article-type highwire-cite-metadata">Reply</span><span class="separator-pipe"></span><span  class="highwire-cite-metadata-art-cat highwire-cite-metadata"><span class="wrapper">LETTER</span></span></div>
  
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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">H. Kuno</span>, <span class="highwire-citation-author" data-delta="1">O. Sakai</span> and <span class="highwire-citation-author" data-delta="2">R. Hayashi</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">August 2018,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">39 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(8) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E98; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A5756 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-62139--6675696991" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">H. Kuno </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Diagnostic Radiology
National Cancer Center Hospital East
Kashiwa, Chiba, Japan</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=H.%2BKuno%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Kuno%20H&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AH.%2BKuno%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-4337-2782" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for H. Kuno</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">O. Sakai </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Departments of Radiology, Otolaryngology–Head and Neck Surgery, and Radiation Oncology
Boston Medical Center, Boston University School of Medicine
Boston, Massachusetts</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=O.%2BSakai%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Sakai%20O&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AO.%2BSakai%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-3462-5116" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for O. Sakai</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">R. Hayashi </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Head and Neck Surgery
National Cancer Center Hospital East
Kashiwa, Chiba, Japan</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=R.%2BHayashi%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Hayashi%20R&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AR.%2BHayashi%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-4889-4539" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for R. Hayashi</a></li></ul></div></div></div>  </div>

  
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    <div class="item-list"><ul class="tabs inline panels-ajax-tab"><li class="first"><a href="/content/39/8/E98" class="panels-ajax-tab-tab" data-panel-name="jnl_ajnr_tab_art" data-target-id="highwire_article_tabs" data-entity-context="node:62139" data-trigger="" data-url-enabled="1">Article</a><a href="/panels_ajax_tab/jnl_ajnr_tab_art/node:62139/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li><li><a href="/content/39/8/E98/tab-references" class="panels-ajax-tab-tab" data-panel-name="jnl_ajnr_tab_refs" data-target-id="highwire_article_tabs" data-entity-context="node:62139" data-trigger="tab-references" data-url-enabled="1">References</a><a href="/panels_ajax_tab/jnl_ajnr_tab_refs/node:62139/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li><li><a href="/content/39/8/E98/tab-article-info" class="panels-ajax-tab-tab" data-panel-name="jnl_ajnr_tab_info" data-target-id="highwire_article_tabs" data-entity-context="node:62139" data-trigger="tab-article-info" data-url-enabled="1">Info &amp; Metrics</a><a href="/panels_ajax_tab/jnl_ajnr_tab_info/node:62139/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li><li class="last"><a href="/content/ajnr/39/8/E98.full.pdf" class="panels-ajax-tab-tab" data-panel-name="jnl_ajnr_tab_pdf" data-target-id="highwire_article_tabs" data-entity-context="node:62139" data-trigger="tab-pdf" data-url-enabled="1"><i class="icon-file-alt"></i> PDF</a><a href="/panels_ajax_tab/jnl_ajnr_tab_pdf/node:62139/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li></ul></div>  </div>

  
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    <div data-panels-ajax-tab-preloaded="jnl_ajnr_tab_art" id="panels-ajax-tab-container-highwire_article_tabs" class="panels-ajax-tab-container"><div class="panels-ajax-tab-loading" style ="display:none"><img class="loading" src="http://ajnr-stage2.stage.highwire.org/sites/all/modules/contrib/panels_ajax_tab/images/loading.gif" alt="Loading" title="Loading" /></div><div class="panels-ajax-tab-wrap-jnl_ajnr_tab_art"><div class="panel-display panel-1col clearfix" >
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">We appreciate Dr Ginsberg's interest and comments on our article, “Comparison of MR Imaging and Dual-Energy CT for the Evaluation of Cartilage Invasion by Laryngeal and Hypopharyngeal Squamous Cell Carcinoma.”<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> We agree that the hypopharyngeal cancer case (presented in Fig 1) demonstrated lateral extralaryngeal tumor extension through wrapping around the posterior border of the thyroid cartilage on both MR imaging and dual-energy CT. Therefore, this case was defined as T4a disease, regardless of the cartilage invasion finding. We agree that determining both extralaryngeal extension and thyroid cartilage penetration is extremely important for treatment decision-making. Tumors that extend through potential spaces such as the thyrohyoid membrane and the thyroarytenoid gap might behave differently from those that penetrate through the cartilage, with the latter being more aggressive and potentially more likely to fail nonsurgical therapy.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a>,<a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a></sup> However, in clinical practice, patients with T4 disease do not always inevitably undergo laryngectomy, and patients without transcartilaginous tumor extension may be potential candidates for function-preserving treatment to some degree, and discussion with the patients forms part of the treatment decision-making process. Accurate diagnosis to avoid overestimation of thyroid cartilage invasion is important in the treatment decision-making process, irrespective of extralaryngeal spread. Beitler et al<sup><a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></sup> reported that extralaryngeal spread without thyroid cartilage penetration was more common than previously expected in patients with advanced laryngeal and hypopharyngeal cancers and that CT often involved an overdiagnosis in predicting cartilage penetration with a sensitivity of 75%.</p><p id="p-2">In our study, extralaryngeal tumor extension was confirmed pathologically in 34 of 55 (62%) patients with advanced hypopharyngeal and laryngeal cancers; however, only 17 of 34 (50%) patients demonstrated cartilage invasion.<sup><a id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1</a></sup> Extralaryngeal spread can be reasonably well identified on conventional CT, dual-energy CT,<sup><a id="xref-ref-5-1" class="xref-bibr" href="#ref-5">5</a></sup> and MR imaging; however, extralaryngeal spread “with cartilage invasion” is sometimes overdiagnosed using conventional CT and MR imaging.<sup><a id="xref-ref-5-2" class="xref-bibr" href="#ref-5">5</a><a id="xref-ref-6-1" class="xref-down-link" href="#ref-6"><span>⇓</span></a>–<a id="xref-ref-7-1" class="xref-bibr" href="#ref-7">7</a></sup></p><p id="p-3">As Dr Ginsberg has mentioned concerning laryngeal cancer, tumor erosion limited to the inner cortex of the thyroid cartilage indicates a T3 lesion, whereas erosion of the outer cortex of the thyroid cartilage defines a T4a tumor. However, unlike the larynx, thyroid or cricoid cartilage invasion in hypopharyngeal cancers indicates a T4a lesion, even with localized cartilage invasion, and accurate staging requires a precise diagnosis of subtle cartilage invasion. Dual-energy CT may be helpful as a first-line technique for accurate staging to define the T-stage, particularly when distinguishing T4 from lower-stage lesions and to detect regional lymph nodes (N-staging) and distant metastasis (M-staging).<sup><a id="xref-ref-8-1" class="xref-bibr" href="#ref-8">8</a></sup> Contrast-enhanced MR imaging remains useful for excluding cartilage invasion and for evaluation of prevertebral space invasion in patients with very advanced local disease.</p><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-39.8.E98.1" data-doi="10.3174/ajnr.A5530"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Kuno</span>  <span class="cit-name-given-names">H</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Sakamaki</span>  <span class="cit-name-given-names">K</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Fujii</span>  <span class="cit-name-given-names">S</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Comparison of MR imaging and dual-energy CT for the evaluation of cartilage invasion by laryngeal and hypopharyngeal squamous cell carcinoma</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2018</span>;<span class="cit-vol">39</span>:<span class="cit-fpage">524</span>–<span class="cit-lpage">31</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.3174/ajnr.A5530</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>29371253</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzOS8zLzUyNCI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zOS84L0U5OC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-39.8.E98.2" data-doi="10.1002/hed.21081"><div class="cit-metadata"><ol class="cit-auth-list"><li>
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</li><li><span class="cit-auth"><span class="cit-name-surname">Li</span>  <span class="cit-name-given-names">B</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Bobinski</span>  <span class="cit-name-given-names">M</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Gandour-Edwards</span>  <span class="cit-name-given-names">R</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Overstaging of cartilage invasion by multidetector CT scan for laryngeal cancer and its potential effect on the use of organ preservation with chemoradiation</span>. <abbr class="cit-jnl-abbrev">Br J Radiol</abbr> <span class="cit-pub-date">2011</span>;<span class="cit-vol">84</span>:<span class="cit-fpage">64</span>–<span class="cit-lpage">69</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1259/bjr/66700901</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>20858661</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiYmpyYWRpbyI7czo1OiJyZXNpZCI7czo5OiI4NC85OTcvNjQiO3M6NDoiYXRvbSI7czoxOToiL2FqbnIvMzkvOC9FOTguYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">7.</span><a class="rev-xref-ref" href="#xref-ref-7-1" title="View reference 7. in text" id="ref-7">↵</a><div class="cit ref-cit ref-journal" id="cit-39.8.E98.7" data-doi="10.1148/radiol.2492072183"><div class="cit-metadata"><ol class="cit-auth-list"><li>
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 39</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 8 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Aug 2018 </div></div>
      
      
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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">H.</span> <span class="nlm-surname">Kuno</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">O.</span> <span class="nlm-surname">Sakai</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">R.</span> <span class="nlm-surname">Hayashi</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Aug 2018, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">39 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(8) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E98; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A5756 </span></div>
  
  
  
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    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Aug 2018, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">39 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(8) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E98; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A5756 </span></div>
  
  
  
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