1. Head & Neck radiology with Christine Glastonbury and Jennifer Gillespie

我和Frank提前插播一下，告诉大家Radiopaedia 2026很快就会到来，时间是2021年7月。

Frank and I here just cutting in before today's episode to let you know that Radiopaedia twenty twenty six is coming up very soon, July '21.

今年活动持续六天，比去年多了一天。

It's six days this year rather than five days.

活动内容包括讲座、直播、病例工作坊、海报展示和小组讨论。

It's full of lectures, livestreams, case workshops, poster sessions, panel discussions.

Radiopaedia的全通证持有者可以免费参加，在125个中低收入国家也是免费的。

It's free for Radiopaedia, all access pass holders, free in a 125 low and middle income countries.

除此之外，你也可以直接注册参加这次会议。

Outside of that, you can also just register for the conference itself directly.

我们采用了分级定价，尽量让大家都负担得起。

We have tiered pricing to try and make it as accessible as possible.

盖尔，你打算说点什么，还是就坐在那儿？

Gayle, are you gonna say anything or just sit there?

我就说一点，今年这个会议刚好跨了一个周末，所以如果你请不了一整周的假，我想凑出四天还是没问题的。

Only that this year, it straddles a weekend so that if you can't get a whole week off, you can cobble together at least four days, I reckon.

当然，你还能随时回看所有点播内容。

And, of course, you've got lots of on demand access.

就算你没法参加直播环节、没法在聊天里和讲者互动，也完全能后来补上所有内容。

So even if you can't make it during the live components where you get to interact with speakers in the chat, you can catch up on everything.

你没必要像有些人那样，硬撑着六天全程直播、一刻不睡。

You don't have to, like some people seem to try, actually watch all of it live for the whole six days running and never sleep.

我们记得，到第三天就收到一封邮件，

We got remember, we got that email from someone by day three,

那人说：我真的撑不住了。

It was like, I can't do it anymore.

每四个小时就有一场，我实在顶不住了。

I can't every session is every four hours.

我已经连续七十二小时没合眼了。

I haven't slept in seventy two hours.

我真的不行了。

I can't do it.

我们其实也试着解决这个问题。

Well, we've tried to fix that as well.

当我们安排六天的活动时，特意留出了一段时间休息，盖洛德。

When we've gone to six days, we've actually we've blocked out one session as a break, Gaylord.

从物理上讲，有人——比如维卡什·沙阿——今年完全有可能看完所有直播环节。

So physically, it could be possible for somebody, I'm thinking Vikash Shah, to watch every single live session of the conference this year.

如果你真是这样做的，请告诉我们，我们会给你寄一个特别徽章。

If that's you, please write into us, and we'll send you a special badge.

本来这只是一个三十秒的简短广告，打算放在每集开头，结果估计要拖得更长了。

Anyway, this was supposed to be, like, a thirty second little ad to go at the front of the episodes, but it's probably gonna go much longer.

不过还是非常感谢。

But thank you very much.

现在，你可以开始听你原本想听的那期播客了。

And now you can listen to the actual episode of the podcast that you intended to listen to.

欢迎首次来到Radiopaedia阅读室，这档播客不谈书本、不聊诗歌，也不看茶渣或手相。

Welcome for the very first time into the Radiopaedia reading room, a podcast unconcerned with books or poetry, tea leaves or palmistry.

这只是一个朴实无华的放射学播客。

It is but a humble radiology podcast.

我是安德鲁·迪克森，每期节目都如约出现的搭档是弗兰克·加拉。

My name is Andrew Dixon, and joining me as he has promised to do every episode is my cohost, Frank Gala.

我可没答应过这种事。

I have promised no such thing.

我只答应尽量抽空来，当然，像往常一样，你负责所有工作，我只要露个面就行。

I promise to attempt to be here sometimes and provided you, as usual, do all of the work, and I can just turn up.

我希望咱们根本不用干多少活。

I'm hoping we don't have to do very much work.

我只要点一下录制，然后上传就行了。

I click record and then upload.

计划就是这样。

That's the plan.

尽量少剪辑。

Minimal editing.

我记得有人说过，开播客的第一个建议是：先把前三集录好，然后扔进垃圾桶，重新开始，因为那几集肯定都很差。

I actually remember reading the number one tip for starting a podcast was to record your first three episodes and then to throw them in the bin and start over because they'll almost certainly be terrible.

这建议 probably 挺有道理，但我们不打算听，毕竟没那个时间。

It's probably good advice, but we're not gonna take it because we haven't got time for that.

最近怎么样，弗兰克？

How have you been, Frank?

我还不错。

I've been pretty good.

刚过完一月的学校假期，说实话，我很享受能和孩子们还有妻子待在一起，不过她这阵子工作挺忙的。

Getting over the January school holidays, which are always I mean, I love the fact that I get to spend time with my boys and my wife, although she's been working a lot.

但真很难抽出时间干活。

But it is pretty challenging to find time to do any work.

假期和工作之间的平衡，一直让我挺头疼的。

And balancing holidays is an ongoing stressful thing for me.

我还没找到诀窍。

I haven't quite worked out the knack.

也许等孩子们长大不再愿意陪我了，这问题也就不存在了。

Maybe by the time the boys are too old and don't want to spend time with me, it won't be an issue I suppose.

这不正是让人担心的地方吗？

That's the worry, isn't it?

等他们真想独立了，你才说：‘咱们去度假吧’，那时候就晚了。

By the time they're ready to move on and you're like, Hey, let's do a holiday.

我们大概该说说这个播客打算怎么做了。

We probably should introduce how this podcast is going to work.

最近我意识到，我们每年为线上大会录了很多场与全球顶尖嘉宾的对谈。

So recently, I realized that we record a whole bunch of panel discussions with amazing speakers from around the world for our annual virtual conference.

但录完之后，这些内容基本就石沉大海了。

And afterwards, these are essentially they're essentially lost.

它们和大会的正式演讲不一样，那些演讲都会被收入我们的课程库永久保留。

They disappear as opposed to the conference lectures themselves which remain in our lecture collections.

所以我想到，不如把这些对谈重新剪辑一下，做成播客，让大家都能听。

So I thought, how about we repackage these discussions into a podcast for everyone to enjoy?

所以我们就这么定了。

So that's what we're gonna do.

有些节目会像今天这样讨论临床放射学，其他则会涉及放射学中非临床的方面。

Some episodes are going to be clinical radiology discussion like today's episode, while others will cover some nonclinical aspects of radiology.

我们会听到世界各地不同人的声音，各种视角，但核心主题始终是放射学。

We'll hear a lot of different voices from around the world, lots of different perspectives with the common theme being radiology.

如果我们有时间和精力，弗兰克，我觉得我们也可以顺便录点额外的小内容，对吧？

And if we have the time and energy, Frank, I think we might also try and record a few little extra things here and there, won't we?

我觉得这会非常好。

I think that would be really good.

周围有那么多我想聊聊的人，这正好是个借口。

There's so many people around that I'd love to have the excuse to talk to.

可我们总是抽不出时间去做这件事。

And we never seem to find the time to do that.

这些人里有些是Radiopaedia的编辑，还有一些是我们自己单位的同事。

Some of those people are editors from Radiopaedia, others are colleagues from our own workplaces.

有些人在这些年里我们见过面，也有些根本没碰过面，但我们都想找个理由跟他们聊聊。

There's people that we've met around the years or even never met, but want to have the excuse to talk to.

所以，如果你能把你的部分都搞定，那这就能成为一个很好的机会。

So hopefully, if you can do your side of it, which is all of it, we can use that as an opportunity.

这个想法部分源于我们一位Radiopaedia的朋友，他建议我们该开始拍些TikTok之类的视频。

This came about in part because one of our friends of Radiopaedia was suggesting that we should start doing some TikToks and things like that.

我看了眼TikTok，心想：这真不适合我。

I had a look at TikTok, I was like, this is not this is not for me.

其实我工作中也有几个人跟我说，安德鲁，你拍TikTok绝对合适。

And I actually had a few people at work going, Andrew, you'd be really good at TikTok.

但我还是说：不行。

And I'm like, no.

真的不行。

No.

绝对不行。

No.

播客可能更合适一些。

Podcast is probably a better fit.

如果我能把盖洛德也拉进来，估计会挺有意思的。

And if I can drag Gaylord into it, it'll probably be pretty entertaining.

所以。

So

所有不需要拍视频、也不用剪辑的内容都应该做。

Anything that doesn't have video that needs to be edited should be

没错。

Absolutely.

这正是我所期待的。

That's what I'm hoping anyway.

今天的节目，我们回听一下2021年我在Radiopaedia上与克里斯汀·格拉斯顿伯里和詹妮弗·吉尔斯皮共同录制的头颈科讨论会。

So for today's episode we're going back to a head and neck panel discussion that I recorded with Christine Glastonbury and Jennifer Gillespie at Radiopaedia twenty twenty one.

我选这一期，是因为这是我主持的第一场讨论会，两位嘉宾都特别棒。

I've chosen this one because I think it's the very first panel that I ever hosted And both the guests are absolutely delightful.

这里需要说明一下，这场讨论是在克里斯汀关于口腔肿瘤的讲座和珍关于术后颈部影像的讲座之后立即进行的。

For context this took place immediately after Christine s lecture on oral cavity tumours and Jen s lecture on imaging of the postoperative neck.

这两场讲座其实都可以在我们网站的头颈部讲座合集中找到。

Both lectures can actually be found in our head and neck lecture collection on the website.

不过，这场讨论本身基本上就能独立理解。

However this discussion should largely make sense on its own.

事实上，先听这场小组讨论，之后如果感兴趣再回去看讲座，可能反而是一种更有趣、更高效的方式。

In fact listening to the panel and then if interested going back and watching the lectures might actually be a fun and different more efficient way of doing it as well.

好了，我们开始吧。

Alright so let's get into it.

接下来，一起来听一听克里斯汀·格拉斯顿伯里和珍·吉尔克里斯皮的这场小组讨论。

Let's have a listen to this panel discussion with Christine Glastonbury and Jennifer Gillespie.

之后，弗兰克和我会再回来，继续聊上几句。

And then afterwards Frank and I will be back for a little bit more of a chat.

现在，我很荣幸邀请刚刚登场的两位讲者——来自加州大学旧金山分校的克里斯汀·格拉斯顿伯里，以及来自皇家布里斯班和妇女医院的珍·吉尔克里斯皮，来进行一场简短的小组讨论。

It's now my pleasure to welcome the two speakers we have just seen, Christine Glastonbury from UCSF and Jennifer Gillespie from Royal Brisbane and Women's Hospital for a quick panel discussion.

欢迎两位。

So welcome to both of you.

一如既往的精彩演讲。

Fantastic talks as always.

克里斯汀，你的互动真棒。

Christine, interactive.

你一说到口底三角区，我立马就用手摸了摸，看来这效果不错。

You had me fingering my retromolar trigone in no time, so I guess that's a good thing.

有那么一会儿，克里斯汀，你还让大家拍个口腔底部的照片发给你。

At one point, Christine, you actually asked people to take a selfie of your floor of mouth and email it to you.

所以如果有人在看的话，克里斯汀，

So if anyone's watching, Christine,

你的邮箱是多少？

what's your email address?

Christine.glastonbury@ucsf.edu。

Christine.glastonbury@ucsf.edu.

我想收集一张大家口腔底部的照片拼图

I I'd like to have a collage of everybody's floor

口腔底部的

of mouth.

我们会发一条推文展示这个拼图

We'll tweet that out.

一张口腔底部自拍的拼图

A collage of floor of mouth selfies.

我根据你们两位的演讲准备了一些问题，咱们一个一个来聊

So I've got some questions based on both of your talks, we'll kinda just go through those.

当然，也特别欢迎你们聊聊任何想讨论的内容

But very happy to discuss anything you guys wanna discuss.

那我先问你，Christine

So I'll start with you, Christine.

在你的演讲里，还有Jen的演讲中，关于口腔肿瘤的发病情况，影像上的表现其实都很细微

A lot of what we're looking at in your talk with oral cavity tumours, and in fact, in Jen's talk as well with tumor occurrence, the imaging findings were very subtle.

对吧？

Right?

克里斯汀，我第一个问题想问你，作为放射科医生，我们有没有什么办法能让这份工作没那么难，还是说这个领域本来就特别棘手？

And I guess my first question to you, Christine, would be, is there anything that we can do as a radiologist to actually make our job easier or is it always super hard in this area?

安德鲁，这个问题问得太好了，我觉得头颈部影像教学最难的地方，就是很多人一听到头颈部就害怕，觉得太复杂，而且很多征象都很隐蔽。

So I think this is, it's such a great question, Andrew, because I think one of the hardest things I think with teaching head and neck is people are afraid of head and neck because it seems hard and some of the findings are subtle.

但我之所以喜欢教这个领域，也特别热爱做头颈部诊断，就是因为这里其实藏着一些关键的诀窍。

But I think one of the reasons I like teaching it and why I really just love doing head and neck is that there are a few secrets.

我在讲课时，最想做的就是把这些诀窍分享出来。

That's really what I try to do in my lectures is share the secrets.

如果你掌握了几个小技巧，比如看到颌下腺肿大、颌下腺导管扩张，这往往就是一个信号，提示口底可能有肿瘤。

And I think if you learn a couple of the tricks, like for example, when you see a dilated submandibular gland, a duct of a submandibular gland, that's a key that there may be a tumour in the floor of mouth.

类似这样的细节。

Little things like that.

当你看多了头颈部的影像，就会发现一些规律——比如鳞状细胞癌是最常见的肿瘤，但其实它就属于同一种病理类型。

And once you start looking at a lot of head and neck scans, you start to see this pattern that they're kind of, I mean, squamous cell carcinoma is the most common tumour, but it's like one histology.

所以这种表现还挺有规律的。

So it's pretty predictable behaviour.

看起来很难，因为解剖结构太多，但其实只要掌握几个诀窍，再反复看大量扫描图像就行了。

So it seems really hard because there's a lot of anatomy, but really it's just a matter of learning a few tricks and then really just looking at scan after scan.

我平时会特别注意那个区域肌肉的正常厚度，比如颊肌，还有脂肪间隙的情况。

I saw a fair bit of knowing the normal kind of thickness of the muscles in that area, the buccinator muscle, for example, and looking at the fat planes.

对吧？

Right?

留意脂肪是否被推移或消失。

Looking for displacement or effacement of fat.

你也是这么看的吗，珍？

Is that what you kind of look for, Jen?

是的。

Yeah.

而且我觉得多看很多正常扫描片，才能建立起对正常样子的直观感受。

And I think just looking at lots of normal scans so that you get an idea of what normal is supposed to be.

得多练，但也得熟记解剖结构。

A lot of practice, but a lot of knowing the anatomy, really.

珍在她的讲座里也提到过这一点。

And Jen talks about this in her lecture.

了解病史，一切都会不一样。

Knowing the history changes everything.

说实话，如果我只看头颈部的影像，不参考任何病史，我肯定会犯遍所有错误。比如我提到的口腔癌，有些病灶根本看不见。

I mean, really, I would make every mistake in the book if I just looked at head and neck scans and didn't have some history of, for example, like I talk about an oral cavity, some of them are almost impossible to see.

很多声门肿瘤，肉眼根本看不出来，但你的任务其实不是找原发灶。

A lot of glottic tumours, you can't really see, but your job is not so much to find the primary.

更重要的是找深层浸润、骨质侵犯、神经周围肿瘤扩散，或者淋巴结有没有受累。

It's really more of looking for the deep invasion and involvement of the bone or perineural tumour spread or looking for lymph nodes.

所以你得掌握一些病史，当然，看大量影像、对解剖结构了如指掌，这才是关键。

So you kind of have to have some history, but yeah, looking at a lot of scans, getting really comfortable with anatomy is critical.

珍，你刚才在演讲里提到，你会去翻病理报告之类的资料。

Jen, you actually mentioned in your talk, your process that you actually, you know, kind of dig up the pathology reports and things like that.

你能再详细说说吗？

Can you go into a bit more detail?

你具体是怎么做的？大概要花多少时间？

Like, what do you actually do and how much time does it take?

是的。

Yeah.

这确实是个难题，对吧？

Well, that's the trick, isn't it?

做这些事真的很费时间，但有些扫描图像实在太难判断了，任何能帮上忙的线索都特别有用。

It takes so much time to do this, but I you know, there's such difficult scans that anything that you can use to make it easier is always helpful.

我们把IMR和我们的系统整合在一起了。

So we have the IMR linked to our pack.

所以我可以直接打开病人的档案，查看手术记录和病理报告。

So I can just open up the patient's record, look at the operative notes, look at the pathology.

我总是会看这些资料，还有以前的影像，因为知道肿瘤最初的位置，对判断它可能复发的地方特别有帮助。

So I always look at those, always the old scans because it's so helpful to know exactly where the tumour was to start with so that you can look where it's possibly going to recur.

所以我想，在私立诊所里这确实很难，因为你只是看个片子，知道他们做过手术。

And this is why I guess it's really hard in private practise as well when you're kind of seeing a scan and you know they've had surgery.

你能看到那里做了颈部清扫，但你没有相关信息，而且时间也很紧。

You can see the neck dissection there, but you haven't got the information and you've also got time pressure.

你根本没时间去翻找那些资料。

You haven't got the time to be digging up all that stuff.

所以你能理解，为什么在学术机构工作的人有更多时间仔细查看，而一些外部机构出的报告可能达不到你期望的质量。

And so you can kind of understand as, you know, people who work in academic institutions have a little bit more time to look at things why some of the reports you might see from outside might not be to the quality that you'd want.

确实挺难的。

And it is hard.

克里斯汀，在某个

Christine, at one

时刻，学术界的人。

point do academics.

我是个胆小鬼。

I'm a chicken.

能多一点时间。

To have a little bit more time.

你曾经明确提到，病理检查和影像学上都没有发现肿瘤有神经周围浸润的迹象。

At one point, you very deliberately stated that the tumor didn't show any evidence of perineural invasion on pathology or perineural tumor spread on imaging.

这一点在接下来卡特的讲座里会讲到，我觉得珍也提过。

And this is actually something that is covered in the next lecture by Carter, and I think Jen mentioned it as well.

她在病理报告中特别留意神经周围浸润的情况。

And something that she looks for in pathology reports is perineural invasion.

不过我想，为了帮助那些可能从未注意过这两个术语区别的观众，你能解释一下它们到底是什么意思吗？

But I wonder if you for just for the benefit of people who are watching who may not have ever considered the distinction between those two terms, what they actually mean.

当然。

Absolutely.

问得好，安德鲁。

Great question, Andrew.

你听得很认真。

You were listening.

你确实听得很认真。

You were really listening.

我们都听得很仔细。

We all were.

TNI是一种组织学上的发现，指肿瘤侵入、环绕并穿透神经。

TNI is a histological finding of tumor invasion in, around and through nerves.

这是一种真正的组织学表现。

So it's true histological finding.

它和神经周围肿瘤扩散有明显区别。

And it's really distinct from perineural tumour spread.

神经周围肿瘤扩散是指肿瘤从原发灶沿着神经做宏观上的延伸，可能在临床上或影像上就能观察到。

So perineural tumour spread is a macroscopic tumour extension along a nerve from the primary tumour, and that it may either be clinically apparent or radiologically apparent.

TNI这种组织学上的侵袭会降低所有患者的预后，尤其是那些手术切缘接近的患者。

So PNI, which is that histological invasion, worsens the prognosis of all patients and particularly those who have close surgical margins.

它还与区域复发风险显著升高密切相关。

And it's very much associated with an increased risk of regional recurrence.

关于这一点，已经有大量研究数据了。

So there's a lot of data on that.

所以我知道珍在她的讲座里提到，她会仔细看病理报告，确认有没有PNI，因为如果肿瘤有这种组织学浸润，你就得特别担心它会在局部，尤其是淋巴结那里复发。

And so I know Jen mentions it in her lecture that she looks at the report to see if there's PNI, because this is, if you have a tumour that has PNI and histology, this is one you're going to be really worried about recurring locally, particularly, and in lymph nodes.

相比之下，我们在影像检查中寻找的神经周围肿瘤扩散，并不增加区域转移的风险，但可能带来严重的并发症。

So by comparison, perineural tumour spread that you and I are looking for on the imaging scan is actually not associated with a greater risk of regional metastasis, but the morbidity can be severe.

所以在规划放疗范围时——我和放疗科医生一起做这个——我们会看有没有扩散迹象，他们有时会提前对这些神经进行放疗，因为不处理的话会引起症状。

And so when you're planning radiation fields, and I get to do that with my radiation oncologists, you're looking to see if it's spreading and they will sometimes preemptively radiate those nerves because it will result in symptoms.

如果出现明显的神经周围肿瘤扩散，患者会感到疼痛，还可能出现麻木或其他感觉神经功能障碍。

If they have gross perineural tumour spread, they'll have pain, they can have numbness, other sensory nerve dysfunctions.

当然，肿瘤就是沿着神经走，最终侵入大脑的。

And of course, it's how it accesses, it goes along the nerve to access the brain.

你绝对不希望神经周围肿瘤扩散靠近大脑。

And you don't want to have perineural tumour spread getting near the brain.

这种状况真的很难清除。

It's really hard to get rid of.

所以PNI是一个指标，表明这个肿瘤局部复发的风险很高。

So the PNI is an indicator that this is a tumour that has a high risk of local recurrence.

当Jen和我看到这个结果时，都会觉得这个病例比其他病例更让人担心局部复发。

And so when Jen's reading that and I'm reading that, you're thinking this is one I'm more worried about than others for recurring locally.

所以在随访时，我会特别仔细地检查有没有局部复发的迹象。

So on follow ups, I'm really looking carefully to make sure it's not locally recurring.

而神经周围肿瘤扩散，指的是我们在影像上看到的肉眼可见的形态。

But perineural tumor spread is that macroscopic appearance that we see on imaging.

是的。

Yeah.

Jen，轮到你了。

Jen, back to you.

我们见过不少肿瘤复发的病例，PET检查能清楚显示复发灶和淋巴结转移，但单靠CT很难发现。

We saw quite a few cases of tumor recurrence where there was PET really clearly showing that there was recurrent disease and nodal spread, but it was quite tough on the CT alone to spot them.

这就让人不禁想问，为什么我们不把PET作为这些患者随访的首选影像手段呢？

And it kinda begs the question, why why do we not use PET as the primary imaging modality to follow-up these patients?

克里斯汀，你能谈谈在美国PET是怎么使用的吗？因为这里在澳大利亚可能不太一样。

And then I guess, Christine, if you could give your perspective of how PET is used in The United States because it might be a bit different here in Australia.

詹，轮到你了。

So, Jen?

如果资源不受限、钱不是问题，我们肯定会给每个病人做PET检查。

Well, I guess if we had unlimited resources and all the money in the world, we would be doing pets on everybody.

显然，澳大利亚和美国在影像检查的经费支持方式上是不一样的。

Obviously, there's a different way that we fund imaging in Australia compared to The States.

而且我觉得，很多地方还跟影像设备的可及性有关。

And I think a lot of places it's also about accessibility of imaging modalities.

我们通常在患者术后首次复查时都会做PET，如果结果正常，后续就改用CT了。

So certainly we would do a PET for most of our cases in the first instance of their first postoperative imaging, but then go to CT following that if the PET was clear.

很多患者住得离医院特别远。

A lot of our patients come from a long way away.

比如昆士兰州的患者，得开车十二个小时才能到最近的PET扫描仪那里。

So we have patients in Queensland who would have to travel twelve hours by car to get to their nearest PET scanner.

所以，这其实跟可及性有关。

So, you know, it's a bit about accessibility.

因此，大家都会选CT而不是PET，但理想情况下，人人都该做PET。

So people are gonna go and choose the CT rather than the PET scan, but ideally PET everybody.

克里斯汀，在美国，对于这些患者的随访，PET和CT的获取情况怎么样？

And Christine, what's it like in The US from access to PET versus CT for following up these patients?

我有两点想说。

Well, I have kind of two things.

首先，我对PET的看法很复杂，因为假阳性很多，而且PET的类型也不一样。

One is I have very mixed feelings about PET because there are a lot of false positives and there's also different types of PETs.

有人做PET，也有人做增强CT，对我来说，头颈部检查中增强CT是必不可少的。

People do PET and they do a nice contrast enhanced CT, which for me is essential in the head and neck.

如果没做好质量高的增强CT，大部分时候都是白费功夫，因为假阳性和假阴性都太多了。

If you don't have a good quality contrast enhanced CT, I think you're wasting your time most of the time because of all the false positives and false negatives that happen.

詹在演讲中提到的那些并发症，你们在PET上是看不到的，对吧？

And a lot of those complications that we saw in Jen's talk, you're not gonna spot them on the PET, are you?

要发现这些问题，必须做增强CT。

You need contrast CT to spot a lot of those things.

没错。

Right.

很多地方收费一样，却只做普通CT。

And a lot of places will charge same price and they'll do a CT.

我经常遇到患者在外院做的CT，图像质量差得像从太空拍的一样。

I usually describe that we get a lot of those from patients having them done on the outside and the CT looks like it was shot from space.

视野特别小，完全没有对比剂。

Like it's this little small field of view, there's no contrast.

我就想，这地方肯定有问题。

And I'm like, well, there's something there.

Jen展示的一些病例就特别好，她用的都是增强CT。

In Jen's like, she shows some beautiful cases where she has a contrast enhanced CT.

把PET和增强CT放在一起看，结果一目了然。

When you put the PET with it, you're like, yeah, obvious.

但如果没有好的CT，那纯粹是白费时间。

But without the good CT, it's a waste of time.

说到医疗，美国简直一团糟。

So The US, when it comes to healthcare, is a complete disaster.

越多并不意味着越好。

More is

这正是我想听的。

This is all I wanted to hear.

这正是我当初问对人了的原因。

That's the main reason I asked the Right.

越多并不意味着越好。

More is not better.

能不能得到服务，完全看你有多少钱、有没有医保。

And having access depends on how much money you have and health insurance.

我觉得这事还是少提为妙。

It's really the less said about that, the better, I think.

这真的很难。

It's very difficult.

我得说，最让人头疼的一点是，我在澳大利亚接受的培训，那里每个人都能顺利获得真正需要的治疗。

I have to tell you, that's one of the toughest things is, you know, I trained in Australia, everybody has great access to what you really need.

可这里的人往往花光所有积蓄，却未必能得到该有的治疗。

People here go broke and they don't even necessarily get what they really need.

真的非常棘手。

It's really hard.

不过话说回来，如果能获得这些检查资源，很多人确实会做PET扫描。比如化疗放疗后，或者手术切除加放疗后，通常会在八周左右做一次基线扫描——如果是口咽部肿瘤，或者头颈部大部分区域，比如口腔，一般先做CT作为基线，三个月后再做一次PET基线扫描。

Having said that, if you have access to things, a lot of people do get PET and the classic after chemo radiation, for example, or after surgical resection and radiation will get a baseline scan, either MR if it's an oropharyngeal tumour or most of the head and neck, the oral cavities, for example, they will get a CT as a baseline, usually at eight weeks and then a three month baseline PET.

之后是继续用CT还是改用PET-CT，主要取决于那次检查的质量如何。

And where it goes from there, whether it's just CT or whether it's going to be a PET CT, will largely depend on if that study is really good.

如果那次检查效果很好，我们通常就继续沿用同一种方式，直到发现明显复发迹象，才考虑用PET。

If that study is really good, usually we will just continue with that modality and we won't use PET until we see there's gross recurrence.

现在我们主要关注的是有没有远处转移。

And now we're looking for metastatic spread.

那我们在这里该怎么处理呢？

And what are we going to do for here?

鼻咽癌的情况不同，它在确诊时就更容易出现转移。

The difference is with nasopharyngeal carcinoma, which has much greater tendency for metastatic disease at presentation.

所以我们更倾向于用PET来随访。

And we're more likely to follow with PET.

但总的来说，在美国，这主要看你的保险覆盖范围和你有多少钱。

But by and large, it depends what your insurance company is and how much money you have in The United States.

是的。

Yeah.

这确实挺让人难过的，对吧？

It's it's sad, isn't it?

从CT解读的角度来说，我们主要是在寻找细微的变化，对比之前的扫描，再往前推，甚至再往前推，看看有没有缓慢生长或逐渐出现的迹象。

I guess from a CT interpretation point of view, it's really looking for quite subtle changes and comparing with the prior scan, but also the one before that and the one before that to look for things that might be growing slowly or happening slowly.

我记下了你讲座里的一些关键点，现在想跟你复述一下。

I just have written down some key takeaway points that I've taken from your talks, and I'm just gonna kind of speak them to you.

你可以随时点头表示认同。

And you can feel free to just nod along.

不用非得开口回应。

You don't need to respond verbally.

你就静静地感受一下，我从你演讲里学到的这些要点。

You can just, you know, feel the appreciation for the things that I've taken away from your talk.

如果你想要插话澄清什么，随时都可以。

If you want to interject and clarify anything, then feel free.

关于克里斯汀的演讲，我记下了一个小技巧：用纱布帮助患者在做MRI时鼓起脸颊，因为患者在MRI机器里很难长时间保持这个姿势。

So for Christine's talk, I've written down that tip about using gauze for the puffed out cheek view on MRI because a patient can't really do that for very long in an MRI scanner.

效果非常好。

Works really nicely.

真的吗？

Does it?

其实特别简单。

It's really easy.

我们十几年前读过一篇关于这个的论文，记不清具体多少年了。

We read a paper on it, I don't know how many, fifteen years ago.

这方法特别简单。

It's really easy.

耳鼻喉医生把纱布给他们，病人带着来就诊，进磁共振仪之前往嘴里一放就行。

ENT surgeon gives them the gauze, they bring it to their appointment, and they put it in just before they go into the magnet.

结果图像上就是一片黑色。

And it just looks black.

但这样能把脸颊推离肿瘤。

But it pushes the cheek away from the tumour.

不过，就算不取假牙，对某些肿瘤的成像也有明显帮助。

But even leaving the dentures in looked like it was quite useful for some of those tumours as well.

对吧？

Right?

如果把假牙取出来，就有点失去组织之间的分离度了。

If you took the dentures out, you're kind of losing a bit of separation between

我知道。

I know.

这难道不令人着迷吗？

Isn't that fascinating?

确实如此。

Yeah.

从来没人写过或做过这件事，但我看CT片的时候注意到了。

No one's ever written about that or done that, but I was looking at it on CTs.

我当时就想，

I was like,

对，没错。

kinda Yeah.

观察得很到位。

Good observation.

你提到硬腭的肿瘤和其他口腔部位不太一样，这点很有意思。

Your point about the hard palate kinda being different to the rest of the oral cavity in terms of the tumours that arise there.

这种情况我见得太多了。

I see this all the time.

每次我把硬腭肿瘤的病例交给实习生，他们第一反应总是鳞状细胞癌，即使肿瘤已经明显沿着腭大神经管向上蔓延，他们甚至都不会考虑唾液腺小肿瘤的可能性。

Every time I give a hard palate tumour case to one of our trainees, the first thing they say is always SCC, and minor salivary gland tumours may not even come up in their differential even if there's obvious tumours spreading up the greater palatine canal or something.

所以我想再强调一下，你真正面对的是唾液腺小肿瘤，一定要仔细检查腭大神经管，看有没有神经周围扩散到翼腭窝的情况。

So I think it's just worth reemphasizing that that you're really talking about minor salivary tumors there and to have a great look at that greater palatine canal for perineural spread up into the pterygopalatine fossa.

我接下来要讲的是牙龈鳞癌会侵犯骨骼。

The next thing I've written down is the gingival SCC goes to the bone.

尤其是做CT时，要特别留意骨皮质的侵蚀迹象。

And so look at CT in particular for cortical erosions.

如果还没做CT，一定要补一个。

So get a CT if you haven't got one.

如果确实已经侵犯到骨头，那手术方案就得改了，因为你必须做下颌骨切除。

And then if it is going to the bone, that's gonna change your surgery, obviously, because you're gonna have to do a mandiblectomy.

所以一定要用骨算法做CT，别只用软组织算法，因为你真正要找的是骨皮质侵蚀，这关系到是否要行边缘性下颌骨切除。

And so always get bone algorithm, not just soft tissue algorithm, because you're really looking for that cortical erosion for the marginal mandibularectins.

我在这儿写的下一点，是我们之前讨论过的：下颌下腺阻塞可能是口底肿瘤的线索。

The next thing I've written here is what we already discussed, the obstructed submandibular gland as a clue to the floor of mouth tumor.

这挺有意思，因为很多时候，我觉得是通过超声检查发现的。

That's interesting because often, I think that presents often with ultrasound.

对吧？

Right?

你给患者做超声，是因为下颌下腺肿了。

You're doing an ultrasound for a swollen submandibular gland.

结果看到导管扩张了。

You see some dilated ducts.

我就在想，是不是该更主动地去排查有没有小肿瘤，是不是该直接安排核磁共振来查清楚，还是……

And I just wonder how often whether I should be more often kinda looking for a small tumor and whether I should be going towards doing an MRI to look for that or do

你是不是觉得，不如让患者自己拍个口底的照片？

you think Or get the patient to do a selfie of the floor of their mouth.

也许这还真是个办法。

Maybe that's the thing.

你最好在报告里明确写上这一点。

You need to actually, you know, maybe put that in your report.

建议将口腔底部是否有肿瘤表现与影像结果做关联分析。

You know, correlation with any appearance in the floor of the mouth of a tumor would be recommended.

我们看到的肿瘤影像厚度，并不等于实际的浸润深度。

The next thing I've written here is the imaging thickness of the tumours that we see does not equal the depth of invasion.

肿瘤的真正深度，还得靠病理科医生来判断。

So the pathologist is going to tell us what the depth is.

如果肿瘤是外生性长得很大的，那病理结果可能并不能真实反映浸润情况。

If you've got a big exophytic tumour then that might not be representative when you actually do the pathology.

所以我们的工作重点，是把肿瘤的范围准确勾勒出来。

And so our job is more to map the tumor.

你刚才说得挺到位的。

Thought you described that well.

病理科医生也不一定能说清楚肿瘤具体会往哪里扩散。

Kind of, you know, the pathologist isn't gonna tell them necessarily where it's going.

我们可以对它进行定位。

We're going to be able to map it.

然后，根据这些信息，就能预测它可能扩散到哪里，以及外科医生需要做多大范围的手术。

And then from there, you can predict where it's gonna potentially spread to and how much surgery the surgeon needs to do.

这就是我从你的演讲中得到的主要收获。

So that's what I took away from your talk.

太好了。

Perfect.

讲得太棒了。

That was great.

他们现在根本不用听讲座了。

Didn't even I they now they don't need to listen to the lecture.

直接列个清单就行。

You can just, like, list it out.

完美。

Perfect.

还有，

And,

珍妮，从你的分享中，我有几点收获。

Jenny, from your talk, a few things that I took away.

放疗后淋巴组织萎缩，这一点我以前没想过，还有那种对侧腭扁桃体的淋巴组织，我们常误以为是对侧病灶。

Atrophy of lymphoid tissue occurring post radiotherapy, you hadn't thought about that before, and then confusing that kind of contralateral palatine tonsil that we often see that lymphoid tissue there for being contralateral disease.

因为它看起来确实很不对称，而你本来就是在找这种不对称，结果突然发现这边有个大肿块。

Because it does look it looks very asymmetric and that's what you're trying to look for and suddenly you go, oh, look at this big lump over here.

我觉得这个观点特别好。

So I thought that was a really good point.

关于肌瓣和移植物的区别，这个部分。

The muscle flap versus sorry, flap versus graft, the differentiation between those.

我的一些学员真的应该看看你讲的这部分。

Some of my trainees could definitely do with watching that part of the talk.

而且肌瓣应该保持肌肉本身的外观。

But also the muscle flap should maintain that kind of muscle appearance.

这毕竟是块肌肉。

Like, it's a muscle.

虽然会有点萎缩，但在随访影像上，它还是会保持那种条纹状的外观。

It's a bit gonna become atrophic, but it's still gonna have that kind of striated appearance to it on the follow-up images.

你提到的另一点是，如果这个皮瓣的体积随时间增加，那就值得警惕了。

And then the other point you made is that kind of any increase in volume of that flap over time is suspicious.

所以，它应该是越来越小才对。

So if anything, it should get smaller.

对吧？

Right?

是的。

Yeah.

我觉得关于皮瓣，大家往往只盯着手术区域正中间看，但其实周边区域同样关键，因为复发常常就发生在手术边缘那里。

And I think one of the things with the flap is that you tend to look right in the middle of where the operation was, but it's really key to look around the edges as well because, you know, the edge of where the surgery is is often where you can recur.

我这里记下的最后一点是，做了咽喉切除术后残留的甲状腺组织。

And then the final one I've written down here is residual thyroid post the, you know, pharyngolaryngectomy.

你切掉了一侧，另一侧的甲状腺还在。

You've taken out one side of The other thyroid's still there.

但因为新建的气管造成了结构变形，剩下的半侧甲状腺看起来会呈圆形，容易被误认为淋巴结。

But because of the distortion of the, you know, the neo trachea that you've kinda put in there, you get this kinda rounded appearance to the the remaining hemithyroid, and that can be confused for a lymph node.

我觉得这点特别好，因为归根结底，你就是要认出甲状腺典型的形状。

So I thought that was really good because, yeah, again, you're just looking for that typical thyroid shape.

如果你没看到，但看到任何圆形的东西，第一反应都会觉得不对劲，对吧？

And if you don't see it, anything round, anything round you normally think, automatically think is bad, right?

所以这点一定要记在心里。

So just worth keeping in the back of your mind.

这些都是非常到位的见解。

Those are all great points.

珍的讲解太精彩了。

Jen's lecture is fantastic.

你注意到了吗？我这儿安排的是轻松的讲座。

You notice I got the easy lecture here.

这些观点都很到位。

They are great points.

我见过不少这类类固醇被做活检的情况。

I've seen a number of those steroids being biopsied.

那种不对称的淋巴组织，在PET图像上也特别明显。

And that asymmetric lymphoid tissue, that's a huge thing on PET as well.

这真是个典型的PET假阳性例子。

I was gonna say that's a nice false positive on PET.

两侧对比很清晰。

Great contrast on side.

确实如此。

Yeah.

当一侧做选择性颈清扫时摘除了下颌下腺，另一侧的下颌下腺因为有轻度FDG摄取，PET上就会显得不对称，容易被误认为是肿块。

And when they take out the submandibular gland on one side, as a selective neck dissection, and the other one gets called a mass on PET because there's, you know, some mild FDG uptake in a normal submandibular gland, and it looks like a mass because it's asymmetric.

对临床医生来说，也可能会摸到它，误以为是淋巴结。

Or a palpable node for the clinicians, like, they build the submandibular gland and think it's a node.

是的

Yeah.

我们真是天生就追求对称，对吧？

We're so built for the symmetry, aren't we?

没错。

Yep.

再次感谢两位精彩的讲座，也感谢你们对本次会议以及Radiopaedia的大力支持。

So thank you both again for your fantastic lectures and also just for your support of the conference and for Radiopaedia in general.

我知道，尤其是克里斯汀，你一直对我们所做的工作给予大力支持，我非常感激。

I know Christine, in particular, you've always been very supportive of what we've been doing, and I'm very thankful for that.

希望你们接下来的会议日程愉快。

I hope you enjoy the rest of the conference, both of you.

接下来，我们将继续进行高级头颈部专题，有请卡特·卡瓦纳带来演讲。

And we're going to continue this advanced head and neck session now with a lecture from Carter Cavanaugh.

她就住在那边几百米外，演讲主题是神经周围肿瘤扩散与颅底。

She lives just a few 100 meters that way, and that's on perineural tumor spread and the skull base.

等 session 结束后，我会回来展示几个实时病例。

And then I'll be back at the end of the session to show a few live cases.

别走开，后面还有。

So stick around for that.

再次感谢克里斯汀和珍，那我们先告辞了。

And Christine and Jen, thanks again, and bye for now.

待会儿见。

See you later.

非常感谢你，安德鲁。

Thanks so much, Andrew.

很高兴见到你们两位。

Good to see you, both.

我也很高兴见到你们。

Great to see you too.

再见。

See you.