De-Escalated Adjuvant Therapy After Transoral Robotic Surgery for Human Papillomavirus-Related Oropharyngeal Carcinoma: The Sinai Robotic Surgery (SIRS) Trial.

BACKGROUND: Treatment of human papillomavirus-related oropharyngeal squamous cell carcinoma (HPVOPC) results in unprecedented high survival rates but possibly unnecessary toxicity. We hypothesized that upfront surgery and neck dissection followed by reduced-dose adjuvant therapy for early and intermediate HPVOPC would ultimately result in equivalent progression-free survival (PFS) and overall survival while reducing toxicity. METHODS: This study was a nonrandomized phase II trial for early-stage HPVOPC treated with transoral robotic surgery (TORS) followed by reduced-dose radiotherapy. Patients with previously untreated p16-positive HPVOPC and <20 pack years' smoking history were enrolled. After robotic surgery, patients were assigned to group 1 (no poor risk features; surveillance), group 2 (intermediate pathologic risk factors [perineural invasion, lymphovascular invasion]; 50-Gy radiotherapy), or group 3 (poor prognostic pathologic factors [extranodal extension [ENE], more than three positive lymph nodes and positive margin]; concurrent 56-Gy chemoradiotherapy with weekly cisplatin). RESULTS: Fifty-four patients were evaluable; there were 25 in group 1, 15 in group 2, and 14 in group 3. Median follow-up was 43.9 months (9.6-75.8). Disease-specific survival was 98.1%, and PFS was 90.7%. PFS probability via Kaplan-Meier was 91.3% for group 1, 86.7% for group 2, and 93.3% for group 3. There were five locoregional failures (LRFs), including one distant metastasis and one contralateral second primary. Average time to LRF was 18.9 months (9.6-59.0); four LRFs were successfully salvaged, and the patients remain disease free (11.0-42.7 months); one subject remains alive with disease. CONCLUSION: The results indicate that upfront surgery with neck dissection with reduced-dose radiation for T1-2, N1 stage (by the eighth edition American Joint Committee on Cancer staging manual) HPVOPC results in favorable survival with excellent function in this population. These results support radiation dose reduction after TORS as a de-escalation strategy in HPVOPC. IMPLICATIONS FOR PRACTICE: Transoral robotic surgery can provide a safe platform for de-escalation in carefully selected patients with early-stage human papillomavirus-related oropharyngeal cancer. In this clinical trial, disease-specific survival was 100%, over 90% of the cohort had a reduction of therapy from standard of care with excellent functional results, and the five patients with observed locoregional failures were successfully salvaged.

Rotation of the Ipsilateral Supraorbital Rim Around the Horizontal Axis in Unilateral Coronal Synostosis: A Craniometric Analysis of the Emergence Profile.

INTRODUCTION: Unilateral coronal synostosis (UCS) results in well-defined dysmorphic changes including sphenoid malposition yielding posterior displacement of the supraorbital rim. Although variation in the ipsilateral supraorbital rim emergence profile has been suggested, it has not been previously investigated. The authors sought to characterize the emergence profile of the ipsilateral supraorbital rim in UCS through craniometric analysis. METHODS: Thirty-five nonsyndromic UCS patients (0-18 months) with CT images obtained before operative intervention and 16 control patients (0-24 months, 32 orbits) were included. Craniometric measurements were performed to quantify the emergence profile of the ipsilateral supraorbital rim and locate the likely apex of rotation. RESULTS: The ipsilateral supraorbital rim was significantly rotated around the horizontal axis when measured in reference to the 0° vertical in UCS versus control patients by an average difference of 7.3° to 11.3° across age groups (P < 0.05). No significant effect modification was detected between age and UCS on ipsilateral supraorbital rim emergence profile (P > 0.05). Additional angles with vertices around the superior orbital circumference were then measured to locate the likely apex of rotation and revealed a significant decrease in the posterior orbital roof to 0° horizontal in UCS patients by an average of 9.3° to 22.1° in children under 1 year old (P < 0.01). CONCLUSION: Variation in the emergence profile of the ipsilateral supraorbital rim in UCS is quantified, and the apex of this rotation likely lies at the posterior orbital roof. The novel quantification and characterization of this deformity will better direct the operative approach and enable a more accurate correction.

CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis but Importance in Surgical Planning.

OBJECTIVE: The purpose of this study was to determine the incidence of sinonasal anatomic variants and to assess their relation to sinonasal mucosal disease. MATERIALS AND METHODS: A retrospective evaluation of 192 sinus CT examinations of patients with a clinical history of rhinosinusitis was conducted. The CT scans were evaluated for the presence of several anatomic variants of the sinonasal cavities, and the prevalence of each variant was calculated. Prevalences of all sinonasal anatomic variants were compared between patients who had minimal to no apparent imaging evidence of rhinosinusitis and those who had radiologic evidence of clinically significant rhinosinusitis. RESULTS: The most common normal variants were nasal septal deviation, Agger nasi cells, and extension of the sphenoid sinuses into the posterior nasal septum. We found no statistically significant difference in the prevalence of any of the studied anatomic variants between patients with minimal and those with clinically significant paranasal sinus or nasal cavity disease. CONCLUSION: Analysis of every routine CT scan of the paranasal sinuses obtained for sinusitis or rhinitis for the presence of different anatomic variants is of questionable value unless surgery is planned.

Maxillofacial Skeleton and Facial Anatomy.

In this article, we discuss the anatomy and development of the face. One should become familiar with the layers, muscles, vessels, and nerves of the face. Embryologic development of the face and supporting structures is also discussed. Additionally, different clinical manifestation of facial paralysis is highlighted.

Cancers of the oral cavity and oropharynx: FDG PET with contrast-enhanced CT in the posttreatment setting.

The combined use of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and contrast material-enhanced computed tomography (CT) for posttreatment monitoring of cancers of the oral cavity and oropharynx has steadily increased in recent years. FDG PET/CT offers many advantages for evaluating the effects of therapy, determining whether residual or recurrent disease is present, and assessing the extent of nodal disease. Because of the high negative predictive value of this imaging test, some have advocated the deferral of neck dissection in patients with negative findings at FDG PET/CT after chemotherapy and radiation therapy; positive findings may have a similarly heavy influence on the future course of treatment. Thus, the accuracy of image interpretation is crucial. However, the interpretation of posttreatment FDG PET images is challenging, with multiple potential pitfalls and limitations that could lead to an incorrect analysis. Accuracy depends on a detailed knowledge of the patient's treatment history and a thorough understanding of the kinds of changes that might result from treatment. Awareness of the principles underlying the selection of the optimal interval between the completion of treatment and the first follow-up FDG PET/CT examination is especially important, since an interval that is too short could lead to false-positive or false-negative findings. A period of 12 weeks or more is generally recommended, but the optimal waiting period depends on the extent of therapy and other factors. If recurrence or progression is suspected during the waiting period, contrast-enhanced CT or magnetic resonance imaging should be performed without FDG PET.

FDG PET with contrast-enhanced CT: a critical imaging tool for laryngeal carcinoma.

Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has evolved to be an essential imaging modality in the evaluation of laryngeal carcinoma. Although the modality has limited utility in assessing the extent of the primary tumor, FDG PET has proved to be superior to anatomic modalities in the detection of lymph node and distant metastases. The role of FDG PET in the evaluation of patients with laryngeal tumors that are clinically classified as N0 has not shown consistent usefulness because of the innate resolution limitations of the camera. In the posttherapy setting, however, FDG PET has consistently demonstrated a high negative predictive value in the identification of recurrent disease, both during the course of therapy and during long-term follow-up. In addition, contrast material-enhanced computed tomography (CT) in conjunction with FDG PET has demonstrated a complementary role by allowing for superior anatomic coregistration and therefore more definitive diagnosis. There is sufficient evidence that with further advances in PET technology, this modality will likely become more useful in the detection of small lesions and occult nodal disease, as well as in guiding the management of laryngeal carcinoma.

Occult contralateral nodal disease in oropharyngeal squamous cell carcinoma patients undergoing primary TORS with bilateral neck dissection.

BACKGROUND: Knowledge of the rate of occult contralateral nodal disease for oropharynx cancers (OPSCC) in the era of Human Papillomavirus-dominated disease would inform practitioners as to who may be a candidate for unilateral neck management. The objective of this study was to determine the rate of pathologic contralateral positive nodes in patients in OPSCC patients with pT1 and pT2 disease treated with TORS and bilateral neck dissections (BND). METHODS: Retrospective review of medical records was performed at Princess Margaret Cancer Center, Toronto; Icahn School of Medicine at Mount Sinai, New York City; and Montefiore Medical Center, New York City. Patients with pT1-2 N0-3 (AJCC 8th Edition) OPSCC disease treated with TORS and BND were included. RESULTS: Thirty-two patients met inclusion criteria. Twelve patients (37.5%) had a tonsil primary site, 19 (59.4%) patients had a base of tongue primary site, and 1 (3.1%) patient had a pharyngeal wall primary. Twenty-four (75%) patients were known to be p16+. Twenty-seven patients (84.4%) were radiographically negative in the contralateral neck preoperatively, and two of these patients had pathologic contralateral positive nodes. The occult pathologic contralateral nodal metastasis rate was 7.4% (2/27). The sensitivity, specificity, positive predictive value, and negative predictive value of suspicious contralateral nodes on preoperative imaging for pathologically positive nodes were 33.3%, 86.2%, 20% and 93% respectively. In the p16+ subgroup, the occult nodal positive rate in the contralateral neck was 5%. CONCLUSIONS: pT1-2 OPSCC patients undergoing TORS and elective contralateral neck dissection have a low rate of pathologic contralateral nodal positivity.

Occult Nodal Disease and Occult Extranodal Extension in Patients With Oropharyngeal Squamous Cell Carcinoma Undergoing Primary Transoral Robotic Surgery With Neck Dissection.

IMPORTANCE: The historically reported rates of subclinical cervical nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) predate the emergence of human papillomavirus as the predominant causative agent. The rate of occult nodal disease with changing etiology of OPSCC is not known, and it is challenging to anticipate which patients will be upstaged postoperatively and will require adjuvant therapy. OBJECTIVE: To assess the rate of nodal upstaging and occult extranodal extension (ENE) in a multi-institutional population of patients with pathologic (p)T1-2 OPSCC treated by transoral robotic surgery and neck dissection. DESIGN, SETTING AND PARTICIPANTS: This retrospective, multicenter cohort study of 92 participants at 2 US institutions (Albert Einstein College of Medicine, Bronx, New York [n = 38], and Icahn School of Medicine at Mount Sinai, New York, New York [n = 39]) and 1 Canadian institution (Princess Margaret Hospital, Toronto [n = 15]) examined the rate of postoperative pathologic upstaging for 92 patients with pT1-2 OPSCC undergoing transoral robotic surgery with neck dissection from August 2007 to December 2016. A neuroradiologist at each site blinded to final pathologic diagnosis reviewed preoperative imaging; these findings were compared with operative pathology and applied for tumor staging using the eighth edition of the American Joint Committee on Cancer Cancer Staging Manual. The statistical analysis was performed on December 18, 2018. MAIN OUTCOMES AND MEASURES: Occult pathologic nodal disease and change in nodal category postoperatively. RESULTS: Of 92 patients who met the inclusion criteria, 76 (83%) were male, and they had a mean (SD) age at surgery of 59.5 (10.5) years; 70 patients (84%) with available p16 status were positive. Five of 18 patients (28%) who had no evidence of nodal disease on imaging had occult pathologic nodal disease. Seven of 32 patients (22%) presenting with no nodal disease or with a single metastatic node on imaging received pathologic upstaging because of multiple positive nodes, indicating implementation of additional adjuvant treatment not anticipated after a priori imaging. Changes included 12 patients (13%) who had pathologic nodal upstaging and 12 (13%) with pathologic nodal downstaging in the eighth edition of staging. In the cohort, 24 patients (27%) had pathologic ENE, and 5 of 39 patients (13%) had occult ENE in the absence of radiographic evidence. CONCLUSIONS AND RELEVANCE: Predicting pathologic staging preoperatively for patients with OPSCC undergoing transoral robotic surgery and neck dissection remains a challenge. Although nodal size, tumor size, and location do not help predict ENE, the presence of nodes on imaging and nodal category may help predict ENE. Our findings suggest a small proportion of patients might benefit from further adjuvant therapies not predicted by preoperative imaging based on occult nodal upstaging and ENE.

Correlation of positron emission tomography standard uptake value and pathologic specimen size in cancer of the head and neck.

PURPOSE: To correlate positron emission tomography (PET) standard uptake value (SUV) with pathologic specimen size in patients with head-and-neck cancers. METHODS AND MATERIALS: Eighteen patients with Stage II-IVB head-and-neck cancer with 27 tumors who underwent PET and computed tomography (CT) imaging of the head and neck followed by surgical resection were selected for this study. Various SUV thresholds were examined, including the software default (SUV(def)), narrowing the window by 1 standard deviation (SD) of the maximum (SUV-1SD), and SUV cutoff values of 2.5 or greater (SUV2.5) and 40% or greater maximum (SUV40). Volumetric pathologic data were available for 12 patients. Tumor volumes based on pathologic examination (gold standard), CT, SUV(def), SUV-1SD, SUV2.5, and SUV40 were analyzed. RESULTS: PET identified five tumors not seen on CT. The sensitivity of PET for identifying primary tumors was 94% (17 of 18). The Sensitivity of PET for staging the neck was 90% (9 of 10), whereas the specificity was 78% (7 of 9). The SUV2.5 method was most likely to overestimate tumor volume, whereas SUV(def) and SUV-1SD were most likely to underestimate tumor volume. CONCLUSIONS: The PET scan provides more accurate staging of primary tumors and nodal metastases for patients with advanced head-and-neck cancer than CT alone. Compared with the gold standard, significant variability exists in volumes obtained by using various SUV thresholds. A combination of clinical, CT, and PET data should continue to be used for optimal treatment planning. The SUV40 method appears to offer the best compromise between accuracy and reducing the risk of underestimating tumor extent.

Role of 3D CT in the evaluation of the temporal bone.

In recent years, three-dimensional (3D) multiplanar reformatted images from conventional cross-sectional computed tomographic (CT) data have been increasingly used to better demonstrate the anatomy and pathologic conditions of various organ systems. Three-dimensional volume-rendered (VR) CT images can aid in understanding the temporal bone, a region of complex anatomy containing multiple small structures within a relatively compact area, which makes evaluation of this region difficult. These images can be rotated in space and dissected in any plane, allowing assessment of the morphologic features of individual structures, including the small ossicles of the middle ear and the intricate components of the inner ear. The use of submillimeter two-dimensional reconstruction from CT data in addition to 3D reformation allows depiction of microanatomic structures such as the osseous spiral lamina and hamulus. Furthermore, 3D VR CT images can be used to evaluate various conditions of the temporal bone, including congenital malformations, vascular anomalies, inflammatory or neoplastic conditions, and trauma. The additional information provided by 3D reformatted images allows a better understanding of temporal bone anatomy and improves the ability to evaluate related disease, thereby helping to optimize surgical planning.

Prognostic value of radiographic extracapsular extension in locally advanced head and neck squamous cell cancers.

OBJECTIVES: We investigated associations between radiographic evidence of nodal extracapsular extension (rECE) and outcomes for locally advanced head and neck squamous cell cancers (LAHNC). MATERIALS AND METHODS: We conducted a single-institution retrospective study of 258 consecutive LAHNC patients with accessible pretreatment contrast-enhanced neck CT scans, who completed definitive or adjuvant radiation therapy. All scans were reviewed by an expert head and neck radiologist for evidence of rECE. Kaplan-Meier and Cox regression multivariate analyses (MVA) were performed to evaluate the impact of rECE on overall survival (OS), progression free survival (PFS), distant control (DC), and locoregional control (LRC). RESULTS: One-hundred forty patients were rECE-positive and 118 were rECE-negative. The rECE-positive cohort had more cN3 disease (11.6% vs. 0.8%) and heavier smoking histories (60.0% vs. 44.9% with ⩾10-pack-years). The rECE-positive cohort had significantly worse 3-year OS (64.3% vs. 82.8%, p=0.002), PFS (58.9% vs. 76.0%, p=0.001), DC (72.3% vs. 90.6%, p<0.001), and LRC (75.9% vs. 89.8%, p=0.002). On MVA, rECE independently predicted for worse OS, PFS, DC, and LRC for LAHNC overall. On subset analysis of HPV-positive oropharyngeal cancers, rECE was not a significant prognosticator. CONCLUSION: For all sites of LAHNC, except HPV-positive oropharyngeal cancers, presence of rECE independently predicts for worse disease control and survival. Further studies are needed to validate these findings and demonstrate whether rECE may be considered for risk-stratifying patients for clinical trial design and treatment decisions.

Necrotic nasopharyngeal mucosa: an ominous MR sign of a carotid artery pseudoaneurysm.

Massive hemoptysis is not commonly seen in patients who have nasopharyngeal carcinoma. It most often is the result of both radiation therapy and skull base infection. We present a practical imaging approach by using MR imaging and conventional angiography that may facilitate the prevention of such life-threatening bleeding and help provide effective control of infection. With the aid of these studies, clinicians may be able to manage this condition with more confidence.

Radiographic Thrombus within the External Jugular Vein: Report of a Rare Case and Review of the Literature.

We are reporting a case of a 91-year-old male with a primary malignancy of the right parotid gland with radiographic thrombus extension within the right external jugular vein. He was treated with palliative radiation therapy to the right parotid mass with a marked clinical response. The rarity of this occurrence as documented in the review of the literature provides for uncertainty with regard to proper management. Radiographic evidence of thrombus in the absence of clinical manifestations, the role of anticoagulation, and the proper radiation target delineation were all challenges encountered in the care of this patient. Our case represents a rare occurrence with unique radiologic findings that has implications for management.

Imaging evaluation of lymphadenopathy and patterns of lymph node spread in head and neck cancer.

Accurate and consistent characterization of metastatic cervical adenopathy is essential for the initial staging, treatment planning and surveillance of head and neck cancer patients. While enlarged superficial nodes may be clinically palpated, imaging allows identification of deeper adenopathy as well as clinically unsuspected pathology and thus imaging has become an integral part of the evaluation of most head and neck cancers patients. This review will focus on the evaluation of cervical adenopathy, summarizing the currently used nomenclature and imaging approach for determining cervical lymph node metastases in head and neck malignancies. The imaging-based classification, which has also been adopted by the American Joint Committee on Cancer, will be presented, the morphologic characteristics used to identify metastatic nodes will be reviewed and the typical nodal spread patterns of the major mucosal cancers of the head and neck will be examined.

The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease.

BACKGROUND AND PURPOSE: The incidence of middle turbinate pneumatization, or concha bullosa, has been well described in the literature. However, to our knowledge, no study has evaluated concha bullosa in relation to nasal septal deviation. We sought to analyze the incidence of concha bullosa and any correlation with nasal septal deviation and paranasal sinus disease. METHODS: Three neuroradiologists retrospectively reviewed findings of 1095 consecutive paranasal sinus CT studies conducted between 2001 and 2002. All examinations were performed for evaluation of a symptom referable to the sinonasal region. Paranasal sinus inflammatory disease was identified and graded as mild, moderate, or severe. Sphenoid, ethmoid, maxillary, and frontal sinuses were each graded separately on both sides. If a concha bullosa was present, it was graded in size as small, moderate, or large. If bilateral concha were present, sizes were compared and when one was larger, it was identified as dominant. When nasal septal deviation was present, it was graded as mild, moderate, or severe. The direction of nasal septal deviation was identified as the face of the convex surface. RESULTS: There was a clear association between the presence of a unilateral concha, or a dominant concha (in the case of bilateral concha), and the presence of nasal septal deviation (P < .0001). Moreover, there was a significant relationship between the presence of concha bullosa and deviation of the nasal septal to the contralateral side (P < .0001). This inverse association was present regardless of the size of the concha bullosa or degree of septal deviation. In every case, there was some preservation of air channels between the dominant concha and the nasal septum. Seventy-three percent of patients with concha bullosa had paranasal sinus inflammatory disease; 78% of patients without concha bullosa also had some form of inflammatory disease. CONCLUSION: Concha bullosa is a common anatomic variant. There is a strong association between the presence of a concha bullosa and contralateral deviation of the nasal septum. Nasal septal deviation away from the dominant concha, with preserved adjacent air channels, suggests that the deviation is not a direct result of mass effect from the concha. No increased incidence of paranasal sinus disease exists in patients with concha bullosa.

Granulocytic sarcoma of the temporal bone.

We report an unusual case of granulocytic sarcoma involving the temporal bone. The occurrence of this tumor usually heralds acute myelogenous leukemia or the onset of the blastic phase of chronic myelogenous leukemia. Recognition of this rare entity is important, because early aggressive chemotherapy can cause regression of the tumor, as in our case, and thus improve patient longevity.

CT and MR imaging findings associated with subacute thyroiditis.

Subacute granulomatous thyroiditis is an uncommon disease that occurs most often in women in their second to fifth decades of life. This disease usually presents with thyroid tenderness, a low grade fever, and occasional dysphagia. The disease resolves spontaneously, usually without thyroid function abnormalities. We herein present the CT and MR imaging findings of two cases of subacute granulomatous thyroiditis.

Orbital Lyme disease: MR imaging before and after treatment: case report.

Lyme disease is a multi-system organ disease caused by Borrelia burgdorferi. Although ocular manifestations have been reported, these remain a rare feature of the disease. To our knowledge, the radiology literature has not documented orbital Lyme disease both before and after treatment. We present the MR imaging findings of florid Lyme disease affecting the extraocular muscles in a 46-year-old man. A follow-up MR imaging study performed 6 months after a course of antibiotic therapy revealed complete resolution of the myositic changes.

Amyloidosis concurrently involving the sinonasal cavities and larynx.

Localized amyloidosis is an uncommon benign disorder. The purpose of this report is to present the case of a 21-year-old man who had localized amyloidosis simultaneously involving the sinonasal cavities and the larynx. The rarer sinonasal lesion demonstrated CT findings of adjacent "fluffy" bone changes, possibly representing a new finding suggestive of this disorder. At MR imaging, the amyloid had signal intensity similar to that of skeletal muscle on T1- and T2-weighted images. After contrast material administration, the amyloid enhanced at most minimally, but peripheral enhancement about the mass was present. The importance of this case lies in the multifocal presentation of this uncommon disorder, and the imaging findings herein may provide a new sign of this paranasal sinus disease.

Spread of goiters outside the thyroid bed: a review of 190 cases and an analysis of the incidence of the various extensions.

OBJECTIVES: To analyze the distribution of thyroid goiters into the mediastinum and/or behind or along the sides of the pharynx, and to review the anatomy of the spaces in the neck that explains these extensions. METHODS: We used a 28-month period, to retrospectively identify 190 cases of neck goiters that underwent computed tomographic imaging. The maximal size of a normal thyroid gland and the limits of the normal thyroid bed were defined on the basis of established anatomic measurements. Standard definitions of the mediastinum and its compartments were also used. Each case was reviewed by 3 radiologists, and extension of the thyroid gland into the mediastinum or cranially behind or along the sides of the pharynx was noted. All cases were correlated with clinical observations. RESULTS: Of the 190 goiters, 106 (55.8%) were confined to the thyroid bed, 70 (36.8%) extended into the mediastinum, and 14 (7.4%) extended behind or along the sides of the pharynx. All 70 cases that extended into the mediastinum involved the anterior mediastinum, and 5 (7.1%) of these extended into the posterior mediastinum. CONCLUSIONS: Goiterous extension outside of the thyroid bed occurred in 84 (44.2%) of cases. Although extension cranially behind the pharynx is uncommon, the physician should be aware of this diagnosis and the fascial anatomy that explains its occurrence. All of the goiters that were in the posterior mediastinum also had a component in the anterior mediastinum.