Advances and residual knowledge gaps in the neck management of head and neck squamous cell carcinoma patients with advanced nodal disease undergoing definitive (chemo)radiotherapy for their primary.

PURPOSE: Substantial changes have been made in the neck management of patients with head and neck squamous cell carcinomas (HNSCC) in the past century. These have been fostered by changes in cancer epidemiology and technological progress in imaging, surgery, or radiotherapy, as well as disruptive concepts in oncology. We aimed to review changes in nodal management, with a focus on HNSCC patients with nodal involvement (cN+) undergoing (chemo)radiotherapy. METHODS: A narrative review was conducted to review current advances and address knowledge gaps in the multidisciplinary management of the cN+ neck in the context of (chemo)radiotherapy. RESULTS: Metastatic neck nodes are associated with poorer prognosis and poorer response to radiotherapy, and have therefore been systematically treated by surgery. Radical neck dissection (ND) has gradually evolved toward more personalized and less morbid approaches, i.e., from functional to selective ND. Omission of ND has been made feasible by use of positron-emission tomography/computed tomography to monitor the radiation response in cN+ patients. Human papillomavirus-driven oropharyngeal cancers and their cystic nodes have shown dramatically better prognosis than tobacco-related cancers, justifying a specific prognostic classification (AJCC) creation. Finally, considering the role of lymph nodes in anti-tumor immunity, de-escalation of ND and prophylactic nodal irradiation in combination are intense areas of investigation. However, the management of bulky cN3 disease remains an issue, as aggressive multidisciplinary strategies or innovative combined treatments have not yet significantly improved their prognosis. CONCLUSION: Personalized neck management is an increasingly important aspect of the overall therapeutic strategies in cN+ HNSCC.

International assessment of interobserver reproducibility of flap delineation in head and neck carcinoma.

Background: Several reports have suggested that radiotherapy after reconstructive surgery for head and neck cancer (HNC), could have deleterious effects on the flaps with respect to functional outcomes. To predict and prevent toxicities, flap delineation should be accurate and reproducible. The objective of the present study was to evaluate the interobserver variability of frequent types of flaps used in HNC, based on the recent GORTEC atlas.Materials and methods: Each member of an international working group (WG) consisting of 14 experts delineated the flaps on a CT set from six patients. Each patient had one of the five most commonly used flaps in HNC: a regional pedicled pectoralis major myocutaneous flap, a local pedicled rotational soft tissue facial artery musculo-mucosal (FAMM) (2 patients), a fasciocutaneous radial forearm free flap, a soft tissue anterolateral thigh (ALT) free flap, or a fibular free flap. The WG's contours were compared to a reference contour, validated by a surgeon and a radiologist specializing in HNC. Contours were considered as reproducible if the median Dice Similarity Coefficient (DSC) was > 0.7.Results: The median volumes of the six flaps delineated by the WG were close to the reference contour value, with approximately 50 cc for the pectoral, fibula, and ALT flaps, 20 cc for the radial forearm, and up to 10 cc for the FAMM. The volumetric ratio was thus close to the optimal value of 100% for all flaps. The median DSC obtained by the WG compared to the reference for the pectoralis flap, the FAMM, the radial forearm flap, ALT flap, and the fibular flap were 0.82, 0.40, 0.76, 0.81, and 0.76, respectively.Conclusions: This study showed that the delineation of four main flaps used for HNC was reproducible. The delineation of the FAMM, however, requires close cooperation between radiologist, surgeon and radiation oncologist because of the poor visibility of this flap on CT and its small size.

Dental management in head and neck cancers: from intensity-modulated radiotherapy with photons to proton therapy.

INTRODUCTION: Despite reduction of xerostomia with intensity-modulated compared to conformal X-ray radiotherapy, radiation-induced dental complications continue to occur. Proton therapy is promising in head and neck cancers to further reduce radiation-induced side-effects, but the optimal dental management has not been defined. MATERIAL AND METHODS: Dental management before proton therapy was assessed compared to intensity-modulated radiotherapy based on a bicentric experience, a literature review and illustrative cases. RESULTS: Preserved teeth frequently contain metallic dental restorations (amalgams, crowns, implants). Metals blur CT images, introducing errors in tumour and organ contour during radiotherapy planning. Due to their physical interactions with matter, protons are more sensitive than photons to tissue composition. The composition of restorative materials is rarely documented during radiotherapy planning, introducing dose errors. Manual artefact recontouring, metal artefact-reduction CT algorithms, dual or multi-energy CT and appropriate dose calculation algorithms insufficiently compensate for contour and dose errors during proton therapy. Physical uncertainties may be associated with lower tumour control probability and more side-effects after proton therapy. Metal-induced errors should be quantified and removal of metal restorations discussed on a case by case basis between dental care specialists, radiation oncologists and physicists. Metallic amalgams can be replaced with water-equivalent materials and crowns temporarily removed depending on rehabilitation potential, dental condition and cost. Implants might contraindicate proton therapy if they are in the proton beam path. CONCLUSION: Metallic restorations may more severely affect proton than photon radiotherapy quality. Personalized dental care prior to proton therapy requires multidisciplinary assessment of metal-induced errors before choice of conservation/removal of dental metals and optimal radiotherapy.

Avoidance or adaptation of radiotherapy in patients with cancer with Li-Fraumeni and heritable TP53-related cancer syndromes.

The management of patients with cancer and Li-Fraumeni or heritable TP53-related cancer syndromes is complex because of their increased risk of developing second malignant neoplasms after genotoxic stresses such as systemic treatments or radiotherapy (radiosusceptibility). Clinical decision making also integrates the risks of normal tissue toxicity and sequelae (radiosensitivity) and tumour response to radiotherapy (radioresistance and radiocurability). Radiotherapy should be avoided in patients with cancer and Li-Fraumeni or heritable TP53 cancer-related syndromes, but overall prognosis might be poor without radiotherapy: radioresistance in these patients seems similar to or worse than that of the general population. Radiosensitivity in germline TP53 variant carriers seems similar to that in the general population. The risk of second malignant neoplasms according to germline TP53 variant and the patient's overall oncological prognosis should be assessed during specialised multidisciplinary staff meetings. Radiotherapy should be avoided whenever other similarly curative treatment options are available. In other cases, it should be adapted to minimise the risk of second malignant neoplasms in patients who still require radiotherapy despite its genotoxicity, in view of its potential benefit. Adaptations might be achieved through the reduction of irradiated volumes using proton therapy, non-ionising diagnostic procedures, image guidance, and minimal stray radiation. Non-ionising imaging should become more systematic. Radiotherapy approaches that might result in a lower probability of misrepaired DNA damage (eg, particle therapy biology and tumour targeting) are an area of investigation.

CT-Guided Percutaneous Gastrostomy without Preliminary Placement of a Nasogastric Tube.

Percutaneous radiologic gastrostomy (PRG) requires preliminary gastric inflation through a nasogastric tube (NGT) to safely perform gastric puncture. However, in case of pharyngeal or esophageal obstruction, NGT placement may be impossible even with a hydrophilic angiography catheter and wire. This brief report describes percutaneous computed tomography (CT)-guided gastrostomy with a 2-stick approach without nasogastric insufflation in 13 patients. Technical success rate was 100% with a mean of 1.8 punctures ± 1.0 to access the gastric lumen. Traversal of the colon and liver with a 22-gauge needle was necessary in 4 and 1 patients, respectively. There were no major complications. Minor complications occurred in 6 patients (46%). CT-guided percutaneous gastrostomy is technically feasible with minimal morbidity.

Mummified Thyroid Syndrome.

OBJECTIVE: The purpose of this article is to highlight the various sonographic characteristics that should help to differentiate a restructured benign collapsed thyroid nodule from histologically proven thyroid carcinoma by different imaging means, including Doppler sonography, and fine-needle aspiration cytologic analysis. CONCLUSION: Benign thyroid nodules may display morphologic changes over time, which can have misleading sonographic features suggestive of malignancy. Precise knowledge of certain sonographic imaging features, such as regular eggshell calcifications, peripheral hypoechoic or hypoechoic rim, posterior shadowing, and absence of intranodular vascularization, and meticulous comparison with previous images showing thyroid nodule shrinkage over time are useful for reaching the correct final diagnosis. Fine-needle aspiration cytologic assessment of such initially suspicious thyroid nodules and sonographic follow-up contribute to establishing the final diagnosis of benign thyroid findings. Knowledge of the elements described should help to identify the so-called mummified thyroid nodule and avert surgical excision.

Thyroid calcifications: a pictorial essay.

Incidental diagnosis of thyroid nodules is very common on adult neck ultrasonography examination. Thyroid calcifications are encountered in benign thyroid nodules and goiters as well as in thyroid malignancy. Depiction and characterization of such calcifications within a thyroid nodule may be a key element in the thyroid nodule diagnosis algorithm. The goal of this paper is to display typical radio-pathological correlations of various thyroid pathologies of benign and malignant conditions in which the calcification type diagnosis can play a key role in the final diagnosis of the thyroid nodule.

Jugular Vein Invasion Diagnosis and Prognosis in Thyroid Carcinomas.

Diagnosis of venous jugular invasion by means of traditional imaging is very rarely reported in the literature. Doppler ultrasound definitively helps to diagnose the tumor thrombus, the extent, and helps in redefining the TNM stage of such an aggressive thyroid tumor.

Pedunculated Hepatic Hemangioma Masquerading as a Peritoneal Tumor. A Case Report.

BACKGROUND: Although being classically located inside the liver parenchyma, hemangiomas may occasionally develop outside the extra-hepatic capsule, thus appearing as a pedunculated mass. CASE REPORT: We report the case of a 66-year-old anal cancer female patient presenting with an asymptomatic sub-hepatic mass. Incidental diagnosis of a pedunculated hepatic hemangioma was strongly suggested by the typical imaging features on computed tomography (CT) and magnetic resonance (MR) examinations, and was confirmed by histopathological examination. CONCLUSIONS: Exophytic pedunculated growth is a rare and atypical feature of hepatic hemangioma. Thin contrast- enhanced sections and multiplanar CT and MR scan reformations helped to the final diagnosis of hemangioma, showing its origin from the liver edge. Surgical resection is mandatory to prevent threatening mass pedicle torsion.

Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy.

Background: Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy. Methods: A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT. Results: Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications. Conclusion: Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.

[Issues and implementation of postoperative radiotherapy after flap reconstructive surgery in head and neck cancers]. / Enjeux et mise en œuvre de radiothérapie postopératoire après chirurgie reconstructrice avec lambeau dans les cancers de la tête et du cou.

The management of head and neck cancers is multidisciplinary, often relying on the use of combined treatments to maximize the chances of cure. Combined treatments are however also responsible for cumulative side effects. The aim of reconstructive surgery with a flap is to restore a function lost with the loss of substance from the tumor resection. However, changes in reconstructive surgery have impact of postoperative radiotherapy planning. The optimization of imaging protocols for radiotherapy planning should make it possible to identify postoperative changes and to distinguish flaps from surrounding native tissues to delineate the flaps and document the spontaneous evolution of these flaps or dose-effect relationships in case of radiotherapy. Such changes include atrophy, fibrosis of soft tissue flaps and osteoradionecrosis of bone flaps. Radiotherapy optimization also involves standardization of the definition of target volumes in situations where a flap is present, a situation that is increasingly common in routine care. This evolution of practice, beyond the essential multidisciplinary consultation meetings defining treatment indications, requires a close radio surgical collaboration with respect to technical aspects of the two disciplines. Doing so, anticipation of relapse and toxicity profiles could possibly lead to propose strategies for personalized de-escalation of multimodal treatments through interdisciplinary trials.

Percutaneous screw fixation of acetabular roof fractures by radiologists under CT and fluoroscopy guidance.

OBJECTIVE: The aim of this study was to evaluate CT- and fluoroscopy-guided percutaneous screw fixation by radiologists in the management of acetabular roof fractures. SUBJECTS AND METHODS: Fifty-two consecutive adult patients with a nondisplaced and isolated acetabular roof fracture were prospectively treated by an interventional radiologist who made a percutaneous screw fixation under CT and fluoroscopy guidance. All these procedures were performed under local anesthesia. The postoperative follow-up ranged from 36 to 48 months. RESULTS: For each patient, two 6.5-mm Asnis III screws were inserted to fix the roof acetabular fracture. The mean procedure time was 45 minutes (range, 30-90 minutes). No complications were observed. Follow-up CT showed evidence of fracture healing. No evidence of secondary displacement, degenerative changes, or screw failure was noted. Using the rating system of D'Aubigne and Postel, all patients had excellent results. CONCLUSION: The results of our study showed that nondisplaced acetabular roof fractures could be successfully treated by a minimally invasive technique with an excellent long-term outcome.

CT- and fluoroscopy-guided percutaneous discectomy for lumbar radiculopathy related to disc herniation: a comparative prospective study comparing lateral to medial herniated discs.

OBJECTIVE: To evaluate and compare two groups of patients with sciatica due to intervertebral disc herniation with no neurologic deficit. The groups consisted of patients with intervertebral disc herniation in a medial location (group 1) and those in a lateral location (group 2). MATERIALS AND METHODS: A total of 200 patients were included in the study and were followed for a minimum of 6 months. In our series, we treated 80 postero-lateral herniated discs (40% of cases), 46 postero-medial herniated discs (23%), and 74 foraminal herniated discs (37%). Level L3-L4 was treated in 30 cases (15%), L4-L5 in 98 cases (49%), and L5-S1 in 72 cases (36%). The procedure was performed under dual guidance: fluoroscopic and CT. A helical probe was activated. It penetrates the herniated disc and causes the pulpous material to be mechanically evacuated through the probe. All 200 patients were followed for a minimum of 6 months. RESULTS: In group 1, the patients had a mean pain score of 7.9 ± 2.5 VAS units (range 6-10 units) prior to intervention. This was reduced to 3.2 ± 2.1 VAS units (range 0-10 units) at 48 h follow-up and increased to 3.9 ± 1.2 VAS units (range 0-10 VAS units) at 1 month follow-up and further reduced to 2.7 ± 1.2 units (range 0-10 VAS units) at 6 month follow-up. In group 2, the patients had a mean pain score of 8.2 ± 3.2 VAS units (range 6-10 units) prior to intervention. This was reduced to 2.8 ± 1.5 VAS units (range 0-10 units) at 48 h follow-up and decreased to 1.5 ± 0.9 VAS units (range 0-10 units) at 1 month and further reduced to 1.1 ± 0.5 VAS units (range 0-10 units) at 6 months. CONCLUSION: Our study showed that results were more satisfactory for the hernia located laterally (postero-lateral, foraminal, and extra-foraminal) as compared to the hernia located posteromedially.

Inhalation study of polymethyl methacrylate following radiologist exposure during percutaneous vertebroplasty.

OBJECTIVE: To assess the atmospheric concentrations of methyl methacrylate (MMA) vapors during percutaneous vertebroplasty for the interventional radiologist and the other operating room staff. MATERIALS AND METHODS: During percutaneous vertebroplasty, a polymethyl methacrylate (PMMA) mixture (about 20 mL) was prepared with a mixing system in a normally ventilated room. Atmospheric concentrations of MMA vapors were measured by a gas absorbent badge for individual exposure (GABIE) passive sampler attached to the surgical gowns of the interventional radiologist and the other operating room staff over a period of 460 min. Active sampling was performed over 15 min with an individual pump placed near the breathing zone of the radiologist. MMA vapor concentrations were then measured using gas chromatography and activated charcoal tubes. RESULTS: Mean MMA vapor concentrations measured by the GABIEs over the period of 460 min were 0.51 parts per million (ppm) for the radiologist and 0.22 ppm for the other operating room staff. The emission peaks measured by using charcoal tubes over 15 min were 3.7 ppm. CONCLUSION: MMA vapor concentrations during percutaneous vertebroplasty were well below the recommended maximum exposure of 100 ppm over the course of an 8-h workday.

Pneumatization of the skull base due to valsalva maneuver.

Objectives : We herewith report the case of a 43-year-old patient who experienced a skull base fracture associated with minimal trauma. The computed tomography scan examination showed unusual extensive pneumatization of the skull base. This patient used to perform repeated Valsalva maneuvers on a daily basis since childhood. Methods : A literature search and analysis of pneumatization mechanisms was performed. Results : Extensive skull base pneumatization has already been reported in patients performing daily Valsalva maneuver. Two pathogenic hypotheses are discussed: the bone cavity expansion through communicating spaces and cavitation secondary to increased intra-osseous pressure transmitted via the venous network with subsequent bone marrow ischemia. Conclusion : Valsalva maneuver may be the cause of an extensive skull base pneumatization. We hypothesize that the Valsalva maneuver may induce bone marrow ischemia that may, if repeated and prolonged, lead to pneumatization.