Active upper aerodigestive tract hemorrhage in patients with head and neck cancers: the "dot-in-sludge" sign.

Active extravasation into the upper aerodigestive tract is a dramatic and potentially life-threatening complication in patients with head and neck cancers. It prompts presentation to the emergency room and subsequent urgent imaging to identify the source of hemorrhage. Imaging of these patients may be complicated by treatment-altered anatomy, posing a challenge to the emergency radiologist who needs to rapidly identify the presence of active hemorrhage and the potential source vessel. This retrospective review summarizes the clinical and imaging findings of 6 oropharyngeal and oral cavity squamous cell cancer (SCC) patients with active upper aerodigestive tract hemorrhage. Most patients had advanced stage disease and prior radiation therapy. All CECT or CTA exams on presentation demonstrated the "dot-in-sludge" sign of active extravasation, as demonstrated by a "dot" of avidly enhancing extravasated contrast material layered against a background "sludge" of non-enhancing debris in the lumen of the upper aerodigestive tract. Common sources of hemorrhage included the lingual, facial, and superior thyroidal arteries. Familiarity with these findings will help radiologists increase their accuracy and confidence in interpreting these urgent, complex examinations.

The impact of operability status on outcomes in patients with T4 larynx cancer undergoing larynx preservation.

BACKGROUND: Large analyses of T4 larynx cancer (LC) have raised concerns that larynx preservation (LP) contributes to reduced survival compared with laryngectomy (LGX). The role of operability has not been previously considered as a confounder. METHODS: We queried the National Cancer Database for T4M0 LC diagnosed 2004-2015. Patients were categorized as undergoing LGX, chemoradiotherapy but operable (LP-operable), and chemoradiotherapy inoperable (LP-inoperable). Overall survival (OS) was estimated by Kaplan-Meier. Cox multivariate analysis (MVA) identified variables associated with OS. RESULTS: We identified 1405 LGX, 164 LP-operable and 1969 LP-inoperable patients. Compared with LGX, MVA demonstrated worse OS among LP-inoperable (HR 1.28 95%CI 1.17-1.40, p < 0.01) but not LP-operable patients (HR 1.12 95%CI 0.91-1.39, p = 0.28). CONCLUSIONS: LP-operable patients did not have significantly worse OS than those undergoing LGX.

Comparison of 3D constructive interference in steady state (CISS) and T2 sampling perfection with application optimized contrasts using different flip angle evolution MR imaging of the intracranial trigeminal nerve and central skull base neuroforamina.

BACKGROUND AND PURPOSE: Due to surgical advancements, the accurate detection of perineural disease spread has become increasingly important in the management and prognostication of head and neck cancers, though MR evaluation has thus far been limited by technical and logistic challenges. The purpose of this study was to specifically evaluate the relative capability of 3D CISS and 3D T2-SPACE imaging to delineate the proximal intracranial divisions of the normal trigeminal nerve, an area important in determining the resectability of intracranial perineural disease. MATERIALS AND METHODS: A single center HIPAA-compliant, IRB approved retrospective review of 40 patients with clinical temporal bone/internal auditory canal MR imaging was conducted. 20 patients with 3D CISS images and 20 patients with 3D T2-SPACE images met inclusion criteria. Two radiologists scored the sequences on a 3-point scale based on ability to visualize anatomic structures surrounding the trigeminal nerve in Meckel's cave, intracranial trigeminal divisions, skull base neuroforamina, and proximal extracranial mandibular division. RESULTS: The following anatomic locations scored significantly better in the T2-SPACE sequence compared to the CISS sequence for both raters: intracranial V3 (p < .05), foramen ovale (p < .05), and extracranial V3 (p < .01). The average scores for the anterior Meckel's cave and foramen rotundum were higher for the T2-SPACE sequence, although not significantly. Percent interobserver agreement ranged from 50 to 90% and 65-100% for the different anatomic locations on the CISS and T2-SPACE sequences, respectively. CONCLUSION: 3D T2-SPACE was found to be superior to 3D CISS in the evaluation of the distal intracranial and extracranial portions of the normal trigeminal nerve.

To Scan or Not to Scan: The Dilemma of Posttreatment Imaging Surveillance of Head and Neck Cancer.

Locoregional recurrence remains common after treatment of head and neck cancer, warranting careful surveillance in follow-up. Although randomized data support an initial positron emission tomography/computed tomography several months after treatment, evidence supporting subsequent imaging is limited, and most recurrences ultimately manifest clinically. Cooperative group studies and consensus guidelines vary widely in their recommendations regarding surveillance imaging. Patients with indeterminate findings, new symptoms, or areas difficult to examine in clinic may avoid invasive and potentially morbid interventions with judicious use of subsequent imaging. For any patient undergoing posttreatment imaging, standardized reporting criteria provide a framework for risk-stratification that can enhance communication and potentially guide management.

Initial Referring Physician and Radiologist Experience with Neck Imaging Reporting and Data System.

OBJECTIVES/HYPOTHESIS: Neck Imaging Reporting and Data System (NI-RADS) is a radiology reporting system developed for head and neck cancer surveillance imaging, using standardized terminology, numeric levels of suspicion, and linked management recommendations. Through a multidisciplinary, interdepartmental quality improvement initiative, we implemented NI-RADS for the reporting of head and neck cancer surveillance CT. Our objective is to summarize our initial experience from the standpoints of head and neck cancer providers and radiologists. STUDY DESIGN: Quality improvement study. METHODS: Before and 3 months post-implementation, surveys were offered to referring physicians (n = 21 pre-adoption; 22 post-adoption) and radiologists (n = 17 pre- and post-adoption). NI-RADS utilization was assessed over time. RESULTS: Survey response rates were 62% (13/21) and 73% (16/22) for referring physicians pre- and post-adoption, respectively, and 94% (16/17) for radiologists pre- and post-adoption. Among post-adoption provider respondents, 100% (16/16) strongly agreed or agreed with "I want our radiologists to continue using NI-RADS," "The NI-RADS numerical rating of radiologic suspicion is helpful," and "The language and style of NI-RADS neck CT reports are clear and understandable." Among radiologist respondents, 88% (14/16) strongly agreed or agreed with "NI-RADS improves consistency among our radiologists in the reporting of surveillance neck CTs." Radiologist NI-RADS utilization increased over time (46% month 1; 72% month 3). CONCLUSIONS: Most referring physicians and radiologists preferred NI-RADS. Head and neck cancer providers indicated that NI-RADS reports are clear, understandable, direct, and helpful in guiding clinical management. Radiologists indicated that NI-RADS improves radiologist consistency in the reporting of surveillance neck CT, and radiologists increasingly used NI-RADS over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:349-355, 2022.

Posttreatment Magnetic Resonance Imaging Surveillance of Head and Neck Cancers.

Treatment strategies and recommended surveillance imaging differ for head and neck cancers depending on subsite and neoplasm type, and pose confusion for referring physicians and interpreting radiologists. The superior soft tissue resolution offered by magnetic resonance imaging is most useful in the surveillance of cancers with high propensities for intraorbital, intracranial, or perineural disease spread, which most commonly include those arising from the sinonasal cavities, nasopharynx, orbits, salivary glands, and the skin. This article discusses recommended surveillance protocoling and reviews treatment approaches, common posttreatment changes, and pearls for identifying disease recurrence in a subsite-based approach.

Interrater Reliability of NI-RADS on Posttreatment PET/Contrast-enhanced CT Scans in Head and Neck Squamous Cell Carcinoma.

Purpose To evaluate the interrater reliability among radiologists examining posttreatment head and neck squamous cell carcinoma (HNSCC) fluorodeoxyglucose PET/contrast-enhanced CT (CECT) scans using Neck Imaging Reporting and Data System (NI-RADS). Materials and Methods In this retrospective study, images in 80 patients with HNSCC who underwent posttreatment surveillance PET/CECT and immediate prior comparison CECT or PET/CECT (from June 2014 to July 2016) were uploaded to the American College of Radiology's cloud-based website, Cortex. Eight radiologists from seven institutions with variable NI-RADS experience independently evaluated each case and assigned an appropriate prose description and NI-RADS category for the primary site and the neck site. Five of these individuals were experienced readers (> 5 years of experience), and three were novices (< 5 years of experience). In total, 640 lexicon-based and NI-RADS categories were assigned to lesions among the 80 included patients by the eight radiologists. Light generalization of Cohen κ for interrater reliability was performed. Results Of the 80 included patients (mean age, 63 years ± 10 [standard deviation]), there were 58 men (73%); 60 patients had stage IV HNSCC (75%), and the most common tumor location was oropharynx (n = 32; 40%). Light κ for lexicon was 0.30 (95% CI: 0.23, 0.36) at the primary site and 0.31 (95% CI: 0.24, 0.37) at the neck site. Light κ for NI-RADS category was 0.55 (95% CI: 0.46, 0.63) at the primary site and 0.60 (95% CI: 0.48, 0.69) at the neck site. Percent agreement between lexicon and correlative NI-RADS category was 84.4% (540 of 640) at the primary site and 92.6% (593 of 640) at the neck site. There was no significant difference in interobserver agreement among the experienced versus novice raters. Conclusion Moderate agreement was achieved among eight radiologists using NI-RADS at posttreatment HNSCC surveillance imaging. Keywords: CT, PET/CT, Head/Neck, Neck, Neoplasms-Primary, Observer Performance Supplemental material is available for this article. © RSNA, 2021.

Characterizing postoperative physiologic swallow function following transoral robotic surgery for early stage tonsil, base of tongue, and unknown primary human papillomavirus-associated squamous cell carcinoma.

BACKGROUND: Data objectively evaluating acute post-transoral robotic surgery (TORS) swallow function are limited. Our goal was to characterize and identify clinical variables that may impact swallow function components 3 weeks post-TORS. METHODS: Retrospective cohort study. Pre/postoperative use of the Modified Barium Swallow Impairment Profile (MBSImP) and Penetration-Aspiration Scale (PAS) was completed on 125 of 139 TORS patients (2016-2019) with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma. Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scores were retrospectively calculated. Uni/multivariate analysis was performed. RESULTS: Dysfunctional pre-TORS DIGEST scores were predictive of post-TORS dysphagia (p = 0.015). Pre-TORS MBSImP deficits in pharyngeal stripping wave, swallow initiation, and clearing pharyngeal residue correlated with airway invasion post-TORS based on PAS scores (p = 0.012, 0.027, 0.048, respectively). Multivariate analysis of DIGEST safety scores declined with older age (p = 0.044). Odds ratios (ORs) for objective swallow function components after TORS were better for unknown primary and tonsil primaries compared to base of tongue (BOT) (OR 0.35-0.91). CONCLUSIONS: Preoperative impairments in specific MBSImP components, older patients, and BOT primaries may predict more extensive recovery in swallow function after TORS.

Best Practices: Application of NI-RADS for Posttreatment Surveillance Imaging of Head and Neck Cancer.

Imaging surveillance is an important component of posttreatment management of head and neck cancers. There is variability in the surveillance regimen used by various practitioners and institutions, with no official National Comprehensive Cancer Network guidelines for patients showing no symptoms beyond 6 months posttreatment. Moreover, imaging of the neck after treatment is a complex examination with significant interreader heterogeneity, particularly in terms of the manner in which degree of suspicion for disease recurrence is expressed. The Neck Imaging Reporting and Data System (NI-RADS) was introduced by the American College of Radiology (ACR) in 2018 as a practical guide for the interpreting radiologist. NI-RADS is a proposed interpretive framework that can be applied to any standardized or institutional surveillance imaging protocol. NI-RADS simplifies communication between radiologists and referring clinicians and provides management guidance linked to specific levels of suspicion. The ACR NI-RADS Committee also provided general best practice recommendations for imaging surveillance modality and timing in the 2018 white paper. This article will review existing literature regarding choice of modality and timeline for surveillance in treated cancer of the head and neck. NI-RADS will then be presented as an approach to imaging reporting, interpretation, and design of next steps in management.

Outcomes and Predictive Value of Post-adjuvant Therapy PET/CT for Locally Advanced Oral Squamous Cell Carcinoma.

OBJECTIVES/HYPOTHESIS: For locally advanced oral squamous cell carcinoma (OSCC) treated by surgery and adjuvant therapy, consensus has yet to be reached on whether the optimal time to initiate surveillance positron emission tomography/computed tomography (PET/CT) scan is before or after adjuvant therapy. In this study, we characterize the utility of PET/CT scans obtained 3 months after adjuvant therapy. STUDY DESIGN: PET/CT scans were obtained for 220 patients with stage III, IVA, or IVB OSCC who underwent resection followed by adjuvant radiotherapy or chemoradiotherapy. METHODS: Using the Neck Imaging Reporting and Data System, PET/CT scans were dichotomized as suspicious (primary or neck category ≥3, or distant lesion present) versus nonsuspicious. We then computed differences in locoregional progression, distant progression, and overall survival; positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity; and success rate of salvage. RESULTS: Sixty-seven patients (30%) had suspicious PET/CT scans, which were significantly associated with local failure (hazard ratio [HR] 14.0, 95% confidence interval [CI] 7.3-26.6), distant failure (HR 18.4, 95% CI 9.6-35.3), and poorer overall survival (HR 9.5, 95% CI 5.0-17.9). Overall PPV, locoregional PPV, NPV, sensitivity, and specificity were 85%, 79%, 73%, 58%, and 92%, respectively. Among those with biopsy-confirmed progression, 37 patients (65%) underwent salvage therapy; four (11%) were without evidence of disease at last follow-up. CONCLUSIONS: For locally advanced OSCC, PET/CT scan 3 months after adjuvant therapy is strongly predictive of disease recurrence and survival, demonstrating improved performance over postoperative imaging in previous studies. Following a suspicious post-adjuvant therapy PET/CT scan, cure of locoregional recurrence is possible but unlikely. LEVEL OF EVIDENCE: 4 Laryngoscope, 2020.

NI-RADS for head and neck cancer surveillance imaging: What, why, and how.

The Neck Imaging Reporting and Data System (NI-RADS) was conceived in 2016 with the objective of standardizing assessment and reporting in surveillance imaging for patients with head and neck squamous cell carcinomas and their subsequent management. The goals are to simplify radiology reports while increasing the consistency and accuracy of the interpretation of cancer surveillance imaging; enable better communication among clinicians and between clinicians and patients; facilitate outcomes research; and ultimately improve patient survival, morbidity, and mortality. The objective of the current study was to provide the background as to why and how NI-RADS was conceived and what it entails in radiology reporting.

Predictive Value of First Posttreatment Imaging Using Standardized Reporting in Head and Neck Cancer.

OBJECTIVE: The Neck Imaging Reporting and Data System (NI-RADS) is a standardized numerical reporting template for surveillance of head and neck squamous cell carcinoma (HNSCC). Our aim was to analyze the accuracy of NI-RADS on the first posttreatment fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (PET/CECT). STUDY DESIGN: Retrospective cohort study. SETTING: Academic tertiary hospital. SUBJECT AND METHODS: Patients with HNSCC with a 12-week posttreatment PET/CECT interpreted using the NI-RADS template and 9 months of clinical and radiologic follow-up starting from treatment completion between June 2014 and July 2016 were included. Treatment failure was defined as positive tumor confirmed by biopsy or Response Evaluation Criteria in Solid Tumors criteria. Cox proportional hazards models were performed. RESULTS: This study comprised 199 patients followed for a median of 15.5 months after treatment completion (25% quartile, 11.8 months; 75% quartile, 20.2 months). The rates of treatment failure increased with each incremental increase in NI-RADS category from 1 to 3 (4.3%, 9.1%, and 42.1%, respectively). A Cox proportional hazards model demonstrated a strong association between NI-RADS categories and treatment failure at both primary and neck sites (hazard ratio [HR], 2.60 and 5.22, respectively; P < .001). In the smaller treatment subgroup analysis, increasing NI-RADS category at the primary site in surgically treated patients and treatment failure did not achieve statistically significant association (HR, 0.88; P = .82). CONCLUSION: Increasing NI-RADS category at the baseline posttreatment PET/CECT is strongly associated with increased risk of treatment failure in patients with HNSCC.

Prognostic value of radiographically defined extranodal extension in human papillomavirus-associated locally advanced oropharyngeal carcinoma.

BACKGROUND: Pathologic extranodal extension (ENE) has traditionally guided the management of head and neck cancers. The prognostic value of radiographic ENE (rENE) in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (HPV + OPX) is uncertain. METHODS: Patients with HPV + OPX with adequate pretreatment radiographic nodal evaluation from a single institution were analyzed. rENE status was determined by neuroradiologists' at time of diagnosis. Distant metastasis-free survival (DMFS), overall survival (OS), and locoregional recurrence-free survival (LRFS) were estimated using Kaplan-Meier methods. Cox proportional hazards models were fit to assess the impact of rENE on survival endpoints. RESULTS: Hundred sixty-eight patients with OPX + squamous cell carcinomas diagnosed between April 2008 and December 2014 were included for analysis with median follow-up of 3.3 years. Eighty-eight percent of patients received concurrent chemoradiotherapy. rENE was not prognostic; its presence in patients with HPV + OPX did not significantly impact OS, LRFS, or DMFS. CONCLUSIONS: In patients with HPV + OPX, rENE was not significantly associated with OS, LRFS, or DMFS.

Smoking, age, nodal disease, T stage, p16 status, and risk of distant metastases in patients with squamous cell cancer of the oropharynx.

BACKGROUND: With an expectation of excellent locoregional control, ongoing efforts to de-intensify therapy for patients with human papillomavirus-associated squamous cell oropharyngeal cancer necessitate a better understanding of the metastatic risk for patients with this disease. The objective of this study was to determine what factors affect the risk of metastases in patients with squamous cell cancers of the oropharynx. METHODS: Under a shared use agreement, 547 patients from Radiation Therapy Oncology Group 0129 and 0522 with nonmetastatic oropharyngeal squamous cell cancers who had a known p16 status and smoking status were analyzed to assess the association of clinical features with the development of distant metastases. The analyzed factors included the p16 status, sex, T stage, N stage, age, and smoking history. RESULTS: A multivariate analysis of 547 patients with a median follow-up of 4.8 years revealed that an age ≥ 50 years (hazard ratio [HR], 3.28; P = .003), smoking for more than 0 pack-years (HR, 3.09; P < .001), N3 disease (HR, 2.64; P < .001), T4 disease (HR, 1.63; P = .030), and a negative p16 status (HR, 1.60; P = .044) were all factors associated with an increased risk of distant disease. CONCLUSIONS: Age, smoking, N3 disease, T4 disease, and a negative p16 status were associated with the development of distant metastases in patients with squamous cell cancers of the oropharynx treated definitively with concurrent chemoradiation.

ACR Neck Imaging Reporting and Data Systems (NI-RADS): A White Paper of the ACR NI-RADS Committee.

Imaging surveillance after treatment for head and neck cancer is challenging because of complicated resection and reconstruction surgery, in addition to posttreatment changes from radiation and chemotherapy. The posttreatment neck is often a source of anxiety for diagnostic radiologists, leading to suboptimal reporting and no standardized guidance for next management steps. Nevertheless, imaging is critical for detecting submucosal recurrences in a timely manner, so that patients remain candidates for salvage surgery. In 2016, the ACR convened the Neck Imaging Reporting and Data Systems (NI-RADS) Committee with the goals to (1) provide recommendations for surveillance imaging; (2) produce a lexicon to distinguish between benign posttreatment change and residual or recurrent tumor in the posttreatment neck; and (3) propose a NI-RADS template for reporting on the basis of this lexicon with defined levels of suspicion and management recommendations. In this article, the authors present the ACR NI-RADS Committee's recommendations, which provide guidance regarding the management of patients after treatment for head and neck cancer.

Radiographic Imaging Does Not Reliably Predict Macroscopic Extranodal Extension in Human Papilloma Virus-Associated Oropharyngeal Cancer.

BACKGROUND: Radiographic concern for lymphatic extranodal extension (ENE) impacts upfront management decisions for patients with human papilloma virus (HPV) oropharyngeal squamous cell carcinoma (OPSCC). Therefore, we set out to evaluate the accuracy of preoperative contrast-enhanced computed tomography (CECT) to predict major ENE (> 2 mm). METHODS: Twenty-seven consecutive patients with HPV-associated OPSCC who presented at our institutional multidisciplinary tumor board were staged radiographically with positron emission tomography (PET/CT) and CECT, and underwent primary transoral robotic resection and neck dissection. CECT imaging results were correlated with pathologic ENE (pENE). RESULTS: CECT specificity for all pENE was 69 and 75% for radiologist 1 and 2, respectively. For pENE > 2 mm, the sensitivities were 88 and 100%, but specificities were 52.6 and 63.2%. Positive predictive values (PPV) were 43.8 and 53.3%; negative predictive values were 90.9 and 100%. On logistic regression analysis, only size ≥3 cm (OR 4.7-5.4, p < 0.02, 95% CI 1.3-44.0) demonstrated significant correlation with major ENE > 2 mm. CONCLUSIONS: Preoperative imaging for HPV-associated OPSCC had a PPV for pENE > 2 mm of 44-55%, based on any interruption in the capsule or invasion into the perinodal fat. The PPV is low and equipoise in treatment decision making for patients with HPV-associated OPSCC may require other imaging characteristics.

Making Time for Patients: Positive Impact of Direct Patient Reporting.

OBJECTIVE: Using a novel patient-centric approach, we assessed the impact of direct patient radiology reporting on the patient experience and patient perception of radiologists in a high-volume head and neck clinic. MATERIALS AND METHODS: A single head and neck surgeon at a large academic center identified prospective outpatients who met the following inclusion criteria: having received treatment for head and neck cancer and having recently undergone surveillance imaging using the Neck Imaging Reporting and Data System template at our institution. The surgeon introduced the concept and gave patients a survey with questions before and after the radiology consultation. The radiologist met with the patient in the head and neck clinic's examination room, explaining the role of the radiologist and reviewing imaging findings. RESULTS: Twenty-seven patients completed surveys. An improved understanding of the role of the radiologist was noted (41% of patients before consultation vs 67% after consultation). After the consultation, fewer patients (56-22%) wanted to hear from the referring physician only, and more patients wanted to hear from the radiologist only (26-44%) or from both the referring physician and the radiologist (19-33%). A total of 70-93% of patients had an improved understanding of imaging findings and follow-up recommendations after meeting with the radiologist. Most patients expressed an interest in reviewing future studies with a radiologist (93%) and found the consultation helpful (96%). CONCLUSION: Direct patient reporting by the radiologist is feasible in a high-volume head and neck clinic and has a positive impact on the patient experience. Major factors that enabled direct patient reporting included our embedded reading room and the use of a standardized reporting template. After the consultation, more patients wanted to receive information from the radiologist and had a better understanding of the imaging results.

Neck Imaging Reporting and Data System.

The Neck Imaging Reporting and Data System (NI-RADS) is a practical and clinically useful imaging surveillance template designed to guide appropriate imaging follow-up and next-management steps. This article is a practical guide for using NI-RADS to reduce report-generation time for radiologists and create useful reports for referring clinicians and patients. A review of the report template and legend is followed by a case-based and pictorial review of the proper assignment of NI-RADS categories.

Magnetic Resonance Imaging of Temporomandibular Joints of Children.

PURPOSE: To identify magnetic resonance imaging (MRI) findings of temporomandibular joints (TMJs) in healthy children. MATERIALS AND METHODS: This was a retrospective study of children younger than 18 years undergoing MRI of the head for non-autoimmune indications at Children's Healthcare of Atlanta (Atlanta, GA). Patients with congenital or acquired conditions associated with potential TMJ pathology were excluded. Medical records and MRIs were reviewed to document demographic data. Three neuroradiologists independently recorded specific predetermined MRI findings of the TMJ. The outcome variable was the presence or absence of TMJ findings at MRI. Descriptive and bivariate statistics were used to identify associations (significant at P ≤ .05). RESULTS: Eighty-seven patients (54 boys, 33 girls; mean age, 11.2 yr) met the inclusion criteria. Seventy percent of TMJs had condylar enhancement, 64% of joints had glenoid marginal synovial enhancement, 56% had condylar margin synovial enhancement, and 19% had condylar T1 hyperintense signal. There were no joints with condylar erosion, condylar volume loss, or effusion. Findings of normal marrow development were decreased condylar enhancement and greater condylar T1 signal with increased age. CONCLUSION: This study found a greater than 60% prevalence of synovial enhancement in healthy children. In a healthy child, MRI findings of TMJ synovial enhancement should be carefully correlated with a clinical evaluation.