Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction.

INTRODUCTION: The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction. METHODS: Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients. RESULTS: The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients. CONCLUSION: The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

The Comparison of Electroacoustic and Subjective Voice Quality in Type 3 and 4 Transoral Laser Cordectomy for Early-Stage Glottic Carcinoma.

One of the main issues in early-stage glottic carcinoma management is the voice quality following different types of treatment modalities. In type 3 and 4 transoral laser cordectomies, the voice outcomes can show significant differences due to the extent of the vocal muscle resection. This study aims to compare the voice quality in patients who underwent type 3 and 4 laser cordectomy for early-stage glottic carcinoma. A total of 30 patients who underwent type 3 (15 patients) and type 4 (15 patients) laser cordectomy for T1a glottic carcinoma between May 2018 and 2020 were included in this retrospective comparative study. Electroacoustic voice analysis and Voice Handicap Index-10 were performed in the postoperative twelfth month and the outcomes were compared between two laser cordectomy groups. The mean age of all patients was 48.6 ± 4.2 years. Noise-to-harmonic ratio, jitter, shimmer, pitch perturbation quotient and amplitude perturbation quotient values were significantly different between two groups (p < 0.05). Fundamental frequency and Voice Handicap Index-10 scores showed no statistically significant difference (p > 0.05). This study reports significantly better results for type 3 against type 4 laser cordectomy by means of objective voice analysis outcomes, except fundamental frequency. On the other hand, self-reported subjective analysis showed very similar results for both groups. Further studies combining data with multiple objective and subjective analyses with larger patient series and longer follow-up are warranted.

The potential applicability of facial nerve monitoring as a navigation tool in parotid gland surgery

Abstract Objectives: The aim of this study was to assess the relationship between the stimulation amplitude and the distance to the facial nerve. Methods: This study was designed as a prospective clinical study. A total of 20 patients (12 males, 8 females) were included. Partial superficial parotidectomy was performed in all patients with intraoperative facial monitoring. Measurements were made on the main trunk and major branches. Stimulation was started at 1 mA and incrementally increased to 2 and 3mA's. The shortest distance creating a robust response (>100mV) was recorded. Results: At 1 mA, 2 mA and 3 mA stimulation intensity, the average distance between the tip of the stimulation probe and the main trunk was 2.20±0.76 mm (range 1-3 mm), 3.80±0.95 mm (range 2-5 mm), 4.80±1.05 mm (range 3-7 mm) respectively. The stimulus intensity was inversely proportional in respect to the distance between the nerve and the tip of the stimulus probe (P < .00). The same relation was present in the facial nerve major branch measurements (P < .00). Conclusion: The proportional stimulation amplitude and distance to the facial nerve is thought to be a reliable auxillary method to assist the surgeon by facilitating the estimation of the distance to the facial nerve during extracapsular dissection and minimally invasive cases where the facial nerve isn't routinely dissected. Level of evidence: Level 3.

The use of chimeric-superthin anterolateral thigh flap in reconstruction of laryngopharyngoesophagectomy defects of hypopharyngeal cancer.

INTRODUCTION: Due to 3D defects after resection of hypopharyngeal cancers, free flaps have become as first option for reconstruction and the anterolateral thigh flap (ALT) has been chosen frequently for soft tissue defects. Chimerization of the skin island of the ALT is also possible which can result in reconstruction of multiple defects simultaneously and monitorization of buried flaps. However, ALT can be bulky in some patients. The superthin ALT is well established by some authors especially for extremities but there is no study about the use of this modification in pharyngoesophageal defects. We present our experience of using chimeric-superthin ALT for pharyngoesophageal reconstructions. PATIENTS AND METHODS: Between 2019 and 2022, six patients (one female and five male) underwent hypopharyngeal tumor resection and experienced chimeric-superthin ALT flap reconstructions. Patients' ages were ranged between 53 and 71 (mean: 64) years old. The type of tumor was squamous cell carcinoma (SCC) for all patients. Three patients had total and three patients had 75% of pharyngoesophageal defects. Defect size was between 10 × 7 cm and 12 × 8.5 cm (mean: 87.08 cm2 ). All flaps were harvested as 5 mm thickness with two skin perforators. All flaps were divided into two individual skin islands as chimeric fashion. One of the skin islands was used for esophageal reconstruction and the other was used for both flap monitorization and tensionless closure of anterior neck skin. RESULTS: Total flap size was between 18 × 9 cm and 21 × 11 cm (mean: 200 cm2 ). In two patients, anastomoses were performed to pectoral branch of thoracoacromial vessels. Neck vessels were chosen as recipient for remaining patients. Wound dehiscence occurred in two patients between the neck skin and monitor island and was re-sutured without any problems. There was no partial or total flap necrosis and all flaps survived. The follow up period was between 4 and 9 months (mean: 5.6). All patients had a successful functional outcome as swallowing. CONCLUSION: The superthin-chimeric ALT flap is a useful option when classical ALT is bulky in defects of hypopharyngeal cancer.

Flow through fibula and fasciocutaneous free flaps in oromandibular reconstruction.

INTRODUCTION: The osteocutaneous fibula is a workhorse flap for oromandibular reconstruction. Skin paddles not only perform soft tissue reconstruction but also serve as a monitor for the fibula. In cases where the skin paddle cannot be harvested as desired due to variations, two challenges arise, such as fibula follow-up and the need for a second free flap so recipient. Moreover, there may not be enough recipient vessels for the double flaps in the neck. This report aimed to address the difficulties mentioned above with the use of flow-through free flaps in composite oromandibular reconstructions. PATIENTS AND METHODS: Between 2019 and 2021, five (three Female, two Male) patients underwent flow-through technique as free fibula and fasciocutaneous flaps due to variations in fibular skin paddle or insufficiency of recipient vessels in the neck. Ages of patients were between 45 and 75 years. Four patients underwent surgery for tumor and one patient for the result of radionecrosis. ALT, chimeric ALT, and RFFF were selected as second free flaps. RESULTS: The size of the fasciocutaneous flaps ranged from 6 × 4 cm to 14 × 11 cm. Mandibular defects ranged from 6 to 16 cm. 1 venous occlusion occurred post-op 1st day and was salvaged. One hematoma and one wound dehiscence occurred postoperatively and were salvaged successfully. One Partial tongue necrosis occurred due to previous radiotherapy and additional tumor surgery. No additional complication occurred. All flaps survived. Follow-up period was between 3 months and 2 years. Patient who had tongue necrosis experienced swallowing and speech difficulty and Percutaneous endoscopic gastrostomy tube was placed post-operative 2 months. Functional finale outcomes were successful for other patients. CONCLUSION: Flow-through technique provides fibula monitoring with avoiding to find second recipient. Customizing free flaps under more favorable conditions as on the operation table before fixation of the bone can be a useful approach.

Transferring pectoral muscle flap to depleted neck to create a new recipient source for free flaps in head and neck reconstruction.

INTRODUCTION: The thoracoacromial vessels (TA) are one of the options as recipient for free flaps in head and neck reconstruction when the neck is depleted. However, it has limitations such as need of vein graft or kinking and being under pressure on clavicle. The authors describe a new modification of using pectoral branch of TA as recipient vessel. PATIENTS AND METHODS: Between July 2019 and January 2022, 8 patients (1 female, 7 male) underwent head and neck reconstructions with free flaps. Age of patients ranged from 53 to 73 years old. All surgeries were because of SCC. Defects were including 3 total lower lip, 2 pharyngoesophageal defects, 1 cheek, lower and upper lip, 1 mandible, cheek and mount floor and 1 tongue and mount floor. Defects were between 12 × 5 cm and 21 × 9 cm. Pectoral branch of TA was transposed to the depleted neck as pectoral muscle flap to prevent kinking and pressure. Over the clavicle, the proximal root of the pedicle of muscle was found and dissected distally until tensionless anastomoses could be accomplished between the muscle and free flaps. ALT, MSAP, and Radial forearm free flaps were used as free flaps. In one patient the fibula and ALT flaps were used as flow through so the pedicle of ALT flap was anastomosed to pectoral muscle pedicle. Pectoral muscle was rotated 180° on its horizontal axis after finishing anastomoses to guard anastomoses from radiated neck skin. Muscle was fixed to sternocleidomastoid muscle with sutures to maintain its position. All donor sites were closed primarily. RESULTS: The diameter of recipient artery was between 1 and 1.6 mm. The veins were approximately same as arteries. All anastomosis were performed end-to-end fashion. Three patients needed skin grafts to closure of tight radiated neck skin. Complications as 1 hematoma and 1 wound dehiscence were salvaged successfully. All flaps survived. Patients were followed up between 2 and 6 months. Our first patient died at post-operative 6th month so long follow-up could not be achieved. The final outcomes such as chewing, oral competence and swallowing were successful for remaining patients. CONCLUSION: Transposing TA as pectoral muscle flap to the neck can decrease need of vein graft and prevent kinking or pressure of the pedicle on the clavicle.

The potential applicability of facial nerve monitoring as a navigation tool in parotid gland surgery.

OBJECTIVES: The aim of this study was to assess the relationship between the stimulation amplitude and the distance to the facial nerve. METHODS: This study was designed as a prospective clinical study. A total of 20 patients (12 males, 8 females) were included. Partial superficial parotidectomy was performed in all patients with intraoperative facial monitoring. Measurements were made on the main trunk and major branches. Stimulation was started at 1 mA and incrementally increased to 2 and 3 mA's. The shortest distance creating a robust response (>100 mV) was recorded. RESULTS: At 1 mA, 2 mA and 3 mA stimulation intensity, the average distance between the tip of the stimulation probe and the main trunk was 2.20 ± 0.76 mm (range 1-3 mm), 3.80 ± 0.95 mm (range 2-5 mm), 4.80 ± 1.05 mm (range 3-7 mm) respectively. The stimulus intensity was inversely proportional in respect to the distance between the nerve and the tip of the stimulus probe (P < .00). The same relation was present in the facial nerve major branch measurements (P < .00). CONCLUSION: The proportional stimulation amplitude and distance to the facial nerve is thought to be a reliable auxillary method to assist the surgeon by facilitating the estimation of the distance to the facial nerve during extracapsular dissection and minimally invasive cases where the facial nerve isn't routinely dissected. LEVEL OF EVIDENCE: Level 3.

Comparison of Current Free Flap Options for Intraoral Lining and Tongue Reconstruction.

Free flaps have become the main alternative for intraoral reconstruction in current practice. However, controversy exists on pros and cons of different free flap options for this challenging area. Although there are various studies focusing on different free flap options, comparative studies are very few and there is not a single study comparing all 4 thin free flap options for intraoral reconstruction. Between 2018 and 2021, 30 patients underwent intraoral reconstruction. Four pliable and thin flaps, medial sural artery perforator flap, superficial circumflex iliac artery perforator flap, radial forearm free flap, and superthin anterolateral thigh flap were used for reconstructions and compared per functionality and patients' quality of life. One medial sural artery perforator flap and 1 superficial circumflex iliac artery perforator flap failed because of perfusion problems, and the remaining flaps survived. Harvest time and donor site closure were with significant difference ( P <0.05) between groups. Quality of life results were similar except one of the disease-specific questions. In authors' opinion, anterolateral thigh flap is the best option in normal-weight individuals because of its reliability, pliability, and constant reliable vascular structure. Although other options may be considered in overweighted patients, thinly elevated anterolateral thigh flap still seems to be the most reliable option.

Fiberoptic endoscopic evaluation of swallowing (FEES) study: the first report in children to evaluate the oropharyngeal dysphagia after esophageal atresia repair.

BACKGROUND: The aim of this study was to evaluate the swallowing problems by fiberoptic endoscopic evaluation of swallowing (FEES) study in both short- and long-gap patients after esophageal atresia (EA) repair. METHODS: Hospital records of patients who had undergone surgery for EA were reviewed retrospectively. Patients were divided into two groups as short-gap (SG) group (n:16) and long-gap (LG) group (n:10) to compare the swallowing problems. FEES study was performed, and the results were discussed in detail. RESULTS: There were twenty-six (16 M/10 F) patients with a mean age at evaluation was 7.52 ∓ 3.68 years. Mean follow-up period was 75.35 ∓ 44.48 months. In FEES study, pharyngeal phase abnormalities were detected in 10 patients (38.4%). Pharyngeal phase abnormalities were detected significantly higher in LG group (p:0.015). Laryngeal penetration/aspiration was seen in four patients on FEES study (15.3%). All of them was in LG group (40%). Laryngeal penetration/aspiration was seen significantly higher in LG group (p:0.014). CONCLUSION: This is the first study to conduct FEES study in children after esophageal atresia repair to evaluate their swallowing conditions. Even though our sample is small, swallowing problems are more common than expected in the cases of LG when compared to SG.

Dentate nucleus signal intensity changes on T1-weighted MRI after repeated administrations of linear and macrocyclic gadolinium-based contrast agents: a pediatric intraindividual case-control study.

BACKGROUND: An association between consecutive administrations of macrocyclic gadolinium-based contrast agent (mcGBCA) gadobutrol and linear (L)-GBCA gadopentetate dimeglumine and gadolinium retention in the pediatric brain remains incompletely understood. PURPOSE: To compare signal intensity (SI) changes in the dentate nucleus (DN) on unenhanced T1-weighted imaging (T1WI) in children who obtained mcGBCA gadobutrol with those who had previously received L-GBCA gadopentetate dimeglumine. MATERIAL AND METHODS: This retrospective study included 27 children who received L-GBCA gadopentetate dimeglumine followed by mcGBCA gadobutrol and two different control groups matched for age and sex for both periods, each involving 27 individuals with no GBCA administration from January 2010 to January 2020. DN-to-middle cerebellar peduncle (MCP) SI ratios on T1WI were determined. A repeated-measures ANOVA was performed to compare the T1WI SI ratio between children exposed to GBCA in each of the two periods and controls. Pearson correlation analysis was conducted to determine any correlation between SI ratios and confounding parameters. RESULTS: T1WI SI ratio was significantly higher in those who had only L-GBCA (1.005±0.087) or subsequent mcGBCA gadobutrol (1.002±0.104) than in control groups 1 (0.927±0.041; P<0.001) and 2 (0.930±0.041; P=0.002), respectively, but no significant difference of the T1WI SI ratio was noted between L-GBCA period and subsequent mcGBCA gadobutrol period (P=0.917). T1WI SI ratios and the L-GBCA administration number revealed a modest but significant correlation (correlation coefficient=0.034; P=0.016). CONCLUSION: Previous administration of gadopentetate dimeglumine is associated with increased T1WI SI in the DN, while subsequent administration of gadobutrol does not demonstrate any additional SI increase in the pediatric brain.

Diffusion Tensor Imaging of the Dentate Nucleus After Repeated Administration of Gadobutrol in Children.

This study aimed to investigate possible signal changes in the dentate nucleus (DN) on diffusion tensor imaging (DTI) after administration of gadobutrol in a pediatric cohort. Total of 50 pediatric patients (mean age: 6.2 ± 4.3 years) with normal renal function exposed exclusively to the macrocyclic GBCA (mcGBCA) gadobutrol and 50 age- and sex-matched control patients with nonpathological neuroimaging findings (and no GBCA administration). Mean diffusivity (MD) and fractional anisotropy (FA) values were determined in the DN. A paired t test was performed to compare FA, MD values, and DN-to-middle cerebral peduncle (MCP) T1WI SI ratios between children exposed to gadobutrol and controls. Pearson correlation analysis was conducted to determine any correlation between FA and MD values as well as T1WI SI ratios and confounding parameters. The mean FA values of DN was significantly lower in children with mcGBCA than in the control group (p < 0.001; non-GBCA group, 0.299 ± 0.03; mcGBCA group, 0.254 ± 0.05), but no significant difference of the T1WI SI ratio was noted between the mcGBCA group (0.946 ± 0.06) and the control group (0.963 ± 0.05; p = 0.336). There was also a significant MD value difference between mcGBCA group and control group (p < 0.001; non-GBCA group, 0.152 ± 0.02 × 10-3 mm2/s; mcGBCA group, 0.173 ± 0.03 × 10-3 mm2/s). A significant correlation was identified between FA/MD values and the number of mcGBCA administration (FA; correlation coefficient = - 0.355, p = 0.011 and MD; correlation coefficient = 0.334, p = 0.018). The administration of the gadobutrol was associated with higher MD and lower FA values in DN suggesting a difference in cerebellar tissue integrity between children exposed to mcGBCAs and control group.

Blood Count Parameters can be Useful in Predicting Vascular Events in Microvascular Surgery: Results of a Preliminary Study.

BACKGROUND: Vascular events are a major cause of flap failure and identifying patients who are at risk is of paramount importance. In the past, many studies have been conducted to investigate the effect of blood count parameters for ischemic events such as peripheral vascular diseases. AIMS: This study aimed to evaluate whether blood count parameters can have predictive value for vascular events in microvascular flap surgery. METHODS: Elective cases with free flap microsurgery performed in a single center were reviewed from 2015 to 2019. Demographic data, comorbidities, flap types, perioperative complications, and preoperative blood count parameters from the hospital records were screened. RESULTS: A total of 147 patients were included in the study, taken from the 163 patients undergoing free tissue transfer. The rate of thrombosis and partial necrosis was 8.8%, was 8.2%, respectively, and the total flap loss due to these complications was 5.4%. Only patient age, gender, and length of hospital stay were correlated with flap loss. According to the preoperative blood count results, there were significant differences between vascular events and leucocyte, and neutrophil counts. CONCLUSION: The findings of this preliminary study suggest that these parameters may be used in predicting vascular events in flap surgery.

Differentiation between primary CNS lymphoma and atypical glioblastoma according to major genomic alterations using diffusion and susceptibility-weighted MR imaging.

PURPOSE: We aimed to differentiate primary central nervous system lymphoma (PCNSL) from atypical glioblastoma (GB) and distinguish major genomic subtypes between these tumors using susceptibility-weighted imaging (SWI) along with diffusion-weighted imaging (DWI). METHODS: Thirty-one immuno-competent patients with PCNSL stratified by BCL2 and MYC rearrangement, and 57 patients with atypical GB (no visible necrosis) grouped according to isocitrate dehydrogenase-1 (IDH1) mutation status underwent 3.0-Tesla MRI before treatment in this retrospective study. Region of interest analysis with apparent diffusion coefficient (ADC) and SWI signal intensity values of the tumors were normalized by dividing those of contralateral white matter. The independent-samples t-test and Kruskal-Wallis test were utilized to compare parameters. The diagnostic ability of each parameter and their optimal combination was evaluated by logistic regression analysis and receiver operating characteristic. RESULTS: PCNSL with rearrangement of both MYC and BCL2 (n = 7) [mean relative (r) ADCmean:0.87 ±â€¯0.06, rADCmin:0.72 ±â€¯0.08] demonstrated significantly lower rADCmean, and rADCmin compared to other PCNSLs (n = 24) (rADCmean:1.19 ±â€¯0.18, rADCmin:1.03 ±â€¯0.17;p < 0.001) and GBs (p < 0.001). GB without IDH1 mutation (n = 44) (mean rSWI value:0.95 ±â€¯0.15) demonstrated significantly lower rSWI value compared to GB with IDH1 mutation (n = 13) (rSWI value:1.13 ±â€¯0.09;p < 0.001) and PCNSL (p < 0.001). The incorporation of rADCmean and rSWI parameters distinguished GB with IDH1 mutation [Area under the curve (AUC):0.985] with sensitivity and specificity of 94.3 and 100 % respectively; and PCNSL with rearrangement of both MYC and BCL2 (AUC:0.982) with sensitivity and specificity of 100 % and 95.4 %, respectively. CONCLUSiONS: Combined analysis of SWI and DWI could differentiate atypical GB from PCNSL and distinguish major genomic subtypes between these tumors.

Machine Learning-Based Multiparametric Magnetic Resonance Imaging Radiomics for Prediction of H3K27M Mutation in Midline Gliomas.

OBJECTIVE: H3K27M mutation in gliomas has prognostic implications. Previous magnetic resonance imaging (MRI) studies have reported variable rates of tumoral enhancement, necrotic changes, and peritumoral edema in H3K27M-mutant gliomas, with no distinguishing imaging features compared with wild-type gliomas. We aimed to construct an MRI machine learning (ML)-based radiomic model to predict H3K27M mutation in midline gliomas. METHODS: A total of 109 patients from 3 academic centers were included in this study. Fifty patients had H3K27M mutation and 59 were wild-type. Conventional MRI sequences (T1-weighted, T2-weighted, T2-fluid-attenuated inversion recovery, postcontrast T1-weighted, and apparent diffusion coefficient maps) were used for feature extraction. A total of 651 radiomic features per each sequence were extracted. Patients were randomly selected with a 7:3 ratio to create training (n = 76) and test (n = 33) data sets. An extreme gradient boosting algorithm (XGBoost) was used in ML-based model development. Performance of the model was assessed by area under the receiver operating characteristic curve. RESULTS: Pediatric patients accounted for a larger proportion of the study cohort (60 pediatric [55%] vs. 49 adult [45%] patients). XGBoost with additional feature selection had an area under the receiver operating characteristic curve of 0.791 and 0.737 in the training and test data sets, respectively. The model achieved accuracy, precision (positive predictive value), recall (sensitivity), and F1 (harmonic mean of precision and recall) measures of 72.7%, 76.5%, 72.2%, and 74.3%, respectively, in the test set. CONCLUSIONS: Our multi-institutional study suggests that ML-based radiomic analysis of multiparametric MRI can be a promising noninvasive technique to predict H3K27M mutation status in midline gliomas.

Dentate Nucleus Signal Intensity Changes in Children with Adrenoleukodystrophy in Comparison to Primary Brain Tumor with and without Radiotherapy after Gadobutrol Administration.

BACKGROUND AND PURPOSE: To determine whether cerebral adrenoleukodystrophy (cALD) or brain irradiation in patients with primary brain tumor affects T1-weighted imaging (T1WI) signal intensity (SI) of the dentate nucleus (DN) in a pediatric cohort who had received consecutive macrocyclic gadolinium-based contrast agent (mcGBCA) gadobutrol. METHODS: This study included 97 pediatric patients who underwent mcGBCA-enhanced MRI from 2010 to 2020 (29 children with primary brain tumors without brain radiation therapy [mcGBCA group-1], 33 children with primary brain tumors and radiation treatment [mcGBCA group-2], 35 children with cALD [mcGBCA group-3], and 97 sex-/age-matched control subjects [subgroups matched to each of the three subject groups] without GBCA administration). The DN-to-middle cerebellar peduncle (MCP) SI ratios on T1WI were then determined. A paired t-test was performed to compare SI ratios between children exposed to mcGBCA in each group and control subjects. The relationships between SI ratios and confounding variables were analyzed utilizing the Pearson correlation analysis. RESULTS: The DN-to-MCP SI ratio was significantly higher of mcGBCA group-2 (1.046±.071) or mcGBCA group-3 (.972±.038) than in the control group-2 (.983±.041, P<.001) and control group-3 (.937±.051, P = .002), respectively, but no significant difference of the SI ratio was noted between mcGBCA group-1 (.984±.032) and control-group-1 (.982±.035, P = .860). No significant correlation was noted between SI ratio values and the cumulative dose or number of mcGBCA administrations, age, or the elapsed time between the MRI examinations (all P>.05). CONCLUSIONS: Hyperintense T1WI signal in the DN may be seen in children with brain tumors undergoing brain irradiation, as well as in children with cALD.

Correlation between dynamic susceptibility contrast perfusion MRI and genomic alterations in glioblastoma.

PURPOSE: To determine if dynamic susceptibility contrast perfusion MR imaging (DSC-pMRI) can predict significant genomic alterations in glioblastoma (GB). METHODS: A total of 47 patients with treatment-naive GB (M/F: 23/24, mean age: 54 years, age range: 20-90 years) having DSC-pMRI with leakage correction and genomic analysis were reviewed. Mean relative cerebral blood volume (rCBV), maximum rCBV, relative percent signal recovery (rPSR), and relative peak height (rPH) were derived from T2* signal intensity-time curves by ROI analysis. Major genomic alterations of IDH1-132H, MGMT, p53, EGFR, ATRX, and PTEN status were correlated with DSC-pMRI-derived GB parameters. Statistical analysis was performed utilizing the independent-samples t-test, ROC (receiver operating characteristic) curve analysis, and multivariable stepwise regression model. RESULTS: rCBVmean and rCBVmax were significantly different in relation to the IDH1, MGMT, p53, and PTEN mutation status (all p < 0.05). The rPH of the p53 mutation-positive GBs (mean 5.8 ± 2.8) was significantly higher than those of the p53 mutation-negative GBs (mean 4.0 ± 1.5) (p = 0.022). Multivariable stepwise regression analysis revealed that the presence of IDH-1 mutation (B = - 2.81, p = 0.005) was associated with decreased rCBVmean; PTEN mutation (B = - 1.21, p = 0.003) and MGMT methylation (B = - 1.47, p = 0.038) were associated with decreased rCBVmax; and ATRX loss (B = - 1.05, p = 0.008) was associated with decreased rPH. CONCLUSION: Significant associations were identified between DSC-pMRI-derived parameters and major genomic alterations, including IDH-1 mutation, MGMT methylation, ATRX loss, and PTEN mutation status in GB.

Not a pearl necklace: synchronous papillary carcinoma of thyroglossal duct cyst and thyroid gland.

We report an unusual case of synchronous papillary carcinoma of thyroglossal duct cyst (TGDC) and thyroid gland. Here, the radiology findings, surgical approach and subsequent management, and pathology of an synchronous papillary carcinoma of TGDC and thyroid gland are described.

Effect of at Least 10 Serial Gadobutrol Administrations on Brain Signal Intensity Ratios on T1-Weighted MRI in Children: A Matched Case-Control Study.

BACKGROUND. An association is recognized between linear gadolinium-based contrast agents (GBCAs) and intracranial gadolinium retention in children. The relation between macrocyclic GBCAs and gadolinium retention remains incompletely understood. OBJECTIVE. The purpose of this study was to assess whether 10 or more administrations of the macrocyclic GBCA gadobutrol are associated with increased signal intensity (SI) in the dentate nucleus (DN) and globus pallidus (GP) on unenhanced T1-weighted MRI of children and to explore clinical variables potentially associated with T1 hyperintensity. METHODS. The case group consisted of 25 children (13 boys, 12 girls; mean age, 7 ± 4 years; range, 2-18 years) who underwent at least 10 (mean, 15 ± 6; range, 10-34) contrast-enhanced MRI examinations exclusively with gadobutrol. The control group consisted of 25 age- and sex-matched patients undergoing MRI who had never been exposed to gadolinium. Two observers in consensus using a 3-point scale assessed visual T1 hyperintensity in the DN and GP. One observer placed ROIs on T1-weighted images to mark the DN, GP, middle cerebellar peduncle (MCP), and pulvinar of the thalamus bilaterally to compute mean DN-to-MCP and GP-to-thalamus SI ratios. SI ratios were compared between the macrocyclic GBCA and control groups. In the macrocyclic GBCA group, Pearson correlation analysis was conducted between SI ratios and clinical variables. ROI measurements were repeated by the original reader and an independent reader, and interobserver and intraobserver agreement were computed by means of Lin concordance correlation coefficient (ρc). RESULTS. No patient had visual T1 hyperintensity in the DN or GP. No significant difference between the macrocyclic GBCA and control groups was observed for DN-to-MCP SI ratio (0.95 ± 0.05 vs 0.95 ± 0.03; p = .67) or GP-to-thalamus SI ratio (1.05 ± 0.06 vs 1.04 ± 0.06; p = .65). In the macrocyclic GBCA group, no significant correlation was observed between DN-to-MCP SI ratio or GP-to-thalamus SI ratio and age (r = 0.355, p = .08; r = 0.167, p = .42), number of contrast-enhanced MRI examinations (r = 0.247, p = .23; r = 0.203, p = .33), mean time between examinations (r = 0.193, p = .36; r = 0.047, p = .82), or cumulative macrocyclic GBCA dose (r = 0.434, p = .07; r = 0.270, p = .19). Interobserver and intraobserver agreement was substantial for DN-to-MCP SI and GP-to-TH SI ratios (ρc = 0.931-0.974). CONCLUSION. Ten or more serial gadobutrol administrations were not associated with T1 hyperintensity in the DN or GP of children. CLINICAL IMPACT. Selection of gadobutrol as an MRI contrast agent may reduce risk of gadolinium retention in children. The findings may help guide practices for GBCA administration to children.

Urea Cycle Disorders: A Neuroimaging Pattern Approach Using Diffusion and FLAIR MRI.

BACKGROUND AND PURPOSE: This study aimed to assess characteristic regions of MRI involvement utilizing diffusion weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) at urea cycle disorder (UCD) diagnosis to determine the possible association between initial MRI patterns within 10 days of the first hyperammonemia episode, serum ammonia levels, and severity of neurological outcome based on clinical follow-up of >30 days. METHODS: Ten patients with UCDs (4 females; median age: 5.4 years, age range: 6 days-54 years) were included who underwent MRI during a first episode of hyperammonemia. The topographical distribution of the DWI and FLAIR abnormalities in the cerebral cortex, deep gray matter, white matter, posterior limb of internal capsule, cerebral peduncle, and cerebellum was evaluated. Possible correlations between the brain injury patterns on DWI/FLAIR images, serum ammonia levels, and severity of neurological outcome were investigated by a trend correlation. RESULTS: The UCD cohort (n = 10) involved four ornithine transcarbamoylase deficiencies, four argininosuccinic aciduria, one carbomoylphosphate synthetase deficiency, and one citrullinemia type-1. The observed trend in the distribution of DWI abnormalities as the severity of neurological sequela outcome increased was with diffuse cerebral cortex or corpus striatum involvement. Patients with initial peak serum ammonia ≥450 µmol/L had a grade 2 to 4 outcome, and those with peak ammonia <450 µmol/L had a grade 0 or 1 outcome. CONCLUSIONS: The presence of more severe neurological outcome could be associated with diffuse cerebral cortex or corpus striatum involvement on DWI and high serum ammonia levels in patients with UCD.

Non-hematologic diagnosis of systemic mastocytosis: Collaboration of radiology and pathology.

Systemic mastocytosis (SM) is a hematologic disease with a wide range of clinical courses ranging from an indolent condition with normal life expectancy to exceedingly aggressive disorder with a poor prognosis. The symptoms and signs of SM result from the release of mast cell mediators with heterogeneous functions, and/or organ damage from neoplastic mast cell infiltration, or both. Diagnostic criteria for SM are well-defined by the World Health Organization (WHO). However, the diagnosis of SM can be difficult when especially it is not in the differential diagnosis. Routinely used radiologic techniques (e.g., X-ray, ultrasound, CT scans can show findings such as lytic-, sclerotic- or mixed-bone lesions, splenomegaly, hepatomegaly, retroperitoneal or periportal mesenteric lymphadenopathy, and omental thickening). It is essential to emphasize that the constellation of these radiologic findings should strongly concern of SM, especially in patients who also have a skin rash, allergic reactions, gastrointestinal tract symptoms (lasting, intermittent nausea, diarrhea), paroxysmal tachycardias, unexplained weight loss, persistent bone pain, cytopenias, liver dysfunction, eosinophilia. These findings, even coincidentally noted, will likely lead to a tissue biopsy, which reveals diagnosis (as we discussed and illustrated some tissue biopsies here). Moreover, the role of MRI and new techniques such as [18-fluorodeoxyglucose positron emission computed tomography, fibroscan] in the diagnosis of SM have been discussed. Furthermore, we reviewed the use of radiologic methods to evaluate treatment response and prognostication of SM..