Article

CT and MR appearance of recurrent malignant head and neck neoplasms after resection and flap reconstruction

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Abstract

To describe the appearance of recurrent malignant neoplasms in patients who have undergone resection of primary head and neck tumors with flap reconstruction. Thirty-two examinations, 26 CT and 6 MR scans, were retrospectively reviewed in 25 patients with documented recurrent malignant neoplasms. Confirmation of disease was by biopsy or disease progression. The flaps included 15 myocutaneous, 6 free composite, 2 jejunal free grafts, and 2 combined jejunal and myocutaneous flaps. The most common location of recurrence was in the primary tumor bed involving the undersurface or suture line of the reconstruction flaps, 14 of 32 scans; both nodal and flap recurrence was seen in 12 of 32 scans. When examining patients who may have recurrent disease after flap reconstruction, the radiologist should be aware of the type of flap used and the expected appearance. Tumor recurrence in this patient population is manifest either as a focal recurrent mass at or near the suture line of the reconstruction flap, or nodal disease, usually in the contralateral neck.

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... It is important to assess the edge of the surgical bed and deep to the flap as this may be a site of tumour recurrence. 34,35 Surgical complications Surgical complications following treatment of head and neck malignancy generally occur early in the postoperative period and are similar to those that occur elsewhere. These include bleeding, infection, wound breakdown, and flap necrosis. ...
... Early local tumour recurrence may be difficult to appreciate due to the adjacent post-surgical and DXT changes, but typically occurs at the site of the original tumour or along the margins of the flap (Fig 11). 4,34 On CT, a soft-tissue mass with enhancement or new bone/cartilage destruction are concerning features. 36 Mucosal ulceration is an expected finding in the treatment field. ...
... 33 T2 sequences are useful to distinguish scar from tumour, with scar tissue being of comparatively lower signal on T2. 21,34,35 Diffusion-weighted imaging may be helpful as a tumour with increased cellularity generally has a lower ADC value than post-treatment fibrosis. 38,39 Figure 11 Types of tumour recurrence. ...
Article
Post-treatment imaging of the neck is complex. It is important to have an understanding of the expected treatment related appearances as well as the possible complications. Common findings after radiation therapy include generalised soft-tissue oedema and thickening of the skin and platysma muscle. There are a number of complications of radiation that may be seen on imaging, including osteoradionecrosis, chondronecrosis, and accelerated atherosclerosis. Surgical procedures are variable depending on the primary tumour site and extent. The use of flap reconstructions can further complicate the imaging appearances. Any new nodule of enhancement or bone/cartilage erosion should raise concern for tumour recurrence. It is also important to assess for nodal recurrence. A standardised approach to reporting may help to increase accuracy and guide treatment decisions.
... However, patients who have undergone head and neck surgery may have characteristic radiographic findings, including gross alteration of the normal anatomy, placement of wide variety of foreign objects, myocutaneous flaps, skin and soft tissue swelling, ill-defined tissue planes, gastracking along the surgical margin, surgery-or radiationrelated enhancement (21)(22)(23). Within a few months of surgery, these changes often make it difficult to differentiate postoperative abscess in the neck from non-infected fluid, such as seroma, hematoma, and lymphocele (22,23). ...
... However, patients who have undergone head and neck surgery may have characteristic radiographic findings, including gross alteration of the normal anatomy, placement of wide variety of foreign objects, myocutaneous flaps, skin and soft tissue swelling, ill-defined tissue planes, gastracking along the surgical margin, surgery-or radiationrelated enhancement (21)(22)(23). Within a few months of surgery, these changes often make it difficult to differentiate postoperative abscess in the neck from non-infected fluid, such as seroma, hematoma, and lymphocele (22,23). ...
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Background Differentiation of postoperative neck abscess from non-infected fluid is important because the treatment is different.PurposeTo determine specific CT findings that might help to differentiate abscesses from non-infected fluid collections in the postoperative neck.Material and Methods We retrospectively reviewed CT scans of 50 patients (43 men and 7 women; mean age, 62.5 ± 8.9 years) who had postoperative fluid collections in the neck (26 abscesses and 24 non-infected fluid collections). Diagnosis of an abscess was determined by a positive bacteria culture from the fluid collection. Diagnoses were correlated with the following CT findings: anatomic spaces involved, the maximum transverse diameter, margin, attenuation, rim enhancement, gas bubbles, and manifestations of soft tissue adjacent to a fluid collection.ResultsRim enhancement pattern and soft tissue manifestations showed significant differences between abscess and non-infected fluid. The reliable CT findings for abscess were: (i) rim enhancement > 50% of the circumference, 54% sensitive, 71% specific, and 62% accurate; and (ii) severe soft tissue manifestations, 39% sensitive, 92% specific, and 64% accurate. There were no significant differences in the anatomic spaces involved, the maximum transverse diameter, margin, attenuation, and gas bubbles between abscess and non-infected fluid.ConclusionCT findings that may help differentiate postoperative neck abscess from non-infected fluid were rim enhancement > 50% of the circumference and severe soft tissue manifestations.
... This is especially important for CT. The characteristic CT findings of recurrent tumor are 1) a progressively enlarging mass at the primary site or along the surgi-cal margin or 2) a progressively enlarging lymph node (3,4). Very advanced tumors may erode bone. ...
... The MR imaging criteria for recurrent tumor are an enlarging enhancing infiltrating mass that is of intermediate to high signal intensity on T2-weighted images. Prior studies suggest that abnormal soft tissue that has decreased T2-weighted signal intensity is suggestive of post-treatment scarring rather than recurrent tumor (3,4,8,10,11). There are numerous published reports on the ability of MR to detect recurrent HNSCCA; however, there is currently a paucity of data commenting on the diagnostic accuracy. ...
... Several reports have described the imaging appearance of reconstructive flaps in the head and neck (1)(2)(3)(4)(5). The majority concern CT or MR imaging with respect to the fatty component of the graft. ...
... However, that point was not referenced, and may not be widely known. Of three patients in the series by Hudgins et al (5) imaged after contrast administration, only one muscular flap component was noted to enhance. Our higher rate of occurrence of muscular enhancement may be partly explained by a larger study group and partly by the use of fat suppression in our postcontrast sequence, a technique known to be associated with greater conspicuity of enhancement. ...
Article
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Myocutaneous flaps are commonly used for reconstruction in head and neck surgery. The purpose of this study was to characterize the MR imaging findings of the muscular component of these flaps, with an emphasis on enhancement patterns. Recognition of these imaging findings is important in differentiating postoperative changes from recurrent tumor. MR studies were evaluated in 25 patients who had undergone 27 flap reconstructions after resection of a head and neck tumor. Twenty were free flaps and seven were pedicled rotation flaps, and a dominant component of all flaps was muscle. MR images were reviewed for signal intensity, enhancement characteristics, and morphology over a period of 7 to 79 months. On baseline postoperative images, 21 flaps showed moderate or intense enhancement of the muscular graft component relative to nonenhancing native muscle, three flaps showed mild enhancement, and three showed no enhancement. On follow-up images, 18 flaps that initially had intense enhancement showed persistent intense enhancement, and three showed decreasing enhancement. Two flaps with initial mild enhancement were unchanged on follow-up, and one became nonenhancing. None of the initially nonenhancing flaps subsequently enhanced. T1 signal intensity of muscular graft components was always isointense with normal muscle, whereas T2 signal intensity was variable and tended to be stable. Ninety-three percent of our muscular flap components showed striations typical of normal muscle and were best identified on T1-weighted images. No significant imaging differences were found between pedicled and free flaps. Most muscular flap components show moderate or intense enhancement on fat-suppressed contrast-enhanced MR images that may persist for many months and be quite striking. Radiologists should be familiar with the typical postoperative appearance of predominantly muscular flaps to avoid misdiagnosis as tumor extension or recurrence.
... Subcutaneous fat has been shown to be a useful and stable reference tissue for signal intensity evaluations in MRI (Dooms et al, 1986). MRI studies in patients with different neuromuscular diseases show different patterns of changes in the size and signal intensity of muscles (Murphy et al, 1986;Lamminen et al, 1990;Hudgins et al, 1994). Many studies have been conducted on the MRI appearance of denervated skeletal muscles including both traumatic and postoperative neuropathies and denervated free microvascular muscle flaps (Murphy et al, 1986;Lamminen et al, 1990;Fleckenstein et al, 1993;Salmi et al, 1995;Chong et al, 2001;Fischbein et al, 2001;Bendszus et al, 2002). ...
... In a study describing MRI findings in two patients with perineural spread of tumours, T2 prolongation was seen in facial muscles, suggesting denervation changes (Fischbein et al, 2001). Denervated microvascular free flaps have been studied with MRI (Hudgins et al, 1994;Salmi et al, 1995;Wester et al, 1995;Chong et al, 2001). Nerve supply to the microvascular flap is surgically interrupted, leading to muscle atrophy, which results in a predominantly fatty appearance of the flap on MR images (Wester et al, 1995;Salmi et al, 1995). ...
Article
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Microneurovascular free muscle transfer with cross-over nerve grafts in facial reanimation Loss of facial symmetry and mimetic function as seen in facial paralysis has an enormous impact on the psychosocial conditions of the patients. Patients with severe long-term facial paralysis are often reanimated with a two-stage procedure combining cross-facial nerve grafting, and 6 to 8 months later with microneurovascular (MNV) muscle transfer. In this thesis, we recorded the long-term results of MNV surgery in facial paralysis and observed the possible contributing factors to final functional and aesthetic outcome after this procedure. Twenty-seven out of forty patients operated on were interviewed, and the functional outcome was graded. Magnetic resonance imaging (MRI) of MNV muscle flaps was done, and nerve graft samples (n=37) were obtained in second stage of the operation and muscle biopsies (n=18) were taken during secondary operations.. The structure of MNV muscles and nerve grafts was evaluated using histological and immunohistochemical methods ( Ki-67, anti-myosin fast, S-100, NF-200, CD-31, p75NGFR, VEGF, Flt-1, Flk-1). Statistical analysis was performed. In our studies, we found that almost two-thirds of the patients achieved good result in facial reanimation. The longer the follow-up time after muscle transfer the weaker was the muscle function. A majority of the patients (78%) defined their quality of life improved after surgery. In MRI study, the free MNV flaps were significantly smaller than originally. A correlation was found between good functional outcome and normal muscle structure in MRI. In muscle biopsies, the mean muscle fiber diameter was diminished to 40% compared to control values. Proliferative activity of satellite cells was seen in 60% of the samples and it tended to decline with an increase of follow-up time. All samples showed intramuscular innervation. Severe muscle atrophy correlated with prolonged intraoperative ischaemia. The good long-term functional outcome correlated with dominance of fast fibers in muscle grafts. In nerve grafts, the mean number of viable axons amounted to 38% of that in control samples. The grafted nerves characterized by fibrosis and regenerated axons were thinner than in control samples although they were well vascularized. A longer time between cross facial nerve grafting and biopsy sampling correlated with a higher number of viable axons. P75Nerve Growth Factor Receptor (p75NGFR) was expressed in every nerve graft sample. The expression of p75NGFR was lower in older than in younger patients. A high expression of p75NGFR was often seen with better function of the transplanted muscle. In grafted nerve Vascular Endothelial Growth Factor (VEGF) and its receptors were expressed in nervous tissue. In conclusion, most of the patients achieved good result in facial reanimation and were satisfied with the functional outcome. The mimic function was poorer in patients with longer follow-up time. MRI can be used to evaluate the structure of the microneurovascular muscle flaps. Regeneration of the muscle flaps was still going on many years after the transplantation and reinnervation was seen in all muscle samples. Grafted nerves were characterized by fibrosis and fewer, thinner axons compared to control nerves although they were well vascularized. P75NGFR and VEGF were expressed in human nerve grafts with higher intensity than in control nerves which is described for the first time. Kasvohermohalvauksen kirurginen hoito hermotetulla lihassiirteellä Pitkäaikainen kasvohermohalvaus on potilaalle henkisesti raskas ja kuormittava sairaus, sillä se vaikeuttaa merkittävästi sosiaalista kanssakäymistä ja aiheuttaa suuren kosmeettisen ja toiminnallisen haitan näille potilaille. Osa näistä potilaista hyötyy leikkaushoidosta, ja lisätiedon saanti leikkaustulokseen vaikuttavista tekijöistä on ensiarvoisen tärkeää, jotta oikeat potilaat voidaan valita ja leikkausmenetelmiä parantaa. Pitkäaikaisen kasvohermohalvauksen paras tunnettu hoitomuoto on hermotettu vapaa lihassiirre. Se mahdollistaa kasvojen lihasten toiminnan ja tunteiden ilmaisun.Tässä kaksivaiheisessa leikkauksessa tuodaan ensin vastakkaiselta puolelta kasvoja terveestä kasvohermosta hermosiirrettä käyttäen hermotus halvaantuneelle puolelle. Toisessa leikkauksessa noin puoli vuotta myöhemmin siirretään muualta kehosta vapaa lihassiirre. Tämän lihassiirteen oma hermo yhdistetään aiemmin halvaantuneelle puolelle tuotuun hermosiirteeseen ja verisuonet yhdistetään paikalla oleviin verisuoniin. Optimaalisessa tapauksessa tämä hermotettu lihassiirre alkaa toimia korvaten halvaantuneet kasvojen lihakset, ja potilas saa ilmeensä ja hymynsä takaisin. Tässä väitöskirjatyössä selvitettiin tämän leikkaushoidon pitkäaikaistuloksia ja potilastyytyväisyyttä sekä niitä tekijöitä, jotka vaikuttavat toiminnalliseen lopputulokseen. Potilaista noin 60% saavutti hyvän kasvojen lihassymmetrian ja toiminnallisen tuloksen, ja 78% koki elämänlaatunsa parantuneen selvästi. Pitkä seuranta-aika leikkauksen jälkeen heikensi toiminnallista tulosta. Magneettikuvauksen perusteella lihassiirre kutistui merkittävästi. Magneettikuvauksessa normaalilta näyttävä lihassiirre myös toimi hyvin. Lihas- ja hermossiirteen koepaloista selvitimme, että sekä lihassiirteen säikeet että hermosiirteen toimivien hermojen määrä oli merkittävästi vähentynyt myös silloin, kun lihassiirteen toiminta oli hyvä. Kaikista hermossiirteistä löysimme hermokasvutekijäreseptoria (p75NGFR) ja verisuonikasvutekijää (VEGF), mutta terveistä hermoista näitä ei löytynyt.Hermokasvutekijäreseptorin ilmeneminen oli yhteydessä hyvään toiminnalliseen tulokseen. Aiemmin näiden kasvutekijöiden ilmenemistä ei ole kuvattu ihmisen hermosiirteissä. Tässä väitöskirjatyössä etsimme selittäviä tekijöitä hyvälle tai heikolle lihastoiminnalle vapaassa, hermotetussa lihassiirteessä. Lisäksi tutkimustuloksemme valottavat yleisimminkin vapaan hermosiirteen sekä vapaan hermotetun lihassiirteen piirteitä ja kasvutekijöiden ilmenemistä niissä. Tulevaisuudessa kasvutekijähoidot saattavat auttaa hermoston sairauksista tai vammoista kärsiviä potilaita.
... 44 Although it is not common, tumor may also deposit along the dura in distant sites from the operative cranial base. 48,51 Complications Diagnosis of CSF leak in the postoperative patient can be challenging due to the confounding factors of perioperative nasal irrigations, general inflammation, and the presence of nasal packing. A postoperative CSF leak can be confirmed with a beta-2 transferrin test. ...
Article
Endoscopic endonasal approaches have widely accepted techniques for managing benign and malignant processes along the entire ventral skull base with similar or better results compared with open procedures, but with lower rates of complication. Managing pathology affecting the skull base can be challenging because of complex anatomy and the proximity of critical neurovascular structures. Postoperative imaging can be challenging, because of surgical alterations of normal anatomy and the now common use of complex reconstruction techniques. Understanding the normal imaging appearance of skull base reconstruction is important for accurate postoperative interpretation and delineation between normal reconstructive tissue and recurrent neoplasm.
... They also reported that sensitivity and specificity were 88% and 100% with PET, but 25% and 75% with CT and MR, respectively. Hudgins et al. (26) reported that in head and neck cancer, MR could not easily distinguish between postradiation fibrosis and recurrence. McGuirt et al. (18) also reported that PET was superior to CT in terms of sensitivity and specificity, and that if PET revealed no areas of high metabolism, pathologic examination could be delayed. ...
Article
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To determine the accuracy of CT and positron emission tomography (PET) in the diagnosis of recurrent uterine cervical cancer. Imaging findings of CT and PET in 36 patients (mean age, 53 years) in whom recurrent uterine cervical cancer was suspected were analyzed retrospectively. Between October 1997 and May 1998, they had undergone surgery and/or radiation therapy. Tumor recurrence was confirmed by pathologic examination or follow-up studies. In detecting recurrent uterine cervical cancer, the sensitivity, specificity, and accuracy of CT were 77.8%, 83.3%, and 80.5%, respectively, while for PET, the corresponding figures were 100%, 94.4%, and 97.2%. The Chi-square test revealed no significant difference in specificity (p =.2888), but significant differences in sensitivity (p =.0339) and accuracy (p =.0244). PET proved to be a reliable screening method for detecting recurrent uterine cervical cancer, but to determine the anatomical localization of recurrent tumors, and thus decide an adequate treatment plan, CT was eventually needed.
... 9 Recurrent tumor in the resection bed with a flap reconstruction typically occurs at the margins of the flap where they interface with the surgical bed. 6,8,17,18 In patients with a neopharynx, a new focal luminal soft tissue thickening and narrowing at the surgical margin between the flap and the native mucosa, focal thickening of the wall of the neopharynx, or the formation of a fistula may indicate tumor recurrence (Fig. 7). 8,17 A recurrence typically enhances and is best delineated on postcontrast T1weighted images using fat saturation. ...
Article
This article addresses the clinical evaluation and some of the more common flaps and grafts used to reconstruct the surgical bed after excision of primary head and neck cancers and nodal metastases. This focused summary is intended to enhance the reader's understanding and improve the interpretation of posttreatment MR imaging. A practical approach to MR imaging evaluation of the postoperative reconstructed neck is presented. Readers of this article will become familiar with the normal appearances of commonly used flaps, recognize common complications, be able to delineate residual and recurrent neoplasm, and learn to avoid interpretative pitfalls.
... While the imaging features of microsurgical free flaps [4][5][6] have been described and imaging features suggesting recurrent tumor have also been delineated, 7,8 we have observed an unusual finding on neck CT scans of new bone developing in patients with prior fibular free flap placement. This new bone has been described in the surgical literature, predominantly in case reports, and has been ascribed to heterotopic ossification arising from fibula periosteum, which is preserved as part of the vascular pedicle during microvascular reconstruction. ...
Article
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Background and purpose: The fibular free flap, often used for osseous reconstruction following extirpation of head and neck malignancies, has been associated with heterotopic periosteal ossification. We aimed to determine the frequency and radiologic characteristics of this process and describe its clinical correlates. Materials and methods: Surgical records for 2 years and neck imaging reports for 10 years were evaluated to identify patients with fibular free flap reconstruction and CT and/or PET/CT imaging available for review. The images were evaluated for the quality, type, and contour of ossification, and the reports were reviewed for associated clinical findings and radiologic impressions. Results: Of 32 patients with posttreatment CT or PET/CT imaging, ossification was evident in 16 patients (50%) as early as 1 month following fibular free flap reconstruction. In 8 patients, it mimicked a new bone; in 5, it appeared as linear attenuation; in 2, as multiple short segments; and in 1 patient, a mixed appearance was found. No associated FDG uptake was seen on PET/CT. On MR imaging, these findings were extremely subtle or not appreciable. In only 1 patient was new bone associated with symptoms. Conclusions: Periosteal ossification of the vascular pedicle is commonly evident on CT following fibular free flap, even as early as 1 month after reconstruction, though the finding is not typically noted on imaging. While symptoms related to new bone are uncommon, they may mimic recurrent tumor. The location and pattern of ossification and the absence of a soft-tissue mass or FDG uptake are useful distinguishing imaging features.
... Neoplastic recurrence in skull base surgery is seen as new and/or growing tissue at the interface of the flap recipient bed and reconstructive tissue (Figs 13 and 14). 8,22,23 Tumor recurrence typically has local mass effect and is infiltrative or nodular tissues that lack striated muscle architecture or fat composition of the normal myocutaneous regional or free flaps (Figs 7 and 10). Tumor recurrence may also demonstrate signal intensity and/or enhancement different from the abutting reconstructive layers and similar to the tumor on the pretreatment scan (Figs 13 and 14). ...
Article
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Pathology affecting the skull base is challenging as a result of complex anatomy and critical neurovascular structures. A spectrum of open and endonasal endoscopic surgical approaches have evolved to maximize surgical outcomes. Postoperative CT and MR imaging can be challenging because of surgical alteration of normal anatomy, and complex reconstructions of the surgically-created defects using an arsenal of tissues and grafts. This article reviews common skull base reconstructions based on anatomic locations and surgical techniques and provides a practical approach to their postoperative imaging interpretation. Understanding the normal imaging appearance of skull base reconstruction is paramount for accurate postoperative interpretation and delineation between normal reconstructive tissue and neoplasm. The learning objectives of this paper were to understand the expected postoperative imaging appearance of the common skull base reconstructions and to distinguish between normal reconstructive tissues and neoplasm.Learning Objective: To understand the expected post-operative imaging appearance of the common skull base reconstructions and to distinguish between normal reconstructive tissues and neoplasm.
... Hence, imaging studies are often required. It is therefore important to recognise the normal appearances of flaps and not to confuse them with tumour recurrence [3] . Flap reconstruction is best evaluated with MRI. ...
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Cancer is a leading cause of death in most parts of the world. Most patients will undergo multiple imaging studies following treatment. The regular follow up of these patients often leads to the early detection of tumour recurrence or the onset of treatment complications. Early diagnosis may result in the timely institution of appropriate therapy thereby improving the survival and morbidity rates. This review addresses difficulties related to demonstrating early tumour recurrence and nodal metastasis and focuses on the complications seen in the central nervous system, cranial nerves and brachial plexus following radiotherapy.
... The MR signal intensity and en- hancement pattern have been described and are predictable, with moderate-to-intense enhancement. 13,[24][25][26] In the early posttreatment period, the flap may be edematous, hypointense on T1-weighted images (Fig 13), hyperintense on T2-weighted images, and enhance with gadolinium contrast. Later, the mus- cular portion of the flap decreases in bulk and becomes heter- ogeneous on T1-and T2-weighted MR images and relatively more hypoattenuating on CT as the denervated muscle be- comes fatty. ...
Article
Head and neck surgical reconstruction is complex, and postoperative imaging interpretation is challenging. Surgeons now use microvascular free tissue transfer, also known as free flaps, more frequently in head and neck reconstruction than ever before. Thus, an understanding of free flaps, their expected appearance on cross-sectional imaging, and their associated complications (including tumor recurrence) is crucial for the interpreting radiologist. Despite the complexity and increasing frequency of free flap reconstruction, there is no comprehensive head and neck resource intended for the radiologist. We hope that this image-rich review will fill that void and serve as a go to reference for radiologists interpreting imaging of surgical free flaps in head and neck reconstruction.
... Las localizaciones más frecuentes de recurrencia tumoral, y por tanto donde mayor atención debemos prestar, son: el lecho tumoral tras la radiación, los márgenes de resección quirúrgicos o del colgajo ( fig. 8) y la vecindad del traqueostoma, en pacientes sometidos a cirugía 21,24,27,61,62 . ...
Article
The management of patients with head and neck cancer implies a multidisciplinary treatment with surgery, radiotherapy and chemotherapy. Imaging is crucial in their follow-up, especially when the tumor recurrence is not clinically evident. Radiologically distinguishing post-treatment changes from a tumor recurrence is a challenge due to the anatomical alteration due to surgical techniques and their reconstructions, radiotherapy treatment and chemotherapeutic guidelines. The differential diagnosis must include the possible complications derived from radiotherapy (mucosal necrosis, osteoradionecrosis, vasculopathy, cerebral radionecrosis) and surgery (wound infections, flap necrosis, fistulas,...). A wide knowledge of the expected findings of multimodal treatment and its complications is essential for an accurate diagnosis of tumor recurrence. Finally, choosing the appropriate image study and having a baseline post-treatment study is also relevant for a suitable radiological control. Copyright © 2019 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.
... 59,60 The most common locations of tumour recurrence, and, therefore, the site of most interest, are: the tumour bed after radiation, the surgical or flap resection margins (Fig. 8) and adjacent to the tracheotomy in patients undergoing surgery. 21,24,27,61,62 The CT scan usually shows a hyperdense lesion, with soft tissue density, expansive, pseudonodular morphology and infiltrating appearance, measuring over 1 cm, with or without new appearance or increased extent of bone destruction. 4,11,27 If the suspicious mass shows a lower density than muscle, it will rarely be malignant and will often correspond to oedema. ...
Article
The management of patients with head and neck cancer implies a multidisciplinary treatment with surgery, radiotherapy and chemotherapy. Imaging is crucial in their follow-up, especially when the tumor recurrence is not clinically evident. Radiologically distinguishing post-treatment changes from a tumor recurrence is a challenge due to the anatomical alteration due to surgical techniques and their reconstructions, radiotherapy treatment and chemotherapeutic guidelines. The differential diagnosis must include the possible complications derived from radiotherapy (mucosal necrosis, osteoradionecrosis, vasculopathy, cerebral radionecrosis) and surgery (wound infections, flap necrosis, fistulas, …). A wide knowledge of the expected findings of multimodal treatment and its complications is essential for an accurate diagnosis of tumor recurrence. Finally, choosing the appropriate image study and having a baseline post-treatment study is also relevant for a suitable radiological control.
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Head and neck reconstructive surgery after cancer ablative surgery is now commonly performed with closure of the surgical defects by microvascular free tissue transfer. The most common flaps used for reconstruction are the radial forearm flap, the anterolateral thigh flap and fibula flap. Radiographic appearance of these flaps depends on the individual components of the flap, and may consist of skin, fat, muscle and/or bone. There are various adverse outcomes in these patients, the most significant being tumour recurrence that typically occurs at the flap margins. Other flap complications include flap necrosis from vascular thrombosis or infection. The goal of this article is to enhance radiologists’ familiarity with different methods of flap reconstruction, flap margins and vascular anastomoses that will lead to a better appreciation of expected postoperative radiographic appearance. Key Points • Flaps are the most common reconstructive techniques used in neck cancer surgery. • Imaging appearance of flaps depends on their components and time since surgery. • Most tumour recurrence after reconstruction occurs at the margins of the flap.
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It may well be that imaging of the post-treatment head and neck is among the most difficult tasks faced by the radiologist. Pitfalls are everywhere, and opportunities for error endless. In this manuscript, an attempt is made to categorize many of the various types of pitfalls that exist in imaging the operated head and neck patient. The radiologist can avoid error by remembering certain common postoperative appearances and not misinterpreting them as abnormal, by having available baseline postoperative studies, and by gaining experience in this very challenging aspect of head and neck radiology.
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The purpose of this study was to evaluate the magnetic resonance imaging (MRI) characteristics of recurrent tumours in patients who had undergone resection of primary head and neck tumours with flap reconstruction. MR examinations obtained from 25 patients who had undergone resection and flap reconstructive surgery for malignancy were analysed retrospectively. Tumour recurrence was confirmed by biopsy in 22 patients, and clinically in 3 patients. The features of the recurrent tumours in the scars were reviewed. Twenty-one patients had a locally recurrent mass, while 4 had a locally recurrent mass in addition to regional lymph node metastases. Twenty-four of the recurrent tumours were localized in the recipient flap beds, near the anastomotic site. In 9 of 25 (36%) patients, the recurrent tumours extended intracranially, either directly, or through the foramina at the skull base. Tumour recurrence after flap reconstruction most often occurred at or near the anastomotic site. MRI is useful for detection of recurrence after flap reconstructive surgery in patients with head and neck cancer.
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Introduction: Reconstruction of large head and neck operative beds requires moving tissue from one region to another. These flaps may be rotated to cover a defect with the vascular supply intact, or the vascular supply can be transected and re-anastamosed to vessels in the operative bed. This article will review the types of flaps that have been developed to reconstruct treatment sites in the head and neck, describe the expected findings of a flap, and illustrate the appearance of flap complications, especially recurrent tumor. Methods and materials: Thirty-five patients with flap reconstruction were imaged either as a baseline study, or because of clinical suspicion for recurrent tumor. All patients had undergone resection of squamous cell carcinoma of the head and neck, with flap reconstruction. The computed tomographic (CT) and magnetic resonance (MR) images were retrospectively reviewed, with the clinical history and biopsy results, to determine the imaging findings of recurrent disease. Results: Recurrent tumor in the resection bed or flap appeared as a focal mass, usually at the interface of the operative site and the flap. Induration of the fat around the flap, or the fat within the flap, was an indirect finding associated with recurrence. Nodal recurrence, either ipsi or contralateral to the primary, was common. Conclusion: It is important to be aware of the type of flap used to reconstruct head and neck surgical defects. The expected appearance of the flap, and findings associated with recurrent disease are predictable, and are illustrated in the article.
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The aim of this study was to assess the value of fused MR and Tl-201 single photon emission computed tomography (SPECT) images in the diagnosis of recurrent head and neck tumors in patients after flap reconstruction surgery. Twenty-four patients after resection of primary head and neck tumors with flap reconstruction were suspected of having recurrent tumor by follow-up MR examination. Both MR examination and Tl-201 SPECT were prospectively performed to produce fused images. For qualitative analysis, two independent readers separately evaluated the existence of tumor recurrence in the fused images. The Tl-201 uptake of the lesion (Tl index) was also quantitatively compared with that of the normal nuchal muscles. Eighteen patients were histologically proved as having recurrence. The remaining 6 patients, false positive on MRI alone, had non-recurrence. Using the fused images, false positive was found in 1 case for one reader and 2 cases for the other reader. The Tl index of recurrent tumors was significantly higher (p < 0.001) than that of non-recurrent mass lesions. In the assessment of recurrent tumors following flap reconstruction surgery in the head and neck, the use of fused MRI and Tl-201 SPECT images can reduce the number of false positives.
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We present the non-contrast-enhanced CT finding of high attenuation within metastatic regional lymph nodes in two patients with stage I or II tongue carcinoma during a follow-up period. The attenuation values of these lesions were approximately 70 HU or more. One patient had a level I node, and the other had a level II node. Contrast-enhanced CT failed to reveal these hyperattenuated areas within the nodes. Histopathologic examination revealed that these hyperattenuated areas were strongly correlated with the area of marked keratinization of metastatic foci. If contrast-enhanced CT had been the only imaging technique used, these lesions might have been overlooked. The clinician should be aware of the characteristic findings of non-contrast-enhanced, as well as contrast-enhanced, CT when investigating lymph node metastases at an early stage in patients with stage I or II tongue carcinoma during the follow-up period.
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Thallium-201 single-photon emission computed tomography (SPECT) can be used to detect primary squamous cell carcinoma (SCCA) of the head and neck. Nevertheless, there have very few studies performed to evaluate the ability of thallium-201 to depict recurrent SCCA. The purpose of this study was to compare the ability of thallium-201 SPECT with CT to enable detection of recurrent SCCA of the upper aerodigestive tract. Thirty-three patients with a history of previously treated SCCA of the extracranial head and neck underwent thallium-201 SPECT imaging and contrast-enhanced CT. A neuroradiologist and nuclear medicine physician with knowledge of the primary site evaluated all thallium-201 studies for abnormal radiotracer uptake at the primary site. These results were correlated with histologic findings and clinical follow-up in all patients. All patients were followed up for a minimum of 2 years after completion of treatment. The McNemar test was used to determine statistical significance. The diagnostic accuracy of thallium-201 SPECT was as follows: sensitivity, 88%; specificity, 94%; positive predictive value, 93%; and negative predictive value, 89%. The diagnostic accuracy of CT was as follows: sensitivity, 100%; specificity, 24%; positive predictive value, 55%; and negative predictive value, 100%. The diagnostic accuracy of thallium was superior to CT (P = .01). Thallium-201 SPECT is superior to CT for differentiating recurrent tumor from post-treatment changes and may complement CT in the evaluation of previously treated SCCA of the extracranial head and neck.
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The purpose of the present study is to evaluate the background fat intensity suppression instability of each area in the head and neck region, and in the post-reconstruction with metal plate and myocutaneous flap, of patients with oral cancer using fat-saturated (FS) images. STIR and FS T2-weighted images at pre- and post-surgery in 59 patients with oral cancer were scored for uniformity of fat suppression and tissue conspicuity in each region of the head and neck. The scores of FS on uniformity of fat suppression pre-operatively were worse than those of STIR in the mandibular level, but not lesion and tissue conspicuity. However, the deterioration both of scores between pre- and post-surgery using FS was worse than that using STIR using metal plate and/or myocutaneous flap. At diagnosis, we should recognize on MR images using FS that instability of the status of fat suppression might be brought about by respective area and reconstruction with metal plate and myocutaneous flap of patients with oral cancer.
Article
Evaluation of head and neck cancer with imaging is a topic that is far more extensive than can be covered in this article. The main reason for head and neck imaging is to evaluate the true extent of disease to best determine surgical and therapeutic options. This process includes evaluation of the size, location, and extent of tumor infiltration into surrounding vascular and visceral structures. Important anatomic variants must be pointed out so the surgeon can avoid potential intraoperative complications. These variant scan be evaluated with the appropriate multiplanar and three-dimensional images to provide as much information as possible to the surgeon preoperatively. Second, nodal staging should be assessed in an effort to increase the number of abnormal nodes detected by physical examination and, more important, to precisely define their location by a standard classification system that can be understood and consistently applied by the radiologist, surgeon, radiation oncologist, and pathologist. Although secondary to the previously described tasks, imaging frequently enables a limitation of the diagnostic and histologic possibilities based on lesion location and signal-attenuation characteristics, which may lead the clinical investigation along a different path. saving the patient unnecessary risk and shortening the time to diagnosis and ultimate treatment. This article has attempted to detail the current state of the controversy between CT, MRI, and other modalities, and has emphasized the constant evolution of this controversy because of the evolving imaging technology. Although CT and MRI are both well suited to evaluation of the deep spaces and submucosal spaces of the head and neck, each has some limitations.MRI has the advantages of higher soft tissue contrast resolution, the lack of iodine-based contrast agents, and high sensitivity for perineural and intracranial disease. The disadvantages of MRI include lower patient tolerance, contraindications in pacemakers and certain other implanted metallic devices, and artifacts related to multiple causes, not the least of which is motion. CT is fast, well tolerated, and readily available but has lower contrast resolution and requires iodinated contrast and ionizing radiation. The current authors' practice is heavily centered on CT for initial evaluation, preoperative planning, biopsy targeting, and postoperative follow-up. They reserve MRI for tumors that are suspicious for perineural,cartilaginous, or bony invasion on CT, or for tumors such as adenoid cystic carcinoma that are highly likely to spread by way of these routes. For patients who have head and neck cancer, a radiologist who is educated in the treatment options, patterns of tumor growth, and important surgical landmarks, and who has a well-established pattern of communication with the head and neck clinical services, including surgery, radiation oncology,and pathology, is key in providing accurate and useful image interpretation.
Article
We performed a prospective study to assess the value of positron emission tomography (PET) with 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) in the prediction of local control in irradiated head and neck squamous cell carcinomas (HNSCCs). Forty-two patients with irradiated HNSCCs underwent 49 FDG-PET scans between 3 and 6 months after the end of radiotherapy. The mean follow-up time after the first FDG-PET scan was 17 months. The result of the FDG-PET scan was true-positive in 6 patients, false-positive in 7 patients, and true-negative in 29 patients. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG-PET scanning were 100%, 81%, 46%, and 100%, respectively. We conclude that FDG-PET scanning is useful for prediction of therapy outcome in irradiated HNSCCs. No biopsy is needed for at least 1 year if an FDG-PET scan is negative. If the scan is positive and the biopsy is negative, decreased FDG uptake measured in a follow-up scan indicates that a local recurrence is unlikely.
Article
The purpose of this study was to describe the survival and volume of microneurovascular muscle flaps at different times after two-stage facial reanimation procedure by using magnetic resonance imaging (MRI) and to compare the functional outcome with MRI findings. Fifteen patients with a mean age of 36 years (range 7-63 years) operated on between 1988 and 1999 were available for this study. The muscles used for functional reconstruction were the latissimus dorsi (eight patients), gracilis (six patients) and serratus anterior (one patient). Hospital charts were reviewed and the clinical outcome of facial reanimation was graded on a scale from 1 to 6 according to House. The mean postoperative follow-up time was 7 years (range 3-14 years). Clinical grading and 1.5 T unit MRI of patients were performed concomitantly. The MR images were evaluated semi-quantitatively so that the muscle structure of the free flaps was graded on a scale from 1 to 4. The free flap area of each slice was defined and the volume of the free flap was calculated. Data were analysed statistically. The long-term functional outcome of the facial reanimation was regarded as good in 10 patients, which means they had only mild or moderate dysfunction of facial movements. In MR images, six free flaps displayed normal muscle structure, another six had a fatty appearance and two displayed severe muscle atrophy; in one patient the muscle tissue could not be identified. The volume of the free flap clearly declined in the course of the follow-up. A correlation was found between good functional outcome and normal muscle structure of the free flap in MRI, p = 0.020. The longer the follow-up time after muscle transplantation the poorer the functional result. A similar correlation was found between abnormal muscle structure in MRI and a long follow-up time. Magnetic resonance imaging can be used to assess the muscle structure of free microneurovascular flaps. Normal findings in MRI seem to correlate with a good clinical outcome in facial reanimation. A good functional result correlates with a shorter follow-up time and normal muscle structure in MRI.
Article
Head and neck radiologists should be familiar with typical post-therapeutic changes on enhanced CT after neck dissection because CT is widely used for the follow-up study in order to detect recurrent tumours at an early stage. The purpose of this study was to reveal post-therapeutic anatomical alterations and non-neoplastic processes demonstrated on enhanced CT. Radical neck dissections were performed in 39 necks and modified radical neck dissections were performed in 8 necks. Post-operative radiotherapy was performed on 21 patients. Follow-up CT, studies were made within a period of 24 months. On enhanced CT, the densities of soft tissues replacing the resected structures were homogeneous in 44 necks and showed no contrast enhancement in 39 necks. During the 24 months after treatment, most of the soft tissues did not increase in size and the attenuation of the soft tissue remained unchanged. In 44 of 47 necks, lymphoedema (LE) was observed around the carotid artery at an early stage, and it converged into the space between internal carotid artery and external carotid artery gradually. In patients without post-operative radiotherapy, LE was observed around the carotid artery in 17 of 23 necks at 3 months after neck dissection and disappeared rapidly thereafter. In patients with post-operative radiotherapy, LE increased until 3 months after radiotherapy and decreased slowly thereafter. This is the first report of enhanced CT evaluation of LE around the carotid artery after neck dissection probably exacerbated by irradiation. Clinicians should be aware of LE around the carotid artery in patients with post-operative radiotherapy because of the possible risk of neck cellulitis at least 1 year after treatment.
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To investigate the capacity of helical CT in the pre- and post-operative management of oromandibular reconstruction of patients with oropharyngeal carcinoma using microvascular composite free flaps. Thirty-four patients with oropharyngeal cancer were examined by helical CT and nine (six men and three women) submitted to oromandibular reconstruction. The osteomyocutaneous flaps used for reconstruction were taken from the iliac crest in six cases and from the fibula in three cases. All patients were examined by CT 1 - 4 days postoperatively and then at 6 monthly intervals. Double helical scans were performed in all cases, with slices of 2 - 3 mm for primary lesion studies and 5 mm for lymph node staging, pitch >/=1 and RI=1. Multiplanar (MPR) and 3D reconstructions were obtained from pre- and postoperative CT examinations. Preoperative CT showed massive bone infiltration in six of the nine surgical patients and marginal infiltration in three. These findings were confirmed histologically. There were no false negatives. The immediate postoperative examination showed correct flap positioning in eight of nine cases. The flap underwent ischemic necrosis in two cases; CT showed very early signs of bone ischemia in both. CT detected two cases of recurrence after about 1 year. Axial CT permitted adequate assessment of the extent of mandibular infiltration and detected early ischemic complications and distant recurrences. Integration with MPR and 3D reconstructions simplified the choice of flap type and size and enabled the postoperative assessment of correct flap positioning. This helped the surgeon plan subsequent rehabilitation with osseo-integrated implants.
Article
To evaluate the clinical usefulness of FDG-PET (fluoro-2-deoxy-glucose-positron emission tomography) in the detection of lymph node involvement and recurrences in patients with head and neck cancer. Retrospective review of 38 patients with biopsy-proven head and neck cancers who underwent clinical, computed tomography (CT), and FDG-PET examinations. Twenty-five patients were studied prior to therapy and 13 patients were evaluated for disease recurrence. All patients were operated and clinical data, CT, and FDG-PET results were correlated with histopathological findings. All primary tumors in 25 patients were detected, with the exception of one small superficial localization of the epiglottis. Histopathological examination showed lymph node involvement in 10 patients; PET detected lymph node involvement in five. FDG-PET found one case of nodal disease not identified by clinical and CT examination. With so few cases, this could be anecdotal. Five false-negative results (microscopic lymph node involvement) and two false positives were noted. Twelve of 13 patients with recurrent disease were correctly identified with FDG-PET. FDG-PET was the only imaging technique to identify local recurrence in two patients and lymph node involvement in two others. One false-positive result occurred in a patient with a foreign body granuloma. FDG-PET is a useful diagnostic modality for the detection of recurrent tumors and, in selected cases, precise lymph node involvement. The best way to further investigate the utility of clinical FDG-PET is in the follow-up of treated patients.
Article
Malignant tumors of oral and sinonasal cavities are the most frequent facial malignancies in adults. Assessment of these tumors requires a multidisciplinary approach and imaging plays a major role to define the precise tumor location, volume and extension and to plan post-treatment follow-up. A combination of computed tomography (CT) and magnetic resonance imaging (MRI) is now established as the optimum modalities for the aim. The overall diagnostic performance of post-treatment FDG PET (CT) for response assessment and surveillance imaging of the disease is excellent. Its negative predictive value remains exceptionally high and a negative post-treatment scan is highly suggestive of absence of viable disease.
Article
Purpose: Tumors that recur following orbital exenteration may not be evident on clinical examination, highlighting the need for imaging surveillance. The goal of this study was to report the imaging characteristics of recurrent tumors following orbital exenteration and free flap reconstruction. Methods: The authors retrospectively reviewed the records of 48 patients who underwent orbital exenteration for the treatment of orbital malignancy and identified 17 recurrent tumors in 17 patients. The lesions were assessed for the presence of a soft tissue mass, imaging characteristics, and fluorodeoxyglucose avidity. Results: The recurrent tumors were detected 1 month to 6 years 10 months (median, 1 year 3 month) after orbital exenteration. On both CT and MRI, all 17 lesions were soft tissue masses at presentation. On CT, the lesions demonstrated heterogeneous to homogeneous to centrally necrotic enhancement; on MRI, the lesions were T1 hypointense to isointense and T2 hypointense to hyperintense. Twelve of the 15 recurrent tumors with available preoperative imaging had an enhancing appearance similar to that of the original tumor. Thirteen of the 17 recurrent tumors were at the margin of a flap placed for reconstruction; the other 4 lesions were remote from the operative site. Conclusion: Recurrent tumors following orbital exenteration and free flap reconstruction demonstrate a wide range of imaging appearances but most often appear as a soft tissue masses often similar in appearance to the primary tumor and arising near the flap margin. Awareness of the imaging features of recurrent disease is important because failure to diagnose recurrence can delay appropriate treatment.
Article
We present a review of the imaging surveillance following treatment for large nerve perineural spread in the skull base. The expected appearance and possible complications following surgery and radiotherapy are discussed. Imaging examples of the possible sites of disease recurrence are also presented.
Article
Modern laryngeal imaging with CT scans or MR images provides critical information about primary tumor extent and the status of the neck nodes. This information is complementary to the physical examination and is essential for treatment planning purposes in all but the smallest laryngeal malignancies. This article focuses on the modalities available for laryngeal cancer imaging, the strengths and weaknesses of those modalities, the imaging anatomy of the larynx, and key imaging features of laryngeal cancer. Also briefly discussed are neck nodes, the post-treatment appearance of the neck, and the problem of tumor recurrence.
Chapter
Occipital neuralgia that does not respond to conservative management is sometimes responsive to occipital nerve stimulation. Bilateral electrodes are implanted in the posterior scalp subcutaneous tissues in contact with the occipital nerves.
Chapter
Flap reconstruction is routinely performed for closing defects created by head and neck tumor resection. Many donor sites and types of flaps are available (Figs. 9.1, 9.2, 9.3, 9.4, 9.5, 9.6, 9.7, 9.8, and 9.9 and Table 9.1). The imaging features of the flaps depend on their composition and nature of the defect. The denervated muscle components of myocutaneous flaps may demonstrate contrast enhancement and high T2 signal on MRI. Tumor recurrence is perhaps the most significant complication associated with flap reconstruction and most commonly occurs at the site of anastomosis. Recurrence can be difficult to discern due to the altered anatomy of the surgical bed. PET/CT can be helpful in such instances. Other complications of reconstructive flaps include necrosis, fistula formation, hematoma, infection, and instability for bone flaps. These are often clinically apparent. In addition, patients may develop hypertrichosis on the skin surface of myocutaneous flaps, which is particularly problematic in neopharynx reconstruction. The risk of this complication is generally lower with radial forearm free flaps than with pectoral flaps, for instance.
Chapter
Imaging plays an important role in lymph node survey in patients with laryngeal cancer. Imaging can modify the initial clinical staging and therapeutic strategy by detecting clinically inaccessible lymph nodes, or by showing invasion of critical structures such as the common and internal carotid arteries. At the post-therapeutic stage, imaging can detect lymph node relapse which may be difficult to palpate.
Article
Interpretation of head and neck imaging after treatment for malignancy poses a challenge even for the experienced neuroradiologist. While computed tomography is often the preferred modality for assessment of the head and neck due to its faster acquisition, magnetic resonance imaging (MRI) is superior in the evaluation of nasopharyngeal, sinonasal and skull base tumors. In this article, we review pretherapy imaging protocols, common surgical approaches and reconstructions, postsurgical and postradiation MRI appearance and complications, MRI criteria for tumor recurrence and clinical applications of advanced MRI techniques as applicable to head and neck tumors.
Article
Aim: To evaluate the utility of diffusion-weighted imaging (DWI) in differentiating post-treatment changes from tumour recurrence in head and neck cancers and to establish a threshold apparent diffusion coefficient (ADC) value to differentiate the two conditions. Materials and methods: This was a prospective study of 80 treated head and neck cancer patients. The patient cohort consisted of a wide spectrum of head and neck sites, including the oral cavity, oropharynx, larynx, hypopharynx, paranasal sinuses, orbits, salivary glands, and infra-temporal fossa. Qualitative analysis of the diffusion images and quantitative analysis of the corresponding ADC maps was performed and the data were correlated with histopathological findings and clinical examinations. Results: The mean ADC value of recurrent tumours in the present cohort was 0. 932±0.19×10(-3) mm(2)/s and the mean ADC value of lesions representing post-treatment changes was 1.394±0.32×10(-3) mm(2)/s. A threshold ADC value of 1.2×10(-3)mm(2)/s used to differentiate post-treatment changes from recurrent head and neck cancers showed the highest combined sensitivity of 90.13%, specificity of 82.5%, accuracy of 86.4%, positive predictive value of 84.4%, negative predictive value of 88.9%, and mean kappa measurement of agreement of 72.8. Conclusion: Combined qualitative and quantitative analysis of DWI is a useful non-invasive technique to differentiate recurrent head and neck malignancies from post-treatment changes using a threshold ADC value.
Article
To facilitate detection of tumor recurrence, the authors reviewed the MRI characteristics of myocutaneous and fasciocutaneous free flaps following orbital exenteration for treatment of orbital or maxillofacial tumors. The authors retrospectively reviewed the MRI characteristics, including T1 and T2 signal intensity, and enhancement pattern of 28 such flaps. The study included 17 myocutaneous flaps and 11 fasciocutaneous flaps placed in 28 patients. For 23 flaps, additional imaging was performed after baseline imaging (range, 2-65 months after surgery). On precontrast T1 imaging, 15 of 17 myocutaneous flaps demonstrated a striated appearance similar to that of native muscle. Twenty-six of the 28 flaps in the series were T2 hyperintense. On baseline imaging, 26 flaps showed linear (n = 5), patchy (n = 10), or homogeneous (n = 11) enhancement. No flaps demonstrated mass-like enhancement. Five fasciocutaneous and 5 myocutaneous flaps showed decreased enhancement on follow-up imaging, while 4 myocutaneous flaps showed increased enhancement. Fourteen patients received postoperative radiation, 4 of which demonstrated increased enhancement, which subsequently decreased in 3 flaps. Fourteen of 23 followed flaps became smaller over time. On MRI, both myocutaneous and fasciocutaneous flaps placed after orbital exenteration generally demonstrate persistent non-mass-like enhancement and T2 hyperintensity, and both types of flaps may become smaller over time. Head and neck radiologists, ophthalmologic and plastic surgeons, and oncologists should be aware of the range of imaging features of these flaps to avoid misinterpreting the postoperative appearance as tumor recurrence.
Article
Imaging is an indispensable tool in patients with clinical suspicion of infrahyoid neck disease. CT and MR imaging can establish a positive diagnosis by showing a true mass (versus a pseudomass). In addition, by defining the exact space of origin of the lesion and its characteristics (CT density, MR signal, homo- or heterogeneity, contour, contrast enhancement), imaging can predict the correct diagnosis. Because it offers multiplanar, multiparameter information, MR imaging, performed with a dedicated coil and appropriate artifact-reduction techniques, usually is the modality of choice.
Article
Head and neck cancers are rising in incidence. In the diagnosis of malignant head and neck cancer, conventional morphological imaging methods, i.e. ultrasonography, radiography, computerised tomography (CT) and magnetic resonance imaging (MR) play a routine role besides clinical investigation. Despite these diverse techniques, the primary tumour often cannot be found. Furthermore, for staging purposes as well as for the detection of tumour recurrence after chemotherapy and/or radiotherapy, morphological examination techniques such as CT and MR are of limited accuracy. Due to promising results in the literature, 18F-fluorodeoxyglucose-positron emission tomography has been playing an increasing role in the assessment of malignant head and neck cancer. The authors present a literature review as well as their own data in comparison to conventional imaging methods.
Article
Accurate early diagnosis and staging is an essential step in the management of recurrent head and neck cancer. Nevertheless, the diagnosis and staging of recurrent head and neck cancer previously treated by radiation therapy often combined with chemotherapy, remains a challenge. The differentiation between radiation induced reaction and recurrent cancer is a difficult clinical and radiological problem. It is clear that timely diagnosis in case of residual or recurrent tumor is of great importance to increase the possibility of cure. A variety of interventions such as office clinical examinations, blood tests, serum tumor marker measurements, imaging studies and endoscopies are being used to follow-up these patients. No single intervention proved to be absolute or complete in being simultaneously sensitive, specific, inexpensive, safe and efficient at detecting suspected recurrence of head and neck cancer, particularly after chemoradiation. In addition to that, there is no clear evidence of what surveillance regimen or frequency is considered the most adequate or effective in this setting. In this article, we analyze the diagnostic difficulties of tumor recurrence after combined treatment with chemotherapy plus radiation therapy and review the role of clinical, endoscopic and imaging techniques in the follow-up of these patients.
Article
The normal appearance of the posttherapy neck after common surgical procedures and chemoradiation therapy is presented, with specific details for each surgical procedure. Subsequently, the authors emphasize the recognition of complications and disease recurrence with illustrated examples.
Chapter
This chapter reviews the diagnostic imaging findings after surgery involving the neck, including reconstruction flaps, neck dissection, parotidectomy, salivary duct stenting and endoscopic stone removal, facial reanimation, oral cavity tumor resection and reconstruction, tonsillectomy and adenoidectomy, transoral robotic surgery, Sistrunk procedure, laryngectomy, voice prostheses, salivary tubes, laryngeal stent, laryngoplasty and vocal fold injection, arytenoid adduction, arytenoidectomy, laryngeal cartilage remodeling, tracheotomy, thyroidectomy, neck exploration and parathyroidectomy, brachytherapy, and vagal nerve stimulation.
Chapter
This chapter reviews the diagnostic imaging findings related to surgery and implants in the scalp and cranium, including occipital nerve stimulator, temporal fossa implants, Mohs micrographic surgery and skin grafting, rotational galeal flap scalp reconstruction, scalp tumor recurrence, burr holes, craniotomy, cranioplasty, autocranioplasty, craniectomy, the meningogaleal complex and suboccipital craniectomy, cranial vault surgical remodeling for craniosynostosis, cranial vault encephalocele repair, absorbable hemostatic agents, duraplasty and sealant agents, intracranial pressure monitors, subdural drainage catheters, and cranial surgery complications.
Chapter
This chapter deals with benign and malignant neoplasms of the oral cavity. It starts with an overview of the relevant anatomy of the floor of the mouth, the tongue, the lips and gingivobuccal regions, the hard palate,and the region of the retromolar trigone. Moreover, the preferred imaging modalities are briefly discussed. The section “Pathology” contains all relevant benign lesions like congenital lesions (such as vascular malformation, dermoid cyst, and lingual thyroid), inflammatory conditions (such as phlegmon, abscess, and ranula), and benign neoplasms (such as pleomorphic adenoma, lipoma, rhabdomyoma, hemangioma, schwannoma, and others). More thoroughly, malignant neoplasms (such as squamous cell cancer, adenoid cystic cancer, mucoepidermoid carcinoma) and their predominant anatomic sites are presented with state-of-the-art illustrations. The chapter ends with a section on recurrent cancer.
Article
The contribution of diagnostic imaging in evaluating the pre- and postoperative status of tongue cancer is essential. Interpretation of postoperative images is made difficult by deformation; therefore, it is necessary to know how surgical technique, biological reaction, postoperative anatomy, and local recurrence are reflected on the images. This study explains the postoperative imaging features of tongue cancer to help in the early detection of local recurrence and avoid inappropriate treatment. We review schematic drawings of representative surgical procedures for tongue carcinoma, variable radiological features in postoperative conditions with or without complications, and typical features of local failures and their mimics. This article clarifies the important tasks of radiologists and clinicians in the postoperative evaluation of tongue carcinoma.
Article
Objectives/Hypothesis To assess the accuracy and utility of positron emission tomography/computed tomography (PET/CT) compared with magnetic resonance imaging (MRI) for detecting head and neck cancer (HNC) recurrence after microvascular reconstructive surgery. Study Design Retrospective cohort study. Methods Analysis of HNC patients who underwent microvascular reconstruction at a single, tertiary academic center following ablative surgery from 1998 to 2015. Forty-six patients aged 61.4 ± 15.8 years with both PET/CT and MRI examinations were identified. Two radiologists were blinded and interpreted each imaging study. Recurrence certainty scores were determined via continuous (0–100) and Likert (“Likely” to “Unlikely”) scales, with larger values indicating a higher likelihood of recurrence. Pathologic confirmation of recurrence was confirmed in 23 patients (50%). Results Among those with primary site recurrences, mean recurrence certainty was significantly higher with PET/CT versus MRI on the continuous scale (63.9 vs. 44.4, P = .006). A receiver operating characteristic analysis for predicting primary site recurrence demonstrated a significantly larger area under the curve of 0.79 for PET/CT compared to 0.64 for MRI (P = .044). Categorization of “Likely” primary site recurrence on PET/CT, versus MRI, had higher sensitivity (0.63 vs. 0.40), but lower specificity (0.90 vs. 1.0). MRI demonstrated higher sensitivity (1.0 vs. 0.78) at detecting regional site recurrences. Conclusion PET/CT demonstrates greater sensitivity than MRI as a surveillance tool for primary site recurrence following microvascular reconstruction where clinical evaluation is hindered by anatomical distortion. Therefore, PET/CT should be pursued as first-line imaging, with MRI utilized for confirmation of positive imaging findings at the primary site. Level of Evidence 2 Laryngoscope, 2021
Article
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Sixty-one CT scans in 20 patients who had undergone head and neck reconstructive surgery using a pectoralis major myocutaneous (PM-MC) flap were retrospectively evaluated to assess the usefulness of Ct in the follow-up of these patients. The normal CT findings in patients with PM-MC flaps are described. Of 13 cases with tumor recurrence, CT examination correctly detected recurrent masses in all cases, including 3 in which there was no clinical sign of recurrence. Postoperative masses mimicking tumor recurrence included deformed breast tissue, hematomas, lymphoceles, and abscesses. Computed tomography was of great value in the detection of tumor recurrence, but careful interpretation is required because a postoperative complication or anatomic alteration may lead to the erroneous diagnosis of tumor recurrence.
Article
Twenty adult mongrel dogs underwent free jejunal transplants to the neck; 10 either died of or had to be sacrificed as a result of postoperative complications, 5 received a 55-Gy'equivalent dose of radiation after 3 weeks, and 5 were followed as controls. Serial manometric and endoscopic evaluations were performed over a 9-month period. Progressive deterioration of the quality and amplitude of peristalsis of the jejunal autografts was observed only in the radiated group. In addition, all dogs in the radiated group developed severe jejunal circumferential constriction and stricture formation. These delayed effects of irradiation on revascularized jejunal autografts should be considered in planning the method of pharyngoesophageal reconstruction as well as the timing of adjuvant radiotherapy.
Article
Radiologists are frequently asked to evaluate cervical lymph nodes with CT or MR imaging to determine if metastases are present, how extensive the metastases are, and if they have spread from lymph nodes to critical adjacent structures such as the carotid artery and skull base. Accurate information of this type is essential if the most appropriate treatment is to be selected. The purpose of this report is to review the diagnostic criteria that are currently used with CT and MR imaging to diagnose metastases in cervical nodes by evaluating nodal size, shape, grouping, and necrosis and extranodal tumor spread. In addition, emphasis is placed on details that should be included in the CT and MR report, such as the location of the nodes, the presence of nodal calcification, and the presence of associated diseases such as parotid cysts that may suggest a specific diagnosis like HIV infection. Because optimal treatment planning depends on the combined information gleaned from the clinical evaluation and the imaging studies, it is essential that there be a close dialogue between clinicians and radiologists.
Article
Patients with recurrent neoplasms of the head and neck present perplexing management problems, and accurate preoperative assessment of their disease is crucial. Thirty-eight patients with suspected recurrent neoplasms comprise this study: 30 had computed tomography scans, 4 had magnetic resonance images, and 4 patients underwent both computed tomography and magnetic resonance imaging to assess the anatomical extent of pathology in 34 malignant and 4 benign tumors. Contrast enhancement was essential for detecting disease on computed tomography scan. Differentiation of recurrent tumor was more difficult when the patient had undergone radiation. Magnetic resonance imaging demonstrated superior visibility in recurrent parotid and paranasal sinus neoplasm, but was less helpful in laryngeal and pharyngeal recurrences. Computed tomography demonstration of a mass with infiltration of normal fat or tissue planes or lymphadenopathy correlated highly with recurrent disease. Imaging techniques and fine points for determining recurrent neoplasms are presented.
Article
Despite recent advances in radiation therapy and chemotherapy, surgical procedures remain the primary modality of head and neck cancer therapy. Adequate surgical resection frequently requires the removal of significant amounts of tissue. The primary concern of the reconstructive surgeon is the restoration of a functional aerodigestive tract. In addition to the prolongation of life, the quality of that life should be taken into consideration. The records of 25 patients undergoing oropharyngeal reconstruction for tumors stage 3 or 4 in the 4-year period from 1983 to 1986 were reviewed. After surgical extirpation, reconstruction was performed using either a pectoralis major musculocutaneous flap or a microvascular free flap. Results were evaluated with emphasis on both the intraoperative and postoperative course. The length of the procedure, time of initiation of oral feedings, time of decannulation, postoperative complications, time of discharge, and quality of life after discharge were considered. Those patients reconstructed with microvascular free flaps were able to tolerate oral feedings sooner and were discharged sooner than those patients reconstructed with pectoralis musculocutaneous flaps. In addition, the patients with pectoralis flaps were twice as likely to have local complications (e.g., superficial wound infection, fistula) as those with free flaps. The quality of the patient's life with respect to deglutition and intelligibility of speech was likewise better for those patients reconstructed with microvascular free flaps. The explanation of these results is presented.
Article
Following radiation treatment, ablative surgery, and surgical flap reconstruction in cases of oral cancer, postoperative follow-up for oral cancer recurrence presents a difficult task. Computed tomography (CT) remains the most accessible method of postoperative assessment; however, it has yet to be conclusively shown to provide an advantage over an adequate history and physical examination. Twenty-four consecutive patients who had undergone flap reconstruction of the oral cavity for advanced or radiorecurrent disease were studied over an 18-month period. Eight patients showed no evidence of recurrent tumor either clinically or by CT scan. Eleven patients had evidence of recurrent disease clinically, which was confirmed by CT. In four patients, clinically unsuspected regional recurrent tumor was revealed by CT. One false negative scan was encountered. CT proved to be a sensitive modality for detecting clinically unsuspected recurrences, particularly regional recurrences.
Article
Thirty-three patients who had undergone prior surgery and/or radiation therapy for malignant neoplasms of the neck were studied with magnetic resonance (MR) imaging. Twenty-seven of these patients were also evaluated with computed tomography (CT). Ten patients were healthy posttreatment volunteers, and 23 had documented tumor recurrence. MR images better demonstrated normal muscular landmarks, especially in patients with obliterated fat planes. Areas of posttreatment fibrosis or scarring were low in signal intensity with all MR pulse sequences. However, in three patients, high signal intensity from postradiation edema of the supraglottic area mimicked neoplasm. In patients with recurrent tumor, MR imaging was superior to CT in defining the relationship of tumor and muscle and in demonstrating vascular anatomy when no intravenous contrast material was given during the CT examination. In two patients tumor and fibrosis were separated on MR images because of signal intensity differences. CT scans, however, showed adjacent bone and cartilage anatomy better. Our data indicate that an MR examination may be helpful in patients in whom CT is indeterminate either because of anatomical distortion or suboptimal demonstration of vascular anatomy.
Article
Review of 15 cases of carotid artery exposure or rupture in patients with no recurrent tumor demonstrated several important principles. Irradiation was a risk factor in 90% of cases of carotid blowout. Only one of five patients (20%) with carotid exposure who had not had irradiation had carotid perforation. Immediate death occurred in two of 15 (13%), and delayed death in five of 15 (33%). The neck wound was successfully controlled in 11 of 15 cases, requiring extracervical vascularized muscle or skin in eight of the 11 cases. Only one of seven pectoralis major flaps failed to control infection in the neck. This review reaffirms the importance of irradiation and orocutaneous fistula as risk factors. A rationale for prophylaxis, treatment of carotid exposure, and treatment of carotid rupture is presented.
Article
Magnetic resonance (MR) images of 21 patients who had undergone radiation therapy were analyzed and compared with those of 15 patients who had untreated tumors. T2-weighted images (TR = 1,500 msec, TE = 90 msec) were most helpful in distinguishing recurrent tumor from radiation fibrosis. Radiation fibrosis, like muscle, usually remained low in signal intensity on T2-weighted images, while tumor demonstrated higher signal intensity. In no patient was the signal intensity of tumor the same or less than muscle on the T2-weighted images. However, relatively high signal intensity on T2-weighted images is not specific for tumor recurrence and may be seen in acute radiation pneumonitis, infection, hemorrhage, and even pulmonary radiation fibrosis.
Article
This review of 50 consecutive myocutaneous flaps provided an opportunity to assess the value of this particular reconstructive technique in head and neck cancer surgery. There is no question that the flap has certain disadvantages. In this series, it was not found to be a reliable means of one-stage pharyngoesophageal reconstruction. However, its technical ease, versatility, and reliability as a one-stage reconstructive technique strongly outweigh any disadvantages and prove it to be a valuable recent addition to head and neck cancer surgery reconstruction.
Article
Sixty-seven patients underwent 73 pectoralis major myocutaneous flap procedures for the immediate reconstruction of defects after resection of head and neck cancers. Thirty-six patients experienced a total of 50 complications for an overall complication rate of 54 percent. There were 3 instances of total flap necrosis, 9 of partial flap necrosis, 12 orocutaneous fistulas, 9 suture line separations, 8 neck wound complications, 1 donor site complication, and 8 mandibular replacement complications. Most complications were minor and did not require a second procedure for correction; however, 36 percent did require a second operation. Eight of 10 patients in whom a metal appliance was placed to restore mandibular continuity required the removal of that appliance due to either flap necrosis, fistula formation, or exposure. Based on our experience, we conclude that attention to flap design, operative technique, and post-operative management were useful in reducing the incidence of complications. We also conclude that a metal appliance was an unsatisfactory means of restoring mandibular continuity when utilized beneath a pectoralis major myocutaneous flap. Although the overall incidence of complications was high, the actual incidence of flaps failing to accomplish their intended purpose and requiring secondary repair was acceptable. The pectoralis major myocutaneous flap was reliable in the reconstruction of defects in the head and neck region.
Article
To otolaryngologists involved in ablative surgery for tumours, restoration of function and appearance after extirpation has always been a matter of concern. This is particularly important for two reasons. In the first place, the function of the pharynx as a pathway for deglutition and respiration makes reconstruction of this area of vital importance. Secondly, while scars, defects and prosthetics in other parts of the body can be easily hidden and camouflaged, this is difficult in the head and neck area. For almost a century skin grafts, free, pedicled or as rotation flaps, have been used for reconstruction. In recent years the development of myocutaneous flaps has considerably altered this picture and this field is rapidly advancing. The purpose of this paper is to acquaint ourselves with this advance and to present our own experience.
Article
A prospective computed tomographic (CT)-clinical study was made of 40 consecutive patients who had undergone myocutaneous flap surgery of the neck and 30 consecutive patients who had undergone radical neck dissection. The postoperative CT appearance of tumor and infection is reviewed. The normal CT landmarks of the neck are also described.
Article
The variety of cervical lymphadenectomy and neck reconstructive procedures that have been developed in the past 20 years has led to confusion about nomenclature in the literature. In addition, some of these operations result in gross alteration of the normal anatomy. The authors review the present classification system for cervical lymph nodes and various lymphadenectomy and reconstructive procedures. Examples of typical postoperative images are given. A protocol for postoperative follow-up is presented, which calls for imaging for 5 years after surgery. Finally, the authors review their experience with 400 cases, 276 of which were initially classified as having no clinical evidence of disease. Recurrence developed in 68 of these (in 62 [91%] within 4-18 months of surgery). Imaging findings altered the postoperative salvage plan in 17 (25%). Clinically occult disease was found at sectional imaging in 47 (17%).
Head and neck reconstruction with pectora lis major myocutaneous flap: CT evaluation
  • K Ohgi
  • A Kohno
  • K Ltabashi
Ohgi K, Kohno A, ltabashi K, et al. Head and neck reconstruction with pectora lis major myocutaneous flap: CT evaluation. J Comput Assist Tomogr1990;14:286-290