Head and neck reconstruction with pectoralis major myocutaneous flap: CT evaluation

Essentials on Oncological Imaging: Postoperative Computed Tomography and Magnetic Resonance Imaging of Oral Tongue Cancer

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.

CT differentiation of abscess and non-infected fluid in the postoperative neck

BACKGROUND

Differentiation of postoperative neck abscess from non-infected fluid is important because the treatment is different.

PURPOSE

To 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.

RESULTS

Rim 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.

CONCLUSION

CT findings that may help differentiate postoperative neck abscess from non-infected fluid were rim enhancement > 50% of the circumference and severe soft tissue manifestations.

Lymphadenopathy in the Mesenteric Pedicle of the Free Jejunal Flap

OBJECTIVE

Reconstructive surgery using the free jejunal flap is sometimes performed to close surgical defects in patients undergoing pharyngolaryngectomy for laryngeal or hypopharyngeal cancer. The clinical significance of lymph nodes in the flap was retrospectively examined.

METHODS

Fifteen patients had undergone a laryngectomy with free jejunal flap reconstruction between March 1996 and October 1999. The appearance and size of lymph nodes of the flap were examined by 3 radiologists.

RESULTS

Lymph nodes were observed in 10 patients. Size increases were noted within 1 year after surgery but not beyond 1 year. The pathologic diagnosis of the excised nodes was reactive lymphadenopathy.

CONCLUSIONS

Lymph nodes may occasionally become apparent in the free jejunal flap. There was no suggestion of metastatic lymph nodes when examined retrospectively. We speculate that this reaction was the result of environmental changes attributable to surgery.

Positron emission tomography/computed tomography true fusion imaging in clinical head and neck oncology: early experience

PURPOSE

Positron emission tomography-computed tomography (PET-CT) is a new imaging modality that provides simultaneous functional and anatomic information. Its application in head and neck oncology is still evolving.

MATERIALS AND METHODS

Five illustrative cases who were scanned with this technique are presented.

RESULTS

The clinical application and impact on clinical management are described and discussed.

CONCLUSION

Our experience indicates that PET-CT will assume a more important role than either CT, magnetic resonance imaging, or PET alone in head and neck cancer imaging.

Flap reconstruction in the head and neck: expected appearance, complications, and recurrent disease

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.

Imaging the treated oral cavity and oropharynx

Cross-sectional imaging has become essential in the evaluation of the treated oral cavity and oropharynx. The purpose of this paper is to review the imaging guidelines for the evaluation of this region and to detail the typical changes encountered on imaging following surgical and radiation treatment for cancer.

MR imaging of recurrent head and neck tumours following flap reconstructive surgery

AIM

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Tumor recurrence criteria for postoperative contrast-enhanced computed tomography after surgical treatment of oral cancer and flap repair

OBJECTIVE

To characterize the computed tomography (CT) findings that distinguish cancer recurrence from postoperative changes that mimic such recurrence.

STUDY DESIGN

We evaluated a total of 72 CT scans from 32 patients who had undergone surgery with either pectoralis major myocutaneous flap or forearm flap. The observers evaluated the presence and pattern of enhancement, the presence of low density areas, and changes in the adipose tissue of the flap.

RESULTS

A persistent zone of high attenuation over 6 months suggested the high possibility of recurrence. However, an enhancement within 6 months occurred both with the recurrent tumor and with postoperative tissue. In the patients with recurrence (n = 12), the enhanced areas were focal (n = 8) or diffuse (n = 4). Focal-type recurrence often occurred at the posterior margin. The presence of low-density areas and changes in the adipose tissue in the flap are also helpful for detecting recurrence.

CONCLUSIONS

The combination of several features seen on CT images can be useful in differentiating tumor recurrence from postoperative tissue changes.

Head and neck tumors: imaging recurrent tumor and post-therapeutic changes with CT and MRI

OBJECTIVE

To evaluate criteria for detection of tumor recurrence and post-treatment changes in patients with head and neck malignancies in computed tomography (CT) and magnetic resonance imaging (MRI).

METHODS AND MATERIALS

Thirty-nine patients with head and neck carcinoma receiving radiochemotherapy were examined before, during and after therapy with MRI. Changes in signal intensity were correlated to histology or clinical course. Three hundred and thirty-one patients with head and neck malignancies were examined with CT after therapy. CT diagnoses were correlated with histology or clinical course.

RESULTS

Main criteria for recurrent/residual tumor in MRI was infiltrative mass with high signal intensity in T2-weighted images and enhancement after Gd-DTPA in T1-weighted images. Radiation-induced changes led to false positive diagnosis in 46% in the interval up to 3 months after therapy and in 58% in the interval 3-6 months after therapy. The combination of a circumscribed, infiltrative mass with contrast enhancement in CT had a sensitivity of 86% and a specificity of 80%.

CONCLUSION

CT could accurately demonstrate postoperative changes and tumor recurrence. MRI had advantages in differentiation of tumor and scar, but edema after radiation therapy can spoil diagnosis.

Clinical evaluation of the pectoralis major flap for reconstruction in head and neck cancer

Sixty two patients (7 women and 55 men) with head and neck cancer underwent 64 musculocutaneous or osteomusculocutaneous reconstructions in the Department of Head and Neck Tumours, Estonian Cancer Centre, from May 1988 to December 1991. Two men had two reconstructions. The patients were evaluated for surgical, functional, aesthetic, and also for oncological results. The flap-related complication rate was higher among women than men (6/7 (86%) compared with 19/57 (33%), p = 0.012), and in the group of osteomusculocutaneous flaps which contained a segment of the fifth or sixth rib compared with the musculocutaneous ones (5/6 (83%) compared with 20/58 (34%), p = 0.03). The functional results were good or satisfactory in 41/60 (68%) of the cases. Mean follow-up time was 32 months; 31/58 (53%) of patients operated on due to primary or recurrent cancer are alive, with or without recurrent disease. We do not recommend the inclusion of rib segments in pedicled pectoral flaps for reconstructions of head and neck defects.