Incidence and predictive factors of retropharyngeal lymph node metastases in patients with oropharyngeal cancer undergoing multimodality treatment planning imaging

BACKGROUND

We investigated the incidence and predictive factors of retropharyngeal lymph node (RPLN) metastases in patients with oropharyngeal cancer (OPC) undergoing multimodality treatment planning imaging before radiotherapy.

METHODS

Consecutive patients with OPC treated with curative-intent radiotherapy from 2017 to 2019 were retrospectively analyzed. Treatment planning comprised contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), and fluorodeoxyglucose-positron emission tomography (FDG-PET) unless contraindicated.

RESULTS

Of 300 patients, 66 (22%) had radiological evidence of RPLN involvement on planning images, compared to 17 (6%) on diagnostic CT alone. On multivariate analysis, RPLN involvement was statistically (p < 0.05) associated with tonsil, soft palate, and posterior pharyngeal wall primaries, and with disease extension to the soft palate or vallecula.

CONCLUSIONS

Multimodality treatment planning imaging reveals a high rate of RPLN metastases from OPC compared to diagnostic CT alone. Patients with tonsil, soft palate, or posterior pharyngeal wall primaries or disease extending to the soft palate or vallecula appear at higher risk.

Phase II study of de-intensified intensity-modulated radiotherapy and concurrent carboplatin/5-fluorouracil in lateralized p16-associated oropharyngeal carcinoma

PURPOSE

To assess cancer control and patient-reported outcomes (PROs) after de-intensified intensity-modulated radiotherapy (IMRT) in lateralized p16-associated oropharyngeal cancer (p16-OPC).

METHODS

Lateralized p16-OPC treated with radiotherapy and concurrent Carboplatin/5-fluorouracil between 2011 and 2014 were enrolled. De-intensified IMRT consisted in elective neck dose of 43.2 Gy/24 fractions and omission of contralateral retropharyngeal/level IV nodes. PROs were assessed using the EORTC QLC-C30 and QLQ-HN35 scales.

RESULTS

Twenty-nine patients were included. Median follow-up was 44 months. As per AJCC 7th Ed, 7%, 83% and 10% of patients had stage III, IVa and IVb. 5-year locoregional control and overall survival rates were 100% and 100%, respectively. Rates of acute were 52% and 35%, respectively. At 2 years post-treatment, 50% and 14% of patients had grade 1 xerostomia and dysgueusia, respectively. Most PROs scores returned to baseline within 8 months post-treatment.

CONCLUSION

De-intensified IMRT was associated with excellent cancer outcomes, and rapid recovery of PROs in lateralized p16-OPC.

Diagnostic Reliability of Leptomeningeal Disease Using Magnetic Resonance Imaging

Brain metastases are seen in 20%-50% of patients with metastatic solid tumors. On the other hand, leptomeningeal disease (LMD) occurs more rarely. The gold standard for the diagnosis of LMD is serial cerebrospinal fluid (CSF) analyses, although in daily practice, the diagnosis of LMD is often made by neuroimaging. Leptomeningeal metastases (LM) have been a relative contra-indication to radiosurgery. It can be noted that focal LMD can be difficult to distinguish from a superficially located/cortical-based brain metastasis which is not a contra-indication for radiosurgery. Hence, justifying the need of a reliable diagnosis method.

The goal of this study was to determine the inter-observer reliability of contrast-enhanced magnetic resonance imaging (gdMRI) in the differentiation of focal cortical-based metastases from leptomeningeal spread.

This is a retrospective review of a prospectively collected database of patients with brain metastases. A total of 42 cases with superficial lesions were selected for review. Additionally, eight control cases demonstrating deep and/or white-matter based lesions were included in the study.

Three neuroradiologists and three radiation oncologists were asked to review each study and score the presence of LM. Inter-observer agreement was calculated using group-derived agreement coefficients (Gwet’s AC1 and Gwet's AC2). Pair-wise inter-observer agreement coefficients never reached substantial values for trichotomized outcomes (LMD, non-LMD or indeterminate) but did reach a substantial value in a minority of cases for dichotomised outcomes (LMD or non-LMD). The control subgroup analysis revealed substantial agreement between most pairs for both trichotomized and dichotomised outcomes.

We observed low inter-observer agreement amongst specialists for the diagnosis of focal LMD by gdMRI. Neuroimaging should not be relied upon to make treatment decisions, notably to deny patients radiosurgery.

Postoperative diffusion weighted MRI and preoperative CT scan fusion for residual cholesteatoma localization

OBJECTIVE

To evaluate the ability of preoperative mastoid high resolution Computerized tomography (CT Scan) fusion with the postoperative diffusion weighted magnetic resonance imaging (Non-EPI DWI) to accurately localize the residual cholesteatoma thus sparing an unnecessary postoperative CT scan radiation.

PATIENTS AND METHODS

this is a prospective study performed in our tertiary care center. We followed up prospectively a consecutive group of patients presenting with middle ear cholesteatoma using preoperative mastoid CT scans, postoperative mastoid CT scan and mastoid diffusion weighted MRI (DWI) between 2012 and 2013. Postoperative DWI were fused to both: the preoperative and postoperative mastoid CT scans. Fused images were evaluated for their ability to detect accurately the location of residual cholesteatoma if any. Results were correlated to the surgical findings.

RESULTS

Twenty-eight patients were included in this study. Ten patients showed middle ear opacity on the postoperative CT scans; the remaining negatively patients were excluded. DWI detected residual cholesteatoma in 3 out of the ten patients. Both CT scans; the pre and postoperative were able to precisely localize the residual cholesteatoma when fused to the postoperative DWI. Intra-operatively, three patients had a residual cholesteatoma that corresponded to the fused radiological images while a fourth patient presenting low signal intensity on the Non-EPI DWI had no cholesteatoma.

CONCLUSION

Diffusion weighted MRI/CT scan fusion combines the advantages of residual cholesteatoma detection and precise localization. Preoperative CT scans performed before the first surgery can be used for the fusion with the Non-EPI DWI in order to spare the patient an unnecessary another CT scan and thus decreasing radiation exposure.

The relevance of preoperative ultrasound cervical mapping in patients with thyroid cancer

BACKGROUND

Cervical lymph node involvement in thyroid cancer is associated with locoregional recurrence and decreased disease-free survival. Preoperative lymph node mapping helps in planning surgery for neck dissection and improves patient outcomes. We sought to perform a qualitative and quantitative analysis of ultrasound mapping for thyroid cancer and evaluate the clinical importance of this exam in terms of identifying the group of patients who would benefit most from subsequent surgical dissection.

METHODS

We retrospectively reviewed the cases of 263 patients who underwent thyroid surgery between 2009 and 2013. We calculated the positive predictive values (PPVs) of ultrasound mapping of both the lateral and central compartments together and the lateral or central compartment individually. A quantitative analysis was performed by comparing the number of positive lymph nodes at ultrasound imaging with histopathologic evaluation.

RESULTS

A total of 136 cases of thyroid cancer in 120 patients met the inclusion criteria for ultrasound mapping analysis. The PPVs (and 95% confidence intervals) were 83.82 (0.76-0.89) for the lateral and central compartments, 85.39% (0.76-0.91) for the lateral compartment, and 80.48% (0.7-0.87) for the central compartment. When comparing the positive lymph nodes at ultrasound imaging with histopathologic evaluation, the result was χ(2) = 10.33 (p = 0.006).

CONCLUSION

This single-institution study indicated that preoperative ultrasound mapping is an accurate imaging procedure for predicting lymphatic spread in differentiated and medullary thyroid cancer. Ultrasound mapping can be used as an efficient tool for surgical planning and prognosis determination, as well as for identifying the group of patients who would benefit most from subsequent surgical intervention.

Xerostomia in patients treated for oropharyngeal carcinoma: comparing linear accelerator-based intensity-modulated radiation therapy with helical tomotherapy

BACKGROUND

In comparison to sliding-window intensity-modulated radiation therapy (sw-IMRT), we hypothesized that helical tomotherapy (HT) would achieve similar locoregional control and, at the same time, decrease the parotid gland dose, thus leading to a xerostomia reduction.

METHODS

The association between radiation techniques, mean parotid dose, and xerostomia incidence, was reviewed in 119 patients with advanced oropharyngeal carcinoma treated with concurrent chemoradiation using sw-IMRT (n = 59) or HT (n = 60).

RESULTS

Ipsilateral and contralateral parotid mean doses were significantly lower for patients treated with HT versus sw-IMRT: 24 Gy versus 32 Gy ipsilaterally and 20 Gy versus 25 Gy contralaterally. The incidence of grade ≥2 xerostomia was significantly lower in the HT group than in the sw-IMRT group: 12% versus 78% at 6 months, 3% versus 51% at 12 months, and 0% versus 25% at 24 months. Total parotid mean dose <25 Gy was strongly associated to a lower incidence of grade ≥2 xerostomia at 6, 12, and 24 months.

CONCLUSION

This retrospective series suggests that using HT can better spare the parotid glands while respecting quantitative analysis of normal tissue effects in the clinic (QUANTEC)'s criteria.

Prognostic Value of Cartilage Sclerosis in Laryngeal Cancer Treated with Primary Radiation Therapy

Objective

In patients with laryngeal cancer, pretreatment diagnosis of cartilage invasion often warrants a surgical or a bimodal treatment. Controversy exists on whether laryngeal cartilage sclerosis on computed tomography (CT) scan is a sign of tumor invasion. Our objective is to evaluate locoregional, laryngectomy-free, disease-specific, and overall survival in patients with laryngeal cancer with or without laryngeal cartilage sclerosis treated with primary radiation therapy.

Study Design

Historical cohort study.

Setting

Tertiary referral university center.

Subjects and Methods

All laryngeal cancer patients treated with primary radiation therapy between 2002 and 2007 were included. Patients with and without laryngeal cartilage sclerosis on CT scan were identified. Patient, tumor, and treatment data were collected. Univariate and multivariate analyses were conducted using Kaplan-Meier survival analyses and Cox proportional-hazards regression.

Results

One hundred eleven patients were included for analysis. Seventy-nine patients were classified as T1 or T2, and 32 patients were classified as T3 or T4. Twenty-three percent of patients had any laryngeal cartilage sclerosis, and 77% of patients had no sclerosis. On univariate and multivariate analyses, there was no statistically significant difference between patients with or without sclerosis. Results did not vary when studying each cartilage separately.

Conclusion

Laryngeal cancer patients with cartilage sclerosis on CT scan do not have significantly different survival than patients without sclerosis. Validation of these results prospectively is warranted.

Predictive Value of Laryngeal Cartilage Sclerosis on CT-Scan

Objective: The value of laryngeal sclerosis as a sign of neoplastic invasion on CT-scan is controversial. We investigated the value of laryngeal cartilage sclerosis on CT-scan as a predictor of locoregional control, success of organ preservation, and survival for patients treated with radiation therapy for laryngeal carcinoma.

Method: Retrospective chart review on patients treated for laryngeal carcinoma with radiation therapy at the CHUM between 2002 and 2007. A head and neck radiologist revised each patient’s pretreatment CT-scan to determine the presence of laryngeal cartilage sclerosis. This variable was correlated with locoregional control, laryngectomy, and survival rates.

Results: Of the 111 patients, 76% were male and 24% female. Their mean age was 61 years. Forty-eight had supraglottic tumors and 63 had glottic tumors. Seven percent had thyroid cartilage sclerosis, 5% cricoid cartilage sclerosis, 55% arytenoid cartilage sclerosis, and 16% arytenoid cartilage sclerosis with adjacent tumor. There was no significant correlation demonstrated between cartilage sclerosis and locoregional control rate, laryngectomy rate and global and disease-free survival.

Conclusion: Cartilage sclerosis on CT-scan cannot be identified as a powerful predictor of treatment failure for patients with laryngeal carcinoma treated with radiation, which confirms our therapeutic attitude.

¹⁸F-FDG-PET imaging in radiotherapy tumor volume delineation in treatment of head and neck cancer

PURPOSE

To determine the impact of (18)F-fluorodeoxyglucose positron emission tomography (PET) in radiotherapy target delineation and patient management for head and neck squamous cell carcinoma (HNSCC) compared to computed tomography (CT) alone.

MATERIALS AND METHODS

Twenty-nine patients with HNSCC were included. CT and PET/CT obtained for treatment planning purposes were reviewed respectively by a neuroradiologist and a nuclear medicine specialist who were blinded to the findings from each other. The attending radiation oncologist together with the neuroradiologist initially defined all gross tumor volume of the primary (GTVp) and the suspicious lymph nodes (GTVn) on CT. Subsequently, the same radiation oncologist and the nuclear medicine specialist defined the GTVp and GTVn on (18)F-FDG-PET/CT. Upon disagreement between CT and (18)F-FDG-PET on the status of a particular lymph node, an ultrasound-guided fine needle aspiration was performed. Volumes based on CT and (18)F-FDG-PET were compared with a paired Student's t-test.

RESULTS

For the primary disease, four patients had previous diagnostic tonsillectomy and therefore, FDG uptake occurred in 25 patients. For these patients, GTVp contoured on (18)F-FDG-PET (GTVp-PET) were smaller than the GTVp contoured on CT (GTVp-CT) in 80% of the cases, leading to a statistically significant volume difference (p=0.001). Of the 60 lymph nodes suspicious on PET, 55 were also detected on CT. No volume change was observed (p=0.08). Ten biopsies were performed for lymph nodes that were discordant between modalities and all were of benign histology. Distant metastases were found in two patients and one had a newly diagnosed lung adenocarcinoma.

CONCLUSIONS

GTVp-CT was significantly larger when compared to GTVp-PET. No such change was observed for the lymph nodes. (18)F-FDG-PET modified treatment management in three patients, including two for which no curative radiotherapy was attempted. Larger multicenter studies are needed to ascertain whether combined (18)F-FDG-PET/CT in target delineation can influence the main clinical outcomes.

Independent evolution of hypervariable regions of HIV-1 gp120: V4 as a swarm of N-Linked glycosylation variants

In this study we have characterized intra-patient length polymorphism in V4 by cloning and sequencing a C2-C4 fragment from HIV plasma RNA in patients at different stages of HIV disease. Clonal analysis of clade B, G, and CRF02 isolates during early infection shows extensive intra-patient V4 variability, due to the presence of indel-associated polymorphism. Indels, coupled to amino acid substitution events, affect the number and distribution of potential N-glycosylation sites, resulting in the coexistence, within the same patient, of V4 subsets, each characterized by different sizes, amino acid sequences, and potential N-glycosylation patterns. In contrast, V3 appears to be relatively homogeneous, with similar V3 associated to significantly different V4 within the same clinical specimen. Based on these data, we propose that during early chronic infection V4 is present as a highly divergent quasispecies, enabling the virus to adopt different conformational structures according to immune constrains and other selective pressures.

An unusual association of a sellar gangliocytoma with a prolactinoma

The simultaneous occurrence of a hypothalamic and sellar gangliocytoma with a pituitary prolactinoma is very rare. The explanation for such an association is not known. We describe the case of a woman who had a coexisting adjacent pituitary prolactinoma and gangliocytoma within the same sellar mass. The tumor cells of the gangliocytoma demonstrated expression of enkephalin, a product of proopiomelanocortin known to be a prolactin secretagogue. We postulate that in this patient there may be a link between gangliocytoma enkephalin and prolactin hypersecretion.

Intra-parenchymal mesenchymal chondrosarcoma of the cerebellum: case report and review of the literature

A 44-year-old male presented with a 3-week history of clumsiness and numbness of the left hemibody. CT scan and MRI revealed a 2 cm mass in the right hemisphere of the cerebellum. The patient underwent a sub-occipital craniotomy with gross total resection of the intra-parenchymal lesion. On pathology, the lesion was found to be compatible with a mesenchymal chondrosarcoma. The patient received adjuvant radiation treatment and remains free of disease 60 months after completion of treatment. Mesenchymal chondrosarcomas are neoplasms that rarely arise intra-cranially. Thirty cases have been found in the literature. Our case resembles more closely six of these cases because the tumour had no dural attachment. We describe our case in more detail and review similar cases found in the English literature.

[Diagnostic criteria in clinical evaluation of multiple sclerosis: role of magnetic resonance imaging]

The objective of this article is to summarize the diagnostic criteria recommended by the International Panel on the Diagnosis of Multiple Sclerosis in 2001. The recommendations of another working group, the Consortium of Multiple Sclerosis Centers Consensus Meeting, which met in Vancouver in 2001, concerning the diagnosis and follow-up of patients with multiple sclerosis are also presented in an effort to standardize the protocols for magnetic resonance imaging of these patients.

Loss of brain volume in endogenous Cushing's syndrome and its reversibility after correction of hypercortisolism

Chronic exposure to excess glucocorticoids results in cognitive and psychological impairment. A few studies have indicated that cerebral atrophy can be found in patients with Cushing's syndrome (CS), but its evolution after cure has not been studied extensively. We report the presence of apparent cerebral atrophy in CS and its reversibility after the correction of hypercortisolism. Thirty-eight patients with CS, including 21 with Cushing's disease and 17 with adrenal CS were studied. The control groups consisted of 18 patients with other non-ACTH-secreting sellar tumors and 20 normal controls. Twenty-two patients with CS were reevaluated after cure. Subjective loss of brain volume was present in 86% of patients with Cushing's disease and 100% of patients with adrenal CS. The values for third ventricle diameter, bicaudate diameter, and subjective evaluation were significantly increased in CS groups in comparison with the control group (P < or = 0.001). Imaging reevaluated at 39.7 +/- 34.1 months after achieving eucortisolism showed an improvement of the third ventricle diameter (P = 0.001), bicaudate diameter (P < 0.0005), and subjective evaluation (P = 0.05). We conclude that brain volume loss is highly prevalent in CS and is at least partially reversible following correction of hypercortisolism.

Computed tomographic abscessogram: a useful tool for evaluation of percutaneous abscess drainage

OBJECTIVE

To evaluate the role of computed tomographic abscessograms (CTABs, consisting of injection of contrast medium through a drainage catheter followed by computed tomographic examination) in the management of patients referred for percutaneous abscess drainage (PAD).

PATIENTS AND METHODS

Over 50 months, 169 patients with 203 abscesses underwent PAD, and 432 CTABs were performed. CTAB was assessed for its ability to influence treatment decisions, detect fistulae and visualize the septic process.

RESULTS

CTABs allowed the detection of fistulous communications in 32% (65/203) of abscesses. In 60 of the 65 patients with fistulae (92%), the specific etiology of the abscess cavity was established through analysis of CTABs. The presence of a pathologic fistula prolonged the catheter drainage time (20.5 v. 11.9 days, p < 0.0001), and the success rate was lower if the drainage catheter was removed before the fistula was closed (90% v. 72%). CTAB images influenced catheter-manipulation decisions for 23 of the 169 patients (14%).

CONCLUSION

CTABs provide important information about the underlying pathologic process while allowing detection of fistulae and ultimately influencing interventional treatment for PAD.

Aortic graft infection: the value of percutaneous drainage

OBJECTIVE

The goal of this study was to compare patients with aortic graft infection treated by primary percutaneous drainage with patients who initially underwent surgery.

MATERIALS AND METHODS

A retrospective review of 23 consecutive patients treated for aortic graft infection was performed. Eleven patients were initially treated with percutaneous drainage and 12 were treated with surgery. The morbidity, mortality, and postprocedural reintervention rates and clinical outcome were analyzed for each group.

RESULTS

The septic process resolved in nine (82%) of 11 patients treated with percutaneous drainage. Of these nine patients, four were treated with percutaneous drainage alone. Drainage was followed by removal of the infected prosthetic graft in the remaining five patients. In the surgical group, sepsis resolved in only four patients (33%) (p = .036). No periprocedural deaths occurred in the percutaneous drainage group, whereas six patients in the surgical group died in the perioperative period (p = .014).

CONCLUSION

Percutaneous drainage can be used as an initial form of treatment in the management of aortic graft infections. Surgery after percutaneous drainage appears to be safer than surgery alone.

Percutaneous drainage of intra-abdominal abscesses in Crohn's disease: short and long-term outcome

OBJECTIVE

To determine whether percutaneous drainage of Crohn's abscesses obviates the need for early surgical drainage.

METHODS

All cases of percutaneous drainage of Crohn's abscesses between 1990 and 1995 were reviewed and classified as a success or failure on the basis of the need for surgery within < 30 days of catheter removal.

RESULTS

Twenty-seven drainage procedures were performed in 24 patients; 15 (56%) were classified as successes, and 12 (44%) were classified as failures. Successes and failures did not significantly differ with respect to patient demographics and Crohn's disease characteristics. Patients whose abscesses were successfully drained had significantly fewer associated fistulae (46.6 vs 92.0%, p = 0.037), and their abscesses tended more often to be first (vs recurrent), spontaneous (vs postoperative), located in the right lower quadrant, and smaller. Patients whose abscesses were successfully drained also tended to spend more time with the catheter in place and to require more imaging procedures. Complications were noted in four cases (15%), enterocutaneous fistula at the site of catheter insertion in three cases and postprocedure fever in one case. Hospital stay was significantly shorter after successful drainage (16.3 +/- 6.9 vs 31.7 +/- 22.1 days, p = 0.017). After a total of 543.5 patient-months of follow-up, subsequent intra-abdominal Crohn's-related surgery was required in only two of the successes and one failure.

CONCLUSIONS

1) Percutaneous drainage of Crohn's abscess successfully obviates the need for early surgery in approximately 50% of cases, and this benefit is maintained on long term follow-up. 2) Percutaneous drainage shortens hospital stay. 3) Crohn's abscesses in various locations, single or multiple, with or without an associated fistula may be successfully drained percutaneously. 4) Presence of an associated fistula may be a risk factor for failure.