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We report clinical, imaging and pathology findings of a patient with leprosy of the great auricular nerve who presented with palpable nodules and numbness of the left ear and scalp. Ultrasound and contrast-enhanced CT imaging of the neck demonstrated diffuse enlargement and enhancement of the great auricular nerve. Biopsy of the enlarged left great auricular nerve revealed granulomatous inflammation with necrosis involving the nerve with rare Fite-positive organisms compatible with mycobacterium. Positive PCR for Mycobacterium leprae of the surgical specimen confirmed diagnosis of Hansen's disease.

Node positive head and neck squamous cell carcinomas (HNSCCs) patients exhibit worse outcomes in terms of regional neck control, risk for distant metastases and overall survival. Smaller non-palpable lymph nodes may be inflammatory or may harbor clinically occult metastases, a characterization that can be challenging to make using routine imaging modalities. Ferumoxytol has been previously investigated as an intra-tumoral contrast agent for magnetic resonance imaging (MRI) for intracranial malignancies and lymph node agent in prostate cancer. Hence, our group was motivated to carry out a prospective feasibility study to assess the feasibility of ferumoxytol dynamic contrast enhanced (DCE)-weighted MRI relative to that of gadolinium-based DCE-MRI for nodal and primary tumor imaging in patients with biopsy-proven node-positive HNSCC or melanoma. Although this institutional review board (IRB)-approved study was prematurely terminated because of an FDA black box warning, the investigators sought to curate and publish this unique dataset of matched clinical, and anatomical and DCE MRI data for the enrolled five patients to be available for scientists interested in molecular imaging., Measurement(s)imaging assay • head and neck squamous cell carcinomaTechnology Type(s)magnetic resonance imagingFactor Type(s)contrast agentSample Characteristic - OrganismHomo sapiens Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.11409516

We report the imaging and clinical findings in 3 patients with osteoradionecrosis of the styloid process, an uncommon consequence of radiation therapy for head and neck malignancy.

OBJECTIVE The aim of this study was to present the imaging findings of pleural metastases from head and neck cancer and correlate them with prognosis for overall survival, which to our knowledge have not received much attention in radiology literature. METHODS We reviewed 23 cases of head and neck cancer with pleural metastases that were seen on head and neck imaging. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT imaging findings were reviewed. The location and cell type of the primary cancer were studied. The effect of the pleural metastases on patient survival was analyzed. RESULTS Twelve (57%) of the 21 cases of pleural metastasis were missed initially on the neck CT but were visible in retrospect. Nine of 11 patients whom we had followed up for 1.5 years or longer have died, often within a few of months of presenting with pleural metastases. CONCLUSIONS The presence of pleural metastasis in head and neck cancer is an extremely poor prognostic indicator for survival. They are potentially missed on the neck CT. Given its significant clinical impact, head and neck radiologists should specifically look for pleural metastasis when reviewing imaging studies of patients with head and neck cancer.

Background The survival advantage of induction chemotherapy (IC) followed by locoregional treatment is controversial in locally advanced head and neck squamous cell carcinoma (LAHNSCC). We previously showed feasibility and safety of cetuximab-based IC (paclitaxel/carboplatin/cetuximab—PCC, and docetaxel/cisplatin/5-fluorouracil/cetuximab—C-TPF) followed by local therapy in LAHNSCC. The primary end point of this phase II clinical trial with randomization to PCC and C-TPF followed by combined local therapy in patients with LAHNSCC stratified by human papillomavirus (HPV) status and T-stage was 2-year progression-free survival (PFS) compared with historical control. Patients and methods Eligible patients were ≥18 years with squamous cell carcinoma of the oropharynx, oral cavity, nasopharynx, hypopharynx, or larynx with measurable stage IV (T0–4N2b–2c/3M0) and known HPV by p16 status. Stratification was by HPV and T-stage into one of the two risk groups: (i) low-risk: HPV-positive and T0–3 or HPV-negative and T0–2; (ii) intermediate/high-risk: HPV-positive and T4 or HPV-negative and T3–4. Patient reported outcomes were carried out. Results A total of 136 patients were randomized in the study, 68 to each arm. With a median follow up of 3.2 years, the 2-year PFS in the PCC arm was 89% in the overall, 96% in the low-risk and 67% in the intermediate/high-risk groups; in the C-TPF arm 2-year PFS was 88% in the overall, 88% in the low-risk and 89% in the intermediate/high-risk groups. Conclusion The observed 2-year PFS of PCC in the low-risk group and of C-TPF in the intermediate/high-risk group showed a 20% improvement compared with the historical control derived from RTOG-0129, therefore reaching the primary end point of the trial.

Background The purpose of this study was to evaluate the long-term outcomes after initial definitive or adjuvant radiotherapy (RT) for T3 laryngeal cancers. Methods We reviewed 412 patients treated for T3 laryngeal squamous cell cancer from 1985 to 2011. Results The 10-year overall survival (OS) was 35%; disease-specific-survival (DSS) was 61%; locoregional control was 76%; and freedom from distant metastasis was 83%. Chemotherapy, age, performance status

Background Enhanced phosphoinositide 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) pathway is one of the key adaptive changes accounting for epidermal growth factor receptor (EGFR) inhibitor-resistant growth in head and neck squamous cell carcinoma (HNSCC). We designed a phase II clinical trial of EGFR tyrosine kinase inhibitor (TKI), erlotinib, in association with the mTOR inhibitor, everolimus, based on the hypothesis that the downstream effects of Akt through inhibition of mTOR may enhance the effectiveness of the EGFR-TKI in patients with recurrent/metastatic HNSCC. Patients and methods Patients with histologically or cytologically confirmed platinum-resistant HNSCC received everolimus 5 mg and erlotinib 150 mg daily orally until disease progression, intolerable toxicity, investigator or patient decision. Cytokines and angiogenic factors profile, limited mutation analysis and p16 immunohistochemistry status were included in the biomarker analysis. Results Of the 35 assessable patients, 3 (8%) achieved partial response at 4 weeks, 1 confirmed at 12 weeks; overall response rate at 12 weeks was 2.8%. Twenty-seven (77%) patients achieved disease stabilization at 4 weeks, 11 (31%) confirmed at 12 weeks. Twelve-week progression-free survival (PFS) was 49%, median PFS 11.9 weeks and median overall survival (OS) 10.25 months. High neutrophil gelatinase lipocalin (P = 0.01) and vascular endothelial growth factor (VEGF) (P = 0.04) plasma levels were significantly associated with worse OS. Conclusions The combination of erlotinib and everolimus did not show significant benefit in unselected patients with platinum-resistant metastatic HNSCC despite a manageable toxicity profile. Markers of tumor invasion and hypoxia identify a group of patients with particularly poor prognosis. Clinical trial number NCT00942734.

Background Preclinical data demonstrate a key role for the epidermal growth factor receptor (EGFR) in the carcinogenesis of cutaneous squamous cell carcinomas (CSCCs). There are, however, limited data on the efficacy of EGFR inhibitors in incurable, recurrent, and/or metastatic CSCC. Objective To determine the response rate to gefitinib in patients with CSCC not amenable to curative therapy including surgery or radiation. Methods This was a single-arm phase II study. A total of 40 patients were treated with gefitinib, 250 mg orally daily, until disease progression or intolerable toxicities. The prespecified target response rate of interest was 20%. Results The overall response rate was 16% (95% confidence interval, 0.06-0.32; 6 partial responses in 37 evaluable patients). An additional 13 patients (35%) had stable disease at 8 weeks. The median durations of response and progression-free survival were 31.4 months (95% confidence interval, 3.91-not applicable) and 3.8 months (95% confidence interval, 2.2-5.7), respectively. The side effect profile was consistent with the previous experience with gefitinib in other tumor types. Limitations This was a single-institution, single-arm study. The prespecified target response rate was not met. Conclusion Gefitinib demonstrated modest activity in incurable CSCC, with a favorable adverse event profile.

Adenocarcinoma of the middle ear is a rare entity that must be distinguished from other adenomatous tumors of the temporal bone. We present the first patient of an intestinal-type adenocarcinoma originating from the middle ear.A 58-year-old woman presented with an 8-year history of left otorrhea. Her middle ear effusions were quite thick and gummy. She underwent eight sets of pressure-equalization tubes within 3 years. In 2011, her physical examination identified a middle ear mass, and she underwent mastoidectomy. A middle ear adenoma was resected. She underwent an additional three mastoidectomies for recurrence, with pathology from the 4th mastoidectomy revealing a diagnosis of adenocarcinoma. Imaging, at that time, showed an extensive temporal bone and Eustachian tube tumor.She underwent a left subtotal temporal bone resection, parotidectomy, infratemporal fossa resection, dural resection, and microvascular free flap reconstruction followed by postoperative proton beam radiotherapy.The final pathology report revealed intestinal-type adenocarcinoma.Treatment was successful and the patient remains disease free 4 years later.This is the first report of an intestinal-type adenocarcinoma of the middle ear and temporal bone. This patient also illustrates the difficulty of accurate histologic diagnosis of adenomatous tumors of the middle ear.

PURPOSE 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. METHODS The authors retrospectively reviewed the MRI characteristics, including T1 and T2 signal intensity, and enhancement pattern of 28 such flaps. RESULTS 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. CONCLUSIONS 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.

Purpose The goal of this study was to describe computed tomographic findings in patients with clinically proven temporal bone (TB) osteoradionecrosis (ORN) (TB-ORN). Materials and methods Computed tomographic scans of 20 patients were retrospectively evaluated for bony and soft tissue abnormalities. Clinical severity was graded based on level of therapy administered: mild (observation), moderate (antibiotics/hyperbaric oxygen), or severe (surgery). Results Radiation dose to the primary tumor ranged from 30 to 75.6 Gy. Time to onset of ORN from completion of radiation therapy was 2 to 22 years (median, 7 years). Clinical findings exposed bone, 20 of the 20 patients; otorrhea, 17 of the 20 patients; hearing loss, 11 of the 20 patients; otalgia, 10 of the 20 patients; facial nerve paralysis, 2 of the 20 patients; gait imbalance, 2 of the 20 patients. Computed tomographic findings: external auditory canal erosions, 18 of the 20 patients; mastoid effusion, 18 of the 20 patients; mastoid bony coalescence, 5 of the 20 patients; enhancing soft tissue, 6 of the 20 patients; soft tissue gas, 6 of the 20 patients; temporomandibular joint/condylar erosion, 3 of the 20 patients.Three patients developed an abscess. Conclusion Mastoid effusion and external auditory canal erosions are commonly seen with TB-ORN. Clinically moderate or severe cases of TB-ORN are more likely to demonstrate enhancing soft tissue (P = 0.002), soft tissue gas (P = 0.002), and temporomandibular joint involvement (P = 0.07).

BACKGROUND AND PURPOSE: Imaging correlates of genetic expression have been found for prognostic and predictive biomarkers of some malignant diseases, including breast and brain tumors. This study tests the hypothesis that imaging findings correlate with relevant genomic biomarkers in oral cavity squamous cell carcinoma. MATERIALS AND METHODS: Surplus frozen tissue from 27 untreated patients with oral cavity squamous cell carcinoma who underwent preoperative CT imaging was analyzed for gene expression. A team of neuroradiologists blinded to the genomic analysis results reviewed an extensive list of CT findings. The imaging correlated with genomic expression for cyclin D1, angiogenesis-related genes (vascular endothelial growth factor receptors and ligands), which relate to enhancement on the basis of other tumor types; and epidermal growth factor receptor, which may relate to proliferation and mass effect. RESULTS: Expression of vascular endothelial growth factor receptors 1 and 2 correlated with the enhancement of the primary tumor (P = .018 and P = .025, respectively), whereas the epidermal growth factor receptor correlated with mass effect (P = .03). Other exploratory correlations included epidermal growth factor receptor to perineural invasion (P = .05), and certain vascular endothelial growth factor receptors and ligands to mass effect (P = .03) and increased (P = .01) or decreased (P = .02) primary tumor size. CONCLUSIONS: We report that CT imaging correlates with gene expression in untreated oral cavity squamous cell carcinoma. Enhancement of the primary tumor and degree of mass effect correlate with relevant genomic biomarkers, which are also potential drug targets. Eventually, treatment decisions may be aided by combining imaging findings into meaningful phenotypes that relate directly to genomic biomarkers.

Criteria for detection of persistent nodal metastases in treated oropharyngeal tumors are sensitive but nonspecific, leading to unnecessary nodal dissections. Developing specific imaging criteria for persistent nodal metastases could improve diagnosis while decreasing patient morbidity.Patients with oropharyngeal squamous cell carcinoma with nodal metastases treated by definitive radiation therapy and subsequent nodal dissection were retrospectively evaluated. One hundred thirty-eight patients had pre- and posttherapy contrast-enhanced CTs evaluated by radiologists blinded to the status of pathologically proved hemineck persistent nodal metastases. Composite scoring criteria for CT, combined from individual parameters, were compared with radiologists' opinions, previous multiparameter criteria, and outcome data.New low-attenuation areas and a lack of size change (20% cross sectional area) were both highly specific for persistent nodal metastases (99%; P = .0004). Extranodal disease on pretherapy imaging was moderately specific (86%; P = .001). The CSC correctly placed 29 patients in a low-risk category compared with 14 by previously reported criteria and radiologist reports. With good second-rater reliability, the CSC cutoff values stratified patients at highest risk of persistent nodal metastases, thereby improving specificity while maintaining sensitivity.Comparing pre- and posttherapy examinations improves specificity by discriminating focal findings and size change compared with a single time point. The CSC can categorize the risk of persistent nodal metastases more accurately than previous CT methods. This finding has the potential to improve resource use and reduce surgical morbidity.

The aim of this report was to describe the computed tomography features of injected carboxymethylcellulose and how it can be mistaken for tumor recurrence. Carboxymethylcellulose is a low-density injectable indicated for short-term vocal fold augmentation. When used in patients with head and neck cancer, differentiating this agent from a neoplastic recurrence can be difficult on imaging. The imaging findings of five patients who received carboxymethylcellulose augmentation are presented to illustrate a potential pitfall of image interpretation. When injectable carboxymethylcellulose is used in cancer patients, knowledge of the injection sites, material used, and procedural history can avoid misinterpretation of monitory imaging.

One case report of a schwannoma involving the sympathetic plexus in the carotid canal has been reported previously. This article presents 2 additional cases of this rare entity with associated clinical and unique radiographic findings. All patients presented with diplopia among other symptoms, and they had enhancing masses that smoothly expanded the carotid canal on cross-sectional imaging. Comparison with the index case and differential diagnosis of more common pathologies in this area are discussed.

BACKGROUND: Treatment options for patients with advanced head and neck squamous cell carcinoma (HNSCC) are scarce. This phase 2 study was conducted to evaluate the safety, tolerability, pharmacokinetics, and efficacy of dasatinib in this setting. METHODS: Patients with recurrent and/or metastatic HNSCC after platinum-based therapy were treated with dasatinib either orally or via percutaneous feeding gastrostomy (PFG). Primary endpoints were 12-week progression-free survival (PFS) and objective response rate with a 2-stage design and early withdrawal if the 12-week PFS rate was ≤20% and no patients had an objective response (OR). Forty-nine serum cytokines and angiogenic factors (CAFs) were analyzed from treated patients. RESULTS: Of the 15 patients enrolled, 12 were evaluable for response, and all patients were evaluable for toxicity. No OR was observed and 2 patients (16.7%) had stable disease (SD) at 8 weeks. The median treatment duration was 59 days, the median time to disease progression was 3.9 weeks, and the median survival was 26 weeks. One patient required a dose reduction, 3 patients required dose interruptions, and 4 patients were hospitalized for toxicity. Dasatinib inhibited c-Src both when administered orally and via PFG. Greater mean drug exposure, decreased half-life, and greater maximum concentration were observed in patients receiving dasatinib via PFG. Eleven baseline CAFs were associated with treatment outcome and 1 CAF, macrophage migration inhibitory factor, was found to be differentially modulated in correlation with SD versus disease progression. CONCLUSIONS: Single-agent dasatinib failed to demonstrate significant activity in patients with advanced HNSCC, despite c-Src inhibition. The toxicity profile was consistent with that reported in other solid tumors, and the drug can be given via PFG tube. Cancer 2011. © 2010 American Cancer Society.

Purpose The optimal roles for imaging-based biomarkers in the management of head-and-neck cancer remain undefined. Unresolved questions include whether functional or anatomic imaging might improve mortality risk assessment for this disease. We addressed these issues in a prospective institutional trial. Methods and Materials Ninety-eight patients with locally advanced pharyngolaryngeal squamous cell cancer were enrolled. Each underwent pre- and post-chemoradiotherapy contrast-enhanced computed tomography (CT) and 18 F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT imaging. Imaging parameters were correlated with survival outcomes. Results Low post-radiation primary tumor FDG avidity correlated with improved survival on multivariate analysis; so too did complete primary tumor response by CT alone. Although both imaging modalities lacked sensitivity, each had high specificity and negative predictive value for disease-specific mortality risk assessment. Kaplan-Meier estimates confirmed that both CT and FDG-PET/CT stratify patients into distinct high- and low-probability survivorship groups on the basis of primary tumor response to radiotherapy. Subset analyses demonstrated that the prognostic value for each imaging modality was primarily derived from patients at high risk for local treatment failure (human papillomavirus [HPV]-negative disease, nonoropharyngeal primary disease, or tobacco use). Conclusions CT alone and FDG-PET/CT are potentially useful tools in head-and-neck cancer–specific mortality risk assessment after radiotherapy, particularly for selective use in cases of high-risk HPV-unrelated disease. Focus should be placed on corroboration and refinement of patient selection for imaging-based biomarkers in future studies.

Purpose To determine the potential efficacy of combining cetuximab with chemotherapy in patients with advanced nodal disease, we conducted a phase II trial with induction chemotherapy (ICT) consisting of six weekly cycles of paclitaxel 135 mg/m2 and carboplatin (area under the curve = 2) with cetuximab 400 mg/m2 in week 1 and then 250 mg/m2 (PCC). Patients and Methods Forty-seven previously untreated patients (41 with oropharynx primaries; 33 men, 14 women; median age, 53 years; performance status of 0 or 1) with squamous cell carcinoma of the head and neck (SCCHN; T1-4, N2b/c/3) were treated and evaluated for clinical and radiographic response. After ICT, patients underwent risk-based local therapy, which consisted of either radiation, concomitant chemoradiotherapy, or surgery, based on tumor stage and site at diagnosis. Results After induction PCC, nine patients (19%) achieved a complete response, and 36 patients (77%) achieved a partial response. The most common grade 3 or 4 toxicity was skin rash (45%), followed by neutropenia (21%) without fever. At a median follow-up time of 33 months, locoregional or systemic disease progression was observed in six patients. The 3-year progression-free survival (PFS) and overall survival (OS) rates were 87% (95% CI, 78% to 97%) and 91% (95% CI, 84% to 99%), respectively. Human papillomavirus (HPV) 16, found in 12 (46%) of 26 biopsies, was associated with improved PFS (P = .012) and OS (P = .046). Conclusion ICT with weekly PCC followed by risk-based local therapy seems to be feasible, effective, and well tolerated. PFS is promising, and this sequential treatment strategy should be further investigated. Patients with HPV-positive tumors have an excellent prognosis.

Purpose [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT) imaging may improve assessment of radiation response in patients with head and neck cancer, but it is not yet known for which patients this is most useful. We conducted a prospective trial to identify patient populations likely to benefit from the addition of functional imaging to the assessment of radiotherapy response. Patients and Methods Ninety-eight patients with locally advanced cancer of the oropharynx, larynx, or hypopharynx were prospectively enrolled and treated with primary radiotherapy, with or without chemotherapy. Patients underwent FDG-PET/CT and contrast-enhanced CT imaging 8 weeks after completion of treatment. Functional and anatomic imaging response was correlated with clinical and pathologic response. Imaging accuracy was then compared between imaging modalities. Results Although postradiation maximum standard uptake values were significantly higher in nonresponders compared with responders, the positive and negative predictive values of FDG-PET/CT scanning were similar to those for CT alone in the unselected study population. Subset analyses revealed that FDG-PET/CT outperformed CT alone in response assessment for patients at high risk for treatment failure (those with human papillomavirus [HPV] –negative disease, nonoropharyngeal primaries, or history of tobacco use). No benefit to FDG-PET/CT was seen for low-risk patients lacking these features. Conclusion These data do not support the broad application of FDG-PET/CT for radiation response assessment in unselected head and neck cancer patients. However, FDG-PET/CT may be the imaging modality of choice for patients with highest risk disease, particularly those with HPV-negative tumors. Optimal timing of FDG-PET/CT imaging after radiotherapy merits further investigation.

OBJECTIVE. We present the largest case series in the English-language imaging literature, emphasizing the variety of presentations of Rosai-Dorfman disease in the head and neck.CONCLUSION. Rosai-Dorfman disease is a rare disorder with multiple sites of involvement in the head and neck.

Objective/Hypothesis: To describe the clinical history and outcome of patients with adenoid cystic carcinoma (ACC) of the external auditory canal (EAC). Study Design: Retrospective case series. Methods: A search of our institution's tumor registry identified 22 patients with ACC of the EAC. Both clinical histories and pathology slides, when available, were reviewed. Results: The mean age at diagnosis was 42 years (median, 38.5 years), and the most common presenting complaints were otalgia and ear canal mass. Nine patients (41%) developed recurrences at a mean of 8 years (median, 8 years) after initial diagnosis, six died of ACC, and three were living with distant metastases at their last follow-up. The mean duration of symptoms at the time of diagnosis was 7.7 years (range, 2–30 years) for patients who developed a recurrence after treatment vs. 1.2 year (range, 0–2 years) for patients who remained disease-free (P = .137). Every patient who had recurrent disease reported a duration of symptoms of ≥2 years (P = .013), and every patient with a duration of symptoms >2 years recurred (P = .002). There was a trend for more local recurrences after limited resection (P = .061). Conclusions: ACC of the EAC often recurs many years after definitive treatment. Although our sample size was too small to make definitive conclusions, we recommend aggressive local therapy with lateral temporal bone resection and adjuvant postoperative radiotherapy. In addition to successful local therapy, early diagnosis may be the only other effective means of preventing distant metastases.

SUMMARY: Two modified fast spin-echo (FSE) techniques (a 2-point and a single-scan triple-echo Dixon) were used for T2-weighted imaging of the head and neck in 7 patients along with conventional FSE with fat saturation. Both Dixon techniques provided consistent and more uniform fat suppression (FS) than conventional FSE. The 2-point Dixon technique was noted to be more susceptible to motion artifacts. The triple-echo Dixon technique offered the best scan time efficiency and overall image quality.

BACKGROUND AND PURPOSE: The purpose of this study was to review CT imaging findings of soft tissue mucosal ulceration in patients following radiation treatment for head and neck malignancies and to correlate these with patient outcomes. MATERIALS AND METHODS: The CT examinations in 20 patients with soft tissue ulceration after radiation therapy for treatment of head and neck cancer were reviewed. External beam radiation therapy was completed between 3 and 61 months (mean, 11.5 months) before the initial diagnosis of soft tissue ulceration. In all 20 patients, the initial diagnosis was made or confirmed on CT examination. RESULTS: Of the 20 ulcerations, 12 did not demonstrate enhancement, and the results of biopsy in 9 of these 12 were negative. Of the 12 nonenhancing ulcerations, biopsy was not performed in 3, but they have been followed clinically and radiologically for 15.7 months without evidence of recurrence. Of the 20 ulcerations, 8 demonstrated adjacent enhancement, and the results of a biopsy in 4 were positive for recurrent cancer and negative in 2; these 2 have been followed for 16.3 months without evidence of recurrence. Biopsy was not performed in 2 ulcerations, but they have been followed for 15.0 months without evidence of recurrence. CONCLUSION: For soft tissue ulceration occurring after radiation treatment, if there is no enhancement or clinical evidence of recurrence, it is likely benign and follow-up without biopsy seems warranted. If the ulceration is associated with adjacent enhancement, then differentiation between radiation necrosis and recurrent tumor is difficult. In these cases, correlation with clinical examination with close interval follow-up is necessary if a biopsy is not performed.

Background. Lymph node metastasis from differentiated thyroid carcinoma may occur outside of the basins at greatest risk of spread, such as the lateral retropharyngeal lymph nodes. The extensive surgery of traditional approaches to the retropharyngeal space are rarely justified in the treatment of metastatic differentiated thyroid cancer. Therefore, a less invasive surgical approach is advantageous in resection of metastatic lateral retropharyngeal nodes. Methods. To assess feasibility and safety, we report transoral excision guided by preoperative ultrasonography in a series of 3 consecutive patients with differentiated thyroid cancer metastatic to the retropharyngeal space. Results. In all cases, the metastatic lateral retropharyngeal lymph node was successfully removed by transoral retropharyngotomy without complications. Conclusions. We advocate a transoral approach guided by preoperative ultrasonography for resection of differentiated thyroid cancer metastatic to the retropharyngeal lymph nodes. The approach is feasible, minimally invasive, and safe in achieving the goals in management of regionally metastatic disease. © 2006 Wiley Periodicals, Inc. Head Neck, 2007

To determine retrospectively the frequency of two artifact patterns that mimic pathologic lesions on computed tomographic (CT) head images acquired in the axial scanning mode with two different multi-detector row CT systems at the same institution.The institutional review board approved this Health Insurance Portability and Accountability Act-compliant study and waived informed consent. The study involved two groups of consecutive patients, a group of 22 (nine men, 13 women; mean age, 56 years; age range, 27-85 years) examined with one multi-detector row CT system with four detector rows, and another group of 13 (seven men, six women; mean age, 69 years; age range, 53-81 years) examined with a different four-detector row CT system. Examinations in each group took place in a 4-week period. CT images were retrospectively evaluated by a neuroradiologist and a physicist for presence, appearance, location (within the image set and on individual images), and size of artifacts. Elimination of artifacts was verified by scanning a water phantom after scanner service and repair.A pseudolesion, or artifact, was identified in scans of four of 22 patients examined with the first scanner and eight of 13 patients examined with the second scanner. The artifact on images obtained on the first scanner, an approximately 2-cm-diameter faintly hyperattenuating and nonenhancing area with hypoattenuating collar, was found at gantry isocenter on every fourth image. A different pattern was found on images obtained on the second scanner: a 1.1-cm-diameter circular area of hypoattenuation with a faintly attenuating rim, that mimicked a cyst. This artifact was observed also at the CT scanner gantry isocenter on every fourth image. Artifacts disappeared after recalibration (first scanner) or collimator cleaning (second scanner).CT scanning in the axial mode can produce a regularly repeating artifact when data from one detector row of a multi-detector row CT scanner are compromised. Because of the risk of misinterpreting such patterns, routine assessment of each detector element is recommended for multi-detector row CT scanners that are routinely used in the axial scanning mode.

Our purpose was to present 3 cases of perineural tumor spread (PNS) to the oculomotor (CN III) nerve. To our knowledge, PNS to CN III has not been previously reported. In the course of advanced PNS, typically with involvement of the cavernous sinus, tumor may spread in a retrograde fashion to involve CN III in the interpeduncular fossa and can even invade the brainstem.

BACKGROUND The objectives of this study were to determine the efficacy, organ-preservation rate, and safety of intraarterial (IA) cisplatin in combination with intravenous paclitaxel and ifosfamide in patients with locally advanced carcinoma of the paranasal sinuses who required orbital exenteration or major craniofacial resection for complete tumor resection. METHODS Patients were treated with intravenous paclitaxel (135 mg/m2) on Day 1, ifosfamide (1000 mg/m2) on Days 1–3, sodium mercaptoethanesulfonate (600 mg/m2) on Days 1–3, and IA cisplatin (100 mg/m2) on Day 1 every 21 days. RESULTS Of 24 study participants, 20 patients received at least 1 course of IA cisplatin, 1 patient had an early death, and 19 patients were evaluable for response. Five of those 19 patients (26%) achieved a complete response (CR), 6 patients (32%) achieved a partial response, and 8 patients (42%) had stable disease or developed progressive disease. Eye-sparing surgery followed by radiotherapy (RT) was feasible in 7 of 24 patients, RT was offered to only 7 patients, whereas 3 patients received chemotherapy and RT, 2 patients refused further therapy, 3 patients underwent craniofacial resection with orbitectomy, and 1 patient was treated systemically for metastatic disease. At the completion of treatment, 14 of 23 patients (61%) with locally advanced disease were disease free, and the orbit was preserved in 21 of 24 patients (88%). The overall survival, progression-free survival, and disease-free survival rates at 2 years were 60%, 50%, and 84%, respectively. Toxicity was substantial, with two patients experiencing cerebrovascular ischemia (one transient and one cerebrovascular accident) and three patients experiencing cranial neuropathy, which was reversible in two patients. CONCLUSIONS Despite the encouraging organ-preservation rate, the approach studied resulted in substantial toxicity, and more effective adjunctive therapy is needed. Alternative approaches, including the integration of targeted therapy agents in induction chemotherapy regimens followed by concomitant chemotherapy and RT or eye-sparing surgery, need further exploration. Cancer 2003. © 2003 American Cancer Society.

Purpose To describe the clinical features and histologic classification of orbital lymphoma secondary to systemic non-Hodgkin lymphoma, to evaluate the efficacy of various treatment modalities for controlling the orbital component of disease, and to analyze vision-related outcomes. Methods In this retrospective case series, the clinical records of patients diagnosed with orbital lymphoma who were treated between January 1999 and May 2001 at the University of Texas M.D. Anderson Cancer Center were reviewed. Demographic data, histologic classification of lymphoma, immunophenotype, stage of disease, treatment outcomes, vision-related outcomes, and duration of follow-up after the diagnosis of orbital lymphoma were recorded in each case. Results At the time of diagnosis, all 15 patients identified either had a previous history of non-Hodgkin lymphoma or had simultaneous involvement of lymph node or other sites. Ten patients (67%) had intermediate-grade or high-grade lymphoma. All 15 patients had a B-cell phenotype. Systemic chemotherapy or immunotherapy was the initial treatment modality in 13 patients; the other 2 patients were treated with radiation as the initial mode of therapy. Eleven patients (73%) achieved complete regression of the orbital tumor; one patient had partial regression of the orbital lymphoma. Loss of vision secondary to compressive optic neuropathy was seen in 5 patients (33%); in 3 of these patients, the orbital lymphoma was diagnosed early and treatment was successful in reversing the loss of vision. One patient had irreversible vision loss secondary to compressive optic neuropathy; in this case, therapy had not been initiated until several months after onset of symptoms. Another patient died of lymphoma before the orbital disease could have responded to therapy. Conclusions Because of often widespread systemic involvement and a usually more aggressive histologic classification than primary orbital lymphomas, secondary orbital lymphomas warrant treatment with systemic chemotherapy or systemic immunotherapy. In some cases, combining such systemic therapy with local radiation treatment is beneficial. Loss of vision as the result of compressive optic neuropathy in this setting can be reversed if systemic therapy is initiated soon after the onset of progressive signs and symptoms of orbital disease.

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.

To compare contrast material-enhanced T1-weighted and fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) images in depicting leptomeningeal metastases.Malignant lesions detected at cytologic examination of cerebrospinal fluid in 70 patients were reviewed. There were 58 studies in which both FLAIR and contrast-enhanced T1-weighted spin-echo MR images were available. A senior neuroradiologist reviewed the images from each sequence individually and separately for signs of leptomeningeal metastases and assigned a diagnostic rating of positive, indeterminate, or negative.Leptomeningeal metastases were depicted in 38 cases on contrast-enhanced T1-weighted spin-echo images and in 20 cases on FLAIR images. In three cases, leptomeningeal metastases were detected by using only FLAIR images. In 20 cases, leptomeningeal metastases were detected by using only contrast-enhanced T1-weighted spin-echo images. FLAIR imaging has a sensitivity of 34% for cytologically proved leptomeningeal metastases. Gadolinium-enhanced MR imaging has a sensitivity of 66%.Used alone, contrast-enhanced T1-weighted images are better than FLAIR images for detecting leptomeningeal metastases. This is particularly true for cases in which leptomeningeal metastases manifest primarily or solely as cranial nerve involvement.

PURPOSE Standard therapies of head and neck squamous cell carcinoma (HNSCC) often cause profound morbidity and have not significantly improved survival over the last 30 years. Preclinical studies showed that adenoviral vector delivery of the wild-type p53 gene reduced tumor growth in mouse xenograft models. Our purpose was to ascertain the safety and therapeutic potential of adenoviral (Ad)-p53 in advanced HNSCC. PATIENTS AND METHODS Patients with incurable recurrent local or regionally metastatic HNSCC received multiple intratumoral injections of Ad-p53, either with or without tumor resection. Patients were monitored for adverse events and antiadenoviral antibodies, tumors were monitored for response and p53 expression, and body fluids were analyzed for Ad-p53. RESULTS Tumors of 33 patients were injected with doses of up to 1 x 10(11) plaque-forming units (pfu). No dose-limiting toxicity or serious adverse events were noted. p53 expression was detected in tumor biopsies despite antibody responses after Ad-p53 injections. Clinical efficacy could be evaluated in 17 patients with nonresectable tumors: two patients showed objective tumor regressions of greater than 50%, six patients showed stable disease for up to 3.5 months, and nine patients showed progressive disease. One resectable patient was considered a complete pathologic response. Ad-p53 was detected in blood and urine in a dose-dependent fashion, and in sputum. CONCLUSION Patients were safely injected intratumorally with Ad-p53. Objective antitumor activity was detected in several patients. The infectious Ad-p53 in body fluids was asymptomatic, and suggests that systemic or regional treatment may be tolerable. These results suggest the further investigation of Ad-p53 as a therapeutic agent for patients with HNSCC.

Case report Three cases of intractable pain arising from widespread metastatic cancer with poor response to opioids were treated with MRI-guided cingulotomy. Results and conclusions In most cases, MRI-guided cingulotomy was associated with significant pain relief and reduced opioid use. To provide insight into the role of MRI-guided cingulotomy in oncologic pain refractory to more conservative measures, the relative risks and benefits of cingulotomy are discussed, along with the course of one patient who experienced postoperative cognitive impairment. This report also describes the relevant neurosurgical and pharmacotherapeutic issues associated with management of pain in patients with widespread metastatic disease.

Diagnostic imaging is frequently used to evaluate the patient who has or may have an infection or other inflammatory lesion in the neck. In fact, these diagnoses and their differentiation from tumor may only be made after a careful radiological evaluation. This review will illustrate the imaging appearance of many of the common inflammatory conditions that may arise in the neck. In most, but not all cases, CT is the imaging study of choice in the initial work-up of this patient population.

BACKGROUND AND PURPOSE: Human papillomavirus–positive oropharyngeal cancers typically have younger age of onset, limited tobacco exposure, and more favorable prognosis than HPV-negative oropharyngeal cancers. We assessed whether HPV-positive and HPV-negative oropharyngeal cancers have consistent differences in pretreatment imaging characteristics. MATERIALS AND METHODS: A retrospective review of 136 pretreatment CT examinations of paired HPV-positive and HPV-negative oropharyngeal cancers matched for T stage, tumor subsite, and smoking status was performed with the reviewing radiologist blinded to HPV status and clinical stage. Demographic/clinical characteristics and imaging characteristics of primary lesions and metastatic nodal disease were compared by use of Fisher exact testing. The McNemar χ2 test was used for the matched-pair analysis. RESULTS: By imaging, HPV-negative tumors were more likely to demonstrate invasion of adjacent muscle (26% versus 6%, P = .013). HPV-positive primary tumors were more likely to be enhancing and exophytic with well-defined borders, whereas HPV-negative primary tumors were more likely to be isoattenuated and demonstrate ill-defined borders, though these results were not statistically significant. HPV-positive tumors were more likely to demonstrate cystic nodal metastases than HPV-negative tumors (36% versus 9%, P = .002). CONCLUSIONS: In this matched and blinded analysis of the imaging differences between HPV-positive and HPV-negative oropharyngeal cancers, HPV-positive carcinomas often had primary lesions with well-defined borders and cystic nodal metastases, whereas HPV-negative primaries more often had poorly defined borders and invasion of adjacent muscle.

Perineural spread along the nasociliary branch of the ophthalmic nerve has not been previously described, to our knowledge. One case of cutaneous squamous carcinoma at the medial canthus and another of melanoma of the nasal ala, with nasociliary nerve perineural spread, are illustrated here. Whereas magnetic resonance imaging is preferred to search for perineural spread, computed tomography may also demonstrate perineural thickening and enhancement. Awareness of the computed tomography appearance of perineural spread will aid in avoiding misdiagnosis.

Modern imaging plays an important role in the management of the patient with a meningioma. From initial diagnosis to postoperative evaluation and follow-up studies, the radiologist must be aware of the various and sometimes atypical imaging appearances of meningioma. This is often very satisfying since the imaging characteristics of meningioma are usually, but not always, diagnostic. This manuscript will briefly review the historical development of the imaging of meningioma and then describe the typical and atypical imaging appearances of this very common intracranial tumor.

Patients with systemic leukemia, especially the acute leukemias, are at an increased risk of developing disease of the CNS or head and neck. Such disease may take the form of direct leukemic involvement, may result from underlying leukemic effects on the immune or hematopoietic systems, or may result from antileukemic therapy. This review presents the imaging and clinical features of the spectrum of CNS and head and neck disease that may be encountered in patients with systemic leukemia. An understanding of the role of radiology in the management of these patients is important to the practicing radiologist who is confronted with a leukemic patient presenting with signs and symptoms of neurologic dysfunction.

Langerhans cell histiocytosis is a systemic disorder consisting of abnormal histiocyte proliferation, in the form of focal deposits. Central nervous system involvement is most common in the hypothalamus, although other sites have been described, such as the cerebellum and the meninges. We present a case with presumed involvement of the corpus callosum and cerebellum, demonstrating gadolinium enhancement on MRI.

Background Radiation therapy can result in osteoradionecrosis (ORN) and mucosal ulceration predisposing to infection. Methods Fourteen patients presenting with infectious sequelae related to mandibular ORN were retrospectively reviewed. Results In most patients, infection followed diagnosis of ORN; but in 4 patients, ORN was not diagnosed until after the time of infection and imaging. An early imaging finding of ORN was lingual cortical defects near the last molar. Pain followed by erythema, purulent drainage, and subperiosteal abscess by imaging were the most common signs of infection. In most patients, conservative management eventually failed and segmental mandibulectomies were required. Conclusions Soft tissue infection with characteristic bone findings such as subperiosteal abscess and cortical bone erosions helps to distinguish infected ORN from recurrent tumor or sterile ORN. In patients previously treated with radiation who present with infection, pain or an avid PET scan with bone involvement, the mandible should be scrutinized.

To assess syringe use among neuroangiographers and evaluate air emboli produced with glass and plastic syringes.Questionnaires on syringes use were sent to 100 members of the American Society of Neuroradiology (ASNR). An in vitro system counted emboli during injections of contrast material and saline solution with either glass or plastic syringes. At Doppler sonography, an embolic signal was defined as the power of the reflected amplitude with auditory and visual confirmation.Of 62 respondents, 11.3% used glass syringes exclusively and 80.6% used plastic exclusively. Glass breakage was experienced by 72.5%, and 40% of them recalled an injury associated with such a breakage. No statistically significant difference was found between glass and plastic syringes for introduction of air emboli, though two outlying values represented larger numbers of emboli in the group with plastic syringes and contrast material.No reason for the continued use of glass syringes was found. No statistically greater risk of air emboli was shown with plastic syringes, and risk of breakage and injury is prevented. Caution is advised when injecting contrast material with plastic syringes because more air emboli may be introduced.

Palatal tumors are often treated with palatectomy or maxillectomy. The resulting surgical defect produces an oroantral communication. An obturator is a removable prosthesis used to close the palatal or maxillectomy defect. Fifteen patients who had undergone palatectomy or maxillectomy for carcinoma and subsequent obturator prosthesis placement were retrospectively studied. Obturators were characterized by Hounsfield units and were subdivided into 3 CT imaging groups: either hyperattenuated, hollow (air-containing), or heterogeneous (isoattenuated to hyperattenuated with internal foci of air). Eight patients had hyperattenuated obturators either representing acrylic resin or Trusoft. Four patients had hollow obturators also composed of acrylic resin or Trusoft. Three patients had heterogeneous obturators, which were composed of only Trusoft. The postoperative imaging of patients treated for palatal or maxillary tumors can be complicated by the presence of obturator prostheses. The intent of this article was to familiarize the reader with the CT imaging features of obturator prostheses.

Summary Sarcomas developing after radiation treatment for primary malignancies of the head and neck are often detected clinically when they are very aggressive. We reviewed the patient demographics and imaging findings in 21 patients with radiation-associated sarcomas (RAS) of the head and neck treated at our institution. Twenty-one RAS of the head and neck were retrospectively reviewed. The lesions were assessed for presence of a soft tissue mass, enhancement pattern, bone destruction, characteristics of tumor matrix, and FDG avidity. The RAS developed 4.5–25 years (mean 12.7 years) after irradiation. On both CT and MRI, all 21 lesions presented with a soft tissue mass. A variable imaging appearance was noted on CT, MR, and PET/CT, most, but not all, demonstrated aggressive features. At a median follow-up time of 19.1 months, 11 of the 21 patients had died from the sarcoma. RAS have variable imaging appearances. While most demonstrate aggressive features, some appear benign, which can lead to misdiagnosis. Head and neck radiologists, surgeons and oncologists who manage patients after radiation treatment should be aware of the wide range of clinical presentations and imaging features of RAS, because failure to diagnose can delay appropriate treatment.

This analysis was undertaken to assess the need for planned neck dissection in patients with a complete response (CR) of involved nodes after irradiation and to determine the benefit of a neck dissection in those with less than CR by tumor site.Our cohort included 880 patients with T1-4, N1-3M0 squamous cell carcinoma of the oropharynx, larynx, or hypopharynx who received treatment between 1994 and 2004. Survival curves were calculated by the Kaplan-Meier Method, comparisons of rates with the log-rank test and prognostic factors by Cox's proportional hazard model.Nodal CR occurred in 377 (43%) patients, of whom 365 patients did not undergo nodal dissection. The 5-year actuarial regional control rate of patients with CR was 92%. Two hundred sixty-eight of the remaining patients (53%) underwent neck dissections. The 5-year actuarial regional control rate for patients without a CR was 84%. Those who had a neck dissection fared better with 5-year actuarial regional control rates of 90% and 76% for those operated and those not operated (p0.001). Variables associated with poorer regional control rates included higher T and N stage, non-oropharynx cancers, non-CR, both clinical and pathological.With 92% 5-year neck control rate without neck dissection after CR, there is little justification for systematic neck dissection. The addition of a neck dissection resulted in higher neck control after partial response though patients with viable tumor on pathology specimens had poorer outcomes. The identification of that subgroup that benefits from additional treatment remains a challenge.

BACKGROUND AND PURPOSE: Incidental positron-emission tomography (PET) uptake in the thyroid bed represents a diagnostic dilemma. Currently, there is no consensus regarding the significance of this finding or the most appropriate approach to management. The purpose of this study was to determine the significance of incidental fluorodeoxyglucose (FDG) uptake in the thyroid gland on [(18)F]FDG–positron-emission tomography (FDG-PET/CT) in patients being initially staged for lymphomas and/or cancers other than of thyroid origin. MATERIALS AND METHODS: A retrospective review was conducted on patients who were incidentally found to have focal FDG uptake in the thyroid bed on initial staging for cancer. Patient records were assessed for age, sex, clinical presentation, standard uptake values (SUV(max)), on FDG-PET/CT, and CT findings in those patients undergoing FDG-PET/CT, fine-needle aspiration (FNA) cytology, and surgical pathologic examination. RESULTS: Thirty patients were identified with incidental FDG-PET uptake in the thyroid bed from 630 studies performed for evaluation of cancer between March 2004 and June 2006. Complete records were available for 18 patients (6 men, 12 women). Five (27.8%) of 18 patients with incidental focal FDG-PET/CT uptake in the thyroid gland demonstrated papillary thyroid carcinoma on final pathologic findings. The mean and SD of SUV(max) was 3.0 ± 1.8 (range, 1.1–7.4) overall, 2.9 ± 1.6 (range, 1.1–6.8) in the patients without malignant growth, and 3.4 ± 2.6 (range, 1.1–7.4) in the 5 patients with papillary thyroid carcinoma. No statistical difference in SUV(max) was noted between patients with papillary thyroid carcinoma and patients with benign pathologic findings (P = .63). CONCLUSIONS: Incidental FDG-PET uptake in the thyroid gland in patients with cancer of nonthyroidal origin is associated with a 27.8% risk for well-differentiated thyroid carcinoma; however, there seems to be no correlation between intensity of FDG uptake and the risk for a malignant process.

Modern imaging techniques play a vital role in the diagnostic evaluation and follow-up of patients with neoplastic disease affecting the skull base. Many of these lesions have a high rate of recurrence if surgical removal is not complete. Newer, more aggressive surgical approaches can have a maximal effect only if the full extent of a lesion is known preoperatively. CT and MR imaging provide the surgeon with detailed information about every site of tumor involvement. Although these lesions are not common in clinical radiologic practice, the radiologist must be prepared to offer a reasonable differential diagnosis and a full evaluation of the extent of disease. This review presents some of the more commonly encountered tumors that can affect the skull base and describes their radiologic features, with emphasis on CT and MR imaging.

Purpose: To describe a case of perineural invasion resulting from squamous cell carcinoma of forehead. Methods: Case report. Results: Perineural invasion resulting from squamous cell carcinoma of the periocular skin can present as a Tolosa-Hunt-like syndrome with lack of radiologic findings on magnetic resonance imaging (MRI) in its early stages. Conclusion: A high level of suspicion for perineural invasion is required when assessing multiple cranial nerve palsies in patients with a history of cutaneous malignancy, despite negative sequential MRI. Perineural invasion must be ruled out by a biopsy of the involved nerves, whenever possible, before empiric therapy with systemic steroids is contemplated.

BACKGROUND AND PURPOSE: ORN is a postradiation complication that has been well-documented in the medical literature. Most cases in the head and neck have been described in the mandible or larynx. Only a handful of cases in the hyoid bone are documented, all in the clinical literature. Our purpose is to present the clinical and imaging features of ORN involving the hyoid bone. MATERIALS AND METHODS: We present a case series of 13 patients with imaging findings highly suggestive of hyoid ORN after radiation therapy for head and neck cancers, in which we observed progressive features of hyoid disruption along with adjacent soft-tissue ulceration. RESULTS: Pretreatment imaging, when available, showed a normal hyoid. Typical postradiation imaging findings included an initial tongue base ulcerative lesion with air approaching the hyoid bone, and subsequent observation of hyoid fragmentation, often with intraosseous or peri-hyoid air and the absence of associated mass-like enhancement. CONCLUSIONS: Findings of hyoid fragmentation, cortical disruption, and soft tissue or intraosseous air in the postradiation therapy patient should strongly suggest the diagnosis of hyoid ORN. It is important recognize this entity because the diagnosis may preclude potentially harmful diagnostic intervention and allow more appropriate therapy.

Objective: Treatment options for recurrent squamous cell carcinoma of the head and neck (SCCHN) following platinum-based therapy are limited. Lonafarnib is a potent, specific inhibitor of farnesyl transferase that demonstrated marked antitumor activity as monotherapy in treatment-naive SCCHN in a phase Ib study. A phase II study of lonafarnib was conducted to determine its efficacy and safety in patients with recurrent, platinum-refractory SCCHN. Methods: This was an open-label, phase II, single-center study in patients with recurrent SCCHN after platinum-based therapy. A Simon 2-stage design was used, with a plan to close the study to further accrual if

Background. Despite the generally favorable prognosis of patients with papillary thyroid cancers, 10-year re- currence rates for patients with stage I to III disease is greater than 20%, with central compartment recurrences common among these recurrent sites. Methods. This study is a retrospective analysis of consecu- tive patients treated by a single surgeon over an 18-month pe- riod of time terminating in 2003. Results. Sixty-three patients underwent a comprehensive dissection of levels VI and VII for papillary thyroid carcinoma dur- ing this period. There was a female predominance of 2:1, with 48% of patients being greater than 45 years of age. The median number of lymph nodes identified was 16 (range, 3-52), with 7 (1-20) lymph nodes pathologically involved. Permanent hypo- parathyroidism was present on presentation in 13% of patients and developed in an additional 5% following surgery. Although recurrent laryngeal paralysis was present on presentation among 8 (13%) of patients, no patients experienced paralysis of documented functioning recurrent laryngeal nerves or necessi- tated tracheotomy. Postoperative thyroglobulin levels were reduced to nondetectable in 71% of the informative cases. Over 60% of patients were discharged on their first postoperative day. Conclusion. Bilateral paratracheal and superior mediastinal dissection is an oncologically safe procedure exhibiting mini- mal morbidity when performed among experienced individuals despite multiple prior surgical procedures or existing vocal cord paralysis. V C 2009 Wiley Periodicals, Inc. Head Neck 31: 1152-1163, 2009

Purpose For patients with stage II to IV laryngeal cancer, radiation therapy (RT) either alone or with concurrent chemotherapy provides the highest rate of organ preservation but can be associated with functional impairment. Thus, we studied the use of induction chemotherapy with or without conservation laryngeal surgery (CLS). Our objectives were to study the sensitivity of laryngeal cancer to platinum-based chemotherapy alone and to highlight the efficacy of CLS in this setting. Patients and Methods Thirty-one previously untreated patients with laryngeal cancer (T2-4, N0-1, M0), who were resectable with CLS, were enrolled. Patients received three to four cycles of paclitaxel, ifosfamide, and cisplatin (TIP) chemotherapy, and response was assessed histologically. Patients with partial response (PR) proceeded to CLS. Patients achieving pathologic complete response (pCR) received an additional three cycles of TIP and no other treatment. Results Thirty patients were assessable for response. With TIP chemotherapy alone, 11 patients (37%) achieved pCR, 10 of whom (33%) remain alive with durable disease remission and no evidence of recurrence over a median follow-up time of 5 years. Nineteen patients (63%) treated with TIP alone achieved PR. The overall laryngeal preservation (LP) rate was 83%, and only five patients (16%) required postoperative RT. No patient required a gastrostomy tube or tracheotomy. Conclusion Chemotherapy alone in selected patients with T2-4, N0-1 laryngeal cancer can provide durable disease remission at 5 years. For patients with PR, CLS provides a high rate of LP. This prospective study suggests that chemotherapy alone may cure selected patients with laryngeal cancer, warranting further prospective investigation.