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Study Design: case series. Objective: The restoration of defects in a single procedure with microvascular free flap reconstruction has become a mainstay of head and neck surgery. Yet in patients with complex defects and pre-existing comorbid medical conditions, a staged-reconstructive approach can enhance the safety of the procedure and improve the patient’s outcome. Methods: We present 3 representative case examples of a larger series of patients who underwent reconstruction of major defects and discuss the usefulness of a staged-reconstructive approach in the management of complex patients. Results: All 3 patients, with an existing composite defect in the setting of prior radiation therapy, underwent successful staged-reconstructive surgery using a variety of free tissue and regional flap transfers. Conclusions: A staged approach facilitates the reconstruction of complex composite defects, increases vessel availability, and mitigates the risk of flap failure. Although this approach commits the patient to multiple procedures and a more prolonged plan of care, it is preferable to 1 operation in specific complex situations with adverse, high-risk clinical features.

Supplemental Digital Content is available in the text., After deployment to Southwest Asia, some soldiers develop persistent respiratory symptoms, including exercise intolerance and exertional dyspnea. We identified 50 soldiers with a history of deployment to Southwest Asia who presented with unexplained dyspnea and underwent an unrevealing clinical evaluation followed by surgical lung biopsy. Lung tissue specimens from 17 age-matched, nonsmoking subjects were used as controls. Quantitative histomorphometry was performed for evaluation of inflammation and pathologic remodeling of small airways, pulmonary vasculature, alveolar tissue and visceral pleura. Compared with control subjects, lung biopsies from affected soldiers revealed a variety of pathologic changes involving their distal lungs, particularly related to bronchovascular bundles. Bronchioles from soldiers had increased thickness of the lamina propria, smooth muscle hypertrophy, and increased collagen content. In adjacent arteries, smooth muscle hypertrophy and adventitial thickening resulted in increased wall-to-lumen ratio in affected soldiers. Infiltration of CD4 and CD8 T lymphocytes was noted within airway walls, along with increased formation of lymphoid follicles. In alveolar parenchyma, collagen and elastin content were increased and capillary density was reduced in interalveolar septa from soldiers compared to control subjects. In addition, pleural involvement with inflammation and/or fibrosis was present in the majority (92%) of soldiers. Clinical follow-up of 29 soldiers (ranging from 1 to 15 y) showed persistence of exertional dyspnea in all individuals and a decline in total lung capacity. Susceptible soldiers develop a postdeployment respiratory syndrome that includes exertional dyspnea and complex pathologic changes affecting small airways, pulmonary vasculature, alveolar tissue, and visceral pleura.

OBJECTIVES/HYPOTHESIS The primary objective of this study was to assess the safety of parathyroidectomy during pregnancy as treatment for hyperparathyroidism (HPTH) in comparison to nonsurgical management plans. Secondary outcomes involved analyzing the safety of surgery in the third trimester and the benefit of operating on asymptomatic pregnant patients. STUDY DESIGN Systematic review. METHODS PRISMA-guided systematic review of all cases of primary hyperparathyroidism during pregnancy published in peer-reviewed English journals on PubMed/MEDLINE, EMBASE, and SCOPUS from 1980 to 2020. RESULTS A total of 75 manuscripts were included in this review describing 382 cases of gestational hyperparathyroidism. The median maternal age was 31 years. Overall, 108 cases (28.3%) underwent parathyroidectomy during pregnancy while 274 cases (71.7%) were treated nonsurgically. The majority of surgeries took place during the second trimester (67.6%). Complications and/or deaths were less likely to occur after surgery in the second trimester (4.48%) as compared to surgery in the third trimester (21.1%). Nine surgically treated cases resulted in infant complications and/or death; however, none of these nine cases had any surgical complications. Despite these complications, the overall infant complication rate for patients who underwent surgical treatment remained lower than that of patients treated with conservative therapy (9.1% vs. 38.9%). CONCLUSIONS This review suggests that for all pregnant patients with diagnosed HPTH, parathyroidectomy should be considered regardless of symptomatology. Our data suggest that parathyroidectomy is associated with fewer risks than more conservative treatments and results in better fetal outcomes. Surgery during the third trimester is feasible and surgery should be considered in both symptomatic and asymptomatic patients. Laryngoscope, 131:1915-1921, 2021.

SUMMARY: The osteomyocutaneous iliac crest free flap is a reconstructive option for segmental mandibular or complex palatomaxillary defects. Familiarity with the radiographic appearance of free flaps such as the iliac crest is necessary for the postoperative evaluation of patients after mandibular, maxillary, or palatal reconstructions because it allows radiologists to properly monitor and interpret the appearance of the flap over time. This study presents a retrospective review of 5 patients who underwent palatomaxillary reconstruction with an iliac crest free flap at our institution. The imaging appearances of the 5 patients were analyzed to determine the key radiographic characteristics of a healthy and successful iliac crest free flap. Radiographic fluency with the imaging appearance of the iliac crest free flap, as well as the new anatomy of the region in the postoperative period, will allow for better interpretation of the flap appearance on imaging and will prevent false identification of tumor recurrence.

BackgroundA systems-level approach to smoking cessation treatment may optimize healthcare provider adherence to guidelines. Institutions such as the Veterans Health Administration (VHA) are unique in their systematic approach, but comparisons of provider behavior in different healthcare systems are limited.MethodsWe surveyed general medicine providers and specialists in a large academic health center (AHC) and its affiliated VHA in the Mid-South in 2017 to determine the cross-sectional association of healthcare system in which the provider practiced (exposure: AHC versus VHA) with self-reported provision of evidence-based smoking cessation treatment (delivery of counseling plus smoking cessation medication or referral) at least once in the past 12 months (composite outcome). Multivariable logistic regression with adjustment for specialty was performed in 2017–2019.ResultsOf 625 healthcare providers surveyed, 407 (65%) responded, and 366 (59%) were analyzed. Most respondents practiced at the AHC (273[75%] vs VHA 93[25%]) and were general internists (215[59%]); pulmonologists (39[11%]); hematologists/oncologists (69[19%]); and gynecologists (43[12%]). Most respondents (328[90%]) reported the primary outcome. The adjusted odds of evidence-based smoking cessation treatment were higher among VHA vs. AHC healthcare providers (aOR = 4.3; 95% CI 1.3–14.4;p = .02). Health systems differed by provision of individual treatment components, including smoking cessation medication use (98% VHA vs. 90% AHC,p = 0.02) and referral to smoking cessation services (91% VHA vs. 65% AHCp = 0.001).ConclusionsVHA healthcare providers were significantly more likely to provide evidence-based smoking cessation treatment compared to AHC healthcare providers. Healthcare systems’ prioritization of and investment in smoking cessation treatment is critical to improving providers’ adherence to guidelines.

PURPOSE: To develop a model to estimate lung cancer risk using lung cancer screening CT and clinical data elements (CDEs) without manual reading efforts. MATERIALS AND METHODS: Two screening cohorts were retrospectively studied: the National Lung Screening Trial (NLST; participants enrolled between August 2002 and April 2004) and the Vanderbilt Lung Screening Program (VLSP; participants enrolled between 2015 and 2018). Fivefold cross-validation using the NLST dataset was used for initial development and assessment of the co-learning model using whole CT scans and CDEs. The VLSP dataset was used for external testing of the developed model. Area under the receiver operating characteristic curve (AUC) and area under the precision-recall curve were used to measure the performance of the model. The developed model was compared with published risk-prediction models that used only CDEs or imaging data alone. The Brock model was also included for comparison by imputing missing values for patients without a dominant pulmonary nodule. RESULTS: A total of 23 505 patients from the NLST (mean age, 62 years ± 5 [standard deviation]; 13 838 men, 9667 women) and 147 patients from the VLSP (mean age, 65 years ± 5; 82 men, 65 women) were included. Using cross-validation on the NLST dataset, the AUC of the proposed co-learning model (AUC, 0.88) was higher than the published models predicted with CDEs only (AUC, 0.69; P < .05) and with images only (AUC, 0.86; P < .05). Additionally, using the external VLSP test dataset, the co-learning model had a higher performance than each of the published individual models (AUC, 0.91 [co-learning] vs 0.59 [CDE-only] and 0.88 [image-only]; P < .05 for both comparisons). CONCLUSION: The proposed co-learning predictive model combining chest CT images and CDEs had a higher performance for lung cancer risk prediction than models that contained only CDE or only image data; the proposed model also had a higher performance than the Brock model. Keywords: Computer-aided Diagnosis (CAD), CT, Lung, Thorax Supplemental material is available for this article. © RSNA, 2021

Rationale- Patients with indeterminate pulmonary nodules (IPNs) at risk of cancer undergo high rates of invasive, costly, and morbid procedures. Objectives: To train and externally validate a risk ...

BACKGROUND Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation. METHODS A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively. RESULTS Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points. CONCLUSIONS The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

Background Schwannomas, benign tumors arising from neurolemmocytes, are the most common type of peripheral nerve tumors. Extracranial schwannomas are most often found in the parapharyngeal space, commonly involving the vagus nerve to cervical sympathetic trunk. Vagal schwannomas present several unique clinical and therapeutic challenges. Methods A comprehensive literature review was conducted on 197 articles reporting 235 cases of cervical vagal schwannomas. Presenting symptoms, treatment approach, and postoperative outcomes were recorded and analyzed. Results Vagal schwannomas commonly present as asymptomatic neck masses. When they become symptomatic, surgical resection is the standard of care. Gross total resection is associated with higher postoperative morbidity compared to subtotal resection. Initial reports using intraoperative nerve monitoring have shown improved nerve preservation. Recurrence rates are low. Conclusion The combination of intermittent nerve mapping with novel continuous vagal nerve monitoring techniques may reduce postoperative morbidity and could represent the future standard of care for vagal schwannoma treatment.

Background Schwannomas are rare benign tumors that arise from the Schwann cells of the nerve sheath. Schwannomas are characteristically indolent, growing approximately 1–3 mm a year. We report a case of cervical sympathetic chain schwannoma (CSCS) with a rapid rate of growth while being regularly imaged for another disease process. Methods A 57-year-old female with a history of papillary thyroid cancer (PTC) presented with a left level IV neck mass discovered on a routine ultrasound. The mass was not visualized on her most recent ultrasound 11 months prior. Results The patient underwent extracapsular enucleation of the schwannoma, which arose from the cervical sympathetic chain. Final pathology confirmed the diagnosis of a benign schwannoma. Conclusions This case serves as a reminder that not all benign CSCSs are indolent and also highlights the fact that the rapid rate of growth of these lesions is not necessarily indicative of a malignant transformation.

Objective Lung cancer is the leading cancer killer in women, resulting in more deaths than breast, cervical and ovarian cancer combined. Screening for lung cancer has been shown to significantly reduce mortality, with some evidence that women may have a greater benefit. This study demonstrates that a population of women being screened for breast cancer may greatly benefit from screening for lung cancer. Methods Data from 18,040 women who were screened for breast cancer in 2015 at two imaging facilities that also performed lung screening were reviewed. A natural language-processing algorithm followed by a manual chart review identified women eligible for lung cancer screening by U.S. Preventive Services Task Force (USPSTF) criteria. A chart review of these eligible women was performed to determine subsequent enrollment in a lung screening program (2016–2019), current screening eligibility, cancer diagnoses and cancer-related outcomes. Results Natural language processing identified 685 women undergoing screening mammography who were also potentially eligible for lung screening based on age and smoking history. Manual chart review confirmed 251 were eligible under USPSTF criteria. By June 2019, 63 (25%) had enrolled in lung screening, of which three were diagnosed with screening-detected lung cancer resulting in zero deaths. Of 188 not screened, seven were diagnosed with lung cancer resulting in five deaths by study end. Four women received a diagnosis of breast cancer with no deaths. Conclusion Women screened for breast cancer are dying from lung cancer. We must capitalize on reducing barriers to improve screening for lung cancer among high-risk women.

Rationale: A prospective longitudinal cohort of individuals at high risk of developing lung cancer was established to build a biorepository of carefully annotated biological specimens and low-dose computed tomography (LDCT) chest images for derivation and validation of candidate biomarkers for early detection of lung cancer. Objectives: The goal of this study is to characterize individuals with high risk for lung cancer, accumulating valuable biospecimens and LDCT chest scans longitudinally over 5 years. Methods: Participants 55–80 years of age with a 5-year estimated risk of developing lung cancer >1.5% were recruited and enrolled from clinics at the Vanderbilt University Medical Center, Veteran Affairs Medical Center, and Meharry Medical Center. Individual demographic characteristics were assessed via questionnaire at baseline. Participants underwent an LDCT scan, spirometry, sputum cytology, and research bronchoscopy at the time of enrollment. Participants will be followed yearly for 5 years. Positive LDCT scans are followed-up according to standard of care. The clinical, imaging, and biospecimen data are collected prospectively and stored in a biorepository. Participants are offered smoking cessation counseling at each study visit. Results: A total of 480 participants were enrolled at study baseline and consented to sharing their data and biospecimens for research. Participants are followed with yearly clinic visits to collect imaging data and biospecimens. To date, a total of 19 cancers (13 adenocarcinomas, four squamous cell carcinomas, one large cell neuroendocrine, and one small-cell lung cancer) have been identified. Conclusions: We established a unique prospective cohort of individuals at high risk for lung cancer, enrolled at three institutions, for whom full clinical data, well-annotated LDCT scans, and biospecimens are being collected longitudinally. This repository will allow for the derivation and independent validation of clinical, imaging, and molecular biomarkers of risk for diagnosis of lung cancer. Clinical trial registered with ClinicalTrials.gov (NCT01475500).

A major goal of lung cancer screening is to identify individuals with particular phenotypes that are associated with high risk of cancer. Identifying relevant phenotypes is complicated by the variation in body position and body composition. In the brain, standardized coordinate systems (e.g., atlases) have enabled separate consideration of local features from gross/global structure. To date, no analogous standard atlas has been presented to enable spatial mapping and harmonization in chest computational tomography (CT). In this paper, we propose a thoracic atlas built upon a large low dose CT (LDCT) database of lung cancer screening program. The study cohort includes 466 male and 387 female subjects with no screening detected malignancy (age 46-79 years, mean 64.9 years). To provide spatial mapping, we optimize a multi-stage inter-subject non-rigid registration pipeline for the entire thoracic space. We evaluate the optimized pipeline relative to two baselines with alternative non-rigid registration module: the same software with default parameters and an alternative software. We achieve a significant improvement in terms of registration success rate based on manual QA. For the entire study cohort, the optimized pipeline achieves a registration success rate of 91.7%. The application validity of the developed atlas is evaluated in terms of discriminative capability for different anatomic phenotypes, including body mass index (BMI), chronic obstructive pulmonary disease (COPD), and coronary artery calcification (CAC)., Comment: Accepted by SPIE2021 Medical Imaging (oral)

BACKGROUND Metastatic thyroid carcinoma to retropharyngeal and parapharyngeal (RP/PP) lymph nodes is rare. Literature suggests previous lateral neck dissection (LND) may alter patterns of lymphatic drainage in the neck, predisposing to these less common sites of spread. METHODS PRISMA-guided systematic search for all published cases detailing RP/PP metastases of well-differentiated thyroid carcinoma from 1970 to 2019. RESULTS Seventy articles were identified and 44 were included, along with seven cases treated at our institution, totaling 239 cases. Cases represented both retropharyngeal (60.7%) and parapharyngeal (39.3%) metastases identified in the initial (27.6%) and recurrent (72.4%) setting. CONCLUSION RP/PP metastases generally present in the recurrent setting. RP/PP metastases often represent high-risk disease, and surgical treatment is recommended.

Objectives Nasopharyngeal carcinoma (NPC) is a rare form of squamous cell carcinoma. Primary NPC is generally treated with radiation and chemotherapy, though recurrence and distant metastases are common. Reports of noncontiguous metastasis to the middle ear and external ear canal (EAC) are rare. Materials and methods Case presentation of a female patient previously treated for NPC, who developed an EAC metastasis. A literature review of all reported cases of metastatic NPC in the middle ear and EAC is also included. Results A patient presenting with noncontiguous metastasis of NPC to the EAC was treated with surgical resection followed by chemotherapy and radiation. The patient successfully completed treatment and is currently alive but with suspected distant metastatic disease at 11 months following treatment. Conclusions NPC metastasis to the EAC is extremely rare. Treatment options are varied, and prognosis is generally poor. The case presented here shows better outcomes than many previous reports.

Lung cancer is the leading cause of cancer mortality in the United States. Certain groups are at increased risk of developing lung cancer and experience greater morbidity and mortality than the general population. Lung cancer screening provides an opportunity to detect lung cancer at an early stage when surgical intervention can be curative; however, current screening guidelines may overlook vulnerable populations with disproportionate lung cancer burden. This review aims to characterize disparities in lung cancer screening eligibility, as well as access to lung cancer screening, focusing on underrepresented racial/ethnic minorities and high-risk populations, such as individuals with human immunodeficiency virus. We also explore potential system- and patient-level barriers that may influence smoking patterns and healthcare access. Improving access to high-quality health care with a focus on smoking cessation is essential to reduce the burden of lung cancer experienced by vulnerable populations.

Background Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES. Methods The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps. Results The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy. Conclusions The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.

Objectives This study sought to assess long-term left atrial appendage (LAA) closure efficacy of the Atriclip applied via totally thoracoscopic (TT) approach with computed tomographic angiography. Background LAA closure is associated with a low risk for atrial fibrillation–related embolic stroke. The Atriclip exclusion device allows epicardial LAA closure, avoiding the need for post-operative oral anticoagulation. Previous data with Atriclip during open chest procedures show a high efficacy rate of closure >95%. Methods Three-dimensional volumetric 2-phase computed tomographic angiography ≥90 days post-implantation was independently assessed by chest radiology for complete LAA closure on all consented subjects identified retrospectively as having had a TT-placed Atriclip at Vanderbilt University Medical Center from June 13, 2011, to October 6, 2015. Results Complete LAA closure (defined by complete exclusion of the LAA with no exposed trabeculations, and clip within 1 cm from the left circumflex artery) was found in 61 of 65 subjects (93.9%). Four cases had incomplete closure (6.2%). Two clips were placed too distally, leaving a large stump with exposed trabeculae. Two clips failed to address a secondary LAA lobe. No major complications were associated with TT placement of the Atriclip. Follow-up over 183 patient-years revealed 1 stroke in a patient with complete LAA closure and no thrombus (hypertensive cerebrovascular accident). Conclusions Angiographic LAA closure efficacy with a TT-placed Atriclip is high (93.9%). The clinical significance of a remnant stump is unknown. Confirmation of complete LAA occlusion should be made before cessation of systemic anticoagulation.

Primary pulmonary artery sarcomas are rare. Moreover, they are notorious for masquerading as a chronic pulmonary embolus. There is much symptom overlap that leads to this relatively common misdiagnosis. We present such a case.

Background Aggressive histologic worst pattern of invasion (WPOI) in surrounding soft tissue has been shown to be predictive of higher local recurrence and poorer survival in oral cavity squamous cell carcinoma (OCSCC) patients. This study investigates whether aggressive WPOI can predict the mandibular invasion phenotype. Methods Patients consecutively diagnosed with OCSCC undergoing a mandibulectomy (marginal or segmental) between 2013 and 2018 were reviewed. Senior physicians re-reviewed radiologic scans and pathologic slides of 44 cases. Results Aggressive WPOI (WPOI-4, 5) is significantly associated with infiltrative bone invasion. Non-aggressive WPOI (WPOI-1, 2, 3) is significantly associated with the absence of bone invasion. Conclusions WPOI has become a useful tool that further characterizes the biologic behavior of OCSCC. Potentially, planned surgery may escalate from a marginal to segmental mandibulectomy based on aggressive WPOI for patients with radiographically uncertain cortical status. Further studies are needed to validate the relationship between OCSCC WPOI and mandible status.

Purpose The aim of this study was to identify predictors of appropriate follow-up for clinically significant incidental findings (IFs) detected with low-dose CT during lung cancer screening. Methods Charts of 1,458 prospectively enrolled lung screening patients from January 1, 2015, to October 31, 2018, were reviewed. IFs, other than coronary artery calcification and emphysema, were identified. ACR practice guidelines defined appropriate patient follow-up. Patient demographic and social characteristics were obtained from the initial shared decision-making visit and the electronic medical record. Factors of interest included age, gender, race, education level, and insurance status. Education level was reported as high school graduate or less or education past high school. A multivariate logistic regression was estimated to assess patient factors associated with appropriate follow-up. Results One hundred thirty-eight participants (9%) with 141 actionable IFs were identified. The overall appropriate follow-up rate was 82%. The most common IFs were renal lesions (16%), dilated thoracic aorta (10%), and pulmonary fibrosis (10%). Univariate analysis of appropriate patient follow-up revealed a significant difference for education level (P = .02). A greater than high school education remained strongly associated with appropriate follow-up after controlling for other demographic factors. Conclusions Appropriate patient follow-up of clinically significant IFs from lung cancer screening is a well-recognized avenue to improve population health. Education level is a significant independent predictor of appropriate follow-up of IFs, whether as a surrogate for low socioeconomic status or as an indication of health literacy. To address these realities, lung screening shared decision making should adapt to consider health care access and health literacy.

Background Detection of early-stage lung cancer improves during subsequent rounds of screening with low-dose CT and potentially leads to saving lives with curative treatment. Therefore, adherence to annual lung screening is important. We hypothesized that adherence to annual screening would increase after hiring of a dedicated program coordinator. Methods We performed a mixed-methods study in a retrospective cohort of patients who underwent lung screening at our academic institution between January 1, 2014, and March 31, 2018. Patients with baseline lung screening examinations performed between January 1, 2014, and September 30, 2016, with Lung CT Screening Reporting & Data System 1 or 2 scores and a 12-month follow-up recommendation were included. We tracked patient adherence to annual follow-up lung screening over time (before and after hiring of a program coordinator) and conducted a cross-sectional survey of patients nonadherent to annual follow-up to elicit quantitative and qualitative feedback. Results Of the 319 patients who completed baseline lung screening with normal results, 189 (59%) were adherent to annual follow-up recommendations and 130 (41%) were nonadherent. Patient adherence varied over time: 21.7% adherence (10 of 46) before hiring a program coordinator and 65.6% adherence (179 of 273) after the program coordinator’s hire date. Patients reported the following reasons for nonadherence to annual lung screening: lack of transportation, financial cost, lack of communication by physicians, and lack of current symptoms. Conclusions Adherence to annual lung screening after normal baseline studies increased significantly over time. Hiring a full-time program coordinator was likely associated with this increased in adherence.

Background Vagal schwannomas are rare, benign tumors of the head and neck. Nerve damage during surgical resection is associated with significant morbidity. A new technique of continuous intraoperative nerve monitoring (IONM) that allows for real-time intraoperative feedback has recently been used for thyroid and cervical spine surgeries but has not previously been used in vagal schwannoma surgery. Methods Case series of three patients who underwent vagal schwannoma excision utilizing this novel IONM technique. The recurrent laryngeal and vagus nerves were monitored via the laryngeal adductor reflex (LAR) using an electromyographic endotracheal tube. Results Three patients with suspected vagal schwannomas were treated surgically using the intracapsular enucleation approach with a combination of intermittent IONM and continuous IONM of the LAR. Conclusion This combination of continuous and intermittent IONM can be used to preserve vagal laryngeal innervation and function and may represent the future standard of care for vagal schwannoma excision.

Annual low dose computed tomography (CT) lung screening is currently advised for individuals at high risk of lung cancer (e.g., heavy smokers between 55 and 80 years old). The recommended screening practice significantly reduces all-cause mortality, but the vast majority of screening results are negative for cancer. If patients at very low risk could be identified based on individualized, image-based biomarkers, the health care resources could be more efficiently allocated to higher risk patients and reduce overall exposure to ionizing radiation. In this work, we propose a multi-task (diagnosis and prognosis) deep convolutional neural network to improve the diagnostic accuracy over a baseline model while simultaneously estimating a personalized cancer-free progression time (CFPT). A novel Censored Regression Loss (CRL) is proposed to perform weakly supervised regression so that even single negative screening scans can provide small incremental value. Herein, we study 2287 scans from 1433 de-identified patients from the Vanderbilt Lung Screening Program (VLSP) and Molecular Characterization Laboratories (MCL) cohorts. Using five-fold cross-validation, we train a 3D attention-based network under two scenarios: (1) single-task learning with only classification, and (2) multi-task learning with both classification and regression. The single-task learning leads to a higher AUC compared with the Kaggle challenge winner pre-trained model (0.878 v. 0.856), and multi-task learning significantly improves the single-task one (AUC 0.895, p, Finalist for the 2020 Robert F. Wagner All Conference Best Student Paper Award, SPIE 2020 Medical Imaging. (Highest award in Image Processing section)

Recently, multi-task networks have shown to both offer additional estimation capabilities, and, perhaps more importantly, increased performance over single-task networks on a "main/primary" task. However, balancing the optimization criteria of multi-task networks across different tasks is an area of active exploration. Here, we extend a previously proposed 3D attention-based network with four additional multi-task subnetworks for the detection of lung cancer and four auxiliary tasks (diagnosis of asthma, chronic bronchitis, chronic obstructive pulmonary disease, and emphysema). We introduce and evaluate a learning policy, Periodic Focusing Learning Policy (PFLP), that alternates the dominance of tasks throughout the training. To improve performance on the primary task, we propose an Internal-Transfer Weighting (ITW) strategy to suppress the loss functions on auxiliary tasks for the final stages of training. To evaluate this approach, we examined 3386 patients (single scan per patient) from the National Lung Screening Trial (NLST) and de-identified data from the Vanderbilt Lung Screening Program, with a 2517/277/592 (scans) split for training, validation, and testing. Baseline networks include a single-task strategy and a multi-task strategy without adaptive weights (PFLP/ITW), while primary experiments are multi-task trials with either PFLP or ITW or both. On the test set for lung cancer prediction, the baseline single-task network achieved prediction AUC of 0.8080 and the multi-task baseline failed to converge (AUC 0.6720). However, applying PFLP helped multi-task network clarify and achieved test set lung cancer prediction AUC of 0.8402. Furthermore, our ITW technique boosted the PFLP enabled multi-task network and achieved an AUC of 0.8462 (McNemar test, p < 0.01)., Accepted by Medical Imaging, SPIE2020

Introduction Although dyspnea with exercise in the pediatric population can be multifactorial, the diagnosis of paradoxical vocal fold motion disorder (PVFMD) in this group is not well characterized. The objective of this study is to review the multiple causes of dyspnea with exercise in children, including the prevalence of PVFMD within this study population. Methods A retrospective review was conducted of patients seen at a tertiary pediatric hospital for exercise-induced dyspnea suspected to be related to PVFMD between January 2007 and July 2015. Inclusion criteria included assessment in a specialty exercise clinic and evaluation by a pediatric otolaryngologist and pulmonologist. Pre- and post-exercise pulmonary function tests and laryngoscopic examinations were performed. Data including co-morbidities, presenting symptoms, prior diagnoses and treatments, final diagnoses, prescribed treatments and outcomes were collected and analyzed. Results 294 patients were evaluated at our institution during the study period. 4 patients were excluded for insufficient data, which left 290 for analysis. 75 were male, 215 female. All patients underwent treadmill testing with monitoring to simulate strenuous exercise. Average patient age was 14.6 years; average BMI was 21.53. The most common sports to elicit symptoms were running and soccer. Patients most frequently complained of stridor or wheezing in addition to dyspnea. Throat tightness was also a common complaint. After evaluation, 86 patients were given the primary diagnosis of exercise-induced PVFMD. 54 patients were diagnosed with physiologic dyspnea and 30 with exercise-induced asthma. Conclusion Pediatric patients presenting with exercise-induced dyspnea can have multiple etiologies for their symptoms including PVFMD. Other causes of dyspnea with exercise should not be underestimated.

Background In head and neck surgery, dead space is typically managed by transferring a secondary pedicled flap or harvesting a larger composite flap with a muscular component. We demonstrate the novel use of prophylactic negative pressure wound therapy (NPWT) to obliterate dead space and reduce possible communication between the upper aerodigestive tract and the contents of the neck. Methods We present a single-institutional case series of five patients with high-risk head and neck cancer treated with NPWT after ablative and reconstructive surgery to eliminate dead space following surgical resection. Results All patients achieved successful wound closure following NPWT, which was applied in the secondary setting to combat infection in one patient and the primary setting to prophylactically eliminate dead space in four patients. Conclusion NPWT can be used to treat unfilled dead space in the primary setting of head and neck ablative and reconstructive surgery and help to avoid wound healing problems as well as the need for secondary flap transfers.

Objectives Hypopharyngeal liposarcomas are rare tumors of the head and neck with only scattered case reports in the literature. They are predominantly seen in male patients with a propensity to occur during the 5th decade of life. Patients typically present with dysphagia and progressive dyspnea over several months. Liposarcomas are typically low-grade; metastasis has not been reported in low-grade disease, and overall prognosis is very good. However, they do have a propensity to recur. Methods Report of one case of hypopharyngeal liposarcoma seen at our institution. Results A 57 year old male with no relevant past medical history presented with two months of globus sensation, frequent throat clearing, tightening sensation, dysphagia, and dyspnea on exertion. The patient was brought to the operating room for transoral robotic-assisted excision. The tumor was readily identified and excised off of the posterior pharyngeal wall at the level of the epiglottis. Pathology on permanent section was consistent with well differentiated, low grade liposarcoma. The patient's clinical course, surgical treatment, and management considerations are discussed here. Conclusions This report is the first known case of a patient with a well differentiated, low grade hypopharyngeal liposarcoma that was successfully resected via transoral robotic surgery (TORS).

Background: Despite widespread recommendation and supportive policies, screening with low-dose CT (LDCT) is incompletely implemented in the US healthcare system. Low provider knowledge of the lung cancer screening (LCS) guidelines represents a potential barrier to implementation. Therefore, we tested the hypothesis that low provider knowledge of guidelines is associated with less provider-reported screening with LDCT. Patients and Methods: A cross-sectional survey was performed in a large academic medical center and affiliated Veterans Health Administration in the Mid-South United States that comprises hospital and community-based practices. Participants included general medicine providers and specialists who treat patients aged >50 years. The primary exposure was LCS guideline knowledge (US Preventive Services Task Force/Centers for Medicare & Medicaid Services). High knowledge was defined as identifying 3 major screening eligibility criteria (55 years as initial age of screening eligibility, smoking status as current or former smoker, and smoking history of ≥30 pack-years), and low knowledge was defined as not identifying these 3 criteria. The primary outcome was self-reported LDCT order/referral within the past year, and the secondary outcome was screening chest radiograph. Multivariable logistic regression evaluated the adjusted odds ratio (aOR) of screening by knowledge. Results: Of 625 providers recruited, 407 (65%) responded, and 378 (60.5%) were analyzed. Overall, 233 providers (62%) demonstrated low LCS knowledge, and 224 (59%) reported ordering/referring for LDCT. The aOR of ordering/referring LDCT was less among providers with low knowledge (0.41; 95% CI, 0.24–0.71) than among those with high knowledge. More providers with low knowledge reported ordering screening chest radiographs (aOR, 2.7; 95% CI, 1.4–5.0) within the past year. Conclusions: Referring provider knowledge of LCS guidelines is low and directly proportional to the ordering rate for LDCT in an at-risk US population. Strategies to advance evidence-based LCS should incorporate provider education and system-level interventions to address gaps in provider knowledge.

Figure 2. Digital subtraction angiography as contrast dye is injected into the central venous catheter confirms cannulation of the internal thoracic artery (at the solid arrow) several centimeters distal to its origin from the subclavian artery (dashed arrow). A 68-year-old man with Crohn’s disease and receiving adalimumab transferred to our institution for respiratory failure and shock complicating an influenza-like illness. He was intubated, and a right internal jugular central venous catheter (CVC) was placed under ultrasound guidance by house staff after three vessel cannulation attempts. Predilation, the position of the wire was misinterpreted as being within the internal jugular on the basis of ultrasound. The post-procedure chest radiograph appeared deceptively normal (Figure 1). Routine transduction for central venous pressure, however, revealed an arterial waveform. Contrast injection demonstrated the CVC to be within the internal thoracic artery (Figure 2). Computed tomography further delineated the path of the catheter (Figures 3 and 4), but the exact track from neck to internal thoracic artery remained unclear (Video 1). The patient died of progressive respiratory failure before planned surgical catheter removal. Antemortem cultures eventually grew Histoplasma capsulatum.

Background Initial reports of transbronchial cryobiopsy for diffuse parenchymal lung disease (DPLD) suggest the diagnostic yield approaches that of surgical lung biopsy (SLB) with an excellent safety profile. Centers performing cryobiopsy differ significantly in procedure technique; an optimal technique minimizing complications but still capable of diagnosing a wide range of DPLDs has not been established. We evaluated our practice of flexible bronchoscopic cryobiopsy in a primarily outpatient setting for patients who required a tissue diagnosis for DPLD of uncertain etiology. Methods Consecutive patients with indeterminate DPLD who underwent bronchoscopic cryobiopsy at a large academic medical center from January 2012 to August 2015 were retrospectively analyzed. Rates of confident histopathologic diagnosis, confident multidisciplinary consensus diagnosis, management change, and complications were determined. Results One hundred four cases were identified. Confident histopathologic diagnoses were established in 44% (46/104) and confident multidisciplinary consensus diagnoses in 68% (71/104). Usual interstitial pneumonia (19/104) and idiopathic pulmonary fibrosis (22/104) were the most common histopathologic and consensus diagnoses, respectively. Five subjects proceeded to SLB after cryobiopsy which was diagnostic in 3. Results of cryobiopsies changed management in 70% (73/104). Complications occurred in 8 cases with no death. Conclusions Cryobiopsy during outpatient flexible bronchoscopy facilitated confident multidisciplinary consensus diagnosis of DPLD in more than two thirds of cases, and appears sufficient to establish the histopathologic diagnosis of usual interstitial pneumonia, with a complication rate that compares favorably to that reported for SLB.

Radiology as a discipline thrives on the dynamic interplay between technological and clinical advances. Progress in almost all facets of the imaging sciences is highly dependent on complex tools sourced from physics, engineering, biology, and the clinical sciences to obtain, process, and view imaging studies. The application of these tools, however, requires broad and deep medical knowledge about disease pathophysiology and its relationship with medical imaging. This relationship between clinical medicine and imaging technology, nurtured and fostered over the past 75 years, has cultivated extraordinarily rich collaborative opportunities between basic scientists, engineers, and physicians. In this review, we attempt to provide a framework to identify both currently successful collaborative ventures and future opportunities for scientific partnership. This invited review is a product of a special working group within the Association of University Radiologists-Radiology Research Alliance.

While autologous split calvaria remains the preferred material for use in pediatric cranioplasty, it may be difficult to split the bone neatly into two distinct pieces, especially in infants and young children. In this paper, the authors present a technique in which numerous split pieces of bone can be readily joined together and conformed to the shape of the specific defect using a customized template and 3D trellis-like basket.

The United States Preventive Services Task Force (USPSTF) recommends low-dose computed tomography screening for lung cancer. However, USPSTF screening guidelines were derived from a study population including only 4% African American smokers, and racial differences in smoking patterns were not considered.To evaluate the diagnostic accuracy of USPSTF lung cancer screening eligibility criteria in a predominantly African American and low-income cohort.The Southern Community Cohort Study prospectively enrolled adults visiting community health centers across 12 southern US states from March 25, 2002, through September 24, 2009, and followed up for cancer incidence through December 31, 2014. Participants included African American and white current and former smokers aged 40 through 79 years. Statistical analysis was performed from May 11, 2016, to December 6, 2018.Self-reported race, age, and smoking history. Cumulative exposure smoking histories encompassed most recent follow-up questionnaires.Incident lung cancer cases assessed for eligibility for lung cancer screening using USPSTF criteria.Among 48 364 ever smokers, 32 463 (67%) were African American and 15 901 (33%) were white, with 1269 incident lung cancers identified. Among all 48 364 Southern Community Cohort Study participants, 5654 of 32 463 African American smokers (17%) were eligible for USPSTF screening compared with 4992 of 15 901 white smokers (31%) (P .001). Among persons diagnosed with lung cancer, a significantly lower percentage of African American smokers (255 of 791; 32%) was eligible for screening compared with white smokers (270 of 478; 56%) (P .001). The lower percentage of eligible lung cancer cases in African American smokers was primarily associated with fewer smoking pack-years among African American vs white smokers (median pack-years: 25.8 [interquartile range, 16.9-42.0] vs 48.0 [interquartile range, 30.2-70.5]; P .001). Racial disparity was observed in the sensitivity and specificity of USPSTF guidelines between African American and white smokers for all ages. Lowering the smoking pack-year eligibility criteria to a minimum 20-pack-year history was associated with an increased percentage of screening eligibility of African American smokers and with equitable performance of sensitivity and specificity compared with white smokers across all ages (for a 55-year-old current African American smoker, sensitivity increased from 32.2% to 49.0% vs 56.5% for a 55-year-old white current smoker; specificity decreased from 83.0% to 71.6% vs 69.4%; P .001).Current USPSTF lung cancer screening guidelines may be too conservative for African American smokers. The findings suggest that race-specific adjustment of pack-year criteria in lung cancer screening guidelines would result in more equitable screening for African American smokers at high risk for lung cancer.

At some point in their lives, patients previously shunted for hydrocephalus may experience chronic, debilitating headaches, despite the fact that their shunts are functioning properly. Previously published reports have suggested that a subset of these patients may be suffering from an iatrogenic craniocerebral disproportion (CCD) and, therefore, may benefit from procedures that expand the available intracranial space. A unified definition of this disorder, however, is lacking. Here, the authors chart the history (including historical terminology) of CCD, review its incidence, describe its signs, symptoms, and associated radiologic findings, and expound upon its pathophysiology. Next, a concise clinical definition of CCD based on the temporal correlation of headaches with the appearance of plateau waves on intracranial pressure (ICP) monitoring is proposed. The authors conclude with a discussion of the various therapeutic strategies employed previously to treat this disorder and present their individualized treatment strategy based upon the simultaneous utilization of ICP monitors and gradual external cranial vault expansion.

A subset of hydrocephalic patients in whom shunts are placed at an early age will develop craniocerebral disproportion (CCD), an iatrogenic mismatch between the fixed intracranial volume and the growing brain. The lack of a reliable, reproducible method to diagnose this condition, however, has hampered attempts to treat it appropriately. For those practitioners who acknowledge the need to create more intracranial space in these patients, the lack of agreed-upon therapeutic end points for cranial vault expansion has limited the use of such techniques and has sometimes led to problems of underexpansion. Here, the authors present a definition of CCD based primarily on the temporal correlation of plateau waves on intracranial pressure (ICP) monitoring and headache exacerbation. The authors describe a technique of exploiting continued ICP monitoring during progressive cranial expansion in which the goal of distraction is the cessation of plateau waves. Previously encountered problems of underexpansion may be mitigated through the simultaneous use of ICP monitors and gradual cranial expansion over time.

OBJECTIVEThe object of this study was to use diffusion tensor imaging (DTI) and tract-based spatial statistics (TBSS) to characterize the long-term effects of hydrocephalus and shunting on white matter integrity and to investigate the relationship of ventricular size and alterations in white matter integrity with headache and quality-of-life outcome measures.METHODSPatients with shunt-treated hydrocephalus and age- and sex-matched healthy controls were recruited into the study and underwent anatomical and DTI imaging on a 3-T MRI scanner. All patients were clinically stable, had undergone CSF shunt placement before 2 years of age, and had a documented history of complaints of headaches. Outcome was scored based on the Headache Disability Inventory and the Hydrocephalus Outcome Questionnaire. Fractional anisotropy (FA) and other DTI-based measures (axial, radial, and mean diffusivity; AD, RD, and MD, respectively) were extracted in the corpus callosum and internal capsule with manual region-of-interest delineation and in other regions with TBSS. Paired t-tests, corrected with a 5% false discovery rate, were used to identify regions with significant differences between patients and controls. Within the patient group, linear regression models were used to investigate the relationship between FA or ventricular volume and outcome, as well as the effect of shunt-related covariates.RESULTSTwenty-one hydrocephalus patients and 21 matched controls completed the study, and their data were used in the final analysis. The authors found significantly lower FA for patients than for controls in 20 of the 48 regions, mostly posterior white matter structures, in periventricular as well as more distal tracts. Of these 20 regions, 17 demonstrated increased RD, while only 5 showed increased MD and 3 showed decreased AD. No areas of increased FA were observed. Higher FA in specific periventricular white matter tracts, tending toward FA in controls, was associated with increased ventricular size, as well as improved clinical outcome.CONCLUSIONSThe study shows that TBSS-based DTI is a sensitive technique for elucidating changes in white matter structures due to hydrocephalus and chronic CSF shunting and provides preliminary evidence that DTI may be a valuable tool for tailoring shunt procedures to monitor ventricular size following shunting and achieve optimal outcome, as well as for guiding the development of alternate therapies for hydrocephalus.

Introduction: Unicentric Castleman’s disease is a rare lymphoproliferative disorder. Patients are usually asymptomatic, anddisease is found incidentally on imaging studies. Although a benign condition, unicentric Castleman’s disease does increase therisk of other malignancies, and therefore, complete surgical resection is recommended. Here we report the case of a 48-year-oldsmoker who presented with an incidental lung mass. Case presentation: A 48-year-old man presented to the hospital with a persistent cough in the setting of a 48-pack-year smokinghistory. A contrast-enhanced CT of the chest revealed a single pulmonary mass in the posterior chest cavity concerning formalignancy. Conclusions: Unicentric Castleman’s disease can be a rare cause of a lung mass. Unlike primary lung malignancy, however,unicentric Castleman’s disease has an excellent prognosis.

Over the last 40 years, craniofacial surgery, in general, and surgery for craniosynostosis, in particular, has witnessed the introduction of a number of new materials for use in operations involving the cranial vault. Some of these materials have proven quite useful over time, while others have failed to meet their stated objectives. In this review, the more popular implant materials are analyzed, and their relative merits and drawbacks are discussed. Craniofacial surgery in the pediatric population has its own unique limitations, quite different from the adult population and those issues are reviewed as well.