Predictors of severe late radiotherapy-related toxicity after hyperfractionated radiotherapy with or without concomitant cisplatin in locally advanced head and neck cancer. Secondary retrospective analysis of a randomized phase III trial (SAKK 10/94)

This secondary analysis was performed to identify predictive factors for severe late radiotherapy (RT)-related toxicity after treatment with hyperfractionated RT +/- concomitant cisplatin in locally advanced head and neck cancer.

Validity and responsiveness of the Core Outcome Measures Index (COMI) for the neck

Patient-orientated outcome questionnaires are essential to evaluate treatment success. To compare different treatments, hospitals, and surgeons, standardised questionnaires are required. The present study examined the validity and responsiveness of the Core Outcome Measurement Index for neck pain (COMI-neck), a short, multidimensional outcome instrument.

Clinical study of mucosa-associated lymphoid tissue lymphomas of the head and neck

Background: Limited information is available on mucosa-associated lymphoid tissue lymphomas arising in the head and neck. Method: A retrospective analysis was conducted of 20 patients who were histologically diagnosed with mucosa-associated lymphoid tissue lymphoma and treated at our institution between January 1990 and December 2009. Results: Treatment consisted of surgical resection alone in two patients (10 per cent), surgical resection with consecutive radiotherapy in one (5 per cent), and radiotherapy alone in eight (40 per cent). Three patients (15 per cent) were treated with systemic chemotherapy, and three (15 per cent) received chemoradiotherapy. Three patients (15 per cent) were informed of the diagnosis but not treated for their condition. Conclusion: All of the 20 patients were still alive after a mean follow-up period of 50.8 months. Local treatment for mucosa-associated lymphoid tissue lymphoma of the head and neck should be the first choice in early-stage disease. However, prolonged follow up is important to determine these patients' long-term response to treatment.

Diffusion-weighted MR imaging in the head and neck

Extracranial applications of diffusion-weighted (DW) magnetic resonance (MR) imaging are gaining increasing importance, including in head and neck radiology. The main indications for performing DW imaging in this relatively small but challenging region of the body are tissue characterization, nodal staging, therapy monitoring, and early detection of treatment failure by differentiating recurrence from posttherapeutic changes. Lower apparent diffusion coefficients (ADCs) have been reported in the head and neck region of adults and children for most malignant lesions, as compared with ADCs of benign lesions. For nodal staging, DW imaging has shown promise in helping detect lymph node metastases, even in small (subcentimeter) nodes with lower ADCs, as compared with normal or reactive nodes. Follow-up of early response to treatment is reflected in an ADC increase in the primary tumor and nodal metastases; whereas nonresponding lesions tend to reveal only a slight increase or even a decrease in ADC during follow-up. Optimization and standardization of DW imaging technical parameters, comparison of DW images with morphologic images, and increasing experience, however, are prerequisites for successful application of this challenging technique in the evaluation of various head and neck pathologic conditions.

Long-term patency of complex bilobular, bisaccular, and broad-neck aneurysms in the rabbit microsurgical venous pouch bifurcation model

In experimental aneurysm models, long-term patency without spontaneous thrombosis is the most important precondition for analyses of embolization devices. We recently reported the feasibility of creating complex venous pouch bifurcation aneurysms in the rabbit with low morbidity, low mortality, and high short-term aneurysm patency. In order to further evaluate our model, we examined the long-term patency rate.

Elective neck dissection for carcinomas of the oral cavity: occult metastases, neck recurrences, and adjuvant treatment of pathologically positive necks

BACKGROUND: Supraomohyoid neck dissection (SOHND) is currently performed in patients with carcinoma of the oral cavity with clinically negative neck. Most investigators consider SOHND as a staging procedure. METHODS: Records of 100 patients with cancer of the oral cavity and clinically negative neck undergoing SOHND were reviewed. The rate and significance of occult metastases are evaluated, the neck recurrences are analyzed and the indication of adjuvant radiation of pN+ necks is discussed. RESULTS: In 34 of 1814 of analyzed lymph nodes, metastatic disease was detected as follows: 30 macrometastases and 4 micrometastases. In 13 of 34 metastases (38%), extracapsular spread was observed. Twenty of 100 patients (20%) had to be upstaged. In 9 of 87 (10%) patients without local recurrence and with a minimal follow-up of 24 months, 5 ipsilateral (4 within the dissection field) and 5 contralateral neck recurrences were observed. Regional recurrence developed in 4% and 35% of patients with pN0 and pN+ necks, respectively. CONCLUSIONS: In 20% of patients with oral cavity tumors and pN0 neck, occult metastases were disclosed. Neck recurrences developed significantly more often in patients with pN+ than in those with pN0 necks. To evaluate the exact indication for an adjuvant treatment of patients with cN0/pN+ necks, prospective studies should be performed.

Virtopsy hemorrhage of the posterior cricoarytenoid muscle by blunt force to the neck in postmortem multislice computed tomography and magnetic resonance imaging

In forensic autopsies, one of the most important and common signs of violence to the neck is hemorrhages of the soft tissues. The Institute of Forensic Medicine in Bern evaluates the usefulness of postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) of forensic cases prior to autopsy. The aim of this study was to prove the sensitivity of postmortem MSCT and MRI in the detection of hemorrhages of the neck muscles. A full body scan prior to and a detailed scan of the explanted larynx after autopsy were performed. MSCT detected multiple fractures of the larynx. Detailed MRI was able to demonstrate the hemorrhage of the left posterior cricoarytenoid muscle. The minor hemorrhage of the right posterior cricoarytenoid muscle could not be detected with certainty. Although more experience is required, we conclude that combined MRI and MSCT examination is a useful tool for documentation and examination of neck muscle hemorrhages in forensic cases.

The deadly broomstick: an unusual missile injury to the neck

A 51-year-old man was struck by the tip of a broomstick weighing 1000 g at the left side of the neck, upon which he collapsed. Intense but delayed cardiopulmonary resuscitation restored the circulation roughly 30 minutes after the incident. Upon admittance to a nearby hospital, an extensive hypoxic cerebral damage was diagnosed. Death due to the severe cerebral damage occurred 5 hours after the incident. An autopsy demonstrated a severe subcutaneous traumatization of the left side of the neck, with a hemorrhage compressing the carotid bifurcation. A prolonged excitation due to this ongoing compression of the baroreceptors in the carotid sinus was assumed to have led to a cardiac arrest. In this case report, the authors discuss the underlying pathophysiology of this potentially lethal and rare reflexogenic incident also known as the Hering reflex and discuss possible therapeutic measures.

Comparison of six radiographic projections to assess femoral head/neck asphericity

Early radiographic detection of femoroacetabular impingement might prevent initiation and progression of osteoarthritis. The structural abnormality in femoral-induced femoroacetabular impingement (cam type) is frequently asphericity at the anterosuperior head/neck contour. To determine which of six radiographic projections (anteroposterior, Dunn, Dunn/45 degrees flexion, cross-table/15 degrees internal rotation, cross-table/neutral rotation, and cross-table/15 degrees external rotation) best identifies femoral head/neck asphericity, we studied 21 desiccated femurs; 11 with an aspherical femoral head/neck contour and 10 with a spherical femoral head/neck contour. To radiographically quantify femoral head asphericity, we measured the angle where the femoral head/neck leaves sphericity (angle alpha). The aspherical femoral head/neck contours had a greater maximum angle alpha (70 degrees ) compared with the spherical head/neck contours (50 degrees ). The angle alpha varied depending on the radiographic projection: it was greatest in the Dunn view with 45 degrees hip flexion (71 degrees +/- 10 degrees ) and least in the cross-table view in 15 degrees external rotation (51 degrees +/- 7 degrees ). Diagnosis of a pathologic femoral head/neck contour depends on the radiologic projection. The Dunn view in 45 degrees or 90 degrees flexion or a cross-table projection in internal rotation best show femoral head/neck asphericity, whereas anteroposterior or externally rotated cross-table views are likely to miss asphericity. Level of Evidence: Prognostic study, level II-1 (retrospective study).

Cementless hemiarthroplasty in femoral neck fractures: evaluation of clinical results and measurement of migration by EBRA-FCA

Aim of the present study was to evaluate migration rates of cementless primary hemiarthroplasty in acute femoral neck fractures. In a longitudinal, prospective study 46 patients were treated by cementless hemiarthroplasty. Clinical follow up was correlated with the EBRA-FCA method. In 30% of all patients stem migration amounted to more than 2 mm; further, these patients were seen to have a high level of activity. A high degree of migration in more than 30% of all patients requires critical scepticism toward further use of the investigated cementless stem as hemiarthroplasty. According to literature, migration of more than 2 mm suggests a high probability of early aseptic loosening. In patients with a low degree of activity good results could be observed; nevertheless, in patients with a high level of activity the combination of the investigated cementless stem with a solid fracture head cannot be recommended.

Intraobserver and interobserver variability of 64-row computed tomography abdominal aortic aneurysm neck measurements

BACKGROUND: Integrity of the abdominal aortic aneurysm (AAA) neck is crucial for the long-term success of endovascular AAA repair (EVAR). However, suitable tools for reliable assessment of changes in small aortic volumes are lacking. The purpose of this study was to assess the intraobserver and interobserver variability of software-enhanced 64-row computed tomographic angiography (CTA) AAA neck volume measurements in patients after EVAR. METHODS: A total of 25 consecutive patients successfully treated by EVAR underwent 64-row follow-up CTA in 1.5-mm collimation. Manual CTA measurements were performed twice by three blinded and independent readers in random order with at least a 4-week interval between readings. Maximum and minimum transverse aortic neck diameters were measured twice on two different levels within the proximal neck. Volumetry of the proximal aortic neck was performed by using dedicated software. Variability was calculated as 1.96 SD of the mean arithmetic difference according to Bland and Altman. Two-sided and paired t tests were used to compare measurements. P values <.05 were considered to indicate statistical significance. RESULTS: Intraobserver agreement was excellent for dedicated aneurysmal neck volumetry, with mean differences of less than 1 mL (P > .05), whereas it was poor for transverse aortic neck diameter measurements (P < .05). However, interobserver variability was statistically significant for both neck volumetry (P < .005) and neck diameter measurements (P < .015). CONCLUSIONS: The reliability of dedicated AAA neck volumetry by using 64-row CTA is excellent for serial measurements by individual readers, but not between different readers. Therefore, studies should be performed with aortic neck volumetry by a single experienced reader.

Influence of pulmonary status and diabetes mellitus on aortic neck dilatation following endovascular repair of abdominal aortic aneurysms: a EUROSTAR report

PURPOSE: To elucidate the association of impaired pulmonary status (IPS) and diabetes mellitus (DM) with clinical outcome and the incidences of aortic neck dilatation and type I endoleak after elective endovascular infrarenal aortic aneurysm repair (EVAR). METHODS: In 164 European institutions participating in the EUROSTAR registry, 6383 patients (5985 men; mean age 72.4+/-7.6 years) underwent EVAR. Patients were divided into patients without versus with IPS or with/without DM. Clinical assessment and contrast-enhanced computed tomography (CT) were performed at 1, 3, 6, 12, 18, and 24 months and annually thereafter. Cumulative endpoint analysis comprised death, aortic rupture, type I endoleak, endovascular reintervention, and surgical conversion. RESULTS: Prevalence of IPS was 2733/6383 (43%) and prevalence of DM was 810/6383 (13%). Mean follow-up was 21.1+/-18.4 months. Thirty-day mortality, AAA rupture, and conversion rates did not differ between patients with versus without IPS and between patients with versus without DM. All-cause and AAA-related mortality, respectively, were significantly higher in patients with IPS compared to patients with normal pulmonary status (31.0% versus 19.0%, p<0.0001 and 6.8% versus 3.3%, p = 0.0057) throughout follow-up. In multivariate analysis adjusted for smoking, age, gender, comorbidities, fitness for open repair, co-existing common iliac aneurysm, neck and aneurysm size, arterial angulations, aneurysm classification, endograft oversizing >or=15%, and type of stent-graft, the presence of IPS was not associated with significantly higher rates of aortic neck dilatation (30.6% versus 38.0%, p>0.05) and did not influence cumulative rates of type I endoleak, endovascular reintervention, or conversion to open surgery (p>0.05). Similarly, the presence of DM did not influence the above-mentioned study endpoints. CONCLUSION: In contrast to observations regarding the natural course of AAAs, impaired pulmonary status does not negatively influence aortic neck dilatation, while the presence of diabetes does not protect from these dismal events after EVAR.

Aortic neck dilatation after endovascular abdominal aortic aneurysm repair: a word of caution

Continuing aortic neck dilatation, most probably an expression of ongoing aneurysmal wall degeneration of the infrarenal aortic segment, has been shown to seriously impair clinical results after endovascular abdominal aortic aneurysm repair. However, conflicting data on the extent and clinical relevance on this observation have recently been published. This article reviews the recent literature, summarizing our current understanding of the role of aortic neck dilatation after open surgical and endovascular abdominal aortic aneurysm repair. In addition, differences in methodology of studies on aortic neck dilatation are highlighted.

Sixty-four-detector CT angiography of infrarenal aortic neck length and angulation: prospective analysis of interobserver variability

PURPOSE: To quantify the interobserver variability of abdominal aortic aneurysm (AAA) neck length and angulation measurements. MATERIALS AND METHODS: A total of 25 consecutive patients scheduled for endovascular AAA repair underwent follow-up 64-row computed tomographic (CT) angiography in 0.625-mm collimation. AAA neck length and angulation were determined by four blinded, independent readers. AAA neck length was defined as the longitudinal distance between the first transverse CT slice directly distal to the lowermost renal artery and the first transverse CT slice that showed at least a 15% larger outer aortic wall diameter versus the diameter measured directly below the lowermost renal artery. Infrarenal AAA neck angulation was defined as the true angle between the longitudinal axis of the proximal AAA neck and the longitudinal axis of the AAA lumen as analyzed on three-dimensional CT reconstructions. RESULTS: Mean deviation in aortic neck length determination was 32.3% and that in aortic neck angulation was 32.1%. Interobserver variability of aortic neck length and angulation measurements was considerable: in any reader combination, at least one measurement difference was outside the predefined limits of agreement. CONCLUSIONS: Assessment of the longitudinal extension and angulation of the infrarenal aortic neck is associated with substantial observer variability, even if measurement is carried out according to a standardized protocol. Further studies are mandatory to assess dedicated technical approaches to minimize variance in the determination of the longitudinal extension and angulation of the infrarenal aortic neck.