Combined SPECT/CT improves detection of initial bone invasion and determination of resection margins in squamous cell carcinoma of the head and neck compared to conventional imaging modalities

Determination of adequate bony resection margins in inflammatory jaw pathologies using SPECT-CT in primary mandibular reconstruction with virtually planned vascularized bone flaps

OBJECTIVES

In advanced stages of osteoradionecrosis, medication-related osteonecrosis of the jaw, and osteomyelitis, a resection of sections of the mandible may be unavoidable. The determination of adequate bony resection margins is a fundamental problem because bony resection margins cannot be secured intraoperatively. Single-photon emission computed tomography (SPECT-CT) is more accurate than conventional imaging techniques in detecting inflammatory jaw pathologies. The clinical benefit for virtual planning of mandibular resection and primary reconstruction with vascularized bone flaps has not yet been investigated. This study aimed to evaluate the determination of adequate bony resection margins using SPECT computed tomography (SPECT-CT) for primary microvascular reconstruction of the mandible in inflammatory jaw pathologies.

MATERIALS AND METHODS

The cases of 20 patients with inflammatory jaw pathologies who underwent primary microvascular mandibular reconstruction after the bony resection margins were determined with SPECT-CT were retrospectively analyzed. The bony resection margins determined by SPECT-CT were histologically validated. The sensitivity was calculated as the detection rate and the positive predictive value as the diagnostic precision. Radiological ossification of the vascularized bone flaps with the mandibular stumps was assessed at least 6 months after reconstruction. The clinical course was followed for 12 months.

RESULTS

The determination of adequate bony resection margins with SPECT-CT yielded a sensitivity of 100% and a positive predictive value of 94.7%. Of all the bony resection margins, 97.4% were radiologically sufficiently ossified with the vascularized bone flap and showed no complications in the clinical course.

CONCLUSIONS

SPECT-CT could increase the probability of determining adequate bony resection margins.

CLINICAL RELEVANCE

SPECT-CT could have a beneficial clinical impact in the context of primary microvascular bony reconstruction in inflammatory jaw pathologies.

[On the relevance of histopathology results in oropharyngeal cancer with mandibular involvement and the necessary imaging]

BACKGROUND

Planning of surgical procedures in patients suffering from oropharyngeal cancer requires appropriate imaging, particularly in consideration of the spatial relationship to the mandible. Resection of portions of the mandible (box, marginal, or segmental resection) is often necessary, while simultaneously avoiding overtreatment. Typically, a computed tomography (CT) scan is initially performed. However, the question arises of whether CT alone is adequate for reliable assessment of mandibular involvement.

MATERIALS AND METHODS

A patient cohort of 25 individuals aged 44-79 years (mean 62 years) undergoing partial oropharyngeal resection with segmental mandibular resection was examined. The indication for segmental resection was based on the close relationship of the tumor to the mandible observed in imaging. Reconstruction was consistently carried out with a reconstruction plate and free or pedicled flaps. Preoperative radiological findings were compared with histopathology results after decalcification of the mandibular bone.

RESULTS

Cortical tumor infiltration was observed in the mandible in 9 patients (36%). Preoperatively, clear bone infiltration had been identified in CT in only 2 of these 9 patients; in the remaining 7, only direct tumor contact with the mandible was evident. Magnetic resonance imaging (MRI) revealed bone infiltration in 1 of these 7 patients.

DISCUSSION

Adhering to safety margins requires a radical surgical approach and reliable intraoperative frozen section analysis. However, at the bone level, intraoperative frozen section analysis is technically impractical due to the required decalcification. Only after decalcification can the entire specimen be assessed for tumor infiltration. In our cohort, a significant discrepancy in terms of bone infiltration was noted between preoperative imaging assessments and postoperative histopathology. CT preoperatively identified bone infiltration in only 8% of our patients. In two thirds of the specimens, no bone infiltration was evident after decalcification and histopathological processing, retrospectively indicating overtreatment by segmental resection; box or marginal resections may have been sufficient in these cases. Therefore, when tumors are adjacent to the bone in CT, MRI should also be performed preoperatively to more reliably detect bone infiltration.

Using Artificial Intelligence to Diagnose Osteoporotic Vertebral Fractures on Plain Radiographs

Osteoporotic vertebral fracture (OVF) is a risk factor for morbidity and mortality in elderly population, and accurate diagnosis is important for improving treatment outcomes. OVF diagnosis suffers from high misdiagnosis and underdiagnosis rates, as well as high workload. Deep learning methods applied to plain radiographs, a simple, fast, and inexpensive examination, might solve this problem. We developed and validated a deep-learning-based vertebral fracture diagnostic system using area loss ratio, which assisted a multitasking network to perform skeletal position detection and segmentation and identify and grade vertebral fractures. As the training set and internal validation set, we used 11,397 plain radiographs from six community centers in Shanghai. For the external validation set, 1276 participants were recruited from the outpatient clinic of the Shanghai Sixth People's Hospital (1276 plain radiographs). Radiologists performed all X-ray images and used the Genant semiquantitative tool for fracture diagnosis and grading as the ground truth data. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were used to evaluate diagnostic performance. The AI_OVF_SH system demonstrated high accuracy and computational speed in skeletal position detection and segmentation. In the internal validation set, the accuracy, sensitivity, and specificity with the AI_OVF_SH model were 97.41%, 84.08%, and 97.25%, respectively, for all fractures. The sensitivity and specificity for moderate fractures were 88.55% and 99.74%, respectively, and for severe fractures, they were 92.30% and 99.92%. In the external validation set, the accuracy, sensitivity, and specificity for all fractures were 96.85%, 83.35%, and 94.70%, respectively. For moderate fractures, the sensitivity and specificity were 85.61% and 99.85%, respectively, and 93.46% and 99.92% for severe fractures. Therefore, the AI_OVF_SH system is an efficient tool to assist radiologists and clinicians to improve the diagnosing of vertebral fractures. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Does preoperative imaging for scalp non-melanocytic skin cancer accurately predict invasion of the cranial vault? A systematic review and meta-analysis

PURPOSE

This study aimed to determine the diagnostic accuracy of CT and MRI in the preoperative detection of bone involvement for non-melanoma skin cancers (NMSCs) located on the scalp. This study further aimed to evaluate the predictive value of these imaging modalities in determining the need for craniectomy and to identify gaps in the existing literature.

METHODS

Electronic searches of the MEDLINE, Embase, Cochrane and Google Scholar databases were performed for English language studies of any type. Studies reporting detection or exclusion of histopathologically confirmed bone involvement through preoperative imaging were identified according to PRISMA guidelines. Studies reporting dural involvement, non-scalp tumours, and lacking tumour type(s) or outcome data were excluded. Outcomes were preoperative imaging result and histopathologically confirmed bone invasion. Meta-analysis was performed and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated (excluding case report and MRI data due to insufficient quality and quantity respectively).

RESULTS

Four studies with a total of 69 patients were included in the final review, of which two studies totalling 66 patients were included in the meta-analysis. Preoperative CT had a sensitivity of 38%, specificity of 98%, PPV of 90% and NPV of 73%.

CONCLUSIONS

The available data suggests that a preoperative CT finding of calvarial involvement by a scalp NMSC is likely to be real, but the absence of such a finding is unreliable. Current evidence suggests that preoperative imaging cannot exclude the necessity for craniectomy and future research is needed, particularly on the role of MRI.

A Review on the Usage of Bone Single-Photon Emission Computed Tomography/Computed Tomography in Detecting Skeletal Metastases in the Post-COVID-19 Era: Is it Time to Ditch Planar and Single-Photon Emission Computed Tomography only Gamma Camera Systems?

Planar whole-body bone scanning (WBS) is widely used to evaluate skeletal lesions seen in cancer and noncancer cases. Frequently, degenerative, or other benign bony changes may give rise to indeterminate lesions that mimic bone metastases. In the post-COVID-19 era, there is an evolutionary phase that puts importance on global development and adaptability, which encompasses to include nuclear medicine practices worldwide. Single-photon emission computed tomography/computed tomography (SPECT/CT) can be used to improve the characterization of these lesions and help to resolve the diagnostic conundrum while reducing the need for patients to undergo multiple different examinations at various imaging departments. The fusion of SPECT and CT allows morphological characterization of functional abnormality detected by focal tracer uptake on planar scintigraphy, which provides a one-stop center imaging in nuclear medicine departments. The objective of this study was to review the diagnostic accuracy of SPECT/CT in diagnosing bone metastases in a variety of oncology and nononcology cases and to determine the feasibility of performing bone SPECT/CT in all suspected cancer cases, including cases of bone infection instead of planar imaging alone. The utilization of hybrid SPECT/CT in indeterminate bone lesions detected on planar WBS can significantly increase the diagnostic confidence and accuracy of image interpretation. Recognition of patterns of disease identified using hybrid imaging can improve the management of patients with potentially lower costs in the long term. Currently, hybrid SPECT/CT machines are becoming a norm in nuclear medicine departments, thus potentially making single planar application machines obsolete in the near future. We hypothesize that in the interest of providing a meaningful interpretation of isotope bone scans, the default protocol should involve the option of acquiring SPECT/CT images rather than relying on whole-body scans only. Departments choosing to upgrade existing equipment or those choosing to invest in only one gamma camera should proactively opt for hybrid SPECT/CT systems.

89Zr-panitumumab PET imaging for preoperative assessment of ameloblastoma in a PDX model

Accurate assessment of tumor margins with specific, non-invasive imaging would result in the preservation of healthy tissue and improve long-term local tumor control, thereby reducing the risk of recurrence. Overexpression of epidermal growth factor receptor (EGFR) has been used in other cancers as an imaging biomarker to identify cancerous tissue. We hypothesize that expression of EGFR in ameloblastomas may be used to specifically visualize tumors. The aims of this study are to measure the specificity of radiolabeled 89Zr-panitumumab (an EGFR antibody) in vivo using patient-derived xenograft (PDX) models of ameloblastoma and positron emission tomography/computed tomography (PET/CT) scans. In PDX of ameloblastomas from four patients (AB-36, AB-37, AB-39 AB-53), the biodistribution of 89Zr-panitumumab was measured 120 h post-injection and was reported as the injected dose per gram of tissue (%ID/g; AB-36, 40%; AB-37, 62%; AB-39 18%; AB-53, 65%). The radiolabeled %ID/g was significantly greater in tumors of 89Zr-panitumumab-treated mice that did not receive unlabeled panitumumab as a blocking control for AB-36, AB-37, and AB-53. Radiolabeled anti-EGFR demonstrates specificity for ameloblastoma PDX tumor xenografts, we believe 89Zr-panitumumab is an attractive target for pre-surgical imaging of ameloblastomas. With this technology, we could more accurately assess tumor margins for the surgical removal of ameloblastomas.

Satisfied quantitative value can be acquired by short-time bone SPECT/CT using a whole-body cadmium-zinc-telluride gamma camera

The aim of this study was to evaluate the quantitative values of short-time scan (STS) of metastatic lesions compared with a standard scan (SS) when acquired by whole-body bone SPECT/CT with cadmium-zinc-telluride (CZT) detectors. We retrospectively reviewed 13 patients with bone metastases from prostate cancer, who underwent SPECT/CT performed on whole-body CZT gamma cameras. STSs were obtained using 75, 50, 25, 10, and 5% of the list-mode data for SS, respectively. Regions of interest (ROIs) were set on the increased uptake areas diagnosed as metastases. Intraclass correlation coefficients (ICCs) of standardized uptake values (SUVs) for the ROIs were calculated between the SS and each STS, and ICC ≥ 0.8 was set as a perfect correlation. Moreover, the repeatability coefficient (RC) was calculated, and RC ≤ 20% was defined as acceptable. A total of 152 metastatic lesions were included in the analysis. The ICCs between the SS vs. 75%-STS, 50%-STS, 25%-STS, 10%-STS, and 5%-STS were 0.999, 0.997, 0.994, 0.983, and 0.955, respectively. The RCs of the SS vs. 75%-STS, 50%-STS, 25%-STS, 10%-STS, and 5%-STS were 7.9, 12.4, 19.8, 30.8, and 41.3%, respectively. When evaluating the quality of CZT bone SPECT/CT acquired by a standard protocol, 25%-STS may provide adequate quantitative values.

Diagnostic efficacy of PET-CT, CT, and MRI in preoperative assessment of mandibular invasion caused by head and neck cancer: A systematic review and meta-analysis

OBJECTIVE

This study aims to conduct a systematic review and meta-analysis of the performance of PET-CT, CT, and MRI in diagnosing mandible invasion induced by head and neck cancer (HNC).

MATERIALS AND METHODS

The MEDLINE, Embase, Science Direct, CNKI and CQVIP databases were searched from inception until August 1, 2020. Then, a meta-analysis was conducted to calculate the combined diagnostic values with the corresponding 95% CIs. Two independent researchers completed the full text screening, data abstraction, and risk assessment.

RESULTS

This meta-analysis included 53 studies (N = 2 946 participants). For the pooled sensitivity (SEN), MRI (SEN: 0.88, 95% CI: 0.81-0.93) was found to have a significantly higher SEN (P = 0.0045), when compared to CT (SEN: 0.77, 95% CI: 0.71-0.82), while compared with PET-CT (SEN: 0.88, 95% CI: 0.64-0.97), the SEN was approximately equal (P > 0.05). The analysis revealed that the combined specificity (SPE) of MRI (SPE: 0.83, 95% CI: 0.74-0.89) and PET-CT (SPE: 0.81, 95% CI: 0.57-0.93) was lower than that of CT (SPE: 0.87, 95% CI: 0.83-0.90), but there was no statistical significance among these (P > 0.05). The comparison of the area under curve (AUC) reflected that PET-CT, CT and MRI have approximately equal summary diagnostic power in detecting mandibular invasion (P > 0.05).

CONCLUSION

The findings suggest that compared with CT, MRI is significantly superior for higher SEN in diagnosing mandibular invasion. The SEN of MRI and PET-CT were approximately equal. For the summary of diagnostic power, more prospective clinical trials that directly compare these three methods are needed in the future.

The use of 3D virtual surgical planning and computer aided design in reconstruction of maxillary surgical defects

PURPOSE OF REVIEW

The present review describes the latest development of 3D virtual surgical planning (VSP) and computer aided design (CAD) for reconstruction of maxillary defects with an aim of fully prosthetic rehabilitation. The purpose is to give an overview of different methods that use CAD in maxillary reconstruction in patients with head and neck cancer.

RECENT FINDINGS

3D VSP enables preoperative planning of resection margins and osteotomies. The current 3D VSP workflow is expanded with multimodal imaging, merging decision supportive information. Development of more personalized implants is possible using CAD, individualized virtual muscle modelling and topology optimization. Meanwhile the translation of the 3D VSP towards surgery is improved by techniques like intraoperative imaging and augmented reality. Recent improvements of preoperative 3D VSP enables surgical reconstruction and/or prosthetic rehabilitation of the surgical defect in one combined procedure.

SUMMARY

With the use of 3D VSP and CAD, ablation surgery, reconstructive surgery, and prosthetic rehabilitation can be planned preoperatively. Many reconstruction possibilities exist and a choice depends on patient characteristics, tumour location and experience of the surgeon. The overall objective in patients with maxillary defects is to follow a prosthetic-driven reconstruction with the aim to restore facial form, oral function, and do so in accordance with the individual needs of the patient.

Fluorescently Labeled Cetuximab-IRDye800 for Guided Surgical Excision of Ameloblastoma: A Proof of Principle Study

PURPOSE

Fluorescently labeled epidermal growth factor receptor (EGFR) antibodies have successfully identified microscopic tumors in multiple in vivo models of human cancers with limited toxicity. The present study sought to demonstrate the ability of fluorescently labeled anti-EGFR, cetuximab-IRDye800, to localize to ameloblastoma (AB) tumor cells in vitro and in vivo.

MATERIAL AND METHODS

EGFR expression in AB cells was confirmed by quantitative real-time polymerase chain reaction and immunohistochemistry. Primary AB cells were labeled in vitro with cetuximab-IRDye800 or nonspecific IgG-IRDye800. An in vivo patient-derived xenograft (PDX) model of AB was developed. The tumor tissue from 3 patients was implanted subcutaneously into immunocompromised mice. The mice received an intravenous injection of cetuximab-IRDye800 or IgG-IRDye800 and underwent imaging to detect infrared fluorescence using a Pearl imaging system (LI-COR Biosciences, Lincoln, NE). After resection of the overlying skin, the tumor/background ratios (TBRs) were calculated and statistically analyzed using a paired t test.

RESULTS

EGFR expression was seen in all AB samples. Tumor-specific labeling was achieved, as evidenced by a positive fluorescence signal from cetuximab-IRDye800 binding to AB cells, with little staining seen in the negative controls treated with IgG-IRDye800. In the animal PDX model, imaging revealed that the TBRs produced by cetuximab were significantly greater than those produced by IgG on days 7 to 14 for AB-20 tumors. After skin flap removal to simulate a preresection state, the TBRs increased with cetuximab and were significantly greater than the TBRs with the IgG control for PDX tumors derived from the 3 patients with AB. The excised tissues were embedded in paraffin and examined to confirm the presence of tumor.

CONCLUSIONS

Fluorescently labeled anti-EGFR demonstrated specificity for AB cells and PDX tumors. The present study is the first report of tumor-specific, antibody-based imaging of odontogenic tumors, of which AB is one of the most clinically aggressive. We expect this technology will ultimately assist surgeons treating AB by helping to accurately assess the tumor margins during surgery, leading to improved long-term local tumor control and less surgical morbidity.

Three-dimensional virtual surgical planning in the oncologic treatment of the mandible

OBJECTIVES

In case of surgical removal of oral squamous cell carcinomas, a resection of mandibular bone is frequently part of the treatment. Nowadays, such resections frequently include the application of 3D virtual surgical planning (VSP) and guided surgery techniques. In this paper, current methods for 3D VSP leads for optimisation of the workflow, and patient-specific application of guides and implants are reviewed.

RECENT FINDINGS

Current methods for 3D VSP enable multi-modality fusion of images. This fusion of images is not restricted to a specific software package or workflow. New strategies for 3D VSP in Oral and Maxillofacial Surgery include finite element analysis, deep learning and advanced augmented reality techniques. These strategies aim to improve the treatment in terms of accuracy, predictability and safety.

CONCLUSIONS

Application of the discussed novel technologies and strategies will improve the accuracy and safety of mandibular resection and reconstruction planning. Accurate, easy-to-use, safe and efficient three-dimensional VSP can be applied for every patient with malignancies needing resection of the mandible.

Defining secure surgical bone margins in head and neck squamous cell carcinomas: The diagnostic impact of intraoperative cytological assessment of bone resection margins compared with preoperative imaging

BACKGROUND

Imaging provides crucial staging information for treatment planning of head and neck squamous cell carcinomas (HNSCCs). Despite technical progress in imaging techniques, defining the extent of bone involvement preoperatively remains challenging and requires intraoperative information to control for adequate resection. The intraoperative cytological assessment of the bone resection margins (ICAB) provides information whether bone is infiltrated by carcinoma. The aim of this study was to assess the diagnostic value of preoperative imaging compared with ICAB in order to achieve carcinoma-free bone margins.

MATERIALS AND METHODS

108 HNSCC patients underwent preoperative computed tomography (CT), magnetic resonance imaging (MRI) and orthopantomogram (OPG) for staging and surgical planning. Curative resection was planned based on imaging. Intraoperatively, the resection margins were controlled by ICAB. The diagnostic value of preoperative imaging and ICAB was assessed with reference to the histological findings.

RESULTS

CT showed a sensitivity of 89.7%, specificity of 63.0%, positive predictive value (PPV) of 85.9%, and negative predictive value (NPV) of 70.8%. MRI revealed a sensitivity of 45.5%, specificity of 66.7%, PPV of 71.4% and NPV of 40.0%. OPG-imaging had a sensitivity of 64.7%, specificity of 76.2%, PPV of 81.5%, NPV 57.1%. In comparison, ICAB provided a sensitivity of 78.6%, specificity of 95.7%, PPV 73.3%, and NPV 96.7%. The accuracy was 82.1%, 52.9%, 69.0%, and 93.5% for CT, MRI, OPG, and ICAB, respectively.

CONCLUSION

Preoperative imaging lacks accuracy in defining adequate bone resection margins, compared with ICAB. ICAB supports preoperative imaging and intraoperative frozen sections to improve bone margin control.

Accuracy of the Cone Beam Computed Tomography in the Detection of Bone Invasion in Patients with Oral Cancer: A Systematic Review

This review article aims to analyze the diagnostic accuracy of the cone beam computed tomography (CBCT) with respect to other imaging methods in detection of bone tissue invasion by oral squamous cell carcinoma (OSCC). The review was carried out of English language studies in PubMed Search, National Library of Medicine, between 1990 and 2017. For each study, sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratio, as well as the diagnostic accuracy, and positive and negative predictive values were calculated. Of the 62 collected articles, 7 fulfilled the inclusion criteria. Tests and respective articles included were computed tomography (CT, four studies), magnetic resonance imaging (MRI, five studies), C (two studies), single-photon emission tomography (SPECT, two studies), multi-slice computed tomography (MSCT, two studies), and panoramic radiography (PR, two studies). The analytic data show values of LR+ were 14.4 (CT), 37.9 (MRI), 27.8 (CBCT), 25.5 (SPECT), 37.0 (MSCT), 4.8 (PR), respectively. The values of LR- were 0.35 (CT), 0.24 (MRI), 0.10 (CBCT), 0.06 (SPECT), 0.31 (MSCT), and 0.36 (PR), respectively. The positive and negative predictive values for bone tissue invasion by OSCC were 90.31%-74.91% (CT), 90.63%-78.69% (MRI), 80.05%-89.83% (CBCT), 72.97%-95.53% (SPECT), 87.44%-73.74% (MSCT), and 84.245%-69.18% (PR), respectively. The level of scientific evidence available today is weak. To better define the impact of CBCT on clinical decision-making, further studies with uniform methodological approach are needed.

Clinical value of 3D SPECT/CT imaging for assessing jaw bone invasion in oral cancer patients

PURPOSE

This study compared the diagnostic accuracy of jaw bone invasion (JBI) of oral cancer observed with three-dimensional (3D) SPECT/CT, CT, and MRI, and evaluated the clinical advantages of 3D SPECT/CT compared to conventional two-dimensional (2D) SPECT/CT.

MATERIALS AND METHODS

From April 2014 to January 2018, consecutive 16 oral cancer patients with suspected JBI, who had preoperatively undergone the imaging tests, were retrospectively enrolled. The likelihood of JBI was independently scored by a radiologist and oral surgeon. Using 2D or 3D SPECT/CT images, 20 oral surgeons delineated virtual surgical areas on 3D-printed jaws for 3 cases in which the extent of JBI was fully pathologically confirmed. The surgeons completed questionnaires regarding surgical planning and explanations for patients using Likert scales.

RESULTS

JBI was found in 9 patients including 5 (56%) with initial bone invasion. 3D SPECT/CT showed very high negative predictive value (100%) and inter-observer agreement (kappa = 0.917). 3D SPECT/CT was more sensitive than CT and MRI when inconclusive findings for JBI were considered negative. Compared to 2D SPECT/CT, 3D SPECT/CT had greater clinical advantages such as surgical planning and explanation to patients (p < 0.005).

CONCLUSION

3D SPECT/CT is useful not only for detecting JBI but also for surgical planning.

Performance of different imaging techniques in the diagnosis of head and neck cancer mandibular invasion: A systematic review and meta-analysis

BACKGROUND

To assess diagnostic efficacy of imaging techniques for mandibular invasion by head and neck cancer.

METHODS

Thirteen databases were searched. Study inclusion, data-extraction and quality assessment were performed independently. STATA 14.0 were mainly used for meta-analysis.

RESULTS

Forty-nine studies were included. For mandibular invasion (cortex and marrow), CBCT, SPECT, CT, MRI, orthopantomography, PET-CT and bone-scintigraphy showed pooled sensitivities of 90%, 97%, 73%, 88%, 75%, 90%, 92%, specificities of 85%, 69% 91%, 90%, 83%, 89%, 79%, AUC of 0.9461, 0.9434, 0.8995, 0.9296, 0.8761, 0.9290, 0.9207, respectively. The combined SROC curves indicated CBCT and SPECT were superior to other techniques. For mandibular medullary invasion (marrow), CT and MRI showed pooled sensitivities of 85% and 93%, specificities of 86% and 84%.

CONCLUSIONS

CBCT was top-priority choice for bone invasion diagnosis. SPECT was recommended for exclusion, CT and MRI were suitable for conformation. Further investigations are needed for mandibular medullary involvement.

Serendipitous Ureteral Stone Revealed on 99mTc-MDP Bone Scintigraphy

A 62-year-old man with esophageal cancer was referred for a Tc-MDP bone scintigraphy for staging. No metastatic lesion in the bone was identified. However, the images showed focally increased activity in the left pelvis, which were confirmed as ureteral stone on the SPECT/CT images.

AHNS Series: Do you know your guidelines? Evidence-based management of oral cavity cancers

Oral cavity squamous cell carcinoma (OCSCC) is the most common nonmelanoma head and neck cancer in the world, with an estimated 405 000 new cases expected each year. Subsites of the oral cavity include the alveolar ridge, buccal mucosa, anterior tongue, tonsillar pillar, retromolar trigone, hard palate, gingiva, and floor of the mouth. In this issue of the AHNS "Do you know your guidelines?" series, we review the evidence-based approach to the management of oral cavity carcinomas based on the framework provided by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.

Molecular Imaging and Oral Cancer Diagnosis and Therapy

Oral cancer is known as one of relatively common type of cancer worldwide. Despite the easy access of the oral cavity to examination, oral tumors are diagnosed in more advanced stages of the disease. Imaging techniques have been recently emerged as non-invasive approaches to detect molecular and cellular changes in living cells and organisms. These techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) could help physicians to screen patients with oral tumors particularly oral squamous cell carcinoma (OSCC) in early stage of the disease. In this review, we discuss that early detection and diagnosis of oral tumors through using more robust and precise imaging techniques and a variety of cellular/molecular biomarkers not only could lead to more effective and less aggressive form of treatment for the disease but also could improve survival rates and lower treatment costs. J. Cell. Biochem. 118: 3055-3060, 2017. © 2017 Wiley Periodicals, Inc.

Mandibular intraosseous pseudocarcinomatous hyperplasia: a case report

Background

Mandibular pseudocarcinomatous hyperplasia is a rare and generally benign pathology. We report on one of these rare cases.

Case presentation

The case history of a 73-year-old white man stated that he had a carcinoma of the oropharynx, which was primarily treated with radiotherapy and chemotherapy 4 years prior. As a result of radiotherapy he developed an osteoradionecrosis of his mandible and a consecutive pathological fracture of his left mandibular angle. Subsequent osteosynthesis was performed with a reconstruction plate. When we first saw him, his reconstruction plate was partially exposed with intraoral and extraoral fistulation. The resected bone of his defect-bordering jaw showed the typical pathohistological findings of an intraosseous mandibular pseudocarcinomatous hyperplasia. After a first reconstruction attempt with an iliac crest graft failed, definitive reconstruction of his mandible with a microvascular anastomosed fibula graft was achieved.

Conclusions

Intraosseous pseudocarcinomatous hyperplasia of the mandible is a rare differential diagnosis in maxillofacial surgery. Besides other benign epithelial neoplasms, such as calcifying epithelial odontogenic tumor, squamous odontogenic tumor, or different forms of ameloblastoma, the far more frequent invasive squamous cell carcinoma needs to be excluded. A misinterpretation of pseudocarcinomatous hyperplasia as squamous cell carcinoma must be avoided because it can lead to a massive overtreatment.

Relaxin-2 Expression in Oral Squamous Cell Carcinoma

Background

When advanced, oral squamous cell carcinoma (OSCC) may involve adjacent non-epithelial structures, and the prognosis is worse for bone invasion. Human relaxin-2 is a peptide hormone that has recently been associated with cancer. It can induce human osteoclast differentiation and activation, suggesting a role in tumor-driven osteolysis. This study was a preliminary assessment of the prognostic role of relaxin-2 in surgical specimens of OSCC tissue and adjacent but uninvolved mandibular/maxillary bone.

Methods

Relaxin-2 immunohistochemical expression and reaction intensity were assessed in tumor and uninvolved adjacent mandibular/maxillary bone specimens from 23 operated OSCC patients.

Results

All OSCC specimens were positive for relaxin-2. The intensity of its reaction in OSCC correlated significantly with the pattern of the tumor's invasion front (p = 0.02), being higher with the infiltrative pattern. Mean relaxin-2 immunohistochemical expression was higher in patients whose OSCC recurred after treatment than those experiencing no recurrence (81.3% ± 22.6% vs. 59.5% ± 29.7%, respectively). A significant direct association emerged between relaxin-2 expression in OSCC specimens and recurrence rate (p = 0.049).

Conclusions

Relaxin-2 expression in OSCC should be further investigated as a potentially useful marker for identifying patients at higher risk of recurrence, who might benefit from closer follow-up and more aggressive adjuvant therapy. In other oncological settings, increasing evidence of relaxin being produced by cancer cells is prompting efforts to synthesize human relaxin-2 analogs capable of acting as antagonists and limiting tumor growth.

Can the inferior alveolar nerve be used as a marker in frozen section for free margin control after segmental mandibulectomy in tumour ablation?

This study critically assessed the possibility of tumour spread along the inferior alveolar nerve (IAN) and its sensitivity as an intraoperative marker for clear bony margin control in frozen section during segmental mandibulectomy. Fifteen patients with oral squamous cell carcinoma (OSCC) involving the mandible and requiring a segmental mandibulectomy were included in this prospective trial. The ends of the IAN were analyzed using quick section analysis and the results compared with those of the definite pathological report. Nerve tissue could be identified in 25 of the 27 specimens collected. No specimen revealed tumour invasion. All histological diagnoses were finally confirmed. Three positive bony margins with microscopic carcinoma infiltrates were found, whereas corresponding nerve tissue did not confirm tumour invasion. This study supports the assumption that the pattern of tumour invasion is rarely primarily along the IAN in OSCC involving the mandible. Quick section analysis of the nerve tissue alone is therefore not a valid marker for intraoperative bony margin control. However, it can be used as an additional intraoperative diagnostic tool combined with other methods in rare cases of primary tumour spread along the IAN. A review of current knowledge regarding bony margin control published in the literature is provided.

Cutaneous squamous cell carcinoma of the scalp in the immunocompromised patient: review of 53 cases

OBJECTIVE

We analyzed outcomes from immunocompromised patients with scalp squamous cell carcinoma (SCC) treated with surgical excision with and without radiation in order to explore 3-year disease-free survival and overall survival.

STUDY DESIGN

The study design was a retrospective chart review.

SETTING

This study was conducted in a private practice setting.

SUBJECTS AND METHODS

The study included 53 immunocompromised patients with an average age of 63.2 years, with scalp squamous cell carcinoma. Pre-operative imaging dictated the extent of resection. Patients with bony involvement received wide local excision including full-thickness craniectomy and cranioplasty. Patients without bony involvement underwent wide local excision and outer-table calvarial resection. All patients were recommended to have post-operative radiation. Patients were followed for a minimum of 3 years.

RESULTS

A total of 53 patients were included in the study. Six patients had pre-operative CT showing bone involvement and were treated with full-thickness craniectomy along with post-operative radiation. Fourteen patients without bone involvement on pre-operative CT were found to have positive bone involvement on final pathology. Forty-five patients underwent post-operative radiation. Patients treated with adjuvant radiation demonstrated a 3-year survival of 80 % and the overall survival was 62 %. In the surgery-only group, the 3-year survival was 62.5 % and the overall survival was 32.5 %.

CONCLUSIONS

Immunocompromised patients with scalp SCC have a poor prognosis. Early detection and treatment are crucial. Based on our results, we recommend wide local excision with at least outer-table calvarial resection, and post-operative radiation. Despite aggressive therapy, patients may still have distant, local, or regional recurrence.

LEVEL OF EVIDENCE

level 2b (retrospective cohort).

Technetium-99m bone scan and panoramic radiography in detection of bone invasion by oral carcinoma

OBJECTIVE

The correct extension of cancer in the bone usually remains undetected on static imaging which may lead to inadequate or over excision. The conventional radiography as well as other anatomical imaging modalities like computed tomography, magnetic resonance imaging often fails to detect functional changes in the bone. However, bone scinitigraphy is highly sensitive in detecting earlier changes in the bone but lack anatomical definition. The purpose of the study was to evaluate the accuracy of combining technetium-99m bone scan and panoramic radiography (Tc scan/PR) over using single diagnostic modality in detection of jaw bone invasion by oral carcinomas. The accuracy of these imaging modalities either alone or in combination were determined by comparing with the histopathological findings.

MATERIALS AND METHODS

Twenty patients with biopsy-proven oral malignant tumors were randomly selected from Oral Medicine and Radiology department over a period of two years. All patients were investigated preoperatively by Tc scan and PR. Lewis - Jones's designed diagnostic criterion was applied on Tc scan/PR to evaluate bone involvement by cancer. To test the accuracy of Tc scan, PR and Tc scan/PR, their results were compared with the histopathological findings of resected specimen.

RESULTS

Hybrid Tc scan/PR had higher specificity, accuracy and positive predictive value (83.3%, 94.7%, 92.8%) than Tc scan alone (50%, 84.2%, 81.2%) and higher sensitivity and negative predictive value (100%, 100%) than PR (69.2%, 55.5%).

CONCLUSION

Combination of Tc scan and PR was more accurate in detecting jaw bone invasion by oral squamous cell carcinoma than Tc scan and PR alone.