The prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in post-irradiated patients with nasopharyngeal carcinoma (NPC) is unknown.

MATERIALS AND METHODS

In a cross-sectional study, 31 NPC and 12 control patients completed questionnaires for GERD/LPR before esophageal manometry and 24-h pH monitoring. The DeMeester score and reflux finding score (RFS) were used to define GERD and LPR, respectively. Risk factors were identified.

RESULTS

51.6% of NPC and 8.3% of control patients, and 77.4% of NPC and 33% of control patients, were GERD-positive and LPR-positive, respectively. The GERD/LPR questionnaire failed to identify either condition in patients with NPC. No parameter differences in esophageal manometry or pneumonia incidence were noted between GERD/LPR-positive and GERD/LPR-negative patients. Post radiotherapy duration, high BMI, lack of chemotherapy, and dysphagia were positive risk factors for GERD/LPR.

CONCLUSIONS

A high prevalence of GERD/LPR in patients with post-irradiated NPC exists, but reflux symptoms are inadequate for diagnosis.

Chest computed tomography analysis of lung sparing morphology: differentiation of COVID-19 pneumonia from influenza pneumonia and bacterial pneumonia using the arched bridge and vacuole signs

INTRODUCTION

This study evaluated the arched bridge and vacuole signs, which constitute morphological patterns of lung sparing in coronavirus disease 2019 (COVID-19), then examined whether these signs could be used to differentiate COVID-19 pneumonia from influenza pneumonia or bacterial pneumonia.

METHODS

In total, 187 patients were included: 66 patients with COVID-19 pneumonia, 50 patients with influenza pneumonia and positive computed tomography findings, and 71 patients with bacterial pneumonia and positive computed tomography findings. Images were independently reviewed by two radiologists. The incidences of the arched bridge sign and/or vacuole sign were compared among the COVID-19 pneumonia, influenza pneumonia, and bacterial pneumonia groups.

RESULTS

The arched bridge sign was much more common among patients with COVID-19 pneumonia (42/66, 63.6%) than among patients with influenza pneumonia (4/50, 8.0%; P<0.001) or bacterial pneumonia (4/71, 5.6%; P<0.001). The vacuole sign was also much more common among patients with COVID-19 pneumonia (14/66, 21.2%) than among patients with influenza pneumonia (1/50, 2.0%; P=0.005) or bacterial pneumonia (1/71, 1.4%; P<0.001). The signs occurred together in 11 (16.7%) patients with COVID-19 pneumonia, but they did not occur together in patients with influenza pneumonia or bacterial pneumonia. The arched bridge and vacuole signs predicted COVID-19 pneumonia with respective specificities of 93.4% and 98.4%.

CONCLUSION

The arched bridge and vacuole signs are much more common in patients with COVID-19 pneumonia and can help differentiate COVID-19 pneumonia from influenza and bacterial pneumonia.

Oro-pharyngo-esophageal radionuclide scintigraphy predicts aspiration pneumonia risk and associated survival in post-irradiated nasopharyngeal carcinoma patients

OBJECTIVE

To demonstrate that oro-pharyngo-esophageal radionuclide scintigraphy (OPERS) not only detects tracheobronchial aspiration after swallowing, but also quantifies the amount of aspiration and subsequent clearance.

METHODS

Data collected between 2014 and 2019 were reviewed for aspiration pneumonia at 12 and 24-months after OPERS. The predictive value for aspiration pneumonia on flexible endoscopic evaluation of swallowing (FEES), videofluoroscopic swallowing study (VFSS), and OPERS, and the overall survival of patients with or without aspiration were determined.

RESULTS

Thirty-seven patients treated with radiotherapy for nasopharyngeal carcinoma (NPC) were reviewed. The incidence of aspiration detected on FEES, VFSS, and OPERS was 78.4%, 66.7%, and 44.4%, respectively. Using VFSS as a gold standard, the sensitivity and specificity of OPERS for aspiration was 73.7% and 100%. The positive and negative predictive values for aspiration were 100% and 66.7%, respectively, with an overall accuracy of 82.8%. A history of aspiration pneumonia was one factor associated with a higher chance of subsequent aspiration pneumonia within 12 months (odds ratio: 15.5, 95% CI 1.67-145.8, p < .05) and 24 months (odds ratio: 23.8, 95% CI 3.69-152.89, p < .01) of the swallowing assessment. Aspiration detected by OPERS was a significant risk factor for future aspiration pneumonia at 12 and 24 months respectively. Significantly, better survival was associated with an absence of aspiration on OPERS only, but not on FEES or VFSS.

CONCLUSION

OPERS predicts the safety of swallowing, the incidence of subsequent aspiration pneumonia, and the survival prognosis in post-irradiated NPC dysphagia patients.

LEVEL OF EVIDENCE

3.

Assessment of pharyngeal motor function using a novel velopharyngeal squeeze maneuver and a novel endoscopic pharyngeal contraction grade scale in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma

Background

To investigate a novel velopharyngeal squeeze maneuver (VPSM) and novel endoscopic pharyngeal contraction grade (EPCG) scale for the evaluation of pharyngeal motor function.

Methods

During endoscopic examination of 77 post‐irradiated nasopharyngeal carcinoma patients and control subjects, VPSM was rated and lateral pharyngeal wall movement graded with EPCG scale during swallowing. Pharyngeal constriction ratio (PCR) measured by videofluoroscopy was used for correlation.

Results

VPSM and EPCG scale showed almost perfect intra‐rater and inter‐rater reliability (Kappa: >0.90). VPSM was present in 61% of patients suggesting good pharyngeal motor function. VPSM was predictive of EPCG scale (Wald statistic = 29.99, p < 0.001). EPCG scale also correlated strongly with PCR (r: 0.812) and was predictive for aspiration (odds ratio: 22.14 [95% CI 5.01–97.89, p < 0.001]).

Conclusions

VPSM and EPCG scale are two novel tools to assess pharyngeal motor function, and both correlate well with pharyngeal contractility and aspiration.

Screening for Fabry Disease in patients with unexplained left ventricular hypertrophy

Fabry Disease (FD) is a systemic disorder that can result in cardiovascular, renal, and neurovascular disease leading to reduced life expectancy. FD should be considered in the differential of all patients with unexplained left ventricular hypertrophy (LVH). We therefore performed a prospective screening study in Edmonton and Hong Kong using Dried Blood Spot (DBS) testing on patients with undiagnosed LVH. Participants found to have unexplained LVH on echocardiography were invited to participate and subsequently subjected to DBS testing. DBS testing was used to measure α-galactosidase (α-GAL) enzyme activity and for mutation analysis of the α-galactosidase (GLA) gene, both of which are required to make a diagnosis of FD. DBS testing was performed as a screening tool on patients (n = 266) in Edmonton and Hong Kong, allowing for detection of five patients with FD (2% prevalence of FD) and one patient with hydroxychloroquine-induced phenocopy. Left ventricular mass index (LVMI) by GLA genotype showed a higher LVMI in patients with IVS4 + 919G > A mutations compared to those without the mutation. Two patients were initiated on ERT and hydroxychloroquine was discontinued in the patient with a phenocopy of FD. Overall, we detected FD in 2% of our screening cohort using DBS testing as an effective and easy to administer screening tool in patients with unexplained LVH. Utilizing DBS testing to screen for FD in patients with otherwise undiagnosed LVH is clinically important due to the availability of effective therapies and the value of cascade screening in extended families.

Pretreatment and early intratreatment prediction of clinicopathologic response of head and neck cancer to chemoradiotherapy using 1H-MRS

PURPOSE

To determine if choline (cho) identified by proton magnetic resonance spectroscopy ((1)H-MRS) performed pretreatment and early in the course of treatment predicts clinicopathologic response of head and neck squamous cell carcinoma (HNSCC).

MATERIALS AND METHODS

In all, 60 patients with HNSCC scheduled to undergo concurrent chemoradiotherapy or radiotherapy alone were recruited. (1)H-MRS was performed pretreatment and early intratreatment (2 weeks after start of treatment). Cho:creatine and cho:water ratios at each timepoint and change in the ratios between the two timepoints were correlated with locoregional failure, distant metastases, overall survival, and cancer-related death. Statistical analysis was performed using logistic regression and chi-square and a P-value of < 0.05 was considered statistically significant.

RESULTS

Cho was identified in 47/49 successful pretreatment spectra and 42 of these 47 underwent successful (1)H-MRS early intratreatment, of which 21 showed persistent cho. Locoregional failure occurred in 15, distant metastases in 6, and death in 15 patients; the follow-up period in survivors ranged from 13-64 months (mean, 39 months). No statistically significant correlation was found between (1)H-MRS parameters and clinical endpoints.

CONCLUSION

The pretreatment cho and change in cho early during a course of treatment did not predict clinical outcome.

Can diffusion-weighted imaging distinguish between normal and squamous cell carcinoma of the palatine tonsil?

The utility of diffusion-weighted imaging (DWI) in the detection of squamous cell carcinoma (SCC) of the tonsils has not been previously investigated. This preliminary study compared DWI of apparent SCC tonsillar tumours with normal tonsils. DWI of the tonsils was performed in 10 patients with newly diagnosed tonsil SCC that was evident on conventional MRI and in 17 patients undergoing cranial MRI for other indications. Regions of interest (ROI) were drawn around each identifiable tonsil on the apparent diffusion coefficient (ADC) map and the mean ADC value for each tonsil was calculated. ADC values for normal and SCC tonsils were compared using the Mann-Whitney U-test. The median ADC and range (x10(-3) mm(2) s(-1)) were found to be 0.814 and 0.548-1.312, respectively, for normal tonsils compared with 0.933 and 0.789-1.175, respectively, for SCC tonsils. ADC values were significantly higher for SCC tonsils than for normal tonsils (p = 0.009). No SCC tonsil had an ADC less than 0.82 x 10(-3) mm(2) s(-1) compared with 58% of normal tonsils. We conclude that there is a difference in the ADC between normal tonsils and SCC tonsils where the cancer is apparent on conventional MRI. These results are promising, although further studies are now required to determine whether DWI can be used to identify or exclude smaller foci of SCC within tonsils where the cancer is not evident on conventional MRI.

MRI of radiation-induced tumors of the head and neck in post-radiation nasopharyngeal carcinoma

The aim of this study was to document the sites and MRI features of radiation-induced tumors (RITs) in the head and neck following treatment for nasopharyngeal carcinoma (NPC). The MRI examinations and clinical records of 20 patients with 21 RITs were reviewed retrospectively. RITs developed 3-30 years after radiotherapy and included eleven squamous cell carcinomas, six sarcomas, two neuroendocrine carcinomas, one mucoepidermoid carcinoma and one meningioma. RITs arose in the maxillary region (9), oro/hypopharynx and oral cavity (5), external auditory canal (4), nasopharynx and sphenoid sinus (2) and brain (1). Radiation-induced carcinoma and sarcoma had MRI features that were useful to distinguish them from recurrent NPC. To improve early detection of RITs, the check areas on an MRI of a patient with previous NPC treated by radiation should always include the maxillary region, tongue, and external auditory canal/temporal bone.

MR imaging of nonmalignant polyps and masses of the nasopharynx and sphenoid sinus after radiotherapy for nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

The development of a new polyp or mass in the radiation field of a previously treated carcinoma is usually an ominous sign of a recurrent cancer, but rarely may it be caused instead by a nonmalignant process. The purpose of this study was to document the MR appearance of unusual nonmalignant polyps or masses (NMPMs) in the nasopharynx and sphenoid sinus arising after radiation treatment of nasopharyngeal carcinoma.

MATERIALS AND METHODS

The MR imaging reports of patients undergoing imaging after radiation therapy for nasopharyngeal carcinoma were reviewed retrospectively to identify patients with unusual polyps and masses in the nasopharynx. The MR images of those patients with no evidence of malignancy on biopsy or follow-up were reviewed.

RESULTS

The MR imaging reports of 1282 patients were reviewed, and 11 patients (1%) with NMPMs in the nasopharynx or sphenoid sinus were identified. Two patterns were identified: contrast enhancing nasopharyngeal polyps ranging in size from 1 to 5 cm (n = 5) and sphenoid sinus masses consisting of a nonenhancing mass filling a nonexpanded sinus (n = 4) and a heterogeneous enhancing mass expanding the sinus (n = 2). Osteoradionecrosis produced a large defect in the roof of the nasopharynx causing direct communication with the sphenoid sinus (n = 6). Histology revealed granulation tissue in all of the patients with variable amounts of fibrin and inflammatory cells. A direct infective etiology was not proved in any patient.

CONCLUSION

NMPMs in the nasopharynx and sphenoid sinus are rare complications after radiation therapy to the skull base, but the radiologist needs to be aware of their appearance so that they can be considered in the differential diagnosis of suspected tumor recurrence.

The impact of 18F-FDG PET/CT on assessment of nasopharyngeal carcinoma at diagnosis

The aim of this study was to determine whether the use of whole-body (18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography (PET)/CT alters staging and management of nasopharyngeal carcinoma (NPC) when compared with current staging practice. 52 patients with Stage III-IV NPC without distant metastases on chest X-ray/CT, abdominal ultrasound or bone scan were recruited for the study. Whole-body (18)F-FDG PET/CT and MRI of the head and neck were performed. The scans were compared for extent of the primary tumour (PT), cervical nodal metastases (CNM) and distant metastases (DM). Any discordance in results was assessed with respect to staging and impact on management. MRI and (18)F-FDG PET/CT scans were discordant in 28 (54%) patients. There was discordance in the extent of PT at 28 sites; in all sites, MRI showed more extensive tumour involving the nasopharynx (n = 8), skull base (n = 14), brain (n = 4) and orbit (n = 2). There was also variation among the extent of CNM in four nodes of the retropharyngeal region, with the nodes being positive on MRI. (18)F-FDG PET /CT did not identify any additional distant metastases but did identify a second primary tumour in the colon. The additional use of (18)F-FDG PET/CT did not "up-stage" the overall stage or change management in any patient. In conclusion, there is discordance between MRI and (18)F-FDG PET/CT, and the additional use of (18)F-FDG PET/CT for the current assessment of NPC at diagnosis does not appear to be justified in this cohort of patients.

Nasopharyngeal Cancers: Which Method Should be Used to Measure these Irregularly Shaped Tumors on Cross-Sectional Imaging?

PURPOSE

To determine whether the standard techniques of measuring tumor size and change in size after treatment could be applied to the measurement of nasopharyngeal cancers, which are often irregular in shape.

METHODS AND MATERIALS

The standard measurements of bidimensional (BDM) (World Health Organization criteria) and unidimensional (UDM) (Response Evaluation Criteria in Solid Tumors [RECIST] criteria), together with the maximum depth of the tumor perpendicular to the pharyngeal wall (DM), were acquired from axial magnetic resonance images of primary nasopharyngeal carcinoma in 44 patients at diagnosis and in 29 of these patients after treatment. Tumor volume measurements (VM), acquired from the summation of areas from the axial magnetic resonance images, were used as the reference standard.

RESULTS

There was a significant association between VM and BDM with respect to tumor size at diagnosis (p = 0.002), absolute change in tumor size after treatment (p < 0.001), and percentage change in tumor size after treatment (p = 0.044), but not between VM and UDM. There was also a significant association between VM and DM with respect to percentage change in tumor size after treatment (p = <0.0001) but not absolute change (p = 0.222).

CONCLUSION

When using simple measurements to assess irregularly shaped nasopharyngeal cancers, the BDM should be used to measure size at diagnosis and the BDM and percentage change in size with treatment. Unidimensional measurement does not reflect size or change in size, and therefore the RECIST criteria may not be applicable to all tumor shapes. The use of DM requires further evaluation.

Endovascular coiling versus neurosurgical clipping for ruptured intracranial aneurysms: significant benefits in clinical outcome and reduced consumption of hospital resources in Hong Kong Chinese patients

OBJECTIVES

Using specific selection criteria to determine whether endovascular coiling as compared to neurosurgical clipping is associated with significant benefits, in terms of 1-year clinical outcomes and consumption of hospital resources, for the treatment of ruptured intracranial aneurysms in Hong Kong Chinese patients.

DESIGN

Retrospective study.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Records of outcomes of 169 consecutive Chinese patients, who were treated with endovascular coiling (n=80) or surgical clipping (n=89), were reviewed. All patients were followed up clinically for a mean of 55 (standard deviation, 201) months and radiologically with sequential digital subtraction angiography at 6 and 18 months after treatment.

RESULTS

The mean ages of patients were 56 (standard deviation, 13) years for the coiling group, and 57 (standard deviation, 13) years for the clipping group (P=0.575). The median aneurysm size was 4 mm in both groups (P=0.898). The severity of subarachnoid haemorrhage in the two groups did not differ (P=0.619). The rate of death or permanent disability leading to dependency (Glasgow Outcome Scale, 1-3) at 1 year was significantly lower in the coiling group (12/80, 15%) as compared to the clipping group (30/89, 34%) [P=0.005], resulting in a risk reduction of 19% (95% confidence interval, 6-32%). There were significantly more frequent admissions into the intensive care unit in the clipping group (P<0.001); the median duration of intensive care unit stay was 2 days (vs 0 days in the coiling group). The incidence of subsequent treatment procedures for residual or recurrent aneurysm was more common in the coiling group (13/80 vs 3/89; P=0.004).

CONCLUSION

Endovascular coiling as compared to neurosurgical clipping for treatment of patients with ruptured intracranial aneurysms is associated with significant benefits in terms of a reduced need for intensive care unit admissions and better general clinical outcomes in Hong Kong Chinese patients.

Hemangioblastoma of filum terminale associated with arteriovenous shunting

BACKGROUND

Spinal arteriovenous shunt typically presents in middle age or in the elderly with a strong male predilection. The clinical presentation is usually progressive neurological deficits such as paraparesis or incontinence due to cord edema, although back pain is also a common presentation. Progress of neurological deficit is typically stopped by occlusion of the shunt (surgically or endovascularly), but the return of loss of function may be found in less than half of these patients. In contrast, spinal hemangioblastomas usually occur in adults, and the most common presentation is pain with radiculopathy. Location in the filum terminale is very rare.

CASE DESCRIPTION

After a review of the medical literature, we identified 7 cases of hemangioblastomas arising from the filum terminale (Am J Neuroradiol. 2005;26:936-945; Acta Neurochir [Wien]. 2000;142:1059-1062; J Neurosurg Sci. 2001;45:58-62; J Clin Neurosci. 2006;13:285-288; Neurosurgery. 1999;44:220-223; Clin Neurol Neurosurg. 1985;87:55-59). We report an additional case of a filum terminale hemangioblastoma occurring in a 64-year-old man with 1 month exacerbation of chronic low back pain. Preoperatively, it was misdiagnosed as filum terminale arteriovenous fistula.

CONCLUSION

Even with modern imaging, preoperative diagnosis can still be difficult.

Delayed complications of radiotherapy treatment for nasopharyngeal carcinoma: imaging findings

Radiotherapy is used to treat a wide variety of head and neck tumours that arise in and around the skull base. The delayed effects of radiation damages a range of structures, including the nervous system, bone, major vessels, mucus membranes, pituitary and salivary glands, as well as increasing the risk of radiation-induced neoplasms. In this review the complications resulting from radiation treatment for nasopharyngeal carcinoma (NPC), a cancer treated with a high dose of radiation to a fairly large region, are illustrated. Many patients with NPC have a long-term survival, so are at risk of developing delayed radiation effects, and hence may demonstrate a wide range of complications on imaging. Other tumours around the skull base treated with radiotherapy include meningiomas, chordomas, chondrosarcomas, pituitary adenomas, paranasal sinus and nasal cavity tumours. In these cases similar complications may be encountered on imaging, although the severity, incidence and location will vary.

Intracranial aneurysms treated with Guglielmi detachable coils: midterm clinical and radiological outcome in 97 consecutive Chinese patients in Hong Kong

BACKGROUND AND PURPOSE

Use of Guglielmi detachable coils (GDCs) has proved to be a promising endovascular treatment for intracranial aneurysms. This study aimed to evaluate midterm clinical and radiologic outcomes of this treatment in Hong Kong Chinese patients, 68% of whom had small aneurysms (< or =5 mm).

METHODS

We included 97 consecutive patients in whom GDCs were placed with curative intent. The patients presented with subarachnoid hemorrhage (n = 80) or mass effect (n = 17). The aneurysms measured 5 cm +/- 2.8 mm; 68% were < or =5 mm. All patients were followed up clinically for an average of 54.5 +/- 20.9 months and radiologically with sequential digital subtraction angiography at 6 and 18 months.

RESULTS

Total occlusion of the aneurysm was successfully achieved in 71.1% of patients after the initial treatment and in 82.5% after subsequent treatments. The retreatment rate was 17.5%. Procedure-related complication and mortality rates were 11.3% and 0%, respectively. The overall mortality was 5%, including mortality due to treatment failure in 1%. Neurologic outcomes were excellent in 77% of patients. Improved neurologic status, unchanged status, and deteriorated status was noted in 61.5%, 22%, and 16.5% of patients, respectively, at the end of the follow-up period. Intrinsic differences existed between Chinese and Western patients regarding the size of the aneurysm at presentation, periprocedural complications, and progression patterns of anatomic outcomes.

CONCLUSION

Endovascular coiling with GDCs is a reasonably effective and safe treatment for intracranial aneurysms in this group of Hong Kong Chinese patients, with favorable clinical and radiologic outcomes.