Benign Ulceration as a Manifestation of Soft Tissue Radiation Necrosis: Imaging Findings

Debnam, J. Matthew; Garden, Adam S.; Ginsberg, Lawrence E.

doi:10.3174/ajnr.a0886

Cited by 27 publications

(17 citation statements)

References 23 publications

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“…Early exclusion of local recurrence by biopsy is recommended. The onset of mucosal ulcer was diagnosed 0–18 months post IMRT completion (mean/median 5/3 months), comparable to published results [18]; complete healing took 1–12 months (mean 3.5).…”

Section: Discussionsupporting

confidence: 86%

Late term tolerance in head neck cancer patients irradiated in the IMRT era

et al. 2013

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BackgroundThe aim was to quantify severe transient and persisting late term effects in our single institution head neck cancer (HNC) cohort treated with curatively intended intensity modulated radiation therapy (IMRT). Hypothesis was if a 2-year follow up (FU) is sufficient to estimate the long term tolerance in HNC irradiated in the IMRT era.MethodsBetween 01/2002-8/2012, 707/1211 (58%) consecutively treated IMRT patients met the inclusion criteria of a FU time >12 months and loco-regional disease control (LRC). 45% presented with loco-regionally advanced disease; 55% were referred for curative definitive IMRT (66 Gy-72 Gy in 30–35 fractions), 45% underwent postoperative IMRT (60-66 Gy in 30–33 fractions). Systemic concomitant therapy was administered in 85%. Highly consistent treatment procedures were performed with respect to contouring processes, dose constraints, radiation schedules, and the use of systemic therapy. Grade 3/4 late term effects were prospectively assessed and analyzed with respect to subgroups at particular risk for specific late effects.ResultsMean/median FU of the cohort was 41/35 months (15–124). 13% of the patients (92/707) experienced any grade 3/4 late effects (101 events in 92/707 patients), 81% in the first 12 months after radiation. 4% of all developed persisting late grade 3/4 effects (25 events in 25/707 patients).ConclusionsIMRT led to a high late term tolerance in loco-regionally disease free HNC patients. The onset of any G3/4 effects showed a plateau at 2 years. The question of the cervical vessel tolerance in disease free long time survivors is still open and currently under evaluation at our institution.

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Section: Discussionsupporting

confidence: 86%

Late term tolerance in head neck cancer patients irradiated in the IMRT era

et al. 2013

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“…MR imaging findings are subtle, and the normally enhancing mucosal line appears discontinuous (72). In more advanced stages, soft-tissue ulcerations are seen at CT and MR imaging as large, well-delineated, "punchedout" defects (Fig 7, Fig E1 [online]) and may lack the characteristic enhancing mucosal layer (32,(71)(72)(73). Tiny air-filled pockets near the ulcerated area and fistula formation are common (13,71,72).…”

Section: Soft-tissue Necrosis and Granulation Tissue-mentioning

confidence: 99%

“…In more advanced stages, soft-tissue ulcerations are seen at CT and MR imaging as large, well-delineated, "punchedout" defects (Fig 7, Fig E1 [online]) and may lack the characteristic enhancing mucosal layer (32,(71)(72)(73). Tiny air-filled pockets near the ulcerated area and fistula formation are common (13,71,72). Extensive soft-tissue necrosis can extend into the skull base, parapharyngeal space, and carotid space and may lead to life-threatening carotid rupture (73).…”

Section: Soft-tissue Necrosis and Granulation Tissue-mentioning

confidence: 99%

“…Radiation therapy-induced soft-tissue necrosis is typically seen at the initial tumor site. It is caused by vascular and lymphatic vessel damage that leads to formation of hypoxic hypovascular tissue, and this "fragile" tissue is prone to necrosis and subsequent infection (71)(72)(73). Soft-tissue necrosis in the head and neck is typically associated with laryngeal or pharyngeal ulcer and occasionally with fistula formation (13,71) (Fig 7).…”

Section: Soft-tissue Necrosis and Granulation Tissue-mentioning

confidence: 99%

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Diffusion-weighted and PET/MR Imaging after Radiation Therapy for Malignant Head and Neck Tumors

Varoquaux¹,

Rager²,

Dulguerov³

et al. 2015

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Interpreting imaging studies of the irradiated neck constitutes a challenge because of radiation therapy-induced tissue alterations, the variable appearances of recurrent tumors, and functional and metabolic phenomena that mimic disease. Therefore, morphologic magnetic resonance (MR) imaging, diffusion-weighted (DW) imaging, positron emission tomography with computed tomography (PET/CT), and software fusion of PET and MR imaging data sets are increasingly used to facilitate diagnosis in clinical practice. Because MR imaging and PET often yield complementary information, PET/MR imaging holds promise to facilitate differentiation of tumor recurrence from radiation therapy-induced changes and complications. This review focuses on clinical applications of DW and PET/MR imaging in the irradiated neck and discusses the added value of multiparametric imaging to solve diagnostic dilemmas. Radiologists should understand key features of radiation therapy-induced tissue alterations and potential complications seen at DW and PET/MR imaging, including edema, fibrosis, scar tissue, soft-tissue necrosis, bone and cartilage necrosis, cranial nerve palsy, and radiation therapy-induced arteriosclerosis, brain necrosis, and thyroid disorders. DW and PET/MR imaging also play a complementary role in detection of residual and recurrent disease. Interpretation pitfalls due to technical, functional, and metabolic phenomena should be recognized and avoided. Familiarity with DW and PET/MR imaging features of expected findings, potential complications, and treatment failure after radiation therapy increases diagnostic confidence when interpreting images of the irradiated neck. Online supplemental material is available for this article.

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“…The final patient in this group has only undergone a single 1-month follow-up clinical visit, at which time throat examination did not reveal evidence of a mass. Debnam et al 17 reported that in cases of soft-tissue radiation-induced ulceration and necrosis, short-term follow-up is warranted if biopsy is not performed because 4 of the 8 cases in their study with enhancement were positive for recurrent malignancy. The remaining 4 in the group either had benign biopsy results or were without tumor on follow-up.…”

Section: Discussionmentioning

confidence: 99%