Clipping of tumour resection margins allows accurate target volume delineation in head and neck cancer adjuvant radiation therapy

Evaluation of computed tomography settings in the context of visualization and discrimination of low dose injections of a novel liquid soft tissue fiducial marker in head and neck imaging

“…Marking of the tumor resection surface using titanium ligature clips in head and neck cancer patients undergoing surgical tumor resection and subsequent free flap soft tissue reconstruction has been demonstrated to permit reliable delineation of this structure in the context of RT planning. This facilitates significant reduction of the radiation dose administered to the graft while maintaining the boost dose to the planning target volume, including the tumor bed [ 9 , 10 ]. However, some shortcomings have to be considered when applying titanium clips in this context: Potential migration of metallic clips may reduce the accuracy of the marking procedure and metal induced artifacts might impair their identification on postoperative imaging [ 13 , 15 , 23 , 30 , 31 ].…”

“…However, some shortcomings have to be considered when applying titanium clips in this context: Potential migration of metallic clips may reduce the accuracy of the marking procedure and metal induced artifacts might impair their identification on postoperative imaging [ 13 , 15 , 23 , 30 , 31 ]. Moreover, if placed superficially in the oral/pharyngeal region, there is a risk of clip detachment and subsequent aspiration and from a technical standpoint, placement of the desired number of clips can be impeded by the imperative to avoid intraoperative delay [ 9 , 10 ].…”

“…underdosing in the area of the target volume and to avoid the risk of overdosing in the area of healthy tissue at the same time [ 7 ]. Especially in case of free flap soft tissue reconstruction, which is performed frequently in patients with large head and neck tumors, precise delineation of the tumor bed in postoperative medical imaging poses a challenging task due to similar contrast values of native and reconstructed soft tissue [ 8 , 9 ]. In this context, intraoperative incorporation of titanium ligature clips has been demonstrated to facilitate precise definition of the tumor bed in postsurgical imaging, allowing for an increased accuracy of adjuvant radiation treatment [ 9 , 10 ].…”

Flap delineation guidelines in postoperative head and neck radiation therapy for head and neck cancers

“…Because a flap is an ectopic tissue taken at a distance from the tumour, it may not be at risk of tumor involvement, except for contiguous extension from tumor seeding at the tissue junction area between native tissues and the flap itself [14,21]. The tissue-flap junction may be better identified using surgical clips [22].…”

Comparison of virtual and titanium clip marking of tumour resection margins for improved radiation planning in head and neck cancer surgery

“…[4][5][6] In most centres, a tumour bed boost is delivered. Usually the electron boost is marked clinically using information such as the area of surgical induration, data on the preoperative tumour location, surgical and histopathological annotations, and postoperative three-dimensional (3D) imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) datasets.…”