In Reference to Functional Imaging in Juvenile Angiofibroma

Abstract

With great interest, we read the article by Schreiber et al. and congratulate the authors for their excellent attempt in validating early postoperative magnetic resonance imaging (MRI) in the diagnosis of persistent juvenile angiofibroma (pJA). 1 Although structural imaging is the most commonly employed method of postoperative surveillance in JA, recently functional imaging with either prostate-specific membrane antigen or somatostatin tracer PET-CT has gained popularity. 2,3 Due to intraoperative bleeding and the difficulty in removing the disease completely, the rate of residual disease even after surgical treatment varies from 13% to 50%. As healing processes and postinflammatory scar enhance with contrast, late postoperative assessment of residual/ recurrent disease remains a major radiological challenge. It is also a known fact that if no residual mass is observed on the first postoperative radiological examination, the risk of subsequent recurrence is low as recurrence is mainly the growth of residual disease. 4 We also believe early contrast-enhanced MRI (CEMRI) could be an immaculate fit for immediate postoperative surveillance. But performing an early MRI would be difficult in patients whose nasal cavity is packed with gelfoam or surgicel and in those patients who are hemodynamically unstable. Further, as the authors mentioned in their study CEMRI leaves you with a score of three possibilities and as per authors only lesions fulfilling the score 3 were diagnosed to have persistence and the score 1 and 2 were kept in serial radiological follow-up for every 6 months till 3 years. This protocol makes the patient and the parents to be in doubt always regarding the persistence and regrowth of the tumor.We recently validated the Postoperative Angiofibroma Radionuclide Imaging Study (PARIS) protocol for easy postoperative surveillance. Functional imaging leaves you with only two possibilities either with uptake or not making the dilemma to be solved. Thakar et al. showed in their series of 22 patients the residual tumors initially identified on CEMRI were also clearly identified on dedicated head and neck spot functional scans with much precision despite postembolization and surgical interventions indicating the greater promise of this scanning for assessment during follow-up compared to CEMRI. The patient who remained negative on functional imaging at first remained asymptomatic at follow ups (17-35 months). 5 Hence, we urge the specialty centers involved in managing these rare tumors to explore the possibility of early functional imaging as an easy postoperative surveillance method for early biochemical and structural pJA. AUTHOR'S CONTRIBUTIONP.S. and K.K.: design and drafting of manuscript and acquisition of information. A.T. and R.K., editing, literature review, and critical revisions. All authors read and approved the final version of the article.