Bilateral Necks Research Articles

Changes in bone mineral density and clinical parameters after stroke in elderly patients with osteopenia.

We aimed to determine the association between changes in bone mineral density (BMD) of the lumbar spine, bilateral femoral necks and clinical parameters in ambulatory older adult patients with stroke who were diagnosed with osteopenia. This retrospective study included ambulatory patients older than 65 years diagnosed with stroke between January 2019 and June 2021. Osteopenia was diagnosed within 1 month after stroke diagnosis. Subsequently, follow-up BMD was performed within 12 to 14 months. The manual muscle test and modified Barthel index were measured as clinical parameters, and bone turnover markers were measured as biochemical markers. The Wilcoxon signed-rank test was used to compare whether a significant difference in the change in BMD was noted at each site measured at 1-year intervals. The BMD of the paretic and non-paretic femoral necks decreased significantly over time, but no significant change was observed in the BMD of the lumbar spine. Bone turnover markers were significantly changed at follow-up. Patients with modified Barthel index of less than 82 had significant bone loss only on the paretic side of the femoral neck. The BMD of the paretic side of the femoral neck was significantly decreased regardless of the strength of the hip and knee extensors. Although older adult patients with stroke and osteopenia can walk independently, more active osteoporosis treatment is needed to prevent bone loss and fractures, including improvement in daily living function and bilateral lower extremity strength training.

Lingual Artery as the Recipient Vessel of Choice in Patients Requiring a Second or Third Free Flap in Recurrent Oral Cancers and Vessel-Depleted Neck: A 5-Year Experience in a Single Institute.

Introduction Reconstruction with free flaps becomes a challenge in recurrent cases having previously treated necks, in patients who have received prior radiation therapy or chemotherapy or both, and where the patient has already undergone free flap reconstruction in a prior surgery. Depleted cervical recipient vessels can increase the complexity of reconstruction in achieving successful free flap prefusion and thereby increasing flap thrombosis and eventually failure. Materials and Methods Over a period of 5 years from January 2018 to February 2023, we encountered a total of 22 cases of recurrent or second primary oral cancer with bilateral necks operated, postadjuvant chemo-radiotherapy, and requiring a second or third free flap reconstruction. In most of the cases we resorted to the lingual artery as the recipient artery of choice. Results No flap loss was reported. No cases were reexplored either for hematoma or for congestion. All patients recovered uneventfully. Conclusion To the best of our knowledge, there has been no paper yet that focuses on the lingual artery to be the recipient vessel of choice in recurrent oral cancers. We find the lingual artery to be a reliable and safe option and advocate its usage as recipient vessel of choice in recurrent oral cancers requiring more than one free flap reconstruction.

Vertebral endplate defects are associated with bone mineral density in lumbar degenerative disc disease.

Evidence has shown that lumbar vertebral endplate defects are clinically relevant and closely related to disc degeneration, but the relationship between endplate defects and bone mineral density (BMD) remains unclear. This study aimed to explore the association between endplate defects and BMD-related values in patients with lumbar degenerative disc disease (LDD). Three hundred and twenty-five Chinese adult subjects diagnosed with LDD underwent dual energy X-ray absorptiometry. Endplate defects were classified using lumbar MRI. Groups were subdivided based on the occurrence rates of defect endplates. BMD at the lumbar vertebral and bilateral femur necks was compared between groups, and the association between endplate defects and lumbar BMD-related values was analyzed and adjusted for confounders including age, sex, serum levels of 25-hydroxy vitamin D (25(OH)D), calcium (Ca) and phosphorus (P). Of 325 patients and 3250 endplates, 59.72% had defects, and 188 patients were divided into the higher defect rate group (occurrence rate > 50%). The higher defect rate group was associated with older age, more common postmenopausal females, higher osteoporosis rates and lower serum Ca and P levels. Lumbar BMD was greater than that at bilateral femur necks and was not equal to osteoporosis diagnosis. Endplate defects were more prevalent in lower segments. The occurrence of endplate defects was positively associated with lumbar BMD-related values in the partial correlation analysis. The association between endplate defects and lumbar BMD varies for subtypes and segments, with a trend of positive association in rim and erosive subtypes after adjusting for confounders. The present study demonstrated that the occurrence of endplate defects was associated with greater lumbar BMD values in patients with LDD. This association varies for different defect subtypes and segments. The results indicated that endplate defects should be taken into consideration in osteoporosis treatment to alleviate disc degeneration.

Dosimetric Comparison of Intensity Modulated Radiotherapy (IMRT) and Intensity Modulated Proton Therapy (IMPT) for Novel Oral Tongue Avoidance Concept in Low-Risk Squamous Cell Carcinoma of the Oral Tongue

<h3>Purpose/Objective(s)</h3> A subset of favorable oral tongue squamous cell carcinoma patients who undergo adequate surgical resection are at low risk of local recurrence to the primary site. Since irradiation of the primary site is the major cause of treatment morbidity during adjuvant radiotherapy, avoidance of this target while still treating the at-risk lymph nodes including the intervening lymphatics between the tongue and neck is an attractive potential treatment strategy. Prior to initiation of an investigator-initiated trial, we sought to quantify the dosimetric advantage of this strategy, hypothesizing intensity modulated proton therapy (IMPT) may further reduce dose to organs at risk (OAR) when avoiding the oral tongue compared to intensity modulated radiation therapy (IMRT). <h3>Materials/Methods</h3> Five consecutive patients with oral tongue cancer treated with postoperative radiation therapy from 8/2020 to 9/2021 were retrospectively reviewed. Novel Clinical Target Volume (CTV) contours were generated that excluded the oral tongue while maintaining coverage of at-risk lymph nodes. Comparison IMRT (X) and IMPT (PBT) plans were generated using both standard treatment volumes (Control) and oral tongue avoidance volumes (Study) (n=4 plans per patient). Dosimetric variables for critical OARs were compared using the paired t-test. <h3>Results</h3> Patients had T1-2 and N0-N2b disease with complete margin-negative partial or hemiglossectomy and bilateral neck dissections. The prescribed dose was 60 Gy in 30 fractions. D95% CTV coverage was similar between X and PBT plans for both Control and Study target volumes. Comparing Control to Study plans, both X (58.9 Gy vs. 38.3 Gy, p=0.007) and PBT (60.2 Gy vs. 26.1 Gy, p<0.001) decreased the mean dose to the oral cavity (OC). Similar results were demonstrated for mean pharyngeal constrictor dose with X (47.7 Gy vs. 44.6 Gy, p=0.003) and PBT (45.0 Gy vs. 34.9 Gy, p=0.001). There was no difference between Control and Study plans for larynx (p>0.19) or parotid (p>0.11) mean dose, or mandible max dose (p>0.59). Comparing the Study plans alone, PBT resulted in a significant reduction in mean OC dose (38.3 Gy vs. 26.1 Gy, p=0.007) and reduction in mean parotid dose (23.3 Gy vs.19.3 Gy, p=0.03) compared to X. For Control plans, there was no difference in OC dose using PBT compared to X but an improvement in mean parotid dose (26.6 Gy vs 19.7 Gy, p=0.02). <h3>Conclusion</h3> This study quantifies the dosimetric advantage of avoiding the oral tongue while still treating the at-risk intervening lymphatics and the bilateral necks during adjuvant radiotherapy for oral tongue cancer. The dosimetric difference between PBT and X was most prominent with an oral tongue avoidance strategy. Prospective studies are warranted to evaluate the clinical efficacy of oral tongue avoidance for favorable oral tongue cancer patients with indications for elective nodal irradiation.

Patterns of care in the radiotherapeutic management of head and neck cancer of unknown primary origin: in search of a standard

AbstractObjectiveTo analyze patterns of care in radiotherapy field design for patients treated for head and neck squamous cell carcinoma of unknown primary origin in the modern era.MethodsFrom January 2014 to April 2018, 33 patients were treated by intensity‐modulated radiation therapy for squamous cell carcinoma metastatic to the cervical lymph nodes of unknown primary origin. A total of 17 patients (52%) were treated by primary radiation; 16 (48%) were treated after surgery. N‐classification was N1 (3 patients); N2a (8 patients); N2b (15 patients); N2c (2 patients); and N3 (5 patients). Human papillomavirus status was positive in 19 (58%) and negative in 14 patients (42%). ResultsA total of 15 patients (46%) were treated with classic comprehensive fields to the entirety of the pharyngeal mucosal axis and bilateral cervical necks. Seven patients (21%) received ipsilateral neck radiation only. The total mucosal axis was irradiated in 15 patients (46%). Among the entire population, the nasopharynx and larynx were intentionally omitted in 36% and 48%, respectively. None of the clinical parameters predicted for the use of less‐than‐comprehensive radiation fields (P &gt; 0.05, for all).ConclusionSignificant variation exists in the radiotherapeutic management of head and neck unknown primary cancer. Further research to better optimize standards is required.

Quantitative evaluation of bone marrow fat content and unsaturated fatty index in young male soccer players using proton magnetic resonance spectroscopy (1H-MRS): a preliminary study.

Marrow fat exists as a distinct adipose tissue and plays a critical role in affecting both the quantity and quality of bone. However, the effect of soccer training on marrow fat has been rarely reported. This study aims to evaluate and characterize the marrow fat content and composition in different bone areas of soccer players and age-matched healthy subjects using proton magnetic resonance spectroscopy (1H-MRS). Between May 2020 and June 2020, 20 professional soccer players (20.7±0.9 years) and 20 age-matched healthy subjects (21.2±0.8 years) were enrolled in this cross-sectional study. The 1H-MRS were acquired from the 3rd lumbar vertebrae, bilateral femoral necks, and distal tibias of all subjects using a single-voxel point-resolved spatially localized spectroscopy (PRESS) sequence. Four soccer players underwent a second magnetic resonance (MR) examination within a 30-minute interval after the initial scan to evaluate test-retest reproducibility. Inter- and intra-observer measurement reliabilities were assessed using 10 randomly selected spectra from the soccer players group. All spectra were processed using the jMRUI software package (http://www.jmrui.eu/). Quantified water and lipid signals were used to calculate fat content (FC) and the unsaturated fatty index (UI). Compared with healthy subjects, we found that soccer players had a lower FC in L3 and bilateral femoral necks and higher UI in the left femoral neck (P<0.05). All FC and UI values of the bilateral distal tibias showed no significant differences between the two groups (P>0.05). The UI values of the right femoral neck or distal tibia were markedly higher than the left side in both inactive subjects and soccer players (P<0.05, except for the femoral neck in players), and there were notable ΔUI differences in the lower limbs between the soccer players and the healthy subjects (P<0.05). Soccer practice can be considered a positive sport that contributes to decreasing FC in lumbar vertebrae and femoral necks and increasing the UI in femoral necks. Quantitative MRS provides an ideal modality to predict marrow fat metabolism caused by mechanical stimulation.

Placing a Bolus Helps to Lower the RT Dose to Pacemaker in IMRT Treatment of Head and Neck Cancer.

Planning IMRT for Head and Neck cancer (HNC) patients can be challenging if a pacemaker is in the vicinity of treatment field. This study investigated the use of bolus on the pacemaker to reduce RT dose. Three patients with HNC with pacemaker were included in this study. All subjects were planned to receive RT to neck nodes on the same side as pacemaker. Patients were simulated in the supine position with an aquaplast mask for immobilization. Patients were treated with a dose painting technique. Prescriptions were as follows: Patient 1, 70Gy, 63Gy, and 56Gy and bilateral neck coverage, patient 2 to 66Gy, 59.4Gy, and 56Gy to ipsilateral neck, and patient 3, 70Gy, 63Gy, and 58.10Gy and bilateral necks to high, intermediate and low risk regions respectively. Plans were generated with and without 1cm bolus on the skin over the pacemaker. Currently, the commonly accepted dose for a pacemaker is <2Gy. All patients were planned with a volumetric modulated arc therapy (VMAT) technique using 6MV energy and 3 full arcs with varying collimator angles. The use of bolus over the pacemaker throughout the treatment course reduces the dose received by the pacemaker without affecting PTVs coverage. There was a 33.4%, 19.6%, 34.9% reduction in dose to the pacemaker in patients 1, 2 and 3 respectively when bolus was used and placed on the device. Conclusions: This novel technique of using bolus while planning IMRT for HNC patients with pacemakers yields significant dosimetric advantages and helps to reduce the dose to the pacemaker.Tabled 1Abstract 2800; TablePacemaker Patientskin to pacemaker distanceDistance PTV to pacemakerMax dose w/o 1cm bolusMax dose w 1cm bolus19mm6cm311.1cGy207.3cGy27mm2cm401.4cGy322.8cGy36mm6cm248.8cGy162cGy Open table in a new tab

Modified cannulated screw fixation in the treatment of Pauwels type III femoral neck fractures: A biomechanical study

BackgroundAchieving satisfactory internal fixation for patients with Pauwels type III femoral neck fractures has become a critical problem. The purpose of this study was to compare a common standard internal reduction and fixation method for femoral neck fractures to the modified fixation methods. MethodsA computed tomography scan of the femur was performed to make a Three-dimensional (3D) model, and a fracture line was simulated in the femoral neck. 3Dfinite element analysis was carried out for different insertion methods of cannulated tension screws. Six healthy femur specimens were harvested from three formalin-fixed cadavers, and Pauwels type III femoral neck fracture was artificially created in bilateral femurs. The right side was treated with the inverted triangle construct method and the left side by the modified screw fixation method. After fixation, uniaxial compression and maximum load experiments on the bilateral femoral necks were carried out using the non-contact full-field dynamic strain measurement system (VIC-3D) on a pressure testing machine. FindingsBoth 3D finite element analysis and biomechanical study showed that the modified screw fixation method(group D) provided better anti-shearing and anti-rotation properties for Pauwels type III femoral neck fractures, and offered better interfragmentary compression. Therefore, this modified screw fixation method can offer patients a better option for treatment of Pauwels type III femoral neck fractures. InterpretationChanging the placement of the anterosuperior screw in the inverted triangle construct as perpendicular to the fracture line has the advantages in anti-shearing, anti-rotation and increasing interfragmentary compression.

Effects of monthly minodronate with or without eldecalcitol addition in osteoporosis patients with rheumatoid arthritis: An 18-month prospective study

ObjectivesIncreasing bone mineral density (BMD) to reduce fracture risk is a primary goal of osteoporosis treatment. This prospective, observational study evaluates the effects of monthly minodronate (MIN; 50 mg) with or without eldecalcitol (ELD) addition in osteoporosis patients with rheumatoid arthritis (RA) during 18 months. MethodsThe cohort was prospectively and randomly split into the MIN monotherapy group (14 cases) and MIN plus ELD group (combination group; 14 cases) due to no reports on the effectiveness and safety of MIN therapy in relation to ELD addition for comparisons of serum tartrate-resistant acid phosphatase (TRACP)-5b, bone alkaline phosphatase (BAP), and BMD of the lumbar 1–4 vertebrae (L-BMD), bilateral total hips (H-BMD; the mean value of the right and left hips), and bilateral femoral necks (FN-BMD) at baseline and at 6, 12, and 18 months of treatment. ResultsBaseline values were comparable between the groups apart from a tendency for higher TRACP-5b in the combination group. Seven of 14 patients in the combination group had received previous bisphosphonate treatment. BAP was significantly more reduced in the monotherapy group at 6 months, with no other remarkable differences for TRACP5b, L-BMD, H-BMD, or FN-BMD during the observation period. ConclusionsThe above findings suggest that regardless of ELD addition, MIN potentially improves BMD during 18 months in osteoporosis patients with RA.

Redefining Patients at Risk of Contralateral Neck Disease for HPV-related Oropharyngeal Cancer: A Pathologic Study of Patients with Bilateral Neck Dissection

HPV positive oropharynx squamous cell carcinomas (OPSCC) have a better prognosis than HPV negative OPSCC. Standard radiation treatment volumes cover at risk nodal regions that drain the primary tumor, and avoidance of the contralateral neck may improve morbidity. However, optimal treatment volumes are still undetermined, especially for base of tongue (BOT) primary tumors, and few studies to date have used surgical series to risk stratify HPV positive patients. We reviewed all patients who received trans-oral robotic surgery (TORS) of primary OPSCC and dissection of bilateral necks to determine risk of contralateral neck disease. After IRB approval, patients with cT1-T3 SCC of the tonsil or BOT who received primary resection and bilateral neck dissection were identified to have HPV positive disease by PCR between 2010 and 2018. Pre-surgical PET scans, CT scans, and physician notes were reviewed for clinical staging according to AJCC 8th edition, and well-lateralized primary disease was defined as lack of soft palate or midline structure involvement. Fisher’s exact test was used to evaluate association of contralateral nodal disease with pre-surgical treatment clinical information. Univariate and multivariate odds ratios were constructed using logistic regression. Out of 111 cases in our cohort, there were 10 (9%) with positive contralateral lymph nodes on pathology, including 6% (3/50) of tonsillar and 11.5% (7/61) of BOT cases. Neither cT stage nor primary site was predictive of contralateral nodal disease. Patients with a well-lateralized BOT primary and without bilateral clinical nodal disease (cN0/N1) were not likely to have pathologic contralateral disease (OR 0.05; 95% CI:0.008-0.317), and was present in 5% of such patients. Among the whole cohort, presenting without bilateral clinical nodal disease was the strongest predictor of lack of pathologic contralateral disease (adjusted OR 0.03; 95% CI:0.005-0.19). Those presenting with both cN0/N1 disease and with a well-lateralized tumor were not likely to have contralateral nodal disease on pathology (OR 0.06; 95% CI:0.013-0.25). Radiographic extranodal extension, smoking history, and multiple clinically suspicious nodes were not associated with contralateral pathologic disease. HPV-related OPSCC cancers that are clinically and radiographically N0-N1 have exceedingly low rates of contralateral disease on pathology. This is the first pathologically driven study to suggest that well-lateralized HPV positive BOT primaries with limited clinical nodal disease may be able to receive elective nodal irradiation to the ipsilateral neck only. Future prospective trials should determine if such BOT primaries can be treated with unilateral neck irradiation in a manner akin to some tonsil primaries, thereby expanding opportunities for HPV-related treatment de-intensification.

Significance of Detecting Serum Complement C3 and C4 in Patients with Multiple Myeloma

To investigate the significance of detecting serum complement C3 and C4 in patients with multiple myeloma (MM) and to explore its correlation with myeloma bone disease (MBD). The levels of serum complement C3 and C4 in 69 MM patients and 30 healthy people were examined by scatter nephelometry. The bone density of L1-4 vertebral body, bilateral femoral neck and bilateral hip joints were measured by dual energy bone density meter (DXA). The levels of serum complement C3 and C4 in MM patients significantly increased in comparison with that in healthy people (P＜0.01). The patients in advanced clinical stage exhibited a higher levels of C3 and C4 than those in stable stage (P＜0.01). In addition, the patients with grade C of MBD had a higher levels of serum complement C3 and C4 than those in patients with grade A and B of MBD (P＜0.01). The levels of serum complement C3 and C4 in MM patients negatively correlated with bone density in L1-4 vertebral body, bilateral femoral necks and hip joints. The correlation coefficients were r=-0.938, r=-0.659, r=-0.745, r=-0.748, r=-0.596 in complement C3 and r=-0.908, r=-0.623, r=-0.710, r=-0.714, r=-0.595 in complement C4, respectively. The levels of complement C3 and C4 positively correlate with the severity of bone disease and bone density in MM patients, which suggests that complement C3 and C4 plays important roles in the development of MBD. The levels of serum C3 and C4 may be the sensitive biomarkers of MBD.

Risk of prolonged opioid use among cancer patients undergoing curative intent radiation therapy for head and neck malignancies

ObjectivePatients undergoing radiation treatment (RT) for head and neck malignancies often suffer significant disease- and treatment-related pain requiring opioids for effective management. However, the prevalence and associated risk factors of prolonged opioid use in this population remain poorly characterized. We sought to quantify the rate of prolonged opioid use among opioid naïve patients receiving curative-intent RT for head and neck malignancies and to identify associated risk factors. MethodsWe retrospectively identified patients who had undergone RT for head and neck malignancies at our institution between Jan 2011 and Sept 2017. Our primary endpoint was persistent opioid use 6-months following completion of RT. Patients were included if they were opioid-naïve, underwent curative intent RT, had adequate follow-up, and did not have residual or recurrent disease within our follow-up period. Univariable and multivariable logistic regression was utilized to identify risk factors for prolonged opioid use. ResultsWe identified 311 patients meeting our inclusion criteria; 40 (12.9%) continued to use opioids 6-months following RT. Univariable analysis found current smoking, alcohol abuse, RT dose, treatment to the bilateral necks, induction chemotherapy, concurrent chemotherapy, PEG tube, daily milligram morphine equivalents, and adjuvant analgesic medication use to be positively associated with prolonged opioid use; prior surgery was negatively associated with prolonged opioid use. Delivery of induction chemotherapy (OR 2.86, CI (95%) 1.32–6.21) and alcohol abuse (OR 3.75, CI (95%) 1.66–8.47) remained statistically significant on multivariable analysis. ConclusionThe prevalence of prolonged opioid use in previously opioid naïve patients undergoing curative intent head and neck RT was just under 13%. Patients with history of alcohol abuse and those who undergo induction chemotherapy were most at risk.

The negative predictive value (NPV) of FDG-PET/CT in the Head and Neck Squamous Cell Carcinoma (HNSCC) N0 patient, the first report of the ACRIN 6685 trial.

6041 Background: This study evaluated the negative predictive value for node negativity in HNSCC. Methods: Patients were enrolled from 8/10 until 12/16 from 38 centers in the US and 1 center in China. This was a prospective, non-randomized trial. The study was designed to recruit 292 patients; however, 287 were enrolled by study closure. Inclusion criteria were newly diagnosed cT2-T4 SCC patients from the head and neck with one side cN0 who were willing to undergo an elective neck dissection. CN0 was determined by a negative neck CT or MR scan. Exclusions included non-SCC, non-surgical candidates, skin, nasopharynx or sinus primaries. PET/CT imaging reading performed centrally and pathology were analyzed at the neck level (left or right). To estimate confidence intervals, we used a nonparametric bootstrap to account for the correlation of data between sides of neck of the same patient. Correlative data and other image analyses will be reported separately. Results: PET/CT scans and pathology were available for 211 (table) N0 sides of neck for review at last interim analysis. NPV estimate with 95% CI for bilateral necks: 0.896 (0.831, 0.950) and specific to the N0 sides: 0.922 (0.862, 0.973). Conclusions: FDG PET/CT has high NPV for node negativity in HNSCC. This may obviate the need for elective neck dissection in N0 HNSCC patients. This trial was open about three times longer than planned, and a major obstacle to accrual was the generalized assumption among the oncology community that PET/CT had a high NPV. Therefore, patients sent to study centers for further diagnosis and treatment often had their PET/CT scans performed on non-ACRIN certified equipment. This required investigators to forgo offering the trial or the PET/CT was repeated. Our results may suggest application for pre-operative PET/CT nodal imaging of other primaries/lymphatic basins staged cN0. Funding from the National Cancer Institute through the grants U01 CA079778, U01 CA080098, CA180820, CA180794. Clinical trial information: NCT00983697. [Table: see text]

Five-year outcomes of an oropharynx-directed treatment approach for unknown primary of the head and neck

PurposeSquamous cell carcinoma of unknown primary (SCCHNUP) is commonly treated with comprehensive radiation to the laryngopharynx and bilateral necks. In 1998, we established a departmental policy to treat SCCHNUP with radiation directed to the oropharynx and bilateral neck. MethodsFrom 1998–2011, 60 patients were treated – N1: 18%, N2: 75% and N3: 7%. 82% underwent neck dissection. 55% received IMRT and 62% underwent concurrent chemoradiotherapy. ResultsAt median follow-up of 54months, 5 patients failed regionally and 4 emerged with a primary (tongue base, hypopharynx and thoracic esophagus). Five-year rates of regional control, primary emergence, distant metastasis, disease-free survival and overall survival were 90%, 10%, 20%, 72% and 79%, respectively. The 5year rate of primary emergence in a non-oropharynx site was 3%. ConclusionThis is the first demonstration that an oropharynx-directed approach yields low rates of primary emergence in SCCHNUP with excellent oncologic outcomes.

Risk Vessels of Retropharyngeal Hematoma During Stellate Ganglion Block.

Bleeding into the retropharyngeal space is a potential complication in stellate ganglion block (SGB). Retropharyngeal hematoma formation is considered to be due to damage of small arteries in the region, although only scanty details of the region are available. The aim of this study was to map the risk blood vessels in the retropharyngeal space to avoid accidental damage during SGB. Contrast-enhanced 3-dimensional computed tomography images performed on 80 patients were reanalyzed retrospectively to construct detailed map of cervical blood vessels that are prone to damage and bleeding during SGB. Of the 160 bilateral necks, 6 (3.8%) and 82 (51.3%) small arteries were identified in the medial portions of the ventral surface of the transverse processes of the sixth and seventh cervical vertebrae, respectively. In particular, 5 of the 6 small arteries detected in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra were the inferior thyroid artery (ITA). Of the 160 vertebral arteries, 2 arteries were missing, 4 (2.5%) entered the transverse foramen of the fifth cervical vertebra, whereas 1 artery (0.6%) entered the transverse foramen of the fourth cervical vertebra. Three-dimensional computed tomography identified the ITA in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra. The risk vessels of retropharyngeal hematoma during SGB could include the ITA.

Incidence of contralateral-bilateral nodes in the human papillomavirus era.

HPV-positive oropharyngeal squamous cell carcinoma has a more favorable prognosis when compared to HPV-negative disease, regardless of the presence of nodal metastases. However, the importance of contralateral neck treatment based on HPV status has not been well studied. Given the historically poor prognostic implications of cervical nodal metastases, this study sought to elucidate the relationship between HPV status and contralateral/bilateral nodal metastasis in patients with oropharyngeal squamous cell carcinoma. Retrospective cohort analysis. Data were collected on patients with oropharyngeal squamous cell carcinoma from 2001 to 2014. Nodal status was determined by contrast-enhanced computed tomography, positron emission tomography, or surgical pathology when available. Survival rates and associations between HPV status and demographic/tumor characteristics were assessed. Of 178 total patients, 46 (26.0%) had contralateral/bilateral metastases. There was no significant difference in incidence of contralateral/bilateral nodal metastases between HPV-positive and HPV-negative patients (24.6% vs. 29.1%, P = .53). Tonsil primaries had significantly lower incidence of contralateral/bilateral nodal metastases compared to tongue base (20.9% vs. 34.3%, P = .048). On multivariate regression, tumor size was the only factor associated with contralateral/bilateral nodal metastases (T4 vs. T1-3 odds ratio = 5.15, 95% confidence interval: 2.4-11.2). Five-year overall survival among all patients with and without contralateral/bilateral nodal metastases was 45.4% and 65.2%, respectively (P = .007). Our results did not show a significantly different incidence of contralateral/bilateral nodal metastases between HPV-positive and HPV-negative patients. T4 stage and tongue base location, however, were associated with contralateral disease. These data suggest treatment of bilateral necks might be warranted in these cases, regardless of HPV status. 4 Laryngoscope, 127:1328-1333, 2017.

Prevalence of vitamin D insufficiency among adolescents and its correlation with bone parameters using high-resolution peripheral quantitative computed tomography.

Vitamin D deficiency and insufficiency are highly prevalent among adolescents in Hong Kong, which is a sub-tropical city with ample sunshine. Vitamin D level is significantly correlated with key bone density and bone quality parameters. Further interventional studies are warranted to define the role of vitamin D supplementation for improvement of bone health among adolescents. The relationship between bone quality parameters and vitamin D (Vit-D) status remains undefined among adolescents. The aims of this study were to evaluate Vit-D status and its association with both bone density and bone quality parameters among adolescents. Three hundred thirty-three girls and 230 boys (12-16years old) with normal health were recruited in summer and winter separately from local schools. Serum 25(OH) Vit-D level, bone density and quality parameters by Dual Energy X-ray Absorptiometry (DXA) and High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT), dietary calcium intake, and physical activity level were assessed. Sixty-four point seven percent and 11.4% of subjects were insufficient [25 ≤ 25(OH)Vit-D ≤ 50nmol/L] and deficient [25(OH)Vit-D < 25nmol/L] in Vit-D, respectively. The mean level of serum 25(OH)Vit-D in summer was significantly higher than that in winter (44.7 ± 13.6 and 35.9 ± 12.6nmol/L, respectively) without obvious gender difference. In girls, areal bone mineral density (aBMD) and bone mineral content (BMC) of bilateral femoral necks, cortical area, cortical thickness, total volumetric bone mineral density (vBMD), and trabecular thickness were significantly correlated with 25(OH)Vit-D levels. In boys, aBMD of bilateral femoral necks, BMC of the dominant femoral neck, cortical area, cortical thickness, total vBMD, trabecular vBMD, BV/TV, and trabecular separation were significantly correlated with 25(OH)Vit-D levels. Vit-D insufficiency was highly prevalent among adolescents in Hong Kong with significant correlation between Vit-D levels and key bone density and bone quality parameters being detected in this study. Given that this is a cross-sectional study and causality relationship cannot be inferred, further interventional studies investigating the role of Vit-D supplementation on improving bone health among adolescents are warranted.

Contralateral Submandibular Gland Sparing in Head and Neck Squamous Cell Carcinoma Is Safe and Improves Patient-Reported Outcomes (PROs)

To determine the feasibility and potential benefits of sparing contralateral submandibular gland (cSMG) during definitive intensity modulated radiation therapy (IMRT) for head and neck squamous cell carcinoma (HNSCC). We reviewed treatment plans, mean doses (MDs) to organs at risk, patient-reported outcomes, and tumor control in 273 patients with HNSCC treated with definitive IMRT to the bilateral necks at our institution between 2005 and 2014. Patients were periodically given the validated xerostomia questionnaire (XQ) and head and neck quality of life questionnaire (HNQOL) pretreatment and at follow-up. The majority (73%) of patients had oropharyngeal cancer. The vast majority of patients, 93.0%, harbored stage III/ IV disease, and 93.0% of patients received concurrent chemotherapy. Median follow-up was 22.5 months (1–115 months), and 662 surveys were analyzed. The medians of MDs to oral cavity (OC) was 36 Gy (8-67 Gy), combined parotid glands (comPG) 31 Gy (6-58 Gy), ipsilateral SMG (iSMG) 66 Gy (28-72 Gy), and cSMG 37 Gy (8-70 Gy). On univariate analysis, significant predictors of XQ summary score (SS) included the MDs of OC (r=0.44, P<.01), comPG (r=0.63, P<.01), and cSMG (r=0.22, P=.04). On multivariate analyses, the comPG MD (r=0.42, P=.04) and time from treatment (r=-0.14, P=.01) were statistical predictors of the XQSS, and the cSMG MD (r=0.21, P=.09) was a marginally significant predictor for XQSS. At the 6- and 12-month timepoints, the cSMG MD is a significant predictor for XQSS (r=0.82, P=.01 and r=0.57, P=.04, respectively), eating domain (r=0.90, P=.01 and r=0.68, P=.02, respectively), fasting domain (r=0.66, P=.04 and r=0.52, P=.07, respectively) and HNQOL (r=0.77, P<.01 and r=0.49, P=.02, respectively). Using 39 Gy cSMG MD as a prespecified threshold based on dose-saliva relationships, regression modeling showed that patients receiving <39 Gy had significantly favorable XQSS in both univariate (r=-22.61, P<.01 and r=-15.18, P=.01, respectively) and multivariate (r=-26.50, P<.01 and r=-13.02, P=.03, respectively) analysis at 6 and 12 months. Moreover, patients receiving <39 Gy had improvement (P<.01) in their XQSS over time after IMRT, while patients receiving >39 Gy did not (P=.29) (data will be presented). Sixty-three percent (172/273) of the patients received <39Gy to the cSMG to preserve salivary output. In this group, the median of MD to cSMG was 31Gy (8-39 Gy), and the majority (75%) was oropharyngeal cancer. There were 28 total tumor recurrences with no failures in contralateral level IB, and only 1 patient failed on the contralateral neck, within the 54 Gy isodose line and in initially noninvolved level II. cSMG MD predicts for both patient-reported xerostomia and QOL after IMRT. cSMG sparing did not compromise disease control. We recommend keeping the cSMG MD to no more than 39 Gy if clinically possible.

Abnormal Bone Mechanical and Structural Properties in Adolescent Idiopathic Scoliosis: A Study with Finite Element Analysis and Structural Model Index.

Previous studies found adolescent idiopathic scoliosis (AIS) is associated with low bone mineral density (BMD) and abnormal bone quality, whilst the association between AIS and their bone strength is unknown. From high-resolution peripheral quantitative computed tomography-generated images, bone mechanical properties can be evaluated with finite element analysis (FEA), and trabecular rod-plate configuration related to trabecular bone strength can be quantified by structure model index (SMI). This study aimed to compare trabecular configuration and bone mechanical properties between AIS and the controls. 95 AIS girls aged 12-14 years and 97 age- and gender-matched normal controls were recruited. Bilateral femoral necks and non-dominant distal radius were scanned by dual-energy X-ray absorptiometry for areal BMD and HR-pQCT for SMI and FEA, respectively. Subjects were further classified into osteopenic and non-osteopenic group based on their areal BMD. Bone mechanical properties (stiffness, failure load and apparent modulus) were calculated using FEA. Linear regression model was used for controlling age, physical activity and calcium intake. AIS was associated with lower failure load and apparent modulus after adjusting for age, whereas AIS was associated with lower apparent modulus after adjusting for all confounders. Osteopenic AIS was associated with more rod-like trabeculae when compared with non-osteopenic AIS, whereas no difference was detected between osteopenic and non-osteopenic controls. This might be the result of abnormal regulation and modulation of bone metabolism and bone modelling and remodelling in AIS which will warrant future studies with a longitudinal design to determine the significance of micro-architectural abnormalities in AIS.

MRI-based morphological evidence of spinal cord tethering predicts curve progression in adolescent idiopathic scoliosis

Background contextExisting prognostic factors for adolescent idiopathic scoliosis (AIS) patients have focused mainly on curve, maturity, and bone-related factors. Previous studies have shown significant associations between curve severity and morphological evidences of relative shorter spinal cord tethering in AIS, and increased prevalence of abnormal somatosensory cortical–evoked potentials and low-lying cerebellar tonsil in severe AIS. Earlier evidence suggests that there might be neural morphological predictors for curve progression. PurposeThe purpose of this study was to identify any morphological predictors associated with cord tethering, as measured by magnetic resonance imaging (MRI), for curve progression in AIS patients. Study design/settingThis is a prospective cohort study. Patient sampleA total of 81 female AIS subjects between 10 and 14 years were included, without surgical intervention during the follow-up period. Outcome measuresMagnetic resonance imaging scans of hindbrain and whole spine and areal bone mineral density (BMD) at bilateral femoral necks were performed. MethodsAll AIS patients were longitudinally followed up starting from initiation of bracing beyond skeletal maturity in 6-month intervals. Clinical and radiographic data were recorded at each clinic visit. Bone mineral density and MRI measurements including ratio of spinal cord to vertebral column length, ratio of anteroposterior (AP) and transverse (TS) diameter of cord, lateral cord space (LCS) ratio, cerebellar tonsil level, and conus medullaris position were obtained at baseline. Only compliant patients with a minimum 2-year follow-up were analyzed. Adolescent idiopathic scoliosis girls were assigned into three groups according to bracing outcome: Group A, nonprogression (curvature increase of less than or equal to 5°); Group B, progression (curvature increase of greater than or equal to 6°); Group C, progression with surgery indication (Cobb angle of greater than or equal to 50° after skeletal maturity despite bracing). The predictors for curve progression were evaluated using univariate analysis and multivariate ordinal regression model. ResultsThe average duration of follow-up was 3.4 (range, 2.0–5.6) years. There were 46 girls (57%) in Group A, 19 (23%) in Group B, and 16 (20%) in Group C. No significant intergroup differences were found in spinal cord length, tonsil level, and conus position. Group C had significantly longer vertebral column length, smaller cord-vertebral length ratio, and higher AP/TS cord ratio compared with Group A, whereas LCS ratio in Group C was significantly increased compared with both Group A and Group B. In regression model, five significant independent predictors including cord-vertebral length ratio (odds ratio [OR]: 1.993 [95% confidence interval {CI}: 1.053–3.771], p=.034), LCS ratio (OR: 2.639 [95% CI: 1.128–6.174], p=.025), initial Cobb angle (OR: 1.156 [95% CI: 1.043–1.281], p=.006), menarche age (OR: 1.688 [95% CI: 1.010–2.823], p=.046), and BMD (OR: 2.960 [95% CI: 1.301–6.731], p=.010) and a marginally significant predictor namely AP/TS cord ratio (OR: 1.463 [95% CI: 0.791–2.706], p=.096) were obtained. ConclusionsOn baseline MRI measurement, cord-vertebral length ratio and LCS ratio are identified as new significant independent predictors for curve progression in AIS, whereas AP/TS cord ratio is suggested as a potential predictor requiring further validations. The earlier MRI parameters can be taken into accounts for prognostication of bracing outcome.