Computed tomographic (CT) scans and magnetic resonance (MR) images obtained in 24 patients with cervical lymphadenopathy were retrospectively and blindly evaluated by two readers for the presence of central nodal necrosis (CNN) and extracapsular nodal spread (ENS). The CT studies were all enhanced, and the MR images were obtained with short repetition time (TR)/echo time (TE), long TR/double echo, and enhanced short TR/TE fat-suppressed sequences. Each MR imaging sequence was interpreted separately and then collectively. Sixty lymph nodes were identified with CT. Sensitivity for CNN was 16%-67% with the unenhanced MR pulse sequences, 50% with enhanced sequences, and 83%-100% with CT. The most accurate reading of MR images for CNN was with the unenhanced T1-weighted and T2-weighted images (86%-87%); the accuracy of CT was 91%-96%. The accuracy of MR imaging for detecting ENS was maximal with T1-weighted images (78%-90%). Gadolinium-enhanced, fat-suppressed images did not improve accuracy in evaluating CNN or ENS. CT is currently more accurate than unenhanced or enhanced MR imaging in detecting CNN or ENS.

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Clinical experience suggests that craniopharyngiomas may temporarily increase in size after radiation therapy (RT). The study goal is to determine the incidence and natural history of this response in a cohort of patients managed at Children's Healthcare of Atlanta (CHOA) or Emory Healthcare (EHC). Between 08/1998 and 06/2009, 41 children and young adults were diagnosed with craniopharyngioma at CHOA and/or EHC. Of these, 21 received external-beam radiation and were included in our analysis. Serial magnetic resonance imaging (MRI) studies were evaluated volumetrically to assess response to RT. Median age at diagnosis was 8.2 years (range 3.2-23.5 years). Median radiation dose was 54.0 Gy using standard fractionation (1.8-2.0 Gy/day). With median follow-up of 41.3 months (range 7.2-121.8 months), actuarial local control and overall survival rates at 5 years were 78.7 % and 100 %, respectively. Of subjects, 52.4 % of subjects (11 of 21) were noted on serial MRI evaluation to have tumor enlargement (mostly cystic component) after radiation before eventual shrinkage without further intervention. For tumors that expanded, the median volume increase was 33.9 % (range 15.6-224.4 %). Median time to maximal tumor/cyst expansion was 1.5 months (range 1.0-5.0 months). Finally, nearly all patients (20 of 21) showed a measurable objective response to therapy by MRI regardless of ultimate disease control. Median time to maximal response post-radiation, as defined by MRI, was 9.5 months (range 3.5-39.9 months). In summary, RT is effective for managing craniopharyngioma. However, despite good ultimate responses, approximately 50 % of the patients show tumor/cyst expansion on MRI over the first few months post-radiation. Caution should be taken not to subject these patients to "salvage surgery" or cyst aspiration during this early time unless there are other overriding surgical indications. Understanding the natural history of this phenomenon could potentially help guide the management of these craniopharyngioma patients.

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