Background Despite better prognosis, there is a group of oropharyngeal squamous cell carcinoma (SCC) human papillomavirus (HPV)+ patients who experience treatment failure and succumb to distant metastasis. Methods Seventy-eight previously untreated patients nested in a concurrent chemoradiation protocol were reviewed to correlate patterns of local-regional tumor extent to distant metastasis. Biomarker assessment was: HPV in situ hybridization and epidermal growth factor receptor (EGFR) immunointensity. Results The 3-year disease-specific survival (DSS) for patients presenting with and without matted nodes was 69% and 94%, respectively (p = .003). Matted nodes were a poor prognostic factor independent of T classification, HPV, EGFR, and smoking status. For patients who were HPV+, 7 of 11 died of distant metastasis and 6 of 7 with distant metastasis had matted nodes. Conclusion Matted nodes are a novel marker of poor prognosis in oropharyngeal SCC independent of established prognostic factors. Matted nodes may identify patients at risk for the development of distant metastasis who could benefit from systemic therapy, whereas patients without matted nodes may be candidates for de-escalation of therapy.

Object We reviewed our experience with pineal cysts to define the natural history and clinical relevance of this common intracranial finding. Methods The study population consisted of 48,417 consecutive patients who underwent brain MR imaging at a single institution over a 12-year interval and who were over 18 years of age at the time of imaging. Patient characteristics, including demographic data and other intracranial diagnoses, were collected from cases involving patients with a pineal cyst. We then identified all patients with pineal cysts who had been clinically evaluated at our institution and who had at least 6 months of clinical and imaging follow-up. All inclusion criteria for the natural history analysis were met in 151 patients. Results Pineal cysts measuring 5 mm or larger in greatest dimension were found in 478 patients (1.0%). Of these, 162 patients were male and 316 were female. On follow-up MR imaging of 151 patients with pineal cyst at a mean interval of 3.4 years from the initial study, 124 pineal cysts remained stable, 4 increased in size, and 23 decreased in size. Cysts that were larger at the time of initial diagnosis were more likely to decrease in size over the follow-up interval (p = 0.004). Patient sex, patient age at diagnosis, and the presence of septations within the cyst were not significantly associated with cyst change on follow-up. Conclusions Follow-up imaging and neurosurgical evaluation are not mandatory for adults with asymptomatic pineal cysts.

Object Pineal cysts are a frequent incidental finding on intracranial imaging. In adults, the prevalence of pineal cysts is estimated to be 1.1–4.3%. However, the prevalence is not well established in younger patients. Methods The authors retrospectively reviewed a consecutive series of 14,516 patients 25 years of age and younger, who underwent brain MR imaging at a single institution over an 11-year period. In patients identified with pineal cysts, the authors analyzed the images according to cyst size, signal characteristics, enhancement pattern, and evidence of local mass effect. Patient characteristics including demographics and other intracranial diagnoses were collected in the pineal cyst population and compared with a randomly selected age- and sex-matched control patient population. The data were evaluated using univariate and multivariate logistic regression, linear regression, and ANOVA. Results The authors identified 288 pineal region cysts (2.0%). The prevalence of pineal cysts was higher in female (2.4%) than in male patients (1.5%; p < 0.001). Pineal cysts were identified in patients of all ages, with an increased prevalence found in older patients (p < 0.001). Pineal cyst size was similar for all age and sex groups. Conclusions Pineal cysts are common in the pediatric population, with an increased prevalence in girls and in older patients.

Background To determine whether the addition of molecular and imaging biomarkers to established clinical risk factors could help predict locoregional failure (LRF) after chemoradiation in human papillomavirus (HPV)-related(+) oropharyngeal cancer (OPC) and improve patient selection for locoregional treatment de-intensification. Methods HPV status was determined for 198 consecutive patients with Stage III/IV OPC treated with definitive chemoradiation from 5/2003–10/2010. The impact of pre-therapy epidermal growth factor receptor (EGFR) overexpression; imaging biomarkers including primary tumor and nodal maximum standardized uptake values on FDG-PET, gross tumor volumes, and matted nodes; and clinical factors on LRF (including residual disease at adjuvant neck dissection) was assessed. Results Primary tumors were HPV+ in 184 patients and HPV-negative in 14. EGFR overexpression was related to HPV-negative status and was univariately associated with LRF in the overall population, but was neither retained in the multivariate model after adjustment for HPV status, nor associated with LRF in HPV+ patients. Similarly, imaging biomarkers were univariately associated with LRF, but correlated with T-stage and/or N-stage and did not remain predictive in HPV+ patients after adjustment for T4- and N3-stages, which were the only significant predictors of LRF on multivariate analysis. Among HPV+ patients with non-T4- or N3-stages, only minimal smoking was associated with decreased LRF. Conclusion(s) The prognostic impact of EGFR overexpression and imaging biomarkers on LRF was predominantly related to their association with HPV-negative status and T- or N-stage, respectively. . Among HPV+ OPC patients treated with uniform chemoradiation, only T4-stage, N3-stage, and smoking contributed to risk-stratification for LRF.

ObjectiveCongenital abnormalities of the spine and spinal cord are referred to as spinal dysraphisms. This article reviews nor mal embryological development of the spine and spinal cord and the imaging findings of congenital abnormalities of the spine and spinal cord with particular focus on MRI. ConclusionKnowledge of the normal development of the spine and spinal cord provides a framework for understanding these complex entities.

Background To determine whether matted nodes (MNs) uniquely identify HPV+ oropharyngeal cancer (OPC) patients at disproportionately high distant failure (DF) risk who may benefit from intensified systemic therapy. Methods 178 stage III/IV HPV+ OPC patients who completed definitive chemoradiotherapy were stratified by risk-group (low-risk=T1-3/N0-2c/<10 pack-years; intermediate-risk=T1-3/N0-2c/≥10 pack-years; high-risk=T4 or N3). Prognostic impact of MNs was assessed. Results At 52-months median follow-up, event rates with and without MNs were: locoregional failure (LRF): 23.3% vs. 12.8%(p=0.16), DF: 50.0% vs. 1.4%(p<0.01), any failure: 73.3% vs. 14.2%(p<0.01); cause-specific-mortality: 56.7% vs. 5.4%(p<0.01), and death: 56.7% vs. 13.5%(p<0.01). In multivariate analyses including risk-group and individual risk-factors, MNs were the strongest predictor for all endpoints except LRF. Among patients without MNs, risk-group discriminated LRF (at 3-years: low-risk=2.0%, intermediate-risk=14.4%, high-risk=24.2%; p<0.01), but not DF (low-risk=0.0%, intermediate-risk=2.1%, high-risk=3.8%; p=0.53). Conclusions MNs portended dramatically increased DF and death risks in HPV+ OPC, identifying a candidate population for consideration of chemo-intensification.

Background The current AJCC staging system may not accurately reflect survival in patients with HPV+OPSCC. The purpose of this study is to develop a system that more precisely predicts survival. Methods CT scans from 156 patients who underwent chemoradiation for advanced-stage OPSCC with >2years follow-up were reviewed. We modeled patterns of nodal metastasis associated with different survival rates. We defined HPV+N1 as a single node <6cm, ipsilaterally,contralaterally or bilaterally. HPV+N2 was defined as a single node ≥6cm or ≥2nodes ipsilaterally/contralaterally or ≥3nodes bilaterally. HPV+N3 was defined as matted nodes. Results There was no significant difference in DSS(p=0.14) or OS(p=0.16) by AJCC classification. In patients grouped by HPV+N1,HPV+N2,and HPV+N3 nodal classification, significant differences in DSS(100%,92%,55%,respectively,p=0.0001) and OS(100%,96%,55%,respectively,p=0.0001) were found. Conclusions A staging system with reclassification of size,bilaterality and matted nodes more accurately reflects survival differences in this cohort of patients. Review of the AJCC staging system with these criteria should be considered for HPV+OPSCC.

Background We recently described the imaging characteristics of multiple confluent regional metastases (matted nodes) and found that this characteristic was associated with distant metastasis in patients with oropharyngeal squamous cell carcinoma (OPSCC). The purpose of this study is to determine if matted nodes are a predictive marker for distant metastasis. Methods Radiologic lymph node characteristics on 205 untreated stage III/IV with OPSCC patients of whom 192 had known HPV status underwent weekly carboplatin and paclitaxel with concomitant IMRT between 2003–2010 with minimum 2 years of follow-up. Results The 3-year DSS for patients with matted nodes was 58% versus 97% with non-matted nodes(p=0.0001). The prevalence of matted nodes in the population was 20%. The positive predictive value of matted nodes for distant metastasis is 66%, and the negative predictive value is 99%. Conclusions Matted nodes are a predictive marker for distant disease and can be used for planning new clinical interventions.