Early Postoperative Magnetic Resonance in the Diagnosis of Persistent Juvenile Angiofibroma

Schreiber, Alberto; Ravanelli, Marco; Ferrari, Marco; Mattavelli, Davide; Rampinelli, Vittorio; Villaret, Andrea Bolzoni; Bertazzoni, Giacomo; Tomasoni, Michele; Gualtieri, Tommaso; Zorza, Ivan; Farina, Davide; Maroldi, Roberto; Nicolai, Piero

doi:10.1002/lary.29293

Cited by 3 publications

(4 citation statements)

References 33 publications

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“…All patients underwent early postoperative MRI after removal of the nasal packing and within 72 hours after surgery. This is part of the protocol employed in our institution, and it is aimed at obtaining a valuable baseline postoperative imaging, devoid of the inevitable inflammatory changes taking place subsequently and possibly confounding the recognition of persistence/relapse of disease 13,14 . Residual disease was defined as radiographic and/or endoscopic evidence of disease immediately following surgery.…”

Section: Methodsmentioning

confidence: 99%

“…This is part of the protocol employed in our institution, and it is aimed at obtaining a valuable baseline postoperative imaging, devoid of the inevitable inflammatory changes taking place subsequently and possibly confounding the recognition of persistence/relapse of disease. 13,14 Residual disease was defined as radiographic and/or endoscopic evidence of disease immediately following surgery. Follow-up included MRI performed yearly for at least 3 years to assess eventual recurrent tumor, as well as periodic nasal and nasopharyngeal endoscopy performed every 4 months in the first year and every 6 months thereafter.…”

Section: Preoperative Assessment and Surgical Managementmentioning

confidence: 99%

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Juvenile Angiofibroma: What Is on Stage?

Bignami

Pietrobon²,

Arosio

et al. 2021

The Laryngoscope

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Objectives/Hypothesis: The aim of the present study is to validate and compare four of the most widely used staging systems for juvenile angiofibroma on a homogeneous cohort of patients.Study Design: Retrospective case series. Methods: A retrospective review of patients treated with endoscopic or endoscopic-assisted surgical resection between 1999 and 2020 was carried out. Each case was classified according to the following staging systems: Andrews-Fisch (1989), Radkowski (1996), University of Pittsburgh Medical Center (2010), and Janakiram (2017). Spearman's rank correlation test and areas under the curve of receiver operator curves were used to assess the correlation between outcomes of interests (blood loss, surgical time, need for transfusion, and persistence of disease) and stage of disease.Results: Seventy-nine patients were included, with a median follow-up time of 25 months (range 12-127 months). Median surgical time was 217 minutes (range 52-625). Median blood loss was 500 mL (range 40-5200) and 27 patients (34.2%) required blood transfusions. Seven patients (8.9%) showed persistence of disease. All classification systems showed a similar association with blood loss, surgical time, persistence of disease, and need for transfusion.Conclusions: Involvement of the infratemporal fossa and intracranial extension was identified as red flags for surgical planning and preoperative counseling, as associated with increased risk for transfusion and persistent/recurrent disease, respectively. No classification system was found to be better than the others in predicting the most important outcomes. Therefore, the simplest and most easily applicable system would be the preferred one to be used in clinical practice.

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Section: Methodsmentioning

confidence: 99%

Section: Preoperative Assessment and Surgical Managementmentioning

confidence: 99%

Juvenile Angiofibroma: What Is on Stage?

Bignami

Pietrobon²,

Arosio

et al. 2021

The Laryngoscope

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“…

We would like to thank you for the opportunity to reply to the letter "Functional imaging in juvenile angiofibroma" by Sakthivel et al and the authors for their interest and feedback concerning our article "Early postoperative magnetic resonance in the diagnosis of persistent angiofibroma." 1 In two recent studies, Sakthivel et al 2,3 proposed and validated a promising postoperative protocol with prostatespecific membrane antigen (PSMA) positron emission tomography-computed tomography (PET-CT) for postoperative surveillance of juvenile angiofibroma (JA).The authors report three major criticisms regarding the limitations of using contrast enhanced magnetic resonance (cMR) as early postoperative imaging.They underline the difficulty of carrying out cMR with nasal packing: indeed, as reported in our previous studies, 1,4 we remove nasal packing within 2 days after surgery, usually before postoperative cMR. However, even when the patient underwent cMR before its removal, no issue of image acquisition or interpretation was observed.They pointed out the impossibility to perform cMR in patients who are hemodynamically instable; however, in our opinion, if there are concerns about hemodynamic instability, the priority should not be early identification of JA persistence, but rather patient stabilization.

…”

mentioning

confidence: 99%

“…We would like to thank you for the opportunity to reply to the letter "Functional imaging in juvenile angiofibroma" by Sakthivel et al and the authors for their interest and feedback concerning our article "Early postoperative magnetic resonance in the diagnosis of persistent angiofibroma." 1 In two recent studies, Sakthivel et al 2,3 proposed and validated a promising postoperative protocol with prostatespecific membrane antigen (PSMA) positron emission tomography-computed tomography (PET-CT) for postoperative surveillance of juvenile angiofibroma (JA).…”

mentioning

confidence: 99%

In Response to Early Functional Imaging in Juvenile Angiofibroma

et al. 2022

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We would like to thank you for the opportunity to reply to the letter "Functional imaging in juvenile angiofibroma" by Sakthivel et al. and the authors for their interest and feedback concerning our article "Early postoperative magnetic resonance in the diagnosis of persistent angiofibroma." 1 In two recent studies, Sakthivel et al. 2,3 proposed and validated a promising postoperative protocol with prostatespecific membrane antigen (PSMA) positron emission tomography-computed tomography (PET-CT) for postoperative surveillance of juvenile angiofibroma (JA).The authors report three major criticisms regarding the limitations of using contrast enhanced magnetic resonance (cMR) as early postoperative imaging.They underline the difficulty of carrying out cMR with nasal packing: indeed, as reported in our previous studies, 1,4 we remove nasal packing within 2 days after surgery, usually before postoperative cMR. However, even when the patient underwent cMR before its removal, no issue of image acquisition or interpretation was observed.They pointed out the impossibility to perform cMR in patients who are hemodynamically instable; however, in our opinion, if there are concerns about hemodynamic instability, the priority should not be early identification of JA persistence, but rather patient stabilization. In our series, all patients were able to tolerate MR without any hemodynamic issues.The authors also comment that the use of three criteria to define cMR positivity increases the risk of dubious cases. Indeed, despite the use of the abovementioned criteria, the result of our study is dichotomic: cMR is considered positive if all the criteria are satisfied, and negative if at least one is not.Therefore, in our opinion, cMR remains the best exam for JA postoperative baseline imaging. In fact, in addition to being radiation-free, its high soft-tissue resolution (0.6 mm) provides precise information on the site and size of residual JA and allows monitoring it over time. We believe functional imaging such as with PSMA PET-CT is an interesting second-line option in cases with extensive scarring and/or critical situations with suspicious cMR. Routine use of PET-CT, however, in addition to exposing young patients to radiation, may not have an acceptable cost-benefit balance.Undoubtedly, further research is warranted to define the best use of these imaging studies after JA resection and compare them appropriately.

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In Reference to Functional Imaging in Juvenile Angiofibroma

Sakthivel¹,

Kamaleshwaran

Thakkar

et al. 2022

The Laryngoscope

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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.

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Early Postoperative Magnetic Resonance in the Diagnosis of Persistent Juvenile Angiofibroma

Cited by 3 publications

References 33 publications

Juvenile Angiofibroma: What Is on Stage?

Juvenile Angiofibroma: What Is on Stage?

In Response to Early Functional Imaging in Juvenile Angiofibroma

In Reference to Functional Imaging in Juvenile Angiofibroma

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