Radiation Induced Mucositis: What the Radiologist Needs to Know.

Radiation induced oral mucositis (RIOM) is a common and debilitating complication of radiation therapy for head and neck cancers. RIOM can lead to oral pain, dysphagia, and reduced oral intake, which can be severe enough to necessitate placement of a feeding tube or utilization of total parenteral nutrition. When severe, RIOM can cause premature termination of radiation therapy and can alter treatment plans leading to suboptimal treatment doses. While patient reporting of RIOM symptoms has been the gold standard of documenting RIOM progression, little has been described in the radiology literature concerning the typical imaging findings of RIOM. Herein, we review the pathophysiology and clinical presentation that underlies the development of RIOM with illustrative cases to highlight the relevant imaging findings related to RIOM for the practicing radiologist.

In-vivo longitudinal imaging of microvascular changes in irradiated oral mucosa of radiotherapy cancer patients using optical coherence tomography.

Mucositis is the limiting toxicity of radio(chemo)therapy of head and neck cancer. Diagnostics, prophylaxis and correction of this condition demand new accurate and objective approaches. Here we report on an in vivo longitudinal monitoring of the oral mucosa dynamics in 25 patients during the course of radiotherapy of oropharyngeal and nasopharyngeal cancer using multifunctional optical coherence tomography (OCT). A spectral domain OCT system with a specially-designed oral imaging probe was used. Microvasculature visualization was based on temporal speckle variations of the full complex signal evaluated by high-pass filtering of 3D data along the slow scan axis. Angiographic image quantification demonstrated an increase of the vascular density and total length of capillary-like-vessels before visual signs or clinical symptoms of mucositis occur. Especially significant microvascular changes compared to their initial levels occurred when grade two and three mucositis developed. Further, microvascular reaction was seen to be dose-level dependent. OCT monitoring in radiotherapy offers a non-invasive, convenient, label-free quantifiable structural and functional volumetric imaging method suitable for longitudinal human patient studies, furnishing fundamental radiobiological insights and potentially providing useful feedback data to enable adaptive radiotherapy (ART).

Occlusal trauma and mucositis or peri-implantitis?

BACKGROUND AND OVERVIEW: The aim of this study was to describe the effects of bruxism in peri-implant bone loss 6 years after the placement of a successful implant-supported prosthesis, to describe its treatment, and to propose a differential diagnosis of the lesion. CASE DESCRIPTION: A 62-year-old, nonsmoking, systemically healthy partially edentulous woman received 2 osseointegrated implants in the mandibular left region, which supported a 3-element fixed prosthesis. Six years later, the patient reported the development of bruxism. Clinical examination results indicated bleeding on probing, deepening of the peri-implant sulcus, and marginal soft-tissue overgrowth. Radiographic images suggested peri-implant bone loss. The authors diagnosed the lesion as trauma from occlusion and mucositis. Treatment involved anti-infective therapy and the use of a bite platform, resulting in bone recovery after 10 months. These results were maintained for 4 years. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Considering the existing contradictions in the literature, this case highlights the role of trauma from occlusion in the onset, progression, and treatment of lesions produced by occlusal overload around osseointegrated implants. In addition, it provides clinical background on the outcomes of anti-infective therapy associated with the use of a bite platform in the treatment of combined lesions of mucositis and trauma from occlusion in osseointegrated implants.

[Mucosal tolerance and low level laser therapy: Is the delegation to radiation technicians possible?]. / Tolérance muqueuse et laser de basse énergie : la délégation aux manipulateurs en radiothérapie est-elle possible ?

Mucositis remains a frequent complication of radiotherapy. Low level laser applications are used to accelerate the healing process. This technique is used routinely in our centre. It is performed by delegation by radiotherapists. The conditions of this delegation of tasks are addressed here.

Correlation of mucositis during head and neck radiotherapy with computed tomography perfusion imaging of the oropharyngeal mucosa.

OBJECTIVE: The objective of this study was to correlate changes in computed tomography perfusion (CTP) parameters in the oropharyngeal mucosa following start of radiotherapy (RT) with acute mucositis in head and neck cancer patients. METHODS: Fifteen patients were prospectively evaluated with serial CTP imaging. Computed tomography perfusion studies were obtained before RT; at weeks 2, 4, and 6 during RT; and 6 weeks after completion of RT. RESULTS: At week 2 during RT, mean transition time increased to 13.9% and 261.8% in patients with and without mucositis, respectively (P = 0.024). At week 6 of RT, patients with grade 3 mucositis had a 325.4% increase in blood flow compared with a 58.3% increase in patients with grade 0-2 mucositis (P = 0.039). Mean transition time decreased by 29.9% and increased by 187.4% in patients with grade 3 and grade 0-2 mucositis, respectively (P = 0.025). CONCLUSIONS: Mean transition time and blood flow changes in the oropharyngeal mucosa correlated with the incidence and severity of RT-related mucositis.

[Jugular vein thrombosis and Lemierre's syndrome--severe complications of oropharyngeal infections]. / Jugularvenenthrombose und Lemierre-Syndrom--schwerwiegende Komplikationen oropharyngealer Infekte.

BACKGROUND: Acute oral or pharyngeal infections usually heal under adequate therapy within a few days. Therefore severe regionary or systemic complications are not regularly seen. PATIENTS AND METHODS: We report on 3 patients in whom during or after apparent recovery from a pharyngeal or perioral infection a one-sided painful swelling of the neck associated with fever and leucocytosis developed. RESULTS: Color Doppler sonography (CDS) revealed unilateral thrombosis of the internal jugular vein (IJV) in all cases, whereupon we initiated high-dosed parenteral antibiotic therapy and therapeutic heparinisation. Furthermore, we drained detectable abscess formations. Nonetheless, in one patient fever attacks occurred postoperatively, accompanied by septic-embolic lung infiltrates, corresponding to Lemierre's syndrome. In all cases, we achieved clinical recovery and remission of infection. The course was significantly prolonged in the patient with pulmonary involvement and in this patient no reperfusion of the IJV was achieved. CONCLUSIONS: Even today serious complications may occur unexpectedly in presumed everyday oral or pharyngeal infections. CDS is a suitable procedure to disclose a jugular vein thrombosis (JVT) promptly and non-invasively. Parenteral antibiotic therapy for at least 10 days is usually the therapy of choice for JVT; additional full-heparinisation is controversially discussed in the professional literature. Septic pulmonary embolism following pharyngeal infection and JVT, as described by Lemierre, was associated with a high rate of mortality in the pre-antibiotic era, and even today may be fatal in spite of appropriate and maximal therapy.

Prospective evaluation to establish a dose response for clinical oral mucositis in patients undergoing head-and-neck conformal radiotherapy.

PURPOSE: We conducted a clinical study to correlate oral cavity dose with clinical mucositis, perform in vivo dosimetry, and determine the feasibility of obtaining buccal mucosal cell samples in patients undergoing head-and-neck radiation therapy. The main objective is to establish a quantitative dose response for clinical oral mucositis. METHODS AND MATERIALS: Twelve patients undergoing radiation therapy for head-and-neck cancer were prospectively studied. Four points were chosen in separate quadrants of the oral cavity. Calculated dose distributions were generated by using AcQPlan and Eclipse treatment planning systems. MOSFET dosimeters were used to measure dose at each sampled point. Each patient underwent buccal sampling for future RNA analysis before and after the first radiation treatment at the four selected points. Clinical and functional mucositis were assessed weekly according to National Cancer Institute Common Toxicity Criteria, Version 3. RESULTS: Maximum and average doses for sampled sites ranged from 7.4-62.3 and 3.0-54.3 Gy, respectively. A cumulative point dose of 39.1 Gy resulted in mucositis for 3 weeks or longer. Mild severity (Grade

In vivo imaging of oral mucositis in an animal model using optical coherence tomography and optical Doppler tomography.

PURPOSE: To assess noninvasive optical coherence tomography (OCT) and optical Doppler tomography (ODT) for early detection and evaluation of chemotherapy-induced oral mucositis. EXPERIMENTAL DESIGN: Cheek pouches of 10 Syrian golden hamsters were imaged using OCT/ODT during development of chemotherapy-induced mucositis. I.p. injections of 5-fluorouracil and mechanical irritation induced oral lesions. At 2, 4, 7, and 11 days, one hamster was sacrificed and processed for histopathology. OCT images were visually examined; ODT results were semiquantified. Imaging data were compared with histologic findings. RESULTS: During the development of mucositis, OCT/ODT identified the following events: (a) change in epithelial thickness (beginning on day 2), (b) loss of surface keratinized layer continuity (beginning on day 4), (c) loss of epithelial (day 4 onwards) and submucosal integrity (day 7 onwards), (d) changes in axial blood flow velocity (increased on days 2 and 4; decreased on day 7), and (e) changes in blood vessel size (diameter doubled on day 2; quadrupled on day 4; unchanged on day 7). The semiquantitative imaging-based scoring system identified the severity of mucositis as defined by histopathology. The combination of imaging criteria used allowed for the detection of early, intermediate, and late mucositic changes. Imaging data gave higher scores compared with clinical scores early on, suggesting that the imaging-based diagnostic scoring was more sensitive to early mucositic change than the clinical scoring system. Once mucositis was established, imaging and clinical scores converged. CONCLUSION: OCT/ODT identified chemotherapy-induced oral changes before their clinical manifestation, and the proposed scoring system for oral mucositis was validated for the semiquantification of mucositic change.

Determining mucosal barrier injury to the oesophagus using CT scan.

INTRODUCTION: Oral mucositis is recognised as one of the most debilitating complications of high-dose cytostatic chemotherapy used to prepare for haematopoietic stem cell transplantation (HSCT), but very little is known about oesophageal mucositis, as endoscopy is not routinely performed. MATERIALS AND METHODS: We incorporate the computed tomography (CT) scan in the diagnostic workup of fever during neutropenia to detect evidence of pulmonary complications. This allowed us to evaluate whether mucosal barrier injury to the oesophagus can be determined. We selected 46 patients without oesophageal cancer or immune suppression (controls), who had a normal oesophagus, and measured the mucosal thickness at the upper part (UP), middle part (MP) and lower part (LP) of the oesophagus. Next, we selected 30 patients having a CT scan done for diagnostic purposes within 14 days after HSCT and measured mucosal thickness at the same levels. We also scored oral mucositis and gut toxicity. RESULTS: The mucosal thickness of the UP, MP and LP, respectively, for the controls (mean +/- SD) was 4.1 mm (+/-1.1), 4.2 mm (+/-1.2) and 4.8 mm (+/-1.3), and the corresponding values for the subjects were 5.9 mm (+/-2.2), 5.9 mm (+/-2.0) and 7.7 mm (+/-3.0). Analysis of variance showed statistically significant differences between subjects and controls at all oesophageal levels. All patients suffered from severe oral mucositis at the time. CONCLUSION: Hence, mucosal barrier injury to the oesophagus can be objectively measured using CT scan.

Bone reactions at implants subjected to experimental peri-implantitis and static load. A study in the dog.

AIM: The aim of the present experiment was to study peri-implant tissue reactions to lateral static load at implants subjected to experimental mucositis or peri-implantitis. MATERIAL AND METHODS: 5 beagle dogs were used. The mandibular premolars were extracted. After 12 weeks, 3 implants were installed in each quadrant of the mandible. In one side, the implants were designed with a SLA surface and in the contralateral side with a turned surface. A plaque control program was initiated. 12 weeks later, the central and posterior implants were connected with an appliance containing an expansion screw. Cotton ligatures were placed around the neck of the anterior and posterior implants in both sides, and the plaque control measures were terminated. Sixteen weeks later the ligatures were removed. After 8 weeks without ligatures, the expansion screws in both sides were activated. Once every 2 week during a 12-week interval, the screws were reactivated. Thus, the model included 3 different experimental sites of each surface group: group M+L (mucositis+load); group P (peri-implantitis); group P+L (peri-implantitis+load). Fluorochrome labels were injected and standardized radiographs obtained. The animals were sacrificed and block biopsies of all implant sites dissected and prepared for histological analysis. RESULTS: It was demonstrated that the lateral static load failed to induce peri-implant bone loss at implants with mucositis and failed to enhance the bone loss at implants with experimental peri-implantitis. The proportion of bone labels and the bone density in the interface zone were significantly higher in group P+L than in group P. CONCLUSION: It is suggested that a lateral static load with controlled forces may not be detrimental to implants exhibiting mucositis or peri-implantitis.

Radiographic patterns of osteomyelitis in the mandible. Plain film/CT correlation.

Mandibular osteomyelitis often is associated with involvement of the masticator space. Assessment of mandibular osteomyelitis should therefore involve assessment of soft tissue involvement of the lesion. The purpose of this study was to clarify the relationship between computed tomography patterns and the presence of inflammation in soft tissues. Thirty-three cases diagnosed with osteomyelitis of the mandible were analyzed radiologically with conventional radiographs and with computed tomography scans. Computed tomography patterns of osteomyelitis were classified into four types, lytic, mixed, sclerotic, and sequestrum patterns. Location, extent of the lesion, and change of the cortical plate were evaluated and compared with conventional radiographic findings. Mixed pattern cases displayed diffuse bone abnormalities, which sometimes were accompanied by cortical plate disruption and periosteal reaction. In addition, most mixed pattern cases showed soft tissue involvement, especially of the masseter muscle. Inflammation of the masseter muscle was found to be related to periosteal reaction and disruption of the buccal cortical plate. The data demonstrate a close interaction between cortical plate disruption and muscle inflammation. The extent of inflammation including soft tissue involvement was better appreciated with computed tomography in osteomyelitis, especially in mixed pattern cases.

Isolated uvulitis due to Haemophilus influenzae type b.

Infections of the uvula are infrequently recognized and have been previously described only in association with group A streptococcal pharyngitis or Haemophilus influenzae type b epiglottitis. Three cases of H influenzae type b bacteremic uvulitis are described. In suspected cases of H influenzae type b uvulitis, a lateral neck radiograph should be performed and parenteral antibiotics initiated.

The appearances of common dental diseases on radionuclide bone images of the jaws.

Radionuclide images of hospital patients were examined for abnormal areas within the jaws. Fourteen of 25 subjects studied showed one or more abnormal image areas, most of which were attributable to common dental lesions revealed by oral examinations. The lesions detectable on images included healing bone sites, periodontal and pulpal disease, residual osteitis and irritations caused by ill-fitting dentures.