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Head and Neck Cancer Soft Tissue Radiation Necrosis—Diagnostic Challenge

Pucar, Darko, MD, PhD*†; Groves, Michael W., MD; Biddinger, Paul, MD§; Figueroa, Ramon, MD; Williams, Hadyn T., MD

doi: 10.1097/RLU.0000000000002356
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A 53-year-old man with T4aN2cM0 tongue base squamous cell carcinoma received definitive chemoradiation. FDG PET/CT at 6 weeks showed partial metabolic response with soft tissue air indicating radiation necrosis at primary site and complete response in the neck. At 9 weeks, contrasted CT showed worsening but nonenhancing ulceration, area biopsied demonstrating a minute carcinoma focus with treatment effect. At 12 weeks, PET/CT showed increased primary site uptake interpreted as disease progression; however, no viable tumor was found at salvage surgery. Because nonenhancing ulceration predicts pure radiation necrosis with no viable tumor, contrasted CT may guide treatment selection in challenging cases.

From the *Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT;

Departments of Radiology and Imaging,

Otorhinolaryngology, and

§Pathology, Augusta University, Augusta, GA.

Received for publication September 10, 2018; revision accepted September 22, 2018.

Conflicts of interest and sources of funding: none declared.

Correspondence to: Darko Pucar, MD, PhD, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar St, New Haven, CT 06511. E-mail:

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