Praveen Jayapal

All Publications

• A Rare Case of Endotracheal Metastases in Head and Neck Squamous Cell Carcinoma: A Case Report and Literature Review. Cureus Krishnan, S., Abbasi, F., Jayapal, P., Selvarajan, D. 2025; 17 (1): e76903

  Abstract

  Head and neck squamous cell carcinoma (HNSCC) typically originates from the squamous cells lining the mucosal surfaces of the head and neck. Patients may present with diverse symptoms, including hoarseness of voice, difficulty swallowing (dysphagia), a neck mass, or a cough. While metastasis is usually regional, distant metastases, including tracheobronchial involvement, though rare, can occur and are often associated with a poor prognosis. Here, we report the case of a 64-year-old patient with a history of smoking who presented with complaints of exertional dyspnea and a chronic cough for six months. Pulmonary function tests confirmed a diagnosis of chronic obstructive pulmonary disease (COPD), and bronchodilator therapy with ipratropium was initiated. Four months later, at a follow-up, the patient reported worsening cough and new-onset hoarseness. A CT scan of the neck revealed a lesion on the left vocal cord, and a flexible nasopharyngolaryngoscopy confirmed a left vocal cord tumor. A biopsy and elective tracheostomy were performed, with pathology demonstrating an invasive, moderately differentiated squamous cell carcinoma. A positron emission tomography-computed tomography (PET-CT) scan showed intense fluorodeoxyglucose (FDG) uptake in the vocal cord lesion and bilateral cervical lymph nodes, leading to a diagnosis of stage IV laryngeal cancer (T3N2cM0). The patient underwent concurrent chemotherapy with cisplatin for seven weeks and radiation therapy targeted at the larynx and bilateral neck lymph nodes. A follow-up laryngoscopy and CT scan of the neck, five months post-diagnosis, showed near-complete resolution of the left vocal cord tumor and a reduction in the size of the cervical lymph nodes. Another PET-CT scan, performed six months post-diagnosis, showed no FDG uptake in the left vocal cord and cervical lymph nodes. However, a small focus of FDG uptake was noted in the upper posterolateral aspect of the tracheoesophageal stripe, which was reported as a tracheoesophageal lymph node. An esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) was planned. However, after a thorough review of PET-CT scan images and discussion at the multidisciplinary team (MDT) meeting, the patient underwent a bronchoscopy instead. This revealed two small endotracheal lesions, confirmed by biopsy as invasive, moderately differentiated keratinizing squamous cell carcinoma. Despite an excellent local response, the patient developed endotracheal metastasis, an uncommon occurrence. This case underscores the complexities in diagnosing head and neck squamous cell carcinoma (HNSCC) with atypical metastatic presentations. It highlights the necessity of an integrated approach for timely diagnosis and expeditious treatment.

  View details for DOI 10.7759/cureus.76903

  View details for PubMedID 39902005

  View details for PubMedCentralID PMC11789541

• A Novel Fetal Magnetic Resonance Imaging Lung Volume Nomogram Stratified by Estimated Fetal Weight. Fetal diagnosis and therapy Farladansky-Gershnabel, S., Jayapal, P., Zalcman, M., Barth, R. A., Rubesova, E., Hintz, S. R., Zhang, J., Leonard, S. A., El-Sayed, Y. Y., Blumenfeld, Y. J. 2024: 1-8

  Abstract

  Fetal magnetic resonance imaging (MRI) lung volume nomograms are increasingly used to prognosticate neonatal outcomes in fetuses with suspected pulmonary hypoplasia. However, pregnancies complicated by fetal anomalies associated with pulmonary hypoplasia may also be complicated by fetal growth restriction (FGR). If a small lung volume is suspected in such cases, it is often unclear whether the lungs are "small" because of underlying lung pathology, or small fetal size. Existing MRI lung volume nomograms have mostly been stratified by gestational age (GA), rather than estimated fetal weight (EFW). Therefore, we aimed to develop a novel fetal lung volume nomogram stratified by EFW.Consecutive fetal MRIs performed at a quaternary medical center from 2019 to 2021 were analyzed. MRIs performed due to fetal lung anomalies and cases with FGR were excluded. All MRIs were performed without IV contrast on GE 3 or 1.5 Tesla scanners (GE Healthcare). Images were reviewed by three experienced fetal radiologists. Freehand ROI in square centimeter was drawn around the contours of the lungs on consecutive slices from the apex to the base. The volume of the right, left and total lungs were calculated in mL. Lung volumes were plotted by both EFW and GA.Among 301 MRI studies performed during the study period, 170 cases met inclusion criteria and were analyzed. MRIs were performed between 19- and 38-week gestation, and a sonographic EFW was obtained within a mean of 2.9 days (SD ± 5.5 days, range 0-14 days) of each MRI. Nomograms stratified by both EFW and GA were created using 200 g. and weekly intervals respectively. A formula using EFW to predict total lung volume was calculated: LV = 0.07497804 EFW0.88276 (R2 = 0.87).We developed a novel fetal lung volume nomogram stratified by EFW. If validated, this nomogram may assist clinicians predict outcomes in cases of fetal pulmonary hypoplasia with concomitant FGR.

  View details for DOI 10.1159/000539709

  View details for PubMedID 38843783

• Magnetic resonance neurography techniques in the pediatric population. Pediatric radiology Jayapal, P., Alharthi, O., Young, V., Obi, C., Syed, A. B., Sandberg, J. K. 2023

  Abstract

  The use of magnetic resonance imaging (MRI) in the evaluation of the central extracranial nervous system, namely the brachial and lumbosacral plexuses, is well established and has been performed for many years. Only recently after numerous advances in MRI, has image quality been sufficient to properly visualize small structures, such as nerves in the extremities. Despite the advances, peripheral MR Neurography remains a complex and difficult examination to perform, especially in the pediatric patient population, in which the risk for motion artifact and compliance is always of concern. Thus, technical aspects of the MR imaging protocol must be flexible but robust, to balance image quality with scan time, in a patient population of varying sizes. An additional important step for reliably performing a successful MR Neurography examination is the non-technical pre-imaging preparation, which includes patient/family education and open communication with referring teams. This paper will discuss in detail the individual technical and non-technical/operational aspects of peripheral MR Neurography, to help guide in building a successful program in the pediatric population.

  View details for DOI 10.1007/s00247-023-05759-7

  View details for PubMedID 37710037

• Improved Detection of Bone Metastases in Children and Young Adults with Ferumoxytol-enhanced MRI. Radiology. Imaging cancer Rashidi, A., Baratto, L., Theruvath, A. J., Greene, E. B., Jayapal, P., Hawk, K. E., Lu, R., Seekins, J., Spunt, S. L., Pribnow, A., Daldrup-Link, H. E. 2023; 5 (2): e220080

  Abstract

  Purpose To evaluate if ferumoxytol can improve the detection of bone marrow metastases at diffusion-weighted (DW) MRI in pediatric and young adult patients with cancer. Materials and Methods In this secondary analysis of a prospective institutional review board-approved study (ClinicalTrials.gov identifier NCT01542879), 26 children and young adults (age range: 2-25 years; 18 males) underwent unenhanced or ferumoxytol-enhanced whole-body DW MRI between 2015 and 2020. Two reviewers determined the presence of bone marrow metastases using a Likert scale. One additional reviewer measured signal-to-noise ratios (SNRs) and tumor-to-bone marrow contrast. Fluorine 18 (18F) fluorodeoxyglucose (FDG) PET and follow-up chest CT, abdominal and pelvic CT, and standard (non-ferumoxytol enhanced) MRI served as the reference standard. Results of different experimental groups were compared using generalized estimation equations, Wilcoxon rank sum test, and Wilcoxon signed rank test. Results The SNR of normal bone marrow was significantly lower at ferumoxytol-enhanced MRI compared with unenhanced MRI at baseline (21.380 ± 19.878 vs 102.621 ± 94.346, respectively; P = .03) and after chemotherapy (20.026 ± 7.664 vs 54.110 ± 48.022, respectively; P = .006). This led to an increased tumor-to-marrow contrast on ferumoxytol-enhanced MRI scans compared with unenhanced MRI scans at baseline (1397.474 ± 938.576 vs 665.364 ± 440.576, respectively; P = .07) and after chemotherapy (1099.205 ± 864.604 vs 500.758 ± 439.975, respectively; P = .007). Accordingly, the sensitivity and diagnostic accuracy for detecting bone marrow metastases were 96% (94 of 98) and 99% (293 of 297), respectively, with the use of ferumoxytol-enhanced MRI compared with 83% (106 of 127) and 95% (369 of 390) with the use of unenhanced MRI. Conclusion Use of ferumoxytol helped improve the detection of bone marrow metastases in children and young adults with cancer. Keywords: Pediatrics, Molecular Imaging-Cancer, Molecular Imaging-Nanoparticles, MR-Diffusion Weighted Imaging, MR Imaging, Skeletal-Appendicular, Skeletal-Axial, Bone Marrow, Comparative Studies, Cancer Imaging, Ferumoxytol, USPIO © RSNA, 2023 ClinicalTrials.gov registration no. NCT01542879 See also the commentary by Holter-Chakrabarty and Glover in this issue.

  View details for DOI 10.1148/rycan.220080

  View details for PubMedID 36999999

• A novel fetal MRI lung volume nomogram stratified by estimated fetal weight Gershnabel, S., Jayapal, P., Zalcman, M., Barth, R. A., Rubesova, E., Hintz, S., Zhang, J., Leonard, S. A., El-Sayed, Y. Y., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2023: S577

  View details for Web of Science ID 000909337401449

• Detection of bone marrow metastases in children and young adults with solid cancers with diffusion-weighted MRI. Skeletal radiology Rashidi, A., Baratto, L., Jayapal, P., Theruvath, A. J., Greene, E. B., Lu, R., Spunt, S. L., Daldrup-Link, H. E. 2022

  Abstract

  OBJECTIVE: To compare the diagnostic accuracy of diffusion-weighted (DW)-MRI with b-values of 50s/mm2 and 800s/mm2 for the detection of bone marrow metastases in children and young adults with solid malignancies.METHODS: In an institutional review board-approved prospective study, we performed 51 whole-body DW-MRI scans in 19 children and young adults (14 males, 5 females; age range: 1-25years) with metastasized cancers before (n=19 scans) and after (n=32 scans) chemotherapy. Two readers determined the presence of focal bone marrow lesions in 10 anatomical areas. A third reader measured ADC and SNR of focal lesions and normal marrow. Simultaneously acquired 18F-FDG-PET scans served as the standard of reference. Data of b=50s/mm2 and 800s/mm2 images were compared with the Wilcoxon signed-rank test. Inter-reader agreement was evaluated with weighted kappa statistics.RESULTS: The SNR of bone marrow metastases was significantly higher compared to normal bone marrow on b=50s/mm2 (mean±SD: 978.436±1239.436 vs. 108.881±109.813, p<0.001) and b=800s/mm2 DW-MRI (499.638±612.721 vs. 86.280±89.120; p<0.001). On 30 out of 32 post-treatment DW-MRI scans, reconverted marrow demonstrated low signal with low ADC values (0.385*10-3±0.168*10-3mm2/s). The same number of metastases (556/588; 94.6%; p>0.99) was detected on b=50s/mm2 and 800s/mm2 images. However, both normal marrow and metastases exhibited low signals on ADC maps, limiting the ability to delineate metastases. The inter-reader agreement was substantial, with a weighted kappa of 0.783 and 0.778, respectively.CONCLUSION: Bone marrow metastases in children and young adults can be equally well detected on b=50s/mm2 and 800s/mm2 images, but ADC values can be misleading.

  View details for DOI 10.1007/s00256-022-04240-0

  View details for PubMedID 36441237

• Ferumoxytol-Enhanced MRI in Children and Young Adults: State of the Art. AJR. American journal of roentgenology Adams, L. C., Jayapal, P., Ramasamy, S. K., Morakote, W., Yeom, K., Baratto, L., Daldrup-Link, H. E. 2022

  Abstract

  Ferumoxytol is an ultrasmall iron oxide nanoparticle, originally approved in 2009 by the FDA for IV treatment of iron deficiency in adults with chronic kidney disease. Subsequently, its off-label use as an MRI contrast agent has increased in clinical practice, particularly in pediatric patients in North America. Unlike conventional MRI contrast agents that are based on the rare earth metal gadolinium [gadolinium-based contrast agents (GBCAs)], ferumoxytol is biodegradable and carries no potential risk of nephrogenic systemic fibrosis. At FDA-approved doses, ferumoxytol demonstrates no long-term tissue retention in patients with intact iron metabolism. Ferumoxytol provides unique MRI properties including long-lasting vascular retention (facilitating high-quality vascular imaging) and retention in reticuloendothelial system tissues, thereby supporting a variety of applications beyond those possible with GBCAs. This Clinical Perspective describes clinical and early translational applications of ferumoxytol-enhanced MRI in children and young adults through off-label use for a variety of settings, including vascular, cardiac, and cancer imaging, drawing on the authors' institutional experience. In addition, we describe current preclinical and clinical research advances using ferumoxytol with regard to cellular and molecular imaging, and also as a novel potential cancer therapeutic agent.

  View details for DOI 10.2214/AJR.22.28453

  View details for PubMedID 36197052

• Predictive Patterns of Pediatric PTLD on PET/MRI Jayapal, P., Sandberg, J., Seekins, J., Nadel, H. SOC NUCLEAR MEDICINE INC. 2022

  View details for Web of Science ID 000893739700122

• Multiparametric CMR Findings in Mrna COVID-19 Vaccine-induced Myocarditis: A Case Series Espejo, M., Hogan, A. H., Toro-Salazar, O. H., Golden, A., Heyden, C., Salazar, J. C., Jayapal, P. AMER ACAD PEDIATRICS. 2022

  View details for Web of Science ID 000917782500346