Carotid blowout in patients with head and neck cancer: associated factors and treatment outcomes

Symptoms and Prognoses of Patients With Breast Cancer and Malignant Wounds in Palliative Care Units: The Multicenter, Prospective, Observational EASED Study

BACKGROUND

This study sought to investigate the symptoms and prognoses of patients with breast cancer and malignant wounds in the palliative care unit setting.

METHODS

This study was a sub-group analysis of a multicenter, prospective, observational study. Patients admitted to 23 palliative care units in Japan between January and December 2017 were enrolled. Data of patients with breast cancer were extracted. We compared demographic characteristics, symptoms, and prognoses by breast cancer malignant wound status. The primary outcome was overall survival. Secondary outcomes included Palliative Prognostic Index (PPI) score, malignant wound characteristics, and symptom burden.

RESULTS

Of 1896 patients, 131 (6.9%) had breast cancer. In this cohort, 44 (33.6%) patients had malignant wounds. Most malignant wounds (88%) were on the back and chest. Malignant wounds were associated with skin redness, erosion, necrosis, or fistula. Symptoms included bleeding, exudate, odor, and pain. Twenty-eight patients (63.6%) needed dressing changes and 14 (31.8%) patients experienced bleeding. None died due to bleeding. In the malignant wounds group, 32 (72.8%) patients had used an opioid dose equivalent to 38 mg of oral morphine daily, compared to 25 mg by 57 (65.5%) patients in the non-malignant wounds group (P = .26). Median PPI scores at hospital admission were 4.5 vs 6.5 (P = .08). Median survival was 23 vs 21 days (P = .48).

CONCLUSIONS

Patients with malignant wounds had a distinct symptom burden profile and tended to use a higher dose of opioids. The effect of malignant wounds on survival was unclear.

Management of post-radiation carotid blowout syndrome in patients with head and neck cancer: A systematic review

BACKGROUND AND PURPOSE

Carotid blowout syndrome (CBS) is a rare but potentially life-threatening complication that can occur in patients with head and neck cancer (HNC), especially with a history of radiotherapy. This study aimed to review and initially compare managements for post-radiation CBS in patients with HNC.

MATERIALS AND METHODS

A systematic review of published studies was performed. Information including management, survival, and complication were collected.

RESULTS

A total of 39 articles and 917 cases were included in the systematic review. The interval between radiation therapy and CBS ranged from 1.2 years to 17.8 years. The managements of CBS included embolization, stent, bypass surgery, surgical ligation, electrocoagulation, flap coverage, arterial repair, and nasopharyngeal packing. The cumulative 30-day, 1-year, and 2-year overall survival rates were 85.2 %, 48.9 %, and 37.0 %, respectively, with a median survival time of 11.3 months. Disease progression and rebleeding were the most common death causes. The lowest rebleeding rate and neurologic complications rate were presented in cases receiving bypass surgery at 1.4 % and 10.8 %, respectively. The highest rebleeding rate of 35.6 % was showed in cases underwent stent, and the highest neurologic complications rate of 32.0 % was showed in cases underwent ligation.

CONCLUSION

Post-radiation CBS in patients with HNC had a low survival rate and high complication rate. Rebleeding and neurologic complication were common complications. Endovascular embolization and stent were the mainstream management, and bypass surgery presented a promising outcome in survival and complication for selected patients.

Risk factors of post-irradiation carotid blowout syndrome in patients with nasopharyngeal carcinoma

PURPOSE

Carotid blowout syndrome (CBS) is a severe complication of radiotherapy in patients with nasopharyngeal carcinoma (NPC). This study is aimed at analyzing risk factors of post-irradiation CBS in patients with NPC.

METHODS

We retrospectively analyzed 660 patients with NPC between 2006 and 2019. The patients were divided into those with and without CBS, and their characteristics and outcomes were evaluated. Independent predictors of CBS were determined by multivariate logistic regression analysis.

RESULTS

We identified 17 NPC patients with CBS in our study. In multivariate logistic regression analysis, lower body mass index (BMI) (P = 0.018), tumor encasement (P = 0.039), local recurrence (P = 0.006), and skull base osteoradionecrosis (P < 0.001) were independent predictors of CBS, and a predictive equation model was established. Log-rank test revealed that patients with low BMI, tumor encasement of carotid vessels, local recurrence, and skull base osteoradionecrosis all exhibited shorter CBS-free time (all P < 0.001).

CONCLUSION

We demonstrated that low BMI, tumor encasement, local recurrence, and skull base osteoradionecrosis were independent predictors for CBS in NPC patients. Physicians can use these factors for the early detection and prevention of CBS.

Endovascular intervention for carotid blowout syndrome and predictors of recurrence: A retrospective and multicenter cohort study

INTRODUCTION

Carotid blowout syndrome (CBS) is a potentially life-threatening complication of head and neck cancer and associated treatment. In this study, we assess the safety and efficacy of deconstructive and reconstructive procedures with a focus on CBS recurrence.

METHODS

We conducted a multicenter retrospective analysis of a prospectively maintained database and identified 80 consecutive neurointerventions for CBS from 2016 to 2020. Patients were divided into 2 groups: deconstructive embolization (68 patients) and reconstructive stenting (12 patients). A comparative analysis was performed between the two groups.

RESULTS

The CBS recurrence rate was 23.8 % with 84.2 % of recurrences occurring within 90 days of the primary event. The median time to rebleeding was 8.0 days (IQR: 2.0 - 28.5) with a mortality rate of 26.3 %. There was no significant difference in rates of peri-operative ischemic stroke (1.5 % vs. 0 %, p=0.672) or peri-operative mortality (1.5 % vs. 0 %, p=0.670). CBS recurrence was significantly higher in the reconstructive group (58.3 % vs. 17.6 %, p=0.002). On multivariate analysis, reconstructive stenting independently predicted rebleeding (adjusted hazard ratio 8.31, 95 % CI: 2.34-29.59, p=0.001). There was no significant association between CBS recurrence and pre-operative (p=0.600) or post-operative (p=0.275) anticoagulant/antiplatelet use.

CONCLUSION

CBS remains a challenging and potentially catastrophic complication of head and neck cancers. Reconstructive procedures, including stenting, predicted CBS recurrence independent of bleeding site or tumor invasion. Postoperative surveillance based on time intervals to CBS recurrence and engineering advancements including improved vessel reconstruction devices have the potential to reduce rehemorrhage rates and improve patient outcomes. Further clinical investigations amongst larger cohorts are needed.

Covered Stent Graft for Treatment of Carotid Blowout Syndrome in Patients With Head and Neck Cancer

Importance

Carotid blowout syndrome (CBS) is a rare life-threatening complication of head and neck cancer that requires either surgical or endovascular treatment such as a carotid occlusion procedure or stent-graft placement. CBS outcomes and complications of its management using endovascular stent-graft placement remain unclear due to limited published data. Given that this treatment approach is increasingly used, understanding its efficacy and associated risks is paramount.

Objective

To evaluate the periprocedural and postprocedural complications and outcomes associated with stent-graft treatment for CBS in patients with head and neck cancer.

Design, Setting, and Participants

This case series study conducted at the Institut Gustave Roussy (Villejuif, France) between January 2006 and December 2021 included all eligible patients with head and neck cancer who experienced CBS and were referred for endovascular treatment. Risk factors and periprocedural and postprocedural data were collected retrospectively from medical records. Data analyses were performed from July 2022 to July 2024.

Exposure

Endovascular stent-graft placement for the treatment of CBS in patients with head and neck cancer.

Main Outcomes and Measures

Periprocedural and postprocedural complications of stent-graft placement. Secondary outcomes were technical success, defined as immediate control of hemorrhage; 30-day and overall survival rates; and risk factors for mortality and rebleeding. Risk factors considered were body mass index (BMI), CBS presentation, hemodynamic status, tumor stage, and radiation dose.

Results

In all, 67 CBS-related stent-graft procedures were performed in 62 patients (mean [SD] age, 55.4 [10.1] years; 10 [16.1%] females and 52 [83.9%] males), most with advanced-stage head and neck cancer, over 15 years. The most frequently observed clinical complications were rebleeding (16 patients [38.8%]) and stroke (9 patients [13.4%]). Immediate hemostasis was achieved in 100% of cases. The survival rate was 77.3% (51 participants) at 30 days postprocedure, with a median (IQR) overall survival time of 59 (32-141.5) days. Acute CBS presentation (risk ratio, 4.30; 95% CI, 1.11-28.23) and BMI (risk ratio, 0.88; 95% CI, 0.77-0.99) showed a statistically significant association with 30-day mortality in univariate analysis.

Conclusions and Relevance

The findings of the case-series study indicate that CBS can be safely managed with endovascular stent-graft placement that preserves carotid patency; however, it carries significant risks of ischemia and rebleeding. These findings suggest that stent grafts should be used only in specific clinical scenarios. Despite achieving a high rate of technical success in controlling hemorrhage, the overall and 30-day survival outcomes underscore the critical implications of CBS in patients with cancer and its associated therapeutic challenges.

The Clinical Outcome of Carotid Blowout Syndrome Showing Non-bleeding Angiography

OBJECTIVE

Patient with carotid blowout syndrome (CBS) may demonstrated non-bleeding digital subtraction angiography (DSA) without identifying pseudoaneurysm or contrast extravasation. Our objective is to evaluate the clinical outcomes for this specific subset of patients.

MATERIALS AND METHODS

A retrospective observational study was conducted on 172 CBS patients who received DSA for evaluation of transarterial embolization (TAE) between 2005 and 2022, of whom 19 patients had non-bleeding DSA and did not undergo TAE.

RESULTS

The age (55.2 ± 7.3 vs. 54.8 ± 11.1), male sex (17/19 vs. 135/153), tumor size (5.6 ± 2.4 vs. 5.2 ± 2.2), cancer locations were similar (P > 0.05) between both groups; except for there were more pseudoaneurysm/active bleeding (85.6% vs. 0%) and less vascular irregularity (14.4% vs. 94.7%) in the TAE group (P < 0.001). In the multivariable Cox regression model adjusting for age, sex, and tumor size, non-bleeding DSA group was independently associated with recurrent bleeding compared to TAE group (adjusted hazard ratio = 3.5, 95% confidence interval: 1.9-6.4, P < 0.001). Furthermore, the presence of vascular irregularity was associated with segmental recurrent bleeding (adjusted HR = 8.0, 95% CI 2.7-23.3, P < 0.001).

CONCLUSION

Patient showing non-bleeding DSA thus not having TAE had higher risk of recurrent bleeding, compared to patient who received TAE. Level of Evidence Level 4, Case Series.

Carotid blowout into the trachea: unusual entity with unexpected management outcome

We present a case report of a patient with a history of aggressive thyroid cancer managed by surgery, chemotherapy, and radiation to the neck. A year later, he presented with hemoptysis. Endobronchial ultrasound showed a pulsatile vessel; however, a CT scan and conventional angiogram were negative. Three days later, a repeat angiogram revealed a pseudoaneurysm arising from the right common carotid artery. Carotid sacrifice was performed after passing balloon test occlusion. Three years later the patient presented with coil herniation into the trachea. The carotid stump was closed with a vascular plug to prevent rebleeding from coil removal. Four months later the patient experienced an intractable cough and underwent laryngoscopy-assisted removal of the residual coil mass. This case report discusses the rare scenario of a carotid blowout into the trachea and the subsequent course of events.

Incidence of Carotid Blowout Syndrome in Patients with Head and Neck Cancer after Radiation Therapy: A Cohort Study

Carotid blowout syndrome (CBS) is a rare yet life-threatening complication that occurs after radiation therapy (RT). This study aimed to determine the incidence of CBS in patients with head and neck cancer (HNC) undergoing contemporary RT and to explore potential discrepancies in the risk of CBS between nasopharyngeal cancer (NPC) and non-NPC patients. A total of 1084 patients with HNC who underwent RT between 2013 and 2023 were included in the study. All patients were under regular follow-ups at the radio-oncology department, and underwent annual contrast-enhanced computed tomography and/or magnetic resonance imaging for cancer recurrence surveillance. Experienced neuroradiologists and vascular neurologists reviewed the recruited patients' images. Patients were further referred to the neurology department for radiation vasculopathy evaluation. The primary outcome of this study was CBS. Patients were categorized into NPC and non-NPC groups and survival analysis was employed to compare the CBS risk between the two groups. A review of the literature on CBS incidence was also conducted. Among the enrolled patients, the incidence of CBS in the HNC, NPC, and non-NPC groups was 0.8%, 0.9%, and 0.7%, respectively. Kaplan-Meier analysis revealed no significant difference between the NPC and non-NPC groups (p = 0.34). Combining the findings for our cohort with those of previous studies revealed that the cumulative incidence of CBS in patients with HNC is 5% (95% CI = 3-7%) after both surgery and RT, 4% (95% CI = 2-6%) after surgery alone, and 5% (95% CI = 3-7%) after RT alone. Our findings indicate a low incidence of CBS in patients with HNC undergoing contemporary RT. Patients with NPC may have a CBS risk close to that of non-NPC patients. However, the low incidence of CBS could be a potentially cause of selection bias and underestimation bias.

Exposed Embolic Coils Observed in a 64-Year-Old Male With Head and Neck Cancer Following Transarterial Embolization for Carotid Blowout Syndrome

Background: Delayed migration and exposure of embolic coils is a rare complication of endovascular therapy for carotid blowout syndrome. Methods: A 64-year-old man with recurrent tongue cancer noticed the presence of foreign body in the malignant wound on the right side of his neck. He had undergone transarterial embolization on his right vertebral artery, right common carotid artery (CCA), and internal carotid artery (ICA) for carotid blowout syndrome 1 month prior. On physical examination, exposed spring-like metallic coils were observed, covered in brownish granulation tissue, at the bottom of the malignant wound. Neck radiograph and computed tomography confirmed the extrusion and migration of the embolic coils. Results: In this case, the patient was managed by transection of the exposed coils at the wound surface with close monitoring. Conclusions: Computed tomography angiography is essential for assessing the condition of the remaining embolic coils. In cases with thrombosed parent arteries, a conservative approach, like the transection of exposed coils, can be employed as part of the management strategy.

Anatomical studies and early results on endoscopic transoral medial pterygomandibular fold approach to salvage retropharyngeal lymphadenectomy in nasopharyngeal carcinoma

OBJECTIVE

Retropharyngeal lymphadenectomy is challenging. This study investigated a minimally invasive approach to salvage retropharyngeal lymphadenectomy in patients with nasopharyngeal carcinoma.

METHODS

An anatomical study of four fresh cadaveric heads was conducted to demonstrate the relevant details of retropharyngeal lymphadenectomy using the endoscopic transoral medial pterygomandibular fold approach. Six patients with nasopharyngeal cancer with retropharyngeal lymph node recurrence, who underwent retropharyngeal lymphadenectomy with the endoscopic transoral medial pterygomandibular fold technique at the Eye and ENT Hospital of Fudan University from July to December 2021, were included in this study.

RESULTS

The anatomical study demonstrated that the endoscopic transoral medial pterygomandibular fold approach offers a short path and minimally invasive approach to the retropharyngeal space. The surgical procedure was well tolerated by all patients, with no significant post-operative complications.

CONCLUSION

The endoscopic transoral medial pterygomandibular fold approach is safe and efficient for retropharyngeal lymphadenectomy.

Acute and definitive management of oropharyngeal hemorrhage in patients with squamous cell carcinoma of the oropharynx

BACKGROUND

Massive oropharyngeal bleeding post-chemoradiotherapy is a life-threatening condition that requires emergent management.

METHODS

This retrospective case series included 11 patients with oropharyngeal squamous cell carcinoma who suffered from massive bleeding during or following treatment with definitive chemoradiotherapy. Details of acute and definitive management of oropharyngeal bleeding are reported.

RESULTS

Nine of 11 hemorrhagic events occurred a mean (SD) of 88.6 days (53.6) after radiotherapy. Airway intubation and embolization were performed in 10 of 11 patients, followed by surgery in 7 of 11 patients. The most commonly embolized vessels were the external carotid and lingual arteries. At the time of discharge, 3 of 11 patients had a tracheostomy, and 7 of 11 continued to use a gastrostomy tube. Four patients died.

CONCLUSIONS

Hemorrhagic complications in oropharyngeal cancer treatment require emergent responses. Developing a workflow for coordination between multidisciplinary teams can maximize probability of survival and decrease morbidity.

Complication of head and neck cancer: Carotid blowout syndrome

Carotid blowout syndrome (CBS) is an uncommon but potentially life-threatening condition characterized by the spontaneous or traumatic rupture of the carotid artery in the neck. Oftentimes, CBS is due a loss of structural arterial integrity from local radiotherapy or surgical procedures. A vast majority of patients who develop CBS also have a previous diagnosis of head and neck cancer. Due to the specific patient population who develop CBS and its life-threatening nature, CBS should be a part of emergency physicians differential for those who present with a chronic neck wound or neurological symptoms in those with a previous head and neck cancer diagnosis. In this case report, a patient with a history of squamous cell carcinoma of the oropharynx who was treated with chemoradiation therapy, presented to the emergency department with spontaneous bleeding from an existing chronic wound on the left lateral neck. Conservative measures were taken including wound dressing, and the patient was discharged to see dermatology for biopsy of a suspected cancerous lesion. Once the chronic lesion was biopsied, the patient had to be immediately rushed to the operating room due to a brisk pulsatile bleeding from puncturing the carotid artery. Proper wound packing and an ultrasound of the neck for a proper diagnosis may have prevented the need for surgical intervention in this case. Although CBS is not common, complications can lead to death as seen in this case. Timely recognition and proper interventions are critical for preventing potentially fatal outcomes in those with CBS.

Reconstructive endovascular treatment of petrous ICA pseudoaneurysm in skull base osteomyelitis: a hidden catastrophe

Skull base osteomyelitis can be more life-threatening in immunocompromised patients and patients with diabetes. Here, we present a case of a petrous internal carotid artery pseudoaneurysm resulting from skull base osteomyelitis in a diabetic male in his 50s. This case report highlights the need to be conscious of the various complications associated with skull base osteomyelitis, be proficient in detecting them and treat them as early as possible for better outcomes. After adequate control of the disease process with medical treatment, immediate management of the aneurysm with balloon angioplasty and stenting was done. Acknowledging the trivial nasal and ear bleed, radiological evaluation is necessary to rule out rare complications like pseudoaneurysms in a diagnosed case of skull base osteomyelitis. In the discussion, we have cited the various treatment methods and similar cases of pseudoaneurysm caused by osteomyelitis. Currently, the patient continues to live a disease and disability-free life.

Summary of Japanese clinical practice guidelines for head and neck cancer - 2022 update edited by the Japan society for head and neck cancer

The aim of the "Japanese Clinical Practice Guidelines for Head and Neck Cancer - 2022 Update" is to review the latest evidence regarding head and neck cancer and to present the current standard approaches for diagnosis and treatment. These evidence-based recommendations were created with the consensus of the Guideline Committee, which is composed of otorhinolaryngologists and head and neck surgeons, together with radiologists, radiation oncologists, medical oncologists, plastic surgeons, dentists, palliative care physicians, and rehabilitation physicians. These guidelines were created by the Clinical Practice Guideline Committee of the Japan Society for Head and Neck Cancer based on the "Head and Neck Cancer Treatment Guidelines 2018 Edition," and the revised draft was compiled after evaluation by the Assessment Committee and public comments. The 'Clinical questions and recommendations' section consists of 13 categories, and 59 clinical questions are described in total. Here we describe 6 clinical questions specific to other sets of guidelines with recommendations and comments.

Outcomes Following Treatment for Carotid Blowout in Head and Neck Cancer Patients

OBJECTIVE

The aim of the study was to determine outcomes after interventional radiology treatment of carotid blowout.

METHODS

Patients with head and neck cancer and who received interventional radiology treatment for carotid blowout between 2000 and 2022 were included. Pre-treatment, treatment, and post-treatment variables were evaluated.

RESULTS

Fourteen patients met inclusion criteria. Eleven patients (78.6%) had a history of radiation. Twelve (85.7%) blowouts occurred within 6 months of recent intervention. Initial treatment was with stenting (n = 9, 64.3%), coil embolization (n = 4, 28.6%), or both (n = 1, 7.1%). Six patients (42.9%) underwent subsequent carotid bypass. Morbidity following treatment included stroke (n = 1) and rebleeding (n = 4). Six-month survival was 57.1%. Of the patients who survived past six months, 5/8 were treated with carotid bypass and coverage. Four patients died of cancer progression, three of rebleeding, and three of medical complications.

CONCLUSION

The majority of carotid blowout occurs within 6 months of surgery or radiation. Many who survive will die of cancer progression or medical illness. Carotid bypass with flap coverage may be a worthwhile treatment for carotid blowout and should be considered as an adjunct to endovascular treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:695-700, 2024.

Bipaddle Pectoralis Major Myocutaneous Flap (PMMC) for Complex Composite Oral Cavity Defects: An Experience of a Tertiary Cancer Centre

Although microvascular free flaps are considered the first choice in head and neck cancer defect reconstruction, their use is limited in developing regions by availability of resources and the expertise .The Bipaddle pectoralis major myocutaneous flap (PMMC flap) is a commonly used flap in head and neck cancer reconstruction, but in literature flap is associated with high incidence of drawbacks including donor site morbidity and added bulk of the flap reducing cosmetics and function. The purpose of the study is to evaluate the Bipaddle PMMC flap reliability, operative technique and outcome in reconstructive head and neck cancer surgery in the era of microvascular free flaps. Its a prospective study in which the records of 50 patients treated with Bippadle PMMC flap reconstruction between January 2022 to July 2022 were systematically collected and reviewed. Data of recipient site, serum albumin, history of adjuvant, recurrence, defect dimension, type of donor site closure, length of hospital stay, postoperative complications and outcomes were analysed. There were 45 males and 5 females with a mean age of 41 years (31-60). Bipaddle PMMC flap reconstruction was done in all patients of advanced squamous cell carcinoma of oral cavity. There were two males with complete necrosis of flap salvaged with latissimus dorsi flap and forehead flap. Minor infections were noted in two female and one male patient, managed conservatively and recovered well with acceptable final outcome. The Bipaddle PMMC flap is reliable for large defects in head and neck reconstructive surgery, particularly when a bulky flap is required to reconstruct composite defects where the lesion is involving the skin. Placing the flap horizontally with inclusion of nipple and areola in most of the patients increased the reach and size of available flap.

Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery: A matched case-control study

BACKGROUND

Although radiotherapy is common for head/neck and chest cancers (HNCC), it can result in post-irradiation stenosis of the subclavian artery (PISSA). The efficacy of percutaneous transluminal angioplasty and stenting (PTAS) to treat severe PISSA is not well-clarified.

AIMS

To compare the technical safety and outcomes of PTAS between patients with severe PISSA (RT group) and radiation-naïve counterparts (non-RT group).

METHODS

During 2000 and 2021, we retrospectively enrolled patients with severe symptomatic stenosis (>60%) of the subclavian artery who underwent PTAS. The rate of new recent vertebrobasilar ischaemic lesions (NRVBIL), diagnosed on diffusion-weight imaging (DWI) within 24 h of postprocedural brain MRI; symptom relief; and long-term stent patency were compared between the two groups.

RESULTS

Technical success was achieved in all 61 patients in the two groups. Compared with the non-RT group (44 cases, 44 lesions), the RT group (17 cases, 18 lesions) had longer stenoses (22.1 vs 11.1 mm, P = 0.003), more ulcerative plaques (38.9% vs 9.1%, P = 0.010), and more medial- or distal-segment stenoses (44.4% vs 9.1%, P<0.001). The technical safety and outcome between the non-RT group and the RT group were NRVBIL on DWI of periprocedural brain MRI 30.0% vs 23.1%, P = 0.727; symptom recurrence rate (mean follow-up 67.1 ± 50.0 months) 2.3% vs 11.8%, P = 0.185; and significant in-stent restenosis rate (>50%) 2.3% vs 11.1%, P = 0.200.

CONCLUSION

The technical safety and outcome of PTAS for PISSA were not inferior to those of radiation-naïve counterparts. PTAS for PISSA is an effective treatment for medically refractory ischaemic symptoms of HNCC patients with PISSA.

Surgical treatment of carotid blowout syndrome after radiotherapy for head and neck malignant tumors: a single-center experience

To explore the treatments for and manifestations of carotid blowout syndrome (CBS) and to further explore the critical role of high-flow bypass combined with parent artery isolation. The clinical data of nine patients with radiotherapy-related CBS who were admitted to our hospital from March 2020 to March 2023 were retrospectively analyzed. Relevant literature was reviewed. From March 2020 to March 2023, nine CBS patients were admitted to Tianjin Huanhu Hospital, including eight males and one female. Digital subtraction angiography was performed for all the patients; all the pseudoaneurysms were located at the petrous segment of the internal carotid artery. A balloon occlusion test was performed on four patients, which was tolerated by all patients. CT and MRI scans showed seven cases of osteonecrosis combined with infection and two cases of tumor recurrence. Emergency permanent parent artery occlusion was performed on six patients, aneurysm embolization was completed in one case, covered stent implantation was performed in one patient, and three cases were treated by cerebral bypass surgery (including two patients with failed interventional treatment). Rebleeding was found in two patients, and no rebleeding was found in the bypass group. Paralysis was found in three patients, and asymptomatic cerebral infarction without permanent neurologic impairment was found in three patients. Two patients died due to tumor progression. Emergency occlusion surgery is lifesaving in the acute phase of CBS. Endovascular therapy cannot prevent the progression of pseudoaneurysms or lower the recurrence rate of bleeding events. High-flow bypass combined with parent artery isolation is a safe and effective method that may facilitate further surgical treatment. Further research is warranted.

The Extent of Tumor Invasion and Therapeutic Embolization Are Associated with Recurrent Hemorrhage in Patients with External Carotid Artery Blowout Syndrome

PURPOSE

To explore the optimal strategies of therapeutic embolization for patients with carotid blowout syndrome in the external carotid artery (ECA), who may also present with arterial tumor invasion or necrosis extending to the internal carotid artery (ICA) or common carotid artery (CCA).

MATERIALS AND METHODS

The study included 110 patients with ECA blowout between 2005 and 2022. Antecedent cross-sectional imaging features were examined, including tumor size, extent of arterial invasion, and air-containing necrosis. Patients were divided into Groups 1 (n = 53, simultaneous ICA/CCA invasion + ECA therapeutic embolization), 2 (n = 18, simultaneous ICA/CCA invasion + ECA-ICA/CCA therapeutic embolization), and 3 (n = 39, no ICA/CCA invasion + ECA therapeutic embolization). Kaplan-Meier and multivariable Cox regression analyses were performed to evaluate associations of clinical, imaging, and therapeutic embolization characteristics with recurrent bleeding.

RESULTS

Multivariable Cox regression revealed that Group 1 was independently associated with a higher risk of recurrent bleeding than that in Group 2 (adjusted hazard ratio, 6.3; 95% CI, 1.7‒23.4; P = .005) and Group 3 (adjusted hazard ratio, 3.8; 95% CI, 1.8‒8.3; P = .001). In the subgroup with simultaneous ICA/CCA invasion, air-containing necrosis around the ICA/CCA was independently associated with recurrent bleeding after therapeutic embolization of the ECA (adjusted hazard ratio, 5.0; 95% CI, 1.8‒13.6; P = .002).

CONCLUSIONS

In patients with ECA blowout treated with therapeutic embolization, there was a lower risk of recurrent bleeding when the extents of arterial invasion and therapeutic embolization were concordant. Air-containing necrosis around the ICA/CCA was associated with recurrent bleeding, so extensive therapeutic embolization to the ICA/CCA should be evaluated in such patients.

A Treatment Approach for Carotid Blowout Syndrome and Soft Tissue Reconstruction after Radiotherapy in Patients with Oral Cancer: A Report of 2 Cases

BACKGROUND

This retrospective case series study aims to demonstrate a salvage technique for the treatment of carotid blow-out syndrome (CBS) in irradiated head and neck cancer patients with a vessel-depleted neck.

METHODS

Between October 2017 and October 2021, two patients (N = 2) with CBS were treated at our institution in a multidisciplinary approach together with the Department of Vascular Surgery. Patients were characterized based on diagnoses, treatment procedures, and the subsequent postoperative course.

RESULTS

Surgical emergency intervention was performed in both cases. The transition zone from the common carotid artery (CCA) to the internal carotid artery (ICA) was resected and reconstructed with a xenogic (case 1) or autogenic (case 2) interposition (end-to-end anastomosis). To allow reconstruction of the vascular defect, an additional autologous vein graft was anastomosed to the interposition graft in an end-to-side technique, allowing arterial anastomosis for a free microvascular flap without re-clamping of the ICA. Because of the intraoperative ICA reconstruction, none of the patients suffered a neurological deficit.

CONCLUSIONS

The techniques presented in the form of two case reports allow for acute bleeding control, cerebral perfusion, and the creation of a vascular anastomosis option in the vessel-depleted neck.

Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS

OBJECTIVES

Carotid blowout syndrome (CBS) is an acute, rare life-threatening hemorrhage that occurs in patients with a history of head and neck cancer and radiation therapy. The primary objective of this review was to identify risk factors and assess treatment and survival outcomes following CBS.

METHODS

A systematic review of published literature was performed. Information including risk factors, treatment, and outcomes of CBS were collected.

RESULTS

A total of 49 articles and 2220 patients were included in the systematic review. Risk factors for developing CBS included a history of radiation therapy, wound complications, and advanced tumor stage. The initial management of CBS included establishing a stable airway, gaining hemostasis, and repletion of blood loss. Endovascular and surgical procedures treat CBS with infrequent rates of rebleeding and periprocedural complications. Short-term survival following treatment of CBS shows high survival rates when considering CBS-related complications and underlying disease, however, long-term survival related to the underlying disease demonstrated high mortality.

CONCLUSIONS

Identifying patients at risk for CBS enables practitioners to counsel patients on life-saving interventions and expected outcomes following treatment of CBS. Treatment of CBS is associated with high short-term survival, although long-term survival related to underlying disease is low.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:576-587, 2023.

Head and Neck Reconstruction With 2-Stage External Pectoralis Major Myocutaneous Flap Transfer

BACKGROUND

In head and neck surgery cases where skin is severely scarred or adhered to surrounding tissue, reconstruction can be difficult to perform using microsurgical tissue or conventional pedicled pectoralis major myocutaneous flap (PMMF) transfer given the risks, which include damage to major vessels when manipulating scarred skin. For such cases, we perform a 2-stage external PMMF transfer, whereby the PMMF is directly sutured to the defect over the neck skin (without manipulation the hardened skin), and the flap division is then performed secondarily.

METHODS

A total of 30 patients who had histories of radiotherapy (60-70 Gy) and prior neck dissection received the 2-stage external PMMF transfer procedure. Indications for the flaps included pharyngeal fistula closure in 12 patients, reconstruction for mandibular necrosis after radiotherapy in 8 patients, salvage surgery for partial or total necrosis of the free flap in 4 patients, and simultaneous reconstruction after tumor excision in 6 patients. Two patients underwent a second external PMMF transfer from the contralateral side because of postoperative complications, yielding a total of 32 flap transfers.

RESULTS

Twenty-nine flaps showed complete flap survival, whereas 3 had partial necrosis. Other complications, despite complete flap survival, included large fistulas requiring additional surgery for fistula closure (1 patient) and small fistulas that were closed without requiring reoperation (7 patients).

CONCLUSIONS

External PMMF transfer offers a safe, simple, and effective option in cases where free flap surgery is considered difficult or the risks associated with neck manipulation are high.

Risk factors for rebleeding and long-term outcomes in patients with head and neck cancer bleeding: a multicenter study

Background

Acute, catastrophic bleeding in patients with head and neck cancer (HNC) is challenging and also a burden for their families and frontline physicians. This study analyzed the risk factors for rebleeding and long-term outcomes in these patients with HNC.

Methods

Patients who presented to the emergency department (ED) with HNC bleeding were enrolled in this study (N = 231). Variables of patients with or without rebleeding were compared, and associated factors were investigated using Cox’s proportional hazard model.

Results

Of the 231 patients enrolled, 112 (48.5%) experienced a recurrent bleeding event. The cumulative rebleeding incidence rate was 23% at 30 days, 49% at 180 days, and 56% at 1 year. Multivariate Cox regression analyses demonstrated that overweight-to-obesity (HR = 0.52, 95% CI 0.28–0.98, p = 0.043), laryngeal cancer (hazard ratio [HR] = 2.13, 95% confidence interval [CI] 1.07–4.23, p = 0.031), chemoradiation (HR = 1.49, 95% CI 1.001–2.94, p = 0.049), and second primary cancer (HR = 1.75, 95% CI 1.13–2.70, p = 0.012) are significant independent predictors of rebleeding, and the prognostic factors for overall survival included underweight (HR = 1.89, 95% CI 1.22–2.93, p = 0.004), heart rate > 110 beats/min (HR = 1.58, 95% CI 1.04–2.39, p = 0.032), chemoradiation (HR = 2.31, 95% CI 1.18–4.52, p = 0.015), and local recurrence (HR = 1.74, 95% CI 1.14–2.67, p = 0.011).

Conclusions

Overweight-to-obesity is a protective factor, while laryngeal cancer, chemoradiation and a second primary cancer are risk factors for rebleeding in patients with HNC. Our results may assist physicians in risk stratification of patients with HNC bleeding.

Air-containing necrosis as the imaging predictor for imminent carotid blowout in patients with head and neck cancer

BACKGROUND AND PURPOSE

Carotid blowout syndrome (CBS) is a devastating complication of head and neck cancer (HNC). In this study, we describe radiological features that can predict imminent (<6 months) carotid blowout in patients with HNC.

METHODS

Cross-sectional CT or MRI were interpreted from 25 treated HNC patients with acute CBS and 50 treated HNC patients without CBS (controls). The tumor size and the distance from the tumor to the carotid trunk was measured. The following imaging findings of the tumor were also recorded: carotid trunk involvement, enhancement pattern, and the presence of air-containing necrosis. The odds ratios of imminent CBS for each imaging finding were estimated using a multivariable logistic regression model.

RESULTS

Compared to the controls, the CBS group had larger tumors (49 ± 18 mm vs. 38 ± 18 mm, p = 0.017), tumors closer to the carotid trunk (0.5 ± 1.7 mm vs. 8.2 ± 14.2 mm, p < 0.001), a higher prevalence of 360° involvement (60% vs. 18%, p < 0.001), more heterogeneous enhancement patterns (84% vs. 50% p < 0.001), and more air-containing necrosis (40% vs. 2% p < 0.001). After multivariable adjustment, the presence of air-containing necrosis remained a significant risk factor for imminent CBS (OR: 20.1, 95% CI: 1.98-204.00; p = 0.011).

CONCLUSION

The presence of air-containing necrosis is associated with a higher risk of imminent CBS. This characteristic imaging finding should be evaluated in the follow-up CT or MRI of HNC patients for early warning.

Preclinical evaluation of a mannose-labeled magnetic tracer for enhanced sentinel lymph node retention in the head and neck

Sentinel lymph node biopsy in cancers of the head and neck offers demonstrated clinical and diagnostic value, but adoption is limited by concerns about the detrimental consequence to survival of false negative results in a highly curable setting. The aim of this study was to demonstrate potential to overcome this via application of a novel mannose-labeled magnetic iron oxide tracer. In a large animal model, preoperative imaging and intraoperative magnetometer detection were used to identify magnetic lymph nodes. Iron quantification mapped the distribution of tracer within lymphatic levels. Over a 4-week test period, uptake of magnetic tracer in lymph nodes increased in a linear-like fashion, with a substantial percentage of accumulated iron (83%) being retained in the sentinel node. This result indicates a high affinity of mannose-labeled particles to the sentinel node, while providing a means for the magnetometer probe to indicate node status based on intraoperative signal.

A Technical Guide to Palliative Ablation of Recurrent Cancers in the Deep Spaces of the Suprahyoid Neck

Treatment options for patients with recurrent head and neck cancer, whether locoregional recurrence of previously treated head and neck cancer or secondary primary malignancy, are limited. Percutaneous ablation is a minimally invasive procedure that can be used with palliative intent in the head and neck to achieve symptomatic relief and local tumor control, potentially fulfilling treatment gaps of current standard of care options. Image guidance is key when navigating the deep spaces of the neck with special attention paid to critical structures within the carotid sheath. This review article provides an overview and highlights the important nuances of performing percutaneous ablations in the head and neck. It covers general principles, ablative modalities, image guidance, procedural technique, expected outcomes, and possible complications.

Management of postradiation late hemorrhage following treatment for HPV-positive oropharyngeal squamous cell carcinoma

BACKGROUND

Acute oropharyngeal hemorrhage is a serious complication for patients with oropharyngeal squamous cell carcinoma (OPSCC), particularly in patients with a history of radiation therapy (RT).

METHODS

Retrospective case series from at a tertiary care center for treated patients with HPV-positive OPSCC presenting with oropharyngeal hemorrhage.

RESULTS

Median time from completion of chemoradiation to first hemorrhagic event was 186 days (range 66-1466 days). Seven patients (58%) required intervention to secure their airway. All patients were evaluated for endovascular intervention, six (50%) were embolized. Eight patients (67%) had a second hemorrhagic event; median time to second bleed was 22 days (range 3-90 days).

CONCLUSIONS

Acute oropharyngeal hemorrhage is a sequelae following treatment for HPV-positive OPSCC. The majority of bleeds occurred within a year of completion of treatment. While more research is needed to determine optimal treatment paradigms, endovascular intervention should be considered, even if noninvasive imaging does not demonstrate active bleeding.

In-Hospital and Long-Term Outcomes in Patients with Head and Neck Cancer Bleeding

Background and Objectives: The purpose of the present study was to elucidate the in-hospital and long-term outcomes of patients with head and neck cancer (HNC) bleeding and to analyze the risk factors for mortality. Materials and Methods: We included patients who presented to the emergency department (ED) with HNC bleeding. Variables of patients who survived and died were compared and associated factors were investigated by logistic regression and Cox’s proportional hazard model. Results: A total of 125 patients were enrolled in the present study. Fifty-nine (52.8%) patients experienced a recurrent bleeding event. The in-hospital mortality rate was 16%. The overall survival at 1, 3 and 5 years was 48%, 41% and 34%, respectively. The median survival time was 9.2 months. Multivariate logistic regression analyses revealed that risk factors for in-hospital mortality were inotropic support (OR = 10.41; Cl 1.81–59.84; p = 0.009), hypopharyngeal cancer (OR = 4.32; Cl 1.29–14.46; p = 0.018), and M stage (OR = 5.90; Cl 1.07–32.70; p = 0.042). Multivariate Cox regression analyses indicate that heart rate >110 (beats/min) (HR = 2.02; Cl 1.16–3.51; p = 0.013), inotropic support (HR = 3.25; Cl 1.20–8.82; p = 0.021), and hypopharygneal cancer (HR = 2.22; Cl 1.21–4.06; p = 0.010) were all significant independent predictors of poorer overall survival. Conclusions: HNC bleeding commonly represents the advanced disease stage. Recognition of associated factors aids in the risk stratification of patients with HNC bleeding.

Clinical predictors of internal carotid artery blowout in patients with radiated nasopharyngeal carcinoma

BACKGROUND

The primary objective is to identify clinical predictors of internal carotid artery (ICA) blowout in radiated nasopharyngeal carcinoma (NPC).

METHODS

Seventeen ICA blowouts, 14 external carotid artery (ECA) bleeds, and 60 controls were identified from January 1, 2007 to July 31, 2020. Multinomial logistic regression was performed to identify features predictive of ICA blowouts.

RESULTS

Headache was significantly more common among ICA blowouts than ECA bleeds and controls (58.8% vs. 7.1% vs. 6.7%, p < 0.001). The petrous skull base and sphenoid sinus lateral wall was eroded in all petrous and cavernous segment blowouts, respectively. Nasoendoscopy showing exposed clivus (OR 20.5, 95%CI 1.3-324.2) and computed tomography demonstrating skull base erosion (OR 17.8, 95%CI 1.0-311.0) were significantly associated with ICA blowouts compared to controls.

CONCLUSIONS

Findings of headache and skull base erosion on nasoendoscopy or imaging during NPC surveillance warrants prophylactic intervention to avoid an ICA blowout.

Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery

BACKGROUND/PURPOSE

The therapeutic efficacy of percutaneous transluminal angioplasty and stenting (PTAS) of post-irradiated stenosis of subclavian artery (PISSA) was not well clarified. This retrospective study was designed to evaluate the technical safety and outcome of the patients of severe symptomatic PISSA accepted PTAS.

METHODS

Between 2000 and 2019, 16 cases with 17 lesions of symptomatic and medically refractory PISSA accepted PTAS were included. We evaluated their technical success, peri-procedural complications and diffusion-weight imaging (DWI) of brain magnetic resonance imaging (MRI), results of symptom relief, and long-term stent patency.

RESULTS

The stenosis of the 17 stenotic lesions were 81.2 ± 11.1%. The most common symptom of the 16 patients was dizziness (14/16, 87.5%). All successfully accepted PTAS without neurological complication and had symptom relief after PTAS (17/17, 100%). Of the 12 patients accepted pre-procedural and early post-procedural MRI follow-up, 2 patients had an asymptomatic tiny acute embolic infarct in the territory of vertebrobasilar system. In a 51.9 ± 54.9 months follow-up, all patients had no severe restenosis and no recurrent vertebrobasilar ischemic symptoms.

CONCLUSION

For patients with PISSA and medically refractory ischemic symptoms, PTAS can be an effective alternative management.

Extracranial/Intracranial Vascular Bypass in the Treatment of Head and Neck Cancer - Related Carotid Blowout Syndrome

OBJECTIVE/HYPOTHESIS

To investigate the endovascular intervention or extracranial/intracranial (EC/IC) vascular bypass in the management of patients with head and neck cancer-related carotid blowout syndrome (CBS).

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective analysis of clinical data of patients with head and neck cancer-related CBS treated by endovascular intervention and/or EC/IC vascular bypass, analysis of its bleeding control, neurological complications, and survival results.

RESULTS

Thrity-seven patients were included. Twenty-five were associated with external carotid artery (ECA); twelve were associated with internal or common carotid artery (ICA/CCA). All patients with ECA hemorrhage were treated with endovascular embolization. Of the 12 patients with ICA/CCA hemorrhage, 9 underwent EC/IC bypass, 1 underwent endovascular embolization, and 3 underwent endovascular stenting. For patients with ECA-related CBS, the median survival was 6 months, and the 90-day, 1-year, and 2-year survival rates were 67.1%, 44.7%, and 33.6%, respectively; the estimated rebleeding risk at 1-month, 6-month, and 2-year was 7.1%, 20.0%, and 31.6%, respectively. For patients with ICA/CCA-related CBS, the median survival was 22.5 months, and the 90-day, 1-year, and 2-year survival rates were 92.3%, 71.8%, and 41.0%, respectively; the estimated rebleeding risk at 1 month, 6 months, and 2 years is 7.7%,15.4%, and 15.4%, respectively. ICA/CCA-related CBS patients have significantly longer survival time and lower risk of rebleeding, which may be related to the more use of EC/IC vascular bypass as a definite treatment.

CONCLUSIONS

For patients with ICA/CCA-related CBS, if there is more stable hemodynamics, longer expected survival, EC/IC vascular bypass is preferred.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1548-1556, 2021.

Comparison of Treatment Modalities in Postirradiation Carotid Blowout Syndrome: A Multicenter Retrospective Review

BACKGROUND

Carotid blowout syndrome (CBS) is not uncommon in our locality, where head and neck cancers, especially nasopharyngeal carcinoma, are prevalent. Traditionally, CBS has resulted in high morbidity and mortality. The treatment paradigm has evolved from open surgery to endovascular interventions, and each treatment modality has its merits and drawbacks. In the present study, we investigated the outcomes of different treatment modalities for postirradiation CBS.

METHODS

We performed a 10-year multicenter retrospective review of the outcomes after endovascular trapping, flow diverters, and bypass surgery from 2009 to 2019.

RESULTS

A total of 53 patients with 60 blowouts were included in the present study. Of the 60 blowout cases, 25 were in the flow diverter group, 27 in the endovascular trapping group, and 8 in the bypass group. The mean survival was 32.2 months, with patient age affecting overall survival (P = 0.002). The stroke rate affected the 3- and 6-month functional outcomes (odds ratio, 7.388 and 6.353; P = 0.008 and P = 0.014, respectively). Of the 24 cases in the flow diverter group, 96% had achieved immediate hemostasis, with a rebleeding rate of 20% (P = 0.009). No rebleeding had occurred with endovascular trapping or bypass. The stroke rate in the endovascular trapping, flow diverter, and bypass groups was 25.9%, 20%, and 12.5%, respectively (P = 0.696).

CONCLUSIONS

Our results have shown that endovascular trapping is the first-line treatment of CBS. For patients with contraindications to endovascular trapping, the flow diverter is an alternative. For patients who have undergone flow diversion alone, definitive treatment such as bypass surgery might be indicated for selected patients to minimize the risk of rebleeding. After endovascular trapping, surgical bypass might be considered for selected patients with a higher risk of stroke.

Bleeding complications in patients with squamous cell carcinoma of the head and neck

Hemorrhage in recurrent and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) may be attributed to chemotherapy and local tumor irradiation. Evidence of the relationship between hemorrhage in R/M HNSCC and targeted therapies, including epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) inhibitors, or immune checkpoint inhibitors, is limited. We aimed to identify epidemiological and clinical data related to the occurrence of hemorrhage in R/M HNSCC and to explore its relationship with various therapies. We describe information obtained from literature searches as well as data extracted from a commercial database and a database from the author's institution (Istituto Nazionale dei Tumori of Milan). Evidence suggests that most bleeding events in R/M HNSCC are minor. Clinical trial safety data do not identify a causal association between hemorrhage and anti‐EGFR agents or immune checkpoint inhibitors. In contrast, anti‐VEGF agents are associated with increased, and often severe/fatal, hemorrhagic complications.

Extracranial vertebral artery to middle cerebral artery bypass in therapeutic internal carotid artery occlusion for epipharyngeal carcinoma: A technical case report

Background:

Vertebral artery (VA) to middle cerebral artery (MCA) bypass is a rarely selected technique because a complex expanded dissection is required, and often, a better donor artery than VA exists. A good indication for VA-MCA bypass is the treatment of head-and-neck malignancies with the sacrifice of the internal carotid artery (ICA) or for carotid artery rupture.

Methods:

A 23-year-old man with epipharyngeal carcinoma, treated by ligating the carotid artery with a VAMCA bypass before chemoradiotherapy, was reported. Radiographic findings showed that the bone of the carotid canal was dissolved, and the right ICA was engulfed by the tumor. As epipharyngeal carcinoma is hypersensitive to radiation, in cases where the tumor rapidly disappears, ICA may dangle in the pharynx and rupture may occur. In addition, to irradiate sufficiently, the ICA may become an obstacle. Hence, we decided to perform carotid ligation with a VA-MCA bypass before radiation and chemotherapy for the primary lesion. We selected the V3 portion of the VA as the donor on the ipsilateral side, as it can supply high-flow cerebral blood flow, which is not influenced by carcinoma and less influenced by irradiation for the epipharynx.

Results:

The VA-MCA bypass was completed without complications followed by endovascular occlusion of the ICA. Induction chemotherapy was initiated for the patient 2 weeks after surgery. The patient achieved a complete response following chemoradiotherapy.

Conclusion:

ICA ligation with VA-MCA high-flow bypass earlier than chemoradiotherapy is useful for epipharyngeal carcinoma as it prevents carotid artery rupture and allows radical intervention.

Risk factors and nomogram for predicting carotid blowout syndrome based on computed tomography angiography

OBJECTIVES

To identify independent factors for head and neck cancer (HNC) patients with carotid blowout syndrome (CBS) and construct a nomogram to predict risk of CBS preoperatively based on computed tomography angiography (CTA) imaging.

SUBJECT AND METHODS

From January 2010 to July 2020, 73 HNC patients who had surgery in hospitalization and underwent CTA examination for head and neck region were included in this study. Vascular alterations and the relationship between carotid artery (CA) and tumor were evaluated in CTA. Clinical and CTA imaging features were distinguished by logistic regression analysis and used to perform receiver operating curve analysis. Nomogram was created to predict risk of CBS and assessed by concordance index (C-index) and calibration curve.

RESULTS

Three independent risk factors were identified, including radical neck dissection, CA surrounded by tumor, and CA invaded by tumor without clear boundary. Area under curve of the combination of 3 variables was 0.836 (95% CI, 0.72-0.952, p < 0.001). The C-index of nomogram was 0.84 (95% CI, 0.73-0.94), and the calibration plot showed a good fitting between prediction and observation.

CONCLUSIONS

We established a useful nomogram based on CTA imaging, which showed a satisfied efficacy for evaluating risk of CBS in HNC patients preoperatively.

Large German Multicenter Experience on the Treatment Outcome of 207 Patients With Adenoid Cystic Carcinoma of the Major Salivary Glands

Introdution

We aimed to evaluate treatment outcome of combined radiotherapy (RT) including photon intensity modulated radiotherapy (IMRT) and carbon ion boost for adenoid cystic carcinomas (ACCs) of the major salivary glands, the currently available largest German collective for this cohort.

Materials and Methods

Overall, 207 patients who were irradiated with combined RT between 2009 and 2019 at Heidelberg University Hospital were analyzed retrospectively for local control (LC), progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier estimates. The majority of patients received postoperative RT (n=176/207, 85%) after previous surgery in large German hospitals mainly Mainz, Freiburg, Mannheim and Heidelberg University Hospitals and 15% received primary RT (n=31/207).

Results

After a median follow-up time of 50 months, 84% of the patients were still alive (n=174/207). Disease progression occurred in 32% of the patients (n=66/207) while local recurrence was diagnosed in 12% (n=25/207), and distant relapse in 27% (n=56/207). Estimated 5-year LC, PFS and OS rates were 84%, 56% and 83% for OS, respectively. In multivariate analysis, we could identify two prognostic subgroups: one subgroup resulting in decreased LC, PFS and OS rates and another subgroup having an additional survival disadvantage in PFS and OS. Patients with a macroscopic tumor disease (yes vs. no; p<0.001 for LC, p=0.010 for PFS and p=0.040 for OS) treated in a definitive setting (vs. postoperative setting; p=0.001 for LC, p=0.006 for PFS, p=0.049 for OS) and tumors of upper T stage (T1-4; p=0.004 for LC, p<0.001 for PFS, p<0.001 for OS) showed significantly more local relapses and a decreased PFS and OS. Upper Age (p<0.001 for both PFS and OS), lower Karnofsky Performance Score (<80% vs. ≥80%; p<0.001 for both PFS and OS) and solid histology (vs. non-solid; p=0.049 for PFS and p=0.003 for OS) were in addition associated with worse survival outcome. Toxicity was moderate with 18% late grade 2 and 3 toxicity.

Conclusions

Combined RT results in superior LC rates compared to photon data with moderate toxicity. In multivariate analysis, upper T stage, the existence of a macroscopic tumor before RT and definitive RT setting were identified as major prognostic factors affecting LC negatively.

Comprehensive Treatment Strategy for Internal Carotid Artery Blowout Syndrome Caused by Nasopharyngeal Carcinoma

OBJECTIVE

To evaluate a treatment strategy for internal carotid artery blowout syndrome caused by nasopharyngeal carcinoma.

STUDY DESIGN

A retrospective analysis of a case series was performed.

SETTING

Carotid blowout syndrome is a catastrophic complication caused by malignant tumor of the skull base.

METHODS

A retrospective analysis based on 69 patients with internal carotid artery blowout syndrome admitted to our center between April 2018 and January 2020 was performed. The patients were divided into 2 groups: an EBBA (internal carotid artery embolization + bypass based on American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology [ASITN/SIR]) group and an embolization/stent group. The follow-up time was 6 to 9 months.

RESULTS

In the EBBA group, 41 patients (41/49, 83.7%) survived. Forty patients had a satisfactory quality of life after 3 months. No death occurred within 3 months. Nonoperative death occurred in 8 cases (8/49, 16.3%). The rate of mortality and disability was 18.4% (9/49). In the embolization/stent group, 16 patients (16/20, 80%) survived. Nonoperative death occurred in 4 cases (4/20, 20%), 3 of which occurred within 1 to 3 months. Four cases reported Modified Rankin Scale ≥2 after 3 months. The rate of mortality and disability was 40% (8/20).

CONCLUSION

A comprehensive revascularization strategy for internal carotid artery (ICA) embolization and intracranial and extracranial bypass grafting based on ASITN/SIR score for ICA blowout syndrome patients not only can prolong the patient survival but also greatly improve the survival probability and quality of life as well as reduce their rate of mortality or disability.

Rupture of carotid artery pseudoaneurysm in the modern era of definitive chemoradiation for head and neck cancer: Two case reports

BACKGROUND

Carotid blowout syndrome (CBS) is a rupture of the carotid artery and is mainly caused by radiation and resection of head and neck cancers or direct tumor invasion of the carotid artery wall. It is a life-threatening clinical situation. There is no established and effective mode of management of CBS. Furthermore, there is no established preceding sign or symptom; therefore, preventive efforts are not clinically meaningful.

CASE SUMMARY

We described two cases of CBS that occurred in patients with head and neck cancer after definitive chemoradiotherapy (CRT) using three-dimensional conformal intensity-modulated radiation therapy. Two men aged 61 and 56 years with locally advanced head and neck cancer were treated with definitive CRT. After completing CRT, both of them achieved complete remission. Subsequently, they had persistent severe pain in the oropharyngeal mucosal region and the irradiated neck despite the use of opioid analgesics and rehabilitation for relief of contracted skin. However, continuous follow-up imaging studies showed no evidence of cancer recurrence. Eleven to twelve months after completing CRT, the patients visited the emergency room complaining about massive oronasal bleeding. Angiograms showed rupture of carotid artery pseudoaneurysms on the irradiated side. Despite attempting to secure hemostasis with carotid arterial stent insertion and coil embolization, both patients died because of repeated bleeding from the pseudoaneurysms.

CONCLUSION

In patients with persistent pain in irradiated sites, clinicians should be suspicious of progressing or impending CBS, even in the three-dimensional conformal intensity-modulated radiation therapy era.

Catastrophic Hemorrhage After Chemoradiation for Advanced Stage Oropharyngeal Carcinoma: A Case Series

OBJECTIVES/HYPOTHESIS

We have seen several incidences of catastrophic bleeding in patients with advanced oropharyngeal squamous cell carcinoma treated nonoperatively. Aside from advanced disease, these patients have not had traditional risk factors for major hemorrhage.

STUDY DESIGN

Retrospective chart review.

METHODS

Patients treated nonoperatively for oropharyngeal squamous cell carcinoma were compared to determine characteristics that may predisposed to bleeding. Five patients with bleeding were identified and compared with a cohort of stage- and treatment-matched patients without bleeding. Blinded imaging review was performed to characterize the tumor site and its relationship to vasculature using standardized systems.

RESULTS

Comparing the bleeder versus nonbleeder groups pre-treatment, the bleeder group had larger tumors (15.4 vs. 8.3 cm² ), greater rates of parapharyngeal fat effacement (80% vs. 20%), and always involved the facial artery. Post-treatment, endophytic ulcerated tumor beds occurred in 100% of bleeders versus 0% of nonbleeders.

CONCLUSIONS

Catastrophic oropharyngeal bleeding may be encountered after cytoreductive therapy. Large deeply invasive tumors seem to set the necessary circumstances. Rapid vascular control with interventional radiology has been largely effective therapy.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1049-1052, 2021.

Carotid blowout-a rare but fatal complication of endoscopic submucosal dissection of superficial hypopharyngeal carcinoma after radiotherapy

Endoscopic submucosal dissection (ESD) has gained wide acceptance as a minimally invasive and curative surgery for superficial head and neck carcinoma. However, the safety of ESD for superficial pharyngeal carcinoma after radiotherapy has not been elucidated. Superficial hypopharyngeal carcinoma of the left pyriform sinus developed in a 76-year-old man who had undergone concurrent chemoradiotherapy for T2N2bM0 pyriform sinus carcinoma on the opposite side 12 months before. He underwent ESD without complications. Because tumor invasion into the muscular layer was a concern, the muscular layer was partially resected with the tumor. Twelve days after discharge, he presented with a sore throat and difficulty in swallowing. Endoscopy and computed tomography revealed necrosis due to wound infection with abscess formation around the left carotid artery. The common carotid artery subsequently ruptured. Although the surgical intervention was performed, he passed away 46 days after ESD due to carotid blowout. ESD is a minimally invasive treatment for superficial head and neck carcinoma, but carotid blowout can occur in cases after radiation. Prior radiotherapy and deeper dissection into the muscular layer may hamper wound epithelization, resulting in infection-induced necrosis and carotid blowout. Diligent monitoring of wound healing is essential in patients who have previously undergone irradiation.

Synchronous reconstruction of esophageal defect and voice with J-flap after laryngopharyngectomy: Indications and outcomes

BACKGROUND

The primary reconstruction goal for patients with laryngopharyngectomy is the restoration of esophagus, whereas voice reconstruction is less readily reconstructed. J-flap is a novel surgical technique designed to reconstruct voice and esophagus synchronously, permitting functional rehabilitation of aerodigestive tract after laryngopharyngectomy.

OBJECTIVES

This study aims to present indications, surgical steps, and outcomes of an innovative technique for synchronous reconstruction of the esophagus and voice tube with a free thigh flap (J-flaps).

METHOD

Single-center study from 2011 to 2017 recruiting patients with hypopharyngeal cancer needing laryngopharyngectomy and J-flaps reconstruction. Patient details were analyzed, and surgical outcomes were examined.

RESULTS

20 patients were recruited with an average age of 61. Tumor staging was IIB or above. The average follow-up period was 15 months. 65% of these patients resumed a full diet. The row phonation rate was 75%. The average maximum phonation time was 8.9 s, and the average number of counting in a breath was 14.

CONCLUSIONS

Most patients achieved a conversational level of speech capacity with a humanoid voice. J-flap can be utilized safely, supporting the social re-integration of these patients with their new voice.