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Yang A, Duan F, Lan Zao R, Hong Xiao X, Yan Wang Z. Clinical and MRI risk factors predicting post-irradiation carotid blowout syndrome in patients with nasopharyngeal cancer. Strahlenther Onkol 2024:10.1007/s00066-024-02247-1. [PMID: 38869645 DOI: 10.1007/s00066-024-02247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/05/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To explore the clinical and imaging features of nasopharyngeal cancer (NPC) complicated by acute carotid blowout syndrome (CBS), analyze the risk factors for CBS, and improve diagnostic vigilance for early intervention. METHODS This retrospective review was conducted between January 2003 and May 2023. Altogether, 49 patients with post-irradiation NPC with CBS and 49 patients without CBS as control group were enrolled. The condition of the patients when CBS occurred was reviewed. Patient characteristics of the CBS and control groups were compared, and binary logistic regression analysis was performed to identify risk factors for CBS. RESULTS All patients in the CBS group were conscious, and 41 patients had a Karnofsky performance assessment scale score of ≥ 70. After interventional therapy, 43 patients survived (the mean survival time of patients after CBS was 3.2 ± 2.1 years). Compared with the control group, the CBS group had a higher incidence of sphenoid sinusitis (81% vs. 52.4%), osteonecrosis (82.9% vs. 51.2%), artery exposure (29.3% vs. 4.9%), and internal carotid artery injury (61% vs. 29.3%). Osteonecrosis and artery exposure were selected as important risk factor for CBS, with p-values of 0.016 and 0.031, respectively. CONCLUSION CBS is an important factor that affects the survival of patients with NPC. If internal carotid artery injury, artery exposure, sphenoid sinusitis, and osteonecrosis are present, especially the latter two signs, the possibility of CBS should be considered.
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Affiliation(s)
- Ang Yang
- Department of MR, Zhongshan City People's Hospital, Sun Wendong Road No. 2, Zhongshan City, Guangdong Province, China.
| | - Fei Duan
- Zunyi Medical University, Zunyi, China
| | | | - Xue Hong Xiao
- Department of MR, Zhongshan City People's Hospital, Sun Wendong Road No. 2, Zhongshan City, Guangdong Province, China
| | - Ze Yan Wang
- Department of MR, Zhongshan City People's Hospital, Sun Wendong Road No. 2, Zhongshan City, Guangdong Province, China
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2
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Gao K, Guo W, Shang Y, Liu G, Zhai X, Li H, Shi M, Tong X. Surgical treatment of carotid blowout syndrome after radiotherapy for head and neck malignant tumors: a single-center experience. Neurosurg Rev 2023; 46:293. [PMID: 37924361 DOI: 10.1007/s10143-023-02193-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 11/06/2023]
Abstract
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.
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Affiliation(s)
- Kaiming Gao
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Wenqiang Guo
- Department of Neurosurgery, Qilu Hospital of Shandong University (Qingdao), 758 Hefei Road, Shibei District, Qingdao, Shandong, 266035, China
| | - Yanguo Shang
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Gang Liu
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Xiang Zhai
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Haiyan Li
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Minggang Shi
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China.
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China.
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China.
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China.
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Slijepcevic AA, Roh J, Pipkorn P, Lipsey K, Bradley JP. Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS. Laryngoscope 2023; 133:576-587. [PMID: 35575599 DOI: 10.1002/lary.30157] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joseph Roh
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kim Lipsey
- Bernard Becker Medical Library, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Joseph P Bradley
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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4
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Li C, Lu J, Luo Y, Feng D. Case report: Endovascular intervention of internal carotid artery pseudoaneurysm secondary to nasopharyngeal carcinoma radiotherapy. Front Surg 2023; 9:1099416. [PMID: 36713655 PMCID: PMC9879062 DOI: 10.3389/fsurg.2022.1099416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023] Open
Abstract
Background Internal carotid artery pseudoaneurysm (PSA) is a serious complication after radiotherapy for nasopharyngeal carcinoma, and once it ruptures and bleeds, it will seriously affect the patient's survival and prognosis. However, because of its relatively low incidence, many medical institutions lack experience in managing this type of emergency. Case information In this case report, we described two cases suffered ruptured internal carotid artery PSA after radiotherapy for nasopharyngeal carcinoma, including their history, diagnosis, and treatment. Both cases underwent emergency endovascular interventions, one of which with long-term healing after embolization of the PSA, and the other one with re-bleeding after embolization and was eventually stopped by embolization of the parent artery. Ultimately, both cases received timely and effective treatment. Conclusion This case report detailed the diagnosis and treatment course of internal carotid artery PSA after radiotherapy for nasopharyngeal carcinoma, which enhanced the understanding of this emergency, and provided valuable information and experience for the treatment strategy of similar PSA on the internal carotid artery.
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Affiliation(s)
| | | | - Yu Luo
- Correspondence: Daqin Feng ; Yu Luo
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5
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Endovascular embolisation of external carotid artery system haemorrhage in radiated nasopharyngeal carcinoma. Eur Arch Otorhinolaryngol 2022; 279:5851-5858. [PMID: 35792916 DOI: 10.1007/s00405-022-07491-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/06/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE To review the effectiveness and safety of embolisation in managing haemorrhage from the external carotid artery (ECA) system in radiated nasopharyngeal carcinoma (NPC) patients. METHODS Radiated NPC patients who presented with severe oronasal bleeding and underwent digital subtraction angiography that excluded blowouts from the internal carotid artery from 2011 to 2021 were reviewed. Those who subsequently underwent embolisation of the ECA system were analysed for technical success rate, post-embolisation re-bleeding rate and complications. RESULTS Seventeen embolisations were performed in fifteen patients during the 10-year period. The technical success rate was 100%, however the early haemostatic rate (no re-bleed within 7 days of embolisation) was 70.6% (12/17) and the overall long-term haemostatic rate was 58.8% (10/17). The re-bleed rates of targeted and empiric embolisations were 33.3% (3/9) and 50.0% (4/8), respectively. The re-bleed rates with liquid agents, coils and particles were 0% (0/7), 33.3% (1/3) and 85.7% (6/7), respectively. Amongst the embolisations utilising liquid agents, 71.4% (5/7) were targeted, distal embolisations. All re-bleeds underwent surgical ligation or repeat embolisation; half of them further experienced recurrent bleeding. There were no significant complications with embolisation. CONCLUSION Although embolisation of the ECA system in NPC has a high technical success rate and is safe, re-bleeding appears to be common. Targeted, distal embolisation with liquid embolics appear to have good haemostatic effect. Clinicians should be aware that patients may need repeated procedures to secure haemostasis.
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6
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Duan BF, Chen HY, Zheng XM, He Q. Acquired unilateral alopecia after arterial infusion chemotherapy in a recurrent nasopharyngeal carcinoma. Cancer Rep (Hoboken) 2022; 5:e1671. [PMID: 35861475 PMCID: PMC9575488 DOI: 10.1002/cnr2.1671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 05/24/2022] [Accepted: 06/17/2022] [Indexed: 02/05/2023] Open
Abstract
Background Intractable nasopharyngeal hemorrhage is a severe complication with high mortality rate in patients with radiation therapy (RT) for nasopharyngeal carcinoma (NPC) that requires emergency treatment. Quite a few of them combine with tumor recurrence. Treatment planning for these patients is extremely difficult for oncologists, and effective treatments are lacking. Case A 42‐year‐old man had a history of recurrent NPC that was treated with 2 cycles of chemoradiotherapies from 2017 to 2019. Five months after the second round of chemoradiotherapy, an episode of massive nasal bleeding occurred. As positron emission tomography (PET) scan revealed tumor recurrence in the left wall of nasopharynx, superselective embolization and subsequent intra‐arterial infusion (IA, 4 times of cisplatin 60 mg + fluorouracil 1.0 g) were performed to stop bleeding and achieve tumor control. To date, the disease‐free survival time has been over 1 year. No tumor recurrence or rebleeding is found except for alopecia on the left side. Conclusions Interventional radiology is important and effective in the treatment of recurrent NPC for both massive nasal bleeding and tumor control. However, the unique complication of unilateral alopecia should not be ignored.
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Affiliation(s)
- Bao-Feng Duan
- Department of Head and Neck Oncology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Hua-Ying Chen
- Department of Head and Neck Oncology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xue-Mei Zheng
- Department of Head and Neck Oncology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Qing He
- Department of Head and Neck Oncology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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7
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Leboucher A, Sotton S, Gambin Flandrin I, Magné N. Head and neck radiotherapy-induced carotid toxicity: Pathophysiological concepts and clinical syndromes. Oral Oncol 2022; 129:105868. [DOI: 10.1016/j.oraloncology.2022.105868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 03/27/2022] [Accepted: 04/12/2022] [Indexed: 01/17/2023]
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8
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Li J, Yi X, He G, Yao D, Bin X, Feng Y, Niu Z, Tan Q, Tang A. Analysis of the risk of death and clinical management for nasal or nasopharyngeal bleeding occurring after radiotherapy for nasopharyngeal carcinoma. Auris Nasus Larynx 2022; 49:703-708. [DOI: 10.1016/j.anl.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 12/17/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
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9
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Zeng L, Wan W, Luo Q, Jiang H, Ye J. Retrospective analysis of massive epistaxis and pseudoaneurysms in nasopharyngeal carcinoma after radiotherapy. Eur Arch Otorhinolaryngol 2021; 279:2973-2980. [PMID: 34623497 DOI: 10.1007/s00405-021-07111-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Epistaxis after radiotherapy for nasopharyngeal carcinoma (NPC) is a common clinical critical illness, which often leads to death of patients. This article focuses on the relationship between massive epistaxis and pseudoaneurysm after radiotherapy in patients with NPC and discusses clinically relevant treatment strategies. METHODS A review was performed in 21 patients with massive epistaxis after radiotherapy for NPC from January 2011 to December 2019, and all of the patients were examined by computed tomography angiography (CTA). We also reviewed the English literature over the past 10 years to analyze the characteristics and related causes of pseudoaneurysms in terms of the clinical stage of NPC, course of radiotherapy, and affected artery. An analysis was performed on the methods of endovascular interventional treatment of such pseudoaneurysms. RESULTS Among the 21 patients, 19 cases had bone destruction of the skull base; 13 cases were also found to have tumor recurrence; 15 cases were in stage III or IV of NPC; pseudoaneurysms were observed in 14 cases, of which nine cases had pseudoaneurysms in the internal carotid artery (ICA), and the rest had pseudoaneurysms in the external carotid artery (ECA). These data were consistent with the results of the literature review. Analysis with imaging revealed that the petrous ICA was the common predilection site. There were 11 out of 14 cases of pseudoaneurysms with sentinel hemorrhage in the initial phase. All 14 pseudoaneurysm patients underwent endovascular interventional therapy, but one died from hemorrhagic shock during the procedure. No rebleeding was observed among the other patients during 72 h after intravascular treatment. Nevertheless, regrettably two patients died on the 10th and 17th days after intervention. CONCLUSION Pseudoaneurysm, which was a serious complication after radiotherapy in patients with NPC, could cause massive epistaxis with high mortality. The formation of a pseudoaneurysm was closely associated with a high carcinoma stage, re-radiotherapy, and local bone destruction and infection. Most cases had sentinel epistaxis, which was considered the bleeding characteristic. The imaging material prompted that pseudoaneurysm had a predisposition to the petrous part of the ICA, while the preferred therapy was endovascular embolization treatment.
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Affiliation(s)
- Liang Zeng
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Wei Wan
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Qing Luo
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Hongqun Jiang
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Jing Ye
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China.
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10
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Xu X, Ong YK, Loh WS, Anil G, Yap QV, Loh KS. Clinical predictors of internal carotid artery blowout in patients with radiated nasopharyngeal carcinoma. Head Neck 2021; 43:3757-3763. [PMID: 34558142 DOI: 10.1002/hed.26869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/25/2021] [Accepted: 08/31/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Xinni Xu
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Yew Kwang Ong
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Woei Shyang Loh
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore, Singapore
| | - Gopinathan Anil
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kwok Seng Loh
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore, Singapore
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Takabayashi K, Takebayashi S, Sakurai J, Gotoh S, Takizawa K. A case of catastrophic epistaxis from the internal carotid artery due to multiple surgeries and irradiations for pituitary tumor: Rescued utilizing high-flow bypass and simultaneous skull base reconstruction. Clin Case Rep 2021; 9:e04697. [PMID: 34466253 PMCID: PMC8385459 DOI: 10.1002/ccr3.4697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022] Open
Abstract
Revascularization for internal carotid artery rupture should be considered immediately under the situation where endovascular treatment is not indicated. Revascularization can prevent the risk of hemorrhage during skull base reconstruction.
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Affiliation(s)
- Kosuke Takabayashi
- Department of Otorhinolaryngology Japanese Red Cross Asahikawa Hospital Hokkaido Japan
| | - Seiji Takebayashi
- Department of Neurosurgery Japanese Red Cross Asahikawa Hospital Hokkaido Japan
| | - Juro Sakurai
- Department of Neurosurgery Japanese Red Cross Asahikawa Hospital Hokkaido Japan
| | - Shuho Gotoh
- Department of Neurosurgery Japanese Red Cross Asahikawa Hospital Hokkaido Japan
| | - Katsumi Takizawa
- Department of Neurosurgery Japanese Red Cross Asahikawa Hospital Hokkaido Japan
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12
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Wu PA, Yuan GY, Zhou RM, Ho WWS, Lu ZQ, Cai JF, Yang SY, Tsang RKY, Chan JYW. Extracranial/Intracranial Vascular Bypass in the Treatment of Head and Neck Cancer - Related Carotid Blowout Syndrome. Laryngoscope 2021; 131:1548-1556. [PMID: 33571390 DOI: 10.1002/lary.29427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/01/2021] [Accepted: 01/12/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Ping-An Wu
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Guo-Yan Yuan
- Department of Surgery, Division of Neurosurgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Ru-Ming Zhou
- Department of Interventional Radiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Wilson Wai-Shing Ho
- Department of Surgery, Division of Neurosurgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhao-Qun Lu
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Ji-Fu Cai
- Department of Neurology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Si-Yi Yang
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Raymond King-Yin Tsang
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Jimmy Yu-Wai Chan
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
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Endovascular treatment for radiation-induced internal carotid artery pseudoaneurysm and usefulness of angiographic and nasal endoscopic confirmation. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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14
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Chang HY, Liu ZG, Li YL, Liu B, Wang WJ, Wang W, Wang YZ. Endovascular stenting and coil embolization for management of radiation-induced pseudoaneurysms of the peripheral arteries. J Int Med Res 2021; 49:300060520984933. [PMID: 33845651 PMCID: PMC8047089 DOI: 10.1177/0300060520984933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective This study was performed to evaluate the safety and efficacy of endovascular stenting and embolization for the management of radiation-induced peripheral arterial pseudoaneurysms. Methods Twelve consecutive patients with radiation-induced peripheral arterial pseudoaneurysms (diameter of 10–30 mm and mean size of 20.42 mm) were admitted to our hospital from 1 January 2015 to 31 October 2019. The patients’ baseline characteristics, perioperative parameters, device characteristics, and curative effects were systematically recorded and analyzed. Results The 12 patients comprised 3 men and 9 women with a mean age of 62.90 ± 13.97 years. The iliac artery was the most commonly involved artery, followed by the subclavian artery. In all patients, the pseudoaneurysms were detected by enhanced computed tomography. Twelve covered stents were deployed (7 or 8 mm in diameter and 50 mm in length). Additional coil embolization was performed in three patients (Patients 8, 9, and 10). The primary and secondary technical success rate was 91.7% and 100%, respectively. Apart from one death caused by rebleeding, no patients developed rebleeding during follow-up. Conclusion Endovascular stenting and coil embolization are feasible and effective for the management of radiation-induced peripheral arterial pseudoaneurysms in highly selected patients.
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Affiliation(s)
- Hai-Yang Chang
- Department of Interventional Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, People's Republic of China.,Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Zhen-Guo Liu
- Department of Oncology, Gaoqing People's Hospital, Gaoqing, Shandong Province, People's Republic of China
| | - Yu-Liang Li
- Department of Interventional Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, People's Republic of China.,Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Bin Liu
- Department of Interventional Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, People's Republic of China.,Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Wu-Jie Wang
- Department of Interventional Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, People's Republic of China.,Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Wei Wang
- Department of Interventional Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, People's Republic of China.,Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Yong-Zheng Wang
- Department of Interventional Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, People's Republic of China.,Interventional Oncology Institute of Shandong University, Jinan, Shandong Province, People's Republic of China
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15
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Wang Y, Dong X, Zhou C, Shi Q, Liu J, Xiong B. Endovascular Management of Intractable Nasopharyngeal Hemorrhage in Patients Irradiated for Nasopharyngeal Carcinoma: A Twelve-Year Experience. Cancer Manag Res 2020; 12:11945-11952. [PMID: 33262648 PMCID: PMC7689356 DOI: 10.2147/cmar.s283968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the efficacy of endovascular treatment of intractable nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and report the relevant endovascular therapeutic experience. Patients and Methods Records of patients who underwent endovascular treatment for intractable nasopharyngeal hemorrhage after irradiation for NPC from January 2007 to December 2019 were reviewed. The demographics, endovascular therapeutic details, and clinical outcomes were analyzed. Results Twenty-four consecutive patients were included in this study. Nineteen patients underwent embolization of the bilateral internal maxillary arteries; one patient underwent embolization of the right internal maxillary artery and the left external carotid artery; one patient underwent embolization of the left internal maxillary artery and the right internal carotid artery, and the other three patients underwent embolization of the unilateral internal carotid artery. During a mean follow-up of 600.9 days (range, 2–1658 days), twenty patients showed no recurrence of bleeding; one patient died of hemorrhagic shock; one patient had recurrent bleeding, and angiography revealed a pseudoaneurysm in the right internal carotid artery, which was then embolized with spring coil after a 30-min occlusion test. Two patients had recurrent bleeding on 2.5 months and 29.9 months respectively after the endovascular treatment, and angiography showed hypervascularity supplied by the bilateral internal maxillary arteries and then was embolized with polyvinyl alcohol particles. The three patients who received re-interventions showed no re-bleeding until the last follow-up. Conclusion Pseudoaneurysm and hypervascularity are the main angiographic characteristics of patients with intractable nasopharyngeal hemorrhage after radiotherapy for NPC, and endovascular treatment provides a safe and effective management approach.
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Affiliation(s)
- Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Xiangjun Dong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
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16
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London NR, Chan JYW, Carrau RL. Transpalatal Approaches to the Skull Base and Reconstruction: Indications, Technique, and Associated Morbidity. Semin Plast Surg 2020; 34:99-105. [PMID: 32390777 DOI: 10.1055/s-0040-1709432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Multiple anterior surgical approaches are available to obtain access to the nasopharynx, clivus, and craniocervical junction. These include the direct and transoral robotic surgery transpalatal, maxillary swing, and endoscopic endonasal approaches. In this article, we describe the indications for these techniques, surgical steps, and associated morbidities. This article is a PubMed literature review. A review of the literature was conducted to assess the techniques, surgical steps, and associated morbidities with transpalatal approaches to the skull base and nasopharynx. The transpalatal approach has been traditionally utilized to obtain surgical access to the nasopharynx, clivus, and craniocervical junction. Morbidity includes velopalatine insufficiency due to shortening of the soft palate from scar contraction or neuromuscular damage, thus leading to hypernasal speech and dysphagia. Middle ear effusion and oronasal or oronasopharyngeal palatal fistula are additional potential morbidities. The choice of surgical approach depends on a variety of factors including the disease location and extent, surgeon experience, and available resources.
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Affiliation(s)
- Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, Maryland
| | - Jimmy Y W Chan
- Division of Head and Neck Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, People's Republic of China
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio.,Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
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17
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Li XY, Sun XS, Liu SL, Chen QY, Guo SS, Liu LT, Yan JJ, Xie HJ, Tang QN, Liang YJ, Guo L, Tang LQ, Mai HQ. The development of a nomogram to predict post-radiation necrosis in nasopharyngeal carcinoma patients: a large-scale cohort study. Cancer Manag Res 2019; 11:6253-6263. [PMID: 31372033 PMCID: PMC6626898 DOI: 10.2147/cmar.s197841] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/30/2019] [Indexed: 12/20/2022] Open
Abstract
Objective: This study aimed to establish a nomogram to predict the risk of post-radiation necrosis in nasopharyngeal carcinoma (NPC) patients. Background: This study was performed to identify influencing factors for developing post-radiation necrosis, and to establish an effective nomogram model to predict individual risks in NPC patients. Methods: 7144 NPC patients receiving radical radiotherapy from 2007 to 2012 were involved in the study, and 207 of them developed nasopharyngeal necrosis (NPN). The clinical characteristics and baseline laboratory results were collected and analyzed. Independent predictive factors were selected using the Cox proportional model and incorporated into the nomogram. The receiver operating characteristic curve and the calibration curve were used to verify discrimination and calibration. Results: The experience of re-irradiation contributed most to the occurrence of NPN (HR, 15.56, 95% CI 10.84–22.35, p<0.001). Clinical factors including age, pathology type, history of diabetes, and original T stage were independent predictors of NPN. Factors reflecting patients’ baseline nutritional and inflammatory status such as hemoglobin, albumin, and C-reactive protein were also significantly associated with the development of NPN. With all independent predictive factors incorporated, a nomogram was generated, and it showed excellent discrimination and calibration. Conclusion: This study was the first large-scale cohort study focusing on the development of NPN and established a nomogram to predict its occurrence based on the clinical and laboratory indicators. The nomogram demonstrated good discriminative capacity and satisfactory agreement, which would offer valuable clues for clinicians to distinguish the high-risk NPN population and maintain close surveillance.
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Affiliation(s)
- Xiao-Yun Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Xue-Song Sun
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Sai-Lan Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Qiu-Yan Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Shan-Shan Guo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Li-Ting Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Jin-Jie Yan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Hao-Jun Xie
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Qing-Nan Tang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Yu-Jing Liang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Ling Guo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Lin-Quan Tang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
| | - Hai-Qiang Mai
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China
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18
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Coburn JA, Golden E, Brucker J, Kennedy TA. Nontraumatic Vascular Emergencies of the Neck. Semin Ultrasound CT MR 2019; 40:157-171. [PMID: 31030739 DOI: 10.1053/j.sult.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Nontraumatic vascular emergencies of the head and neck are uncommon, but can occur in patients with central venous catheters, head and neck infections, and in patients with head and neck cancer. Recognizing the imaging findings of vascular complications in these patient populations is critically important to ensure expeditious treatment to avoid significant morbidity and mortality.
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Affiliation(s)
- John A Coburn
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Edwarda Golden
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin Brucker
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Tabassum A Kennedy
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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19
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Novel intraoperative radiotherapy utilizing prefabricated custom three-dimensionally printed high-dose-rate applicators. Brachytherapy 2019; 18:277-284. [PMID: 30803923 DOI: 10.1016/j.brachy.2019.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) is an effective strategy for the delivery of high doses of radiotherapy to a residual tumor or resection cavity with relative sparing of nearby healthy tissues. This strategy is an important component of the multimodality management of pediatric soft tissue sarcomas, particularly in cases where patients have received prior courses of external beam radiotherapy. PURPOSE Tumor beds with significant topographic irregularity remain a therapeutic challenge because existing IORT technologies are typically most reliable with flat surfaces. To address this limitation, we have developed a novel strategy to create custom, prefabricated high-dose-rate (HDR)-IORT applicators designed to match the shape of an anticipated surgical cavity. METHODS AND MATERIALS Silastic applicators are constructed using three-dimensional (3D) printing and are derived from volumetric segmentation of preoperative imaging. RESULTS HDR preplanning with the applicators improves dosimetric accuracy and minimizes incremental operative time. In this report, we describe the fabrication process for the 3D-printed applicators and detail our experience utilizing this strategy in two pediatric patients who underwent HDR-IORT as part of complex base of skull sarcoma resections. CONCLUSIONS Early experience suggests that usage of the custom applicators is feasible, versatile for a variety of clinical situations, and enables the uniform delivery of high superficial doses of radiotherapy to irregularly shaped surgical cavities.
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20
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Emergency high-flow bypass for the management of ruptured postirradiated internal carotid artery pseudoaneurysms in nasopharyngeal carcinoma patients. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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21
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Anastasiadou C, Maltezos C, Galyfos G, Giannakakis S, Zannes N, Makris N, Sachsamanis G, Papacharalambous G. A carotid bifurcation pseudoaneurysm treated endovascularly in a patient with irradiated neck. VASA 2018; 48:193-195. [PMID: 30265204 DOI: 10.1024/0301-1526/a000748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A carotid artery pseudoaneurysm in an irradiated neck is a rare entity with possible devastating results and management should be multidisciplinary. We present a successful endovascular treatment of a late carotid artery pseudoaneurysm following patch endarterectomy and cervical radiotherapy.
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Affiliation(s)
| | | | - George Galyfos
- 1 Department of Vascular Surgery, General Hospital KAT, Athens, Greece
| | | | - Nikos Zannes
- 2 Department of Interventional Radiology, General Hospital KAT, Athens, Greece
| | - Nikos Makris
- 2 Department of Interventional Radiology, General Hospital KAT, Athens, Greece
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22
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Shimizu Y, Okazaki T, Hamana T, Irifune M. Management of an Internal Carotid Artery Injury Caused by a Displaced Titanium Plate With a Combination of Interventional Vascular Radiology and Surgery. J Oral Maxillofac Surg 2018; 76:1377.e1-1377.e4. [PMID: 29544752 DOI: 10.1016/j.joms.2018.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/12/2018] [Accepted: 02/12/2018] [Indexed: 11/16/2022]
Abstract
Treatment of pseudoaneurysms in the internal carotid artery (ICA) is associated with a high risk of cerebral infarction; therefore, vessel ligation for hemostasis must be avoided. A 66-year-old man had intraoral hemorrhaging. At the time of the initial examination, computed tomography angiography showed jaw plate displacement near the ICA. A more detailed image was obtained using digital-subtraction angiography. After evaluation of the image, a pseudoaneurysm was diagnosed. Six days later, there were concerns about aspiration and airway obstruction; therefore, tracheostomy was performed. Interventional vascular radiology (IVR) and surgery were planned to facilitate complete recovery, removal of the jaw plate, and repair of the pseudoaneurysm. Before surgery, it was confirmed that it would be possible to block blood flow for approximately 20 minutes. Surgery was performed with the patient under general anesthesia. Before plate removal, cardiovascular surgeons exposed the left large saphenous vein and prepared it so that it could be used to patch the vascular wall defect. A balloon type of embolic protection device was placed so that it could be inflated at any time after plate removal via oral surgery. The pseudoaneurysm was found directly under the plate; however, it had adhered to the scar tissue. As removal progressed, hemorrhaging occurred. To achieve hemostasis, the balloon embolic protection device was inflated. The pseudoaneurysm was removed, and a red thrombus was aspirated. On postoperative day 41, bleeding reoccurred. Two days later, embolization using a platinum coil and stent placement were performed through IVR monotherapy. Postoperative progress was favorable, and the patient was discharged 83 days after treatment without neurologic sequelae. ICA pseudoaneurysms located near the skull base are risky and challenging to repair. However, for traumatic aneurysms such as the one in this case, a combination of IVR therapy and surgery is useful for controlling intraoperative hemorrhage.
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Affiliation(s)
- Yoshitaka Shimizu
- Assistant Professor, Department of Dental Anesthesiology, Program of Dental Sciences, Integrated Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Takahito Okazaki
- Assistant Professor, Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoaki Hamana
- Assistant Professor, Department of Oral Maxillofacial Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Masahiro Irifune
- Professor, Department of Dental Anesthesiology, Program of Dental Sciences, Integrated Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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23
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Vastus Lateralis Muscle Free Flap for Skull Base Osteoradionecrosis in Nasopharyngeal Carcinoma. J Neurol Surg B Skull Base 2017; 79:349-352. [PMID: 30009115 DOI: 10.1055/s-0037-1608714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/30/2017] [Indexed: 10/18/2022] Open
Abstract
Objectives To describe the first experience with a free vastus lateralis muscle-only flap to be used to cover and protect the exposed skull base and carotid artery from radiotherapy-induced skull base osteoradionecrosis (ORN). Design Retrospective review of a case series. Setting Tertiary academic medical center. Participants Post treatment nasopharyngeal carcinoma patients with skull base ORN. Main Outcome Measures Coverage of the internal carotid artery (ICA). Results Four patients underwent the procedure. Following the procedure, all patients were documented to have adequate viable soft tissue covering their ICA. Topical nasal steroids were prescribed to all patients as florid granulation tissue was noted to occur overlying the muscle flap in the early postoperative period. There were no flap failures. All patients noted an improvement in speech, cacosmia, and nasal crusting. No significant epistaxis occurred following surgery. Choanal stenosis was noted in three patients. Conclusion For skull base ORN resulting from the treatment of nasopharyngeal carcinoma (NPC) with radiotherapy that fails conservative management, an open approach to the nasopharynx, that allows debridement then placement of a vastus lateralis muscle-only free flap for coverage, offers a unique and viable approach to the management of this challenging condition.
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24
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Anil G, Zhang J, Ong YK, Hui F. Flow-diverter in radiation-induced skull base carotid blowout syndrome: do not write it off! Neurosurg Rev 2017; 40:685-688. [DOI: 10.1007/s10143-017-0875-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/07/2017] [Accepted: 06/26/2017] [Indexed: 11/24/2022]
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Traumatic Anterior Cerebral Artery Pseudoaneurysmal Epistaxis. World Neurosurg 2016; 100:713.e9-713.e16. [PMID: 27939795 DOI: 10.1016/j.wneu.2016.11.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/27/2016] [Accepted: 11/28/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pseudoaneurysmal epistaxis is a rare but emergent condition. We report a case of traumatic anterior cerebral artery pseudoaneurysmal epistaxis and review the published literature. CASE DESCRIPTION A 49-year-old man sustained severe head trauma. He was diagnosed with multiple skull bone fractures, left subdural hematoma, subarachnoid hemorrhage, pneumocephalus, and right frontal hematoma. Subdural hematoma evacuation was done at a local hospital. In the following months, he experienced repeated epistaxis that required nasal packing to stop the bleeding. Digital subtraction angiography showed an anterior cerebral artery pseudoaneurysm protruding into the posterior ethmoid sinus. Embolization of the aneurysm was performed with microcoils, and the parent artery was occluded by thrombosis. The patient presented 1 month later with another epistaxis episode. Digital subtraction angiography showed recanalization of the parent artery and recurrence of the aneurysm. The parent artery was occluded for the second time with coils and Onyx embolic agent. CONCLUSIONS Pseudoaneurysmal epistaxis is rare, and this is the first report of an anterior cerebral artery pseudoaneurysm that manifested with epistaxis. Endovascular intervention has become the first choice of treatment for this disease. The high recurrence rate is the main disadvantage of endovascular intervention. Aneurysm trapping with bypass surgery is another treatment option.
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26
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Wang B, Zu QQ, Liu XL, Zhou CG, Xia JG, Zhao LB, Shi HB, Liu S. Transarterial embolization in the management of intractable epistaxis: the angiographic findings and results based on etiologies. Acta Otolaryngol 2016; 136:864-8. [PMID: 27055585 DOI: 10.3109/00016489.2016.1164896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS Transarterial embolization (TAE) appears to be a safe and effective treatment for patients with intractable epistaxis, despite different etiologies or angiography findings. Idiopathic epistaxis is prone to present with negative angiographic findings. OBJECTIVE To retrospectively evaluate the safety and effectiveness of TAE for intractable epistaxis, and focus on the factors of etiology and angiographic findings. MATERIALS AND METHODS From March 2008 to December 2014, the data of 43 patients with intractable bleeding undergoing TAE were reviewed. The outcomes of interventional therapy were assessed according to different etiology (malignant or benign disease) and angiographic finding (positive or negative angiogram). RESULTS Positive angiographic findings were found in 11 of 12 cases with malignant diseases and 22 of 31 cases with benign diseases, respectively (p = 0.237). Among the 10 cases with negative angiographic findings, the negative angiography rate of idiopathic epistaxis was higher than that of epistaxis with definite etiology (p = 0.003). Bleeding was controlled successfully in all of the 43 patients after embolization. During the mean follow-up period of 24.0 ± 16.7 months, five patients relapsed. No significant difference was found in recurrence rates between malignant and benign diseases or between positive and negative angiography (p = 0.241, p = 0.704, respectively).
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Affiliation(s)
- Bin Wang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Qing-Quan Zu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Xing-Long Liu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Chun-Gao Zhou
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Jin-Guo Xia
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Lin-Bo Zhao
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Hai-Bin Shi
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Sheng Liu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
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27
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Yu YH, Xia WX, Shi JL, Ma WJ, Li Y, Ye YF, Liang H, Ke LR, Lv X, Yang J, Xiang YQ, Guo X. A model to predict the risk of lethal nasopharyngeal necrosis after re-irradiation with intensity-modulated radiotherapy in nasopharyngeal carcinoma patients. CHINESE JOURNAL OF CANCER 2016; 35:59. [PMID: 27357728 PMCID: PMC4928250 DOI: 10.1186/s40880-016-0124-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/14/2016] [Indexed: 11/25/2022]
Abstract
Background For patients with nasopharyngeal carcinoma (NPC) who undergo re-irradiation with intensity-modulated radiotherapy (IMRT), lethal nasopharyngeal necrosis (LNN) is a severe late adverse event. The purpose of this study was to identify risk factors for LNN and develop a model to predict LNN after radical re-irradiation with IMRT in patients with recurrent NPC. Methods Patients who underwent radical re-irradiation with IMRT for locally recurrent NPC between March 2001 and December 2011 and who had no evidence of distant metastasis were included in this study. Clinical characteristics, including recurrent carcinoma conditions and dosimetric features, were evaluated as candidate risk factors for LNN. Logistic regression analysis was used to identify independent risk factors and construct the predictive scoring model. Results Among 228 patients enrolled in this study, 204 were at risk of developing LNN based on risk analysis. Of the 204 patients treated, 31 (15.2%) developed LNN. Logistic regression analysis showed that female sex (P = 0.008), necrosis before re-irradiation (P = 0.008), accumulated total prescription dose to the gross tumor volume (GTV) ≥145.5 Gy (P = 0.043), and recurrent tumor volume ≥25.38 cm3 (P = 0.009) were independent risk factors for LNN. A model to predict LNN was then constructed that included these four independent risk factors. Conclusions A model that includes sex, necrosis before re-irradiation, accumulated total prescription dose to GTV, and recurrent tumor volume can effectively predict the risk of developing LNN in NPC patients who undergo radical re-irradiation with IMRT.
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Affiliation(s)
- Ya-Hui Yu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Wei-Xiong Xia
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Jun-Li Shi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Biodevices and Diagnostics, Institute of Bioengineering and Nanotechnology, Singapore, 138669, Singapore
| | - Wen-Juan Ma
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Radiation Therapy, 3rd Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, P. R. China
| | - Yong Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Yan-Fang Ye
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, P. R. China
| | - Hu Liang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Liang-Ru Ke
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Xing Lv
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Jing Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Yan-Qun Xiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Xiang Guo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
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Liang NL, Guedes BD, Duvvuri U, Singh MJ, Chaer RA, Makaroun MS, Sachdev U. Outcomes of interventions for carotid blowout syndrome in patients with head and neck cancer. J Vasc Surg 2016; 63:1525-30. [PMID: 26926937 PMCID: PMC4884149 DOI: 10.1016/j.jvs.2015.12.047] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/21/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND The purpose of this study was to examine outcomes of a patient cohort undergoing intervention for carotid blowout syndrome associated with head and neck cancer. METHODS Patients with head and neck cancer who presented with carotid distribution bleeding from 2000 to 2014 were identified in the medical record. Primary outcomes were short- and midterm mortality and recurrent bleeding. Standard statistical methods and survival analysis were used to analyze study population characteristics and outcomes. RESULTS Thirty-seven patients were included in the study. The mean age was 60.1 ± 11.4 years (74% male). All malignancies were squamous cell type, stage IV, in a variety of primary locations: 32% oral cavity, 24% larynx, 16% superficial neck, with the remainder in the oropharynx, nasopharynx, and hypopharynx. Fifty-one percent of bleeds were of common carotid, 29% external carotid, and 19% internal carotid origin. Among the patients, 68% presented with acute hemorrhage, 24% with impending bleed, and 8% with threatened bleed. All patients underwent intervention: 38% received endovascular coil embolization, 30% stent grafts, 22% surgical ligation, and 10% primary vessel repair or bypass grafting. Although major complications were rare, 10.8% of patients had perioperative stroke. Sixteen recurrent bleeding episodes involving 12 arteries occurred in 11 patients (29.73%). Median rebleeding time was 7 days (interquartile range, 6-49). Estimated recurrent bleeding risk at 30 days and 6 months was 24% and 34%, respectively. Of the patients, 91.9% survived to hospital discharge. The 90-day and 1-year estimated survivals were 60.9% and 36.6%, respectively. CONCLUSIONS Carotid blowout syndrome associated with head and neck cancer carries poor mid- and long-term prognoses; however, mortality may be related more to the advanced stage of disease rather than carotid involvement or associated intervention. Both surgical and endovascular approaches may be efficacious in cases of acute hemorrhage but carry a significant risk of periprocedural stroke and recurrent bleeding.
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Affiliation(s)
- Nathan L Liang
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa.
| | - Brian D Guedes
- University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, and the VA Pittsburgh Health System, Pittsburgh, Pa
| | - Michael J Singh
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Rabih A Chaer
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Michel S Makaroun
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Ulka Sachdev
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
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Meningitis and brain abscess presenting with epistaxis in a woman with prior head and neck cancer. Case Rep Otolaryngol 2015; 2015:460208. [PMID: 25883822 PMCID: PMC4391153 DOI: 10.1155/2015/460208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/05/2015] [Indexed: 12/01/2022] Open
Abstract
It is estimated that more than 60% of people have epistaxis in their lifetimes, and as such it is a common complaint encountered in emergency medicine. Although epistaxis is usually self-limited and benign, it can occasionally be a sign of serious underlying pathology. We report a case of epistaxis secondary to invasive squamous cell cancer, ultimately leading to pneumocephalus and brain abscess. We recommend a low threshold for neuroimaging in patients with known prior head and neck cancers presenting with epistaxis, as even resolved epistaxis may be related to serious pathology.
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