Case of three delayed complications of radiotherapy: Bilateral vocal cord immobility, esophageal obstruction and ruptured pseudoaneurysm of carotid artery

A Case of Refractory Esophageal Ulcer Caused by Radiotherapy for Hepatocellular Carcinoma

A 77-year-old man who underwent radiotherapy for hepatocellular carcinoma 6 months prior consulted for esophageal obstruction. Esophagogastroduodenoscopy revealed an esophageal ulcer caused by radiotherapy for hepatocellular carcinoma. He was treated with dietary counseling and vonoprazan. After 9 months, the ulcer improved but a moderate stenosis remained. Several factors such as high fraction size, history of chemotherapy, and stress associated with food intake might involve in the development of a radiation-associated ulcer. Opportunities to choose radiotherapy for hepatocellular carcinoma may increase, so we hypothesize that esophageal ulcers might be a complication that should be noted associated with this therapy.

Rupture of Hepatic Pseudoaneurysm Formed Nine Years after Carbon Ion Radiotherapy for Hepatocellular Carcinoma

An 83-year-old man with a history of carbon ion radiotherapy for hepatocellular carcinoma nine years ago presented to a primary care hospital with a fever and abdominal pain. He underwent computed tomography, which revealed the rupture of a hepatic pseudoaneurysm close to the fiducial marker for carbon ion radiotherapy and bleeding into the bile duct. He was successfully treated with transcatheter arterial embolization. Thereafter, re-rupture occurred from a site proximal to the first rupture, and this was treated similarly. It is necessary to be alert for not only tumor recurrence but also pseudoaneurysm occurrence after carbon ion radiotherapy.

Hemodynamic analysis of radiation-induced damage in common carotid arteries by using color Doppler ultrasonography

Purpose

The aim of this study was to assess vascular changes and blood flow abnormalities in the common carotid arteries of patients with head and neck cancers after external radiotherapy, using color Doppler ultrasonography.

Methods

We studied 24 patients treated with external radiotherapy for various head and neck cancers. In order to study the acute effects of irradiation on common carotid blood flow and arterial diameter changes, color Doppler ultrasonography parameters such as peak systolic velocity, end diastolic velocity, mean velocity, systolic-to-diastolic velocity (S/D) ratio, pulsatility index (PI), resistive index (RI), and instantaneous diameter changes were evaluated before and after external radiotherapy. Additionally, the blood volume flow (VF) values in the peak systolic and end diastolic phases, as well as mean velocity, were evaluated throughout three cardiac cycles using B-mode ultrasonic image processing.

Results

The findings showed significant changes in the S/D ratio, PI, and RI of the common carotid arteries before and after external radiotherapy (P<0.05). Moreover, a significant decrease in artery diameter and blood VF was observed after radiotherapy relative to the pretreatment values. A significant correlation was found between the blood VF values estimated using ultrasonic measurements and mathematical methods throughout three cardiac cycles.

Conclusion

The hemodynamic parameters of the common carotid arteries changed during radiotherapy. These arterial changes may lead to late adverse effects of radiotherapy, such as ischemic strokes and ischemic attacks.

Irradiated superficial femoral artery rupture after free flap: a case report and review of the literature

Radical oncologic resection can result in large soft tissue defects with exposure of underlying vessels. Unless immediately covered with viable soft tissue, these vessels are vulnerable to desiccation from air exposure and mechanical trauma. Local radiation treatment also contributes to a decline in vessel wall strength. We present an index case of a patient with prolonged exposure of her femoral bone and superficial femoral artery after an initial failed reconstruction of a soft tissue sarcoma resection defect. We provided coverage using a free latissimus dorsi muscle flap. Two weeks after the initial free flap operation, the patient was readmitted to emergency service with profuse bleeding from beneath the free flap. Intraoperative inspection revealed a 2-cm defect of the irradiated superficial femoral artery. The defect was repaired with cryopreserved human arterial graft, and the flap was reset. This case highlights the importance of immediate coverage of soft tissue defects after oncologic resection. If any vessels are left exposed, they should be closely inspected before a delayed flap coverage to rule out future sources of bleeding that may jeopardize the outcomes of an otherwise successful free flap operation.

Endovascular management of radiotherapy-induced injury to brachiocephalic artery using covered stents

Actinic vascular lesions tend to be stenotic-occlusive lesions. In this article, we present 2 exceptional cases of pseudoaneurysms caused by radionecrosis of the supra-aortic trunks. Both patients were treated by a retrograde carotid approach and deployment of a self-expanding covered stent. Proper exclusion of the pseudoaneurysm was attained in both cases; the first patient remained asymptomatic 12 months later; the second patient died of mediastinitis. Compared with conventional surgery, endovascular management is a viable, less invasive alternative in select patients, especially in life-threatening cases.

Delayed carotid blow-out syndrome: a new complication of chemoradiotherapy treatment in pharyngolaryngeal carcinoma

BACKGROUND

Carotid blow-out syndrome is one of the most devastating complications of head and neck carcinoma. It usually occurs as a post-operative complication or when the tumour compromises the vascular axis.

METHODS AND RESULTS

We report two patients who suffered carotid blow-out syndrome but who did not have the usual predisposing factors. Both patients had a pharyngolaryngeal carcinoma that was treated with chemoradiotherapy. Residual non-tumoural ulceration was seen along the lateral wall of the hypopharynx in both cases. This ulceration eventually reached the vascular axis, precipitating carotid rupture and death.

CONCLUSION

Residual non-tumoural ulceration of the lateral wall of the hypopharynx after chemoradiotherapy should be considered with the utmost caution. Once persistence of the tumour is excluded, surgery is indicated to protect the vascular axis, in order to prevent carotid blow-out syndrome.

A false aneurysm

OBJECTIVE

We report a case of a remaining hemi-thyroid following laryngectomy, which was misinterpreted as a pseudoaneurysm.

METHODS

Case report and comment on this understandable error which is easily avoidable.

RESULTS

A 59-year-old man had undergone salvage laryngectomy for recurrent squamous cell carcinoma of the larynx, which had previously been treated with radiotherapy. Three months after his laryngectomy, he presented with a sore neck and subcutaneous collections. Computed tomography revealed a unilateral mass with high signal contrast uptake anterior to the left common carotid artery, which was thought initially to be a carotid pseudoaneurysm. Further investigation, including ultrasonography and a review by the senior head and neck radiologist, demonstrated that this mass was actually the remnant hemi-thyroid preserved at laryngectomy (which is often misshapen compared with a normal hemi-thyroid). The collections were found to be recurrent tumour, and unnecessary further interventions were avoided.

CONCLUSION

Ultrasonography easily distinguishes between a thyroid remnant and a pseudoaneurysm. Furthermore, the opinion of an experienced head and neck radiologist may be vital when interpreting complex post-surgical head and neck radiology.

Treatment of a cervical carotid pseudoaneurysm that occurred years after laryngectomy and irradiation of a neck tumor

A 62-year-old man presented with rupture of a pseudoaneurysm of the left common carotid artery (CCA) that was induced after radiation therapy and neck surgery. The initial treatment was an endovascular procedure to obliterate the aneurysm with coils, and a covered stent was placed in the parent artery. However, the patient presented with subsequent coil migration, wound infection, and left CCA stenosis. Direct surgical procedures were then performed, including resection of the pseudoaneurysm with coils and stent; replacement of the carotid artery with a saphenous vein graft; and operative wound reinforcement with a pedicle flap. Endovascular treatments may be chosen for vascular diseases after irradiation, because of the low risk of wound infection and fragility of the vessels, but the long-term outcomes of intravascular treatments are still unclear. In direct surgery, dissection of the adhesive tissue and adequate wound healing are difficult. Musculocutaneous flaps with vascular pedicles can achieve good results.