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Chan EL, Rovira A. Head-and-neck Cancer in the Emergency Department: A Contemporary Review of Common Presentations and Management. J Emerg Trauma Shock 2024; 17:33-39. [PMID: 38681881 PMCID: PMC11045002 DOI: 10.4103/jets.jets_40_23] [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: 04/27/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 05/01/2024] Open
Abstract
Head-and-neck cancer (HNC) can present with life.threatening symptoms in the emergency department. Patients can sometimes be misdiagnosed with pulmonary disease due to similar signs and symptoms, ultimately leading to delayed diagnosis and potentially devastating consequences. Reasons for this include lack of awareness of patient risk factors and knowledge of the myriad of presenting complaints in the disease process among physicians working in primary care and in the emergency department. This article explores the contemporary risk factors and common presenting symptoms and discusses initial management for a patient with potential head-and-neck malignancy. Emergency presentations of HNC are wide ranging and can overlap with common respiratory pathologies. Clinician awareness of this can assist the team in deciding what appropriate examination and investigations are required to reduce the risk of delaying diagnosis and further treatment.
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Affiliation(s)
- Ee Lyn Chan
- Department of Anesthesia, Maidstone and Tunbridge Wells Hospital, Royal Tunbridge Wells, Maidstone, UK
| | - Aleix Rovira
- Department of Head and Neck Surgery, Guy's and St. Thomas' Hospital, Great Maze Pond, London, UK
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Lipe DN, Viets-Upchurch J, Hanna EY, Reyes-Gibby C, Chen SR, Elsayem A, Long B. Carotid Blowout Syndrome in the Emergency Department: A Case Report and Review of the Literature. J Emerg Med 2022; 62:e29-e34. [PMID: 35065858 DOI: 10.1016/j.jemermed.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/13/2021] [Accepted: 11/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is an infrequent but dangerous oncologic emergency that must be recognized due to a mortality rate that approaches 40% and neurologic morbidity that approaches 60%. Patients present with a variety of symptoms ranging from asymptomatic to frank hemorrhage, and appropriate recognition and management may improve their outcomes. CASE REPORT A man in his late 60s with squamous cell carcinoma of the oropharynx presented to the emergency department (ED) with hemoptysis and several episodes of post-tussive emesis with large clots. He had been cancer free for multiple years after treatment with chemotherapy and radiation to the neck. Evaluation revealed a necrotic tumor on the posterior pharynx on bedside laryngoscopy and an external carotid pseudoaneurysm that was stented by interventional radiology. The patient experienced recurrent hemorrhage several months later and opted for palliative measures and expired of massive hemorrhage in the ED on a subsequent visit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CBS can be fatal, and early suspicion and recognition are key to ensure that a threatened or impending carotid blowout are appropriately managed. Once carotid blowout is suspected, early resuscitation and consultation with interventional radiology and vascular surgery is warranted.
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Affiliation(s)
- Demis N Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jayne Viets-Upchurch
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cielito Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen R Chen
- Interventional Radiology Department, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahmed Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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Szalkowski G, Karakas Z, Cengiz M, Schreiber E, Das S, Yazici G, Ozyigit G, Mavroidis P. Stereotactic body radiotherapy optimization to reduce the risk of carotid blowout syndrome using normal tissue complication probability objectives. J Appl Clin Med Phys 2022; 23:e13563. [PMID: 35194924 PMCID: PMC9121056 DOI: 10.1002/acm2.13563] [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: 09/15/2021] [Revised: 01/14/2022] [Accepted: 02/02/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To determine the possibility of further improving clinical stereotactic body radiotherapy (SBRT) plans using normal tissue complication probability (NTCP) objectives in order to minimize the risk for carotid blowout syndrome (CBOS). Methods 10 patients with inoperable locally recurrent head and neck cancer, who underwent SBRT using CyberKnife were analyzed. For each patient, three treatment plans were examined: (1) cone‐based without delineation of the ipsilateral internal carotid (clinical plan used to treat the patients); (2) cone‐based with the carotid retrospectively delineated and spared; and (3) Iris‐based with carotid sparing. The dose–volume histograms of the target and primary organs at risk were calculated. The three sets of plans were compared based on dosimetric and TCP/NTCP (tumor control and normal tissue complication probabilities) metrics. For the NTCP values of carotid, the relative seriality model was used with the following parameters: D50 = 40 Gy, γ = 0.75, and s = 1.0. Results Across the 10 patient plans, the average TCP did not significantly change when the plans were re‐optimized to spare the carotid. The estimated risk of CBOS was significantly decreased in the re‐optimized plans, by 14.9% ± 7.4% for the cone‐based plans and 17.7% ± 7.1% for the iris‐based plans (p = 0.002 for both). The iris‐based plans had significant (p = 0.02) reduced CBOS risk and delivery time (20.1% ± 7.4% time reduction, p = 0.002) compared to the cone‐based plans. Conclusion A significant improvement in the quality of the clinical plans could be achieved through the delineation of the internal carotids and the use of more modern treatment delivery modalities. In this way, for the same target coverage, a significant reduction in the risk of CBOS could be achieved. The range of risk reduction varied depending on the proximity of carotid artery to the target.
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Affiliation(s)
- Gregory Szalkowski
- Department of Radiation Oncology, University of North Carolina, North Carolina, Chapel Hill, USA
| | - Zeynep Karakas
- Department of Radiation Oncology, University of North Carolina, North Carolina, Chapel Hill, USA
| | - Mustafa Cengiz
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Sihhiye, Ankara, Turkey
| | - Eric Schreiber
- Department of Radiation Oncology, University of North Carolina, North Carolina, Chapel Hill, USA
| | - Shiva Das
- Department of Radiation Oncology, University of North Carolina, North Carolina, Chapel Hill, USA
| | - Gozde Yazici
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Sihhiye, Ankara, Turkey
| | - Gokhan Ozyigit
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Sihhiye, Ankara, Turkey
| | - Panayiotis Mavroidis
- Department of Radiation Oncology, University of North Carolina, North Carolina, Chapel Hill, USA
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Singh J, Sharma T, Tripathy T. Carotid blowout syndrome: endovascular management of a lesser known oncological emergency: case report. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00587-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Carotid blowout syndrome (CBS) refers to a fatal hemorrhagic complication of cervical carotid arteries that occurs due to rupture of the extracranial carotid artery or one of its major branches in patients treated for head and neck malignancy. In this article, we will discuss two different spectrum of CBS and endovascular approach.
Case presentation
Two cases of per oral bleeding presented in the emergency department. After patients were hemodynamically stabilized, CT angiography was done which showed type II CBS and type III CBS, respectively. This was followed by transfemoral supra-aortic digital subtraction angiogram coil embolization with scaffolding and anchoring technique, respectively, for the patients.
Conclusions
Early recognition of the predictors of CBS by a multidisciplinary team is critical. The endovascular treatment approach is relatively safe and effective with low rates of morbidity and mortality compared to surgical approach in CBS.
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Jacobi C, Gahleitner C, Bier H, Knopf A. Chemoradiation and local recurrence of head and neck squamous cell carcinoma and the risk of carotid artery blowout. Head Neck 2019; 41:3073-3079. [DOI: 10.1002/hed.25796] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
- Christian Jacobi
- Department of Otorhinolaryngology/Head and Neck SurgeryKlinikum rechts der s Isar Technische Universität München München Germany
| | - Constanze Gahleitner
- Department of Otorhinolaryngology/Head and Neck SurgeryKlinikum rechts der s Isar Technische Universität München München Germany
| | - Henning Bier
- Department of Otorhinolaryngology/Head and Neck SurgeryKlinikum rechts der s Isar Technische Universität München München Germany
| | - Andreas Knopf
- Department of Otorhinolaryngology/Head and Neck SurgeryKlinikum rechts der s Isar Technische Universität München München Germany
- Department of Otorhinolaryngology/Head and Neck SurgeryUniversitätsklinikum Freiburg Freiburg Germany
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Carotid Blowout Syndrome. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Fitting NTCP models to SBRT dose and carotid blowout syndrome data. Med Phys 2018; 45:4754-4762. [DOI: 10.1002/mp.13121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 06/01/2018] [Accepted: 07/27/2018] [Indexed: 12/29/2022] Open
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Gahleitner C, Hofauer B, Storck K, Knopf A. Outcome of carotid and subclavian blowout syndrome in patients with pharynx- and larynx carcinoma passing a standardized multidisciplinary treatment. Acta Otolaryngol 2018; 138:507-512. [PMID: 29310495 DOI: 10.1080/00016489.2017.1419575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is one of the most feared emergencies in the head and neck surgery and tends to occur in patients with head and neck cancer, wound complications, pharyngocutaneous fistulas, or after radio(chemo)therapy. CBS is always life threatening and associated with a 50% mortality/morbidity rate. METHODS Between 2007 and 2015, a total of 51 patients who developed CBS caused by the tumour masses or after radio(chemo)therapy were included. All patients underwent a standardised bleeding management. RESULTS In 86% of patients, CBS was associated with manifest carcinoma. Fifty three percent of patients were treated by transcervical surgery, in 36% of these cases surgery was supplemented by endovascular approaches. Severe complications such as re-bleeding or cerebral ischemia occurred infrequently. Seven patients died because of the acute bleeding. CONCLUSION CBS associated with head and neck cancer carries poor mid and long-term prognoses. An interdisciplinary standardised treatment path dramatically reduced overall morbidity and mortality.
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Affiliation(s)
- Constanze Gahleitner
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Benedikt Hofauer
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Katharina Storck
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Andreas Knopf
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Venkatesan R, Hirani N, Willis M, Jana B, Cheema Z. Impending Carotid Blowout From a Large Neck Mass Treated Sequentially With Endovascular Coil Embolization Followed by Induction Chemotherapy. J Oncol Pract 2017; 14:136-138. [PMID: 29016223 DOI: 10.1200/jop.2017.025825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Bagi Jana
- The University of Texas Medical Branch, Galveston, TX
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Prasad KK, Sirsath NT, Naiknaware KV, Rani KS, Bhatia MS. Carotid blowout syndrome: An oncological emergency less discussed. South Asian J Cancer 2017; 6:85-86. [PMID: 28702416 PMCID: PMC5506819 DOI: 10.4103/sajc.sajc_211_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Karthik K Prasad
- Department of Surgical Oncology, M N Budhrani Cancer Institute, Pune, Maharashtra, India
| | - Nagesh T Sirsath
- Department of Medical Oncology, M N Budhrani Cancer Institute, Pune, Maharashtra, India
| | - Kiran V Naiknaware
- Department of Interventional Radiology, M N Budhrani Cancer Institute, Pune, Maharashtra, India
| | - K Sandhya Rani
- Department of Radiation Oncology, M N Budhrani Cancer Institute, Pune, Maharashtra, India
| | - Manish S Bhatia
- Department of Surgical Oncology, M N Budhrani Cancer Institute, Pune, Maharashtra, India
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Abstract
Recent advances in genomic sequencing and omics-based capabilities are uncovering tremendous therapeutic opportunities and rapidly transforming the field of cancer medicine. Molecularly targeted agents aim to exploit key tumor-specific vulnerabilities such as oncogenic or non-oncogenic addiction and synthetic lethality. Additionally, immunotherapies targeting the host immune system are proving to be another promising and complementary approach. Owing to substantial tumor genomic and immunologic complexities, combination strategies are likely to be required to adequately disrupt intricate molecular interactions and provide meaningful long-term benefit to patients. To optimize the therapeutic success and application of combination therapies, systematic scientific discovery will need to be coupled with novel and efficient clinical trial approaches. Indeed, a paradigm shift is required to drive precision medicine forward, from the traditional "drug-centric" model of clinical development in pursuit of small incremental benefits in large heterogeneous groups of patients, to a "strategy-centric" model to provide customized transformative treatments in molecularly stratified subsets of patients or even in individual patients. Crucially, to combat the numerous challenges facing combination drug development-including our growing but incomplete understanding of tumor biology, technical and informatics limitations, and escalating financial costs-aligned goals and multidisciplinary collaboration are imperative to collectively harness knowledge and fuel continual innovation.
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Affiliation(s)
- Daphne Day
- Drug Development Program, Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, M5G 2M9, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,OICR Research Fellow, Ontario Institute for Cancer Research, Toronto, Ontario, M5G 0A3, Canada
| | - Lillian L Siu
- Drug Development Program, Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, M5G 2M9, Canada. .,Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.
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