Carotid blowout syndrome: modern trends in management

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Why do patients with cancer die?

Cancer is a major cause of global mortality, both in affluent countries and increasingly in developing nations. Many patients with cancer experience reduced life expectancy and have metastatic disease at the time of death. However, the more precise causes of mortality and patient deterioration before death remain poorly understood. This scarcity of information, particularly the lack of mechanistic insights, presents a challenge for the development of novel treatment strategies to improve the quality of, and potentially extend, life for patients with late-stage cancer. In addition, earlier deployment of existing strategies to prolong quality of life is highly desirable. In this Roadmap, we review the proximal causes of mortality in patients with cancer and discuss current knowledge about the interconnections between mechanisms that contribute to mortality, before finally proposing new and improved avenues for data collection, research and the development of treatment strategies that may improve quality of life for patients.

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

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

Emergency Management and Nursing Considerations of Carotid Blowout Syndrome

INTRODUCTION

Carotid blowout syndrome is a rare but fatal complication often witnessed secondary to treating patients with head and neck cancer. It occurs when damage and necrosis lead to the carotid artery wall rupture. The symptoms encountered in these patients range from asymptomatic to cardiac arrest. Here, we present 5 cases of carotid blowout syndrome in the emergency department.

CASE PRESENTATIONS

Patients demonstrated symptoms ranging from subtle bleeding to hemodynamic instability, highlighting the diverse nature of carotid blowout syndrome in this population. Notably, while all patients had a history of radiotherapy, some had additional risk factors for carotid blowout syndrome, including prior surgery (n = 2), malnutrition (n = 3), and tracheostomies (n = 2). Definitive diagnoses were established through clinical evaluation and computed tomography angiography. Immediate interventions included bleeding control, resuscitation, and consultations with relevant specialties. Four patients underwent interventional radiology procedures, and 1 patient received otolaryngology care. While 2 patients recovered completely, 1 died in the emergency department, and 1 in the intensive care unit. One patient's clinical course was complicated by a stroke.

CONCLUSION

The approach to the carotid blowout syndrome patient includes complex steps that proceed in a multidisciplinary manner, starting from triage until discharge. Emergency nurses play crucial roles at every stage. They should be aware of carotid blowout syndrome when evaluating patients with head and neck cancer presenting with bleeding. When treating these patients, emergency nurses should be ready for airway interventions, bleeding control, and massive transfusion protocol. In this context, the multifaceted approaches made by nurses contribute significantly to carotid blowout syndrome management in the emergency department.

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

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

Endovascular Management of Post-Irradiated Carotid Blowout Syndrome in Patients with Lower Neck Cancers

OBJECTIVE

Lower neck cancers (LNCs) include specific tumour types and have some different vascular supply or collaterals from other head and neck cancers. This prospective study evaluated the outcome of endovascular management of post-irradiated carotid blowout syndrome (PCBS) in patients with LNC by comparing reconstructive management (RE) and deconstructive management (DE).

METHODS

This was a single centre, prospective cohort study. Patients with LNC complicated by PCBS between 2015 and 2021 were enrolled for RE or DE. RE was performed by stent graft placement covering the pathological lesion and preventive external carotid artery (ECA) embolisation without balloon test occlusion (BTO). DE was performed after successful BTO by permanent coil or adhesive agent embolisation of the internal carotid artery (ICA) and ECA to common carotid artery, or ICA occlusion alone if the pathological lesion was ICA only. Cross occlusion included the proximal and distal ends of the pathological lesion in all patients. Re-bleeding events, haemostatic period, and neurological complications were evaluated.

RESULTS

Fifty-nine patients (mean age 58.5 years; 56 male) were enrolled, including 28 patients undergoing RE and 31 patients undergoing DE. Three patients originally grouped to DE were transferred to RE owing to failed BTO. The results of RE vs. DE were as follows: rebleeding events, 13/28 (46%) vs. 10/31 (32%) (p = .27); haemostatic period, 9.4 ± 14.0 months vs. 14.2 ± 27.8 months (p = .59); neurological complication, 4/28 (14%) vs. 5/31 (16%) (p = .84); and survival time, 11.8 ± 14.6 months vs. 15.1 ± 27.5 months (p = .61).

CONCLUSION

No difference in rebleeding risk or neurological complications was observed between the DE and RE groups. RE could be used as a potential routine treatment for PCBS in patients with LNC.

Brain abscesses following carotid blowout syndrome: a case report

We report a case of intracranial abscesses development in a patient with head and neck cancer after emergent treatment of carotid blowout syndrome with coil embolization. Our patient is a 60-year-old male who presented with hemoptysis and hematemesis, which raised concerns for impending carotid blowout syndrome. Endovascular occlusion was successfully achieved, and the patient was discharged in stable condition. Ten days later, the patient reported headaches and right facial pain, and magnetic resonance imaging revealed multiple intracranial abscesses. Broad-spectrum intravenous antibiotics were administered, leading to a variable response with some abscesses decreasing in size and others increasing. Seven weeks from discharge, the patient had no neurological deficits, and all abscesses had decreased in size.

Complication of head and neck cancer: Carotid blowout syndrome

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

Sentinel ear bleed as a presenting sign for carotid artery blowout due to aspergillus abscess in parapharyngeal space in an immunocompetent infant

Parapharyngeal abscesses leading to complications, although rare after the advent of antibiotics, can lead to serious complications. One such complication is carotid erosion that can lead to a potentially fatal carotid artery blowout. We report a case of a previously healthy infant who presented with fever, ear bleed and progressively increasing swelling in the right side of his neck that led to airway compromise. The child required immediate securing of the airway at presentation. Imaging revealed lobulated abscess with multiple bleeding points eroding the carotid vessels, along with internal jugular venous thrombus. Surgical exploration was done and abscess debulked. Histopathology revealed aspergillus, which was treated with antifungals. He was discharged on oral warfarin after 40 days of hospital stay and remains well on follow-up. Sentinel ear bleed warrants close observation for possibility of carotid artery blowout in children with parapharyngeal abscesses.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 134:695-700, 2024.

Radiomic signatures reveal multiscale intratumor heterogeneity associated with tissue tolerance and survival in re-irradiated nasopharyngeal carcinoma: a multicenter study

BACKGROUND

Post-radiation nasopharyngeal necrosis (PRNN) is a severe adverse event following re-radiotherapy for patients with locally recurrent nasopharyngeal carcinoma (LRNPC) and associated with decreased survival. Biological heterogeneity in recurrent tumors contributes to the different risks of PRNN. Radiomics can be used to mine high-throughput non-invasive image features to predict clinical outcomes and capture underlying biological functions. We aimed to develop a radiogenomic signature for the pre-treatment prediction of PRNN to guide re-radiotherapy in patients with LRNPC.

METHODS

This multicenter study included 761 re-irradiated patients with LRNPC at four centers in NPC endemic area and divided them into training, internal validation, and external validation cohorts. We built a machine learning (random forest) radiomic signature based on the pre-treatment multiparametric magnetic resonance images for predicting PRNN following re-radiotherapy. We comprehensively assessed the performance of the radiomic signature. Transcriptomic sequencing and gene set enrichment analyses were conducted to identify the associated biological processes.

RESULTS

The radiomic signature showed discrimination of 1-year PRNN in the training, internal validation, and external validation cohorts (area under the curve (AUC) 0.713-0.756). Stratified by a cutoff score of 0.735, patients with high-risk signature had higher incidences of PRNN than patients with low-risk signature (1-year PRNN rates 42.2-62.5% vs. 16.3-18.8%, P < 0.001). The signature significantly outperformed the clinical model (P < 0.05) and was generalizable across different centers, imaging parameters, and patient subgroups. The radiomic signature had prognostic value concerning its correlation with PRNN-related deaths (hazard ratio (HR) 3.07-6.75, P < 0.001) and all causes of deaths (HR 1.53-2.30, P < 0.01). Radiogenomics analyses revealed associations between the radiomic signature and signaling pathways involved in tissue fibrosis and vascularity.

CONCLUSIONS

We present a radiomic signature for the individualized risk assessment of PRNN following re-radiotherapy, which may serve as a noninvasive radio-biomarker of radiation injury-associated processes and a useful clinical tool to personalize treatment recommendations for patients with LANPC.

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Delineation of Lingual Artery as an Additional Organ-At-Risk for Stereotactic Body Radiation Therapy of Head and Neck Cancers

Lingual artery (LA) stenosis or bleeding can be a potentially fatal consequence of stereotactic body radiation therapy of recurrent head and neck cancer. We aim to provide delineation guidelines for LA contouring during head and neck radiation. Three experienced radiation oncologists and 1 radiologist studied the course of LA and its anatomic relationships. A step-by-step guideline was formulated for its delineation on contrast-enhanced axial computed tomography scans. We recommend that LA should be considered an important organ at risk for stereotactic body radiation therapy of head and neck cancer. Its delineation and dose constraints should be considered on a case-to-case basis.

Deconstructive vs. reconstructive endovascular treatment paradigms in acute carotid blowout

BACKGROUND

Carotid Blowout (CBO), a neuro-oncological emergency characterized by the rupture of the carotid artery, has been predominantly reported in patients with head and neck cancer who have undergone radiation therapy. In this study, our objective is to share our experience with deconstructive and reconstructive endovascular treatments for CBO.

METHODS

This study includes 17 patients who experienced intractable acute CBO, presenting with ear, oral, or nasal bleeding, between 2003 and 2022. We employed deconstructive embolization using vascular plugs, expanding hydrogel coils, glue, and balloons. If vascular anatomy and pathology permitted, we opted for reconstructive treatment using a covered stent. All patients underwent clini-cal follow-up visits, and we used the modified Rankin Scale to evaluate the clinical success of the procedures. We compared outcomes in terms of complications between the deconstructive and reconstructive treatment methods using the Chi-square test.

RESULTS

The patient cohort had an age range of 20-64 years (mean 50.9), including three females (18%) and 14 males (82%). We conducted 15 endovascular procedures on 14 patients during 19 angiography sessions. All 15 treatments achieved immediate hemo-stasis, resulting in complete technical success (p=1.0). Six patients (35%) underwent reconstructive treatments with covered stents in the internal carotid artery, while nine patients (65%) underwent deconstructive embolization in either the external or internal carotid artery. We found no significant association between the treatment paradigms (deconstructive vs. reconstructive) and the development of complications using a Chi-square test of independence X² (2, n=15)=0.07, p=0.79.

CONCLUSION

Recent advancements in endovascular treatments have shown promising results in managing life-threatening acute CBO cases. Our study found no significant difference in outcomes between deconstructive and reconstructive endovascular paradigms in such patients. However, it is important to note that the available data, including ours, is heterogeneous and scarce, necessitating higher levels of evidence to draw more definitive conclusions.

Review of Cerebral Radiotherapy-Induced Vasculopathy in Pediatric and Adult Patients

Radiation therapy (RT) causes radiation-induced vasculopathy, which requires clinicians to identify and manage this side effect in pediatric and adult patients. This article reviews previous findings about the pathophysiology of RT-induced vascular injury, including endothelial cell injury, oxidative stress, inflammatory cytokines, angiogenic pathways, and remodeling. The vasculopathy is categorized into ischemic vasculopathy, hemorrhagic vasculopathy, carotid artery injury, and other malformations (cavernous malformations and aneurysms) in populations of pediatric and adult patients separately. The prevention and management of this RT-induced side effect are also discussed. The article summarizes the distribution and risk factors of different types of RT-induced vasculopathy. This will help clinicians identify high-risk patients with corresponding vasculopathy subtypes to deduce prevention and treatment strategies accordingly.

Transcatheter Arterial Embolization (TAE) of Cancer-Related Bleeding

Background and Objectives: Roughly 10% of cancer patients experience an episode of bleeding. The bleeding severity can range from occasional trivial bleeds to major bleeding. The treatment for the bleeding may vary, depending on the clinical condition and anatomical site, and may include various strategies, among which TAE is a cornerstone of major bleeding management. However, the existing literature on tumor hemorrhages is inconsistent. The objective of this multicenter retrospective cohort study was to evaluate the effectiveness and safety of arterial embolization in the treatment of tumor hemorrhages in patients with solid cancers. Materials and Methods: The data for patients with solid cancers undergoing TAE for the management of tumor hemorrhages from January 2020 to May 2023 were gathered. Results: A total of 92 patients with cancer-related bleeding were treated between January 2020 and May 2023. No bleeding was detected by X-ray angiography (XA) in 12 (13%) cases; therefore, a blind embolization was performed. The most common bleeding site was the liver (21.7%). A total of 66 tumor hemorrhages were spontaneous. The most commonly used embolic agent was polyvinyl alcohol (PVA) particles (30.4%). Technical success was achieved in 82 (89.1%) cases, with an 84.8% clinical success rate related to 14 cases of rebleeding. Proximal embolization was performed for 19 (20.7%) patients. Complications were recorded for 10 (10.9%) patients. The 30-day bleeding-related mortality was 15.2%. The technical success, clinical success, proximal embolization rate, and 30-day rebleeding were worse in the subset of patients undergoing TAE with coils. Conclusions: Transcatheter arterial embolization (TAE) represents a viable and potentially life-saving therapeutic approach in the management of tumor hemorrhages, demonstrating a notable effectiveness and safety. The TAE of bleeding tumors using coils resulted in a higher rate of non-superselective proximal embolization, with a trend toward lower clinical success rates and higher rebleeding episodes.

[Application of Midline Catheter Placed Under Ultrasound Guidance in Intravenous Therapy for Oral and Maxillofacial Tumor]

Objective

To examine the application effect of ultrasound-guided placement of midline catheter and to select the appropriate placement method of intravenous catheter for patients with oral and maxillofacial tumors.

Methods

We retrospectively analyzed the general data and venous catheter-related information of 143 oral and maxillofacial tumor patients who received treatment between June 2019 and December 2021. There were two patient groups, a control group of patients with inserted peripheral venous catheters (PVC) and an observation group of patients with midline catheters placed under ultrasound guidance. We made a comparative analysis of the incidence of catheter-related complications, including bleeding at the insertion site, phlebitis, catheter blockage, extravasation, etc., in the two groups. When the baseline data from the two groups were not balanced, we used propensity score matching (PSM) to match the general data before comparing the complication incidence between the two groups.

Results

There were 71 patients who underwent 215 times of PVC placement in the control group and 72 patients who underwent 72 times of midline catheter placement in the observation group. There was no significant difference between the patients in the two groups in terms of age, sex, diagnosis, or the use of anticoagulant medication ( P>0.05) . The observation group had longer average length-of-stay than the control group did ( P<0.01). The cost of catheter placement in the observation group was 1080 yuan per set, with the average daily cost being about (56.27±20.23) yuan. Patients in the control group had PVC placement for an average of (3.03±0.93) times. The cost for PVC placement was 96 yuan per time and the average daily cost was about (19.94±7.50) yuan. There was significant difference in the average daily cost between the observation group and the control group ( P<0.01). PSM was performed for the two groups. Before PSM, the incidence of catheter-related complications in the observation group (8.3%, 6/72) was lower than that of the control group (30.2%, 65/215) and the difference was statistically significant ( P<0.01). After PSM, 72 times of catheter placement from each group were included in comparative analysis. The incidence of catheter-related complications in the observation group (8.3%, 6/72) was lower than that of the control group (54.2%, 39/72) and the difference was statistically significant ( P<0.01).

Conclusion

Patients have low incidence of catheter-related complications when they have midline catheter placed under ultrasound guidance, which helps reduce the pain of repeated venous insertion that patients incur and the workload of clinical nurses. The use of midline catheters is appropriate for and should be popularized among patients with oral and maxillofacial malignant tumors, especially patients who have poor peripheral venous conditions and those who are undergoing repair and reconstruction surgeries.

[Treatment experience of neck tumor surgeries involving carotid artery]

Objective:To investigate surgical treatment of carotid artery diseases in neck tumor surgery. Methods:A retrospective analysis of the clinical data on carotid artery treatment was conducted in the five cases of neck tumor surgeries treated at Department of Surgical Oncology, the First Peoples Hospital of Lanzhou from March 2010 to May 2020. Surgical methods, including carotid artery resection and ligation, tumor-involved artery resection and vascular reconstruction, and tumor peeling and carotid rupture repairing were used, respectively. Results:Five cases were successfully operated on. One case of carotid artery ligation was followed by intermittent dizziness and decreased contra-lateral limb strength after the surgery. The remaining patients exhibited no neurological complications. A patient with cervical low-grade myofibroblastoma developed into lung metastases 8 months after the surgery. Another patient with cervical lymph node metastases in papillary thyroid cancer developed into lung metastases 24 months after the surgery. Conclusion:Currently, surgical methods for clinical treatment of diseased carotid arteries include carotid artery resection and ligation, simple tumor peeling, tumor invasion artery resection and vascular reconstruction, and interventional therapy. Each surgical method has its own advantages and disadvantages. Therefore, the choice of treatment depends on the patient's specific conditions, physician's clinical experience, and the equipment available.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Challenges in Managing Intractable Epistaxis in a Post-nasal Surgery and Radiated Cancer Patient: A Case Report and Literature Review

Recurrent epistaxis represents an alarming sign that may suggest a sinister aetiology, especially in patients with previous head and neck malignancy. The recognition of certain potentially life-threatening conditions, namely pseudoaneurysm or tumour recurrence, remains prudence to avoid disastrous repercussion. Nasal endoscopy has become an essential tool in otolaryngology. It can aid identify the underlying cause of epistasis and facilitate therapeutic management. On the other hand, radio imaging is highly sensitive in detecting vascular lesions, besides providing a pre-operative mapping if surgical intervention is planned. This paper reported a patient with sphenoidal sinus squamous cell carcinoma in remission presented with torrential epistaxis not relieved with nasal packing. Despite a repeated angiogram and magnetic resonance image, the identification of the source of bleeding remained futile, culminating in an examination under general anaesthesia. The diagnosis of carotid blowout syndrome was made intraoperatively, and the bleeding was temporarily secured with a muscular patch, preceded by the insertion of a vascular stent. The authors wish to highlight the importance of examination under general anaesthesia if radio imaging does not correlate to the clinical findings. Management options for carotid blowout should be tailored to the patients' medical conditions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03625-4.

Endovascular treatment of femoral artery blow-out caused by skin malignancy

Background

Vascular blow-out syndrome is a life-threatening bleeding condition that usually occurs in the carotid arteries as a result of invasion of head and neck malignant tumors. There are several case reports in the literature on peripheral vascular blow out. To our knowledge, there is no other case report in the literature on blow-out in the femoral artery secondary to skin malignancy.

Case presentation

A 66-year-old male patient, who was diagnosed with skin squamous cell carcinoma (SCC) as a result of tissue sampling due to redness and stiffness in the left inguinal region, underwent emergency surgery with severe bleeding. Since edema and deformations on the skin did not render the operation possible, the patient was taken to the interventional radiology unit by applying pressure compression onto the bleeding area for urgent endovascular treatment. The patient was treated with a stent-graft.

Conclusion

The femoral blow-out is an emergency condition that needs to be managed aggressively, and if left untreated, it can cause serious bleeding, limb ischemia, limb loss, or death. Endovascular stent-graft placement is the first method that should be considered, and this method provides fast and effective treatment.

Idiopathic common carotid artery laceration: A case report

Carotid artery injury is a rare disease often caused by neck trauma or irradiation of head and neck cancer. It is not easy to diagnose quickly without these backgrounds. Herein, we report a case of a 52‐year‐old man with no history of trauma or irradiation whose carotid artery was found to be injured. It was suggested that patients without any other disease but hypertension could have carotid artery injury. Additionally, it was challenging to detect extravasation from the carotid artery by computed tomography scan and ultrasonography in the emergency department. We should consider the possibility of carotid artery injury when examining patients with sudden neck swelling, even without any history of trauma or irradiation.

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

Background

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

Methods

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

Results

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

Conclusions

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

Management of Double Carotid Blow Out with Definitive Repair After Temporizing Stent Graft Placement

Carotid blowout syndrome is a life-threatening complication for patients with head and neck cancer. Temporizing stent graft procedures improve short-term survival and can be the definitive treatment for various reasons, including a poor oncologic prognosis, unsuitability for definitive reconstruction, or a lack of operative options. A second carotid blowout will often be fatal. Preventing such events requires multidisciplinary strategic planning because of a hostile reoperative field. We have described a case of a 44-year-old man with a history of laryngeal cancer who had experienced a carotid blowout. Treated with a stent graft, the patient had experienced a second event 6 weeks later. Treatment involved excision and suture ligation with rotational muscle flap coverage.

Palliation of head and neck cancer: a review of the unique difficulties

Each year, there are 11 900 new diagnoses of head and neck cancers in the UK, with around 4000 deaths. Survival rates are higher for those diagnosed earlier, however, patients are often diagnosed later, with 20% palliative at the time of diagnosis. There is a scarcity of head and neck cancer palliative care literature available. This review article aims to discuss the unique challenges of head and neck cancer palliation. It specifically focusses on the challenges of pain management, airway obstruction, dysphagia, haemorrhage and the psychology of palliative head and neck cancer management. This article explores the advantages and disadvantages of many of the different treatment options available. It is hoped that this article will highlight the unique difficulties encountered by patients with head and neck cancer towards the end of their life and offer insights and suggestions to improve patients' quality of life in their final weeks and months.

Concurrent chemoradiotherapy using gemcitabine and nedaplatin in recurrent or locally advanced head and neck squamous cell carcinoma

BACKGROUND

Patients with recurrent or locally advanced head and neck squamous cell carcinoma (HNSCC) typically have limited treatment options and poor prognosis.

AIM

To evaluate the efficacy and safety of two drugs with potent radio-sensitization properties including gemcitabine and nedaplatin as concurrent chemoradiotherapy regimens in treating HNSCC.

METHODS

This single-arm prospective study enrolled patients with HNSCC to receive gemcitabine on days 1 and 8 and nedaplatin on days 1 to 3 for 21 days. Intensity-modulated radiation therapy with a conventional fraction was delivered 5 days per week. Objective response rate (ORR), disease control rate, and toxicity were observed as primary endpoints. Overall survival (OS) and progression free survival were recorded and analyzed as secondary endpoints.

RESULTS

A total of 24 patients with HNSCC were enrolled. During the median 22.4-mo follow-up, both ORR and disease control rate were 100%. The one-year OS was 75%, and one-year progression-free survival (PFS) was 66.7% (median PFS was 15.1 mo). Recurrent HNSCC patients had a poorer prognosis than the treatment-naïve patients, and patients who achieved complete response had better survival than those in the PR group (all P < 0.05). The most common grade 1-4 (100%) or grade 3-4 toxicities (75%) were hematological, and the most common grade 3-4 non-hematological toxicity was mucositis in 17 (71%) patients.

CONCLUSION

Gemcitabine plus nedaplatin with concurrent chemoradiotherapy is a therapeutic option for HNSCC with predictable tolerability. Considering the high adverse event rate, the optimized dose and schedule must be further explored.

Resection and reconstruction of the carotid artery for head and neck squamous cell carcinoma: a GETTEC study

OBJECTIVES

Main: To describe 1-year overall survival (OS) after primary or salvage management of head and neck squamous cell carcinoma (HNSCC) invading the common or internal carotid artery (CCA/ICA). Secondary: To assess disease control rate, treatment morbidity, and radio-anatomopathologic correlation.

METHODS

Retrospective study of 67 patients, treated between 1999 and 2020 for N3bM0 HNSCC invading the CCA/ICA as identified by CT-scan. Tumors that could not have been resected with a complete en-bloc resection sacrificing and reconstructing the CCA/ICA were excluded. Patients were separated into two groups (primary or salvage treatment) and studied according to the type of treatment they received: radiotherapy/radiochemotherapy (RT/RCT), surgery, or systemic therapy (ST).

RESULTS

For newly treated patients, the 1-year OS was significantly better after RT/RCT (73%) than after surgery (40%, p < 0.0001). In the salvage setting, the 1-year OS after surgery (40%) was better than after ST (14%, statistically suggestive difference with p = 0.0241). Surgery improved cervical control, but distant metastases occurred in more than 50% of cases regardless of treatment. No neurological complication occurred after carotid reconstruction. Perioperative mortality was 7% (1/15). The carotid invasion was confirmed by pathological examination in all five patients with an arterial deformation on CT-scan, in seven among eight patients with CCA/ICA encasement greater than 270°, and in four out of seven patients with CCA/ICA encasement between 180° and 270°.

CONCLUSION

Neck dissection with carotid resection and reconstruction is technically feasible with acceptable neurovascular morbidity. For newly treated patients, survival is better after RT/RCT. For salvage treatment, surgery could be proposed to selected patients.

Carotid Blowout Syndrome in the Emergency Department: A Case Report and Review of the Literature

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neck dissection with carotid artery resection after insertion of a protective endovascular covered stent for recurrent head and neck cancer: a case report

Head and neck cancer involving the carotid artery is usually unresectable. Such involvement often leads to exposure of the carotid artery and the risk of its blow-out. Carotid covered stent placement may be effective in preventing carotid blow-out; however, thus far, there are few published reports of this procedure. We here present a 65-year-old man who developed neck node recurrence of laryngeal cancer involving the carotid artery, which eventually resulted in exposure of that artery and its impending blow-out. A balloon occlusion test was performed to confirm that the circle of Willis was complete. A covered stent was inserted simultaneously into the affected carotid, enabling us to perform en block resection of the tumor and involved carotid artery as an elective procedure. The patient remained alive and disease-free with no complications or sequelae 10 years after this operation. Despite carotid blow-out being considered imminent, insertion of an endovascular covered stent into the affected carotid artery allowed us to investigate the feasibility of carotid resection while simultaneously preventing that artery's rupture. Aggressive surgical resection may lead to maintenance of quality-of-life and long-term survival in selected patients.

Resection of the internal carotid artery in selected patients affected by cancer of the skull base

Invasion of the internal carotid artery (ICA) has been historically considered a criterion of non-resectability of skull base cancer (SBC). Patients affected by SBC who underwent surgery including resection of ICA at two tertiary institutions were included. Demographics, oncologic, and surgical information, complications, and survival outcomes were retrospectively reviewed. Survival outcomes were calculated. Ten patients were included. Three surgical approaches (transnasal endoscopic, transorbital, and transpetrosal) were employed to resect the invaded/abutted tract(s) of the ICA. All patients underwent ICA temporary balloon occlusion test. In two patients, an extracranial-to-intracranial arterial bypass was harvested. Major neuromorbidity was observed in two patients. Perioperative mortality of the series was 10.0%. Mean overall survival was 27.2 months, with 2-year overall and progression-free survival rate of 88.9%. ICA resection is feasible as part of the ablation performed for very advanced SBCs. Survival outcomes are acceptable in adequately selected patients.

When Everything Revolves Around Internal Carotid Artery: Analysis of Different Management Strategies in Patients With Very Advanced Cancer Involving the Skull Base

Internal or common carotid artery encasement (CAE) is observed in almost 2-7% of head and neck cancers (HNC) and designates the tumor with the T4b category. This clinical scenario is associated with a dismal prognosis, owing to the risk for thrombosis and bleeding that usually characterizes such an advanced cancer. Standardized radiological criteria to infer invasion of the carotid artery are lacking. Complete surgical resection in the context of a multimodality treatment is supposed to offer the greatest chances of cure. Surgery can either be carotid-sparing or include carotidectomy. Data on probability of cerebrovascular and non-cerebrovascular complications, risk of carotid blowout, poor oncologic outcomes, and less-than-certain efficacy of diagnostic and interventional preventive procedures against cerebral infarction make it difficult to define surgery as the recommended option among other therapeutic strategies. Non-surgical therapies based on radiation therapy possibly combined with chemotherapy are more frequently employed in HNC with CAE. In this context, carotid blowout is the most feared complication, and its probability increases with tumor stage and cumulative radiation dose received by the vessel. The use of highly conformal radiotherapies such as intensity-modulated particle therapy might substantially improve the manageability of HNC with CAE by possibly reducing the risk of late sequalae. Despite evidence is frail, it appears logical that a case-by-case evaluation through multidisciplinary decision making between head and neck surgeons, radiation oncologists, medical oncologists, diagnostic and interventional radiologists, and vascular surgeons are of paramount value to offer the best therapeutic solution to patients affected by HNC with CAE.

Imaging of Complications of Chemoradiation

Chemoradiation for head and neck cancer is associated with a variety of early and late complications. Toxicities may affect the aero-digestive tract (mucositis, salivary gland injury), regional osseous and cartilaginous structures (osteoradionecrosis (ORN) and chondronecrosis), vasculature (progressive radiation vasculopathy and carotid blow out syndromes), and neural structures (optic neuritis, myelitis, and brain injury). These may be difficult to distinguish from tumor recurrence on imaging, and may necessitate the use of advanced MRI and molecular imaging techniques to reach the correct diagnosis. Secondary radiation-induced malignancies include thyroid cancer and a variety of sarcomas that may manifest several years after treatment. Checkpoint inhibitors can cause a variety of adverse immune events, including autoimmune hypophysitis and encephalitis.

Lymph Node Dissection: Principles and Postoperative Imaging

The management of neck nodes in head and neck cancer is critical, given a markedly increased poor prognosis in patients with nodal metastasis. The surgical management of neck nodes has undergone radical changes secondary to a paradigm shift from curative surgery to nonsurgical organ and function-preserving options, such as radiation therapy. In the neck after treatment, radiologists should be familiar with imaging findings in various types of neck dissections and post-chemoradiation changes, along with signs of residual or recurrent disease. A multidisciplinary approach is essential with well-designed evidence-based surveillance imaging protocols and standardized reporting.

Imaging Features of Postradiotherapy Changes in Head and Neck Cancers

Radiation therapy is the mainstay in the treatment of head and neck cancers, in addition to surgery and chemotherapy. Expected radiotherapy changes evolving over time may be confused with recurrent tumor. Conversely, even residual or recurrent tumor in the setting of postradiotherapy changes may be difficult to identify clinically or even by radiological imaging. Therefore, it is important to be familiar with the temporal evolution of these changes. The purpose of this pictorial essay is thus to illustrate distinctly the expected radiotherapy changes and radiotherapy-related complications in the head and neck region and to differentiate them from tumor recurrence on routine cross-sectional imaging techniques (computed tomography and magnetic resonance imaging).

Reconstructive methods to resolve intractable fistulas that develop after radiation therapy in patients with head and neck cancer

Background

Radiation therapy (RT) is frequently used for supportive treatment and management of advanced head and neck cancers. This study performed a retrospective review of the treatment methods that were used for intractable draining fistulas in seven patients who had received RT for head and neck cancers. Treatment methods used for two of the seven patients are presented in detail.

Methods

From 2009 to 2020, seven patients underwent reconstructive surgery for intractable fistulas which occurred after RT for head and neck cancers. Patient characteristics, medical history, treatment method, and treatment outcome were reviewed for each case. The type of surgery performed, failure rate, and treatment period were also analyzed.

Results

In this study, a total of seven patients received additional management for radiation-induced fistulas. Patients underwent a mean of 3.3± 1.4 surgeries (maximum: six surgeries) to resolve their fistulas. The mean time interval from the first surgery to the last surgery for the patients to achieve resolution of the fistula was 8.7 months. Loco-regional flaps have performed an average of 1.9± 1.5 times. However, all loco-regional flaps failed. Instead, the patients’ intractable fistulas were resolved with the use of distant flaps or free tissue transfers.

Conclusion

Fistulas that develop after head and neck cancer treatment following RT are difficult to treat with simple loco-regional flap procedures. Therefore, more aggressive treatment techniques, such as distant flap or free tissue transfer, may be needed to shorten patients’ treatment periods and avoid unnecessary surgeries.

Predictive factors for bleeding carotid artery pseudoaneurysms in patients with previous radiations for head and neck cancers

BACKGROUND

Bleeding from carotid artery pseudoaneurysms is an emergency condition with high morbidity and mortality. We aimed to identify risk factors predicting pseudoaneurysmal bleeding as the cause of profuse epistaxis in irradiated head and neck cancer patients with suspect carotid blowout or pseudoaneurysms.

METHODS

We retrospectively reviewed consecutive patients with history of radiation therapy for head and neck cancers and with nasal, oral or ear bleeding requiring in-patient treatment from hospital database. Pseudoaneurysms were subgrouped into internal carotid artery (ICA) pseudoaneurysms, and external carotid artery (ECA) pseudoaneurysms. The treatment outcomes were evaluated using 30-day mortality rate, recurrent bleeding, and cerebral infarction.

RESULTS

There were 41 admissions for suspected carotid blowout or pseudoaneurysms from 1 July 2016 to 30 June 2020 with 17 bleeding pseudoaneurysms identified, including 11 internal carotid arteries (ICA) pseudoaneurysms and 6 external carotid arteries (ECA) pseudoaneurysms. Among ICA pseudoaneurysms, six patients passed Balloon occlusion test with embolization and parent artery occlusion (trapping) of ICA performed, and all ECA pseudoaneurysms were embolized with parent artery occlusion (trapping). Baseline hypertension and hypotension on arrival were predictive for pseudoaneurysmal bleeding. The degree of haemoglobin drop was not significantly different between pseudoaneurysmal bleeding and non-pseudoaneurysmal bleeding (2.1 ± 1.4 g/dL vs. 1.6 ± 1.4 g/dL, p = 0.234).

CONCLUSIONS

We identified baseline hypertension and hypotension on arrival as predictive factors for pseudoaneurysmal bleeding in patients with irradiated head and neck cancer. Presence of these risk factors should alert the clinicians to the possibility of carotid pseudoaneurysms.

Phase 1/2a, open-label, multicenter study of RM-1929 photoimmunotherapy in patients with locoregional, recurrent head and neck squamous cell carcinoma

Background

Recurrent head and neck squamous cell carcinoma (rHNSCC) represents a significant global health burden with an unmet medical need. In this study we determined the safety and efficacy of RM‐1929 photoimmunotherapy in patients with heavily pretreated rHNSCC.

Methods

RM‐1929 (anti‐EGFR–IR700 dye conjugate) was infused, followed by tumor illumination. We evaluated safety, tumor response, and pharmacokinetics.

Results

Nine patients were enrolled in Part 1 (dose‐finding) and 30 patients in Part 2 (safety and efficacy). No dose‐limiting toxicities were experienced in Part 1; 640 mg/m² with fixed light dose (50 J/cm² or 100 J/cm) was recommended for Part 2. Adverse events (AEs) in Part 2 were mostly mild to moderate but 19 (63.3%) patients had AE ≥Grade 3, including 3 (10.0%) with serious AEs leading to death (not treatment related). Efficacy in Part 2: unconfirmed objective response rate (ORR) 43.3% (95% CI 25.46%–62.57%); confirmed ORR 26.7% (95% CI 12.28%–45.89%); median overall survival 9.30 months (95% CI 5.16–16.92 months).

Conclusions

Treatment was well tolerated. Responses and survival following RM‐1929 photoimmunotherapy in heavily pretreated patients with rHNSCC were clinically meaningful and warrant further investigation.

Clinical Trial Information

NCT02422979.

Cancer of the External Auditory Canal with Extensive Osteoradionecrosis of the Skull Base after Re-Irradiation with Particle Beams: A Case Report

Re-irradiation with X-rays and particle beams can be used to treat localized recurrence of unresectable head and neck cancer after initial irradiation therapy. However, re-irradiation therapy increases the risk of severe and late sequelae by 4-to 8-fold. It can also result in fatal outcomes, such as rupture of the carotid artery and cerebral necrosis or abscess. A 41-year-old woman was diagnosed with squamous cell carcinoma of the external auditory canal. The patient was initially treated with X-ray irradiation. However, the patient underwent re-irradiation with heavy particle beams and neutron rays for a recurrent tumor. The patient developed necrosis of the skull base involving the facial skin and temporal bone 2 months after the last session of re-irradiation therapy. The tissue in the parapharyngeal and masticatory regions also became completely necrotic, resulting in extensive exposure of the brain parenchyma. Although the patient underwent conservative and surgical treatment, necrosis of the tissue progressed, and a large part of the brain was exposed. Approximately 2.5 years later, although the brain is still exposed, the patient is alive without disease. Although the tumor had subsided and long-term survival was achieved, our patient developed serious osteoradionecrosis of the skull base with extensive brain exposure. For patients who are not candidates for surgery, re-irradiation alone is an option, albeit with poor prospects. This approach should be discussed with the patient while balancing the potential survival gain against the burden of treatment and the risk of complications.

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

OBJECTIVE/HYPOTHESIS

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

STUDY DESIGN

Retrospective case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1548-1556, 2021.