The importance of tumor attachment to the carotid artery

Survival and complications after carotid resection for head and neck squamous cell carcinoma: A systematic review and pooled analysis

OBJECTIVE

The aim of this study is to analyze oncologic outcomes and complications rate after common or internal carotid artery (CCA/ICA) resection for head and neck squamous cell carcinoma (HNSCC).

METHODS

This study was conducted in conformity with the PRISMA statement. A systematic review and pooled analysis was performed for overall survival (OS), disease specific survival (DSS) (primary outcomes), and perioperative death rate (secondary outcome).

RESULTS

A total of 276 patients (males: 76.7%, n = 191/249) with a median age of 59 years (n = 239/276; 95% CI 55.0-61.7) who underwent CCA/ICA resection for HNSCC were included. The median follow-up time was 11 months (n = 276). Estimated pooled OS rates (95% CI) at 1 and 2 years were 52.7% (46.9-59.2) and 29.8% (24.3-36.5), respectively. The median OS (95% CI) was 14 months (12-17). Estimated pooled DSS rates (95% CI) at 1 and 2 years were 58.6% (52.7-65.2) and 34.6% (28.5-41.9), respectively. The median DSS (95% CI) was 16 months (14-19). The perioperative death rate was 6.9% (n = 19/276).

CONCLUSIONS

CCA/ICA resection should be considered as a treatment option for accurately selected patients. Multicentric prospective studies are recommended to develop a predictive score guiding the decision-making process.

Radical Neck Dissection Following Internal Carotid Artery Endovascular Stenting: Case Report and Review of Literature

Carotid artery involvement by head and neck cancer is mostly considered as unresectable disease. Mostly, these cases are treated with definitive chemoradiotherapy. But when there is recurrent disease, choices are limited. Recent advances in vascular reconstruction and intervention radiology lead the way of addressing these cases with reconstruction or endovascular stenting. We tried to address this challenge in the present case. Endovascular stent provided the protection needed while dissecting over internal carotid artery. Such uncommonly performed techniques should be highlighted for further research.

Surgical Management Strategies for Carotid Artery Invasion by Head and Neck Cancer: Ligation Versus Reconstruction

OBJECTIVE

Whether ligation or reconstruction should be performed after radical resection of the tumor and carotid artery in patients with head and neck cancers invading the carotid artery (HNC-CA) has been controversial. This paper provides a review and meta-analysis of the efficacy of these 2 modalities.

DATA SOURCES

PubMed, Cochrane, Web of Science, Scopus, and Ovid databases were searched through August 2023.

REVIEW METHODS

Descriptive, graphical, tabular, and quantitative data were extracted. The statistical outcomes (risk difference, RD) were synthesized under a random-effects model. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines.

RESULTS

A total of 22 papers and 337 patients met the inclusion criteria for the literature review. Statistical analysis showed that the RD of overall survival (OS) rate at 1-year was 32% (95% confidence interval [CI]: 21%-42%) for ligation and 70% (95% CI: 65%-76%) for reconstruction (P < .05). The RD for OS rate at 2-year was 16% (95% CI: 7%-26%) for ligation and 39% (95% CI: 30%-47%) for reconstruction (P < .05). The RD for disease-free survival rate at 1-year was 27% (95% CI: 17%-38%) for ligation and 60% (95% CI: 51%-70%) for reconstruction (P < .05). There were no statistically significant differences (P > .05) between the 2 surgical modalities in terms of locoregional recurrence rate, carotid blowout rate, surgery-related complications rate, neurological complications rate, and perioperative mortality rate.

CONCLUSION

This review demonstrates the significant advantage of carotid artery reconstruction surgery in short-term patient survival, thus making it a recommended option for HNC-CA patients undergoing radical surgery.

Malignant meningioma with jugular vein invasion and carotid artery extension: A case report and review of the literature

BACKGROUND

Grade II and III meningiomas [World Health Organization (WHO) classification] rarely have extracranial metastases via the blood circulation; however, we experienced a case with a metaplastic atypical meningioma and local de-differentiation that metastasized to the jugular vein, carotid artery and subclavian artery at the cervicothoracic junction. Such cases have seldom been reported before.

CASE SUMMARY

The patient was a 30-year-old man who developed right neck masses with dysphagia, labored breathing, dizziness, and occasional earaches. Eight months earlier the patient was diagnosed with a right parietal lobe neoplasm and hemorrhage at a local hospital due to the sudden onset of headaches and left limb weakness, and the post-operative pathology was a metaplastic atypical meningioma (WHO grade II) with local de-differentiation (WHO III). Magnetic resonance imaging revealed a calcified mass at the root of the neck on the right and a large cystic mass in the right parapharyngeal space. Head and neck angiography showed that the right common carotid artery was compressed and completely occluded, and the jugular vein was enveloped by the tumor and occluded. A balloon occlusion test showed no perfusion in the right common carotid artery. Tumor resection, carotid artery ligation, and subclavian artery reconstruction were performed. The tumor was a malignant meningioma. Post-operatively, the patient had Horner's syndrome and hoarseness.

CONCLUSION

This case highlights the importance of the link between a large cervical mass and a primary intracranial tumor. Malignant meningioma should not be considered merely as an intracranial metastasis spread through cerebrospinal fluid, it can also be transferred through the circulation to the parapharyngeal space and the cervical great vessels.

Carotid Artery Involvement in Advanced Recurrent Head and Neck Cancer: A Case Report and Literature Review

BACKGROUND

Surgical management of advanced head and neck tumors involving the carotid artery remains controversial with compromised survival outcomes and heightened risks of morbidity and mortality.

CASE

We describe a case of a 74-year-old lady with previous T1N0M0 left tongue squamous cell carcinoma, who developed a left nodal recurrence encasing the left external carotid artery from the carotid bifurcation. She underwent an extended left radical neck dissection with carotid artery patch plasty and remains well to date, 10 months after surgery.

DISCUSSION

Head and neck tumor recurrences are not uncommon, and radical resection of advanced tumors involving the carotid artery is increasingly performed. Various carotid interventions including tumor peeling, ligation, and resection with reconstruction were reported with differences in survival outcomes, morbidity and mortality.

CONCLUSION

An aggressive surgical approach to advanced tumors involving the carotid artery may be a viable attempt for survival prolongation but requires proper case selection and has to be weighed against the risks of complications to better optimize patient outcomes.

[Resection of recurrent neck cancers with replacement of the carotid artery]

OBJECTIVES

The management of patients with recurrent neck cancer invading the carotid artery is controversial. The aim of this study was to evaluate the overall survival and healthy survival years (QALY) as well as the patency of carotid revascularization after enbloc tumor resection followed by complementary radiotherapy.

METHODS

From 2000 to 2016, 42 consecutive patients with recurrent neck cancer invading the carotid artery underwent resection of the tumor associated with reconstruction of the carotid artery with a PTFE prosthesis (n=31) or with a saphenous vein graft (n=11). In 11 cases, resection was associated with musculocutaneous flap coverage. The primary tumor was a squamous cell carcinoma of the larynx (20 patients) or of the pharynx (9 patients), undifferentiated carcinoma of unknown origin (10 patients) and anaplastic thyroid carcinoma (3 patients). All patients had postoperative radiotherapy (50-70Gy) supplemented in 16 of them by chemotherapy. Nine patients had metastatic dissemination at the time of reoperation with a recurrent tumor ulcerated to the skin in 5 of them.

RESULTS

The combined 30-day mortality and stroke rate was nil. Postoperative morbidity included dysphagia (n=8), vocal cord paralysis (n=6), late wound healing delay (n=2), transient mandibular claudication (n=1) and partial necrosis of the musculocutaneous flap (n=1). No infection and no thrombosis of the bypass were observed during follow-up [median: 31 months, range: 8-167 months]. Twenty-one patients (50%) died from the consequences of the spread of cancer, which had become metastatic, but without local recurrence. The 5-year survival rate was 50.9±8.3%. The median healthy survival year (QALY) was 3.38 [95% CI: 1.70-4.54] with a significant difference between patients without metastasis at the time of reoperation [n=33; QALY=4.02] and those with metastases [n=9; QALY=0.43; P=0.005]. Healthy life expectancy was also significantly longer in patients with laryngeal cancer [n=20, QALY=4.95] compared to patients with other types of tumors [n=22, QALY=1.67; P=0.032].

CONCLUSION

In the absence of metastases, enbloc resection of recurrent neck cancers invading the carotid artery improves the duration and quality of patient survival.

Carotid Reconstruction with Bovine Carotid Heterograft after En Bloc Resection of Squamous Cell Carcinoma with Direct Internal Carotid Invasion

We report a novel use of Artegraft (North Brunswick, NJ) bovine heterograft for carotid reconstruction after resection of a neck squamous cell carcinoma (SCC). A 65-year-old man presented with a large left neck SCC encasing and invading the cervical internal carotid artery (ICA). Computed tomography angiography revealed an incomplete Circle of Willis, and no viable vein conduit on duplex mapping. The patient underwent en bloc resection including portion of the cervical ICA followed by reconstruction with Artegraft which was well tolerated. This represents the first case report of tumor invasion of the ICA reconstructed using Artegraft as conduit.

Preoperative Protective Endovascular Covered Stent Placement Followed by Surgery for Management of the Cervical Common and Internal Carotid Arteries with Tumor Encasement

Objective The objective of this study was to report the outcomes on a preliminary cohort of patients with tumor encasement of either, or both, the cervical internal carotid artery (ICA) and common carotid artery (CCA) following preoperative covered stent placement and surgical resection. Setting This study was set at the University of Florida College of Medicine, Jacksonville, FL. Participants Subjects who received preoperative stenting of the cervical ICA/CCA before surgical resection of head and neck tumors between April 1, 2015, and July 31, 2015 were participated. Main Outcome Measures The outcomes assessed were resectability of tumors after stenting, histopathological assessment of specimen margins, complications associated with stenting. Results Five subjects received preoperative covered stent placement of the ICA/CCA before surgical resection. The mean age was 65.2 years. Median follow-up was 3.5 months. Excision of the adventitia from the stent was performed in all subjects. No intraoperative complications occurred. One vascular-related complication occurred in one subject who suffered occlusion of the stent, sustaining a ministroke. No involvement of tumor at the deep margin (inner surface of adventitia) of the resection was seen in any subjects. Conclusions Preoperative covered stent placement of the cervical ICA/CCA in the management of subjects with head and neck tumors who display encasement on preoperative imaging may represent a safe and effective treatment.

Resection of recurrent neck cancer with carotid artery replacement

OBJECTIVE

The management of patients with recurrent neck cancer invading the carotid artery is controversial. The purpose of this study was to evaluate overall survival rate, primary patency of vascular reconstructions, and quality-adjusted life-years (QALYs) after en bloc resection of the carotid artery and tumor with in-line polytetrafluoroethylene (PTFE) carotid grafting, followed by radiotherapy.

METHODS

From 2000 to 2014, 31 consecutive patients with recurrent neck cancer invading the carotid artery underwent en bloc resection and simultaneous carotid artery reconstruction with a PTFE graft, which was associated in 18 cases with a myocutaneous flap. The primary tumor was a squamous cell carcinoma of the larynx in 17 patients and of the hypopharynx in 7, an undifferentiated carcinoma of unknown origin in 4, and an anaplastic carcinoma of the thyroid in 3. All of the patients underwent postoperative radiotherapy (50-70 Gy), and 10 of them also underwent chemotherapy (doxorubicin and cisplatin).

RESULTS

None of the patients died or sustained a stroke during the first 30 days after the index procedure. Postoperative morbidity consisted of 6 transitory dysphagias, 3 vocal cord palsies, 2 wound dehiscences, 1 transitory mandibular claudication, and 1 partial myocutaneous flap necrosis. No graft infection occurred during follow-up. Fifteen patients (48%) died from metastatic cancer during a mean follow-up of 45.4 months (range, 8-175 months). None of the patients showed evidence of local recurrence, stroke, or thrombosis of the carotid reconstruction. The 5-year survival rate was 49 ± 10%. The overall number of QALYs was 3.12 (95% confidence interval, 1.87-4.37) with a significant difference between patients without metastasis at the time of redo surgery (n = 26; QALYs, 3.74) and those with metastasis (n = 5; QALYs, 0.56; P = .005). QALYs were also significantly improved in patients with cancer of the larynx (n = 17; QALYs, 4.69) compared to patients presenting with other types of tumors (n = 14; QALYs, 1.29; P = .032).

CONCLUSIONS

Aggressive en bloc resection of recurrent neck cancer with PTFE grafting can be curative in patients without metastases at the time of redo surgery. In this subset of patients, extensive neck surgery with carotid artery replacement can lead to excellent local control of the disease with improved quality of survival.

Clinical impact of radiographic carotid artery involvement in neck metastases from head and neck cancer

The treatment of lymph node metastases involving the carotid artery is controversial. The aim of the present study was to determine the outcomes of head and neck cancer patients with radiographic carotid artery involvement in neck metastases. A total of 27 patients with head and neck cancer and radiologically diagnosed advanced metastases involving the common carotid artery or internal carotid artery were enrolled. All patients underwent a primary or salvage neck dissection and surgical carotid peeling. The oncological outcome and survival of all patients were analyzed. Loco-regional control was observed in 13 of the 27 patients (48.1%). During follow-up, five patients (18.5%) developed second primaries and 11 (40.7%) developed distant metastases. The survival time was poor independent of regional control. The median overall survival was 1.55 years and disease-free survival was 0.71 year. Radiographic carotid artery involvement in neck metastases in head and neck cancer appears to correlate with a poor long-term prognosis, with a high rate of distant metastases despite loco-regional control.

Carotid Artery Sacrifice and Reconstruction in the Setting of Advanced Head and Neck Cancer

Objective

To determine oncological and neuromorbidity outcomes in patients with advanced head and neck cancer (stage IVB) requiring sacrifice and reconstruction of the carotid artery.

Study Design

Case series with chart review.

Setting

Tertiary care referral center.

Subjects and Methods

Overall, 51 patients underwent carotid artery sacrifice during surgical treatment of the neck, in both the primary and salvage setting. All patients underwent autogenous in-line carotid artery bypass grafting with either saphenous vein or the deep femoral vein in conjunction with vascular surgery. In all, the study included 39 males and 12 female subjects, with age ranging from 39 to 82 (mean, 62.7).

Results

Two patients (3.9%) had a cerebral vascular accident in the immediate postoperative period. The remaining 49 patients (96%) had no neurologic sequela. Serial ultrasonic evaluation revealed 4 patients with intra-luminal thrombus within the site of reconstruction. Perioperative mortality occurred in a single patient. Disease-related mortality occurred in 9.8% (5) of patients, with an overall 2-year survival of 82%.

Conclusions

We presently report the largest series of surgical treatment for advanced head and neck cancer with carotid artery involvement. We document an overall 2-year survival of 82% in the setting of low perioperative neuromorbidity and mortality rates. We therefore consider carotid artery sacrifice and autogenous vein graft reconstruction in the absence of distant metastatic disease as a viable treatment option for what was once thought to be a palliative procedure.

Late surgical outcomes of carotid resection and saphenous vein graft revascularization in patients with advanced head and neck squamous cell carcinoma

BACKGROUND

In head and neck squamous cell carcinoma, invasion of the carotid artery is a severe mortality predictor. We report an updated experience of 19 patients who underwent head and neck resection for squamous cell carcinoma with concomitant carotid reconstruction. This study aims to analyze overall survival rates, primary patency of the reconstructions, vascular and nonvascular complications, radiotherapy dosing as well as late follow-up and outcomes.

METHODS

From September 1997 to 2011, 19 patients with advanced squamous cell carcinoma with carotid artery invasion were submitted to resection and concomitant vascular reconstruction in a single referred oncological institution. Patient follow-up was done by means of periodic outpatient returns, where clinical and duplex scan evaluations were performed to study graft patency.

RESULTS

The average length of follow-up was 23.3 (± 34.4) months. Nonvascular complications occurred in 6 patients (31.6%). Only 1 (5.3%) vascular complication was observed, resulting from the immediate occlusion of the carotid graft. All patients were submitted to preoperative, adjuvant, or curative intent radiotherapy during the course of the oncologic treatment, with varying doses. Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0%. Three patients (15.9%) are still alive, all without tumor recurrence, and present a disease-free long-term follow-up with patent grafts 21 months, 68 months, and 151 months after surgery.

CONCLUSIONS

Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients. Saphenous vein grafts demonstrated favorable outcomes with low infection and high patency rates, suggesting a valid alternative for arterial reconstruction in these cases.

[Salvage surgery in unresectable tumors of the neck. Outcome after ligation of the common carotid artery]

The aim of this study was to analyze two cases with advance tumors of the neck with infiltration of the common or internal carotid artery. Patients were surgically treated in Department of Otolaryngology Poznan University of Medical Sciences. Authors present the current state of knowledge concerning the proceedings in unresectable tumors of the neck and possibility to use the salvage surgery. Based on literature data and our own experience a risk of the carotid artery infiltrations is difficult to assay in diagnostic procedure. It decrease the possibility of radical surgery resection and indicate the most advance stage. Choosing the proper treatment requires interdisciplinary cooperation: ENT specialist, radiologist, vascular surgeon and oncologist. The high rate of complications and local recurrence rate makes the results of treatment are unsatisfactory.

An investigation of 125I seed permanent implantation for recurrent carcinoma in the head and neck after surgery and external beam radiotherapy

BACKGROUND

A preliminary assessment was conducted of the feasibility, efficacy, and morbidity of 125I seed implantation for recurrent head and neck carcinoma after surgery and external beam radiotherapy.

METHODS

Nineteen patients with recurrent head and neck carcinomas underwent 125I seed implantation under ultrasound or computed tomography guidance. The actuarial D90 of 125I seed implantation ranged from 90 to 160 Gy (median, 131 Gy). The follow-up period ranged from 3 to 44 months (median, 11 months).

RESULTS

The median local control was 24 months (95% confidence interval, 10.2 to 37.8). The one- year, two-year and three-year local controls were 73.3%, 27.5% and 27.5%, respectively, whereas the one-year, two-year and three-year survival rates were 53.0%, 18.2% and 18.2%, respectively, and the median survival was 13 months (95% confidence interval, 6.6 to 19.4). A total of 26.3% of patients (5/19) died of local recurrence and 21.1% of patients (4/19) died of metastases. One suffered from a grade 1 skin reaction.

CONCLUSIONS

125I seed implantation is feasible and safe as a salvage treatment for patients with recurrent head and neck cancers. The high local control results and low morbidity merits further investigation.

Carotid resection and reconstruction associated with treatment of head and neck cancer

Patients with head and neck cancer may experience carotid artery involvement. We present a series of 10 patients, all with stage IVB disease, who required carotid resection and reconstruction to achieve a complete resection. Nine of the 10 patients had previous radiation treatment to the neck. Six died of distant disease, and three died of other causes with no local or regional recurrences. Carotid resection and reconstruction can be done safely, achieving local and regional control.

Internal carotid artery sacrifice for radical resection of skull base tumors

When dealing with skull base tumors that encase the internal carotid artery (ICA), the surgeon must decide between ICA preservation and incomplete tumor resection, or radical resection with ICA sacrifice. In our experience with more than 300 anterior skull base tumors, the ICA was sacrificed in only 10 patients. These tumors were malignant, except for one meningioma that occluded the ICA and produced translent ischemic symptoms. All patients had the ICA resected with the tumor, and all patients underwent revascularization (cervical ICA-MCA saphenous bypass, n = 4; cervical-to-supraclinoid bypass, n = 1; petrous-to-supraclinoid bypass, n = 3; bonnet bypass, n = 2). This small patient series reflects our practice of preserving the ICA whenever possible. We recommend preserving the ICA with benign tumors because they do not invade the artery, or do so only to a limited extent. In addition, similar rates of tumor recurrence are seen after aggressive resection with or without ICA sacrifice. In contrast, we recommend radical tumor resection and sacrifice of the ICA with malignant tumors because they directly threaten the integrity of the ICA and the patient's survival. The ICA should not be considered a limitation to radical tumor resection because the ICA can be reconstructed safely with an appropriate bypass procedure.

Extensive Neck Node Metastases (N3) in Head and Neck Squamous Carcinoma

Objective. Head and neck squamous cell carcinoma (HNSCC) patients with N3 neck disease at presentation are the minority. Prognosis for such patients is poor, but there is disagreement about which treatment policy is best adopted. The aim of this study was to identify which groups of patients are best offered radical treatment, examining factors of association, prognosis, and survival.

Study Design. Prospective cohort study.

Setting. Regional tertiary head and neck cancer unit.

Subjects and Methods. Data were collected prospectively from patients treated for HNSCC with N3 nodal disease between 1975 and 2005. The data collected included age, sex, tumor TNM stage, histological grade, treatment, and survival. Odds ratio was used to calculate whether each parameter was statistically significant. Tumor-specific and observed survival curves were also calculated.

Results. A total of 275 patients had N3 disease. Multivariate analysis confirmed that advanced disease at the primary site (odds ratio = 4.6, P = .0261) mitigated against curative treatment. Comparison of tumor-specific survival between curative and palliative treatment strategies suggests that aggressive treatment is associated with greatly improved survival (median survival = 1.45 years, 95% confidence interval [CI] = 1.23-1.67 years; 5-year survival = 26.6%, CI = 17.14%-36.06%) compared with those treated palliatively (median survival = 3.18 months, CI = 3.06-3.30 months; no 5-year survivors; P < .0001).

Conclusion. A major factor in determining treatment strategies for N3 disease HNSCC is the extent of disease at the primary site. These data suggest that aggressive treatment of the neck improves survival and should be considered in these patients.

Covered stent treatment for an aneurysm of a saphenous vein graft to the common carotid artery

Aneurysmal degeneration of a saphenous vein graft is a rare complication and, so far, only three cases involving a carotid artery have been described. We report the case of a patient with a cervical neoplasm presenting carotid invasion, who underwent en bloc tumor resection and carotid reconstruction with a saphenous vein graft. Six years later, during follow-up, an aneurysm of the carotid graft was detected. Endovascular intervention was performed using a covered stent. Three years after this intervention, the patient was found to be asymptomatic, and computed tomography showed that the covered stent was patent, without complications.

CT-guided iodine-125 seed permanent implantation for recurrent head and neck cancers

BACKGROUND

To investigate the feasibility, and safety of 125I seed permanent implantation for recurrent head and neck carcinoma under CT-guidance.

RESULTS

A retrospective study on 14 patients with recurrent head and neck cancers undergone 125I seed implantation with different seed activities. The post-plan showed that the actuarial D90 of 125I seeds ranged from 90 to 218 Gy (median, 157.5 Gy). The follow-up was 3 to 60 months (median, 13 months). The median local control was 18 months (95% CI, 6.1-29.9 months), and the 1-, 2-, 3-, and 5- year local controls were 52%, 39%, 39%, and 39%, respectively. The 1-, 2-, 3-, and 5- survival rates were 65%, 39%, 39% and 39%, respectively, with a median survival time of 20 months (95% CI, 8.7-31.3 months). Of all patients, 28.6% (4/14) died of local recurrence, 7.1% (1/14) died of metastases, one patient died of hepatocirrhosis, and 8 patients are still alive to the date of data analysis.

CONCLUSION

CT-guided 125I seed implantation is feasible and safe as a salvage or palliative treatment for patients with recurrent head and neck cancers.

Arterial reconstructions associated with the resection of malignant tumors

OBJECTIVE

When trunk arteries are affected by malignant neoplasia, and surgical treatment involving tumor and arterial resection is used, the vascular reconstruction must be performed immediately to avoid ischemia in the brain and large tissue masses. The objective of this study was to analyze the results obtained with the treatment of patients with malignant neoplasia who underwent tumor and vascular resection associated with arterial reconstruction. The primary patency of reconstructions, the occurrence arterial complications, and patient survival were assessed.

METHODS

Thirty-six patients with cervical, abdominal, or lower limb neoplasias were followed up. These patients underwent elective operations at Hospital do Câncer A.C. Camargo, São Paulo, between September 1997 and September 2004. They were divided into 3 groups according to tumor location: Cervical (14), lower limbs (13), and Abdomen (9). Thirty-eight arterial reconstructions were performed in these 36 patients.

RESULTS

There were 5 arterial complications: 2 early- and 3 late-stage. The early complications consisted of 1 symptomatic carotid occlusion with sequelae and 1 femoral graft rupture without sequelae. The late-stage complications consisted of 1 symptomatic carotid occlusion, 1 occlusion of an axillary-carotid graft, and 1 occlusion of a branch of the aortobifemoral graft, all without sequelae. There was no difference between the primary arterial patency rates. All the deaths (22) resulted from progression of neoplasic disease.

CONCLUSIONS

Arterial reconstructions associated with resection of malignant neoplasia in cervical, abdominal, or lower limbs can be carried out with low rates of morbidity and mortality. There was no difference in the primary arterial patency rates among the groups studied.

Advanced cervical metastasis involving the carotid artery

PURPOSE OF REVIEW

This paper will review recent reports of the surgical management of the carotid artery when cancer is adherent to it and will highlight the author's experience at Clarian Health Partners in Indianapolis.

RECENT FINDINGS

Recent trends in treating metastatic neck cancer with chemoradiation initially and reserving surgery for the treatment of residual or recurrent disease has tasked the head and neck surgeon with extirpating cancer in significantly altered tissue with loss of tissue planes and scarring that conceals the extent of cancer spread. Cancer that is adherent to the carotid presents a treatment dilemma to the surgeon, given that historically the local control and survival has been dismal and the complications of surgery are high.

SUMMARY

The heavy burden of deciding to resect the carotid artery involved with recurrent or residual cancer should be balanced against the natural history of the disease process if not it is treated. It requires detailed understanding by the patient and family as well as coordination among the interventional radiologist, anesthesiologist, radiation oncologist, intensivist, and head and neck surgeon.

Neck dissections: radical to conservative

BACKGROUND: Neck dissection is an important surgical procedure for the management of metastatic nodal disease in the neck. The gold standard of neck nodal management has been the radical neck dissection. Any modification in the neck dissection is always compared with this standard. Over the last few decades, in order to alleviate the morbidity of radical neck dissection, several modifications and conservative procedures have been advocated. These procedures retain certain lymphatic or non-lymphatic structures and have been shown not to compromise oncological safety. METHODS: A literature search of the Medline was carried out for all articles on neck dissections. The articles were systematically reviewed to analyze and trace the evolution of neck dissection. These were then categorized to address the nomenclature, management of node positive and node negative neck including those who had received chemoradiation. RESULTS: The present article discusses the neck nodal nomenclature, the radical neck dissection, its modifications and migration to more conservative procedures and possible advances in the near future. CONCLUSION: Radical neck dissection is now replaced with modified radical neck dissections in most situations. Attempts are being made to replace modified radical neck dissections with selective neck dissections for early node positivity. Sentinel node biopsy is being studied to address the issue of node negative neck. More conservative surgeries are likely to replace the 'radical' surgeries of bygone era. This process is facilitated by earlier detection of the disease and better understanding of cancer biology.

The management of carotid artery rupture

Carotid artery rupture is fortunately an uncommon complication of head and neck cancer treatment. Eleven episodes of carotid artery rupture following irradiation and major head and neck resection were identified over a 6-year period. We review our experience and discuss the predisposing factors that can cause this complication, important aspects of management and outcome. During this 6-year period, 11 episodes of carotid artery rupture were treated in our unit. All patients had received prior irradiation (more than 60 Gy) and undergone a major surgical resection or resections. The average age was 59 years; all patients had a salivary fistula, local infection and a manifest 'herald bleed' just before their major carotid artery rupture. These patients were resuscitated, taken to theatre and the neck explored, with control of the vessel and debridement of necrotic tissue. Soft tissue coverage was in the form of a flap. Many of the factors predisposing to carotid artery rupture can be ameliorated or treated early in order to avoid this complication. Early and aggressive nutritional support together with correction of haematological abnormalities promote wound healing and prevent tissue breakdown. The detection and treatment of infection also reduces fistula formation and wound compromise. We present our protocol for the early, aggressive management of these patients with carotid artery rupture.

Imaging of neoplasms of the paranasal sinuses

The assessment of sinonasal malignancies requires a multidisciplinary team approach.Advances in pretherapeutic imaging have significantly contributed to the managementof sinonasal tumors. CT and MR imaging play complementary roles in the assess-mentand staging of these malignancies by determining the presence or absence of exten-sionof disease into the skull base and its foramina, the orbit, and the intracranial compartment.

Microsurgical Free Flap Reconstruction Outcomes in Head and Neck Cancer Patients after Surgical Extirpation and Intraoperative Brachytherapy

OBJECTIVES

The management of recurrent or persistent head and neck cancer poses a challenging problem. Salvage surgery for these individuals consists of ablative surgery, interstitial brachytherapy, and microsurgical free flap reconstruction. This study reviews complications after such reconstruction.

METHODS

We reviewed 139 consecutive head and neck cancer patients undergoing free flap reconstruction from January 1994 to May 2002. These included 66 patients with recurrent head and neck cancer undergoing intraoperative brachytherapy (IOBT) and free flap reconstruction and 73 undergoing free flap reconstructions only. A total of 142 reconstructions were performed, with three patients in IOBT group receiving two free flap reconstructions per patient, giving us a total of 69 reconstructions in the IOBT group versus 73 in the non-IOBT group. Nine patients were excluded from the IOBT group because of nonsynchronous use of brachytherapy and reconstruction, and 10 patients were excluded from the other group because they had prior radiotherapy or surgical treatment, leaving us with a total of 123 reconstructions, 60 in the IOBT group and 63 in the non-IOBT group. The IOBT group patients received iodine Vicryl seed implants, palladium seed implants, or both, to deliver an average dose of 79.3 +/- 31.8 Gy (mean +/- 1SD) to the surgical bed.

RESULTS

All patients were followed for evidence of local wound complications. The IOBT group showed multiple complications in 23 (38.33%) of 60 reconstructions, the most common being wound dehiscence in 11. This, when compared with the non-IOBT group complications (15.87%), was found to be statistically significant (chi test, P <.01).

CONCLUSION

IOBT increases the rate of complications in patients undergoing microvascular free tissue transfer. This, however, should not deter or alter the aggressiveness of cancer therapy used for managing recurrent head and neck cancer.

Resection and replacement of the carotid artery in metastatic head and neck cancer: literature review and case report

Metastases of advanced tumours of the oral cavity sometimes affect the cervical segments of the carotid arteries. The situation is worse in the 5-10% of cases in which the metastasis involves the common or internal carotid to such an extent that resection and replacement of the artery become necessary. Following clinical, CT/NM, and angiographic examinations, a surgical plan for the resection and reconstruction of the affected vascular segment is formulated. In preparing a treatment plan, emphasis must be placed on the expected quality of life, and careful consideration must be given to the extent of the operation.A survey of the international literature reveals that the reported mean 1-year complaint free survival rate after resection and reconstruction varies between 0 and 44%. In our experience, the wall of the carotid vessels is very resistant to tumour invasion in a large majority of patients. When radical surgery and reconstruction are carried out in the same session, does this increase the long-term cure rate and lengthen patient survival? A number of authors agree that radical interventions do not alter the survival indices significantly, but may improve the quality of life and regional control of the disease. The controversy over this topic is illustrated by means of a case report.

Management of neck metastasis with carotid artery involvement

OBJECTIVES

To demonstrate aggressive management of neck metastasis adherent to the internal or common carotid artery using sound oncologic principles while minimizing the significant risk of complications.

STUDY DESIGN

Our 13 year experience of treating patients with recurrent or residual neck metastasis adherent to the internal or common carotid artery was retrospectively reviewed.

METHODS

Angiography was used in patients who demonstrated fixation of the carotid artery on examination or imaging, followed by balloon test occlusion and single photon emission computer tomography (SPECT) scanning. The majority of carotid resections were reconstructed with a vein graft, especially if there was insufficient collateral cerebral circulation. Radical resection of the soft tissue including the carotid artery was performed followed by 15 to 20 Gray of electron beam delivered directly to the deep tissue. More recently, the carotid has been permanently occluded preoperatively, if possible. The assessment of the cerebral circulation and management of the carotid artery were analyzed as was survival, site of recurrence, and complications.

RESULTS

Fifty-eight charts were reviewed. The majority of patients (41) had their carotid artery reconstructed at time of resection, and the remaining had either the artery ligated or permanently occluded preoperatively. Strokes occurred in 11 patients. The median disease-specific survival was 12 months, with 24% of patients dying from distant metastasis.

CONCLUSIONS

The high risk of complications, loss of life's quality, and mortality must be balanced against the natural history of the disease if left untreated. The decision is a heavy burden for the patient, family, and head and neck surgeon.

Significado prognóstico do linfonodo metastático N3 em carcinomas epidermóides de cabeça e pescoço

OBJETIVO: Avaliar os resultados do tratamento da doença metastática em estádio avançado (N3) e sua relação com o prognóstico do carcinoma espinocelular de cabeça e pescoço. MÉTODO: Foram revisados as informações de prontuários de 241 pacientes, com carcinoma espinocelular de boca, orofaringe, laringe e hipofaringe com metástases cervicais maiores que 6 cm (N3) submetidos à cirurgia e/ou radioterapia, no Departamento de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia do Hospital Heliópolis, Hosphel, São Paulo, de 1988 a 1998. Nos pacientes submetidos à cirurgia foi avaliada a radicalidade cirúrgica, macroscopicamente completa ou não, e naqueles tratados pela radioterapia, foi analisada a resposta do sítio primário e do pescoço imediatamente ao término do tratamento. A sobrevida livre de doença foi estimada pelo método de Kapplan Meier no grupo submetido à cirurgia. RESULTADOS: A irressecabilidade da lesão primária e metastática no pescoço justificou a indicação da radioterapia na dose média de 65 Gy, em 69 pacientes ocorrendo resposta completa no sítio primário em 24(36%), no pescoço em 12 (18%), e em ambos os sítios em 11 casos (16%). No grupo sumetido à cirurgia seguido de radioterapia, a dose média foi de 56 Gy. Dos 25 pacientes com ressecção macroscópica radical do pescoço, cinco (20%) recidivaram, e dos cinco com ressecção incompleta e radioterapia, dois tiveram sobrevida de sete a 12 meses após o tratamento, quando foram perdidos de seguimento. A sobrevida livre de doença em dois anos neste grupo foi de 58%. CONCLUSÕES: Para pacientes com linfonodo metastático N3, o esvaziamento cervical seguido de radioterapia foi eficiente no controle regional da doença enquanto que nos inoperáveis, a radioterapia é um tratamento paliativo.

Extracranial-intracranial bypass for reconstruction of internal carotid artery in the management of head and neck cancer

Extracranial-intracranial bypass surgery was performed prior to carotid resection in eight patients with head and neck carcinoma that involved the carotid artery near the skull base. Four patients underwent the standard one-stage extracranial-intracranial bypass procedure. A two-stage procedure was performed in the remaining four patients. The procedure first involved an anastomosis between the M3 segment of the middle cerebral artery and the superficial temporal artery, followed by a bypass between the M2 segment of the middle cerebral artery and the internal carotid artery. One of the patients who underwent the standard one-stage extracranial-intracranial bypass procedure suffered an intraoperative infarction. Despite even longer occlusion times of the M2 segment, none of the patients who underwent the two-stage bypass suffered from any serious neurologic consequences. Three of seven patients who underwent the curative operations, survived more than 4 years, however, the remaining patients died within 1 year from recurrence. Our results show that carotid artery resection yields an opportunity for cure. In extracranial-intracranial bypass surgery, the temporary occlusion of the middle cerebral artery may also induce serious ischemia; however, the two-stage extracranial-intracranial bypass procedure appears to minimize the risk.

Salvage of advanced squamous cell carcinomas of the head and neck: internal carotid artery sacrifice and extracranial–intracranial revascularization

Object

Squamous cell carcinoma (SCC) of the head and neck may involve the carotid artery (CA) in the neck or skull base. Whether tumor resection should be associated with sacrifice of the CA is debatable.

Methods

Records obtained in five consecutive patients (three men, and two women; mean age 58 years, range 47–69 years) treated for recurrent or progressive SCC involving the internal carotid artery (ICA) at the skull base were reviewed retrospectively. The ICA was sacrificed, an extracranial–intracranial (EC–IC) bypass was performed using a saphenous vein graft, and the tumor and involved ICA segment were resected.

Gross-total resection of the SCC was achieved in four cases. One patient died of an acute postoperative stroke due to bypass occlusion and did not undergo tumor resection. No other permanent ischemic or neurological deficits were noted. The other four patients died of tumor progression (survival range 2–40 months, mean 14 months). One patient survived for more than 2 years (2-year overall survival rate 20%). Histological tumor invasion of the CA wall was verified in one of the three evaluated specimens.

Conclusions

A high rate of morbidity and mortality is associated with cases in which skull base CA sacrifice and an EC–IC bypass are performed. Not all resected arteries are shown to have malignant infiltration on histological examination. Better preoperative imaging criteria are needed to define malignant infiltration of the ICA at the skull base. Chemotherapy and radiotherapy without aggressive tumor resection may be an option for these patients.

Hypotensive endovascular test occlusion of the carotid artery in head and neck cancer

Object

To evaluate the reliability of balloon test occlusion with hypotensive challenge (BTO and HC) as a predictor of neurological complications before internal carotid artery (ICA) sacrifice in patients with advanced head and neck cancer, the authors retrospectively reviewed the medical records of patients presenting to their institutions between 1992 and 1997 in whom this preoperative assessment was performed.

Methods

Eleven patents who were candidates for extended comprehensive neck dissection (ECND) and potential ICA sacrifice were included in the study. Eight patients tolerated the test and underwent endovascular occlusion or surgical ligation of the ICA before ECND (four patients), preservation of the ICA at the time of surgery (three patients), or palliative therapy (one patient). Of three patients in whom BTO and HC failed, one patient received palliative treatment only; the other two underwent ECND with preservation of the ICA. In the group of patients who passed the test and underwent ICA occlusion or ligation before ECND, fatal thromboembolic stroke occurred within 24 hours of permanent balloon occlusion in one patient, resulting in a combined neurological morbidity/mortality rate of 25% in this subset of patients and an overall complication rate of 9% in this series.

Conclusions

The authors found that BTO and HC offers a simple and reliable method of preoperative risk assessment when ICA resection is planned for regional control of disease in advanced head and neck cancer. This management option, however, is associated with a potential for neurological complication that must be weighed against the natural course of the disease and the risks and benefits of other treatment modalities.

Carotid reconstruction in patients operated for malignant head and neck neoplasia

CONTEXT

Patients with malignant head and neck neoplasia may present simultaneous involvement of large vessels due to the growth of the tumoral mass. The therapeutic options are chemotherapy, radiotherapy, surgery or combined treatments.

OBJECTIVE

To analyze the result of surgical treatment with carotid reconstruction in patients with advanced malignant head and neck neoplasia.

DESIGN

Prospective.

SETTING

Hospital do Câncer A.C. Camargo, São Paulo, Brazil.

PARTICIPANTS

Eleven patients operated because of advanced malignant head and neck neoplasia that was involving the internal and/or common carotid artery.

MAIN MEASUREMENTS

By means of clinical examination, outpatient follow-up and duplex scanning, we analyzed the patency of the carotid grafts, vascular and non-vascular complications, disease recurrence and survival of the patients.

RESULTS

Six patients (54.5%) did not present any type of complication. There was one vascular complication represented by an occlusion of the carotid graft with a cerebrovascular stroke in one hemisphere. Non-vascular complications occurred in five patients (45.5%). During the follow-up, eight patients died (72.7%), of whom seven had loco-regional tumor recurrence and one had pulmonary and hepatic metastases (at an average of 9 months after the operation). Seven of these patients presented functioning grafts. The three patients still alive have no tumor recurrence and their grafts are functioning (an average of 9 months has passed since the operation).

CONCLUSIONS

Patients with advanced malignant head and neck neoplasia involving the carotid artery that are treated surgically present a prognosis with reservations. When the internal and/or common carotid artery is resected en-bloc with the tumor, arterial reconstruction must be performed. The long saphenous vein is a suitable vascular substitute.

Imaging of neoplasms of the paranasal sinuses

The assessment of sinonasal malignancies requires a multidisciplinary team approach. Advances in pretherapeutic imaging have significantly contributed to the management of sinonasal tumors. CT and MR imaging play complementary roles in the assessment and staging of these malignancies by determining the presence or absence of extension of disease into the skull base and its foramina, the orbit, and the intracranial compartment.

One stage carotid artery resection: reconstruction in radiated head and neck carcinoma

PURPOSE

Management of the carotid artery involved with metastatic squamous cell carcinoma continues to be a topic of much discussion. Early reports, for the most part, focused on the sequel of ligation and the development of various tests to predict patient tolerance for the procedure. More recent alternatives have described resection reconstruction in multistage procedures. By using immediate reconstruction with autogenous arterial grafting, carotid artery resection can be accomplished in patients with radiation failure in a single stage. This technique can be used without the addition of myocutaneous flaps, controlled fistulas, or intracranial surgery advocated for usage with alternative techniques.

PATIENTS AND METHODS

Immediate reconstruction after resection of the carotid artery with superficial femoral arterial graft is described.

RESULTS

In a series of 18 high-risk patients with radiation failure, the artery was successfully resected and reconstructed in 1 stage without any neurologic or vascular complications. The technique has been associated with prolonged survival in selected patients.

CONCLUSION

Carotid artery resection and immediate reconstruction can be performed in high-risk radiation failure patients with acceptable complications, and is associated with prolonged survival in selected cases.

Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: technical case report

OBJECTIVE AND IMPORTANCE

Head and neck cancer that invades the internal carotid artery (ICA) represents a significant management challenge. We describe a novel technique that allows for aggressive tumor removal without disrupting blood flow through the affected ICA.

CLINICAL PRESENTATION

A 62-year-old man was referred to our institution for management of a neck malignancy involving the ICA. Cerebral angiography suggested that there was good collateral flow from the opposite hemisphere, but the patient reported visual loss in the ipsilateral eye during balloon test occlusion of the ICA.

INTERVENTION

A self-expanding stent was deployed in the ICA; it spanned the entire length of the artery involved by tumor. One month later, the patient underwent tumor resection. During surgery, a long ICA arteriotomy was performed directly down to the mesh of the stent. A neoendothelium had formed within the stent, which prevented arterial bleeding. The carotid wall was dissected from the stent without difficulty and removed en bloc with the surrounding tumor. The exposed stent was wrapped circumferentially with a synthetic patch material. The patient tolerated the procedure well, and postoperative angiography demonstrated normal filling of the ICA.

CONCLUSION

We describe a novel approach to a patient with head and neck cancer involving the cervical ICA. Preliminary stenting, which allows time for endothelialization before surgery, may permit aggressive tumor resection without interrupting flow through the ICA. This technique obviates the need for complicated carotid reconstruction procedures and avoids the risk of delayed ischemia from carotid sacrifice.

The Role of Ultrasonography in the Management of Tumors of the Neck

By themselves, clinical examination and palpation do not provide an accurate assessment of metastatic neck nodes. They do not yield sufficient information to ascertain the benign or malignant nature of nodes or to determine the presence of extracapsular spread and vascular invasion. The use of real-time ultrasonography with high-frequency transducers can significantly improve the evaluation of patients with neck masses. We studied the use of ultrasound in evaluating metastatic neck disease in 25 patients. We found that it is useful not only in detecting neck nodes, but in assessing their characteristics and the degree of vascular invasion. We recommend that ultrasonography be routinely performed as part of the evaluation of all patients with head and neck masses. It is also valuable in the postoperative or postirradiation followup of patients whose necks are otherwise difficult to evaluate.

Assessment of carotid artery invasion in patients with head and neck cancer

PURPOSE

Define radiological and histological features in which patients with head and neck cancer would benefit from a carotid artery resection. Resection of the carotid artery has been advocated for local control of advanced squamous cell carcinoma of the head and neck. To provide appropriate preoperative counseling and optimize the utilization of resources, the criteria for patient selection has to be defined.

METHODS

Thirty-four patients underwent carotid artery resection based on the clinical impression of tumor fixation. Eighteen and 28 patients were evaluated using computed tomography (CT) and histological analysis, respectively. The distance between the tumor cells and external elastic lamina was measured. CT scans were examined to determine the circumference of tumor attachment around the carotid artery.

RESULTS

Clinical assessment predicted tumor within 1.8 mm of the carotid artery in 68% of cases. The overall survival for patients with tumor greater than 1.8 mm (N = 9) was better than that of patients with less (N = 19) than 1.8 mm (33.3% vs. 5.3%; median 24 versus 9 mo, P = .0899). Three of six patients (50%) with less than 180 degrees circumference tumor attachment had tumor within 1.8 mm from the external elastic lamina. Eight of twelve patients (67%) with tumors encompassing more than 180 degrees of the artery wall had tumor within 1.8 mm from the external elastic lamina. The overall survival rates for patients with tumor attachment greater and less than 180 degrees were 8.3% and 33%, respectively.

DISCUSSION

Tumor invasion into the carotid artery was the strongest predictor of outcome. Clinical assessment was as predictive as CT for tumor invasion. If tumor involvement of the carotid artery is less than 180 degrees, peeling the tumor is an alternative to carotid artery resection.

Invasion of the internal carotid artery by cavernous sinus meningiomas

BACKGROUND

Meningiomas are the most common tumor involving the cavernous sinus. Although these tumors have been known to invade adjacent structures such as bone, soft tissue, and brain, invasion of the internal carotid artery (ICA) by meningiomas has only been recognized recently. The authors evaluate the extent of carotid wall involvement in nine patients with cavernous sinus meningiomas encasing the ICA who underwent en bloc resection of the cavernous sinus.

METHODS

The en bloc tumor-ICA specimens were fixed in formalin, embedded in paraffin, and sectioned on a rotary microtome. Hematoxylin and eosin, EVG, and HVG stains were performed and evaluated by light microscopy.

RESULTS

There were four males and five females with a mean age of 47 years. Eight patients had not undergone previous surgery, whereas one patient had been operated on before. In this latter case, however, the cavernous sinus was not entered during the first operation. In all patients, stenosis of the ICA was confirmed by preoperative angiography and/or magnetic resonance imaging (MRI). In seven cases, the tumors were excised en bloc along with the stenotic ICA segment. A petrous-to-supraclinoid ICA bypass was performed in these seven patients. In two cases, the tumor was excised with the stenotic artery, but no bypass was performed. The final pathological diagnosis was meningothelial meningioma. In all cases tumor cells were found in the adventitia of the cavernous carotid with stenosis of the arterial lumen. Compression and/or obliteration of the vasa vasorum within the adventia was noted in all specimens. In four cases, the tumor was found to have invaded the external elastic lamina. In two instances the external elastic lamina was disrupted and the tumor focally extended into the media.

CONCLUSIONS

These findings suggest that in the case of cavernous sinus meningiomas with encasement and stenosis of the intracavernous ICA, invasion of the vessel wall has occurred. The effect of these findings on the management of cavernous sinus meningiomas and the involved ICA is discussed.

The role of brachytherapy in head and neck cancer

By precision dose delivery to a well-defined target, brachytherapy fulfills the complementary goals of delivering sufficient dose for tumor cell kill while sparing normal adjacent structures. The unique properties of this modality, either used alone or implemented in a combined modality setting with surgery or external-beam irradiation, offer an ideal means of enhancing the therapeutic ratio by exploiting the effect of local therapies while respecting normal tissue tolerance. Brachytherapy also provides an effective technique for the retreatment of patients with recurrent, persistent, or second primary head and neck malignant tumors in a previously irradiated region. The benefits of this treatment modality are reflected in excellent reported local control rates, shortened overall treatment times, reduced functional deficits, improved quality of life, and decreased costs. Successful brachytherapy relies, however, on close collaborative efforts between radiation oncologists and surgeons, careful assessment of the patient, precise planning, and technique that adheres to the rules of a system. Brachytherapy has been clearly identified as an effective, safe, and appealing modality in the treatment of head and neck malignancies.

Effects of postoperative external beam irradiation after carotid artery stripping of nodal metastasis

PURPOSE

The objective of this study was to determine the effects of postoperative external beam irradiation (PEBI) on patients after stripping the carotid vessel of nodal metastasis.

PATIENTS AND METHODS

Of 245 patients who underwent radical neck dissection for cancer of the upper aerodigestive tract between 1981 and 1995, 13 patients with nodal metastasis adherent to the carotid artery (NMCA) received a full course of PEBI after the tumor was peeled off the carotid vessel. Patterns of treatment failure, survival, and serious morbidity were evaluated.

RESULTS

At the time of last follow-up (range, 3 to 125 months), fewer than half of the patients (46%) were free of disease, and two patients (15%) had developed distant metastases. The estimated 2-year survival rate was 23%. There were no intraoperative, postoperative, or post-radiation therapy complications.

CONCLUSION

PEBI after carotid artery stripping of tumor can achieve locoregional disease control in select patients without an increased risk of vessel rupture. However, if the prognosis for patients with NMCA is to improve, other effective management strategies need to be investigated.

Carotid resection and replacement with autogenous arterial graft during operation for neck malignancy

Carotid artery resection as part of the management of advanced head and neck cancers remains controversial. Since 1991, 30 patients have undergone resection of the carotid artery with immediate reconstruction using superficial femoral artery as replacement conduit. There was one stroke/death. Forty-three percent developed neck wound problems but no grafts failed or hemorrhaged. Mean follow-up was 20 months (3-76) and mean life expectancy was 16 months from the time of surgery. Fifty-eight percent were free of local recurrence at the time of death. There was a 35% disease-free survival rate at 2 years. These results compare favorably with alternative therapy including carotid ligation or shaving tumor from the carotid artery. Given the importance of cerebral perfusion and local tumor control we offer superficial femoral artery as a durable conduit for immediate extracranial carotid reconstruction in the often hostile environment associated with cancer resection in the neck.

An approach for acute disruption of large arteries in patients with advanced cervical cancer: endoluminal balloon occlusion technique

OBJECTIVE

To test the feasibility of an intraluminal balloon occlusion technique for the control of sudden arterial disruption from cervical branches in patients with advanced malignancy.

BACKGROUND

A sudden disruption of large cervical arteries is a devastating complication of advanced cervical malignancy and local infection.

METHODS

Three patients with this complication underwent endoluminal balloon occlusion before surgical management. A double-lumen balloon catheter was introduced from the femoral artery to the bleeding point. Angiographic examination of the intracranial cross-filling could be performed by the injection of contrast medium from the opposite carotid artery, and consciousness levels could be directly confirmed under unilateral carotid occlusion.

RESULTS

Resection of the carotid or innominate artery was safely performed in all the patients. No neurologic complications occurred. Bleeding did not recur during follow-up (range 5-32 months).

CONCLUSIONS

This experience, although limited, suggests that surgical intervention to control cervical arterial bleeding with intraluminal balloon occlusion prevents excessive bleeding, decreases the risk of damage to the central nervous system, and improves the outcome in these critically ill patients.

Results of surgery for head and neck tumors that involve the carotid artery at the skull base

To evaluate the results of surgery in patients with head and neck cancers that involved the internal carotid artery at the skull base the authors retrospectively reviewed a consecutive series of 17 patients who underwent surgery at Mount Sinai Hospital over a 4-year period. In general, patients who underwent tumor resection with carotid preservation had less advanced disease (two of seven tumors were recurrences) than patients who underwent tumor resection with carotid sacrifice (seven of 10 tumors were recurrences). Of seven patients who underwent resection with carotid preservation, six had good outcomes (five patients alive in good condition, one dead at 2.2 years) and none had strokes. Of seven patients who underwent resection with carotid sacrifice and bypass, five had good outcomes (four alive in good condition, one dead at 2.5 years with no local recurrence) and two suffered graft occlusions that led to strokes, one of which was major and permanently disabling. Of three patients who underwent resection with carotid sacrifice and ligation without revascularization, there were no good outcomes: all three patients died within 6 months of surgery, two having suffered major permanently disabling strokes. The overall results (11 [65%] of 17 with good outcomes at an average follow-up period of 2.1 years) compared very favorably with historical nonsurgical controls. The authors conclude that tumor resection with carotid preservation carries the lowest risk of stroke and should usually be the treatment of choice. For patients with more advanced and recurrent disease, in whom it is believed that carotid preservation would prevent a safe and oncologically meaningful resection, carotid sacrifice with carotid bypass may be a useful treatment option. Carotid sacrifice without revascularization seems to be the treatment option with the least favorable results.