VOLUME
33
䡠
NUMBER
23
䡠
AUGUST
10
2015
JOURNAL OF CLINICAL ONCOLOGY
D I A G N O S I S
I N
O N C O L O G Y
emission tomography–computed tomography scanning and direct visualization, was consistent with clinical stage IV. The patient complained of difficulty swallowing and right jaw pain. Physical examination of the neck showed a right ulcerated mass measuring 12 ⫻10 ⫻ 4 cm involvingtherightsubmandibularareaanderodingthroughtheskinwith active oozing. The mass resulted in tracheal deviation to the left and restricted range of movement. The patient underwent fiberoptic laryngoscopy with no evidence of airway obstruction or additional lesions. Relevant laboratory tests showed a corrected calcium level of 14.3 mg/dL and hemoglobin of 6.8 g/dL. Computed tomography scanning of the neck with contrast was performed and revealed a large heterogeneous mass in the right base of the neck, involving level II and III lymph nodes and measuring approximately 8.5 ⫻ 6.1 ⫻ 5.6 cm. The right internal jugular vein was compressed and there was involvement of the right external carotid artery. The lesion was accessible for fine-needle aspiration, and cytopathology evaluation demonstrated squamous cell carcinoma. Because of the settled herald bleed and the compromise of the vascular axis by the tumor mass of the right external carotid artery, a diagnosis of impending CBS was made. It was decided to commence chemotherapy using docetaxel 75 mg/m2 on day 1, cisplatin 75 mg/m2 on day 1, and fluorouracil 750 mg/m2 on days 1 through 5 every 21 days (TPF regimen). The patient underwent his first cycle with good tolerance to treatment and an approximately 20% decrease of his tumor mass. The Interventional Radiology department was consulted on admission, and a carotid angiography (Fig 1A) showed the tumor
Impending Carotid Blowout Syndrome Introduction Neglected head and neck squamous cell carcinoma is unusual in clinical practice. In this late stage of the disease, vascular complications are often treated emergently. One of the most feared complications is carotid blowout syndrome (CBS), which is defined as rupture of the carotid artery or branches caused by the tumor mass compromising the vascular axis or as a result of chemoradiation therapy.1 The level of severity is further subdivided into three clinical syndromes: threatened blowout, which refers to a clinically exposed vessel or radiologic evidence of tumor invasion to the vascular structure; impending blowout, when a herald bleed has settled spontaneously; and acute carotid blowout syndrome, with profuse, uncontrollable bleeding.2,3 There are no objective reports of optimal management of these lesions and only a few case descriptions with single-modality intervention.4-8 We present a case of advanced giant-size head and neck squamous cell carcinoma that was successfully treated with induction docetaxel, fluorouracil, and cisplatin, followed by embolization and concurrent cetuximab with radiation therapy. Case Report A 48-year-old white man with a 30 pack-year smoking history was admitted to our university hospital in late March 2012 with a bleeding mass in the right side of the neck. The mass had been present and untreated for the last 2 years and previous work-up, including positron
A
B
Right
Precoil angiography
Postcoil embolization Fig 1.
Journal of Clinical Oncology, Vol 33, No 23 (August 10), 2015: pp e97-e98
© 2014 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on June 24, 2016. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
e97
Peguero et al
A
B
C
Fig 2.
mass being fed by the right carotid external artery system. One of the branches was bleeding through the eroded skin, and the decision was made to perform a glue coil embolization (Fig 1B, arrow) of the index bleeding pedicle. The bleeding ceased after embolization and thereafter the patient received two more cycles of TPF. His calcium levels and hemoglobin returned to normal ranges. He completed concurrent therapy with cetuximab 250 mg/m2 per week and radiation therapy at 70 Gy over 35 daily fractions in October of 2012. Additional clinical-radiologic follow-up was consistent with full response of the neck mass (Fig 2A, April 2012; Fig 2B, October 2012; Fig 2C, January 2013). Discussion CBS continues to be a life-threatening complication in head and neck squamous cell carcinoma. The type of intervention is driven by the severity of the clinical presentation. Procedures in short case series such as surgical ligation, endovascular stenting, embolization, and radiation therapy have been reported as single-intervention maneuvers.5-10 Early reports with surgical ligation were associated with mortality at a rate as high as 100%; thus, endovascular techniques have emerged as a therapeutic alternative for the treatment of CBS.11 Short-term complications from endovascular therapy can be lethal and include repeat hemorrhage, carotid artery dissections, thromboembolic events, and cerebrovascular accidents. They result from the introductory device manipulation of the vessels and are more frequent when embolization is combined with stents and graft procedures.12 Impending CBS in locally advanced head and neck cancer can be treated successfully with sequential approaches such as induction chemotherapy followed by vascular interventions to sustain relevant clinical responses or to further decrease the volumetric burden of a given tumor mass. To our knowledge, there are no reports in the literature of neglected head and neck squamous cell carcinoma with impending CBS treated with induction TPF, embolization, and radiation therapy in a sequential approach. Descriptions of case series like these will be useful to detect the unknown risk of CBS complications from multimodality treatment. Furthermore, the clinical response presented in this report
should raise awareness of the importance of multidisciplinary intervention in this fatal event.
Julio Peguero, Anas Khanfar, Siva Mannem, Maurice Willis, and Avi Markowtiz The University of Texas Medical Branch, Galveston, TX
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Esteller E, Leo´n X, de Juan M, et al: Delayed carotid blow-out syndrome: A new complication of chemoradiotherapy treatment in pharyngolaryngeal carcinoma. J Laryngol Otol 126:1189-1191, 2012 2. Rimmer J, Giddings CE, Vaz F, et al: Management of vascular complications of head and neck cancer. J Laryngol Otol 126:111-115, 2012 3. Roh JL, Suh DC, Kim MR, et al: Endovascular management of carotid blowout syndrome in patients with head and neck cancers. Oral Oncol 44:844-850, 2008 4. Wilner HI, Lazo A, Metes JJ, et al: Embolization in cataclysmal hemorrhage caused by squamous cell carcinomas of the head and neck. Radiology 163:759-762, 1987 5. Broomfield SJ, Bruce IA, Luff DA, et al: Endovascular management of the carotid blowout syndrome. J Laryngol Otol 120:694-697, 2006 6. Bates MC, Shamsham FM: Endovascular management of impending carotid rupture in a patient with advanced head and neck cancer. J Endovasc Ther 10:54-57, 2003 7. Koutsimpelas D, Pitton M, Ku¨lkens C, et al: Endovascular carotid reconstruction in palliative head and neck cancer patients with threatened carotid blowout presents a beneficial supportive care measure. J Palliat Med 11:784-789, 2008 8. Sesterhenn AM, Iwinska-Zelder J, Dalchow CV, et al: Acute haemorrhage in patients with advanced head and neck cancer: Value of endovascular therapy as palliative treatment option. J Laryngol Otol 120:117-124, 2006 9. Powitzky R, Vasan N, Krempl G, et al: Carotid blowout in patients with head and neck cancer. Ann Otol Rhinol Laryngol 119:476-484, 2010 10. Morrissey DD, Andersen PE, Nesbit GM, et al: Endovascular management of hemorrhage in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 123:15-19, 1997 11. Chaloupka JC, Putman CM, Citardi MJ, et al: Endovascular therapy for the carotid blowout syndrome in head and neck surgical patients: Diagnostic and managerial considerations. AJNR Am J Neuroradiol 17:843-852, 1996 12. Hoppe H, Barnwell SL, Nesbit GM, et al: Stent-grafts in the treatment of emergent or urgent carotid artery disease: Review of 25 cases. J Vasc Interv Radiol 19:31-41, 2008
DOI: 10.1200/JCO.2013.48.9641; published online ahead of print at www.jco.org on March 31, 2014
■ ■ ■
e98
© 2014 by American Society of Clinical Oncology
JOURNAL OF CLINICAL ONCOLOGY
Downloaded from jco.ascopubs.org on June 24, 2016. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
33
䡠
NUMBER
23
䡠
AUGUST
10
2015
JOURNAL OF CLINICAL ONCOLOGY
D I A G N O S I S
I N
O N C O L O G Y
emission tomography–computed tomography scanning and direct visualization, was consistent with clinical stage IV. The patient complained of difficulty swallowing and right jaw pain. Physical examination of the neck showed a right ulcerated mass measuring 12 ⫻10 ⫻ 4 cm involvingtherightsubmandibularareaanderodingthroughtheskinwith active oozing. The mass resulted in tracheal deviation to the left and restricted range of movement. The patient underwent fiberoptic laryngoscopy with no evidence of airway obstruction or additional lesions. Relevant laboratory tests showed a corrected calcium level of 14.3 mg/dL and hemoglobin of 6.8 g/dL. Computed tomography scanning of the neck with contrast was performed and revealed a large heterogeneous mass in the right base of the neck, involving level II and III lymph nodes and measuring approximately 8.5 ⫻ 6.1 ⫻ 5.6 cm. The right internal jugular vein was compressed and there was involvement of the right external carotid artery. The lesion was accessible for fine-needle aspiration, and cytopathology evaluation demonstrated squamous cell carcinoma. Because of the settled herald bleed and the compromise of the vascular axis by the tumor mass of the right external carotid artery, a diagnosis of impending CBS was made. It was decided to commence chemotherapy using docetaxel 75 mg/m2 on day 1, cisplatin 75 mg/m2 on day 1, and fluorouracil 750 mg/m2 on days 1 through 5 every 21 days (TPF regimen). The patient underwent his first cycle with good tolerance to treatment and an approximately 20% decrease of his tumor mass. The Interventional Radiology department was consulted on admission, and a carotid angiography (Fig 1A) showed the tumor
Impending Carotid Blowout Syndrome Introduction Neglected head and neck squamous cell carcinoma is unusual in clinical practice. In this late stage of the disease, vascular complications are often treated emergently. One of the most feared complications is carotid blowout syndrome (CBS), which is defined as rupture of the carotid artery or branches caused by the tumor mass compromising the vascular axis or as a result of chemoradiation therapy.1 The level of severity is further subdivided into three clinical syndromes: threatened blowout, which refers to a clinically exposed vessel or radiologic evidence of tumor invasion to the vascular structure; impending blowout, when a herald bleed has settled spontaneously; and acute carotid blowout syndrome, with profuse, uncontrollable bleeding.2,3 There are no objective reports of optimal management of these lesions and only a few case descriptions with single-modality intervention.4-8 We present a case of advanced giant-size head and neck squamous cell carcinoma that was successfully treated with induction docetaxel, fluorouracil, and cisplatin, followed by embolization and concurrent cetuximab with radiation therapy. Case Report A 48-year-old white man with a 30 pack-year smoking history was admitted to our university hospital in late March 2012 with a bleeding mass in the right side of the neck. The mass had been present and untreated for the last 2 years and previous work-up, including positron
A
B
Right
Precoil angiography
Postcoil embolization Fig 1.
Journal of Clinical Oncology, Vol 33, No 23 (August 10), 2015: pp e97-e98
© 2014 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on June 24, 2016. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
e97
Peguero et al
A
B
C
Fig 2.
mass being fed by the right carotid external artery system. One of the branches was bleeding through the eroded skin, and the decision was made to perform a glue coil embolization (Fig 1B, arrow) of the index bleeding pedicle. The bleeding ceased after embolization and thereafter the patient received two more cycles of TPF. His calcium levels and hemoglobin returned to normal ranges. He completed concurrent therapy with cetuximab 250 mg/m2 per week and radiation therapy at 70 Gy over 35 daily fractions in October of 2012. Additional clinical-radiologic follow-up was consistent with full response of the neck mass (Fig 2A, April 2012; Fig 2B, October 2012; Fig 2C, January 2013). Discussion CBS continues to be a life-threatening complication in head and neck squamous cell carcinoma. The type of intervention is driven by the severity of the clinical presentation. Procedures in short case series such as surgical ligation, endovascular stenting, embolization, and radiation therapy have been reported as single-intervention maneuvers.5-10 Early reports with surgical ligation were associated with mortality at a rate as high as 100%; thus, endovascular techniques have emerged as a therapeutic alternative for the treatment of CBS.11 Short-term complications from endovascular therapy can be lethal and include repeat hemorrhage, carotid artery dissections, thromboembolic events, and cerebrovascular accidents. They result from the introductory device manipulation of the vessels and are more frequent when embolization is combined with stents and graft procedures.12 Impending CBS in locally advanced head and neck cancer can be treated successfully with sequential approaches such as induction chemotherapy followed by vascular interventions to sustain relevant clinical responses or to further decrease the volumetric burden of a given tumor mass. To our knowledge, there are no reports in the literature of neglected head and neck squamous cell carcinoma with impending CBS treated with induction TPF, embolization, and radiation therapy in a sequential approach. Descriptions of case series like these will be useful to detect the unknown risk of CBS complications from multimodality treatment. Furthermore, the clinical response presented in this report
should raise awareness of the importance of multidisciplinary intervention in this fatal event.
Julio Peguero, Anas Khanfar, Siva Mannem, Maurice Willis, and Avi Markowtiz The University of Texas Medical Branch, Galveston, TX
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Esteller E, Leo´n X, de Juan M, et al: Delayed carotid blow-out syndrome: A new complication of chemoradiotherapy treatment in pharyngolaryngeal carcinoma. J Laryngol Otol 126:1189-1191, 2012 2. Rimmer J, Giddings CE, Vaz F, et al: Management of vascular complications of head and neck cancer. J Laryngol Otol 126:111-115, 2012 3. Roh JL, Suh DC, Kim MR, et al: Endovascular management of carotid blowout syndrome in patients with head and neck cancers. Oral Oncol 44:844-850, 2008 4. Wilner HI, Lazo A, Metes JJ, et al: Embolization in cataclysmal hemorrhage caused by squamous cell carcinomas of the head and neck. Radiology 163:759-762, 1987 5. Broomfield SJ, Bruce IA, Luff DA, et al: Endovascular management of the carotid blowout syndrome. J Laryngol Otol 120:694-697, 2006 6. Bates MC, Shamsham FM: Endovascular management of impending carotid rupture in a patient with advanced head and neck cancer. J Endovasc Ther 10:54-57, 2003 7. Koutsimpelas D, Pitton M, Ku¨lkens C, et al: Endovascular carotid reconstruction in palliative head and neck cancer patients with threatened carotid blowout presents a beneficial supportive care measure. J Palliat Med 11:784-789, 2008 8. Sesterhenn AM, Iwinska-Zelder J, Dalchow CV, et al: Acute haemorrhage in patients with advanced head and neck cancer: Value of endovascular therapy as palliative treatment option. J Laryngol Otol 120:117-124, 2006 9. Powitzky R, Vasan N, Krempl G, et al: Carotid blowout in patients with head and neck cancer. Ann Otol Rhinol Laryngol 119:476-484, 2010 10. Morrissey DD, Andersen PE, Nesbit GM, et al: Endovascular management of hemorrhage in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 123:15-19, 1997 11. Chaloupka JC, Putman CM, Citardi MJ, et al: Endovascular therapy for the carotid blowout syndrome in head and neck surgical patients: Diagnostic and managerial considerations. AJNR Am J Neuroradiol 17:843-852, 1996 12. Hoppe H, Barnwell SL, Nesbit GM, et al: Stent-grafts in the treatment of emergent or urgent carotid artery disease: Review of 25 cases. J Vasc Interv Radiol 19:31-41, 2008
DOI: 10.1200/JCO.2013.48.9641; published online ahead of print at www.jco.org on March 31, 2014
■ ■ ■
e98
© 2014 by American Society of Clinical Oncology
JOURNAL OF CLINICAL ONCOLOGY
Downloaded from jco.ascopubs.org on June 24, 2016. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
