Cerebral revascularization and carotid artery resection at the skull base for treatment of advanced head and neck malignancies

Object Resection of cancer and the involved artery in the neck has been applied with some success, but the indications for such an aggressive approach at the skull base are less well defined. The authors therefore evaluated the outcomes of advanced skull base malignancies in patients who were treated with bypass and resection of the internal carotid artery (ICA). Methods The authors retrospectively reviewed the charts of all patients with advanced head and neck cancers who underwent ICA sacrifice with revascularization in which an extracranial-intracranial bypass was used between 1995 and 2010 at the Barrow Neurological Institute. Results Eighteen patients (11 male and 7 female patients; mean age 46 years, range 7–69 years) were identified. There were 4 sarcomas and 14 carcinomas that involved the ICA at the skull base. All patients underwent ICA sacrifice with revascularization. One patient died of a stroke after revascularization. A second patient died of the effects of a fistula between the oral and cranial cavities (surgery-related mortality rate 11.1%). Eight months after the operation, 1 patient developed occlusion of the bypass and died. Complications associated with the bypass surgery included 1 case of subdural hematoma (SDH) with blindness, 1 case of status epilepticus, and 1 case of asymptomatic bypass occlusion (bypass-related morbidity 16.7%). Complications associated with tumor resection included 3 cases of CSF leakage requiring repair and shunting, 1 case of hydrocephalus requiring shunting, 1 case of SDH, and 1 case of contralateral ICA injury requiring a bypass (tumor resection morbidity rate 33.3%). In 1 patient treated with adjuvant therapy before surgery, the authors identified only a radiation effect and no tumor on resection. In a second patient the bypass was occluded, and her tumor was not resected. The other 16 patients underwent gross-total resection of their tumor. Excluding the surgery-related deaths, the mean and median lengths of survival in this series were 13.2 and 8.3 months, respectively (range 1.5–48 months). Including the surgery-related deaths, the mean and median lengths of survival were 11.8 and 8 months, respectively (range 17 days–48 months). At last follow-up all patients had died of cancer or cancer-related causes. Conclusions Despite maximal surgical intervention, including ICA sacrifice at the skull base with revascularization, patient survival was dismal, and the complication rate was significant. The authors no longer advocate such an aggressive approach in this patient population. On rare occasions, however, such an approach may be considered for low-grade malignancies.

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Gamma Knife surgery for skull base chordomas and chondrosarcomas

Journal of Neurosurgery ◽

10.3171/jns-07/10/0752 ◽

2007 ◽

Vol 107 (4) ◽

pp. 752-757 ◽

Cited By ~ 69

Author(s):

Toshinori Hasegawa ◽

Dai Ishii ◽

Yoshihisa Kida ◽

Masayuki Yoshimoto ◽

Joji Koike ◽

...

Keyword(s):

Skull Base ◽

Gamma Knife ◽

Tumor Volume ◽

Tumor Resection ◽

Gamma Knife Surgery ◽

High Rate ◽

Tumor Control ◽

Low Grade ◽

The Mean ◽

Skull Base Chordomas

Object The purpose of this study was to evaluate radiosurgical outcomes in skull base chordomas and chondrosarcomas, and to determine which tumors are appropriate for stereotactic radiosurgery as adjuvant therapy following maximum tumor resection. Methods Thirty-seven patients (48 lesions) were treated using Gamma Knife surgery (GKS); 27 had chordomas, seven had chondrosarcomas, and three had radiologically diagnosed chordomas. The mean tumor volume was 20 ml, and the mean maximum and marginal doses were 28 and 14 Gy, respectively. The mean follow-up period was 97 months from diagnosis and 59 months from GKS. Results The actuarial 5- and 10-year survival rates after GKS were 80 and 53%, respectively. The actuarial 5- and 10-year local tumor control (LTC) rates after single or multiple GKS sessions were 76 and 67%, respectively. All patients with low-grade chondrosarcomas achieved good LTC. A tumor volume of less than 20 ml significantly affected the high rate of LTC (p = 0.0182). No patient had adverse radiation effects, other than one in whom facial numbness worsened despite successful tumor control. Conclusions As an adjuvant treatment after resection, GKS is a reasonable option for selected patients harboring skull base chordomas or chondrosarcomas with a residual tumor volume of less than 20 ml. Dose planning with a generous treatment volume to avoid marginal treatment failure should be made at a marginal dose of at least 15 Gy to achieve long-term tumor control.

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

Neurosurgical FOCUS ◽

10.3171/foc.2003.14.3.7 ◽

2003 ◽

Vol 14 (3) ◽

pp. 1-5 ◽

Cited By ~ 16

Author(s):

Iman Feiz-Erfan ◽

Patrick P. Han ◽

Robert F. Spetzler ◽

Giuseppe Lanzino ◽

Mauro A. T. Ferreira ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Head And Neck ◽

Skull Base ◽

Squamous Cell ◽

Internal Carotid ◽

Tumor Resection ◽

High Rate ◽

Neurological Deficits ◽

Preoperative Imaging

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.

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Oncologic surgical resection with intravascular covered stent placement in patients with carotid artery encased by metastatic cancer---Our experience with 5 patients

10.22541/au.161847088.80761095/v1 ◽

2021 ◽

Author(s):

Kai Liu ◽

Haidong Zhang ◽

Huanyu Jiang ◽

Shanchun Gong ◽

Xianjun Lyu ◽

...

Keyword(s):

Blood Flow ◽

Carotid Artery ◽

Head And Neck ◽

Stent Placement ◽

Tumor Resection ◽

Covered Stent ◽

Advanced Head ◽

Artery Blood Flow ◽

Complete Tumor Resection ◽

Complete Tumor

Importance: Tumor encasement of the common carotid artery (CCA) and/or the internal carotid artery (ICA) in patients with advanced head and neck tumors represents a significant surgical challenge. At present, there are few reports on the treatment approach that can achieve the maximal oncological resection and reduce the difficulty of operation without affecting the carotid artery blood flow. Objective: To examine whether the combination of oncologic complete tumor resection and intravascular covered stent placement is more advantageous in the management of advanced head and neck cancer. Design, Setting, and Participants: Five patients with advanced head and neck squamous cell carcinoma (AHNSCC) invading one side of the carotid artery were retrospectively enrolled. The contrast-enhanced computed Tomography (CT) and angiography were performed to assess the severity of extrinsic tumor compression to the carotid artery. Covered stent was placed intra-arterially at least 1 cm proximal and distal beyond the area of tumor involvement. The tumor and the involved carotid artery were resected, and pectoralis major flap transfer was utilized for coverage of the great vessels supported with intra-arterial covered stent. Main Outcomes and Measures: Efficacy of oncologic complete tumor resection combined with endovascular stent placement. Results: The post-stenting demonstrated an improvement in the appearance and caliber of the affected carotid artery. Four patients experienced transient bradycardia and hypotension. All five patients underwent R0 resection. Postoperatively, the flap all had rich vascularity and healing. Three patients underwent adjuvant radiotherapy or chemoradiation. With median follow-up 6.5 months, one patient died of multiple organ failures at 6.5 months after surgery; one patient developed tracheal stoma recurrence and treated with salvaged surgery; the three other patients had no disease recurrence in their last follow-ups. Conclusions and Relevance: Surgical resection with intravascular covered stent placement could potentially achieve the maximal oncological resection without compromise carotid artery blood flow in patients with carotid artery encased head and neck cancer.

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

Journal of Neurosurgery ◽

10.3171/jns.1997.86.5.0787 ◽

1997 ◽

Vol 86 (5) ◽

pp. 787-792 ◽

Cited By ~ 36

Author(s):

Michael H. Brisman ◽

Chandranath Sen ◽

Peter Catalano

Keyword(s):

Carotid Artery ◽

Head And Neck ◽

Skull Base ◽

Treatment Option ◽

Good Condition ◽

Tumor Resection ◽

Consecutive Series ◽

Content Type ◽

Results Of Surgery ◽

Fine Print

✓ 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 perservation 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.

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Lateral skull base malignancies

Neurosurgical FOCUS ◽

10.3171/foc.2002.12.5.9 ◽

2002 ◽

Vol 12 (5) ◽

pp. 1-4 ◽

Cited By ~ 6

Author(s):

Benjamin M. McGrew ◽

C. Gary Jackson ◽

Raquel A. Redtfeldt

Keyword(s):

Skull Base ◽

Postoperative Radiotherapy ◽

Survival Rates ◽

Tumor Resection ◽

Surgical Techniques ◽

Local Tumor Control ◽

Tumor Control ◽

Lateral Skull Base ◽

The Mean ◽

Poor Outcomes

Object Historically poor outcomes have been characteristic in patients with lateral skull base malignancies. As advances in skull base surgical techniques have been made, complete resection has increasingly been achieved. This has resulted in improved survival rates and local tumor control. Methods The authors performed a retrospective review of 95 patients treated for lateral skull base malignancies. The mean age of the patients was 49.4 years. There were 44 females and 51 males. The mean follow-up period was 50 months. Resection was performed in all patients, and postoperative radiotherapy was undertaken in 54% of the cases. Local disease control was maintained in 73% of the patients. Tumor involvement of the facial nerve and intracranial tumor extension did not jeopardize the rate of local control. Conclusions Despite the fact that technical advances in skull base surgery have resulted in a higher incidence of complete tumor resection and improved survival rates, a respect for the poor prognosis historically associated with lateral skull base malignancies should be maintained and treatment should be appropriately aggressive.

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