Carotid Blowout Syndrome Research Articles

Endovascular management of the carotid blowout syndrome: a single-center experience.

It is aimed to present endovascular treatment of carotid blowout syndrome (CBS) in patients with head and neck cancer. A retrospective review was performed on patients with carotid blowout syndrome between 2012 and 2018 in our hospital. A total of ten patients with prior history of head and neck cancer surgery and radiation therapy were investigated with clinical, postoperative and follow-up findings as well as technical outcome. Digital subtraction angiography of the carotid arteries was performed in all the cases for the diagnosis of the source of bleeding. Detachable coils and covered stents were used in endovascular treatment of carotid blowout syndrome. After the procedures, all patients were admitted to the intensive care unit for the follow-up of both hemodynamic and neurologic conditions. Thirteen diagnostic and endovascular treatment sessions were performed in 10 patients. Seven patients had major surgery for head and neck cancer and all patients were treated with chemoradiotherapy. Head and neck cancers in seven of the ten patients were persistent and pharyngocutaneous fistula developed in five patients. Two patients had impending CBS and eight patients had acute CBS. A total number of 19 vascular lesions in 10 patients were detected and 4 patients had multiple lesions. In three patients, additional endovascular treatment of stent-graft deployment had required due to recurrent hemorrhage after a mean time of 5.33days (range 1-11days). As a conclusion, covered stent application with or without coil embolization is a safe and efficient technique in treatment of CBS secondary to head and neck cancers.

Common carotid artery ligation at the proximal side before rupture in patients with ligation or occlusion of the external carotid artery at risk of carotid blowout syndrome.

Carotid blowout syndrome (CBS) is among the fatal complications in head and neck cancer treatment. However, the optimal treatment for CBS has not been established yet. This study aimed to describe our experience with two patients at high risk of CBS who underwent common carotid artery (CCA) ligation at the proximal side of the bleeding point under local anesthesia and before CCA rupture, and to review and compare the medical records of these two patients against 10 CBS cases treated in our department. The institutional electronic medical record was searched, and clinical information was extracted for all patients who showed CBS from 2007 to 2017. Our treatment method was performed as follows. Ligation of the proximal side of the CCA was performed under local anesthesia. The CCA was identified and clamped with two bulldog forceps for 10 minutes to check for any adverse neurological symptoms. Subsequently, the CCA was ligated using 2-0 silk threads and sutured with an absorbable suture between the silk threads. However, ligation or occlusion of the external carotid artery by previous treatment is a prerequisite for this method. Eight patients received interventions, with six patients undergoing prophylactic interventions before rupture. Four patients who did not undergo treatment died owing to CBS. Two patients who underwent treatment with the novel method did not experience re-bleeding, but their conditions deteriorated owing to cancer progression. The present method is one of the treatment choices for CBS, especially in patients with an 'impending' risk of CBS.

Chemoradiation and local recurrence of head and neck squamous cell carcinoma and the risk of carotid artery blowout.

Carotid blowout syndrome (CBS) is a rare but life-threatening complication of head and neck squamous cell carcinoma (HNSCC). Chemoradiation (CRT) may make CBS more likely, but so far no longitudinal analysis of different treatment strategies has been conducted. In the present study, 1072 patients with HNSCC were divided into groups depending on whether they had experienced CBS. Disease-related data were analyzed using chi-square test, Fisher exact test, and Student's t test. Survival rates were calculated using Kaplan-Meier test, log-rank test, and the Cox regression analysis for forward selection. Thirty-six patients suffering from CBS demonstrated significantly advanced T status (P = .001) and UICC stage (P = .004) when compared with unaltered counterparts. After adjustment for UICC stage, OS was comparable in both groups, whereas the mean recurrence-free survival (RFS) rate was better in unaltered patients (67 vs 24 months; P < .0001). Cox regression for forward selection revealed local recurrence (hazard ratio [HR], 1.9; P < .0001), T status (HR, 1.9; P = .03), and CRT (HR, 2.0; P < .0001) as independent risk factors for mortality related to CBS. CBS is a rare event in patients with HNSCC demonstrating reduced OS/RFS. Advanced T status, C/RT, and the recurrence of local tumors increase the risk of CBS-associated death.

Viabahn stent extrusion into the airway in association with nasopharyngeal squamous cell carcinoma

Carotid blowout syndrome is a rare condition where blood extravagates from the carotid artery due to vessel damage. Frequently, this is an emergency that needs to be treated by endovascular stent deployment. Rarely, these stents erode through the blood vessel wall and extrude into the airway or oropharynx. Here, we present the case of a 48-year-old male with a history of nasopharyngeal squamous cell carcinoma that had a Viabahn stent placed due to carotid blowout. Six months later, the stent was extruded into the airway and the patient coughed up the stent. The patient remained asymptomatic during stent extrusion and a computerized tomography angiography demonstrated cessation of flow in the carotid artery. This is a rare but serious side effect of stent placement in the setting of nasopharyngeal cancer and carotid blowout syndrome.

Intervening in the Acute Phase of Postradiation Carotid Blowout Syndrome.

Introduction Acute carotid blowout syndrome (aCBS) is a severe complication of head and neck cancer (HNC). It can be defined as a rupture of the extracranial carotid arteries, or one of their branches, that causes life-threatening hemorrhage, and which nowadays can be treated with urgent endovascular intervention. Objective We retrospectively evaluate the endovascular management of aCBS and its outcome in years of survival. Methods Retrospectively, we describe our experience with endovascular control of aCBS in patients treated for HNC. We review the characteristics, pathology, endovascular treatment and morbidity and assess the gain in life years. Results Nine individuals were included in this study. Four patients had been previously diagnosed with laryngeal squamous cell carcinoma (SCC), one with paranasal SCC, one with nasopharyngeal carcinoma and three with oral or maxillary adenocarcinoma. All subjects underwent radiotherapy and surgical excision to different extents. Twelve endovascular procedures were performed for injuries to the internal carotid artery ( n = 3; 25%), external carotid artery ( n = 1; 7%) or one of their branches ( n = 8; 67%). Deconstructive methods were used in nine procedures, and three procedures were mainly reconstructive with deployment of covered stents. Total control of bleeding was achieved in all individuals with no intraprocedural complications. Conclusion Endovascular therapy is an effective alternative for the management of exsanguinating CBS. In our series, this palliative therapy increased the overall patient survival by an estimated 9 months.

Carotid blowout syndrome: modern trends in management.

Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon complication of head and neck cancer that can be rapidly fatal without prompt diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity against the patient’s blood pressure, mainly in patients who have undergone surgical procedures and radiotherapy due to cancer of the head and neck, or have been reirradiated for a recurrent or second primary tumor in the neck. Among patients irradiated prior to surgery, CBS is usually a result of wound breakdown, pharyngocutaneous fistula and infection. This complication has often been fatal in the past, but at the present time, early diagnosis and modern technology applied to its management have decreased morbidity and mortality rates. In addition to analysis of the causes and consequences of CBS, the purpose of this paper is to critically review methods for early diagnosis of this complication and establish individualized treatment based on endovascular procedures for each patient.

Radiation Dose-Volume Tolerance for Hypofractionated Head-and-Neck Retreatments: A Report from the HyTEC Normal Tissue Complication Probability Working Group for Carotid Blowout Syndrome

Radiation Dose-Volume Tolerance for Hypofractionated Head-and-Neck Retreatments: A Report from the HyTEC Normal Tissue Complication Probability Working Group for Carotid Blowout Syndrome

Carotid Blowout Syndrome: A Rare Case of Bleeding Which Can Be Initially Missed in Patients

Introduction: There are two types of Carotid blowout syndrome (CBS): Threatened or type I carotid blowout refers to an exposed carotid artery as a result from a previous neck dissection or flap reconstruction. Impending or type II carotid blowout is seen in a patient with a short duration of acute hemorrhage that resolves spontaneously or controlled with applied pressure. Case Report: 69-year-old F presents to the Emergency Room with complaints of difficulty swallowing solids and liquids for the past 2-3 weeks. PET/CT and biopsy revealed T3N0M0 supraglottic squamous cell carcinoma and several rounds of chemo-radiation therapy were completed with a complete clinical response. With concern for airway obstruction, the patient underwent a tracheostomy and subsequent total laryngectomy for recurrence of the malignancy. Several weeks later, the patient was seen in the Emergency Room for difficulty in swallowing and food impaction. The obstruction was subsequently removed. On physical exam, the patient was a thin, cachectic, fully oriented and in no acute distress. The patient was admitted to the ENT service for esophageal stenosis with possible esophageal dilation. A nasogastric tube was subsequently placed, and the patient was observed to be sipping fluids without difficulty. After a few hours, she started vomiting large amounts (>500 cc) of bright red blood, passing clots and bleeding from the nose. ENT performed a flexible fiberscopic laryngoscopy, but no lacerations were seen and there was no active bleeding in the upper aerodigestive tract down. CT Angio of the neck revealed the injury to the distal branches of the external carotid artery as the location of the hemorrhage. The patient was taken for emergent embolization and 4 coils were successfully deployed in the right external carotid artery just distal to the occipital artery with a resolution of the bleed. Discussion: CBS continues to be a life-threatening complication in head and neck squamous cell carcinoma. CBS is typically seen in patients with head and neck cancers usually treated with radiation therapy which weakens the arterial wall and eventually leads to rupture. The gold standard for diagnosis is with angiography. Impending CBS in the 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.

Fitting NTCP models to SBRT dose and carotid blowout syndrome data

To estimate the radiobiological parameters of three popular NTCP models, which describe the dose-response relations of carotid blowout syndrome (CBOS) after stereotactic body radiotherapy (SBRT). To evaluate the goodness-of-fit and the correlation of those models with CBOS. The study included 61 patients with inoperable locally recurrent head and neck cancer treated with SBRT using CyberKnife (Accuray, Sunnyvale, CA) at the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey between June 2007 and March 2011. The dose-volume histograms of the internal carotid were exported from the plans of all the patients. The follow-up results regarding the end point of carotid blowout syndrome were collected retrospectively. Initially, univariable analyses (Wilcoxon rank-sum or Chi-square tests) and a multivariate logistic regression analysis were performed between the outcome data and a list of clinical and treatment factors to identify significant correlations. Additionally, the Lyman-Kutcher-Burman (LKB), Relative Seriality (RS), and Logit NTCP models were used to fit the clinical data. The fitting of the different models was assessed through the area under the receiver operating characteristic curve (AUC), Akaike information criterion (AIC), and Odds Ratio methods. The clinical/treatment factors that were found to have a significant or close to significant correlations with acute CBOS were Age at the time of CK (P-value=0.03), Maximum carotid dose (P-value=0.06), and CK prescription dose (P-value=0.08). Using Dmax , physical DVH, and EQD2Gy -DVH as the dosimetric metrics in the NTCP models, the derived LKB model parameters were: (a) D50 =45.8Gy, m=0.24, n=n/a; (b) D50 =44.8Gy, m=0.28, n=0.01; and (c) D50 =115.8Gy, m=0.45, n=0.01, respectively. The AUC values for the dosimetric metrics were 0.70, 0.68, and 0.61, respectively. The differences in AIC between the different models were less than 2 and ranged within ±0.9. The maximum dose to the internal carotid less than 34Gy appears to significantly reduce the risk for CBOS. Age at the time of CK, Maximum carotid dose, and CK prescription dose were also found to correlate with CBOS. The values of the parameters of three NTCP models were determined for this endpoint. A threshold of gEUD <34.5Gy appears to be significantly associated with lower risks of CBOS.

Verification of bleeding points in carotid blowout syndrome using guidewire manipulation.

Carotid blowout syndrome (CBS) is a catastrophic complication of aggressive treatment of head and neck cancer. Early detection of bleeding points with embolization is a life-saving procedure; however, some bleeding points may be difficult to identify. Our aim was to determine whether guidewire manipulation (GWM) could be used to verify bleeding point locations in patients with CBS. Of the 92 patients with CBS referred for embolization in a 5-year period, 14 men and one woman (mean age 58years) had bleeding points at locations that could not be definitely determined. We used GWM to verify the presence of these bleeding points. We assessed the anatomy of the ruptured arteries, technical details of GWM, and the angiographic and clinical outcomes. Bleeding points were difficult to detect because of the presence of small arterial pouches (n = 6) or multiple small arterial pouches (n = 9) in the unilateral or bilateral carotid arteries. Bleeding point locations were accurately identified using GWM in the internal carotid artery (n = 7), carotid bulb (n = 4), or common carotid artery (n = 4). Balloon-assisted GWM was applied in one patient. Fiber coils (n = 15) and/or liquid adhesives (n = 2) were used to occlude the affected artery. Endovascular management was technically successful in all patients and resulted in immediate cessation of hemorrhage without recurrence in a mean 22-month clinical follow-up. GWM is a simple and effective method for verifying bleeding points in ruptured arteries and preventing erroneous occlusion by embolization.

Prediction of Borderzone Infarction by CTA in Patients Undergoing Carotid Embolization for Carotid Blowout.

Permanent common carotid artery and/or ICA occlusion is an effective treatment for carotid blowout syndrome. Besides postoperative thromboembolic infarction, permanent common carotid artery and/or ICA occlusion may cause borderzone infarction when the collateral flow to the deprived brain territory is inadequate. In this study, we aimed to test the predictive value of CTA for post-permanent common carotid artery and/or ICA occlusion borderzone infarction in patients with carotid blowout syndrome. In this retrospective study, we included 31 patients undergoing unilateral permanent common carotid artery and/or ICA occlusion for carotid blowout syndrome between May 2009 and December 2016. The vascular diameter of the circle of Willis was evaluated using preprocedural CTA, and the risk of borderzone infarction was graded as very high risk, high risk, intermediate risk, low risk, and very low risk. The performance of readers' consensus on CTA for predicting borderzone infarction was excellent, with an area under receiver operating characteristic curve of 0.938 (95% confidence interval, 0.85-1.00). We defined very high risk, high risk, and intermediate risk as positive for borderzone infarction, the sensitivity, specificity, positive predictive value, and negative predictive value of CTA for borderzone infarction were 100% (7/7), 62.5% (15/24), 43.8% (7/16), and 100% (15/15), respectively. The interobserver reliability was excellent (κ = 0.807). No significant difference in the receiver operating characteristic curves was found between the 2 readers (P = .114). CTA can be used to predict borderzone infarction after permanent common carotid artery and/or ICA occlusion by measuring the collateral vessels of the circle of Willis.

Abstract No. 441 VIABAHN stent-graft placement for emergent/urgent cervical cerebrovascular artery disease: a single-center experience of 22 cases

To report our single-center experience of Viabahn stent-graft placement for acute bleeding or pseudoaneurysms of innominate, cervical carotid, or vertebral artery in emergent/urgent clinical conditions. A retrospective study was conducted between Jan 2003 and Sep 2017. A total of 22 patients (14 male, 8 female; age range 18–82 years, mean 55.8 years and median 56 years) were treated with 22 Viabahn stent grafts (9 carotid blow-out syndrome and 13 pseudoaneurysms with or without dissection: 4 innominate, 4 common carotid, 12 internal carotid, 1 both common and internal carotid, and 1 vertebral artery involvement). The stent-graft patency was evaluated by angiogram, contrast-enhanced CT, MRA, ultrasonography, or direct observation during surgery. The mean and median imaging follow-up periods were 740 and 193 days, respectively. Technical success was 100% (22/22). Dual antiplatelet agents were given in 20 patients either immediately before or after the deployment of the stent-grafts. No immediate procedure-related complications occurred. Two unstable patients with carotid blow-out syndrome died of severe systemic disturbance within 8 days, despite successful bleeding cessation by the procedure. Three patients underwent subsequent bypass surgery within 17 days for concern about infection. One stent-graft occlusion occurred 195 days after the procedure with unexpected cession of antiplatelet therapy. One significant hemorrhagic complication was observed and died 125 days after the procedure (esophagocutaneous fistula). Two patients were lost to follow-up. Among the remaining 13 patients, 11 patients demonstrated 6 months or longer stent-graft patency and 2 developed more than 50% stenosis. Viabahn stent-grafting may be safe and useful for the management of emergent/urgent arterial bleeding or pseudoaneurysms involving cervical cerebrovascular arteries.

Ruptured extracranial carotid artery: Endovascular treatment with covered stent graft

Background and purposeRupture of the extracranial carotid artery is a rare, but potentially disastrous event. We aimed to review the clinical presentations and radiologic findings of this entity and to evaluate the efficacy of endovascular treatment with covered stent graft. Materials and methodsSince January 2009, eight patients with extracranial carotid artery rupture received endovascular treatment with covered stent graft. We retrospectively reviewed their medical records and radiologic findings. ResultsThe ruptured sites were in the common carotid artery (n=5), cervical ICA (n=2) and petrous ICA (n=1), respectively. The causes of injury included spontaneous (n=2), carotid blowout syndrome (CBS) (n=2), iatrogenic (n=2) and traumatic (n=2). Technical success and immediate hemostasis were achieved in all cases. Procedure-related complications occurred in 3 patients (37.5%). In a patient, the ipsilateral angular branch of the MCA was occluded during the procedure and it was completely reopened via mechanical thrombectomy without any neurologic deficit. Minor cerebral infarction was developed in 2 patients (25%). During a mean follow-up of 334 days (range 3–2053 days), two patients died: one from recurrent CBS and the other from aspiration pneumonia. ConclusionsThe covered stent grafting is an effective method for the treatment of extracranial carotid artery rupture.

Abstract TMP108: Stroke Prediction for Patient Undergoing Carotid Artery Occlusion for Carotid Blowout Syndrome Using Computed Tomography Angiography of the Circle of Willis

Permanent common and/or internal carotid artery occlusion (PCO) is an effective treatment for carotid blowout syndrome (CBS). However, PCO may cause stroke, especially border zone infarction, when the collateral flow to the deprived brain territory is insufficient. In this study, we aimed to test the predictive value of collateral reserve on computed tomography angiography (CTA) for assessing post-PCO stroke risk in patients with CBS. In this retrospective institutional review board–approved study, we included 31 patients receiving unilateral PCO for CBS between May 2009 and December 2016. Two neuroradiologists evaluated all preprocedural CTA to determine the collateral reserve of the circle of Willis. The risk of post-PCO stroke was graded into very high risk, high risk, intermediate risk, low risk, and no risk, and were subjected to receiver operating characteristic curve analysis. Defining the very high risk and high risk groups as positive, the performance of reader’s consensus on CTA for predicting border zone infarction was excellent, with an area under receiver operating characteristics curve of 0.938 (95% confidence interval: 0.85–1.00). The overall sensitivity, specificity, positive predictive value, and negative predictive value was 85.7%, 87.5%, 66.7%, and 95.5%, respectively. The interobserver reliability was excellent (κ = 0.807). No significant difference in the receiver operating characteristics curves were found between the two readers (P = 0.114). In conclusion, CTA can be used to predict border zone infarction after PCO by measuring the collateral reserve of the circle of Willis.

Outcome of carotid and subclavian blowout syndrome in patients with pharynx- and larynx carcinoma passing a standardized multidisciplinary treatment

Background: Carotid blowout syndrome (CBS) is one of the most feared emergencies in the head and neck surgery and tends to occur in patients with head and neck cancer, wound complications, pharyngocutaneous fistulas, or after radio(chemo)therapy. CBS is always life threatening and associated with a 50% mortality/morbidity rate.Methods: Between 2007 and 2015, a total of 51 patients who developed CBS caused by the tumour masses or after radio(chemo)therapy were included. All patients underwent a standardised bleeding management.Results: In 86% of patients, CBS was associated with manifest carcinoma. Fifty three percent of patients were treated by transcervical surgery, in 36% of these cases surgery was supplemented by endovascular approaches. Severe complications such as re-bleeding or cerebral ischemia occurred infrequently. Seven patients died because of the acute bleeding.Conclusion: CBS associated with head and neck cancer carries poor mid and long-term prognoses. An interdisciplinary standardised treatment path dramatically reduced overall morbidity and mortality.

Carotid Dosimetry and the Risk of Carotid Blowout Syndrome After Reirradiation With Head and Neck Stereotactic Body Radiation Therapy

Tocorrelate carotid dose and risk of carotid blowout syndrome (CBOS) after stereotactic body radiation therapy (SBRT), hypothesizing that carotid dose does not correlate with CBOS. We retrospectively reviewed 186 patients with recurrent, previously irradiated head and neck cancer treated between January 2008 and March 2013. Patients treated early in our experience with incomplete dosimetry were excluded from analysis (n = 111). A total of 75 patients were identified, providing 150 carotid arteries for analysis. Median follow-up was 8months (range, 1-91months) for all patients, and 37months for surviving patients (range, 31-91months). Patients were treated with linear accelerator-based SBRT to a median dose up to 44Gy (range, 40-50Gy) in 5 fractions delivered on a twice-weekly basis. Concurrent cetuximab was used in 63 patients (84%). The bilateral common, internal, and external carotid arteries were delineated 2cm above and below the planning target volume. The maximum dose to 0.1cm3 (D0.1cc), 1cm3 (D1cc), and 2cm3 (D2cc) of the carotid and the mean carotid dose from SBRT were recorded and analyzed for association with carotid bleeding events, using binary logistic regression. Median reirradiation interval was 20months (range, 3-423months), and median prior radiation dose was 70Gy (range, 52.5-140Gy). Sixteen patients (21.3%) received more than 1 course of SBRT, and the cumulative carotid doses from fused summary plans were recorded. The overall median D0.1cc, D1cc, D2cc, and mean carotid doses were 40.8Gy (interquartile range [IQR], 21.6-47.6Gy), 26.8Gy (IQR, 14.1-42.1Gy), 15.4Gy (IQR, 8.4-32.7Gy), and 15.0Gy (IQR, 8.9-23.3Gy), respectively. There were a total of 4 bleeding events (5.3%): 2 patients (2.7%) had mucosal bleeds that resolved after embolization of carotid branches, and 2 patients (2.7%) died from complications of CBOS. In the 2 patients with CBOS the D0.1cc was 48.4Gy and 47.6Gy, respectively. There was no significant association between bleeding events and D1cc (P = .280), D2cc (P = .571), or mean dose (P = .568). There was a trend toward increased risk of bleeding and D0.1cc (P = .080). These results demonstrate a low risk of bleeding after reirradiation with SBRT when 5 fractions are delivered on nonconsecutive days, even when tumor is completely encasing the carotid artery. Although limited by the low number of events, no significant association was found between dose-volume parameters and the risk of carotid bleeding. No CBOS was noted when D0.1cc was <47.6Gy.

Safety and effectiveness of endovascular embolization or stent-graft reconstruction for treatment of acute carotid blowout syndrome in patients with head and neck cancer: Case series and systematic review of observational studies.

Indications for treatment and outcomes after endovascular management of carotid blowout syndrome for patients with head and neck cancer are not well defined. We investigated the safety and effectiveness of endovascular embolization and stent-graft reconstruction. A literature review was performed for studies published between 2001 and 2015 with relevance to treatment outcomes. Our institutional database was examined to identify patients treated with endovascular techniques. A total of 266 patients were included. Rates of procedural stroke were higher after embolization of internal carotid artery (ICA)/common carotid artery (CCA) compared to stent graft (embolization 10.3%; stent graft 2.5%; P < .02). Stent graft of ICA/CCA was associated with higher rates of recurrent bleeding (embolization 9.1%; stent graft 31.9%; P < .01). Both embolization and stent grafts are safe therapeutic options for acute carotid blowout syndrome. Embolization for ICA/CCA carotid blowout syndrome was associated with higher risks of procedural stroke and lower recurrent bleeding compared to stent grafts.

Delayed extrusion of embolic coils into the airway after embolization of an external carotid artery pseudoaneurysm

Carotid blowout syndrome (CBS) is a known devastating complication of head and neck surgery. The risk of developing CBS increases in the setting of radiation therapy, wound breakdown, or tumor...

Operative management of catastrophic bleeding in the head and neck

The otolaryngologist commonly performs several procedures in close proximity to the carotid and innominate arterial systems. In this article, we will discuss the management of catastrophic bleeding following adult tonsillectomy and tracheostomy, as well as the management of carotid blowout syndrome in head and neck cancer patients. Although the bleeding risk from tonsillectomy is considered very low, the acceptance of transoral robotic surgery as a treatment modality of oropharyngeal head and neck carcinomas makes the spectre of catastrophic oropharyngeal bleeding more real. Aggressive resection in this area can leave minimal parapharyngeal fat over the carotid artery and damage from manipulation of smaller vessels can lead to pseudoaneurysms. Tracheostomy also carries a very low but real risk of trachea-innominate artery fistula, which has devastating consequences. Finally, we will discuss how to identify head and neck cancer patients who are at risk for carotid blowout syndrome as well as appropriate interventions to manage this condition.

Effect of intratumoral abscess/necrosis on the outcome for head and neck cancer patients treated by hypofractionated stereotactic re-irradiation using CyberKnife®.

The aim of the present study was to elucidate the effect of intratumoral abscess/necrosis (AN) on the outcome of patients with recurrent head and neck cancer (HNC) treated by stereotactic radiotherapy. The records of 67 patients treated with CyberKnife® in four institutes between August 2000 and July 2010 were reviewed. The frequency of AN appeared to be increased in younger postoperative patients with large ulcerative tumors. The AN+ group exhibited a better initial response rate compared with the AN− group (64 vs. 33%, respectively; P=0.04). The 1-year local control rate was 51 and 75% in the AN+ and AN− groups, respectively (P=0.01), while the respective 1-year overall survival rates were 53 and and 71% (P=0.0004). A total of 21 patients (31%) experienced grade ≥3 toxicities, and carotid blowout syndrome (CBOS) was found in 11 patients, resulting in 8 deaths. A significantly larger proportion of patients in the AN+ group developed CBOS (8/18; 44%) compared with the AN− group (3/49; 6%) (P=0.001). Therefore, AN may be an important prognostic factor for patients with recurrent HNC, as well as a predictor of lethal toxicity due to CBOS.