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Original Investigation |

Impact of Surgical Resection on Survival in Patients With Advanced Head and Neck Cancer Involving the Carotid Artery

Nauman F. Manzoor, MD1; Jonathon O. Russell, MD1; Aliye Bricker, MD2; Shlomo Koyfman, MD3; Joseph Scharpf, MD1; Brian Burkey, MD1; Mumtaz J. Khan, MD1
[+] Author Affiliations
1Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
2Department of Diagnostic Neuroradiology, Cleveland Clinic Foundation, Cleveland, Ohio
3Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
JAMA Otolaryngol Head Neck Surg. 2013;139(11):1219-1225. doi:10.1001/jamaoto.2013.4917.
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Importance  The present study addresses the survival benefit of aggressive surgical treatment of head and neck cancer involving the carotid artery.

Objective  To assess survival outcomes in patients treated for advanced squamous cell carcinoma involving the carotid artery using different treatment strategies.

Design, Setting, and Participants  Retrospective study at a tertiary care center of 44 consecutive patients with squamous cell carcinoma involving the carotid artery from 2005 to 2012 with a median follow-up of 12 months. The radiologist was blinded to the outcome of surgical procedures.

Interventions  Surgery with or without radiotherapy, and definitive chemoradiation.

Main Outcomes and Measures  Overall survival and rates of locoregional and distant failures. The hypothesis was formulated before data collection.

Results  Of 44 patients, 35 (80%) were treated with curative intent with surgery with or without adjuvant therapy (n = 27 [61%]) or definitive chemoradiation therapy (n = 8 [18%]), while 9 patients (21%) were treated in a palliative fashion. Patients treated with curative intent had improved overall survival (median survival, 13.5 months) compared with the palliative group (median survival, 3.6 months) (P = .001). Of patients treated with curative intent, those with previously untreated disease (n = 14 [40%]) had an improved outcome relative to patients with recurrent or persistent disease (n = 21 [60%]), with median survival of 38.7 and 9.6 months, respectively (P = .008). Patients were treated with curative intent using 3 different treatment strategies (ie, carotid artery resection with or without reanastamosis) (n = 6 [17%]), curative peeling with or without adjuvant therapy (n = 21 [ 60%]), and definitive chemoradiation therapy (n = 8 [23%]). Survival outcome was not significantly different between subgroups treated with curative intention (P = .47). When reviewed by a head and neck radiologist in a blinded fashion (n = 30), preintervention imaging had a positive predictive value of 72.7% for resectability of cancer involving the carotid artery. In cases with almost circumferential involvement (>270°) and narrowing of the carotid artery, the disease was unresectable (n = 3).

Conclusions and Relevance  Advanced head and neck cancer involving the carotid artery can be treated with curative intent with favorable results in most patients. If disease burden merits, an aggressive approach involving resection with or without reanastamosis of the carotid artery can be used without significant added morbidity.

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Figure 1.
Overall Survival in Patients Treated With Curative vs Palliative Intent

Kaplan-Meier plots of survival probability in patients with regional metastatic disease involving the carotid artery. A, Patients treated with a curative intent had a significantly better survival compared with the palliative group (P = .001). B, Patients with recurrent or persistent disease had a worse survival rate than previously untreated patients with advanced regional metastatic (P = .008).

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Figure 2.
Overall Survival in Patients Treated With Curative Intent Using Different Treatment Modalities

Kaplan-Meier plots of survival probability in patients with regional metastatic disease involving the carotid artery. A, Patients treated with curative intent with different strategies had no significant difference between groups (P = .47). B, Patients treated with curative peeling of the tumor had no significant difference with respect to postoperative adjuvant therapy (P = .18).

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Figure 3.
Degree of Involvement of the Internal Carotid Artery (ICA) in Different Treatment Groups

Axial contrast-enhanced computed tomographic scan in a patient with unresectable recurrence involving the carotid artery. A, The tumor (black arrows) is seen both encasing and narrowing the right ICA (white arrow). B, Degree of carotid artery encasement. CRT indicates chemoradiation therapy.

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