Fatal carotid blowout syndrome after BNCT for head and neck cancers

doi:10.1016/j.apradiso.2015.08.007

Applied Radiation and Isotopes

Volume 106, December 2015, Pages 202-206

https://doi.org/10.1016/j.apradiso.2015.08.007 Get rights and content

Highlights

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This study is fatal carotid blowout syndrome after BNCT for head and neck cancers.
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Thirty-three patients in our institution who underwent BNCT were analyzed.
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Two patients (2/33) developed CBS.
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The presence of skin invasion from recurrent lesions after irradiation is an ominous sign of CBS.
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We must be aware of these signs to perform BNCT safely.

Abstract

Boron neutron capture therapy (BNCT) is high linear energy transfer (LET) radiation and tumor-selective radiation that does not cause serious damage to the surrounding normal tissues. BNCT might be effective and safe in patients with inoperable, locally advanced head and neck cancers, even those that recur at previously irradiated sites. However, carotid blowout syndrome (CBS) is a lethal complication resulting from malignant invasion of the carotid artery (CA); thus, the risk of CBS should be carefully assessed in patients with risk factors for CBS after BNCT. Thirty-three patients in our institution who underwent BNCT were analyzed. Two patients developed CBS and experienced widespread skin invasion and recurrence close to the carotid artery after irradiation. Careful attention should be paid to the occurrence of CBS if the tumor is located adjacent to the carotid artery. The presence of skin invasion from recurrent lesions after irradiation is an ominous sign of CBS onset and lethal consequences.

Introduction

Boron neutron capture therapy (BNCT) has attracted attention as a potential therapy for recurrent and advanced head and neck tumors. Currently, clinical trials are being conducted to verify the usefulness of BNCT for head and neck cancers (Suzuki et al., 2014). However, carotid blowout syndrome (CBS) has become a serious complication of BNCT because of the life-threatening toxicity associated with this therapy. Determining the characteristics of CBS is important for the safe use of BNCT. Until now, the precise prediction and prevention of CBS after BNCT remain to be achieved. In this work, we explored the risk factors for CBS after BNCT.

Section snippets

Patients and methods

Between October 2003 and December 2011, we treated 33 new and recurrent head and neck cancer patients using BNCT. The indications for BNCT were as follows: (1) newly diagnosed T3/T4 advanced and recurrent head and neck cancer (HNC), (2) a maximum tumor depth within 5 cm from the skin surface to achieve a curative dose to the target using an epithermal neutron beam, and (3) a tumor/normal tissue boron concentration ratio (T/N ratio)>2.5. The T/N ratio is calculated from the results of¹⁸

Results

Table 2 shows the clinical results of the 18 patients. After BNCT, two patients developed CBS that proved fatal; the survival time after CBS onset was approximately 2 month. Two common features were found in these patients: (1) Skin defects were caused by tumor invasion, and (2) Recurrence occurred close to the carotid artery after irradiation. The course of these two patients from post-BNCT to CBS was 1 month after BNCT in one (mid-involvement IG) and 2 months after BNCT in the other case

Discussion

CBS is one of the most devastating complications of head and neck cancer. It generally occurs as a postoperative complication or when the tumor compromises the vascular axis (Esteller et al., 2012). This hazardous complication usually presents as an acute trans-oral or trans-cervical hemorrhage and is accompanied by high rates of mortality and neurological morbidity (Yung-Shang Lin et al., 2015). CBS after BNCT refers to the clinical signs and symptoms related to rupture of the carotid artery,

Conclusion

BNCT is effective for head and neck cancer. However, widespread skin invasion and recurrence after irradiation are risk factors for CBS after BNCT. Careful attention should be paid to the development of CBS if the tumor is located adjacent to the carotid artery. The presence of skin invasion from recurrent lesions after irradiation is an ominous sign of CBS onset and lethal consequences in terms of CBS onset. We must be aware of these signs to perform BNCT safely. This BNCT protocol for

Conflicts of interest

None.

Acknowledgments

This work was supported by JSPS for Scientific Research (C) Number 24592611.

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There are more references available in the full text version of this article.

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Citation Excerpt :
The importance of this review is that carotid artery evaluation was not regularly conducted before BNCT in most institutes. Previous Japanese studies have found that the incidence rate of CBS in patients who receive BNCT of the head and neck region is about 5%.14,15 In a systemic review involving 27 published articles and more than 1500 patients with salvage re-irradiation for head and neck cancers, an incidence rate of 2.6% was reported, with 76% of the CBS episodes being fatal.4
The incidence rate of oral and pharyngeal cancers in Taiwan has increased gradually over the past few decades. The standard treatment strategy for oral and pharyngeal cancers includes surgery or radiotherapy, with concurrent chemotherapy in certain types of tumors. Unfortunately, in-field recurrence is sometimes inexorable. Furthermore, re-irradiation of the recurrence site may cause severe complications due to the tolerance of normal tissue to radiation therapy. One fatal complication is carotid blowout syndrome (CBS). Boron neutron capture therapy (BNCT) is a new modality of radiation therapy, which is also mentioned as targeted radiotherapy. It is a feasible treatment that has the potential to spare normal tissue from being damaged by irradiation while simultaneously treating the primary tumor. In this presentation, we will share our experience with BNCT in treating recurrent head and neck cancers, as well as the prevention and management of CBS.
We evaluated 4 patients with head and neck cancers treated by BNCT in Taiwan. All patients had undergone surgery previously and had received postoperative concurrent chemoradiotherapy.
The 4 patients in this study were diagnosed with head and neck malignancies. The median follow-up period after the first course of BNCT was 15.1 months. After BNCT, 2 patients developed impending CBS, and 1 of them died. The remaining 3 patients survived until the last date of follow-up.
Pre-BNCT carotid artery evaluation through computed tomography angiography and early intervention if necessary is crucial when treating patients with recurrent head and neck cancers by BNCT.
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Fatal carotid blowout syndrome after BNCT for head and neck cancers

Highlights

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

Conflicts of interest

Acknowledgments

Appl. Radiat. Isot.

Boron neutron capture therapy outcomes for advanced or recurrent head and neck cancer

J. Radiat. Res.

SERA an advanced treatment planning system for neutron therapy and BNCT

Trans. ANS

Neutron irradiation under continuous BPA injection for solving the problem of heterogenous distribution of BPA

Carotid blow-out syndrome: a new complication of chemoradiotherapy treatment in pharyngolaryngeal carcinoma

J. Laryngol. Otol.