From the Guidelines
The carotid bifurcation is the most commonly involved segment in cases of nodal squamous cell carcinoma (SCC) with carotid involvement. In cases of nodal SCC, the carotid bifurcation is anatomically positioned where cervical lymph nodes frequently drain, making it particularly vulnerable to tumor invasion from metastatic nodal disease 1. This area also has less protective adventitial tissue compared to other segments of the carotid artery, facilitating tumor invasion. Some key points to consider in the context of carotid involvement in nodal SCC include:
- The approach to staging and posttreatment imaging varies and depends on the anatomic site and pathology, with initial staging directed at establishing the correct tumor, nodal, and metastases (TNM) staging 1
- A comprehensive evaluation of adenopathy is performed for nodal “N” staging purposes, comprising laterality, size of nodes, and, in the case of nasopharynx, nodal level 1
- Presence of nodal metastases typically results in upstaging of the disease and will change treatment planning, including the extent of neck dissection or radiation field 1 Understanding the predilection for bifurcation involvement is important for surgical planning and management of these challenging cases.
From the Research
Carotid Involvement in Nodal Squamous Cell Carcinoma (SCC)
- Carotid artery invasion is a severe mortality predictor in head and neck squamous cell carcinoma 2
- Advanced head and neck cancer involving the carotid artery can be treated with curative intent with favorable results in most patients 3
- Carotid resection can be performed with an acceptable cerebral risk in selected patients, and preoperative carotid occlusion seems to result in decreased postoperative mortality and morbidity rates 4
Surgical Approaches
- Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients 2
- Carotid artery resection with or without reanastamosis, curative peeling with or without adjuvant therapy, and definitive chemoradiation therapy are different treatment strategies used in patients with curative intent 3
- Tumor peel-off is preferred to carotid resection to reduce mortality and cerebrovascular complication, unless the middle layer of the artery wall is involved 5
Treatment Outcomes
- Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0% in patients who underwent carotid resection and saphenous vein graft revascularization 2
- Median survival was 13 months and 1,2,3,5-year overall survival rate was 44.6%, 16.2%, 12.5%, 8.3% respectively in patients with metastatic squamous carcinoma involving carotid artery 5
- Covered stent implantation combined with radical tumor resection yields similar survival outcomes compared with conventional carotid artery resection and reconstruction, but with significantly lower surgical risk and difficulty, and faster postoperative recovery 6