Head and Neck Cancers Program: Redefining Resectability in Head & Neck Cancers

Transcript

• 00:00The Yale Smilow Cancer Center CME
• 00:04event on head and neck cancer.
• 00:07We are really happy to have you
• 00:09all join us and we're very happy to
• 00:13have these illustrious speakers.
• 00:14It's an interesting topic that I
• 00:17think I hope you find interesting.
• 00:20I mean, you're logging in,
• 00:21you saw the program, so,
• 00:23you know, obviously you do.
• 00:26This is interesting because our
• 00:29speakers in talking about redefining.
• 00:31Resectability and head and neck cancer.
• 00:34None of them are actually had an
• 00:36extra cancer surgeons, interestingly.
• 00:37But I think that's just speaks
• 00:40to the importance of having a
• 00:43multidisciplinary team in some of our
• 00:45most challenging head neck cancer cases.
• 00:48So we have 4 speakers today and our
• 00:53first talk is by Doctor Mandell.
• 00:57He is a professor of neurosurgery,
• 00:59executive vice chair and
• 01:01the director of Yales.
• 01:02Spine oncology program.
• 01:05Spine tumor program.
• 01:08He's going to be speaking to us
• 01:09about the surgical management
• 01:11of head and neck spine tumors.
• 01:13We often look at these types of tumors.
• 01:15We look at their imaging and we
• 01:16kind of shriek and we wonder
• 01:17what to do as head next to it.
• 01:19And even some of the, you know, the,
• 01:20the advanced head next turn would
• 01:21do some of the craziest surgery.
• 01:23But when it starts involving the spine,
• 01:25we often start thinking about
• 01:27unresectable ability palliative.
• 01:28But we're going to hear doctor
• 01:31Mandell's perspective on this.
• 01:32Thank you,
• 01:33doctor Mendel.
• 01:34Thank you, guys. So thank you sell
• 01:38for inviting me to to give this talk.
• 01:42I've asked to talk about the surgical
• 01:44management of head and explaine tumors.
• 01:46So Justin, I wanted to start with a couple
• 01:49of generic slides in a sense that spine
• 01:51tumors involving all cancer types and can
• 01:54be aggressive and debilitating causing
• 01:56significant amount of pain and rapid
• 01:59development of neurological problems.
• 02:00So especially when it comes to the
• 02:02neck cervical problems, patient can
• 02:05progress to paraparesis paralysis,
• 02:07typically it can affect arms,
• 02:09legs, bowel, bladder fraction,
• 02:10increase all kind of problems.
• 02:12And so the uniqueness of spine
• 02:14oncology is that we're dealing with.
• 02:16All type of cancers and a lot of
• 02:18these cancers ended up in the neck.
• 02:20So some of that wanted to start with
• 02:22these crazy slide at once I put
• 02:25together and that is operative decision
• 02:26of algorithm of how to manage a lot
• 02:29of these problems as so mentioned
• 02:31you start seeing these lesions in
• 02:33the neck like what are you going
• 02:35to do and all of these things that
• 02:36you see here and maybe not a lot of
• 02:38science into what we do makes the the
• 02:41decision making it very difficult
• 02:43and not just that there's actually
• 02:45a paper that published that the.
• 02:47Impact of weekend hospital admissions on
• 02:50the timing of intervention and outcome
• 02:53after surgery shows that if we get.
• 02:55Called for tumour cases on a Friday,
• 02:58Saturday or Sunday.
• 02:59Sometimes we don't do the same
• 03:01thing if we get called on a Monday,
• 03:03Tuesday or Wednesday.
• 03:06So anyway,
• 03:06what's the uniqueness about this patient
• 03:08population? You all know about this.
• 03:09I'm gonna go these streets very quickly.
• 03:11These are sick patients.
• 03:13There's a long list of issues,
• 03:16including specifically to the spine,
• 03:18unlikely fusion, poor bone quality,
• 03:20hardware failure, and then timing of surgery.
• 03:23When is the right time to do surgery?
• 03:25These are all things that are
• 03:27going to go very fast.
• 03:28But these patients are immunocompromised
• 03:30because of decreased white cells.
• 03:32There's issues with infected
• 03:33vertebroplasty is now.
• 03:35Their nutritional status is not that great.
• 03:37They have problems with the
• 03:38fact that they are on steroids,
• 03:40which leads to all kind of, you know,
• 03:42side effects associated with that.
• 03:45A lot of these patients are coagulopathic.
• 03:49And from our point of view,
• 03:51uh,
• 03:52a lot of these cases require a
• 03:53plastic closure secondary to the
• 03:55fact that these patients may have
• 03:57already previously been radiated.
• 03:59They may need flaps,
• 04:00they may need the vascularized bone grafts.
• 04:03Sometimes these wounds are big
• 04:05issues for us in spine surgery.
• 04:08This is a patient who had a sarcoma
• 04:11involving the posterior neck muscles
• 04:14that's been resected locally three or
• 04:16four or five times and ultimately.
• 04:19Uh,
• 04:19this cancer have invaded all the
• 04:22power musculature off the neck.
• 04:25The spine itself was not involved,
• 04:26but all the muscle itself were
• 04:28involved with the tumor and we
• 04:30ended up resecting it.
• 04:32And this is the kind of
• 04:33hardware that we ended
• 04:34up needing to put there because
• 04:36all the posterior musculature
• 04:37has been removed from the neck.
• 04:39So clearly, you know,
• 04:40this is some of the stuff that we can do,
• 04:44but we need our colleagues to be
• 04:46able to close this and actually
• 04:48publish the paper with the.
• 04:49Plastic colleagues,
• 04:50Ian Valeria is right now the head of
• 04:53plastic at the at the at the MGH that
• 04:56it is a multidisciplinary approach for
• 04:59complex oncological spine coverage.
• 05:01A lot of these cases require really a big
• 05:04consultation with our plastic colleagues.
• 05:06So when it comes to to spine tumors,
• 05:08the two kinds that we're talking
• 05:10about are the metastatic spine
• 05:12tumors and the primary bone tumors.
• 05:14They are very distinct different
• 05:17surgical plans.
• 05:18If it's primary tumors then really we're
• 05:20trying to cure the patient of cancer
• 05:22by removing the cancer or at least
• 05:25the long term survival if it's metastatic,
• 05:27the plan is palliation.
• 05:29Adjuvant therapy for primary
• 05:30is very limited for metastatic.
• 05:33There is some adjuvant therapy available
• 05:35and then when it comes to the surgical
• 05:37technique for primary bone tumors,
• 05:39we're really trying to figure out
• 05:41a way not to get into the tumor
• 05:43itself so we minimize spillage.
• 05:44And potential recurrence.
• 05:45So we need to clean margins
• 05:47around it versus metastatic,
• 05:49which is really most of
• 05:50the time intralesional.
• 05:51Even though this is not a neck case,
• 05:56I wanted to present it just for.
• 05:59Explaining this principle,
• 06:00this is a 51 year old who comes in
• 06:03with one week of progressive foot
• 06:05weakness and bound bladder dysfunction.
• 06:07And you can see right here that there is a a,
• 06:10a lesion in the sacrum that's
• 06:12filling up the sacral canal.
• 06:14The question is whether to take these
• 06:16guys to surgery because there's bound
• 06:18bladder incontinence and foot weakness.
• 06:20This patient was take it for an
• 06:22emergent decompression of the nerve
• 06:24roots and you can see a few more cuts,
• 06:26but the intraoperative biopsy
• 06:27came back as cancer sarcoma,
• 06:29which is a primary bone.
• 06:31These primary bone tumors require unblocker
• 06:33section and not any traditional resection.
• 06:36Where you're getting into the tumor,
• 06:38it's over this, this.
• 06:39There's no clean margins.
• 06:41This tumor is going to recur.
• 06:43The clearly the patient symptoms
• 06:44got better after the decompression.
• 06:46The bowel,
• 06:47bladder symptoms got better,
• 06:48the food weakness got better,
• 06:50but the patient ended up coming back
• 06:53complaining of some boldness and he says
• 06:55the school is sticking out of my back.
• 06:57Can you revise it?
• 06:59And this is how he presented.
• 07:01And you can see this little
• 07:02bump in the back of his back.
• 07:03There was a year after his surgery and
• 07:05that bumped you can see in the red.
• 07:07You know was not as cool poking up.
• 07:10This is a recurrence of tumor for an
• 07:13unfortunate intralesional resection.
• 07:15The transferring rendering
• 07:17having cancer forever.
• 07:19The only chance that he had
• 07:20was with his first surgery.
• 07:21He also had a broken rod that
• 07:24ultimately require removing this bump
• 07:27Unblocker section of this little mass,
• 07:29knowing that it's not going to be curative,
• 07:32and then devising is construct and then
• 07:34doing a huge flap to be able to close
• 07:37this one in order to clean this up.
• 07:39So I call it Bo, the triple W,
• 07:41the wrong operation on the wrong
• 07:43patient by the wrong surgeon.
• 07:45Sometimes you gotta know
• 07:46what it is you you doing.
• 07:48And from our point of view
• 07:50is no surgeons sometimes,
• 07:51sometimes we put such a huge emphasis
• 07:53on the neurological aspect, they've
• 07:55bowel bladder incontinence or foot weakness.
• 07:58But a lot of these cases you got to
• 08:00think about is an oncologist first.
• 08:02When it comes to knowing whether you dealing
• 08:03with the primary tumor or made a study,
• 08:05you gotta know the biopsy,
• 08:06you gotta know what the results are.
• 08:09This always will allow you to establish
• 08:11whether you're dealing with the primary bone
• 08:14tumor versus versus metastatic disease.
• 08:16This is a patient with a
• 08:17codoma quote UN quote.
• 08:18It was read they didn't wanna do a biopsy,
• 08:20but this it turns out to be an ependymoma
• 08:23which was a completely different scenario.
• 08:25So how do you do these biopsies?
• 08:27You can see right here in the neck a
• 08:29very large cervical with suspicious
• 08:31of the cervical called DOMA and in
• 08:34the sacrum and other large suspicious
• 08:36of cervical chordoma.
• 08:37You do not want to do a biopsy to the mouth.
• 08:40The the biopsy person are going
• 08:42to look through the path of least
• 08:44resistance and the shortest.
• 08:46Path,
• 08:46they obviously would like to go to the mouth.
• 08:48It's right there.
• 08:49And if you suspect that it's
• 08:51a primary bone tumor,
• 08:53don't go through the mouth because we
• 08:55can't resect it in an unblocked fashion.
• 08:57That track is going to be contaminated,
• 08:59so either go from the back.
• 09:01Uh, and stay very close to the midline.
• 09:03Here is what we do when we mark
• 09:05these incision,
• 09:06these biopsy tracks we can get around
• 09:08include the track with the specimen
• 09:10is a couple of examples on the sake
• 09:13of chordomas where the track site
• 09:16is included within the resection
• 09:17itself and then the track and the
• 09:20sacrum here came out in one piece.
• 09:22Stay away from having putting
• 09:24those needles very far away.
• 09:25Make sure that you're either posterior
• 09:27or very close to the midline so
• 09:29that you can reset the track.
• 09:31With the biopsy.
• 09:32So again these are the primary
• 09:34versus the metastatic disease.
• 09:36Always think when it comes to surgery
• 09:38whether this is an unblocker section
• 09:40for primary bone tumors when the tumor
• 09:43borders are not violated or whether
• 09:45you do intralesional resection.
• 09:47Metastatic lesions are typically
• 09:49intralesional resections.
• 09:51It's a very prominent disease
• 09:531.2 millions a year,
• 09:55about half death per year.
• 09:57It's a major cause of death
• 09:59complication due to metastatic disease,
• 10:00and the skeletal system is the
• 10:02third most common site.
• 10:03The spine is the most common
• 10:05sight of skeletal Mets,
• 10:06and as many as 90% of cancer patient
• 10:08will have spinal metastases and up to
• 10:1130 of those will have neck pain
• 10:13or some neurological issues.
• 10:14So here's a case that the Charles actually
• 10:16is very familiar with and I thought,
• 10:19well, this might as well presented.
• 10:20This is a 67 year old lady who has.
• 10:22How would cancer start having significant
• 10:25amount of neck pain and radicular pain?
• 10:27And you can see right here on the
• 10:29X-rays that there is a pathologic
• 10:31fracture of the cervical spine.
• 10:33She's unable to move her neck well,
• 10:35she's already having radiculopathy,
• 10:37and this is clearly a metastatic
• 10:40disease related to thyroid cancer.
• 10:42Yeah, what are you gonna do about it?
• 10:43We obviously not going for
• 10:45a curative disease here,
• 10:46but pain is an indication for
• 10:49surgery and neurological issues many
• 10:52times is indication for surgery.
• 10:54You can see the MRI,
• 10:55there is code compression.
• 10:57The body is involved with
• 10:59tumor proven as thyroid cancer.
• 11:01The the the the the spinal
• 11:03cord is compressed.
• 11:05She's at risk of losing function and
• 11:07already have a lot of neck pain.
• 11:08You can see on this on the axial
• 11:10view that the vertebral artery.
• 11:12Is involved with tumor.
• 11:13This is not gonna be a curative disease.
• 11:16And again,
• 11:17you can see there's a little bit of
• 11:19tumor poking behind the vertebral
• 11:20body above the vertebral artery is
• 11:22clearly engulfed by these tumor.
• 11:24The CT scan shows pathologic fracture.
• 11:26This patient has significant
• 11:28mechanical neck pain.
• 11:29Is this spine stable or unstable?
• 11:31You can see right here that we have
• 11:33many ways of figuring out basis
• 11:35on all kind of you know tables of
• 11:37deciding whether this is a stable
• 11:39neck or whether there's a chance
• 11:41that this can continue to break.
• 11:43And then with thyroid cancer,
• 11:45these are highly vascular tumors
• 11:46and you can see right here on
• 11:49the angiogram that Charles did
• 11:51how vascularized this tumor is,
• 11:53which makes these surgeries somewhat
• 11:55risky to be able to go in and go after these.
• 11:59Christmas light,
• 11:59the appearance of of her what we
• 12:02call a puff of smoke where there is
• 12:04significant chance of bleeding as
• 12:06you're going in there because this is
• 12:08going to be an intralesional resection.
• 12:10So what we do here is there
• 12:12is an indication for surgery.
• 12:14We can help with the neck pain,
• 12:16we can decompress the spinal canal
• 12:18and this is the kind of construct that
• 12:20we do where we replace the vertebra.
• 12:23We have nice sets of retractors.
• 12:24Now it's Milo that we just got last month.
• 12:27We can put these retractors to
• 12:28be able to help us.
• 12:29This is intraoperative pictures.
• 12:31You can see these beautiful
• 12:33retractors that are table mount.
• 12:35You can see the plate.
• 12:37And this is what it looks like
• 12:38after the surgery.
• 12:39And you can see there's a nice cage
• 12:41that replace the broken vertebrae.
• 12:43There's a nice plate that's sitting
• 12:45across of it and that patient,
• 12:47you can see the CT scan with
• 12:49the reconstruction.
• 12:49There's complete replacement
• 12:50of these vertebral body.
• 12:52This patient neck pain completely
• 12:54resolved immediately after this surgery.
• 12:56This patient doesn't need to wear a
• 12:57collar for the rest of her life and
• 12:59the neck pain has completely resolved.
• 13:00The fear of paralysis is gone.
• 13:03And here is what the MRI looks like with
• 13:05the spinal cord now decompressed and
• 13:06then we follow it with a new program
• 13:08that we have here in our smile where we
• 13:11do stereotactic radiosurgery for the
• 13:13residual tumor around the vertebral
• 13:15artery to kill whatever tumors left behind.
• 13:18We can mark exactly we go at the level
• 13:21above and the level below and Lily keel
• 13:24whatever microscopic cells that left behind.
• 13:26And you know in this particular
• 13:28case there were three levels that
• 13:29radio surgery that was done.
• 13:31This is not conventional radiation.
• 13:33Patient.
• 13:33So the risk to the esophagus the the
• 13:36vocal cords is significantly less.
• 13:38This is a paper that we can do even
• 13:40up to three or more contiguous that
• 13:42your bodies is a paper from the James
• 13:45Cancer Hospital with all the radiation
• 13:47oncologist he just came out in the
• 13:49last few months and here is another
• 13:51case 55 year old and you can see
• 13:54right here there's a T1 pathologic
• 13:56fractures we may call you guys to help
• 13:58us with access to get down to low.
• 14:02A T1C7 sometimes T2 vertebrae where
• 14:05we wanna do vertebra ectomy.
• 14:07Unfortunately these tends to be
• 14:08behind the sternum and if you guys
• 14:11cannot get us to be able to do the
• 14:13work then sometimes this is what it
• 14:15take where we plan on going from.
• 14:17You know,
• 14:18through a typical NT approach to the neck.
• 14:20But if it looks like we are unable
• 14:22to get down to T1,
• 14:23then sometimes we need our thoracic
• 14:25surgeon to do, to split the sternal,
• 14:27in essence to get down,
• 14:29to be able to get to do the vertebra ectomy.
• 14:31And this is the illustration of
• 14:34what it actually means.
• 14:36So for us to be able to put this,
• 14:38the screws, to put the plate,
• 14:40to do all the reconstruction,
• 14:42the break is a philic vein can
• 14:43be sometimes in our vein, in our,
• 14:45in our way, and and that's why.
• 14:48Some of these illustrations show why
• 14:50sometimes we need you guys to help us
• 14:52with getting us the accesses, the,
• 14:54the accessibility to be able to do this work.
• 14:57And sometimes on these low thoracic,
• 14:59upper,
• 15:00lower cervical region with short neck,
• 15:02those veins can be in our way.
• 15:05The manubrium you can see right here,
• 15:06sometimes it's completely in the way
• 15:08and we have to split the manubrium
• 15:10in order to get the down there.
• 15:12And this is what it looks like
• 15:14after the reconstruction.
• 15:15Sometimes we have fractures like
• 15:16this case particularly where there
• 15:18was an advantage.
• 15:19Fracture from a thyroid met and in
• 15:21this case what I ended up doing is
• 15:23we did a cement injection through
• 15:24the back of the mouth.
• 15:26You can see right here this has
• 15:28been published or with my ENT
• 15:30colleagues you see on the left side.
• 15:32You guys use this cloud retractors
• 15:34moving the tongue out of the way,
• 15:36moving the ugly out of the way and
• 15:38we can drive the needle right into
• 15:40the C2 vertebral body and injects
• 15:42cement right into the C2 vertebra
• 15:44to stabilize that broken vertebrae
• 15:47saving an exhibitor cervical
• 15:49fixation for something like that.
• 15:51And we ended up using both the
• 15:56stereotactic radiosurgery and
• 15:58stereotactic CT imaging guidance with
• 15:59fluoroscopy to get these cases going.
• 16:02So this was a technical note.
• 16:03How it's getting done.
• 16:04There are many percutaneous techniques
• 16:06that there is a common thing to do for
• 16:09fractures and now we start looking at
• 16:11actually doing it for cervical fractures,
• 16:14other things that we deal with in the neck.
• 16:16This is an intradural lesion and
• 16:19this is a severe intradural lesion.
• 16:20You can see the code is being squashed.
• 16:23This turned out to be a chloroma
• 16:24that after you can see the Peskin
• 16:27was very active and we ended up
• 16:29without the biopsy radiating it in,
• 16:31the tumor melted away and this
• 16:33is kind of like the.
• 16:34Aspect of metastatic disease that we
• 16:36own on all of these fractures look and
• 16:38see whether we can help at least with
• 16:41the pain and decompress the spinal cord.
• 16:43Primary tumor is really the key when
• 16:45it comes to a lot of work with the Ant
• 16:47or ENT colleagues when it comes to
• 16:49really our goal is to cure the patient.
• 16:51These are the tumors we talking about.
• 16:53They could domas the condo sarcomas
• 16:55are the main ones.
• 16:56These require unblock resection
• 16:58unblocker section means that you we
• 17:01have to find a way where we don't
• 17:03we remove the tumor in one piece.
• 17:05You don't get into the tumor in order
• 17:08to not have clean margins around it.
• 17:11Here is a case of a cervical
• 17:13Congress sarcoma.
• 17:14You can see the tumor in the neck,
• 17:15it's wrapped around the vertebral artery.
• 17:18And couple of cases here,
• 17:19you can see the tumor in blue.
• 17:21There's one vertebral artery
• 17:23that's completely in case with
• 17:24this Congress sarcoma.
• 17:26And here is the tumor right here.
• 17:28This is definitely something we can do,
• 17:30an unblocker section.
• 17:31And so the way we approach doing these
• 17:33is we start in the back actually.
• 17:36To stabilize things and separate the tumor
• 17:39away from the spinal cord, that's the key.
• 17:43We put our hardware in there.
• 17:45We, you can see right here the spinal cord
• 17:47and the bottom and the tumor in the neck.
• 17:49We can expose it from the back end.
• 17:52We can put our huddle in the back.
• 17:54We have to like get some
• 17:55nerve roots and not only that,
• 17:57you can see the nerve roots right here.
• 17:58The C3C4 and C2 nerve roots
• 18:01are being ligated away.
• 18:02To be able to release these tumor.
• 18:04We can also.
• 18:06Sacrifice the vertebral artery.
• 18:07Get underneath the vertebral
• 18:09artery and sacrifice the vertebral
• 18:10artery above and below.
• 18:12In fact,
• 18:12we put a coil on the top and then
• 18:15ligated in the vertebral artery,
• 18:17so we have no issues with bleeding.
• 18:19And once this is the the the tumor in the
• 18:22neck is separated from the spinal cord
• 18:25and instrumented we go from the front.
• 18:28This lady particular didn't have a long neck,
• 18:30but with my ENT colleagues you can see
• 18:33right here we can dissect The Karate Kid.
• 18:36You know, the. They are all the
• 18:38venous structures to get down there.
• 18:40You can see that once everything
• 18:42is moved to the side,
• 18:43we can cut through the front of the
• 18:46three vertebras and actually removed.
• 18:48You can see the three vertebrae
• 18:50with the pathologic fracture.
• 18:51All have been removed in one
• 18:53piece with clean margins.
• 18:54And once it's out,
• 18:55you can see through the opening the dura,
• 18:58you can see in fact the posterior
• 19:00rod from the front.
• 19:02And then after it's done,
• 19:03we can put a cage in with a plate and
• 19:05that's what it looks like at the end
• 19:08where the reconstruction is complete.
• 19:10And the tumor has been removed.
• 19:13This is a much more complicated
• 19:15case on another codoma.
• 19:16You can see the extent of this codoma tumor.
• 19:18Again, we start in the back.
• 19:20The idea is separating it away
• 19:22and we start from the back.
• 19:24We ligating the nerve roots.
• 19:26You can see right here the 3234 and
• 19:29five actually has been sacrificed here.
• 19:32You can see the Tibaldi has been
• 19:34skeletonized on the other side
• 19:35with the nerve roots above it.
• 19:37We then typically put a silastic
• 19:39sheath so we can see the difference.
• 19:41Between the spoiler code,
• 19:42when we come from the front,
• 19:43we put a long construct from the back.
• 19:48This is what it looks like from the back.
• 19:50We do between the front and the
• 19:52back and angiogram to make sure
• 19:53there's no spasms to the vessels.
• 19:55And then with you guys,
• 19:57this is a trans mandibular approach,
• 19:59which you can go through the mandible,
• 20:01get to the back of the neck,
• 20:02mobilize the vessel, you can see the tumor.
• 20:05And through a transmittable approach you
• 20:07can see the vertebral artery on one side.
• 20:09That's how it looks like when
• 20:11the tumor is out.
• 20:12This is a very big tumor and you can
• 20:15see then we can sneak underneath a
• 20:17cage with the cage actually engaging
• 20:20the C1 and C1 arch and that top school
• 20:23is actually going to the NTSC one
• 20:25arch and into the tip of the odontoid.
• 20:28This is the visualization of what
• 20:30it looks like and you can see
• 20:32the nervous has been ligated,
• 20:33the tumor is out and that's.
• 20:36The the way the construct,
• 20:37look at the end of this in order
• 20:39to try and do an alpaca section,
• 20:40and you can see on the top left
• 20:42hand picture how the screw and
• 20:43the top goes to the anterior arch
• 20:45and into the tip of the odontoid.
• 20:47And that's what it looks like at the end.
• 20:49So yeah, these are complex cases.
• 20:52And again,
• 20:53I just wanted to get briefly to the
• 20:55extent of these cases.
• 20:56A lot of those may require vascularized bone.
• 20:59It can be used also in the neck.
• 21:01This is vascularized bone that
• 21:02we use for sacral lesions.
• 21:04These are cases that are very complicated.
• 21:06What we actually use the leg,
• 21:08the femur and the tibia to close,
• 21:10for example,
• 21:11a pelvic rings we have described these
• 21:14cases is an autologous bone graft,
• 21:16vascularized bone graft.
• 21:17This works amazing and you can see
• 21:20right here how you can see right here
• 21:22female with a vessel attached to it and
• 21:24a tibia with a vessel attached to it
• 21:26to be able to close this pelvic rings.
• 21:29This is what it looks like
• 21:30at the end of the case.
• 21:31This is a.
• 21:32This was cases that have been described by
• 21:34my plastic colleagues about how they do this.
• 21:36Quotation of flaps,
• 21:37and this is some of those exit.
• 21:39This is a patient after the surgery,
• 21:41so these are obviously a big
• 21:44time surgeries when it comes to
• 21:46doing these unblocker sections.
• 21:47But the the the the principle is the same.
• 21:51We always have to figure out if we can
• 21:53put some sort of a vascularized bone
• 21:55graft to be able to get a nice fusion.
• 21:57At the end of these cases there
• 22:00are some emerging technology that
• 22:02I start working at the the spine.
• 22:04Research Institute at Ohio State in our,
• 22:07you know,
• 22:07I'm start working and doing it here.
• 22:08There's a lot of 3D printers,
• 22:10a lot of 3D reconstruction that
• 22:12we did in the lumbar spine.
• 22:13Now we can do it in the neck,
• 22:15we can reconstruct the cancer.
• 22:17We know where it is and we can then
• 22:19start thinking about the type of
• 22:21reconstructions that we can go about
• 22:23doing and then do a specific 3D printers,
• 22:26those that have cycle,
• 22:27there is a 3D printer.
• 22:28These are personalized vertebral bodies that
• 22:31are fit right into the potential defect.
• 22:34So in conclusions.
• 22:35Management should be individualized.
• 22:37It clearly is a multidisciplinary.
• 22:40This is one picture from the James Cancer.
• 22:42So you can see the magnitude of how
• 22:44many people are involved in these cases,
• 22:46you know between orthopedic
• 22:47neurosurgeon and on and on and on.
• 22:49There's just these are two
• 22:51default type of surgery.
• 22:53So thank you very much.
• 22:57Thank you. Doctor Mendel,
• 22:58that's just very, you know,
• 23:00just amazing stuff to see
• 23:02what you're doing here.
• 23:04There are a bunch of questions in the chat.
• 23:06So if you know if you can
• 23:07stay on for a few questions,
• 23:09one individual asked about recordings,
• 23:12yes, that will be available e-mail
• 23:14to registered guests and available on
• 23:16yalecancercenter.org and the YouTube channel.
• 23:18But 22 clinical questions here.
• 23:21One has to do with prevertebral fascia,
• 23:25so as head and neck cancer surgeons.
• 23:27I'm doing a lot with squamous cell carcinomas
• 23:30of the pharynx and the throat and the neck.
• 23:33The prevertebral fascia has.
• 23:36Essentially been a T4B disease,
• 23:39unresectable, don't even bother.
• 23:42Don't even try.
• 23:44But what are your thoughts on, you know,
• 23:47if that is the only site of some
• 23:49questionable sometimes we're not even sure,
• 23:51is it involved?
• 23:52Is it not, you know,
• 23:53and it can really change the the
• 23:55course of a patient's treatment
• 23:56on if it's involved or not.
• 23:58So can you just comment on local
• 24:01tumors from the throat with
• 24:04prevertebral fascia involvement,
• 24:05whether that's her?
• 24:06Acceptable or not and especially
• 24:07in those cases where we're just
• 24:09not sure if it's involved or not.
• 24:10Any thoughts on that?
• 24:11Yes. So I'm going to go to this
• 24:14particular slide on the case that
• 24:16Charles and I have done right
• 24:17here and you can see right here,
• 24:19this is the radio surgery picture of a tumor
• 24:23that's involved the prevertebral fascia.
• 24:25The radio surgery can map exactly
• 24:27where we are going to deliver that
• 24:30radiation unlike the typical Convention
• 24:32radiation that goes through everything
• 24:34if there is any suspicion of the.
• 24:36Private table fascia here is the
• 24:38sagittal and here is the axiom you
• 24:40can see that there is a dose of
• 24:43radiation that's being given to
• 24:44the private civil fashion itself.
• 24:46So if there is a if there is a
• 24:49suspicion for it and on these cases
• 24:52with this you know whenever there's
• 24:54a cervical met the suspicion that
• 24:55there is a primitive of fashionable
• 24:57it always is high we always will
• 24:59include it in the radio surgery field.
• 25:01We don't necessarily you know we
• 25:03remove a lot of it in our approach
• 25:05to get down to the vertebral.
• 25:06Buddy, but even if we don't remove it,
• 25:09we feel very comfortable that
• 25:10with radiosurgery we can control
• 25:12the disease at that site.
• 25:15Yeah, that that is great.
• 25:16And I know you and I have discussed
• 25:18some cases where there's some direct
• 25:20invasion maybe or maybe not to
• 25:22the prevertebral fascia where we,
• 25:23you know, you say we're well,
• 25:24you know what, you can get in
• 25:26there and you can take down some
• 25:27of the prevertebral fashion,
• 25:28even drill down some of the
• 25:30bone on block resection.
• 25:32So different techniques that
• 25:34these will file already a surgery
• 25:36because we can remove the growth aspect,
• 25:38the microscopic aspect will
• 25:40follow with radiosurgery. Yeah,
• 25:41absolutely. So that's great.
• 25:42And there's another question
• 25:43which you did touch.
• 25:44On about vascularized bone graft,
• 25:48specifically from the fibula for
• 25:50cervical spine reconstruction,
• 25:52either for osteoradionecrosis,
• 25:53which is a problem that we often
• 25:57see as head and neck cancer
• 25:59surgeons and also just in general.
• 26:01What is what is your experience with
• 26:03fibular bone grafts for cervical spines?
• 26:05Amazing. So we want Fusion,
• 26:08we want bone growth, artificial, you know,
• 26:11Bond Bank does don't work as well,
• 26:14my experience. Vascular,
• 26:15the bone growth is just absolutely amazing.
• 26:17So if there's any way to
• 26:18get a vascular bone graft,
• 26:20I think that's the way to go.
• 26:22So definitely it's require some coordination,
• 26:24uh, when it comes to work to take
• 26:26it from how big do you need it?
• 26:28What's the likelihood that you
• 26:30will survive those kind of things.
• 26:32But I think whenever there's
• 26:33a opportunity to do it,
• 26:35especially for our point of view,
• 26:36a lot of these patients end up not fusing,
• 26:38right, unlike the trauma and
• 26:39the degenerative spine with
• 26:40bone growth over time.
• 26:41And they implant becomes one
• 26:43with the surrounding in cancer
• 26:45after chemotherapy and radiation,
• 26:47it doesn't happen.
• 26:48So we completely relying on the hardware,
• 26:50so these vascularized.
• 26:51Don't just give us the security of fusion,
• 26:54the bone growth around it,
• 26:55and heal.
• 26:56Yeah, no, that's great to hear.
• 26:58It's a great question too,
• 26:59because we often think of the
• 27:00fibula mainly for mandible,
• 27:01maxillary reconstruction.
• 27:02But let's not forget that
• 27:04our spine colleagues can use
• 27:06vascularized bone grafts as well,
• 27:08even for ORN and complications
• 27:10of head neck cancer treatment.
• 27:12So they, thank you very much,
• 27:14Doctor Mandell,
• 27:15really appreciate that kind
• 27:17of pushing the envelope for,
• 27:19you know, in in spinal surgery.
• 27:21And it's great to his head neck
• 27:23surgeons to hear what is actually
• 27:24available if you have the right
• 27:26expertise at your institution.
• 27:28Thank you you so much. Right.
• 27:30So our next speaker is another
• 27:33neurosurgeon executive.
• 27:34He's the vice chair of clinical
• 27:36affairs of neurosurgery at Yale,
• 27:38and he's a neurovascular
• 27:40surgeon Doctor Charles Matouk.
• 27:42The next two talks kind of go hand in hand,
• 27:45especially in my practice of head and
• 27:47neck cancer surgeon, because again,
• 27:49the carotid artery, similar T4B disease.
• 27:51We think of it as the some, you know,
• 27:54often is thought of as an untouchable area,
• 27:56but there are cases.
• 27:58Doctor Matuk and Doctor Thomas and
• 28:00know that we we can take it down.
• 28:03We need to take it down.
• 28:04It is the best option.
• 28:05Of course,
• 28:06we need to know if we can safely
• 28:07take it down and then what to
• 28:09do after we've taken it down.
• 28:10And that's why Doctor Matuk and Doctor
• 28:12Thomason are going to speak to us about that.
• 28:14So doctor Matuk,
• 28:15if you could tell us about the
• 28:17carotid artery and doctor Matthew,
• 28:20stop sharing for a moment.
• 28:21Doctor Matute can pull up.
• 28:23So Doctor Matuk is going to talk to
• 28:25us about carotid artery preoperative.
• 28:28Uh,
• 28:29assessment?
• 28:30Thanks
• 28:31so much, Sarah. Thanks for having me, Judy.
• 28:34That's impossible to follow.
• 28:37Sorry, what I am going to do see apology
• 28:40not accepted but very very impressive,
• 28:42very impressive slide that
• 28:44can work over the years.
• 28:45I'm going to try to let me
• 28:48see if I can do this here.
• 28:50Can you guys see my screen?
• 28:51OK, just by chance
• 28:54we see this some slides or
• 28:56something on this side as well, but
• 28:58let me try to let me try to fix that up here.
• 29:04But even if not, we can,
• 29:05we can see it.
• 29:09Even better. Perfect,
• 29:11perfect. So what what I'm going to try to
• 29:13do today is to to give you a an overview
• 29:16of how to think about the carotid artery
• 29:19and a preop assessment when you're
• 29:22looking to maximize an oncological
• 29:24resection often or for recurrent but
• 29:26you know sometimes a primary tumor.
• 29:29And what I again I'm going to sort of
• 29:31try to introduce you to some terms and
• 29:34some specific anatomy so that when you're
• 29:37considering these types of options.
• 29:39You can communicate I guess best
• 29:42with us and hopefully that will
• 29:44translate to better you know decision
• 29:47making for for our patients.
• 29:49So we'll, we'll start a little bit
• 29:51with some new neurovascular anatomy,
• 29:53which you guys don't, you know,
• 29:56necessarily always think about and then
• 29:59talk about specifically balloon test
• 30:01occlusion and some sort of Nuggets that
• 30:03you can take home with you after this talk.
• 30:06And then we'll just go quickly
• 30:08through one case and see how we use
• 30:11it here at Yale New Haven Hospital.
• 30:13So this is a, you know,
• 30:17a 3D rendering of a CTA of the head
• 30:19and neck of of one of our patients.
• 30:22And it's just to make sure that
• 30:24we're on the same page.
• 30:25And for trainees that, you know,
• 30:29we have two carotid arteries,
• 30:31one on the right, one on the left that go on,
• 30:33you know, go up the front of our necks.
• 30:36And we also have two paired vertebral
• 30:38arteries and here you can see
• 30:39it on the lateral.
• 30:40It's usually a smaller vessel,
• 30:42significantly smaller than
• 30:44the vertebral artery.
• 30:45And there's two paired vertebral arteries
• 30:47that go also up to the base of the
• 30:49skull and go on to supply the brain.
• 30:50And so you can think of,
• 30:52you can think of the neurovascular anatomy
• 30:55as being supplied by these four neck vessels,
• 30:59right.
• 30:59So the two carotid arteries in the front
• 31:01of the tuber tibial arteries in the back,
• 31:03you can think of it a
• 31:04little bit like a stool.
• 31:06And the the stool basically feeds a
• 31:09circle of vessels in the center of
• 31:11the brain called the circle of Willis.
• 31:14And we're going to go specifically through.
• 31:16What you know what that means and
• 31:18and why it's important to think about
• 31:21when we're entertaining decisions
• 31:22about carotid resection plus or minus
• 31:25reconstruction in the in the context
• 31:27of head and neck cancer surgery.
• 31:30So this is the same patient that we
• 31:32we just saw in the earlier slide and
• 31:35I'm going to walk us through here you
• 31:37know what we call the circle of Willis.
• 31:38So we're the two red dots are are
• 31:42both the the internal carotid arteries
• 31:44which are the the termination of
• 31:46these carotid arteries.
• 31:47Well, inside the hub,
• 31:49so those are both the left ICA and
• 31:52the right ICA.
• 31:52And what I've done here is that
• 31:55the I've tried to label the main
• 31:58bifurcation points of the terminal
• 32:00internal carotid artery,
• 32:02so it branches into two branches,
• 32:04you know,
• 32:05one is the anterior cerebral
• 32:07artery and this
• 32:08is called the A1 segment.
• 32:10And and this goes towards
• 32:11the nose or the midline,
• 32:13and then laterally there's the middle
• 32:15cerebral artery and this year's term,
• 32:18the M1 segment.
• 32:21And that that those are the two
• 32:23main sort of like bifurcation
• 32:25points of the of the ICA termination
• 32:27and that occurs on both the right
• 32:30and the left side obviously.
• 32:32So here again is the M1,
• 32:33here's the A1.
• 32:34Here you can see the internal
• 32:36carotid heading down towards the
• 32:37skull base and then it sort of
• 32:39goes up and then branches into The
• 32:41Chew those two different vessels.
• 32:43If we look at the back of the head,
• 32:46you can see here that the basilar
• 32:48artery forms from a fusion
• 32:49of both vertebral arteries.
• 32:51They're closing up the right
• 32:52and left side of the head,
• 32:53so here's our of the neck,
• 32:55so here's the right side
• 32:56and here's the left side.
• 32:57And they fuse,
• 32:58so it's a little bit different
• 33:00than the the carotid arteries,
• 33:02which will sort of like go up on each
• 33:04side of the neck and then continue
• 33:07on the right and left side and the
• 33:09head before doing their bifurcations.
• 33:11The vertebral arteries,
• 33:12which go up on both sides of the neck,
• 33:14fuse at the base of the skull and
• 33:17then go up as a common basilar
• 33:19artery before bifurcating again.
• 33:21And that has implications about how safe
• 33:24it is to take a vertebral artery and,
• 33:27and doctor Mandel mentioned that
• 33:29a few times in his talk versus
• 33:31a carotid artery in the workup.
• 33:32That's required for both.
• 33:34Has to do with this anatomical
• 33:36nuance that the vertebral arteries
• 33:37fuse into the basilar artery,
• 33:39a common channel,
• 33:40before going on to supply the circle
• 33:42of Willis. Where's the carotids?
• 33:44Do not they supply the circle
• 33:46of Willis independently,
• 33:47each one right and left independently?
• 33:50As the basilar artery comes up,
• 33:52it divides into these two branches,
• 33:53which we call the posterior
• 33:55cerebral arteries,
• 33:56labeled the right P1 and left
• 33:58P1 segments individually now.
• 34:01There are communications that
• 34:03can occur between the posterior
• 34:06circulation supplied by the vertebral
• 34:08artery and the anterior circulation
• 34:10supplied by the carotid arteries,
• 34:12and here's an example of
• 34:14these communicating vessels.
• 34:16Which will, which will connect the right PCA,
• 34:19the P1 segment to the internal
• 34:21carotid artery.
• 34:22And here you can see that best on this side.
• 34:24There's a smaller vessel that we
• 34:25can see over here on this side.
• 34:27These are the natural communications
• 34:30between the anterior and posterior
• 34:32circulation.
• 34:33We also have a communicating artery
• 34:35that connects the right A1 on the left,
• 34:38a one that communicating artery which
• 34:40is often less than a millimeter in size.
• 34:43Connect both hemispheres, so in a
• 34:46sense connects both carotid circulations.
• 34:49So now you essentially have this ring,
• 34:51which was the top of the stool that
• 34:53we talked about in the last example,
• 34:55and this represents a complete
• 34:57circle of Willis.
• 34:59Right.
• 34:59And so in doing this,
• 35:01if you sacrifice 1 vessel
• 35:02and we're going to go
• 35:04through this in more detail,
• 35:05you can see that the other vessels
• 35:08have a route to get blood to the part
• 35:11of the brain that is now compromised
• 35:14in terms of its blood supply.
• 35:16So sometimes we're born without
• 35:18a complete circle of Willis,
• 35:20and in fact that's that's the norm.
• 35:22The norm is that we don't have
• 35:25symmetric large pcom arteries
• 35:27bilaterally and a large acom artery.
• 35:30And that's when we can get into problems
• 35:34with therapeutic carotid artery sacrifice,
• 35:36because just by chance in the way
• 35:40we were born, sometimes we're born
• 35:42with an incomplete circle of Willis,
• 35:44and that circle can be variably.
• 35:46Incomplete.
• 35:46So in some instances it might
• 35:48just be an asymmetry so that one
• 35:51pecom is smaller than the other,
• 35:53or an acom artery is smaller
• 35:55than it normally is.
• 35:56Sometimes there's complete aplasia
• 35:58so there's like non development,
• 36:00they're aplastic vessels.
• 36:01So there's like we don't see a vessel,
• 36:03there's no vessel connecting,
• 36:05for example, the ICA termination,
• 36:07there's like and and the and
• 36:10and the communicating artery.
• 36:12For example,
• 36:12there might be a missing A1 segment and
• 36:15its entirety and you can't know that.
• 36:17Unless you sort of spent some time
• 36:19with the CTA and T is this out?
• 36:22So in this example, we're going to say,
• 36:24well, let's say we,
• 36:25we're going to sacrifice the carotid
• 36:27artery in the neck over here.
• 36:29So that still means that,
• 36:31that means what that means if
• 36:33we sacrifice the carotid artery
• 36:34in the neck is that.
• 36:35The MCA and the ACA territories of
• 36:37the brain can still get blood by
• 36:39traveling up the Basler artery,
• 36:41the P1 segment across here,
• 36:44this pcom segment to the
• 36:46internal carotid artery,
• 36:47and then fill the A1 and the M1 segments
• 36:50and their corresponding territories.
• 36:52Or you can get contralateral blood
• 36:55coming from the right eye CA across
• 36:58an acom artery to supply again the A1
• 37:01segment on the left and the M1 segment.
• 37:03Now let's say that you're born
• 37:05without a right A1 segment,
• 37:07so this is gone.
• 37:08Or that the acom artery itself is gone,
• 37:11and you don't have that just
• 37:13because you were born that way.
• 37:15And that you were born without
• 37:17a pecom artery on this side.
• 37:18Now you have what was referred
• 37:20to as an isolated circulation,
• 37:22so that if you take the internal
• 37:23carotid artery on this side,
• 37:25there can be no compensatory
• 37:27blood throw across from the
• 37:29right carotid artery to supply.
• 37:31This left MCA territory.
• 37:33Either from the front or from the
• 37:35back through pecan and that's what we
• 37:38would call an isolated circulation.
• 37:40So if you were doing, for example,
• 37:42a carotid endarterectomy on this
• 37:44patient and the patient was under
• 37:46a general anesthetic and you
• 37:48were using electrophysiological
• 37:49monitoring to look at the patient,
• 37:51you would put your cross clamp on
• 37:53the internal carotid artery and
• 37:54your electrophysiology would just
• 37:56go flat to zero and then you would
• 37:58take the clamp off and then over a
• 38:00few seconds it would come back up.
• 38:02So these are patients that you know.
• 38:04That need a shunt right during the procedure
• 38:08because otherwise their brain is going
• 38:10to be ischemic for a period of time.
• 38:12Sufficiently, it just,
• 38:13it just takes like about 10 minutes
• 38:16or so to create an infarct which
• 38:18is an irreversible brain injury.
• 38:20So that's what we're trying to avoid.
• 38:22And and because we don't have this
• 38:25sort of information robustly or we
• 38:27want to challenge it and test it,
• 38:29that's the purpose of the balloon test
• 38:32occlusion is that we're essentially
• 38:34stressing the circle of Willis that
• 38:37we see on a CTA and to see whether
• 38:40or not the patient can tolerate it.
• 38:42State in terms of.
• 38:44They're, they're,
• 38:45they're aschematic tolerance, right?
• 38:49Alright, so let's continue.
• 38:53So this is how it works in practice so.
• 38:57We've been through like multiple
• 38:59modifications of this technique
• 39:00and every institution has a
• 39:02different version of this.
• 39:03What we typically use is Umm we do
• 39:072 arterial punctures, 1 in the leg.
• 39:09We place the big sheep in the leg and
• 39:12we place a smaller sheep in the arm.
• 39:14Through the sheath and the leg.
• 39:15We can go up through the body and
• 39:17we can access the common carotid
• 39:18artery and we can inflate a balloon.
• 39:22And once we inflate
• 39:23that balloon, it's typically done
• 39:24on the proximal internal carotid
• 39:27artery or in the OR in the, sorry,
• 39:28in the in the proximal internal carotid
• 39:30artery or the distal common carotid
• 39:32artery depending on whether or not there's
• 39:35atheromatous disease or sometimes these
• 39:37patients have radiation induced changes.
• 39:39So we don't want to, we don't want
• 39:41to disrupt that sort of pathology.
• 39:43We inflate the balloon and we then
• 39:46examine the patient clinically.
• 39:48So these patients are awake so
• 39:50we can ask them like things like,
• 39:53do you know where you are,
• 39:54what year is it, what's the date,
• 39:56what's the day, spell world forward,
• 39:58spell world backwards?
• 39:59Can you repeat this sentence,
• 40:01do serial sevens backwards to try to
• 40:03get a sense about whether or not these
• 40:06patients are going to have language deficits.
• 40:09And very often during these exams,
• 40:11I'm trying to be conversational
• 40:13with the patient.
• 40:13Because one of the first things that
• 40:15goes is their ability to sort of like
• 40:18tell small jokes if we're joking
• 40:20around or to understand contacts,
• 40:22they start to get more confused.
• 40:23And it's obvious that their brain
• 40:24is is laboring a little bit.
• 40:26This sort of the sort of,
• 40:29you know, make it work as normal.
• 40:31So we're also testing their motor
• 40:33strength and their sensory and
• 40:35position sense of their joints.
• 40:37And we do this over a period of
• 40:3920 to 30 minutes and during this
• 40:41time when the balloon is inflated.
• 40:44We can also then go through this
• 40:46vessel here and we can inject the
• 40:48other blood vessels in the brain.
• 40:49And we can angiographically show
• 40:52that the a common pcom are actually
• 40:55supplying the brain and that the
• 40:58timing of filling even though
• 41:00there's a balloon up in the carotid
• 41:02is relatively symmetric.
• 41:04And that the venous phase of the
• 41:06angiogram so that the the blood is also
• 41:09emptying symmetrically from both hemispheres,
• 41:11even with the 1 carotid occluded.
• 41:14Then after all that's done at Yale,
• 41:17we do a hypotensive challenge.
• 41:18So I'll ask our anesthesiologist
• 41:20to lower the blood pressure by 20%
• 41:23for more than 5 minutes from his
• 41:26baseline systolic blood pressure.
• 41:28And during that period of time,
• 41:30we're also testing the patient
• 41:31clinically as well.
• 41:33So we use at Yale these three
• 41:35different parameters.
• 41:36Early in my practice here,
• 41:37we also did a nuclear medicine test,
• 41:40which is very easy to administer,
• 41:42but I found it to be not very.
• 41:44Helpful in terms of additive information,
• 41:46but essentially what it is,
• 41:48is that you take a a lipophilic
• 41:50nuclear medicine tracer,
• 41:52you inject it transvenous sly.
• 41:54So through an IV it then circulates and
• 41:56it's pumped out as a bolus through the heart.
• 41:59And when it gets when it goes
• 42:01through the brain because the brain
• 42:03has a lot of fat in it,
• 42:05the nuclear medicine tracer gets
• 42:07stuck in the brain and you want
• 42:09to see symmetric uptake again on
• 42:11both sides of the brain to pass.
• 42:14That particular task,
• 42:15there's also modifications
• 42:17using perfusion imaging or
• 42:19transcranial Doppler,
• 42:20but I haven't found those to
• 42:22be particularly useful either.
• 42:23And in meta analysis of this technique that
• 42:26are done for therapeutic carotid sacrifice,
• 42:29there's no sort of like clear benefit to
• 42:34doing these sort of adjunctive measures,
• 42:36including hypotensive challenge.
• 42:37But at Yale, we do these three and
• 42:40we found it to be effective and
• 42:42we used this sort of setup.
• 42:44Just some sort of like facts that you can
• 42:46take home with you after this talk if you
• 42:49did a non selective permanent sacrifice,
• 42:52if the ICA for a head and neck
• 42:54cancer or an A giant aneurysm or
• 42:57sometimes for direct carotid fistulas,
• 42:59things of that nature.
• 43:01We think that about 20 to 30% in the
• 43:04literature at 17 to 40% of patients
• 43:06will have an ischemic insult.
• 43:08What's interesting is that they
• 43:09often occur right away,
• 43:10but sometimes they occur after
• 43:12three to four days with even
• 43:14like minimal physiological.
• 43:15Disruption.
• 43:17You know, such as a you know a Valsalva
• 43:20maneuver when going to the bathroom or or or.
• 43:23Really minimal disruption so if you
• 43:27use balloon test occlusion to inform,
• 43:30doing a safe carotid sacrifice or.
• 43:34Whether you realize that they're,
• 43:36they're not going to tolerate a carotid
• 43:38sacrifice and you have to do some kind
• 43:40of reconstruction of the carotid artery,
• 43:42whether that be endovascular
• 43:44or using open surgical bypass,
• 43:46then the complication rate really falls to,
• 43:49to, to less than 4%.
• 43:51Now 4% sounds like a small
• 43:53number and you know, compared to,
• 43:55I don't know, UDI, you know,
• 43:57what are the complications that
• 43:59you quote for, for those big,
• 44:01you know, resections,
• 44:02maybe you don't even get to
• 44:04them because it's intuitive.
• 44:05That there's going to have high
• 44:06complication rates, right,
• 44:08but four, 4%,
• 44:10right.
• 44:10With you know what that means is that
• 44:14you know four out of 100 patients
• 44:16that you do this to are going to
• 44:18have a problem even though they
• 44:20passed the balloon test occlusion.
• 44:22So 4% is not nothing,
• 44:24right,
• 44:24like 4% is the rate of ischemic stroke
• 44:27for a patient who presents with
• 44:30symptomatic high grade carotid stenosis,
• 44:32right.
• 44:32If you're any higher than 4% then.
• 44:35You probably shouldn't be doing
• 44:36the operation.
• 44:37So even though 4% sounds good and this
• 44:40is in the context of hopefully achieving
• 44:44like a curative oncological resection,
• 44:47it is still a significant complication
• 44:49rate compared to many things that
• 44:51we do because here we're really
• 44:52talking about the rate of having a
• 44:54stroke and strokes can be disabling.
• 44:57Thankfully,
• 44:57the rate of complications of the
• 45:00balloon test occlusion itself are very low.
• 45:02So it's like less than 1%.
• 45:04It's like often quoted.
• 45:060.8% from this Umm,
• 45:08you know,
• 45:09sort of like well cited meta
• 45:11analysis of the literature.
• 45:12So I think that getting the
• 45:14information is always helpful
• 45:16if you're considering a carotid
• 45:18sacrifice that during a head and
• 45:20neck surgery discussion and workout.
• 45:24Just very quickly,
• 45:25this is also a patient of Sara's
• 45:28that we recently have taken care of.
• 45:31But you know, a woman in her
• 45:3360s had had tongue cancer.
• 45:35She had a partial glossectomy years
• 45:37ago and she now comes back with a
• 45:40neck mass and they do a fine needle
• 45:42aspirate of the neck mass and it comes
• 45:45back as squamous cell carcinoma.
• 45:46So then the question is on on the amaging.
• 45:49It looks like the left common carotid artery
• 45:52is really encased by the tumor and so.
• 45:54Can you safely resect and take
• 45:57down the carotid artery to achieve
• 46:00an oncological resection,
• 46:02understanding that there's other options,
• 46:03including, you know, radiation,
• 46:05chemotherapy, and other things?
• 46:08Or do you need, you know,
• 46:10if that's the decision to to to do something,
• 46:13does it need to be augmented by something
• 46:15that Doctor Tomlinson is going to talk about,
• 46:17which is some kind of like endovascular
• 46:20or surgical bypass to augment
• 46:23the carotid sacrifice.
• 46:25So again, this is what it sort
• 46:27of looks like in real life.
• 46:28This is what the balloon looks like
• 46:30and the common carotid artery,
• 46:31it's inflated.
• 46:32We generally inflate it for about
• 46:3425 to 30 minutes and then we test
• 46:37the patient clinically.
• 46:38With the balloon inflated,
• 46:39you can now see that injection of
• 46:41the right common carotid artery fills
• 46:42across this beautiful acom artery
• 46:44and you have beautiful symmetric
• 46:45filling of the left MCA territory.
• 46:47And here you also have very nice
• 46:50filling through a pcom artery of the
• 46:53internal product artery on the left side.
• 46:55And so this is a patient that passed
• 46:58on both clinical angiographic and
• 47:02hypotensive challenge grounds.
• 47:05So we would expect her rate of having.
• 47:08In a schema complication after
• 47:10therapeutic carotid sacrifice to be,
• 47:12you know, less than 4%.
• 47:14So that's the that's the sort of
• 47:17way to think about I think carotid
• 47:19sacrifice and how balloon test
• 47:21occlusion can can sort of help
• 47:23you figure some of this stuff out.
• 47:27That's great, Charles.
• 47:29Thank you so much.
• 47:30I think this is exactly the
• 47:32type of information that this
• 47:34audience was was looking for.
• 47:36And it's very enlightening to hear Yale's
• 47:40approach to this under your leadership,
• 47:42the, the, the the the three
• 47:44techniques that that you look for.
• 47:45There are two questions.
• 47:47Number one is do you involve
• 47:49anesthesia in these cases at all?
• 47:51You do say patients are wide awake,
• 47:52but can you just describe some of the
• 47:54anesthesia requirements for these?
• 47:56Yeah, it's important to have and and.
• 47:57Actually, my experience now
• 47:59having worked in a bunch of Umm,
• 48:01you know the the other hospitals in
• 48:03our health system outside of Yale New
• 48:06Haven Hospital that have angiography,
• 48:08the anesthesiologist there are
• 48:11usually outstanding because you
• 48:13know what you what you need is a.
• 48:16You do need to involve anesthesia and
• 48:18you need an anesthesia team that's
• 48:21accustomed to doing sort of awake
• 48:24interventions and manipulating blood
• 48:26pressure in an awake patient and not,
• 48:30you know, I think that very often
• 48:33my experience has been at Yale New
• 48:35Haven Hospital where I think we
• 48:38do potentially like more complex
• 48:40and like sicker patients that that
• 48:43the the there's definitely a bias.
• 48:45Towards putting people to sleep
• 48:48under general anesthetic.
• 48:49And so often when I when I go to
• 48:51the more community hospitals,
• 48:53people are actually very well
• 48:55versed in how to do this stuff.
• 48:56But you do need to involve anesthesia
• 48:59and we often have the patients
• 49:01deeper at the beginning for the
• 49:04puncture so it's not so painful
• 49:06and uncomfortable and and then we
• 49:08lighten the sedation throughout you
• 49:11know the subsequent minutes so that
• 49:13we can get that an examination so.
• 49:16If you have a patient that you're
• 49:18twilight state where they're sort of
• 49:21like agitated and not directable,
• 49:22that's not going to be a productive
• 49:25balloon test occlusion.
• 49:26And we unfortunately we've had
• 49:27cases that we've had to abort.
• 49:29You can always do a balloon test
• 49:32occlusion under a general anesthetic,
• 49:34and you can augment that with
• 49:36electrophysiology or you can decide
• 49:38that the angiographic criteria alone
• 49:40is sufficient that if you truly
• 49:42have something that looks like
• 49:44what's up on the screen now.
• 49:46That that's probably sufficient,
• 49:49but, you know,
• 49:49it's I think that the proofs in
• 49:52the pudding and the sense that if
• 49:54you have an awake patient you feel
• 49:56much better that they've tolerated
• 49:59this balloon test occlusion,
• 50:00but it's not always possible.
• 50:02So yeah,
• 50:03and asked me if I was needed
• 50:05especially with that drop in the blood
• 50:07pressure which is for us as surgeons
• 50:09another little safeguard because it
• 50:10can happen during these big surgery.
• 50:12So that's great.
• 50:13Second question has to do with the
• 50:15risks of the test itself and what,
• 50:18what do you tell your patients and is
• 50:20it different in a patient who's been
• 50:22radiated already has carotid disease,
• 50:24you know and it is is versus
• 50:26unirradiated Genova carotid,
• 50:27what risk do you tell patients
• 50:29about this test itself?
• 50:30So I think it's a great question.
• 50:32The real answer and and it for the
• 50:34surgeons of the artist it's intuitive is
• 50:36that like not every carotid is the same,
• 50:38not every thyroid cancer is the same, right.
• 50:40There's going to be nuances
• 50:42based on little technical detail.
• 50:44So if a person has like an impossible
• 50:46aortic arch that's full of calcium and
• 50:49has like radiation changes to his common
• 50:51carotid artery that's very friable,
• 50:53that might be a patient that you look
• 50:56at and say that the risk of doing the
• 50:58balloon test occlusion may not be warranted.
• 51:01You know that the complication
• 51:02rate sort of increases.
• 51:03Significantly, but for an average patient,
• 51:06I would say that we can do this with a
• 51:08less than 1% risk of having a stroke.
• 51:11Just as a comment,
• 51:12if anyone does this in the, you know,
• 51:14if there's like an interventionist
• 51:15in the in the crowd,
• 51:17it's often like very nice to put this balloon
• 51:20if you can in the internal carotid artery.
• 51:22Because after 30 minutes there
• 51:24might be clot in theory that can
• 51:26accumulate below the balloon.
• 51:27And so you can flush before
• 51:30deflating the balloon and sort
• 51:32of wash out any debris into the.
• 51:34External carotid artery,
• 51:35which isn't an eloquent territory.
• 51:37So that adds I think a
• 51:39level of safety and we do,
• 51:41we use that approach as well when
• 51:42we're looking at these patients.
• 51:45Just quick question,
• 51:46any differences between the TLR
• 51:48occlusion versus karate occlusion?
• 51:51That's a great question.
• 51:52And and I I talked a little bit
• 51:54about like in terms of like you
• 51:57know what the the internal carotid
• 51:59artery goes up on each side of the
• 52:02head and we'll supply that circle
• 52:04of Willis stool top individually.
• 52:07This is actually misleading because the
• 52:10vertebral artery fuses into the basilar
• 52:13artery as it comes along the skull.
• 52:15Place like near the brain stem and then
• 52:19divides again and so because of that
• 52:22taking a non dominant or codominant
• 52:24vertebral artery is much much better
• 52:27tolerated and probably does not
• 52:30require a test occlusion because of
• 52:33that anatomical configuration, right?
• 52:36Because of this fusion issue is that the
• 52:38one vertebral artery will then supply
• 52:41the basilar artery which will then
• 52:43supply the circle of Willis through both.
• 52:45PC's, and that's a nice feature
• 52:48where we get into issues is,
• 52:50and this happens occasionally when a tumor
• 52:53involves the dominant vertebral artery,
• 52:56this now becomes an issue and you can do
• 53:02a balloon test occlusion in that case.
• 53:04But often the deficits that we're
• 53:06looking for are more complicated
• 53:08in terms of like brain stem
• 53:11ischemia and it can be very scary
• 53:13to see somebody become frankly.
• 53:15Turned it on the table.
• 53:17And so often if a if a dominant
• 53:19vertebral arteries involved,
• 53:21we're talking about reconstructive
• 53:22strategies either with stenting
• 53:24or some sort of bypass.
• 53:29That's great.
• 53:29Thank you so much, Charles.
• 53:31Really appreciate you talking
• 53:33to all of us here today.
• 53:36If you want to stop sharing
• 53:37and introduce Doctor Conison,
• 53:38which is kind of the second
• 53:41part of redefining resectability
• 53:43and head neck cancer, you know,
• 53:46the three of us have definitely
• 53:47worked on cases together where,
• 53:49you know, we got to know,
• 53:50can we take the crowd,
• 53:51what's going to happen?
• 53:52And then Doctor Tonnison,
• 53:53who is a vascular surgeon here at Yale,
• 53:56is going to talk to us about,
• 53:58well, what what do you do?
• 53:59After we've taken the carotid
• 54:01artery and I think it's very
• 54:02critical that we we work together
• 54:04in surgeries head neck surgeon
• 54:05with the vascular surgeon.
• 54:06So Doctor Thomason please share
• 54:08your screen and take it away.
• 54:11Well, thanks. These two proceeding
• 54:13talks just remind me of why I initially
• 54:17wanted to be a neurosurgeon and and
• 54:19anyway now I do something much more,
• 54:22more boring vascular surgery.
• 54:24So thank you both.
• 54:25That was that was fantastic.
• 54:30He's trying to share.
• 54:33Ohh spoiler alert.
• 54:37Trying to do the slideshow.
• 54:39All right. All set.
• 54:41Everyone can see and hear.
• 54:43It looks great. Thank you.
• 54:45All right, amazing.
• 54:46So I'm going to dovetail on
• 54:50Charles's talk and go go into complex
• 54:53carotid artery reconstruction,
• 54:55particularly focusing on neck surgery,
• 54:58of course, and I'll,
• 54:59I'll go through all that.
• 55:04So I'm going to briefly define carotid
• 55:07artery reconstruction and the indications,
• 55:09review some of the existing data,
• 55:12and discuss some of the techniques
• 55:14as well as conduit choices.
• 55:21But to take a step back,
• 55:22these are some of our standard
• 55:25carotid revascularization options.
• 55:27This is a much more common thing that
• 55:30that we deal with is vascular specialists
• 55:33to remove the plaque from a carotid
• 55:36artery for atherosclerotic disease.
• 55:38And this is what it looks like in a pictorial
• 55:41form and then in histological specimen.
• 55:44And similarly,
• 55:45there is a a different technique now,
• 55:48a very popular as well,
• 55:50trans carotid artery.
• 55:51Revascularization and and this is a
• 55:53used in order to insert a stent into
• 55:56the artery and here's the stenosis
• 55:58and the internal carotid here and you
• 56:01can actually see this little pocket.
• 56:02So this is an ulcerated stenosis and
• 56:05this artery is stented and as the
• 56:08stent is placed there's actually a
• 56:10system that reverses the blood flow to
• 56:13minimize the risk of plaque embolization.
• 56:16So I show these only because familiar
• 56:18familiarity of the with the carotid artery.
• 56:21Really largely comes with experiences
• 56:24with atherosclerotic disease,
• 56:26which is, you know,
• 56:28probably 100 times more common
• 56:30than what I'll be discussing in the
• 56:33rest of the rest of the talk here.
• 56:39So revascularization is usually
• 56:41dealing with atherosclerotic disease
• 56:43like I showed you in the carotid
• 56:45artery is generally left incite you.
• 56:47We don't remove chunks or parts of
• 56:49the carotid artery other than the the
• 56:51internal layers with an endarterectomy
• 56:53and with with the carotid stent,
• 56:55we're not removing anything,
• 56:57but the reconstruction refers to
• 56:59actually resecting full thickness of
• 57:02the artery wall that's damaged in some
• 57:04fashion or needs to be resected perhaps.
• 57:07For oncological reasons,
• 57:09the indications are quite different.
• 57:12Carotid revascularization procedures
• 57:13are designed to prevent stroke,
• 57:16and that's pretty much it.
• 57:18The indications for reconstruction
• 57:20are variable also,
• 57:21as I'll show you in the next.
• 57:23Slide revascularization, very common.
• 57:27Reconstruction? Not so much,
• 57:29and the techniques are different.
• 57:30Reconstruction will involve a
• 57:32vein graft or a PTFE graft,
• 57:35as I'll show you.
• 57:36And because of the complexity
• 57:37of the reconstructions,
• 57:39these are tend to be multidisciplinary
• 57:41teams and have a higher risk
• 57:43of cranial nerve injury.
• 57:50And so moving forward into
• 57:53carotid reconstruction,
• 57:55there are a variety of indications
• 57:57for this and really I was asked to
• 58:00talk about the last one because this
• 58:02of course coincides with what our.
• 58:04Oncological next surgeons do,
• 58:05but I'd be remiss if I didn't mention
• 58:08some of these other reasons because
• 58:10a lot of the information that we have
• 58:14about reconstruction for cancer is
• 58:16extrapolated from similar techniques that
• 58:18we use for these other other issues.
• 58:21So for example.
• 58:22This is a patient who has had a
• 58:25carotid stent and you can kind of
• 58:27see the outline of the stent here.
• 58:29And this patient has a severe
• 58:31in stent stenosis and you know,
• 58:34this can be treated.
• 58:36Charles might opt to treat this
• 58:38with a balloon,
• 58:39a repeat of balloon angioplasty
• 58:41and get a good result.
• 58:42But what if it keeps coming back or they're,
• 58:44you know,
• 58:45for some reason the patient can't have
• 58:47a balloon angioplasty of this area.
• 58:50OK well potentially you can actually resect.
• 58:53All of this and put in a vein
• 58:55graft or a bypass.
• 58:56So that's just an example of a
• 58:59recurrent disease, and here's a.
• 59:03A patient of mine from several years ago.
• 59:06This is a a 70 year old man who
• 59:08had a prior carotid endarterectomy
• 59:10for a high grade stenosis and then
• 59:14a couple of years later developed
• 59:16a recurrent high grade stenosis.
• 59:18And this is actually quite rare
• 59:21because karate endarterectomies tend
• 59:23to be quite durable in you know,
• 59:2690 plus percent of patients,
• 59:28but unfortunately not in this gentleman.
• 59:30And he actually had some organized.
• 59:32Rhombus on the inside of the
• 59:34carotid patch and just looked,
• 59:35you know,
• 59:36it looked somewhat terrifying on
• 59:39the ultrasound.
• 59:40And so after you know pretty extensive
• 59:42discussion he was concerned about
• 59:44stroke recurrence and I was concerned
• 59:46about that and we opted to do a
• 59:48a vein graft and so it's a little
• 59:50it's a little video here it just it
• 59:53basically just shows it pulsing but.
• 60:00But you can see actually on the outside,
• 01:00:01here's the edges of the the patch
• 01:00:03and this that I had to open up
• 01:00:06and and the vein graft goes up
• 01:00:07from the proximal side here,
• 01:00:09which is down towards the chest,
• 01:00:11up towards the internal.
• 01:00:13This is all internal carotid karada
• 01:00:15up that the up at the top of the.
• 01:00:18Top of the neck there.
• 01:00:25And so another situation that we may
• 01:00:27have to get into doing some sort of
• 01:00:31carotid repair or reconstruction,
• 01:00:33although not perhaps as as
• 01:00:35commonly is a carotid body tumor.
• 01:00:38And so I, I like to mention these
• 01:00:40because I'm interested in these and I,
• 01:00:42I I think they're very fascinated.
• 01:00:44I think a lot of us are fascinated
• 01:00:46with carotid body tumors because
• 01:00:47they have such a exotic pathology
• 01:00:49and they look very interesting
• 01:00:50under a microscope and they're.
• 01:00:52You know, they're just very
• 01:00:54fascinating on little tumors.
• 01:00:55Fortunately, they're rarely malignant.
• 01:00:58And this is from actually one of
• 01:01:00my my older one of my old partners
• 01:01:03Jeb Hallett did this 50 year old.
• 01:01:0650 year Mayo Clinic experience many
• 01:01:08years ago and it's really been a a
• 01:01:11landmark paper which categorized
• 01:01:13these tumors nicely into into the
• 01:01:16Shamblin state Shamblin stages here
• 01:01:18and kind of showed a correlation
• 01:01:21between these three levels of.
• 01:01:24Disease and the degree of complications
• 01:01:27that you can expect and as you
• 01:01:29can see in cross section here,
• 01:01:32Shamblin 1 tumor kind of sits between
• 01:01:35the internal and the external.
• 01:01:37And then a Shamblin 2 starts to
• 01:01:39impinge upon the vessels a little bit
• 01:01:41more and gets a little more dicey.
• 01:01:43And then a three, you know,
• 01:01:45it just basically is like, you know,
• 01:01:47is like a little fruit sitting
• 01:01:49inside the jello mold here.
• 01:01:51I mean,
• 01:01:51it's really,
• 01:01:52really encompassing the blood
• 01:01:53vessels and these are of course.
• 01:01:55The most difficult to manage and tend
• 01:01:59to involve cranial nerves and and
• 01:02:01may have a higher end do and have a
• 01:02:05higher risk of treating nerve palsy.
• 01:02:08But when it gets to carotid reconstructions,
• 01:02:10fortunately,
• 01:02:11most of these do not require
• 01:02:13a carotid reconstruction,
• 01:02:14and the rate of carotid reconstruction
• 01:02:17has gone down over over time,
• 01:02:19as I'll show you in the.
• 01:02:21More recent, more recent series,
• 01:02:24but in this older series they
• 01:02:26had to do a lateral suture,
• 01:02:28meaning just a simple suture
• 01:02:29repair in in about 9% of cases.
• 01:02:32And then some sort of little
• 01:02:34patch or or even a graft and 25%.
• 01:02:38Of these patients.
• 01:02:43And so more more recently,
• 01:02:44just a couple of months ago,
• 01:02:46this article from some of our
• 01:02:49colleagues in Mexico came out and
• 01:02:52this is the largest database of
• 01:02:55carotid body tumors that actually
• 01:02:57crosses 3 continents in 11 countries.
• 01:03:00And so there's a lot of information here.
• 01:03:03I I put up the balloon occlusion
• 01:03:04because I knew that the Charles
• 01:03:06will be talking about that.
• 01:03:07And they actually found that
• 01:03:09balloon occlusion was only done,
• 01:03:11only performed in about 22% of
• 01:03:14patients and interestingly.
• 01:03:15Only about 2% of those were positive and.
• 01:03:20And about a third of these were
• 01:03:23categorized as Shamblin 3 or the more,
• 01:03:25the more severe tumors.
• 01:03:28And you know what they what they did find
• 01:03:31though is that when the carotid artery.
• 01:03:33Is involved as it may,
• 01:03:35may likely be with more advanced tumors,
• 01:03:39the risk goes up and I think
• 01:03:41that's intuitive, right.
• 01:03:42So if you have to resect a part of the
• 01:03:44carotid artery in addition to the tumor,
• 01:03:45there's increased risk of
• 01:03:47blood loss and potentially.
• 01:03:50Stroke and cranial nerve problems.
• 01:03:52So the risk of stroke though
• 01:03:54ultimately was pretty low,
• 01:03:55but they did find that, you know,
• 01:03:56doing something else with the carotid,
• 01:03:58whether that's.
• 01:03:58A graft, or whether that's an
• 01:04:00endarterectomy or something else.
• 01:04:02That of course does elevate your.
• 01:04:05Risk of complications.
• 01:04:06Fortunately,
• 01:04:06most of the cranial nerve
• 01:04:08palsies were just temporary.
• 01:04:14And so I take a little sidebar here just
• 01:04:18to show about preoperative embolization.
• 01:04:20I think the authors hopefully of the
• 01:04:23capacity database here will maybe get
• 01:04:25into the details a little bit more,
• 01:04:28perhaps in future articles on embolization.
• 01:04:31They really didn't touch on it
• 01:04:32too much in this in this article.
• 01:04:36We we've looked at a few cases
• 01:04:39here at here at Yale.
• 01:04:41One of my partners doctor on Missouri.
• 01:04:44We published this little article here.
• 01:04:47It's got some cute pictures,
• 01:04:48but what this shows is that here's
• 01:04:51a carotid body tumor and this is
• 01:04:53the common carotid artery here,
• 01:04:55and then the internal carotid
• 01:04:56artery and the external with all
• 01:04:58of the all of the branches,
• 01:04:59the ascending pharyngeal
• 01:05:01and etcetera etcetera.
• 01:05:03And using these little micro coils of
• 01:05:05platinum based coils to embolize all
• 01:05:08of these little branches potentially
• 01:05:10reduces your blood loss in the operating
• 01:05:13room and can decrease the vascularity.
• 01:05:15They have not yet been able to show
• 01:05:18an association between that and
• 01:05:20decreased risk of cranial nerve injury,
• 01:05:22however.
• 01:05:22Intuitively you would think that
• 01:05:24that would be the case,
• 01:05:26but I guess further a larger
• 01:05:27studies will show that.
• 01:05:31And this is just an example.
• 01:05:34Of a Shamblin 2 tumor.
• 01:05:35So fortunately, this did not require
• 01:05:39a carotid body reconstruction.
• 01:05:41You can see in cross section here the
• 01:05:43internal carotid artery and some of
• 01:05:45the little branch up here and the big,
• 01:05:47big tumor right here.
• 01:05:49Hopefully I'm showing you this with my mouse.
• 01:05:52And then here you can see if you
• 01:05:54look closely, here's the the tumor,
• 01:05:56there's a little loop around
• 01:05:58the carotid artery here,
• 01:05:59and then we're coming across one of the
• 01:06:02little branches and this little guy here.
• 01:06:04This little coil, this little metal thing,
• 01:06:06you actually when you come across
• 01:06:07some of these little branches,
• 01:06:08the little coils just, you know,
• 01:06:09come out and and, you know,
• 01:06:11there they are and they don't
• 01:06:13really cause much inflammation,
• 01:06:14which is not really, really nice.
• 01:06:16And then here is the external carotid
• 01:06:18artery and here's the internal
• 01:06:20carotid artery and the common
• 01:06:22carotid artery with the yellow loop,
• 01:06:24the internal again with the red loop.
• 01:06:27And here's the tumor which it's
• 01:06:28almost been fully mobilized.
• 01:06:30It's almost ready to come,
• 01:06:32come popping out for our
• 01:06:34friendly pathologist.
• 01:06:35Uh, but uh, in this case,
• 01:06:37you know,
• 01:06:38this tumor could be mobilized
• 01:06:39and and no sutures actually had
• 01:06:41to be placed on the carotid.
• 01:06:43Artery itself.
• 01:06:47And so now moving into more of the
• 01:06:51details of carotid artery reconstruction.
• 01:06:53And this is a perhaps a nice little
• 01:06:56figure that demonstrates this very simply.
• 01:06:58You have to remove a chunk of the
• 01:07:00carotid artery and you have to
• 01:07:02replace it with some sort of graft,
• 01:07:03whether that's vein or a prosthetic graft.
• 01:07:06And in this situation,
• 01:07:08the external carotid artery is just
• 01:07:10ligated and that is tolerated quite well in
• 01:07:13this series of 41 patients over 17 years.
• 01:07:16So again.
• 01:07:17But this is not a common phenomenon,
• 01:07:19and this was done at UCLA.
• 01:07:22And this was published way back in 2008.
• 01:07:24They demonstrated all of these different
• 01:07:27indications for carotid reconstruction.
• 01:07:30You know, interestingly enough,
• 01:07:31again none,
• 01:07:32none for a cancer at least were
• 01:07:35were noted in this.
• 01:07:37A particular article.
• 01:07:44And then. We really have to think
• 01:07:47about the type of conduit we use.
• 01:07:49When I refer to conduit,
• 01:07:50I mean what are we replacing that
• 01:07:52part of the carotid artery with?
• 01:07:53Are we replacing it with a vein or
• 01:07:56a some sort of prosthetic graft?
• 01:07:58Those are pretty much the choices.
• 01:08:00You can use saphenous vein.
• 01:08:01You can use a deep vein from the leg,
• 01:08:03you can use a Dacron or a PTFE graft.
• 01:08:06Some people have actually used superficial
• 01:08:08femoral artery and then replaced
• 01:08:10the artery in the leg with a graft.
• 01:08:12OK, that's you know, you can use
• 01:08:14that too and I think you know the.
• 01:08:15The decision making is important,
• 01:08:17but here's an article from
• 01:08:19actually some former partners of
• 01:08:21mine up at Albany Medical Center,
• 01:08:24and they compare the types of conduits.
• 01:08:27With regards to patency,
• 01:08:28because really that that's really
• 01:08:30not determined in this particular
• 01:08:33location and they found very similar.
• 01:08:36Survival of the of the bypass over time.
• 01:08:40Again, most of these indications
• 01:08:42were not for cancer, though.
• 01:08:44This was for occlusive disease, for trauma.
• 01:08:47Infections.
• 01:08:48All the infections,
• 01:08:51of course, got vein grafts.
• 01:08:52Would not be appropriate to do
• 01:08:54a prosthetic in that situation.
• 01:08:56And then carotid aneurysms
• 01:08:59or pseudoaneurysms notably,
• 01:09:01they had a preponderance of
• 01:09:03prosthetic grafts in their series,
• 01:09:05which you know,
• 01:09:05clearly shows their favoritism for,
• 01:09:09for that there were no differences
• 01:09:12in the outcomes.
• 01:09:14Either.
• 01:09:18And so now we're getting into the discussion
• 01:09:21of advanced neck cancers and what is the role
• 01:09:24for carotid sacrifice and reconstruction.
• 01:09:27And I always like to put up a little
• 01:09:29rowing thing because I used to row,
• 01:09:31so I not always, but anyway,
• 01:09:33there it is because it's such a
• 01:09:35nice demonstration of teamwork.
• 01:09:37And I I apologize if I left somebody
• 01:09:40out here. I hope not, you know,
• 01:09:42but all of these specialists and.
• 01:09:46And caregivers are a part of the team
• 01:09:49that care for these patients with.
• 01:09:52Had neck cancer.
• 01:09:54So you know, I think one of the questions
• 01:09:56that I always ask is, you know,
• 01:09:57I can put the blood vessels back together,
• 01:09:59but you know,
• 01:10:00you guys help me out as this indicated.
• 01:10:02Is this the best treatment?
• 01:10:03Is radiation better?
• 01:10:05Is chemotherapy better?
• 01:10:06Is is this going to give
• 01:10:08the patient what they want?
• 01:10:09Is this going to give the patient a
• 01:10:11quality of life or are they going to have?
• 01:10:13You know a lot of morbidity from this
• 01:10:15and and what are the patients goals.
• 01:10:17So I think having that sort of discussion
• 01:10:20you know particularly with the.
• 01:10:22With the otolaryngologist
• 01:10:24and the medical oncologist,
• 01:10:26the radiation oncologist,
• 01:10:27particularly when it gets into
• 01:10:29these complex tumors,
• 01:10:31is really.
• 01:10:31Really essential so that we can
• 01:10:34present to the patient what we
• 01:10:36think are the pros and cons and
• 01:10:39expectations for recovery as well
• 01:10:41as the potential morbidity that the
• 01:10:43patient may may not anticipate.
• 01:10:49So, you know, my understanding of
• 01:10:51the indications for carotid sacrifice
• 01:10:53and reconstruction are that these
• 01:10:55are advanced head and neck cancers,
• 01:10:57particularly a squamous cell cancers and
• 01:10:59a few others in case or or at least a
• 01:11:02**** and can involve the carotid artery.
• 01:11:05And you know, oncologists and surgical
• 01:11:08oncologists need to get clean margins
• 01:11:11in order to be able to consider the.
• 01:11:14Resection successful,
• 01:11:15so peeling or shaving off the artery
• 01:11:19certainly I think is is done,
• 01:11:21but does have risk of leaving behind
• 01:11:24microscopic disease and I think
• 01:11:26in one series it was about 40%.
• 01:11:28Moreover, there is a risk of weakening
• 01:11:30the wall of the artery which can
• 01:11:32lead to the much feared complication
• 01:11:35of carotid blowout syndrome.
• 01:11:39So, you know,
• 01:11:40and then people talk about ligation,
• 01:11:42but as as doctor Matuk mentioned,
• 01:11:44I think that really has a high
• 01:11:46risk of a of a stroke,
• 01:11:48just plain old ligation and so.
• 01:11:53We think about doing a reconstruction
• 01:11:55and when we think about the patients
• 01:11:58long term survival with regards to
• 01:12:00the completeness of that resection.
• 01:12:02The largest series I could find was
• 01:12:05from 2015 fifty one patients with
• 01:12:09carotid sacrifice and reconstruction
• 01:12:12over 17 year period for swimming,
• 01:12:15both primary and recurrent
• 01:12:18squamous cell cancers.
• 01:12:19And a pretty good results I I
• 01:12:23think only two strokes and 82%.
• 01:12:28Two year disease free survival.
• 01:12:34In this meta analysis,
• 01:12:35the results are a little bit more sobering.
• 01:12:39This meta analysis,
• 01:12:40I believe it's from gosh believe
• 01:12:43the Netherlands, published in 2000.
• 01:12:4718 and they reviewed, you know,
• 01:12:50really a heterogeneous group.
• 01:12:51So maybe not best for a meta analysis.
• 01:12:53But anyway, it was a review,
• 01:12:54and they looked at 24 studies published over,
• 01:12:57you know, several decades,
• 01:12:59so just a total of 357 patients.
• 01:13:02And these included the squamous cell cancers,
• 01:13:05some salivary cancers and thyroid cancers.
• 01:13:09Low mortality,
• 01:13:113.6% and permanent stroke deficits were 3.6%.
• 01:13:16As well, a carotid blowout,
• 01:13:211.4% and carotid blowout.
• 01:13:22I guess for the audience here just
• 01:13:25that refers to a, you know, you know,
• 01:13:27basically where the carotid artery,
• 01:13:29the wall is so weak that it
• 01:13:31begins bleeding and patient,
• 01:13:33you know, begins exsanguinating,
• 01:13:35which necessitates a urgent.
• 01:13:38A surgery, a covered stent can perhaps be
• 01:13:42used in that situation and in a in a pinch.
• 01:13:45And then they really noted that only
• 01:13:48in seven studies was it even mentioned
• 01:13:50the use of balloon occlusion testing.
• 01:13:52So that was really inconsistently used.
• 01:13:55And I really, you know,
• 01:13:55I really love the, the protocol
• 01:13:57that Doctor Matouk described here.
• 01:13:59That's just,
• 01:13:59I think it it sounds very
• 01:14:02comprehensive and and and elegant.
• 01:14:04The but the one year survival,
• 01:14:07you know, is pretty sobering
• 01:14:1152.4%. It was a little better in the more
• 01:14:13recent time period in this meta analysis.
• 01:14:20And so my old partner told me that his old
• 01:14:24mentor told him that an open blood vessel
• 01:14:26is better than a closed blood vessel.
• 01:14:28So like I carry around all these little,
• 01:14:30you know, words of wisdom from over the
• 01:14:33years and then repeat them as as need be.
• 01:14:36So this is one of the the things that
• 01:14:38stuck with me and I think, you know,
• 01:14:40that's of course not always true,
• 01:14:42but I think in this situation
• 01:14:44it probably is true.
• 01:14:45And so we think about reconstructing
• 01:14:48the carotid arteries.
• 01:14:49I mean, I don't think there's
• 01:14:51a ton of downside to doing it.
• 01:14:52You have to have good exposure,
• 01:14:55proximal and distal control.
• 01:14:56I wouldn't be a vascular surgeon if I
• 01:14:59didn't mention proximal and distal control,
• 01:15:01which refers to having clamps or
• 01:15:03control of your blood vessels so that
• 01:15:05they you don't lose control of them,
• 01:15:07so that you're able to control and
• 01:15:09manipulate both the inflow and the outflow.
• 01:15:12Coexisting atherosclerotic disease inside
• 01:15:14the carotid artery can be problematic.
• 01:15:17You certainly wouldn't want to
• 01:15:18place a clamp on a part of the
• 01:15:20blood vessel where it is diseased.
• 01:15:22And severe atherosclerotic disease
• 01:15:23would probably need to be managed
• 01:15:25a little bit differently than just
• 01:15:27a straightforward resection of the
• 01:15:29healthy part of the blood vessel that's,
• 01:15:31you know, involved with the tumor,
• 01:15:33the conduits of choice.
• 01:15:34I mentioned saphenous vein, femoral vein.
• 01:15:37I I like to use a Dacron or PTFE.
• 01:15:41This is a carotid. Clavian bypass here.
• 01:15:43We use Dacron or PTFE frequently in this
• 01:15:46sort of situation and it holds up quite well.
• 01:15:50There's a lot of evidence that shows at
• 01:15:52least for carotid subclavian bypasses,
• 01:15:54if I can extrapolate a little bit,
• 01:15:56again,
• 01:15:56which I think I have to given
• 01:15:58the rarity of these conditions.
• 01:16:00But we do some carotid subclavian
• 01:16:02bypasses quite frequently for things
• 01:16:05like thoracic aneurysms and dissections.
• 01:16:07And these bypasses have a very good
• 01:16:10longevity, probably because they're.
• 01:16:13Short and wide little, little bypass,
• 01:16:15which is kind of similar to what
• 01:16:16I'm talking about with carotids.
• 01:16:18If there's going to be,
• 01:16:19or if you if you can possibly
• 01:16:21anticipate oropharyngeal contamination,
• 01:16:23you would want to use a vein
• 01:16:24graft and not a prosthetic.
• 01:16:25Of course, shunting is really complex.
• 01:16:27I,
• 01:16:28I value the information from
• 01:16:30the balloon occlusion test,
• 01:16:31but there are additional considerations.
• 01:16:34Umm, it's also showing that,
• 01:16:36you know,
• 01:16:37surgeons who routinely shunt
• 01:16:39during carotid and daughter ectomy
• 01:16:41have a lower risk of shunting.
• 01:16:44Complications.
• 01:16:46And perhaps somebody who shunts selectively
• 01:16:48during a carotid endarterectomy.
• 01:16:50So there's some issues with kind of,
• 01:16:52you know, practice.
• 01:16:53I'm a routine shunter,
• 01:16:54but I think for something like replacing a,
• 01:16:56a segment of the common carotid artery,
• 01:16:58sometimes it can be more
• 01:17:00cumbersome to insert the shunt.
• 01:17:01You're going to use it for one anastomosis,
• 01:17:03you're going to take it
• 01:17:04out about halfway through.
• 01:17:04The other one,
• 01:17:05you know,
• 01:17:06it kind of adds a lot of time and
• 01:17:09complexity that you may or may not
• 01:17:10need to do.
• 01:17:11So the the decision for shunting
• 01:17:14is is really something to.
• 01:17:16That's really quite complex.
• 01:17:20Heparin is, you know,
• 01:17:22another staple of vascular surgery.
• 01:17:23And I think once you're manipulating
• 01:17:25those blood vessels and touching them,
• 01:17:27particularly if they,
• 01:17:28if they're healthy blood vessels,
• 01:17:30they can go into spasm in a healthy
• 01:17:32person or a younger person if
• 01:17:34they're not atherosclerotic and they
• 01:17:36can form thrombus and they're and
• 01:17:39they're pro thrombotic prothrombotic.
• 01:17:41So you know I like to give a little bit
• 01:17:42of Hepburn once you're kind of, you know,
• 01:17:44messing around with the blood vessels.
• 01:17:47And and these other things are,
• 01:17:48you know pretty standard I think,
• 01:17:50you know doing a muscle flap coverage
• 01:17:52if there's going to be not much
• 01:17:53tissue coverage over this area can
• 01:17:55really be a valuable asset as well.
• 01:17:57Certainly adds time to the case.
• 01:18:01So this is all about getting good
• 01:18:03exposure of the blood vessel.
• 01:18:05This is the left carotid
• 01:18:06artery here, of course.
• 01:18:08But what this demonstrates is that,
• 01:18:10you know, if you can't get
• 01:18:11proximal on the blood vessel,
• 01:18:12you can't get below where you need
• 01:18:15to get to get proximal control.
• 01:18:17You may need to have a sternotomy and
• 01:18:20call in our thoracic friends to help
• 01:18:23us out because the sternotomy right
• 01:18:25down the middle actually provides
• 01:18:26nice exposure of the carotid all
• 01:18:29the way down to the aortic arch,
• 01:18:30which is shown here.
• 01:18:32This is A and this is extrapolated
• 01:18:34from a a trauma textbook.
• 01:18:36But you know,
• 01:18:37the same principles and exposure
• 01:18:39apply to all of these things.
• 01:18:40Distal exposure, you know,
• 01:18:42that's something I would rely upon,
• 01:18:45my skull based.
• 01:18:46Surgeons to help out with.
• 01:18:51So I think this is my last slide.
• 01:18:53This is a case with Doctor Mera,
• 01:18:56gentleman who had a recurrent recurrent
• 01:18:59squamous cell carcinoma with the
• 01:19:02tumor budding the carotid Umm and
• 01:19:05we resected the carotid artery.
• 01:19:08And then Doctor Merrick resected all the
• 01:19:11other stuff and and got clear margins,
• 01:19:14which is a great. You know,
• 01:19:16this involves some cranial nerves.
• 01:19:17He did have some dysphasia that resolved.
• 01:19:21Fortunately, after about a month
• 01:19:23and just just showing that.
• 01:19:26You know, everything we do is humbling.
• 01:19:27This gentleman's desire was to
• 01:19:29get to his daughter's wedding and
• 01:19:31to live long enough to do that.
• 01:19:33And he did, and he and he lived
• 01:19:36another 14 months after this.
• 01:19:38And so I think it it just,
• 01:19:39you know,
• 01:19:40goes back to what is the patient wanted
• 01:19:44and what is their experience going
• 01:19:46to be and how humbling it is to do
• 01:19:48these big operations and and realizing that.
• 01:19:53That we can't always cure everybody.
• 01:19:56Thank you.
• 01:19:59Thank you, Doctor Thomas.
• 01:20:00And that was a really great talk
• 01:20:02and really I think discuss a lot,
• 01:20:05but a lot of the complexities involved in
• 01:20:07the decision making about these cases,
• 01:20:09which is really probably you know the
• 01:20:11technical aspects what we're discussing.
• 01:20:13But the decision making is also
• 01:20:15perhaps even more challenging once
• 01:20:17you've done some of these two
• 01:20:18questions and in fact I think you
• 01:20:20may have actually answered these,
• 01:20:22but so I'm going to go through them quickly.
• 01:20:24One of them was about the choice
• 01:20:27of graft material when.
• 01:20:29Even if there's or if it's
• 01:20:31a composite resection,
• 01:20:32so the oral cavity or France is
• 01:20:34involved with a carotid artery
• 01:20:36sacrifice and correct me if I'm wrong,
• 01:20:39but I think you said you prefer
• 01:20:40to use vein grafts in that case as
• 01:20:43opposed to synthetic materials,
• 01:20:44is that
• 01:20:45correct? I definitely.
• 01:20:46So if there's going to be oral pharyngeal
• 01:20:48contamination or you anticipate that,
• 01:20:50then harvesting staff and Spain from
• 01:20:52the leg would be a good choice.
• 01:20:54On the other hand, sometimes that
• 01:20:56vein is a little bit too small.
• 01:20:57It's, you know, it could be 3/4.
• 01:20:59Millimeters, and if you're going to
• 01:21:01replace the common carotid artery
• 01:21:02or something a little bit larger,
• 01:21:04or the veins too small,
• 01:21:04it may be better.
• 01:21:06To use femoral vein,
• 01:21:07you can use the deep femoral vein
• 01:21:09and they're you know some side
• 01:21:11effects of that but but usually
• 01:21:12we can we can work around that.
• 01:21:14So that's another alternative.
• 01:21:15You could also use superficial
• 01:21:18femoral artery provided that arteries
• 01:21:19is healthy but I would not use
• 01:21:22a prosthetic in that situation.
• 01:21:24And the second question had to do with
• 01:21:27flap coverage afterwards which you also
• 01:21:29did discuss but I'll just reiterate.
• 01:21:31So oftentimes when we are as
• 01:21:33head next surgeons at the point
• 01:21:35where we're talking about.
• 01:21:37Saccharin, carotid artery.
• 01:21:38It's not just a carotid artery.
• 01:21:39It's general cloud of mastoid muscle.
• 01:21:41It's, you know, basically, you know,
• 01:21:43sometimes the skin of the neck.
• 01:21:44And so there can be a very large soft
• 01:21:48tissue defect with a prosthetic.
• 01:21:51Graft in there, some type of graft,
• 01:21:53even a venous graft in there.
• 01:21:54And so I would say, yeah,
• 01:21:56we would would routinely use flop
• 01:21:58coverage in those cases of the
• 01:22:00pectoralis muscle flap is a great option,
• 01:22:03which is a a flap first described
• 01:22:06here at Yale as well in 1979 or 1980.
• 01:22:09So it's it's a great.
• 01:22:12Yeah, I think it's,
• 01:22:13it's very important all work together.
• 01:22:14Thank you very much,
• 01:22:15Doctor Thompson for that.
• 01:22:16I think it was a great follow up to
• 01:22:18Doctor Matouk's talk as well and just
• 01:22:20emphasizes the multidisciplinary
• 01:22:21team required for this. All right.
• 01:22:24Well, great.
• 01:22:25So our next talk is Doctor Bhatia.
• 01:22:27So if you want to,
• 01:22:30if you have stopped sharing,
• 01:22:31so Doctor Bhatia and hers get hers going.
• 01:22:33But redefining respectability
• 01:22:34and head neck cancer again is the
• 01:22:37topic of today's discussion.
• 01:22:39And an important part of that is induction.
• 01:22:43Therapy so I'm going to stop sharing and
• 01:22:45have Doctor Bhatia pull up her slides.
• 01:22:47Doctor Bhatia is an esteemed
• 01:22:49medical oncologist who works at Edna
• 01:22:52Cancer here and associate professor
• 01:22:53at Yale School of Medicine.
• 01:22:57Thank
• 01:22:57you. Carol. Am I hurt? OK.
• 01:23:01Everything's good. We see our
• 01:23:02slides and we can hear you.
• 01:23:04Good evening, everyone.
• 01:23:05Thank you for the opportunity.
• 01:23:07Today I'll be reviewing
• 01:23:09the role of induction,
• 01:23:10systemic therapy and head neck cancers.
• 01:23:12It's a very broad and evolving topic.
• 01:23:15So you know, keeping the time in mind,
• 01:23:17I'm going to breathe through
• 01:23:18some of the slides here.
• 01:23:20So you know, as I've been it's
• 01:23:22been discussed extensively today,
• 01:23:23definitive local treatment with
• 01:23:25surgery obviously forms a key part of
• 01:23:27curative intent treatment and head,
• 01:23:29neck cancers, but sometimes can
• 01:23:31be associated with morbidity,
• 01:23:33loss of function,
• 01:23:34especially when disease is in the vicinity
• 01:23:36of critical structures like the tongue,
• 01:23:38the larynx,
• 01:23:39the orbit, etcetera.
• 01:23:40And the integration of chemo into
• 01:23:42the treatment plan has allowed to
• 01:23:44formulate organ sparing surgery
• 01:23:46or even radiation treatments.
• 01:23:48So chemo is incorporated one of
• 01:23:50three ways in treating head,
• 01:23:51neck cancers either as induction
• 01:23:54or neoadjuvant,
• 01:23:55which is given prior to definitive
• 01:23:57surgery or radiation or concurrently
• 01:23:59with radiation as upfront treatment
• 01:24:01or adjacently following surgery,
• 01:24:03usually in combination with radiation.
• 01:24:06Today's talk will focus on the clinical
• 01:24:08utility of induction systemic therapy.
• 01:24:11So the first trial probably that
• 01:24:13showed the utility of sequential
• 01:24:15chemo followed by radiation
• 01:24:17as a surgical alternative.
• 01:24:19Curative treatment treat creatively
• 01:24:20treating larynx cancers was the VA
• 01:24:23larix trial and patients who patients
• 01:24:25got 2 cycles of Platinum 5A few induction.
• 01:24:28Those that had at least a 50%
• 01:24:30response to two cycles went on
• 01:24:32to get a third cycle and then
• 01:24:34radiation and surgery was used as
• 01:24:36salvage for any residual disease
• 01:24:38for patients on the experimental arm.
• 01:24:40And there was no difference in
• 01:24:43overall survival between the surgical
• 01:24:44arm and the sequential induction
• 01:24:46chemo followed by radiation arm.
• 01:24:48But larynx preservation was able
• 01:24:50to be achieved in about 64% of
• 01:24:53patients versus obviously 0%
• 01:24:55in the salvage surgery arm.
• 01:24:57There were differences in the
• 01:24:59patterns of failure with less distant
• 01:25:01metastases with patients getting chemo,
• 01:25:03but more local regional failures in
• 01:25:05the chemo arm and similarly in Europe.
• 01:25:08E RTC ran a phase three trial in
• 01:25:11patients with locally advanced
• 01:25:12hypopharynx cancer and which until
• 01:25:15then required surgical resection of
• 01:25:17the larynx and patients were randomized.
• 01:25:19Again to either induction Platinum
• 01:25:215 FU followed by radiation for
• 01:25:24complete responders versus surgery
• 01:25:25followed by radiation and patients
• 01:25:27with a partial or no response to
• 01:25:30induction also underwent surgery.
• 01:25:32Only complete responders got radiation.
• 01:25:34The endpoints were progression
• 01:25:36free and overall survival and
• 01:25:38survival with a functional larynx.
• 01:25:40Complete response was seen in over
• 01:25:42half the patients on the induction
• 01:25:44arm and survival larynx preservation
• 01:25:46distant metastatic rate while
• 01:25:48all improved on the chemo arm,
• 01:25:50so making that a new standard of care.
• 01:25:51In Europe as well?
• 01:25:53Subsequently 2 phase three trials
• 01:25:56Tax 323 which was conducted in Europe
• 01:25:59and Tax 324 which was conducted in
• 01:26:01the US explored adding a third agent
• 01:26:04as an induction regimen so attack
• 01:26:07saying to platinum and five FU.
• 01:26:09The primary endpoint for these trials
• 01:26:11was progression free survival for
• 01:26:13tax 323 and overall survival for tax
• 01:26:16324. There were minor differences
• 01:26:18in doses between the two trials.
• 01:26:21Both progression free and overall
• 01:26:23survival were improved with the
• 01:26:25addition of taxane compared
• 01:26:26to Platinum 5 if you alone.
• 01:26:29So this became the new standard
• 01:26:30of care induction regimen.
• 01:26:32As far as possible there were more
• 01:26:34toxicities with the addition of
• 01:26:361/3 drug which is not surprising.
• 01:26:38So more neutropenia is more febrile.
• 01:26:40Neutropenia as or hospital
• 01:26:42admissions for some patients.
• 01:26:44So this is a difficult regimen
• 01:26:47in general for patients who are
• 01:26:49frail or elderly and tax 324 like
• 01:26:51I mentioned similar trial but on
• 01:26:53in in the United States adding
• 01:26:55a taxane to platinum and five a
• 01:26:57few again improvement in overall
• 01:26:59and progression free survival but
• 01:27:01at a cost of more toxicities.
• 01:27:03So these this regimen the three drug
• 01:27:05taxane Platinum 5 FU is in general
• 01:27:07pretty unsuitable for frail and
• 01:27:09elderly patients we have to carefully.
• 01:27:11Like what kind of patient can
• 01:27:13tolerate this treatment?
• 01:27:15Umm. See? I'm sorry. Saturday.
• 01:27:25OK, sorry about that.
• 01:27:26So now that we knew that TPF the
• 01:27:29taxane Platinum 5 if you the three
• 01:27:31drug combination was a better
• 01:27:33induction regimen than Platinum 5 FU.
• 01:27:35The GORTEX trial was a European
• 01:27:37trial that sought to compare the
• 01:27:39two regimens for their larynx
• 01:27:40preserving ability in patients with
• 01:27:42larynx and hypopharynx cancers.
• 01:27:44So if you remember the VA larynx
• 01:27:46trial compared just use platinum
• 01:27:47five if he was induction.
• 01:27:49This trial used taxane Platinum 5
• 01:27:53FU 220 patients were randomized.
• 01:27:55With larynx and hypopharynx cancers
• 01:27:57where surgery would require our total
• 01:28:00laryngectomy and responders to induction,
• 01:28:02chemo went on to get 70 degree of radiation
• 01:28:05with or without concurrent chemotherapy.
• 01:28:08Non responders went on to get
• 01:28:10salvage surgery followed by radiation
• 01:28:11plus or minus chemo.
• 01:28:13And although Cytopenias were again seen
• 01:28:15more frequently in the three drug arm,
• 01:28:18in the taxane Platinum 5 FU more patients
• 01:28:20were able to have objective responses
• 01:28:23and achieve larynx preservation.
• 01:28:25So this became a preferred.
• 01:28:26Measurement for induction even
• 01:28:27for these patients and although
• 01:28:29I won't be showing the data or
• 01:28:31discussing those slides here,
• 01:28:33but we do use induction chemo at
• 01:28:36our institution as an approach
• 01:28:38for chemo selection for T4
• 01:28:40larynx patients to help improve,
• 01:28:42to help improve patient selection for
• 01:28:44those that would respond to radiation and
• 01:28:47ultimately recover laryngeal function.
• 01:28:49This practice comes from the
• 01:28:50University of Michigan experience,
• 01:28:52which was able to improve the larynx
• 01:28:55preservation rate from 40 to 50%.
• 01:28:57With chemo radiation up front versus
• 01:28:59chemo selection followed by chemoradiation
• 01:29:01then it went up closer to 60%.
• 01:29:04Although the role of induction was
• 01:29:07established for organ preservation,
• 01:29:08what really remained unclear at this
• 01:29:10point was how it improved survival when
• 01:29:12compared to chemo radiation alone.
• 01:29:14And the Spanish trial attempted to
• 01:29:16answer this question by randomizing
• 01:29:18patients to one of three treatment arms.
• 01:29:20So they either got chemo radiation alone
• 01:29:23or the two drug induction followed by
• 01:29:25chemo radiation or the three drug induction.
• 01:29:28Followed by chemoradiation.
• 01:29:29There were no significant differences
• 01:29:32between progression free time to
• 01:29:34treatment failure or overall survival.
• 01:29:35Across the three arms,
• 01:29:37the plants have flattened,
• 01:29:38doses were high and almost half the
• 01:29:41patients were unable to complete the
• 01:29:43treatment as was indicated in the protocol.
• 01:29:46Subsequently, there were other trials.
• 01:29:48I'm probably going to skip all the
• 01:29:49data in it, but the D side trial,
• 01:29:51the paradigm trial,
• 01:29:53and the tremplin trial,
• 01:29:55all of them compared induction
• 01:29:58chemo followed by chemo radiation
• 01:30:00versus chemo radiation alone.
• 01:30:02And although some of them were
• 01:30:04underpowered to detect a difference
• 01:30:06in the two arms because they
• 01:30:07didn't meet the planned accrual,
• 01:30:09in general there was no difference in
• 01:30:12survival between induction followed by
• 01:30:14chemo radiation versus chemo radiation alone.
• 01:30:16So although it's a great
• 01:30:18strategy for organ preservation,
• 01:30:19it doesn't really add meaning to
• 01:30:21patients where your your outcomes
• 01:30:23with cure are pretty high and no
• 01:30:26critical organ is at risk with
• 01:30:28chemo radiation up front.
• 01:30:32Subsequently, there was a meta
• 01:30:34analysis of TPLF in India as
• 01:30:36used as induction from 5 trials,
• 01:30:38which included about 1700 patients and
• 01:30:41although TPF decreased the hazard for depth
• 01:30:45progression free and distant disease.
• 01:30:48You know, in terms of how it
• 01:30:49compared to Chemoradiation alone,
• 01:30:51similar similar patterns of findings.
• 01:30:54The absolute survival benefit was
• 01:30:56very comparable to what was reported
• 01:30:58with concurrent chemoradiation,
• 01:31:00and May in fact lead to even inferior local
• 01:31:03regional control compared to CHEMORADIATION.
• 01:31:06There were also concerns about patients
• 01:31:08being actually able to start and complete
• 01:31:10definitive radiation following induction
• 01:31:12in the meta analysis with the TPF's,
• 01:31:15only 73% of patients were
• 01:31:16able to initiate subsequent.
• 01:31:18Party.
• 01:31:18So about 1/4 of patients cannot and
• 01:31:20only half of them were able to get
• 01:31:23the plan concurrent chemotherapy.
• 01:31:24Again highlighting just the need for
• 01:31:27careful patient selection in terms
• 01:31:29of who might be able to tolerate a
• 01:31:31long course of induction followed
• 01:31:33by concurrent chemoradiation.
• 01:31:34So given the significant tolerability
• 01:31:36concerns that we see with TPF,
• 01:31:39ECOG studied and alternative induction
• 01:31:41regimen of Carbo Taxol cetuximab which
• 01:31:43is a weekly treatment just six weeks
• 01:31:45and done and followed by the same regimen.
• 01:31:48Concurrent with radiation,
• 01:31:49but at lower doses of the chemo drugs.
• 01:31:52And although it hasn't been
• 01:31:54compared head-to-head with TPF,
• 01:31:55which still remains the gold standard,
• 01:31:57the three-year overall and event
• 01:32:00free survival were very similar
• 01:32:02with this regimen compared to TPF
• 01:32:04and contrasting to the TPF data,
• 01:32:0690% of patients were actually able to
• 01:32:09complete subsequent chemo radiation,
• 01:32:10making it a very attractive option
• 01:32:12for elderly and frail patients.
• 01:32:14So we tend to use this regimen
• 01:32:15actually quite a bit and have
• 01:32:17had quite a bit of success.
• 01:32:18As an alternative to TPF.
• 01:32:21And finally,
• 01:32:22I'm just going to run through some of the
• 01:32:25other indications where we do induction
• 01:32:27chemotherapy with head neck cancers.
• 01:32:29The nasopharynx cancer is is a
• 01:32:31definite where we offer induction or
• 01:32:33adjuvant chemotherapy in addition
• 01:32:35to concurrent chemoradiation.
• 01:32:37And that data comes from this meta analysis,
• 01:32:40which actually showed an improvement
• 01:32:42in survival for both concurrent chemo
• 01:32:44radiation and concurrent followed by
• 01:32:46adjuvant chemo radiation with adjuvant
• 01:32:49chemo actually adding an incremental benefit.
• 01:32:51When compared to concurrent alone and
• 01:32:53in addition to this meta analysis,
• 01:32:55there have been multiple randomized trials
• 01:32:58comparing different induction regimens,
• 01:32:59whether it be TPDF or gemcitabine, cisplatin.
• 01:33:02All of these trials come
• 01:33:05from EBV positive patients.
• 01:33:07And in general, there's an improvement
• 01:33:09in recurrence free survival,
• 01:33:11failure, free survival,
• 01:33:12overall survival with the
• 01:33:14addition of chemotherapy.
• 01:33:15So as a community,
• 01:33:16we all just strongly believe that
• 01:33:18induction or adjuvant chemo in
• 01:33:20addition to concurrent chemo.
• 01:33:21Radiation as a survival benefit
• 01:33:23and nasopharynx cancers and this
• 01:33:25is the current standard of care
• 01:33:27in HPV disease induction.
• 01:33:29Platinum,
• 01:33:30taxane and cetuximab were used as
• 01:33:32a means to subsequently deescalate
• 01:33:34radiation doses to 54 Gray instead
• 01:33:36of 70 Gray for responders and their
• 01:33:38primary endpoint for this trial was
• 01:33:41two year progression free survival.
• 01:33:4370% of patients achieved primary
• 01:33:46site complete response and two
• 01:33:48year PFS and OS were 96% each for
• 01:33:51patients who had not high risk.
• 01:33:53So less than T4,
• 01:33:54less than bilateral neck disease,
• 01:33:56less than 10 pack your smoking history,
• 01:33:58and significantly fewer patients
• 01:34:00had dysphagia to solids or impaired
• 01:34:02nutrition at 12 months post treatment.
• 01:34:04So this is as a de escalation strategy
• 01:34:06worthy of further investigation and is being
• 01:34:09moved through the ECOG community right now.
• 01:34:12Induction chemo also is fairly well
• 01:34:14established and locally advanced
• 01:34:16paranasal sinus cancer, especially
• 01:34:18those that involve close to the orbit.
• 01:34:20And there's retrospective
• 01:34:22data from about 123 patients,
• 01:34:24most of which had T4 disease at MD Anderson.
• 01:34:27These patients had a 63% response rate,
• 01:34:3081% orbit preservation rate and very
• 01:34:33encouraging overall survival for the cohort.
• 01:34:36Likewise for sinonasal
• 01:34:38undifferentiated cancers,
• 01:34:39which is another very aggressive
• 01:34:40type of sinonasal cancers we have.
• 01:34:42Retrospective data that showed almost
• 01:34:44a 70% response rate to induction
• 01:34:47platinum etoposide with responders
• 01:34:48doing better with subsequent chemo
• 01:34:50radiation and non responders
• 01:34:52doing better with pelvic surgery.
• 01:34:54So it serves a dual purpose,
• 01:34:55one of improving outcomes and two
• 01:34:58of actually selecting patients
• 01:34:59that might do better with surgery
• 01:35:02afterwards versus radiation.
• 01:35:03And lastly,
• 01:35:04immunotherapy has been looked at
• 01:35:06recently as an induction regimen
• 01:35:08in patients with high risk oral
• 01:35:10cavity HPV negative tumors.
• 01:35:12This was a small prospectively.
• 01:35:13Treated cohort from Dana Farber,
• 01:35:1536 patients who got a single dose
• 01:35:17of Pembroke prior to surgery.
• 01:35:19The treatment was safe.
• 01:35:21You know there were no surgical delays,
• 01:35:24post-op radiation or chemo radiation
• 01:35:26were done as a standard of care
• 01:35:28based on pathology and adjuvant.
• 01:35:30Pembroke was also used in high risk
• 01:35:32patients with positive margins or
• 01:35:34extranodal extension and grade 3 or
• 01:35:364 adverse events or delay of surgery
• 01:35:38did not occur like I said and the one
• 01:35:41year relapse rate for this high risk.
• 01:35:43Cohort was actually really good.
• 01:35:45It was only about 16% versus
• 01:35:47what we expect to see,
• 01:35:48which is about 30 to 40%
• 01:35:50in high risk patients.
• 01:35:53They also classified pathologic
• 01:35:55tumor response by grade and PTR 2
• 01:35:59was actually the highest degree of
• 01:36:02pathologic tumor response over 50%,
• 01:36:05which was seen in almost 1/4 of the
• 01:36:07patients on this trial with just that
• 01:36:09single dose of immunotherapy, preop.
• 01:36:10And another quarter of almost 1/4 of
• 01:36:13patients had a minor pathologic response,
• 01:36:16so 25 to 50%,
• 01:36:17which is also not insignificant.
• 01:36:20And then another group,
• 01:36:22the radiation.
• 01:36:22Group at Dana Farber also looked at
• 01:36:25an EVO versus ibinabo as induction for
• 01:36:28again high risk oral cavity tumors.
• 01:36:30Although some patients did have adverse
• 01:36:32events with the Nivo and IPI plus nivo,
• 01:36:35there were no surgical delays again.
• 01:36:37In addition,
• 01:36:38there wasn't evidence of response
• 01:36:39in both arms.
• 01:36:40Major responses over 90% were seen
• 01:36:43in four of these 29 patients,
• 01:36:46three in the Nivo plus IPI arm
• 01:36:47and one in the NIEVO alone arm.
• 01:36:49Again together these data just suggests
• 01:36:51that there is clinical tolerability.
• 01:36:53And possibly effectiveness for neoadjuvant
• 01:36:55immunotherapy alone in a small
• 01:36:57proportion of patients which
• 01:36:59are carefully selected.
• 01:37:01Finally, just to summarize the indications
• 01:37:03for induction chemo and head and
• 01:37:05neck that we tend to use at spinal,
• 01:37:08we broadly categorize these as
• 01:37:09fairly definitive for induction
• 01:37:11and those were induction can be
• 01:37:13considered at our institution.
• 01:37:14We almost always consider induction for T4,
• 01:37:17larynx and hypopharynx cancer patients
• 01:37:19to select out those that would be most
• 01:37:21appropriate for organ preservation
• 01:37:23without with definitive radiation.
• 01:37:25And we also recommended for nasopharynx,
• 01:37:27paranasal sinus and sinonasal
• 01:37:29undifferentiated cancers.
• 01:37:31It is worth considering induction for
• 01:37:33highly symptomatic patients where
• 01:37:34rapid tumor shrinkage is desired.
• 01:37:36So for instance,
• 01:37:37for airway protection for bleeding,
• 01:37:39we also consider it when we
• 01:37:41suspect early metastatic disease
• 01:37:43to assess response prior to more
• 01:37:45definitive surgery or radiation.
• 01:37:47And finally,
• 01:37:47immunotherapy as an induction is really
• 01:37:49for carefully selected patients.
• 01:37:51Like I said, high risk PD,
• 01:37:53one positive and preferably within the
• 01:37:55context of a clinical trial since the
• 01:37:57data really is very early in terms of how.
• 01:38:00Motions do with neoadjuvant
• 01:38:03immunotherapy and that's all I have.
• 01:38:05Thank you for your attention and
• 01:38:06be happy to take any questions.
• 01:38:10Thank you doctor Batcha.
• 01:38:12That was a great,
• 01:38:14efficient overview of induction,
• 01:38:16chemotherapy and head and neck cancer.
• 01:38:18There is one question.
• 01:38:22When? You present this option to patients,
• 01:38:26it seems like almost like magic.
• 01:38:28Oh, you can give me some medicine,
• 01:38:31and the surgery that the surgeon just told
• 01:38:33me about could be less morbid or have
• 01:38:36a higher chance of getting it all out.
• 01:38:38But when you see these patients
• 01:38:40and to discuss induction,
• 01:38:41chemotherapy, what are,
• 01:38:42what do you tell them are some of the risks,
• 01:38:45why? It's not just why,
• 01:38:46why we're not just doing it in
• 01:38:48everybody in every situation.
• 01:38:50Well, how do you,
• 01:38:50how do you counsel patients
• 01:38:52about the use of this?
• 01:38:54I'm pretty upfront about what the
• 01:38:56odds of response, what the odds of
• 01:38:58tumor progression are going to be.
• 01:39:00So across the board we see
• 01:39:02about 70 to 80% of patients in
• 01:39:04general responding to inductions.
• 01:39:05So the odds are high but it's not 100%.
• 01:39:08So that's what I clarify right at the get go.
• 01:39:10There is a 20 to 30% risk that the
• 01:39:13disease might either not shrink or
• 01:39:15actually progress with induction and
• 01:39:17that may risk surgery in the future.
• 01:39:19So you know where surgery is an
• 01:39:21option now and we're trying to
• 01:39:23shrink it to preserve organs.
• 01:39:24We may lose that window for surgery.
• 01:39:26Now we of course do try
• 01:39:28to minimize that risk.
• 01:39:29You know,
• 01:39:29we're clinically following them closely.
• 01:39:31If I have any doubts about progression,
• 01:39:33I do get scans pretty frequently.
• 01:39:35So we do scans like almost every three
• 01:39:37to four weeks with induction if we have
• 01:39:40any doubts about a lack of response.
• 01:39:42But that is something I counsel
• 01:39:44patients on pretty extensively.
• 01:39:46You know, they're obviously for those
• 01:39:48that are standing to lose an eye now,
• 01:39:50you know,
• 01:39:50hopefully that if it doesn't shrink,
• 01:39:52they still stand to lose an eye.
• 01:39:54So a lot of them.
• 01:39:55Will actually agree to induction
• 01:39:57if they have that little chance of
• 01:39:59preserving the eye or preserving the larynx.
• 01:40:02But, you know,
• 01:40:03I I'm pretty forthright about what I say,
• 01:40:05and I do tell them that, you know,
• 01:40:07some of them will tell me afterwards, oh,
• 01:40:09we've responded so nicely to an induction.
• 01:40:10Do we even need the surgery?
• 01:40:11So,
• 01:40:12you know,
• 01:40:12I'm clear about induction is as a
• 01:40:14means to get to surgery or get to radiation.
• 01:40:16It's not going to replace eventually
• 01:40:19needing that surgery anyway.
• 01:40:22That's really great.
• 01:40:23Thank you for clarifying that you want
• 01:40:26to stop sharing and share my screen.
• 01:40:28So I think this that what you just presented,
• 01:40:30Dr Bhatti is just a great example of the
• 01:40:33need for multidisciplinary management
• 01:40:35of these patients and discussion.
• 01:40:38I mean, you know,
• 01:40:39you'll take phone calls from me
• 01:40:41about patients that were considering
• 01:40:42induction and I think you're right.
• 01:40:44As a surgeon, what we want to know is,
• 01:40:46well, if he doesn't,
• 01:40:47if this patient he or she does not respond,
• 01:40:49if it progresses,
• 01:40:51what's the worst case scenario?
• 01:40:53And as you pointed out if you know
• 01:40:55we're already going to take their
• 01:40:56carotid artery and it progresses a
• 01:40:58little you know we're already prepared
• 01:41:00for that over saving and I we're
• 01:41:02going to take ways and we have some
• 01:41:04progression towards the the eye you
• 01:41:06know what do we lose by trying induction.
• 01:41:09I think those are the discussions
• 01:41:10that we have in our tumor boards and
• 01:41:12it's not always so clear cut and as
• 01:41:14you point out I think the patients
• 01:41:16need to understand the risks involved.
• 01:41:18So thank you very much.
• 01:41:20I wanted to thank all of our
• 01:41:22presenters here on talking about.
• 01:41:24Redefining Resectability and head
• 01:41:26neck cancers, as you can see,
• 01:41:29we do need to work as a team with
• 01:41:31our neurosurgery colleagues,
• 01:41:32vascular surgery colleagues and
• 01:41:34of course the multidisciplinary
• 01:41:36head neck cancer team.
• 01:41:37So thank you to all our presenters
• 01:41:40and I really appreciate that we are.
• 01:41:43Pretty much on time,
• 01:41:44not too far behind,
• 01:41:45so thank you all very much and thank
• 01:41:46you for the attendees for all joining.
• 01:41:48This will be posted at yalecancercenter.org
• 01:41:51and will be emailed to the many
• 01:41:53people who registered as well.
• 01:41:55Thank you so much.
• 01:41:57Thank you.
• 01:41:58So thank you. Thank you.