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

September 15, 2022

Information

September 14, 2022

Presentations by: Ehud Mendel, MD, MBA, Charles Matouk, MD, Britt Tonnessen, MD, and Aarti Bhatia, MD, MPH

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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.