A 86-year-old male patient presented to UAMS with a neck mass that had been growing rapidly for two months near his right ear.
One year previously, the patient had been treated at a different facility for a skin cancer in the same area. His squamous cell carcinoma was removed and the wound was covered with a skin graft.
The initial examination by head and neck oncology surgeon Emre Vural, M.D., FACS, and CT scans indicated that the patient was a good candidate for surgery. However, the tumor was growing so rapidly that at the time of the initial surgery attempt, Vural found the tumor had spread and was attached to and enveloping the carotid artery, the main blood supply to the brain. Vural closed to consult with the patient, family and vascular surgeon Mohammed Moursi, M.D.
Moursi examined the patient and provided a consultation, and Vural discussed the options with the patient and his family.
Because of the involvement of the carotid artery, it was a high-risk surgery for stroke. The only way to completely remove the tumor was to remove the carotid artery. In addition, not replacing the artery after removal could lead to catastrophic stroke.
Moursi proposed replacing the carotid artery with a vein from the patient’s thigh. Additional risks associated with this approach include narrowing or leakage of the grafted vein.
Other risks associated with the larger scope of the surgery included dysphasia, hoarseness and reduced motor control of the tongue due to the additional involvement of the vagus nerve and hypoglossal nerve.
However, left unchecked, the rapidly growing tumor could have caused the same complications, growing into the carotid, rupturing it and causing catastrophic stroke. Radiation or chemotherapy might have slowed the tumor’s growth rate, but would not have stopped it.
The patient opted for the team surgery with Vural performing an extended radical neck resection and flap repair and Moursi replacing the carotid artery with a vein graft.
During the operation, Vural removed the sternocleidomastoid muscle, spinal accessory nerve and internal jugular vein. He removed the squamous cell carcinoma, which was based in the patient’s lymph nodes but was also adhering to the patient’s skin from the undersurface and attached to the carotid artery, vagus nerve and hypoglossal nerve. He isolated the section of tumor that was involved with the carotid artery and suspended it.
Moursi prepared the vein graft from the patient’s thigh so that it was exposed and ready for harvest. They gave the patient a blood thinner. They then clamped the carotid artery before the tumor and after the tumor, on the heart side and the brain side of the tumor. Moursi took the carotid artery out with the tumor, leaving two ends of the carotid artery to work with.
Moursi placed a shunt inside the vein graft and then put the shunt inside the artery in one end and then the other side in the other end. They allowed blood flow to travel through the shunt, with the vein on the outside of the shunt. Then Moursi sewed each end of the vein to each end of the artery, removing the shunt just before the last stich.
The success of the graft was confirmed intraoperatively by ultrasound.
Vural resumed his work, covering the large skin and neck defect left by the extended radical neck dissection with a flap of healthy tissue — muscle, skin and original blood supply — from the patient’s pectoralis major muscle.
The patient was discharged after drain removal five days after surgery.
At his two-week checkup, the wound was healing nicely and the flap was completely viable.
The patient was experiencing the expected outcomes of dysphasia and some limitation in tongue mobility due to the removal of the vagus and hypoglossal nerves.
He was otherwise neurologically intact, without any signs of stroke.
The patient’s next steps will be to undergo radiation and chemotherapy.
Both Vural and Moursi are board-certified, fellowship-trained surgeons. While this particular set of circumstances was rare, both noted they frequently work on high-risk, complicated cases in an interdisciplinary fashion. Working together and with other subspecialties prepares them to handle unexpected cases like these.
To make a referral to the UAMS Head and Neck Cancer Clinic, call 866-826-7362 or 501-296-1200.