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Endovascular Management of Tumors of the Head, Neck, and Spine

PanVascular Medicine

  • 254 Accesses

Abstract

The improvement of technique, materials, and chemotherapy regimens have significantly increased the role of endovascular therapy in tumor management. Preoperative embolization of tumors with polyvinyl alcohol (PVA) particles is both safe and beneficial in reducing intraoperative blood loss and operating time. While there are other embolic agents available, including liquid embolisates and detachable coils, they are primarily used for specific situations. Newer agents such as embospheres and cellulose beads may have a larger role in the future due to being more uniform in size than PVA particles, but evidence to support this is lacking.

Provocative testing with Wada testing prior to embolization has a limited role as there is a high false-negative rate. Balloon test occlusions can provide useful information when vessel sacrifice is being considered for tumor management.

Preoperative embolization of hyper-vascular tumors such as meningiomas and juvenile nasopharyngiomas has less morbidity than surgery alone. Complications of embolization primarily involve dangerous anastomoses. Avoiding embolizations that are high risk and understanding how to minimize these risks are key in keeping morbidity low. Carotid blowout is a life-threatening complication of tumors of the neck and is managed utilizing endovascular technique, either via constructive or deconstructive methods.

Intra-arterial (IA) chemotherapy has recently begun to show promise in both primary and metastatic disease as both a primary modality and adjunct to standard therapy. Utilizing cerebral hemispheric dose calculations and appropriate catheter positioning and technique has reduced neurotoxicity as well as increasing local chemotherapy doses delivered IA when compared to conventional intravenous chemotherapy.

The blood–brain barrier presents unique challenges in treating tumors of the central nervous system. There has been an increasing use of IA osmotic blood–brain barrier disruption with IA chemotherapy with little evidence to support its benefit. Other mechanisms of blood–brain barrier disruption are under investigation.

Advances in retinoblastoma over the past 10 years have made IA melphalan with or without carboplatin a safe procedure with significant globe sparing and reduction in retinal seeding. Early results of IA bevacizumab in gliomas are promising, showing tumor size reduction and suggesting a role for vascular endothelial growth factor (VEGF) inhibitors in hyper-vascular tumors. There is an increasing role of intra-arterial Abraxane and platin containing compounds in the management of neck carcinomas with good success. The future of IA chemotherapy is promising as selective targeting of tumors based on angiogenesis and other tumor-specific features becomes more feasible.

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Abbreviations

Balloon test occlusion:

is when a vessel is temporarily occluded to assess collateral blood supply. This is typically done when there is the possibility that the vessel in question will be occluded and blood supply to organs distal to the occlusion is desired. If there is insufficient flow to the organ from other vessels, it is considered a failed test.

Blood–brain barrier:

is a physiological barrier which regulates the passage of molecules from the blood to the central nervous system.

Blood–brain barrier or blood–tumor barrier disruption:

is the act of disrupting the natural barriers which exist between the blood vessels and the brain or tumor. This is usually done for the purpose of enhancing drug delivery to the tumor as these barriers shield them from foreign substances.

Blood–tumor barrier:

is a physiological barrier which regulated the passage of molecules from the blood to the tumor parenchyma.

Carotid blowout syndrome:

is a massive hemorrhage from the common carotid artery or its branches. This is secondary to trauma or invasion of the carotid artery by infiltrative tumors with subsequent weakening and rupture of the vessel wall.

Embolic agents:

are materials introduced into a vessel for the purpose of occlusion of the blood supply of a tumor.

Endovascular therapy:

is a form of minimally invasive surgery designed to access many regions of the body via major blood vessels. Basic techniques involve the introduction of a catheter percutaneously into a large blood vessel, typically the femoral artery. The catheter is then guided to the region of interest.

Endovascular tumor embolization:

is the method by which the vascular supply of a tumor is reduced or removed using embolic agent by the endovascular therapy route.

Intra-arterial chemotherapy:

is the delivery of chemotherapeutic drugs to a tumor by releasing them locally into the feeding arteries of the tumor.

Parent vessel occlusion:

is the destructive embolization of an artery that feeds a specific territory (or parent) such as a hemisphere of the brain or tumor.

Posterior reversible encephalopathy syndrome:

is a syndrome characterized by headache, confusion, seizures, and visual loss.

Provocative testing:

is a test conducted to assess the risk of neurological sequela if intra-arterial embolization or parent vessel sacrifice were to be performed from the catheter site where the test is performed. This is performed using medications that temporarily prevent neuronal depolarization with amobarbital and/or lidocaine. It is occasionally utilized before endovascular embolization or surgical resection.

Spatial dose fractionation:

is a method of calculating the dose of chemotherapeutic drug to be delivered to specific arterial territories of the brain. It limits the dose for toxicity based on the maximum tolerable dose injected into each hemispheric blood circulation.

Streaming:

is when the chemotherapeutic drug flows into nontarget vessels during infusion due to slow or continuous infusion. This produces a more asymmetric dose delivered to the arteries being infused, thereby reducing predictability of the infusion and potentially reducing the dose delivered to the tumor and increasing the chemotherapeutic drug dose to healthy parenchyma.

Vascular endothelial growth factor:

is a signal protein produced by cells that stimulates vasculogenesis and angiogenesis.

AChor:

Anterior choroidal

ACNU:

Nimustine (1-(4-amino-2-methyl-5-pyrimidinyl)-methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride)

AMA:

Accessory meningeal artery

AP:

Anterior posterior

APA:

Ascending pharyngeal artery

ASA:

Anterior spinal arteries

BBB:

Blood–brain barrier

BBBD:

Blood–brain barrier disruption

BCNU:

Bis-chloroethylnitrosourea also known as carmustine

BTB:

Blood–tumor barrier

BTB:

Blood–tumor barrier

BTO:

Balloon test occlusion

CBS:

Carotid blowout syndrome

CCA:

Common carotid artery

CNS:

Central nervous system

CT:

Computed tomography

DMSO:

Dimethyl sulfoxide

ECA:

External carotid artery

EEG:

Electroencephalogram

EVOH:

Ethylene vinyl alcohol copolymer

GABA:

Gamma-aminobutyric acid

IA:

Intra-arterial

ICA:

Internal carotid artery

IMA:

Internal maxillary artery

IV:

Intravenous

JNA:

Juvenile nasopharyngeal angiofibroma

LS:

Lenticulostriate

MCA:

Middle cerebral artery

MMA:

Middle meningeal artery

MRI:

Magnetic resonance imaging

MRI:

Magnetic resonance imaging

NBCA:

N-butyl cyanoacrylate

PCA:

Posterior cerebral artery

PComm:

Posterior communicating

PMA:

Posterior meningeal artery

PRES:

Posterior reversible encephalopathy syndrome

PSA:

Posterior spinal arteries

PVA:

Polyvinyl alcohol

RADPLAT:

Radiotherapy and concomitant intra-arterial cisplatin (RADPLAT)

SPARC:

Secreted protein acidic and rich in cysteine

STA:

Superficial temporal artery

TAGM:

Tris-acryl gelatin microspheres

VA:

Vertebral artery

VEGF:

Vascular endothelial growth factor

VHL:

von Hippel–Lindau

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  1. Department of Neurosurgery, Weill Cornell Medical Center, 525 East 68th Street M-220, Box 99, New York, NY, 10065, USA

    Michael Crimmins M.D. (Active Duty, U.S. Army Medical Corps, Interventional Neuroradiology Fellow), Mohammed Amin Banihashemi M.D. (Research Fellow), Y. Pierre Gobin M.D. (Professor of Radiology in Neurosurgery and Neurology; Director, Interventional Neuroradiology), Jared Knopman M.D. (Vascular Neurosurgeon) & Athos Patsalides M.D., MPH (Assistant Professor of Radiology in Neurology and Neurosurgery)

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  1. Michael Crimmins M.D.
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  2. Mohammed Amin Banihashemi M.D.
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  3. Y. Pierre Gobin M.D.
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  4. Jared Knopman M.D.
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  5. Athos Patsalides M.D., MPH
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Correspondence to Michael Crimmins M.D. .

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    Peter Lanzer

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Crimmins, M., Banihashemi, M.A., Gobin, Y.P., Knopman, J., Patsalides, A. (2014). Endovascular Management of Tumors of the Head, Neck, and Spine. In: Lanzer, P. (eds) PanVascular Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37393-0_100-1

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  1. Latest

    Endovascular Management of Tumors of the Head, Neck, and Spine
    Published:
    20 February 2016

    DOI: https://doi.org/10.1007/978-3-642-37393-0_100-2

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    Endovascular Management of Tumors of the Head, Neck, and Spine
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    DOI: https://doi.org/10.1007/978-3-642-37393-0_100-1

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