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Vascular control for safe resection of huge vascular masses in head and neck

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Background and Objectives: Surgical resection of head and neck masses is challenging when the masses are of vascular nature. The objectives of this paper are to emphasize the importance of a team approach for safe resection of such lesions with a key role of the vascular surgeon in obtaining the vascular control. Methods: three patients with huge vascular masses in head and neck were safely resected after a proximal vascular control. Results: the masses were of different pathological natures (benign soft tissue tumour, soft tissue sarcoma and complex congenital arterio-venous malformation). Conclusion: A team of vascular, general, orthopedic and plastic surgeon is preferred to deal with vascular masses in head and neck because resection of such lesions should not be limited to standard procedures, but tailored to the biology and location of the individual mass.
Publication Date: 2008

Publication Name: Zanco J Med Sci

Published in: Health & Medicine
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Vascular control for safe resection of huge vascular masses in head and neck

  1. 1. Vascular Control for Safe Resection . ... .. . . Zanoo J. Med. Sci. , Vol. 12 (Special Isue), 1008 Vascular Control for Safe Resection of Huge Vascular Masses in Head and Neck DrAbdulsaIam Y. Taha‘ Dr. Kalandar Kaznazani" Dr. Ari R. Zangana"‘ Dr. Madhat M. Mahdi'“‘ ABSTRACT Background and Objectives: Surgical resection of head and neck masses is challenging when the masses are of vascular nature. The objectives of this paper are to emphasize the importance of a team approach for safe resection of such lesions with a key role of the vas- cular surgeon in obtaining the vascular control. Methods: three patients with huge vascular masses in head and neck were safely re- sected after a proximal vascular control. Results: the masses were of different pathological natures (benign soft tissue tumour, soft tissue sarcoma and complex congenital arteriovenous malformation). Conclusion: A team of vascular, general, orthopaedic and plastic surgeon is preferred to deal with vascular masses in head and neck because resection of such lesions should not be limited to standard procedures, but tailored to the biology and location of the individual mass. Key words: Vascular control, Head and Neck, Vascular masses. 'NTR°DUcT'°N5 done by a general surgeon revealing intra- To be well-exposed is half the operation. The is no substitute to detailed knowledge of vascular anatomy and familiarity with different exposures of major vessels at the thoracic inlet in order to safely resect vas- cular lesions in this critical area. Herein, we present three cases of huge vascular masses in head and neck of different pathological natures safely resected by a team involving a vascular surgeon. The aim of the study is to emphasize the importance of vascular control and the team approach for surgical management of such masses. Case(1): J. K. A: Benign soft tissue tu- mour A 31-yr. old man from Omara, south of Iraq consulted us in September 2000, complain- ing of a huge solid painless mass in left neck of 4 yr. duration associated with pain and numbness in left arm. Three years ear- lier, the patient had an incisional biopsy *Professor and Head of Department of Thoracic and cardiovascular Surgery] College of Medidnel University of Sulaimani/ Suiairnanil Region of Kurdistan] Iraq. muscular capillary haemangioma. In addi- tion, he had Doppler siudy and angiogra- phy 2 years (Figure 1) before showing a highly vascular mass receiving its blood supply from left subclavian artery. ,1 1 Figure (1): Doppler study and angiography showing a highly vascular mass “Consultant General Surgeon) suiaimani Teaching Hospital] Suiaimanil Region of Kurdistan] Iraq. *"Assistant Professor of Plastic Surgery] Sulaimanl Teaching Hospital] suiaimanll Region of Kurdistan] Iraq. "flnssinani: Professor of Orthopaedic Surgery] College of Medicine] University of Basrahl Basrah / Iraq. 5
  2. 2. Vascular Contact for Safe Rsection . ... .. . . Physical examination showed a huge solid mass in left neck, fixed, non-tender, with no thrill or bruit. The carotid and radial pulses were normal. Chest examination, chest ra- diograph, complete blood picture and ESR were normal. The patient was scheduled for surgery. Left 4"‘ space anterolaleral tho- racotomy was performed first. The left sub- clavian artery was isolated and encircled by a tape. Then an oblique incision was made over the mass in the posterior triangle of the neck. Two skin flaps were created. The overlying muscles were densely adherent to the capsule. The mass was solid and encapsulated, densely adherent medially to the spine. Nerve trunks were also incorpo- rated into the mass; separated. The pedicle of the tumour was originating inferiorly from the base of the neck (thoracic outlet). The tumour could ultimately be completely ex- cised giving the impression of neurogenic tumour. Grossly, the pathologist described the mass as 9 x 6 x 5 cm yellowish-white in colour, lobulated surface. Rubbery in con- sistency with skeletal muscles attached to its periphery. Microscopical examination revealed a loose myxoid stroma; prolifera- lion of small and medium-sized thick- walled blood vessels mixed with significant amount of adipose tissue and entrapped skeletal muscle fibers. Two pathologists read the slides (Figure 2) and reported no evidence of malignancy but disagreed about the exact diagnosis (aggressive an- giomyxoma, myxoid form neurofibroma, intramuscular capillary haemangioma and angiolipoma of skeletal muscles). .3‘ v.1 0 g e c) S ‘E ‘ . 4. Figure (2): Microscopic slide case 1 an J. Med. Vol. 12 rspedai issue), zoos The patient had a smooth postoperative course. He had slight ptosis of left eye (Figure 3) and slight limitation of left shoul- der abduction (both resulted from traction on nerve trunks during surgery) . The pa- tient was discharged home on 10"‘ postop- erative day. Both complications resolved completely in one month. Figure (3): Postoperative photo case 1 Case (2): N. O. H: Malignant Soft Tissue Tumour (Fibrosarcoma) A 55 yr. old man, non-smoker, from Omara, south of Iraq consulted us in Sep- tember 2001 complaining of huge right su- praclavicular mass of 3 yr. duration associ- ated with severe pain in right shoulder radi- ating along the upper limb. The patient claimed that the mass appeared following a strenuous movement of shoulder and then progressively enlarged. Physical ex- amination revealed a big rounded non- tender solid mass fixed in right supraclavi- cular fossa (Figure 4) associated with great engorgement of veins (varicosed) on ante- rior chesl wall and right upper limb which was hot to feel. The right radial pulse was intact. The patient had FNAC done for him 3 months earlier with a diagnosis of (non- epithelial tumour). Chest examination, chest radiograph and CBP were normal. ESR= 40 mmlhr. MRI scan ( Figure 5) showed well-defined encapsulated big tu-
  3. 3. Vasoular Control for safe Raenion . ... .. . . zaneo J. Med. sd. , Vol. 12 (5DedaI issue), zoos mass extending high in the neck and low into the axilla compressing but not invading the upper ribs with no evidence of intratho- racic extension or pulmonary metastases. . ..~“ ¢ . ,«. /’ x. (,, _( , ,, Figure (4): Preoperative photo case 2 Figure (5): Preoperative MRI case 2 MR Arteriography (Figure 6) revealed a highly vascular tumour compressing the subclavian artery. The patient deserved surgical exploration to resect the tumour. Direct incision was made over the mass. Once the capsule was opened, severe bleeding ensued from a very friable tumour. Pieces of tumour were taken for biopsy. . ». , ‘,7.. . g‘t": ’/I ‘I! , _ , :3, ' - Figure (6): MRA of case 2 Bleeding was uncontrollable by electrocau- tery, pressure or application of surgicel; thus the wound was closed over packs. The biopsy result was undifferentiated sar- coma. The patient was prepared for radical resection and forequarter amputation. He accepted surgery and its possible risks. One-week later, definite surgery was per- formed. in order to achieve proximal vas- cular control of the innominate vessels; median sternotomy was done with exten- sion along right clavicle. The clavicle was resected to obtain the necessary exposure. There was great engorgement of major veins due to mass compression. The sub- clavian artery was coursing through the tumour. The artery and vein were isolated and ligated proximal to the tumour after tedious difficult dissection. The patient was then turned into the lateral position. The resection was completed by forequarter amputation. There was a huge tumour mass (23 x 9 x 8 cm) involving the head of humerus. Tube drains (mediastinal, right pleural and submuscular) were left after adequate haemostasis. The wound was primarily closed. A small area in the cervi- cal wound was primarily skin grafted (Figure 7). The patient had a smooth post- operative course apart from wound infec- tion; managed conservatively. Biopsy re-
  4. 4. Vascular Control for Safe Resection . ... .. . . Zanoo J. Med. Sci. , Vol. 12 (Special issue), 2008 fibrosarcoma. The patient was discharged home one month postoperatively and sent for DXT. He is well 5 months after surgery. F Figure (7): Postoperative photo case 2 Case 3: M. A. R Huge congenital arterio- venous malformation of the face. A 28- year old man from Sulaimania- Kurdi- stan-Iraq, who was a known case of huge congenital arterio-venous malformation of right face, presented with a long-standing mass of many years duration. His face was severely disfigured and thus he was so- cially embarrassed. He used to cover his face and the lesion so that it will not be seen by people. He had episodes of bleed- ing from areas in the mass as well as puru- lent discharge due to secondary infection. The mass was involving the right side of the mouth and thus his speech and eating were impaired as well. The patient gave a history of many previous operations by plastic and general surgeons. The opera- tions were complicated by severe bleeding and failed to eradicate the mass. He had been seen by a French vascular surgeon visiting Sulaimania, but did not agree to operate on him. Physical examination re- vealed an extensive mass involving the whole right face including the ear and most of the mouth extending superiorly to the scalp and inferiorly to the neck (Figure 8). The mass was red in colour with areas of ulceration and bloody purulent discharge, hot to feel and partly compressible. Once the compression was released, the mass refilled with blood. The neck vessels were greatly enlarged. Thrill and bruit were pre- sent over right neck. The pulse rate was rapid indicating a hyperdynamic circulation. Scars of old operations were visible. ‘] Vi. ..» l‘‘yV>7V'‘. l_l. A. V , .‘ , >. r ““*se. .,«-. ;;: :.. ~ » l t Figure (8): Preoperative phto case 3 Angiography was done 3times. The last one ( Figure 9) showed a highly vascular lesion in right face and scalp receiving its arterial supply from a hypertrophied branch of right subclavian artery as well as a con- tra-lateral carotid artery contribution. The patient was seen by a team of vascular, general and plastic surgeon. The initial im- pression and advice was to refer him abroad for therapeutic embolization. '*-:34‘ Figure (9): Angiogram case 3 V The patient could not arrange treatment abroad and insisted to have surgery de- spite the high risks. Ultimately, we decided
  5. 5. Vacularconhrnl fotsafe Radian . ... .. . . Zanco J. Md. Sci, Vol. 12 (Special Isue), 2008 to operate on him after a thorough explana- tion of the operative risks. The patient was examined the moming of operation by flexi- ble oesophagoscopy which excluded pha- ryngeal involvement. Then a nasotracheal intubation was done. The neck was placed in hyperextension. Right neck incision was done with creation of 2 skin flaps. Careful dissection and isolation of right common carotid artery and its bifurcation was done. The hypertrophied artery that gave supply to the lesion was isolated, ligated and di- vided (Figure 10). Another arterial feeder was also ligated and divided. I > . Fig 10 intraop photo case (3) After proximal vascular control, the stage of resection began. Severe bleeding occurred despite the proximal vascular control indi- cating a contralateral arterial supply. The bleeding vessels were under-run. The re- section was near total. The angle of the mouth was not resected. Haemostasis was secured. The raw area was covered by skin graft taken from the thigh (Fig 11). Postop- erative course was smooth. The patient had a second session for resection of re- sidual part of the mass involving the mouth. Figure (11): Postoperative photo case 3 DISCUSSION: Case 1 and 2 had presented with huge solid painless mass in the region of the neck (thoracic outlet). Soft tissue sarcoma can arise in any part of the bod and usu- ally present as painless lump", however the thoracic outlet is unique in its impor- tance as it represents a traffic area for many vital structures. The larger the mass, the more likely it is to be a sarcoma "3. Progressive growth increases the probabil- ity that the tumor will prove malignant '; however, case 1 proved to be a benign tu- mor despite its huge size and progressive growth. The mass was present for a rela- tively long duration (4 years) in case 1and 2.The insidious onset of soft tissue sarco- mas is their benign presentation that too frequently induces a false sense of security in both patient and physician ‘. A patient with a soft tissue mass of recent origin with no known specific cause (e. g., recent trauma to that area) should be assumed to have a soft tissue sarcoma until proven otherwise, although other benign condition should be considered in the differential di- agnosis Z. The three patients had preop- erative angiography (conventional an- giography in case 1and 3and MR arte- riography in case 2). The good quality of MRA beside its noninvasiveness is impres- sive. All lesions were highly vascular; re- ceiving their blood supply from a major ar- tery (subclavian in each). All patients re- quired proximal vascular control: Ieft 4"‘ space anterolateral thoracotomy in case 1, median sternotomy with supraclavicular extension and clavicular resection in case 2 and right neck exploration in case 3). It would not have been possible to perform safe resection of these masses without a proximal vascular control. incisional biopsy was performed in case 1 and 2. The biopsy should be performed by a surgeon who is prepared to treat the tumor if it proves to be a sarcoma, and who can place the bi- opsy incision where it does not compro- mise the planned treatment ‘*5. Major am- putation was required in case 2
  6. 6. Vascular Control for Safe Resection Zanco J. Med. Sci. , Vol. 12 (Special issue), 2008 (forequarter amputation) due to the location of tumor at the proximal extremity so that preservation of upper limb was not possible with radical resection of the tumor. Fore- quarter amputation is an infrequently per- formed operation in places other than ma- jor referral centers 2. It is a major surgical procedure indicated primarily in the treat- ment of malignant lesions involving the bony and soft tissue parities of the upper part of the arm, shoulder and scapula ‘. Surgical treatment should be curative for a patient with benign tumor and it should be the best for the patient with malignant dis- ease if it is resectable. Therefore; we be- lieve it is always worthy to give the patient the chance of surgery despite the special location, big size or high vascularlty of the mass. In the presented cases, the mass was very big at presentation and progres- sively growing and associated with severe pain in case 2. The fact that the mass in case 2 was well encapsulated with no evi- dence of invasion of surrounding structures by MRI favored its resectability. Local con- trol of soft tissue sarcoma requires resec- tion with a generous margin of seemingly normal tissue. in the 1950s and 1960s the widespread acceptance of radical surgery, particularly radical amputations for extrem- ity sarcoma, lowered the rate of local failure to between 12 and 20%. It was 50 to over 90% in the first half of the twentieth century when the adopted surgical policy at that time was resection of apparent tumor up to pathologically proven tumor-free margins 1' '7'”. The majority of AVMs are develop- mental errors that occur between the 4"‘ and 10"‘ weeks of embryogenesis. The causative factors are unknown. All AVMs are present at birth, but they are not always evident clinically. Head and neck AVMs are haemodynamlcally active. The majority of AVMs can be managed medically, but those which demonstrate progressive growth require surgical intervention. Surgi- cal indications include hemorrhage, con- gestive heart failure, nonhealing ulcers and functional impairment. Embolization is an option for treatment and should be considered when conservative measures have failed or when the vascularlty of the malformation needs to be reduced prior to surgical resection. Most AVMs are not amenable to complete surgical excision. Resectability depends on the degree of extension into adjacent structures. Patients with disease that extends into the deep fascia, muscle or bone are not surgical candidates. In one study, 15 patients with AVMs treated surgically, two thirds of them improved, 13% were unchanged and 20% were worse after surgical excision 9. A team of vascular, general, orthopaedic and plastic surgeon is preferred to deal with vascular masses in head and neck be- cause resection of such lesions should not be limited to standard procedures, but tai- Iored to the biology and location of the indi- vidual mass. REFERENCES: 1. William C. Wood. Soft tissue tumors in Oxford Textbook of Surgery on CD- ROM 1995. 2. Constantine P. Karakousis. Soft tissue sarcomas in General Surgery edited by Wallace P. Ritchie, Jr. Glenn Steele, Jr. and Richard H. Dean. J. B. Lippincott Company 1995. P 451. 3. Benign lipomatous tumors and Fibrosarcoma in Soft Tissue Tumors edited by Franz M. Enzinger and Sharon W. Weiss. The C. V. Mosby Co. 1983. 4. Mansour KA and Powell RW Modified technique for radical tmnsmediastinal forequarter amputa- tion and chest wall resection. J Thorac Cardio- vasc Surg. 1978 Sep; 76(3): 358-63. 5. Gemer RE, Moore GE, Pickren JW. Soft tissue sarcomas. Ann Surg 1975; 181: 803-8. 6. Mankins HJ, Lange TA, Spanier S3. The hazards of biopsy in patients with malignant primary bone and soft- tissue tumors. J Bone Joint Surg 1982; 8: 1121-7. 7. Monson D, Finn H, Montag A and Simon M. Anatomic extent of soft tissue sarcomas of the extremities: implications for surgical strategy. ProcASCO1'. -390: 9: 1207. 8. Pandey M and Chandramohan K. Soft tissue sarcoma of the head and neck region in adults. J Oral Maxillofac Surg 2003; 32: 43-48. 9. Mark D Morasch and Dipen Maun. Artriovenous Fistulas. e Medicine. 10

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