Could carotid blowout syndrome in advanced head and neck cancer with circumferential involvement of the ICA be prevented by stent placement prior to palliative radioimmunotherapy? – A case report

Introduction The aim of this case report is to draw attention to posttherapeutic bleeding under immune checkpoint inhibitors and to explain possible interventions. In addition to side effects such as skin changes, autoimmune colitis, autoimmune hepatitis and endocrinopathies¹, immune-mediated side effects with potential bleeding risk under PD-1 and PDL-1 inhibitors have been described in the literature with immune thrombocytopenia and autoimmune hemolytic anemia.^{2 3 4} Furthermore, carotid blowout syndrome (CBS) in advanced head and neck cancer with circumferential involvement of the carotid artery is a well discussed and feared complication.⁵ Is there a way to prevent this?

Case report We present a case report of a 66-year-old patient with recurrence of cT4 cN2b cM0 hypopharyngeal carcinoma after primary radiochemotherapy until 11/19. The patient received palliative radiotherapy combined with 4 doses of pembrolizumab until 09/21. A few weeks later, he suffered from acute oral rebleeding. Surgical hemostasis was not effective. This is why a neuroradiological transarterial stent placement of the proximal ICA as well as a coiling of the left ECA was performed. Under this procedure, hemostasis was sufficient and the patient survived without further damages.

Conclusion Especially in advanced head and neck cancer with circumferential involvement of the carotid artery, there is a risk of CBS due to autolysis processes and resulting destabilization of the vessel wall under immunotherapy⁶, about which patients should be explicitly informed. If necessary, stent placement should be considered prior to immunotherapy to avoid a life-threatening emergency situation.

*** References with the author of this abstract***

Publication History

Article published online:
24 May 2022