45 years male diagnosed as case of carcinoma Hard palate. Cytology was suggestive of malignant cells, keratinizing squamous cell ca. His CECT Neck revealed right side palate lesion in posterior part with irregular soft tissue thickening 1.7×1.3×0.8 cm with mild extension into anterior part soft palate ? Mitotic. He received 3 cycles of chemotherapy and no further treatment.
After 8 months he had right side neck lymph node. He was treated with Chemotherapy and Radiation Therapy. There was persistent residual neck node in right side neck
Considering short time interval from radiation therapy and large size of lymph node he received further chemotherapy. His PET CT later on show right neck node decrease in metabolic activity
There were some very difficulty challenges in this case
- Right Level II Neck Node – reaching upto Skull Base
- Distal Control of Internal Carotid artery not possible
- Ballon testing to occlude internal carotid artery is option – hesitant in post radiation setting and later interpretation.
- Apart from Surgery, no other curative option left.
So, with thorough understanding an innovative approach was planned for this case.
* INTERNAL CAROTID ARTERY STENTING was done.
Following which he was kept on blood thinner and metronomic chemotherapy for 8 weeks. After which he underwent definitive Surgery.
He underwent Surgery: Right radical Neck Dissection + External Carotid Artery excision + Internal jugular vein excision + Pectoralis Major Myocutaneous Flap. Lower division of facial nerve identified and saved with excision of cervical branch and lower parotid gland. Internal Carotid artery and Vagus nerve were saved. Patient was discharged in time.
Difficult scenario in advance cancer patients sometimes requires extreme measures in safe manner for cure and successful outcome.
