
==== Front
Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00768-4
10.1016/j.radcr.2024.07.182
Case Report
Usefulness of computed tomography aortography and dye infusion in confirming the feeding arteries for effective treatment of a large squamous cell carcinoma of the lower lip with a single intra-arterial infusion chemotherapy combined with radiotherapy
Ueda Shota MD, PhD uedaaa@wakayama-med.ac.jp
⁎
Sonomura Tetsuo MD, PhD
Okuhira Ryuta MD
Mimura Ryosuke MD
Kumamoto Akihiko MD
Minamiguchi Hiroki MD, PhD
Department of Radiology, Wakayama Medical University, Wakayama, Japan
⁎ Corresponding author. uedaaa@wakayama-med.ac.jp
29 8 2024
11 2024
29 8 2024
19 11 53505353
23 7 2024
31 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A 73-year-old male presented with a lower lip squamous cell carcinoma (SCC) (23 mm in diameter). Systemic imaging, including computed tomography (CT) and positron emission tomography, showed no evidence of distant metastasis. Due to the large size of the tumor, reconstruction after surgical tumor removal was considered to be difficult. Therefore, we decided to initially perform intra-arterial chemotherapy. Under local anesthesia, a catheter was inserted via the femoral artery. CT aortography from the ascending aorta was performed to visualize the precise vascular anatomy. The tumor's feeding arteries were confirmed by injecting indigo carmine dye through the catheter. Then, 87.5 mg of cisplatin was selectively injected through the left and right facial arteries (total dose of 175 mg). The tumor significantly shrank and almost disappeared 1 month after chemotherapy. Although additional intra-arterial chemotherapy was considered, the risks associated with the procedure meant that radiotherapy was performed instead. There were no signs of recurrence at the 2-year follow-up. In this patient, a single intra-arterial infusion chemotherapy combined with radiotherapy achieved complete disappearance of a large SCC of the lower lip. This treatment strategy allowed us to preserve the functional and cosmetic aspects of the patient's lower lip with minimal side effects. CT aortography and dye infusion were important in confirming the tumor's feeding arteries.

Keywords

Lip cancer
Intra-arterial infusion chemotherapy
Squamous cell carcinoma
Radiotherapy
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pmcIntroduction

Surgical treatment is often chosen for the treatment of lip cancers. However, functional issues such as eating and speaking disorders can arise after surgery, and the patient's quality of life can decline. Cosmetic problems can also occur. Therefore, treatment strategies that consider functional and cosmetic aspects are required. One such strategy is intra-arterial infusion chemotherapy. Robbins et al. [1] first reported super-selective intra-arterial chemoradiotherapy (RADPLAT) for head and neck cancers. Since then, RADPLAT has also been performed in Japan for the treatment of localized advanced oral cancers. However, there are few comprehensive reports on intra-arterial infusion chemotherapy for lip cancers. Most reports of intra-arterial drugs involved the use of methotrexate and peplomycin sulfate, and there are few reports of cisplatin [[2], [3], [4], [5], [6]]. We report a case in which single intra-arterial infusion chemotherapy with cisplatin combined with radiotherapy led to the complete disappearance of a large squamous cell carcinoma (SCC) of the lower lip.

Case report

A 73-year-old male presented with SCC of the lower lip (23 mm in diameter) (Fig. 1). Systemic imaging, including computed tomography (CT) and positron emission tomography, showed no evidence of distant metastasis. Owing to the large size of the tumor, reconstruction after tumor removal was considered to be difficult. Therefore, we decided to initially perform intra-arterial chemotherapy. Under local anesthesia, a 6 Fr. short sheath (Terumo, Tokyo, Japan) was inserted through the femoral artery. CT aortography from the ascending aorta using a 4 Fr pigtail catheter (Medikit, Tokyo, Japan) was performed to visualize the precise vascular anatomy of the face (Fig. 2). Both facial arteries were identified as feeding arteries. Using a 0.035 inch guidewire (Piolax, Yokohama, Japan), a 4 Fr JB2 catheter (Medikit) was inserted into the external carotid artery, followed by a 6 Fr guiding catheter (ENVOY; Johnson & Johnson, Tokyo, Japan). A 1.7/2.8 Fr microcatheter (Veloute; Asahi Intecc, Aichi, Japan) was then inserted into both facial arteries using a 0.014 inch microguidewire (CHIKAI V; Asahi Intecc, Aichi, Japan). Arteriography of both facial arteries showed tumor staining in the lower lip (Fig. 3). Drug distribution was confirmed by injecting indigo carmine dye through the catheter (Fig. 4). Then, 87.5 mg of cisplatin was selectively injected through the left and right facial arteries (total dose of 175 mg; 100 mg/m2). The tumor significantly shrank and almost disappeared 1 month after chemotherapy. Although additional intra-arterial chemotherapy was considered, the risks associated with the procedure were considered to be too high and radiotherapy was performed instead. There were no signs of recurrence at the 2-year follow-up (Fig. 5).Fig. 1 Squamous cell carcinoma (23 mm in diameter) on the patient's lower lip.

Fig 1

Fig. 2 Volume-rendered image created from computed tomography aortography shows the right facial artery (arrow, pink color) and the left facial artery (arrowhead, light blue color) feed the tumor.

Fig 2

Fig. 3 Angiography. Facial arteriography of the right (A) and left (B) facial arteries showing tumor staining (arrows) in the lower lip.

Fig 3

Fig. 4 Photographs taken after indigo carmine dye infusion. (A) The right side of the lower lip was stained blue following dye infusion through the right facial artery. (B) The left side of the lower lip was stained blue following dye infusion through the left facial artery.

Fig 4

Fig. 5 Course of treatment. Photographs obtained 1 week after chemotherapy (A), 2 weeks after chemotherapy (B), 1 month after chemotherapy (C), and after radiotherapy (D). The tumor completely disappeared after a single intra-arterial infusion of chemotherapy combined with radiotherapy.

Fig 5

Discussion

Although there are several reports describing intra-arterial infusion chemotherapy for the treatment of lip cancer, few have involved chemotherapy using cisplatin [[2], [3], [4], [5], [6]]. In those reports, cisplatin was infused through the superficial temporal artery and repeated over several cycles. For head and neck cancers, Robbins et al. proposed RADPLAT, whereby chemotherapy is infused through the femoral artery using the Seldinger technique [1]. RADPLAT involves 4 sessions of intra-arterial infusion chemotherapy using cisplatin at a dose of 150 mg/m2 once a week with simultaneous radiotherapy. In a Japanese clinical trial of patients with localized advanced maxillary sinus cancer, a single dose of cisplatin was injected at a dose of 100 mg/m2 [7]. In the current case, after consultation with a dermatologist, we selected intra-arterial infusion chemotherapy using cisplatin with a dose of 100 mg/m2. Sodium thiosulfate was intravenously administered simultaneously to the intra-arterial infusion to neutralize the systemic effects of cisplatin. There were no side effects related to cisplatin.

The femoral artery approach with the Seldinger technique carries the risk of stroke, one of the serious adverse events associated with the procedure. In prior studies, the occurrence rate of stroke (grade ≥ 2) was reported to be 1.6%-8.2% [[7], [8], [9], [10], [11]]. Our patient experienced no adverse events due to the catheter procedure. We believe that administering a single intra-arterial infusion chemotherapy could reduce the adverse events associated with the procedure. In addition, the adverse effects associated with radiotherapy could be alleviated by reducing the tumor size with chemotherapy compared with performing radiotherapy alone. In patients with a large tumor, this combination treatment offers functional and cosmetic advantages over surgery.

In our patient, CT aortography and arterial injection of indigo carmine dye were performed to accurately identify the tumor's feeding arteries, which enabled safe and effective treatment. Selective CT arteriography is also effective, but artifacts caused by metal in the mouth can be problematic. Even if the tumor is not very large, it may be fed by the contralateral artery. Therefore, a combination of intra-arterial dye injection, angiography, and CT arteriography is required to determine the tumor's feeding arteries.

Conclusion

A single intra-arterial infusion chemotherapy combined with radiotherapy achieved complete disappearance of a large SCC of the lower lip. This treatment allowed us to preserve the functional and cosmetic aspects of the patient's lower lip with minimal side effects. CT aortography and dye infusion were important in confirming the tumor's feeding arteries.

Patient consent

The patient provided informed consent for preparation and publication of this case report.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments: This study was not supported by any funding.
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References

1 Robbins KT Vicario D Seagren S Weisman R Pellitteri P Kerber C A targeted supradose cisplatin chemoradiation protocol for advanced head and neck cancer Am J Surg 168 5 1994 419 422 10.1016/s0002-9610(05)80089-3 7977964
2 Kishi K Matsunaka M Sato M Sonomura T Sakurane M Uede K. T1 and T2 lip cancer: a superselective method of facial arterial infusion therapy–preliminary experience Radiology 213 1 1999 173 179 10.1148/radiology.213.1.r99oc06173 10540658
3 Wu CF Chen CM Chen CH Shieh TY Sheen MC. Continuous intraarterial infusion chemotherapy for early lip cancer Oral Oncol 43 8 2007 825 830 10.1016/j.oraloncology.2006.10.012 17207655
4 Wu CF Chang KP Huang CJ Chen CM Chen CY Steve Lin CL Continuous intra-arterial chemotherapy for downstaging locally advanced oral commissure carcinoma Head Neck 36 7 2014 1027 1033 10.1002/hed.23408 23784874
5 Sheen YT Chen YY Sheen MC. Case report of a huge lower lip cancer successfully treated with intra-arterial infusion chemotherapy Int J Surg Case Rep 71 2020 82 84 10.1016/j.ijscr.2020.04.034 32446228
6 Onishi M Takahashi K Maeda F Akasaka T Amano H. Successful treatment of squamous cell carcinoma on the lip with continuous intra-arterial peplomycin infusion chemotherapy: a report of 27 cases Eur J Dermatol 32 2 2022 287 289 10.1684/ejd.2022.4235 35866907
7 Homma A Mikami M Matsuura K Onimaru R Yoshida D Shinomiya H Head and Neck Cancer Study Group of the Japan Clinical Oncology Group (JCOG-HNCSG). Dose-finding and efficacy confirmation trial of the superselective intra-arterial infusion of cisplatin and concomitant radiation therapy for locally advanced maxillary sinus cancer (JCOG1212): results of the efficacy confirmation phase in patients with T4aN0M0 Int J Radiat Oncol Biol Phys 118 5 2024 1271 1281 10.1016/j.ijrobp.2023.11.031 38008195
8 Rabbani A Hinerman RW Schmalfuss IM Amdur RJ Morris CG Peters KR Radiotherapy and concomitant intraarterial cisplatin (RADPLAT) for advanced squamous cell carcinomas of the head and neck Am J Clin Oncol 30 3 2007 283 286 10.1097/01.coc.0000258118.38177.74 17551306
9 Robbins KT Kumar P Harris J McCulloch T Cmelak A Sofferman R Supradose intra-arterial cisplatin and concurrent radiation therapy for the treatment of stage IV head and neck squamous cell carcinoma is feasible and efficacious in a multi-institutional setting: results of Radiation Therapy Oncology Group Trial 9615 J Clin Oncol 23 7 2005 1447 1454 10.1200/JCO.2005.03.168 15735120
10 Rasch CR Hauptmann M Schornagel J Wijers O Buter J Gregor T Intra-arterial versus intravenous chemoradiation for advanced head and neck cancer: Results of a randomized phase 3 trial Cancer 116 9 2010 2159 2165 10.1002/cncr.24916 Erratum in: Cancer 2010;116(15):3750 20187094
11 Robbins KT Kumar P Wong FS Hartsell WF Flick P Palmer R Targeted chemoradiation for advanced head and neck cancer: analysis of 213 patients Head Neck 22 7 2000 687 693 10.1002/1097-0347(200010)22:7<687::aid-hed8>3.0.co;2-w 11002324
