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Successful Treatment of Syncope in Head and Neck Cancer With Induction Chemotherapy

University of Illinois at Chicago, Chicago, IL

A 54-year-old white man presented with progressive dysphagia, weight loss, hoarseness, and neck mass over several months. A fine needle aspiration of the neck mass revealed moderately differentiated squamous cell carcinoma. A computed tomography (CT) scan of the neck showed a tumor of the left tonsil with marked left peritonsillar extension and bilateral metastatic neck nodes, and the (T) tumor was noted to encase the (C) left carotid artery while the left internal jugular vein was not seen due to compression by (Ns) matted nodes (Fig 1A). A few weeks later he had a sudden loss of consciousness. When the emergency response team arrived, he was noted to have a blood pressure of 64/40 mmHg without a palpable pulse. A pacemaker was placed; however, the syncope persisted occurring several times a week and occasionally associated with prodromal dizziness and weakness. When he was transferred to our institution, sudden precipitous drops in blood pressure without changes in heart rate were observed. He was monitored in the intensive care unit, and norepinephrine was administered successfully during these episodes. The syncope was thought to be associated with the cancer, and radiation therapy was contemplated. However, the patient was unsafe for transport due to the unpredictable hypotension. Therefore, induction chemotherapy of cisplatin (100 mg/m² on day 1) and fluorouracil (1,000 mg/m² continuous infusion on days 1 through 4) was started. The last hypotensive event occurred on day 5 of induction chemotherapy and never recurred. After one cycle of induction chemotherapy, the patient received concurrent chemoradiotherapy. CT scan performed 1-month postchemoradiotherapy showed a considerable reduction in the tumor size, with significantly diminished tumor size surrounding the (C) left internal carotid artery and visualization of the (J) left internal jugular vein (Fig 1B). CT scan and endoscopic examination performed 1month after post-treatment modified radical neck dissection showed no evidence of disease, and the syncope never returned.

Syncope from head and neck cancer (HNC) is rare and is a diagnosis of exclusion, estimated to occur in less than one of 250 patients.^1,2 The syncope is presumed to occur when a tumor mass invades the baroreceptor within the carotid sinus or when it disrupts the afferent nerve fibers of the glossopharyngeal nerve that carries baroreceptor information from the carotid sinus to the brainstem (Fig 2). ¹ Attempts to relieve syncope have included vasoconstrictive drugs, cardiac pacemaker placement, radiotherapy, and surgical resection of the glossopharyngeal nerve.³ Cardiac pacemaker rarely achieves relief of syncope.^1,3 Conversely, surgery and radiotherapy have been shown to be more effective. However, surgery is often palliative only and radiotherapy poses the risk of a syncopal event in an unmonitored environment.^1,3 Induction chemotherapy is being explored in locally advanced HNC because with improvements in local control rates, the risk of distant recurrences becomes an increasing concern. Recent studies report significant initial response to induction chemotherapy. For example, one study reported that one cycle of induction chemotherapy (docetaxel, cisplatin, and fluorouracil) decreased the tumor mass by more than 50% in approximately 75% of patients with laryngeal cancer.⁴

View larger version (15K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 2. Illustration by Adrienne J. Boutwell, MAMS © 2006.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

Fig 1.

REFERENCES

1. Macdonald DR, Strong E, Nielsen S, et al: Syncope from head and neck cancer. J Neurooncol 1 : 257 -267, 1983[CrossRef][Medline]

2. Kala GK, Lee C, Coatesworth AP: Malignant vasovagal syndrome? Int J Clin Pract 58 : 93 -95, 2004[CrossRef][Medline]

3. Bauer CA, Redleaf MI, Gartlan MG, et al: Carotid sinus syncope in head and neck cancer. Laryngoscope 104 : 497 -503, 1994[Medline]

4. Urba S, Wolf G, Eisbruch A, et al: Single-cycle induction chemotherapy selects patients with advanced laryngeal cancer for combined chemoradiation: A new treatment paradigm. J Clin Oncol 24 : 593 -598, 2006[Abstract/Free Full Text]

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