Intra-arterial chemotherapy for head and neck cancer was first reported by Klopp et al. [1] and Sullivan et al. [2] in the 1950s. They reported insertion of a straight catheter into ECA via STA or a superior thyroid artery (Fig. 13.1a, b). The efficacy of treatment with intra-arterial chemotherapy has been reported [3–6].

Flow of the anticancer agents to the tumor bed is unstable with this method, because the tip of the catheter may be easily displaced near the tumor-feeding artery in ECA by neck extension. The tip of a straight catheter is located slightly peripheral to the tumor-feeding artery in ECA (Fig. 13.2a), and the anticancer agents can be administered to the tumor with a manual one-shot injection of high pressure (Fig. 13.2b). On the other hand, anticancer agents cannot be administered to the tumor when a syringe pump is used because of low pressure (Fig. 13.2c).

This method was developed to overcome the disadvantages associated with the techniques mentioned above. A hook-shaped catheter is inserted from STA in retrograde fashion into a tumor-feeding artery; the usefulness of this method in combination with radiotherapy has been reported [23–27].

Before treatment, 3-dimensional computed tomography angiography (3D-CTA) of the carotid artery is necessary to identify the main tumor-feeding arteries and determine the morphology of the tumor-feeding artery originating from ECA (Fig. 13.4). Patients with severe calcification of the carotid artery or stenosis of the internal/external carotid artery are ineligible (Fig. 13.5a, b).

Catheterization from STA is performed according to the method of Hattori, Fuwa and Tohnai [23–25] (HFT method) [28] (Figs. 13.6, 13.7, and 13.8). STA is exposed by a 30-mm skin incision in the preauricular region of the affected side (Fig. 13.7a, b). Indwelling needle is inserted into STA (Fig. 13.7c), and an inner needle is removed from an outer needle A 0.016-inch guidewire (GT wire, Terumo Corp., Tokyo, Japan) (Fig. 13.6a) is inserted into the common carotid artery through an outer needle (Fig. 13.7d). A vinyl hook-shaped catheter (NECK, 4 Fr in outer diameter, Medikit Corp., Tokyo, Japan) (Fig. 13.6b) is inserted into STA along the guidewire (Fig. 13.7e) and placed below the bifurcation of the target artery (Fig. 13.7f). The tip of the catheter is then superselectively inserted into the target artery by drawing it back under fluoroscopic guidance (Fig. 13.7g, h), and the position of the catheter is checked by injection of contrast medium and blue dye (Fig. 13.7i, j). When catheterization using a hook-shaped catheter is not stable, the guidewire exchange method is used to replace it with a polyurethane straight catheter (Fig. 13.6c) [29].

When the tumor has two or more feeding arteries, catheters are inserted into the two arteries via STA and OA or bilaterally. Catheterization from OA is performed according to the method of Iwai et al. [30] (Fig. 13.8). OA is identified posterior of the mastoid process by an ultrasonic blood flow detector (Doppler ultrasound) (13.7d, and Fig. 13.8a). A 35-mm skin incision is made, and the sternocleidomastoid muscle and splenius capitis muscle are safely transected using the ultrasonic scalpel without OA injury (Fig. 13.7e, and 13.8b–e). Then, the catheter is superselectively inserted into the target artery under fluoroscopic guidance. The transected muscles, subcutaneous tissues, and skin are sutured, and the catheter is fixed to the skin around the mastoid process.

After catheterization, flow-check digital subtraction angiography (DSA) and angio-CT are performed in all cases (Fig. 13.9a–d). Angio-CT is helpful for detecting tumors by confirming the enhancement of the feeding area and for enabling the catheter to be placed at the appropriate position. Furthermore, weekly confirmation of the feeding artery by injection of a small amount of indigo carmine is important (Fig. 13.9e, f).

Radiotherapy is planned for all patients after appropriate immobilization using a thermoplastic mask and three-dimensional CT-based techniques. Conventional radiotherapy is performed with 4 or 6 MV at 2 Gy/fr/day. The irradiation field is changed according to lymph node status. In cases of N0 disease, the field contains the primary site and levels I–III of the neck on the ipsilateral side. The dose is delivered to 40 Gy/20fr. The portal is then reduced to only the primary site to spare the spinal cord. The total dose delivered to the primary tumor is 60 Gy/30fr. In cases of N1, N2a, and N2b diseases, the field contains the primary site and levels I–V of the neck on the ipsilateral side. The dose is delivered at 40 Gy/20fr. The portal is then reduced to the primary site and lymph node metastases. The dose for the spinal cord ranges from 40 Gy to 45 Gy. The total dose delivered to the primary tumor is 60 Gy/30fr and that to the metastatic lymph node sites is to 50 Gy/25fr. In cases of N2c disease, the field contains the primary site and levels I–V of the neck on bilateral sides. The dose is delivered at 40 Gy/20fr. The portal is then reduced to the primary site and lymph node metastases. The dose to the spinal cord ranges from 40 Gy to 45 Gy. The total dose delivered to the primary tumor is 60 Gy/30fr, and, if at all possible, the total dose delivered to the metastatic lymph node sites is 50 Gy/25fr.