Preservation of the larynx after resection of a carcinoma of the posterior wall of the hypopharynx: versatility of a free flap patch graft

Reconstruction using a free jejunal patch flap in salvage head and neck surgery after radiotherapy

BACKGROUND

Chemoradiotherapy is a standard treatment for functional preservation in patients with advanced head and neck carcinoma. However, chemoradiotherapy increases the risk of postoperative complications.

AIMS/OBJECTIVES

We report the usefulness of reconstruction using a free jejunal patch flap in treating recurrence or residual head and neck carcinoma after radiotherapy. Furthermore, we investigated the factors for the occurrence of postoperative complications in patients who underwent salvage surgery using a free flap transfer.

MATERIAL AND METHODS

This study included 41 patients with head and neck carcinoma who underwent salvage surgery using a free flap transfer, including 11 patients who underwent reconstruction using a free jejunal patch flap. Prognostic analysis was performed for the development of complications.

RESULTS

Ten jejunal patch flaps survived without microvascular problems. One patient underwent revision reconstructive surgery because of flap failure. However, no patient had a pharyngocutaneous fistula. Oral intake could be resumed in all patients at a median 14 days postoperatively. Multivariate logistic regression analysis indicated that the use of cutaneous flaps was significantly associated with the development of complications.

CONCLUSIONS AND SIGNIFICANCE

Free jejunal patch flaps can be considered useful for head and neck reconstruction after radiotherapy for early intake resumption and complication prevention.

Neoadjuvant chemotherapy and transoral robotic surgery for the posterior pharyngeal wall carcinoma

BACKGROUND

The squamous cell carcinoma (SCC) of the posterior pharyngeal wall (PPW) is associated with poor oncological outcomes based on current literature data. We reported the preliminary outcomes of a potential new treatment protocol based on neoadjuvant chemotherapy (NCT) and transoral robotic surgery (TORS).

METHODS

A retrospective single-center case series was performed including a total of 20 patients diagnosed with a SCC of the PPW between October 2010 and September 2021. All patients successfully completed TORS with neck dissection after NCT. Adjuvant treatment was performed in the presence of adverse pathologic features. Loco-regional control (LRC), overall survival (OS), and disease-specific survival (DSS) were defined as the time from surgery to tumor recurrence or death, as appropriate. Survival estimates were calculated by Kaplan-Meier analysis. Surgical data and post-operative functional outcomes were also reported.

RESULTS

Estimated 3-year LRC, OS, and DSS rates (95% Confidence interval) were 59.7% (39.7-89.6), 58.6% (38.7-88.8), and 69.4% (49.9-96.6). The median hospital stay was 21 days (IQR 17.0-23.5). Oral diet and decannulation were achieved after a median of 14 days (IQR 12.0-15.0). Feeding tube and tracheostomy dependence after 6 months was observed in 3 (15%) and 2 (10%) patients, respectively.

CONCLUSIONS

The use of NCT followed by TORS for PPW SCC treatment appears to have good oncological and functional outcomes for both early and locally advanced cancers. Further randomized trials and site-specific guidelines are needed.

Efficacy of Larynx Preservation Surgery and Multimodal Adjuvant Therapy for Hypopharyngeal Cancer: A Case Series Study

Background: Larynx preservation surgery (LPS) combined with multimodal adjuvant therapy (MAT) is re-emerging as treatment option for hypopharyngeal cancer (HPC). This study aims to explore the survival and functional outcome of this combined approach. Methods: This is a retrospective cohort study. Selected patients with primary HPC treated by LPS and MAT at two large Beijing medical centers between 2005 and 2019 were included. In addition to LPS, patients received one or more of the following treatments: preoperative induction chemotherapy, postoperative intensity-modulated radiotherapy, chemotherapy, or targeted therapy. Results: In total, 64 patients were included (62 were men, and median age was 57.5 years). The disease in most patients was in stage III (28.1%) or IV (56.3%), or in stage T2 (34.4%) or T3 (45.3%), based on the TNM scale. Across all patients, the rate of overall survival (OS) was 60.7% at 3 yr and 47.3% at 5 yr. OS was significantly higher for patients with stage I or II disease than for those with stage III or IV disease (HR 8.64, 95% CI 3.69-20.2, log-rank P = .010). Decannulation was successful in 55 patients (85.9%), and swallowing function was satisfactory (stage 0-III, on Functional Outcome Swallowing Scale) for 50 (78.1%). Median Voice Handicap Index-10 score on voice performance was 19 (range 4-40), and median Functional Assessment of Cancer Therapy-General Questionnaire score for QoL was 75 (range 16-105). Conclusions: LPS and MAT can provide satisfactory oncologic control and good functional outcomes for selected patients with HPC, especially those with stage I or II disease.

Use of Supraclavicular Flap by End to Side Technique in Pharyngeal SCC: A Case Report and Review of Literature

Objectives

In recent years, conservation laryngeal surgeries, including partial pharyngectomy, have been introduced as an alternative procedure for selected cases of hypopharyngeal squamous cell carcinoma (HSCC). Reconstruction of these defects presents a considerable challenge for the surgeon after partial pharyngectomy due to its circumferential nature. In this case report, we represent the innovative "End to side" technique to reconstruct hypopharyngeal defect using the rolled supraclavicular flap after laryngeal-preserving partial pharyngectomy.

Methods and Results

A 70-year-old female presented with a history of progressive dysphagia and odynophagia. The evaluations revealed a T3N0M0 SCC of pyriform sinus. The mass was successfully resected through partial pharyngectomy, and the hypopharyngeal defect reconstruction was achieved using the rolled supraclavicular flap via the "End to side" technique. The patient was discharged after decannulation on day 10. The 3-week barium swallow was performed with no evidence of anastomotic leakage, and the oral feeding was started after NG tube removal. At week 5, complete movement of the true vocal cord on the one side and good phonation and deglutition was observed. There was no evidence of recurrence after 1 year.

Conclusions

Laryngeal-preserving partial pharyngectomy and hypopharyngeal reconstruction with the rolled supraclavicular flap via the "End to side" technique could lead to good oncological and functional outcomes in selected cases of pyriform sinus.

Radiation necrosis of the pharyngeal soft tissue: Unique clinical entity reconstructed with a previously unreported composite brachioradialis and flexor digitorum superficialis radial forearm flap

BACKGROUND

The radial forearm free flap (RFFF) is a versatile flap commonly used in head and neck reconstructive surgery. We describe the use of a composite RFFF that includes muscle for reconstruction of a hostile wound of the posterior pharyngeal wall.

METHODS

A 54-year-old male with a history of recurrent right palatine tonsil HPV+ squamous cell carcinoma developed severe soft tissue necrosis of the posterior pharyngeal wall secondary to reirradiation. The defect was reconstructed with a composite RFFF that included the brachioradialis (BR) muscle and the flexor digitorum superficialis (FDS) muscle.

RESULTS

Restoration of this complex defect was successfully accomplished with minimal donor site functional deficits and satisfactory functional outcomes including decannulation and resumption of oral intake.

CONCLUSION

This composite RFFF can be effectively used to reconstruct a hostile wound of the posterior pharyngeal wall. Incorporation of muscle in the reconstruction of complex wounds with soft tissue necrosis is beneficial.

Carcinoma of the posterior wall of the hypopharynx: surgical treatment with larynx preservation

Introduction

Posterior pharyngeal wall is the most rare subsite for hypopharyngeal carcinomas. Because of its rarity, there are few studies published in the literature specifically concerning posterior pharyngeal wall carcinoma.

Objectives

To report our functional results in patients with the carcinoma of the posterior wall of the hypopharynx after surgical treatment by resection via a lateral or infrahyoid pharyngotomy approach, with the preservation of the larynx and reconstruction with a radial forearm free flap.

Methods

The study included 10 patients who underwent surgery for a carcinoma of the posterior wall of the hypopharynx over a 6 year period. The associated postoperative morbidity was investigated and functional results were analyzed.

Results

Nine patients had T3 lesions and one patient had a T2 lesion. The preferred approach to access the hypopharynx was a lateral pharyngotomy in 5 patients and lateral pharyngotomy combined with infrahyoid pharyngotomy in 5 patients with superior extension to oropharynx. The pharyngeal defects were reconstructed successfully with radial forearm free flaps. Four patients received adjuvant radiotherapy only, and 4 patients with N2b and N2c neck diseases received adjuvant chemoradiotherapy. The mean duration of hospitalization was 15.6 days (range, 10–21 days). All patients achieved oral intake in a median time of 74 days (range, 15–180). Decannulation was achieved in all patients and the median time for decannulation was 90 (range, 21–300 days). The mean followup duration was 38.3 months (range, 10–71 months) and 8 patients survived. One patient died due to regional recurrence in the retropharyngeal lymph nodes and 1 patient died due to systemic metastasis.

Conclusion

Primary surgery is still a very effective treatment modality for the carcinoma of the posterior wall of the hypopharynx and does not permanently compromise the swallowing and laryngeal functions if pharyngeal reconstruction is performed with a free flap.

A systematic review of different treatment strategies for the squamous cell carcinoma of the posterior pharyngeal wall

OBJECTIVE

To perform a systematic review of the literature available about the posterior pharyngeal wall squamous cell carcinomas, with a special focus on oncologic outcomes.

METHODS

A comprehensive research was performed on PubMed/MEDLINE, Google Scholar, and Cochrane Library datasets for published studies meeting the established criteria. The last search was conducted on December 8, 2019.

RESULTS

Eleven studies were included in the review, for a total of 534 patients (median age 60.4; male: n = 359, 67.2%). Six of the studies evaluated the oncologic outcomes of primary surgery, while three studies focused on results achieved through primary radiotherapy. Two studies evaluated both surgery and radiotherapy outcomes for the treatment of early or advanced posterior pharyngeal wall carcinoma.

CONCLUSIONS

Primary surgery associated with adjuvant radiotherapy would seem to ensure better oncologic outcomes, especially for locally advanced tumors. Moreover, this systematic review showed that oro- and hypo-pharyngeal wall tumors are similar in terms of clinical and biological behavior.

Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunal Flap Transfer

Background:

The purpose of this study was to examine the relationship between the incidence of dysphagia or fistula formation in an anastomotic region and factors such as extent of resection, gastric tube formation, and irradiation among patients who underwent free jejunal flap transfer.

Methods:

We retrospectively examined 100 cases (88 men and 12 women; average age, 65.8 years; range, 46–88 years) in whom the evaluation of postoperative oral intake was possible after undergoing total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap transfer. Chi-square test (with Fisher transformation, if necessary) was performed to analyze the relationship among resection styles (the resection margin extended to the oropharynx or to the cervical esophagus and gastric tube elevation), radiation therapy history, and incidence of dysphagia or fistula formation.

Results:

One hundred patients were analyzed, and complications such as postoperative fistula and dysphagia occurred in 8 (8.0%) and 20 patients (20.0%), respectively. However, no significant correlation was found between various resection factors and fistula formation or adverse events. At the reconstruction site, other complications such as postoperative lymphorrhea (7%), postoperative hematoma (4%), trachea necrosis (4%), cervical flap necrosis (1%), and thyroid necrosis (1%) occurred. These complications were managed by a cervical open wound and additional minor operation as needed.

Conclusion:

Thus, free jejunal transfer for TPLE is a good reconstruction technique with few complications and postoperative adverse events, regardless of the extent of resection and preoperative radiation therapy.

Reconstruction of esophageal stenosis that had persisted for 40 years using a free jejunal patch graft with virtual endoscopy assistance: A case report

In this report, we present a case in which good results were achieved by treatment using a free jejunal patch graft with virtual endoscopy (VE) assistance in a patient whose swallowing had failed to improve for 40 years after he mistakenly swallowed sulfuric acid, despite pectoralis major myocutaneous flap grafting and frequent balloon dilatation surgery. During the last 20 years, virtual computed tomography imaging has improved remarkably and continues to be used to address new challenges. For reconstructive surgeons, the greatest advantage of VE is that it is a noninvasive modality capable of visualizing areas inaccessible to a flexible endoscope. Using VE findings, we were able to visualize the 3-dimensional shape beyond the stenosis. VE can also help predict the area of the defect after contracture release.

Free skin flap reconstruction after partial hypopharyngectomy with laryngeal preservation

Surgical resection of hypopharyngeal cancer often affects laryngeal function. The aim of this study is to assess the reliability and efficacy of free skin flap transfer after partial hypopharyngectomy with laryngeal preservation. This study designs a retrospective analysis. The subjects were 54 patients who underwent free skin flap reconstruction immediately after partial pharyngolaryngectomy or hypopharyngectomy with laryngeal preservation. The defects were classified into four types based on the location of the hypopharyngeal defect. Functional results were evaluated by routine physical examination findings and parameters related to swallowing function and X-ray barium deglutition examination. Perioperative mortalities and morbidities were reviewed. There were no perioperative mortalities and 98% of the flaps survived. Forty-three patients (80%) were able to eat an unrestricted diet and experienced no aspiration. Restriction of the diet was significantly associated with the extent of oesophageal mucosal resection. In conclusion, free skin flap reconstruction is confirmed to be a safe and effective strategy to maintain laryngeal function and good quality-of-life.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall

PURPOSE

To analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall.

METHODS AND MATERIALS

Between 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up.

RESULTS

The 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%).

CONCLUSIONS

Local-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.

Ten years single institutional experience of treatment for advanced hypopharyngeal cancer in Kyoto University

CONCLUSION

Treatment of advanced hypopharyngeal cancer has become more conservative and more multidisciplinary, and the prognosis has been improved. Induction chemotherapy has the potential to extend organ preservation therapy even in cases with locally advanced primary lesion. It is also important to develop a strategy to reduce distant metastasis and to keep track of second primary cancers.

OBJECTIVES

To update the therapeutic outcome of advanced hypopharyngeal cancer.

METHODS

A total of 72 cases with stage III/IV hypopharyngeal cancer were treated at Kyoto University Hospital during 2000-2008. Surgery was performed in 56 cases; total pharyngolaryngoesophagectomy (TPLE) in 39 cases and partial pharyngectomy (PPX) preserving the larynx in 17 cases. Radiotherapy (RT) with or without concurrent chemotherapy was applied in 16 cases. Induction chemotherapy (ICT) has been applied for 14 cases since 2006 to achieve organ preservation and reduction of distant metastasis. The follow-up period varied from 12 months to 96 months (mean 32 months). Therapeutic outcomes were chart reviewed.

RESULTS

Five years cumulative overall and disease-specific survival (DSS) rates were 52.1% and 63.8%, respectively. DSS rates in cases treated with surgery and those with RT were 65.1% and 56.1%, respectively. N2c status showed the worst prognosis according to nodal disease classification. Local control rates for cases treated with TPLE, PPX, and RT were 97.3%, 100%, and 80.4%, respectively. The effective rate of ICT was 79%, and laryngeal preservation was achieved in 79% of the cases with ICT. Recurrence occurred in 20 cases. Approximately half of the recurrence was distant disease. In the end, 17 cases died of the primary disease, while 10 cases died of other causes, mainly second primary cancers.

Squamous cell carcinoma and Zenker diverticulum

Squamous cell carcinoma in a Zenker diverticulum is a very rare condition. We report a case of a patient with a Zenker carcinoma, who was primarily functionally inoperable and therefore received neoadjuvant radiochemotherapy before cardiac bypass surgery. After a complicated course with cardiogenic shock and myocardial infarction, a re-evaluation of functional risk analysis and the tumor situation revealed operability. Subsequently, partial hypopharyngectomy and partial cervical esophageal resection with lymphadenectomy was performed. Reconstruction of the gastrointestinal continuity was made by interposition of a free small bowel graft and microvascular anastomosis. The postoperative course showed a small anastomotic leakage of the hypopharyngeal-small bowel anastomosis, which was successfully treated conservatively.

Definitive radiotherapy alone or combined with a planned neck dissection for squamous cell carcinoma of the pharyngeal wall

BACKGROUND

In the current study,the authors analyzed the results of definitive radiotherapy for squamous cell carcinoma of the pharyngeal wall.

METHODS

Between 1964 and 2000, 148 patients were treated with definitive radiotherapy. All patients had a 2-year minimum follow-up.

RESULTS

The following 5-year rates of local and ultimate local control were obtained: T1 disease, 93% and 93%; T2 disease, 82% and 87%; T3 disease, 59% and 61%; and T4 disease, 50% and 50%, respectively. Multivariate analysis revealed that twice-daily fractionation (P = 0.0009), American Joint Committee on Cancer Stage I-II disease (P = 0.0051), and oropharyngeal primary site (P = 0.0193) were associated with improved locoregional control. The following 5-year absolute and cause-specific survival rates were obtained: Stage I, 56% and 89%; Stage II, 52% and 88%; Stage III, 24% and 44%; Stage IV, 22% and 34%; and overall, 30% and 49%, respectively. Eight patients (5%) died of complications.

CONCLUSIONS

Locoregional control and survival were found to be related to site, extent of disease, and fractionation schedule. Although outcomes have improved in recent years, the morbidity of treatment was significant in the current study and a substantial proportion of patients died secondary to the malignancy.

Larynx preservation surgery for advanced posterior pharyngeal wall carcinoma with free flap reconstruction: a critical appraisal

To report the functional and oncologic results of larynx preservation surgery with free flap reconstruction for posterior pharyngeal wall carcinoma. Retrospective medical chart review. Tertiary care referral center. We present a series of seven patients, who were treated for an advanced stage posterior pharyngeal wall carcinoma between 1995 and 1998. All patients underwent posterior pharyngectomy with larynx preservation via a suprahyoidal approach for carcinoma of the posterior pharyngeal wall, with radial forearm free flap reconstruction. Complications occurred in three patients with grade 3 comorbidity, one of whom suffered flap loss. After a mean follow-up of 48 months, three patients are alive without disease. One patient is alive with a second primary tongue carcinoma. Two patients died of disease, whereas one patient died of another cause. All patients could be decannulated and maintain their voice. Six out of seven patients were able to take oral nutrition, although four patients needed additional PEG-tube feeding. Posterior pharyngectomy with larynx preservation and radial forearm free flap reconstruction is feasible in selected patients, with acceptable functional results and survival. However, the patient must be aware of the risk of chronic aspiration and the possibility of long-term PEG feedings.

Surgical management of posterior pharyngeal wall carcinomas: functional and oncologic results

BACKGROUND

The optimal primary treatment for posterior pharyngeal wall tumors remains controversial.

METHODS

To assess the relevance of surgical treatment from a functional and oncologic point of view, we reviewed the cases of 77 patients surgically treated between 1984 and 1995. Among them 23 had been previously irradiated. Fifty-five patients underwent a conservative surgery (CS) sparing the larynx; 19 direct closures, 6 reconstructions of the posterior wall with a thoracic myocutaneous flap, 15 with a platysma flap, and 15 with a free forearm flap were performed. Twenty-two patients underwent radical surgery (RS). All previously untreated patients had postoperative radiotherapy. The functional assessment concerned the CS group. Oncologic results, especially local control and survival were studied for the whole group.

RESULTS

Of the 55 patients who underwent CS, 53 (96%) had their canula and 49 (89%) their feeding tube removed. At 1 year, in the platysma and free forearm groups, 21 of the 24 assessable patients were back to exclusive oral intake. For patients treated by primary surgery followed by radiotherapy, the rate of local failure was 11% (18% for tumors greater than 4 cm), and the 5-year survival rate was 35%. For patients who had previous radiotherapy, the rates were, respectively, 52% and 16%.

CONCLUSION

The satisfactory functional results, caused by the improvement of reconstructive procedures, allow conservative surgery even in the case of large tumors. Oncologic results, especially local control, suggest that primary surgery followed by radiotherapy is effective for the treatment of posterior wall cancer. The oncologic results of surgery in a previously irradiated area are poor, and CS is not recommended in these cases.

Surgical management of head and neck cancer

Head and neck cancer surgery continues to evolve through the years and undergo improvement and refinement. In this article, the current state of head and neck cancer surgery is summarized in a site-by-site basis. The most important developments include organ-sparing surgery and microvascular free-tissue transfer for reconstruction.

One-stage reconstruction of defects in the hypopharyngeal region with free flaps

Despite the almost universal poor prognosis, the reconstruction of combined cervical skin and hypopharyngeal defects after extensive resection of tumour should maintain optimal quality of life. From 1992 to 1996 we treated 10 patients with combined skin and hypopharyngeal defects with five fasciocutaneous free flaps, three myocutaneous latissimus dorsi free flaps, one myocutaneous VRAM (vertical rectus abdominis muscle) free flap and one free radial forearm flap. None of our flaps failed. The complications that required revision (one arterial bleeding, one arterial thrombosis, two fistula formations, one superficial wound dehiscence, one haematoma) occurred mainly in those patients having secondary reconstructions. After primary extensive oncological resection of these tumours reconstruction should be done in one stage. The primary reconstruction should provide sufficient pharyngeal lining, a satisfactory covering of cervical soft-tissue, and adequate functional rehabilitation. We have reviewed our experience and conclusions about the advantages, disadvantages, and current indications for different free flaps in the reconstruction of combined hypopharyngeal, cervico-oesophageal, and cervical skin defects.