Palliative total pharyngo-laryngo-esophagectomy

Palliative reconstructive surgery may improve quality of life in high functioning noncurable head and neck oncologic patients

BACKGROUND

Treatment recommendations for palliative patients are guided by functional status and individual needs. The projected success of palliative procedures relies on estimating the risk: benefit ratio, which weighs the expected improvement in life quality to the frailty, metabolic status, and the individual's ability to heal after surgery. Terminal patients have less time in which to judge outcomes; therefore, the timeframe in which we assess these metrics should be modified according to prognosis. We emphasize efficiency over simplicity for reconstructive palliative surgery.

METHODS

We reviewed the literature and supply a representative case to contribute our experiences for the palliative reconstructive surgeon to use in the evaluation and treatment of incurable patients.

RESULTS

Palliative reconstructive surgery carries higher perioperative risk than standard reconstructive surgery; however, aggressive surgical management can improve quality of life. We find the Palliative Performance Scale-a functional, prognostic tool-to be a helpful metric for preoperative evaluation.

CONCLUSIONS

Reconstructive palliative surgery can improve quality of life in dying patients (ie, pain, wound hygiene, and so on) and may even improve survival. We advocate prioritizing efficiency in completing the reconstructive process, which may not be the simplest or least invasive.

The role of surgery in the palliation of head and neck cancer

PURPOSE OF REVIEW

The public demands that 'all modes of treatment' should be offered to patients who present with head and neck cancer. Up to 40% of patients present with advanced stage disease, of whom some 10% have metastatic disease and are currently deemed incurable. This review summarizes the current role and philosophy of surgical interventions in the palliation of head and neck cancer.

RECENT FINDINGS

Patients who present with advanced or recurrent head and neck cancers over the past decade have been offered nonsurgical palliative treatments of radiotherapy with or without chemotherapy, with variable responses. The aims are to achieve tumour shrinkage and gain effective relief of symptoms, such as pain, breathing and swallowing. The use of surgery in the palliation of disease and its symptoms has declined significantly since the 1980s. Within the concept of multidisciplinary clinical working as the 'gold standard' for the provision of optimum care for the head and neck patient, the place for surgery should be discussed within the many options available currently.

SUMMARY

Patients who present with advanced, incurable or recurrent head and neck cancer should be made aware of their prognosis and the potential need and benefits of palliative care. The active involvement of patients and their carers, their desires and wishes should be the prime consideration for any interventions. Careful selection of suitable patients can achieve prolonged symptom relief safely and result in an improvement in their quality of living. The ultimate goal should incorporate not only quality of life but quality of dying.

Palliative surgery for head and neck cancer with extensive skin involvement

OBJECTIVES/HYPOTHESIS

To evaluate the role of regional and free tissue transfer for the palliative management of head and neck cancer with extensive skin involvement.

STUDY DESIGN

Case Series.

METHODS

A retrospective review was performed of patients treated for head and neck cancer with involvement of the skin at the Mount Sinai Medical Center over a 5-year period (2006-2010). Only patients with extensive skin involvement and unresectable tumors who underwent palliative resection and reconstruction were included in the review. Subjects were analyzed for age, gender, performance status, primary site, tumor histology, extent of invasion, type of reconstruction, hospital course, wound complications, adjuvant therapy, survival, and cause of death.

RESULTS

Twenty-five patients met the inclusion criteria for the review. Fourteen patients (56%) underwent regional flap reconstruction, and 11 patients (44%) underwent free flap reconstruction. The average length of stay was 7 days. Twenty-four patients (96%) had a medically uncomplicated postoperative hospital course. Nineteen patients (76%) were treated with adjuvant palliative radiotherapy and/or chemotherapy. Long-term follow-up was achieved for 19 patients. The median follow up in this group was 9.5 months. Eleven of the 21 patients (52%) developed wound complications postoperatively. Eight of these were minor wound dehiscences, while three developed major wound complications. Four patients (16%) had distant metastasis at the time of surgery, and the median time to develop distant metastases after surgery was 6 months. Median survival time was 9.5 months. Twenty-two patients (88%) were discharged in the care of their families with appropriate pain management and without the need for extensive wound care.

CONCLUSIONS

For unresectable tumors with extensive skin involvement, palliative resection and reconstruction is a reasonable treatment option. Although survival may not be affected, addressing the odor, bleeding, pain, and infection associated with skin involvement has the potential to improve a patient's quality of life.

LEVEL OF EVIDENCE

4.