Role of Surgical Salvage for Regional Recurrence in Laryngeal Cancer

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Functional Outcomes after Salvage Transoral Laser Microsurgery for Laryngeal Squamous Cell Carcinoma

OBJECTIVES

Transoral laser microsurgery (TLM) has been increasingly used in lieu of total laryngectomy to treat malignancy after definitive radiation. There are few data in the literature regarding functional outcomes. We retrospectively reviewed voice and swallowing outcomes in patients who underwent TLM for recurrent laryngeal carcinoma.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Forty-two patients were identified with recurrent squamous cell carcinoma of the larynx after definitive radiation therapy from 2001 to 2013: 28 patients with glottic recurrence and 14 with supraglottic recurrence. Swallowing outcomes were evaluated by gastrostomy tube dependence, the MD Anderson Dysphagia Inventory, and the Functional Oral Intake Scale. Voice outcomes were evaluated by the Voice Handicap Index and observer-rated perceptual analysis.

RESULTS

No significant difference was noted between mean pre- and postoperative MD Anderson Dysphagia Inventory scores: 78.25 and 74.9, respectively (P = .118, t = 1.6955). Mean Functional Oral Intake Scale scores after TLM for supraglottic and glottic recurrences were 6.4 and 6.6, respectively. Of 42 patients, 17 (40.5%) required a gastrostomy tube either during radiation or in conjunction with the salvage procedure. Of 17 patients, 15 resumed sufficient oral diet for tube removal. Patients' mean Voice Handicap Index score did increase from 34.3 to 51.5 (P = .047), and their mean perceptual score did decrease from 60.0 to 45.3 (P = .005). However, at 1-year follow-up, there was no significant difference in perceptual score: 61.1 to 57.1 (P = .722).

CONCLUSIONS

TLM is a successful surgical option for recurrent laryngeal cancer with acceptable functional outcomes.

Elective Lymphadenectomy during Salvage for Locally Recurrent Head and Neck Squamous Cell Carcinoma after Radiation

Objective

This study aimed to assess the rate of occult metastases in patients with head and neck mucosal squamous cell carcinoma who have undergone therapeutic neck radiation, and then develop primary site recurrence, without clinical evidence of recurrent neck disease.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

Head and neck mucosal squamous cell carcinoma patients with N+ necks treated with primary radiation who developed primary site recurrence with radiologically resolved neck lymphadenopathy, treated with salvage primary-site surgery with or without elective cervical lymphadenectomy (ECL). Main outcome measures were rate of occult nodal metastases, complication rates, and disease-free survival.

Results

Sixteen patients met inclusion criteria. Of 18 neck sides that underwent either ECL or observation for a mean follow-up of 26 months, 4 (22.2%) were found to have positive occult cervical metastases, all on the ipsilateral side of preradiation neck disease. Patients with advanced T-stage and/or free flap reconstruction were more likely to undergo cervical lymphadenectomy. Patients with persistent (as opposed to recurrent) primary site tumors had the highest rate of occult cervical metastases.

Conclusion

The risk of occult nodal metastases of 22.2%, in this study, may be too high to justify routinely omitting elective cervical lymphadenectomy in this patient population. Lymphadenectomy should especially be considered in patients with persistent tumors, with advanced recurrent T-stage, and undergoing free flap reconstruction.

Role of neck ultrasound during follow-up care of head and neck squamous cell carcinomas

CONCLUSION

No impact of neck ultrasound on the detection rate of neck recurrences of head and neck squamous cell carcinomas (HNSCCs) was seen. The outcome of salvage therapy was not influenced by close neck ultrasound monitoring during follow-up. Tendencies of earlier detection of neck recurrences were noticed.

OBJECTIVES

Neck ultrasound is more feasible for frequent application than computed tomography, while having comparable sensitivity and specificity in detecting neck metastasis. Before this study the effect of neck ultrasound on salvage therapy of neck recurrences when used in short defined intervals during follow-up was unknown.

METHODS

A total of 140 patients with primarily surgically treated HNSCC were enrolled in a follow-up program with defined close time intervals. Neck ultrasound was applied during every follow-up visit. Recurrence rate, survival rate, and outcome of salvage therapy were determined.

RESULTS

Overall recurrences occurred in 35.0% of patients. Local, regional, and distant recurrences were found in 11.4%, 7.9%, and 15.7%. Hypopharyngeal carcinoma and advanced staged tumor showed highest recurrence rates. In all, 24.5% of all recurrences were treated successfully by salvage therapy. Resection of local, regional, and distant recurrences resulted in 3-year survival rates of 43.8%, 36.4%, and 4.5%. The outcome of secondary therapy worsened with advancing initial primary tumor stage.

¹⁸F-FDG PET/CT and MRI in the follow-up of head and neck squamous cell carcinoma

We evaluated the diagnostic performance of (18)F-FDG PET/CT and MRI for the assessment of head and neck squamous cell carcinoma (HNSCC) relapse. Since early treatment might prevent inoperable relapse, we also evaluated THE performance of early unenhanced (18)F-FDG PET/CT in residual tumor detection. The study was prospectively performed on 32 patients who underwent (18)F-FDG PET/CT and MRI before treatment and at 4 and 12 months after treatment. (18)F-FDG PET/CT was also performed 2 weeks after the end of radiotherapy. Histopathology or a minimum of 18 months follow-up were used as gold standard. Before treatment (18)F-FDG PET/CT and MRI detected all primary tumors except for two limited vocal fold lesions (sensitivity 94%). MRI was more sensitive than (18)F-FDG PET/CT for the detection of local extension sites (sensitivity 75 vs 58%), but at the cost of a higher rate of false positive results (positive predictive value 74 vs 86%). For relapse detection at 4 months, sensitivity was significantly higher for (18)F-FDG PET/CT (92%) than for MRI (70%), but the diagnostic performances were not significantly different at 12 months. For the detection of residual malignant tissue 2 weeks post-radiotherapy, sensitivity and specificity of (18)F-FDG PET/CT were respectively 86 and 85% (SUV cut-off value 5.8). (18)F-FDG PET/CT is effective in the differentiation between residual tumor and radiation-induced changes, as early as 2 weeks after treatment of a primary HNSCC. For follow-up, performance of (18)F-FDG PET/CT and MRI are similar except for a higher sensitivity of (18)F-FDG PET/CT at 4 months.

Minimizing complications in salvage head and neck oncological surgery following radiotherapy and chemo-radiotherapy

PURPOSE OF REVIEW

The term salvage surgery denotes oncological surgery after failed radiotherapy or chemoradiotherapy (CRT). Salvage surgery is a high-risk endeavour as it carries a significant risk of complications. The purpose of this review is to assess the ways in which complications from salvage surgery can be prevented and minimized. This is a complex subject and complications are often multifactorial and interrelated. There are many aspects that can be discussed; however, to address each of them individually would be impossible and beyond the scope of this article. We will, therefore, focus this review on the most relevant aspects to current practice for head and neck surgeons.

RECENT FINDINGS

Salvage surgery after failure of radiotherapy and CRT remains controversial and many aspects still lack evidence. Many patients with recurrent cancer are not suitable for salvage surgery due to severe co-morbidities or disease progression. Salvage surgery is best carried out in tertiary centres by experienced multidisciplinary teams. Preoperative assessment and evaluation is critical to success and to minimize complications. Surgical principles include single incisions, delicate tissue handling, use of frozen sections, adopting a critical approach to neck dissections and the use of flaps, secondary surgical voice restoration for laryngectomies and appropriate postoperative care.

SUMMARY

This review emphasizes the importance of a multidisciplinary approach by experienced teams, the centralization of resources and teams, a structured and thorough patient assessment, surgical planning and a systematic attention to detail when addressing patients undergoing salvage surgery.