Clinical outcome of salvage neck dissections in head and neck cancer in relation to initial treatment, extent of surgery and patient factors

Diagnosis of laryngopharyngeal carcinoma through office-based flexible laryngoscopy as a reliable alternative for biopsies under general anesthesia: Faster diagnostics with equal oncological outcome

PURPOSE

Diagnostic endoscopy with biopsy under general anesthesia (DE-GA) is still considered as the established standard to assess laryngopharyngeal cancer patients. Office-based flexible laryngoscopic biopsy (FLB) offers an alternative, but the effect on oncological outcome remains uncertain. Therefore, the diagnostic process and survival of patients undergoing FLB, compared to those undergoing DE-GA were evaluated.

METHODS

Patients suspected of laryngopharyngeal cancer who underwent FLB were evaluated. Patients with FLB-confirmed squamous cell carcinoma (SCC) were matched with DE-GA patients based on tumor site, T-classification, N-classification, age, and p16 overexpression. Time from first visit to diagnosis (FVD), time to treatment interval (TTI), disease-specific survival (DSS) and overall survival (OS) were analyzed.

RESULTS

FLB yielded a definitive diagnosis in 155/164 (95 %) patients. No complications were observed. Ninety-eight of the 124 patients in which FLB revealed a SCC received curative treatment and were compared with 98 matched patients who underwent DE-GA. Median FVD interval was 6 days after FLB and 15 days after DE-GA (p < 0.001). Median TTI interval (FLB: 28 days, DE-GA: 28 days) was equal (p = 0.91). Oncological outcomes were comparable (p > 0.05) between FLB (OS: 2-yr: 76 %, 5-yr: 42 %; DSS: 2-yr: 86 %, 5-yr: 85 %) and DE-GA groups (OS: 2-yr: 76 %, 5-yr: 50 %; DSS: 2-yr: 81 %, 5-yr: 79 %).

CONCLUSION

FLB in the outpatient setting demonstrates a high diagnostic accuracy, is safe, accelerates the diagnostic process and has no negative effects on clinical outcome compared to DE-GA. Therefore, FLB should be considered as the standard diagnostic procedure in patients suspected of laryngopharyngeal cancer.

Advances and residual knowledge gaps in the neck management of head and neck squamous cell carcinoma patients with advanced nodal disease undergoing definitive (chemo)radiotherapy for their primary

PURPOSE

Substantial changes have been made in the neck management of patients with head and neck squamous cell carcinomas (HNSCC) in the past century. These have been fostered by changes in cancer epidemiology and technological progress in imaging, surgery, or radiotherapy, as well as disruptive concepts in oncology. We aimed to review changes in nodal management, with a focus on HNSCC patients with nodal involvement (cN+) undergoing (chemo)radiotherapy.

METHODS

A narrative review was conducted to review current advances and address knowledge gaps in the multidisciplinary management of the cN+ neck in the context of (chemo)radiotherapy.

RESULTS

Metastatic neck nodes are associated with poorer prognosis and poorer response to radiotherapy, and have therefore been systematically treated by surgery. Radical neck dissection (ND) has gradually evolved toward more personalized and less morbid approaches, i.e., from functional to selective ND. Omission of ND has been made feasible by use of positron-emission tomography/computed tomography to monitor the radiation response in cN+ patients. Human papillomavirus-driven oropharyngeal cancers and their cystic nodes have shown dramatically better prognosis than tobacco-related cancers, justifying a specific prognostic classification (AJCC) creation. Finally, considering the role of lymph nodes in anti-tumor immunity, de-escalation of ND and prophylactic nodal irradiation in combination are intense areas of investigation. However, the management of bulky cN3 disease remains an issue, as aggressive multidisciplinary strategies or innovative combined treatments have not yet significantly improved their prognosis.

CONCLUSION

Personalized neck management is an increasingly important aspect of the overall therapeutic strategies in cN+ HNSCC.

Safety of the "incidental" neck dissection or exploration during free tissue transfer after head and neck irradiation

IMPORTANCE

Patients with either local recurrence of head and neck cancer or osteoradionecrosis after prior radiation treatment often require free tissue transfer for optimal reconstruction. In this setting, neck exploration for vessels is necessary, and an "incidental" neck dissection is often accomplished despite clinically negative cervical lymph nodes. While neck surgery in the post-radiated setting is technically challenging, the safety of post-radiated elective neck dissection or neck exploration for vessels is not well-studied, especially for patients undergoing non-laryngectomy salvage resections.

OBJECTIVE

To define intraoperative and postoperative surgical complications for patients undergoing elective neck dissection or exploration with free tissue transfer reconstruction in the post-radiated setting, with attention to complications from neck surgery.

DESIGN

Retrospective cohort study. Patient charts from May 2005 to April 2020 were reviewed.

SETTING

Tertiary care referral center.

PARTICIPANTS

Patients underwent free tissue transfer after prior head and neck irradiation for non-laryngeal local cancer recurrence or second primary, osteoradionecrosis, or for sole reconstructive purposes. Patients with clinically positive neck disease were excluded.

MAIN OUTCOMES AND MEASURES

Intraoperative and postoperative complications including unplanned vessel or nerve injury, hematoma, chyle leak, wound dehiscence, wound infection, fistula formation, flap failure, and perioperative medical complications. Neck exploration and neck dissection patient outcomes were compared by Fisher exact test.

RESULTS

Seventy-two patients (56 men and 16 women) of average age sixty-one (range 34-89) were identified with average follow-up 25.7 months. Most patients (78%) underwent salvage neck dissection, and the rest underwent neck exploration for vessels only. There were five intraoperative neck complications: three vessel injuries and two nerve injuries. There were twenty-six postoperative surgical complications among eighteen patients. There was no difference in surgical complications whether patients underwent neck dissection or exploration only. Two partial and two complete flap failures occurred. There were nine perioperative medical complications among six patients.

CONCLUSIONS AND RELEVANCE

Elective neck dissection or exploration among patients undergoing free tissue transfer in the post-radiated setting carries a risk of both intraoperative and postoperative surgical complications. The present study defines risk of complications and helps to inform patient discussions for risk of complications in the post-radiated setting.

Salvage neck dissection for isolated neck recurrences in head and neck tumors: Intra and postoperative complications

BACKGROUND AND OBJECTIVES

The current evidence regarding complications after salvage neck dissection (ND) for isolated regional recurrences (IRRs) in head and neck cancers is poor. The aim of this study is to evaluate the incidence and differences in complication rates of salvage ND after primary surgery, radiotherapy, chemoradiotherapy, or combined treatments.

METHODS

This was a multicentric retrospective study on 64 patients who underwent salvage ND for IRR in three Italian institutes between 2008 and May 2020.

RESULTS

Complications were detected in 7 of the 34 patients (20.8%) and surgeons described difficult dissection in 20 patients (58.82%). Accidental vascular ligations or nervous injury during surgery were never detected. None of the variables analyzed were statistically significant in predicting the risk of complications, disease-free survival, or overall survival.

CONCLUSIONS

IRR represents a rare entity among total relapses. The incidence of complications after salvage ND for IRR is higher than after primary surgery but at an acceptable rate in experienced hands. However, an adequate balance between functional and oncological outcomes is mandatory.

Opportunities and Limits in Salvage Surgery in Persistent or Recurrent Head and Neck Squamous Cell Carcinoma

Except for HPV-induced cancers of the oropharynx, survival rates in patients with squamous cell carcinoma of the head and neck (HNSCC) have not changed substantially over the last decades. Salvage surgery plays an important role where primary treatment was unsuccessful since 50% of advanced-stage patients relapse after nonsurgical primary treatment. Depending on a variety of factors, a considerable number of patients in whom primary treatment was not successful can still be cured by salvage surgery. It is the goal of this review to elucidate these factors with the aim to counsel patients and their relatives realistically about the chances of being cured.

A comparison of the Thunderbeat and standard electrocautery devices in head and neck surgery: a prospective randomized controlled trial

Purpose

New energy-based sutureless vessel ligation devices, such as the Thunderbeat (Olympus Medical Systems Corp., Tokyo, Japan), could reduce operative time and limit blood loss in head and neck surgery; however, efficacy and safety in major head and neck surgery have not been investigated in a prospective, randomized study.

Methods

This prospective, double-arm, randomized controlled trial consisted of two parts: total laryngectomy (TL) and neck dissection (ND). Thirty patients planned for TL were randomized in two groups. For the ND part, forty-two operative sides were likewise randomized. In both parts, Thunderbeat was used in addition to the standard instrumentation in the intervention groups, while only standard instrumentation was used in the control groups. Primary outcome values were blood loss, operative time and complication rate.

Results

For the TL part there was no difference in mean blood loss (p = 0.062), operative time (p = 0.512) and complications (p = 0.662) between both hemostatic techniques. For the neck dissection part, there was a reduction in blood loss (mean 210 mL versus 431 mL, p = 0.046) and in operative time (median 101 (IQR 85–130) minutes versus 150 (IQR 130–199) minutes, p = 0.014) when Thunderbeat was used. There was no difference in complication rate between both hemostatic systems (p = 0.261).

Conclusion

The Thunderbeat hemostatic device significantly reduces operative blood loss and operative time for neck dissections, without increase in complications. In TL, blood loss using Thunderbeat was comparable with the standard technique, but the operative time tended to be shorter.

Trial registration

UMCG Research Register, Reg. no. 201700041, date of registration: 18/1/2017

Recent Advances and Future Directions in Clinical Management of Head and Neck Squamous Cell Carcinoma

Head and neck squamous cell carcinoma (HNSCC) is the most common cancer arising in the head and neck region. The most common risk factors are smoking, excessive drinking, and human papillomavirus (HPV) infection. While the overall incidence of smoking is decreasing, the incidence of HPV-related HNSCC is increasing in the United States and Western Europe, which led to a shift in understanding of the pathophysiology, treatment, and prognosis of this disease. The outcomes for non-metastatic HNSCC remains very encouraging and continues to improve. Advances in radiation technology and techniques, better organ preserving surgical options, and multidisciplinary treatment modalities have improved cure rates for locally advanced HNSCC patients. The treatment of metastatic disease, however, remains an area of need. The advancement of immune checkpoint inhibitors has provided significantly better outcomes, but only a small proportion of patients obtain benefits. Most recurrent and/or metastatic HNSCC patients continue to have poor survival. This has led to the vigorous investigation of new biomarkers and biomarker-based therapies. Novel therapeutic options including adaptive cellular therapy and therapeutic vaccines are also on the horizon. In this review, we highlight the latest advances in the field of HNSCC and the future direction of research.

Glycoprotein Nonmetastatic Melanoma Protein B as Potential Imaging Marker in Posttherapeutic Metastatic Head and Neck Cancer

Objective

To evaluate expression of potential molecular imaging targets epidermal growth factor receptor (EGFR), glycoprotein nonmetastatic melanoma protein B (GPNMB), and vascular endothelial growth factor (VEGF) in lymph nodes (LNs) with or without head and neck squamous cell carcinoma (HNSCC) metastases after (chemo)radiation.

Study Design

Retrospective study comparing receptor expression in paired lymph nodes after initial treatment.

Setting

A tertiary referral hospital.

Subjects and Methods

Salvage neck dissection specimens of 40 patients treated with (chemo)radiation were selected. LNs that contained viable tumor, reactive changes after initial treatment, and normal LNs were analyzed using immunohistochemically determined H-scores and by calculating sensitivity and specificity rates and positive/negative predictive values (PPVs/NPVs).

Results

EGFR expression was found in 86% and GPNMB expression in 100% of the LNs with viable tumor. VEGF expression was present in all lymph node types. For EGFR, the sensitivity rate was 86%, and specificity rate was 81%. For GPNMB, these were 100% and 75%, respectively. PPV of EGFR was 61.8% and NPV was 98.2%. These were 56.4% and 100% for GPNMB, respectively.

Conclusion

In residual or recurrent HNSCC lymph node metastases, both EGFR and GPNMB show tumor-specific expression in immunohistochemistry, which may prove useful in future molecular imaging in salvage neck dissections. Immunohistochemically detected VEGF expression indicates that this target is not feasible for imaging purposes in salvage surgery. Therefore, GPNMB could be a new potential imaging target showing comparable results to EGFR in immunohistochemistry.

Surgical nodal management in hypopharyngeal and laryngeal cancer

Objective

The aim of this study is to compare pre-therapeutic staging of the loco-regional lymphatic basin and subsequent surgical management in cN0 versus cN+ hypopharyngeal and laryngeal cancer patients.

Methods

We analyzed all hypopharyngeal and laryngeal carcinoma patients treated surgically at a single quaternary medical care and cancer center between 2004 and 2014. We established two groups for patients who underwent neck dissection comparing patients with a low LNR (lymph node ratio) to one with a high LNR. Regarding the cN0 cohort, elective neck dissection was evaluated as a secondary predictor variable. Comorbidities, such as anemia and renal insufficiency, were analyzed as potentially influencing disease-free (DFS) and overall survival (OS).

Results

A total of 310 patients (185 glottic and 125 supraglottic/hypopharyngeal carcinoma) were included. Pre-therapeutic neck MRI-/CT-scan and concomitant neck ultrasound revealed cN+ status in 144 patients resulting in a significant over-staging in 63 patients (44%) who were rated as being pN0 after histological examination. 166 patients were staged cN0 and 21 underwent elective neck dissection (11 local advanced glottic and 10 supraglottic/hypopharyngeal carcinoma). Two cN0 patients showed occult cervical lymph node metastases (10%). Furthermore, we could detect a significant negative impact of the LNR divided by the number of dissected lymph nodes and OS.

Conclusion

The pre-therapeutic clinical evaluation of lymphatic outgrowth is over-staged. OS decreases with increasing LNR divided by the number of dissected lymph nodes. Renal insufficiency and anemia are significant negative factors, decreasing both OS and DFS.

Surgical rescue for persistent head and neck cancer after first-line treatment

PURPOSE

Surgical rescue is a treatment option for persistent disease after first-line treatment treatment of head and neck cancer (HNC).

METHODS

Patients with persistent HNC treated with rescue surgery between 2008 and 2016 were included. Patients who received a rescue neck dissection (ND only) and who received primary site surgery ± ND were analysed separately (primary site surgery ± ND).

RESULTS

During the observation period, 35 patients received ND only and 17 primary site surgery ± ND. No perioperative mortality was observed. In nine patients with ND only and 12 patients with primary site surgery ± ND at least one complication was encountered. 41/52 (79%) patients had a complete response. Median overall survival of patients receiving rescue surgery was 56 months (95% CI 44-69 months). Median overall survival was best for patients with initial laryngeal and oropharyngeal cancer and worst for patients with hypopharyngeal cancer (p = 0.02). Functional deficits following rescue surgery were mainly observed in the domains speech, nutrition, and shoulder/arm mobility. The risk of functional impairment was higher for patients with rescue surgery at the primary tumor site (OR 2.5 ± 2; p = 0.07).

CONCLUSION

Rescue surgery offers patients with resectable, persistent disease a realistic chance to achieve long-term survival. Especially patients with laryngeal and oropharyngeal cancer profited from rescue surgery. Rescue neck dissection is an effective and safe procedure. Patients with rescue surgery at the primary tumor site ± ND should expect complications and permanent functional impairment.

Management of the irradiated N0-neck during salvage pharyngo-laryngeal surgery

BACKGROUND

Salvage surgeries are challenging procedures, with an associated poor prognosis. Management of the N0 neck in those situations remains controversial. We aim to compare oncologic outcomes regarding neck management after surgery for N0 pharyngo-laryngeal carcinoma occurring after loco-regional radiotherapy.

METHODS

We conducted a multicentric retrospective study, including all patients undergoing surgery for persistent, recurrent or new primary N0 carcinoma of the oropharynx, hypopharynx or larynx between 2005 and 2015, following loco-regional radiotherapy.

RESULTS

A total of 239 patients were included, concerning respectively 44%, 34% and 22% oropharyngeal, laryngeal and hypopharyngeal tumors operated. A neck dissection was performed in 143 patients (60%), with an occult nodal metastasis rate of 9%. This rate was higher for hypopharyngeal carcinomas (18%, p = 0.16) and tumors with initial nodal involvement (16%, p = 0.05). With a median follow-up of 60 months, the median overall survival (OS) and progression-free survival rates (PFS) were 34 months and 25 months. We identified negative margin excision status, age at the time of surgery (under 60) and delay between RT and surgery over 2 years as the only variables associated with better OS (p < 0.0001 and p = 0.004) and PFS (p < 0.0001 and p = 0.010) in multivariable analysis, with no difference regarding neck management. Regional progression (alone or with distant metastasis) was noted in 10 cases: 4 in the neck observation group (4%) versus 6 in the neck dissection group (4%).

CONCLUSION

Elective lymph node dissection of irradiated neck should not be routinely performed in patients undergoing surgery for persistent, recurrent or new primary pharyngo-laryngeal carcinomas.

Salvage surgery in head and neck cancer: Does it improve outcomes?

BACKGROUND

Studies reporting outcomes of salvage surgery in locally advanced head and neck squamous cell carcinoma (LAHNSCC) have inherent biases like biological and temporal selection. Our study considered all patients deemed fit for salvage surgery and compared to those who underwent surgery versus those who refused it thus throwing light on the real world benefit of salvage surgery.

METHODS

This was a post hoc analysis of a phase 3 randomized trial conducted between 2012 and 2018. Out of 536 LAHNSCC patients randomised in the study, 113 patients had residual disease or recurrent disease and were planned for salvage surgery in a multidisciplinary clinic. Patients were divided into 2 cohorts for comparison, willing for salvage surgery (n = 91) and unwilling for salvage surgery(n = 22). The primary endpoint was overall survival.

RESULTS

The median follow up was 28.7 months (95%CI 23.9-33.5 months). Out of the 91 patients who were willing for salvage surgery, 78 underwent same. The median survival in cohort of patients willing for salvage surgery was 22.0 months (95%CI 10.1-33.9) while it was 9.7 months (95%CI 6.6-12.8) in patients who were unwilling for salvage surgery (HR = 0.262 95%CI HR 0.147-0.469, p = 0.000).

CONCLUSION

Salvage surgery leads to a substantial improvement in outcomes in head and neck cancers and should be the de facto standard of care in patients who are eligible for the same.

Elective neck dissection (END) and cN0 hard palate and upper gingival cancers: A National Cancer Database analysis of factors predictive of END and impact on survival

BACKGROUND AND OBJECTIVES

The reported risk of nodal metastasis in hard palate and upper gingival squamous cell carcinoma (SCC) has been inconsistent with inadequate consensus regarding the utility of neck dissection in the clinically negative (cN0) neck.

MATERIALS AND METHODS

Using the National Cancer Database, cN0 patients diagnosed with SCC of the head and neck with the subsites of the hard palate and upper gingiva were identified from 2004 to 2014.

RESULTS

A total of 1830 patients were identified, and END was performed on 422 patients with cN0 tumors. Pathologically positive nodes occurred in 14% (59/422) of patients in this cohort. Higher tumor stage, academic hospital type, and large hospital volume (>28 cancer-specific cases/year) were associated with a higher likelihood of END both in univariate and multivariate analyses (P < .05). Patients >80 years of age were less likely to receive END on multivariate analysis (OR 0.52, 0.32-0.84). No variables, including advanced T stage, predicted occult metastases. Cox proportional hazards regression analysis showed that patients who underwent END demonstrated improved OS over an 11-year period (hazard ratio 0.75, P = .002). On subgroup analysis, this improvement was significant in patients with both stage T1 and T4 tumors.

CONCLUSIONS

Tumor stage, hospital type, and hospital volume were associated with higher rates of END for patients with cN0 hard palate SCC and after controlling for clinical factors, END was associated with improved overall survival.

[Neck dissection-Surgical treatment of cervical lymphatic drainage pathways]

Neck dissection (ND) is an essential component of treatment in head and neck squamous cell carcinoma (HNSCC). The extent of ND depends on primary tumor location and T and N stage. Trials have demonstrated improved survival for cN+ status with therapeutic ND as well as for cN0 status with selective ND if the primary has a high incidence of occult metastasis. The accuracy of the procedure is of prognostic relevance. In the prognostic model of the TNM classification, the parameter "N" does not only reflect the number of affected lymph nodes, but also their size and extranodal tumor extension. Due to its better prognosis, a positive human papillomavirus (HPV) status is also incorporated in the present TNM classification. In order to minimize morbidity after ND, one seeks to limit its extent without reducing survival time. To this aim, sentinel node biopsy or surveillance with positron-emission computed tomography (PET-CT) in cN0 necks or after primary radio(chemo)therapy are being investigated.

AHNS Series: Do you know your guidelines? Perioperative antithrombotic management in head and neck surgery

Head and neck surgeons are commonly faced with surgical patients who have underlying medical problems requiring antithrombotic therapy. It is difficult to achieve a balance between minimizing the risk of thromboembolism and hemorrhage in the perioperative period. Data from randomized, controlled trials are limited, and procedure-specific bleed rates are also difficult to pinpoint. The decision is made more difficult when patients with moderate-to-high risk for thromboembolic events undergo procedures that are high risk for bleeding. This is true for many head and neck oncologic surgeries. Furthermore, although elective procedures may be delayed for optimization of antithrombotic medication, emergent procedures cannot. Head and neck surgery often represents the most challenging of all these circumstances, given the potential risk of airway compromise from bleeding after head and neck surgery.