Salvage surgery in head and neck cancer

Salvage transoral robotic surgery in recurrent oropharyngeal carcinoma: a single-center retrospective study

PURPOSE

Salvage surgery is still the best therapeutic option for resectable recurrent oropharyngeal squamous cell carcinoma (rOPSCC). Transoral robotic surgery may potentially reduce the morbidity of standard open approaches. The aim of the study is to present oncological and functional outcomes of a monocentric experience in salvage transoral robotic surgery.

METHODS

We performed a single-center retrospective analysis of patients submitted to transoral robotic salvage surgery with or without neck dissection for cT1-3 rOPSCC. We investigated complication rate, survival outcomes (Overall Survival, Disease Specific Survival, Loco-Regional Recurrence Free Survival) and functional outcomes (tracheal tube and/or gastrostomy dependence).

RESULTS

Sixty-one patients were included in the analysis. No major complications or perioperative deaths were recorded. The estimated 2-year OS was 76.7%, DSS 81.8% and LRRFS 50.5%. In multivariable analysis rpT, PNI (perineural infiltration) and HPV-positivity were significantly associated with LRRFS (Hazard Ratios: T3 vs T1 6.43, PNI yes vs no 4.19, HPV+ yes vs no 2.63). At last follow up, 97% of patients were tracheal tube-free, while 93% were gastrostomy-free.

CONCLUSION

Transoral robotic salvage surgery is a successful treatment in selected patients affected by rOPSCC because it grants good oncologic and functional outcomes.

Effect of radiation therapy on lymph node fluorescence in head and neck squamous cell carcinoma after intravenous injection of indocyanine green: a prospective evaluation

BACKGROUND

Indocyanine green (ICG)-guided surgery has proven effective in the identification of neoplastic tissues. The effect of radiation therapy (RT) on lymph node fluorescence after intravenous injection of ICG has not been addressed yet. The objective of this study was to evaluate the influence of RT on node fluorescence during neck dissection in head and neck squamous cell carcinoma (HNSCC).

RESULTS

Twenty-four patients with planned neck dissection for HNSCC were prospectively enrolled. Eleven were included without previous radiation therapy and 13 after RT. ICG was intravenously administered in the operating room. The resected specimen was analyzed by the pathology department to determine the status of each resected lymph node (invaded or not). The fluorescence of each resected node was measured in arbitrary units (AU) on paraffin blocs. The surface area (mm2) of all metastatic nodes and of the invaded component were measured. The values of these surface areas were correlated to fluorescence values. A total of 707 nodes were harvested, the mean fluorescence of irradiated nodes (n = 253) was 9.2 AU and of non-irradiated nodes (n = 454) was 9.6 AU (p = 0.63). Fifty nodes were invaded, with a mean fluorescence of 22 AU. The mean fluorescence values in the invaded irradiated nodes (n = 20) and the invaded non-irradiated nodes (n = 30) were 19 AU and 28 AU (p = 0.23), respectively. The surface area of metastatic nodes and of the invaded component were correlated to fluorescence values even after previous RT (p = 0.02).

CONCLUSION

No differences were observed between the fluorescence of irradiated and non-irradiated lymph nodes, including invaded nodes. ICG-guided surgery can be performed after failed RT.

TRIAL REGISTRATION

EudraCT ref. 2013-004498-29, registered 29 November 2013. https://www.clinicaltrialsregister.eu/ctr-search/search?query=2013-004498-29.

An academic achievements visualization research since the 21st century: research on salvage surgery for head and neck cancer

Background

Head and neck cancer is the 6th most common malignancy worldwide, and its incidence is still on the rise. The salvage surgery has been considered as an important treatment strategy for persistent or recurrent head and neck cancer. Therefore, we conducted a bibliometric analysis of salvage surgery for head and neck cancer since the 21st century.

Methods

The literature about salvage surgery of head and neck cancer in Web of Science was searched. CiteSpace and VOSviewer were used to analyze main countries, institutions, authors, journals, subject hotspots, trends, frontiers, etc.

Results

A total of 987 papers have been published since the 21st century. These publications were written by 705 authors from 425 institutions in 54 countries. The United States published 311 papers in this field and ranked first. Head & Neck was the most widely published journal. The main keyword clustering included terms such as #0 stereotactic radiotherapy (2012); #1 randomized multicenter (2007); #2 salvage surgery (2004); #3 functional outcomes (2014); #4 transoral robotic surgery (2013); #5 neck high-resolution computed tomography (2010); #6 complications (2008); #7 image guidance (2019). The current research frontiers that have been sustained are "recurrent", "risk factors", and "reirradiation".

Conclusion

The current situation of the salvage surgery for head and neck cancer in clinical treatments and basic scientific research were summarized, providing new perspectives for the development of salvage surgery for head and neck cancer in the future.

Oncological and functional outcomes for transoral robotic surgery following previous radiation treatment for upper aerodigestive tract head and neck cancers. A French multicenter GETTEC group study

BACKGROUND

Transoral robotic surgery (TORS) opens new perspectives. We evaluated the outcomes for patients having undergone TORS after previous radiotherapy.

METHODS

A retrospective multicenter study (n = 138) in a previously irradiated area between 2009 and 2020. Survival was assessed with the Kaplan-Meier method. Prognostic factors were evaluated using a chi-squared test, Fisher's test, or Wilcoxon's test.

RESULTS

The median length of hospital stay was 12.5 days. Bleeding was the most frequent postoperative complication (15.2%, n = 22). Prophylactic vessel ligation did not significantly decrease bleeding. Complications were significantly lower for Tis, T1, and N0 tumors. 91.6% (n = 120) of the patients with a perioperative tracheotomy could be decannulated. Larynx was functional for 65.94% of the patients. The median length of follow-up was 26 months. The 5-year overall and relapse-free survival rates were respectively 59.9% and 43.4%.

CONCLUSION

Oncological and functional results confirmed the value of TORS as a treatment in previously irradiated area.

Results of salvage neck dissection after chemoradiation in locally advanced head and neck squamous cell carcinoma

PURPOSE

Salvage surgery is mandatory when regional persistence/recurrence after chemoradiation. The aim of this study is to describe the outcomes of salvage surgery.

METHODS

A retrospective study was conducted in patients with locally advanced head and neck squamous cell carcinoma that were primarily treated with chemorradiation and underwent salvage neck dissection (ND) with suspected recurrent/persistent nodal disease. All patients had a response evaluation at 12 weeks through clinical examination and computed tomography-positron emission tomography. Decision for ND was taken in case of suspected persistence or if there was suspicion of recurrence, histologically confirmed.

RESULTS

There were 40 patients included. 32/40 (80%) ND were done because of confirmed/suspected persistence and 8/40 (20%) were done because of recurrences. Persistence was confirmed histologically in 14/32 (43.8%) cases and recurrence in 6/8 (75%) cases. Median survival from diagnosis was 39 months (95% CI 28.162-49.838). Significant differences were observed between patients who had viable tumour cells in the sample and those who did not, but the differences were only significant when only deaths due to tumour progression were considered (p = 0.014). 14/32 (43.8%) patients with suspected or confirmed persistence developed a recurrence after the ND and 3/8 (37.5%) patients with suspected or confirmed recurrence developed a new recurrence. New recurrences were more frequent in cases that had viable tumor in the specimen.

CONCLUSIONS

Patients with nodal persistence/recurrence have a poor prognosis, even after salvage surgery. However, in a substantial number of patients the disease is controlled after ND, so it should be offer to these patients.

Algorithms of follow-up in patients with head and neck cancer in relation to primary location and advancement. Consensus of Polish ENT Society Board and Head Neck Experts

Summary

The algorithm of follow-up in patients with head and neck cancer (HNC) has been prepared by a board of Polish Head Neck and Oncology Experts. The aim of this research is to focus on the specificity of HNC monitoring, to review the current trends in follow-up, and to adapt the evidence-based medicine international standards to the capabilities of the local healthcare service.

Materials and methods

The first methodological step was to categorize HNCs according to the estimated risk of failure after the adequate first-line treatment and according to the possibility of effective salvage treatment, resulting in improved overall survival. The final method used in this work was to prepare an authors' original monitoring algorithm for HNC groups with a high, moderate, and low risk of recurrence in combination with a high or low probability of using an effective salvage.

Results

Four categories were established: Ia. low risk of recurrence + effective organ preservation feasible; Ib. low risk of recurrence + effective salvage feasible; II. moderate risk of recurrence + effective salvage feasible; III. high risk of recurrence + effective salvage feasible; and IV. high risk of recurrence + no effective salvage feasible. Follow-up visit consisting of 1. ENT examination + neck ultrasound, 2. imaging HN tests, 3. chest imaging, 4. blood tests, and 5. rehabilitation (speech and swallowing) was scheduled with a very different frequency, at the proposed monthly intervals, tailored to the needs of the group. The number of visits for individual groups varies from 1 to 8 in the first 2 years and from 1 to 17 in the entire 5-year monitoring period. Group IV has not been included in regular follow-up, visits on own initiative of the patient if symptomatic, or supportive care needs, having in mind that third-line therapy and immune checkpoint inhibitors are available.

Conclusion

Universal monitoring algorithm for HNC four groups with a high, moderate, and low risk of recurrence after the adequate treatment in combination with a high or low probability of using an effective salvage is an innovative approach to redeploying system resources and ensuring maximum benefit for patients with HNC.

Elective Revision Surgery in Head and Neck Cancer Patients: A Retrospective Analysis at an Oncology Centre in Porto, Portugal

Introduction Elective revision surgery in head and neck cancer is crucial for refining and optimizing outcomes, ensuring complete tumor removal, and enhancing both functional and aesthetic aspects, ultimately improving the overall quality of life for patients. The aim of this study is to analyze the overall survival (OS) of head and neck cancer patients who underwent elective revision surgery with or without adjuvant treatment between 2019 and 2022, reflecting on the practice between those years in IPO-Porto, Porto, Portugal. Methods This study included 58 patients who underwent 116 major neck surgeries. Multidisciplinary head and neck follow-up records were obtained for every patient. Overall survival and disease-specific survival (DSS) curves were calculated using the Kaplan-Meier method, and statistical significance was determined by the Log-Rank test. We did a retrospective study with an anterograde direction, evaluating the treatments that were previously done by the patients. Results The sample comprised 51 males (87.9%) and seven females (12.1%), with a mean age of 59.02±11.014 years. Head and neck pathology was mostly in the larynx (36.2%). The type of the first surgery was mainly directed to the primary tumor in 62.1% (n=36). In the other 37.9% (n=22), surgery was directed to the primary tumor in association with neck dissection. The type of the second surgery was mainly revision surgery. We found that T4 tumors (HR (hazard ratio) = 10.219, p = 0.006) and hypopharynx tumors (HR = 5.306, p =0.035) were significantly associated with inferior OS. Conclusion In our sample, we found that a T4 and a tumor located in the hypopharynx were significantly associated with inferior OS in elective head and neck oncologic revision surgery. Disease-free survival in patients undergoing revision surgery in our sample is generally poor. In our sample, there was a statistically significant difference in overall survival between the group who underwent surgery for microscopic evidence of persistent tumor (R1) versus clinical and imagiological tumoral persistency. In our sample, the time between the first and second surgeries wasn't linked with an inferior OS. Further studies with larger populations and prospective design, with longer follow-ups can be the road to a better understanding of this issue.

Impact of Salvage Surgery on Health-Related Quality of Life in Oral Squamous Cell Carcinoma: A Prospective Multi-Center Study

BACKGROUND

Patients with recurrent oral squamous cell carcinoma (OSCC) have limited treatment options. Salvage surgery offers potential curative therapy. The need for extensive ablative surgery together with microvascular reconstruction implies invasive and painful treatment with questionable functional outcome. To address the impact of salvage surgery on the health-related quality of life (HRQoL) of patients suffering from recurrent OSCC, a multi-center prospective analysis was initiated.

MATERIAL AND METHODS

Patients with recurrent OSCC from 2015 to 2022 at two German cancer centers were included. Interdisciplinary tumor board decisions determined surgery as the only curative treatment modality. HRQoL, was assessed via a EORTC questionnaire (European Organization for Research and Treatment of Cancer-EORTC: QLQ-C30 and QLQ-H&N35) in dependence of the recurrent tumor stage. Patients completed the questionnaires once before surgery (baseline) and then every 3 months during follow-up or up to the end of treatment.

RESULTS

In total, 55 patients were included. The mean follow-up period was 26.7 ± 19.3 months. Global health status showed superior mean scores after 12 months (60.83 ± 22.58) compared to baseline (53.33 ± 26.41) in stage 1 and 2 recurrent tumors. In advanced recurrent tumors' mean scores for global health showed only minor positive differences after 12 months (55.13 ± 22.7) compared to baseline (53.2 ± 25.58). In terms of the mouth pain, mean scores were lower after salvage surgery in small recurrent tumors after 12 months (20.37 ± 17.73) compared to baseline (41.67 ± 33.07; Wilcoxon two-sample signed-rank test p = 0.028). In advanced recurrent tumors, a significant reduction in mean scores was detected 3 months after salvage surgery (29.7 ± 22.94) compared to baseline (47.76 ± 25.77; Wilcoxon two-sample signed-rank test p = 0.003). Up to 12 months, swallowing function was evaluated inferior compared to baseline independent of tumor stage (Mean score recurrent stage I/II: 12-months 48.15 ± 27.57, baseline 28.7 ± 22.87; stage III/IV: 12-months 49.36.42 ± 27.53; baseline 30.13 ± 26.25).

CONCLUSION

Improved HRQoL could be obtained in advanced recurrent OSCC after salvage surgery despite reduced swallowing function. In small recurrent tumors, overall, HRQoL was superior to baseline. Salvage surgery positively affected pain burden. For advanced recurrent tumors, important pain relieve could be observed as soon as 3 months after surgery.

Performance of Neck Imaging Reporting and Data System (NI-RADS) for Diagnosis of Recurrence of Head and Neck Squamous Cell Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The Neck Imaging Reporting and Data System (NI-RADS) is a reporting template used in head and neck cancer posttreatment follow-up imaging.

PURPOSE

Our aim was to evaluate the pooled detection rates of the recurrence of head and neck squamous cell carcinoma based on each NI-RADS category and to compare the diagnostic accuracy between NI-RADS 2 and 3 cutoffs.

DATA SOURCES

The MEDLINE, Scopus, and EMBASE databases were searched.

STUDY SELECTION

This systematic review identified 7 studies with a total of 694 patients (1233 lesions) that were eligible for the meta-analysis.

DATA ANALYSIS

The meta-analysis of pooled recurrence detection rate estimates for each NI-RADS category and the diagnostic accuracy of recurrence with NI-RADS 3 or 2 as the cutoff was performed.

DATA SYNTHESIS

The estimated recurrence rates in each category for primary lesions were 74.4% for NI-RADS 3, 29.0% for NI-RADS 2, and 4.2% for NI-RADS 1. The estimated recurrence rates in each category for cervical lymph nodes were 73.3% for NI-RADS 3, 14.3% for NI-RADS 2, and 3.5% for NI-RADS 1. The area under the curve of the summary receiver operating characteristic for recurrence detection with NI-RADS 3 as the cutoff was 0.887 and 0.983, respectively, higher than 0.869 and 0.919 for the primary sites and cervical lymph nodes, respectively, with NI-RADS 2 as the cutoff.

LIMITATIONS

Given the heterogeneity of the data of the studies, the conclusions should be interpreted with caution.

CONCLUSIONS

This meta-analysis revealed estimated recurrence rates for each NI-RADS category for primary lesions and cervical lymph nodes and showed that NI-RADS 3 has a high diagnostic performance for detecting recurrence.

EGFR-targeted fluorescence molecular imaging for intraoperative margin assessment in oral cancer patients: a phase II trial

Inadequate surgical margins occur frequently in oral squamous cell carcinoma surgery. Fluorescence molecular imaging (FMI) has been explored for intraoperative margin assessment, but data are limited to phase-I studies. In this single-arm phase-II study (NCT03134846), our primary endpoints were to determine the sensitivity, specificity and positive predictive value of cetuximab-800CW for tumor-positive margins detection. Secondary endpoints were safety, close margin detection rate and intrinsic cetuximab-800CW fluorescence. In 65 patients with 66 tumors, cetuximab-800CW was well-tolerated. Fluorescent spots identified in the surgical margin with signal-to-background ratios (SBR) of ≥2 identify tumor-positive margins with 100% sensitivity, 85.9% specificity, 58.3% positive predictive value, and 100% negative predictive value. An SBR of ≥1.5 identifies close margins with 70.3% sensitivity, 76.1% specificity, 60.5% positive predictive value, and 83.1% negative predictive value. Performing frozen section analysis aimed at the fluorescent spots with an SBR of ≥1.5 enables safe, intraoperative adjustment of surgical margins.

The Lack of Standardized Outcomes for Surgical Salvage of HPV-Positive Recurrent Oropharyngeal Squamous Cell Carcinoma: A Systematic Scoping Review

Although HPV status is known to provide an improved prognosis in initial treatments of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC), it is unclear how it affects patients who receive salvage surgery (SS), which has historically poor survival rates. The purpose of this study was to evaluate the role of SS for patients with locoregional recurrence (LRR) of HPV-positive OPSCC and its impact survival rates. We conducted a scoping review of literature through October 2022 and included 995 individuals. Survival endpoints, such as overall survival (OS), Kaplan-Meier curves, and median post-recurrence survival, were analyzed in addition to demographics. Of all studies, 18.8% (6/32) reported any survival data for SS patients, with the most prevalent reporting 2- and 5-year OS in two studies. Median post-recurrence survival was not reported for SS. These findings reveal the limited and unpredictable reporting of survival-specific data on SS for HPV-positive OPSCC. With limited survival assessment, it is difficult to assess the potential advantages and disadvantages of this therapy to guide clinical decision-making.

Functional Outcomes After Transoral Plus Lateral Pharyngotomy Approach for Advanced Oral and Oropharyngeal Tumors

Objective

The aim of this study was to evaluate our institutional experience with the combined transoral plus lateral pharyngotomy (TO+LP) approach in a subset of patients with advanced or recurrent oral and oropharyngeal malignancy.

Study Design

A retrospective study of procedures utilizing TO+LP for cancer resection between January 2007 and July 2019.

Setting

Tertiary academic medical center.

Methods

Thirty-one patients underwent a TO+LP approach for the resection of oral and oropharyngeal tumors. Functional and oncologic outcomes were analyzed.

Results

Eighteen (58.1%) patients were treated with TO+LP for recurrent disease. Twenty-nine required free tissue transfer and 2 (6.5%) had positive margins. The median time to decannulation was 22 days (range 6-100 days). Thirteen (41.9%) patients still required enteral feeding at their most recent follow-up. Patients without a history of prior radiation were decannulated sooner (p = .009) and were less likely to require enteral feeding at the first postoperative follow-up (p = .034) than those who had prior head and neck radiotherapy.

Conclusion

A TO+LP approach can be used to achieve good functional and oncologic results for selected patients with advanced or recurrent oral and oropharyngeal cancer when minimally invasive options such as transoral robotic surgery, transoral laser microsurgery, or radiotherapy are not possible.

A retrospective study on unresectable or inoperable head and neck cancers treated with stereotactic ablative brachytherapy

Purpose

The aim of the present study was to assess the clinical efficacy and safety of stereotactic ablative brachytherapy (SABT) for unresectable or inoperable head and neck cancers.

Material and methods

This study retrospectively assessed clinical data of 37 patients with unresectable or inoperable head and neck cancers treated with SABT from October 2016 to October 2021. Variables evaluated included local efficacy, local control rate (LCR), overall survival (OS) rate, and radiological adverse effects.

Results

The median follow-up was of 34 months (range, 5-59 months), and LCR at 6, 12, and 24 months was 89.2%, 78.2%, and 69.4%, respectively. The median survival time was 16 months [95% confidence interval (CI): 10.5-21.5 months], and the OS rate at 6, 12, and 24 months was 97.3%, 70.3%, and 34.5%, respectively. The results of univariate analysis revealed that the type of pathology and gross tumor volume (GTV) D₉₀ were related to LCR (p < 0.05). However, the type of pathology, GTV D₉₀, age, and implantation site were related to OS rate (p < 0.05). The results of multivariate analysis showed that the type of pathology and GTV D₉₀ were substantially related to LCR and OS rate (p < 0.05). The evaluation of post-operative radiological adverse reactions revealed that seven cases (18.9%) developed grade 1-2 skin reactions, four cases (10.8%) developed grade 1-2 oral mucosal outcomes, and no cases developed grade 3 or higher adverse reactions. Post-operative seed dislocation occurred in three patients with tongue cancer.

Conclusions

SABT has produced good local control and mild adverse reactions in the treatment of unresectable or inoperable head and neck cancers. Additionally, it is safe, feasible, minimally invasive, and has fewer adverse effects than other treatment modalities.

Prognostic factors in salvage surgery for recurrent head and neck cancer: A systematic review and meta-analysis

INTRODUCTION

Although salvage surgery (SS) is considered the best curative choice in recurrent head and neck cancer, the identification of patients who can benefit the most from this treatment is challenging.

METHODS

We systematically reviewed the prognostic role of pre- and post-surgery factors in patients undergoing SS for recurrent head and neck cancer (oral cavity, oropharynx, hypopharynx, and larynx).

RESULTS

Twenty-five studies met the inclusion criteria out of 1280 screened citations. Pre-surgery factors significantly associated with worse overall survival were age>60 years, advanced initial stage, early recurrence, and regional recurrence; no heterogeneity between study emerged. Among post- surgery factors, worse survival emerged for positive surgical margins, extracapsular extension and perineural invasion.

CONCLUSION

The identification of pre-surgery factors associated with poor outcomes may help the selection of the best candidate to SS; alternative treatments should be considered for high-risk patients. Post-surgery predictors of worse prognosis may guide clinicians in tailoring patients' surveillance.

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.

Full-Thickness Tumor Resection of Oral Cancer Involving the Facial Skin-Microsurgical Reconstruction of Extensive Defects after Radical Treatment of Advanced Squamous Cell Carcinoma

Simple Summary

Advanced malignant tumors of the oral cavity are challenging because they impose serious oncological and functional requirements on the treatment specialist. Depending on the localization and the extent of the primary tumor, a full-thickness resection affecting the facial skin may be necessary to achieve a complete tumor resection. The resulting defects need adequate reconstruction in order to restore the aesthetics and functionality of the orofacial system. In this retrospective analysis, the authors aimed to evaluate treatment techniques for these tumors and analyze the clinical outcome of the related procedures. Full-thickness tumor resection with free flap reconstruction due to advanced cancer was performed in 33 patients.

Abstract

Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.

Salvage surgery in head and neck cancer

Salvage surgery after failed organ preservation treatment offers challenges for both the patient and the surgeon. The outcome is often uncertain and even today, 5‐year overall survival does not exceed 50 per cent. The chemoradiotherapy induced toxicity asks for meticulous discussion and planning in a multidisciplinary manner in a changing environment of increasing incidence of human papillomavirus induced oropharyngeal tumours, evolving surgical techniques and patient participation. Herein, we discuss the latest literature on salvage surgery and the need for identifying the proper prognosticators to ensure for an optimal treatment plan in potentially salvageable patients.