Salvage Surgery for Recurrent Nasopharyngeal Carcinoma

Abstract

Objective: To evaluate the efficacy of salvage surgery in the treatment of recurrent nasopharyngeal carcinoma (NPC) at the primary site. Study Design: A retrospective investigation of the outcome of salvage surgery for 28 patients with recurrent NPC after definite radiation therapy. Methods: The nasopharynx was approached anteroposteriorly by the transmaxillary approach (maxillary swing, maxillectomy) or inferior approach (midline mandibulotomy or median labiomandibular glossotomy), or laterally by modified facial translocation or transpterygoid approach; intentional ligation of the internal carotid artery was performed after establishment of extracranialintracranial (EC-IC) bypass in one patient; postoperative irradiation was given to the patients with positive pathological margins. Results: Nine patients lived without disease for 20 to 93 months (mean interval, 52 mo) after surgery; among them, eight patients had T1 tumors that were resected totally by surgery via anteroposterior approaches and the other patient had postoperative irradiation to control the disease. Seven patients had local recurrence 8 to 21 months after treatment. Four patients developed distant metastases, including one patient with a T2b tumor that was totally resected through modified facial translocation approach with ligation of internal carotid artery. Eight patients died of other causes; internal carotid artery blowout was the cause of death in four of these eight patients. Conclusions: In most cases of recurrence, T1 nasopharyngeal tumors can be resected totally by anteroposterior approaches; for T2 or larger tumors, postoperative irradiation is usually necessary. Otherwise, facial translocation offers a better chance to completely resect the tumors. Internal carotid artery is better ligated if patients have received greater than 70 Gy irradiation or if the artery must be exposed during the surgery. We suggest that EC-IC bypass be used to avoid the possible complications (or cerebral ischemic stroke) caused by ligation of internal carotid artery. The transmaxillary approach is favored in the management of nasopharyngeal tumor recurrence with nasal cavity extension, and midline mandibulotomy is more suitable for resection of posterior margin of nasopharyngeal tumor recurrence. Facial translocation offers the widest operative field and is the most versatile approach for radical resection of nasopharyngeal tumor recurrence, but the surgeon should be skilled in the management of the facial nerves to reduce morbidity.

Endoscopic nasopharyngectomy for locally recurrent nasopharyngeal carcinoma

“…This narrowness can give a false impression that radical endoscopic nasopharyngectomy would be a challenging operation. 6 Actually, since the nasopharynx is relatively spacious and is surrounded primarily by solid bone, it is possible to endoscopically dissect nasopharyngeal tissue, including nasopharyngeal malignancies, along the surface of the bone without injuring any adjacent important organs during the surgery. The present study demonstrates that radical resection of nasopharyngeal malignancies is feasible with the guidance of endoscopy.…”

“…Consequently, resurfacing the nasopharynx and covering the internal carotid artery in a reliable way is required during nasopharyngectomy. 6 Recently, stereotactic navigation guidance was employed during nasopharyngectomy to locate the internal carotid artery bilaterally without surgical exposure, presenting a promising display technique. 14,15 In our study, the deep part of the eustachian tube was used as an anatomical marker of the anterior boundary of the internal carotid artery, and the tumors were dissected anteromedially to the deep part of the eustachian tube which is constantly located in about 0.5 cm anteromedially the internal carotid artery.…”

“…2 Currently, a combination of radiotherapy and chemotherapy remains the standard treatment for new, previously untreated NPC patients, with curative nasopharyngectomy being one of the most effective salvage treatments for patients with locally recurrent NPC (rNPC) following radical radiotherapy. [3][4][5][6][7] However, the nasopharynx is a deep and stenotic structure surrounded by solid bone and adjoined to many important organs. With conventional extranasal surgical approaches, the nasopharynx is exposed by freeing peripheral bone, a procedure resulting in potential risks for functional disability and treatment-related complications.…”

Coronoidectomy in maxillary swing for reducing the incidence and severity of trismus – a reminder

“…Wei et al (1991) popularized this procedure initially used for resection of recurrent nasopharyngeal carcinoma (Wei et al, 1995;King et al, 2000;Shu et al, 2000) and later for other tumours in and around the nasopharynx (Wei et al, 1995).…”

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“…The reconstructive ladder in general begins with healing by secondary intension (granulation tissue) followed by primary closure, skin grafts, local flaps, regional flaps, and microvascular free flaps [21][22][23][24][25][26][27][28][29][30]. In recurrent head and neck cancer surgery, the resulting defect is usually large and complex.…”