Salvage Surgery with Free Flap Reconstruction: Factors Affecting Outcome After Treatment of Recurrent Head and Neck Squamous Carcinoma

Abstract

Patients with recurrent T1 and T2 class are the best candidates for salvage surgery and microvascular flap reconstruction for treatment of recurrent SCC of the head and neck. Patients with T3 and T4 class recurrent cancers and patients who continue to smoke after initial diagnosis and treatment of head and neck SCC are poor candidates to undergo salvage surgery.

When is reoperative surgery not indicated for recurrent head and neck squamous cell carcinoma?

“…In the meta-analysis of Goodwin [1], patients with rT4 recurrence had median cancer-specific survival of 9.3 months and median disease-free survival after salvage surgery of just 5.5 months. Similarly, in the study of Kim et al [6] the average disease-free time interval was 7 months in patients with advanced T classifications (T3-T4). These findings demonstrate the poor outcomes for the majority of these individuals, although many studies do not distinguish between types of previous treatment.…”

“…Although surgical reconstruction of large pharyngeal defects has become increasingly possible over the past several decades because of advances in microvascular reconstructive techniques, the results of surgical salvage for pharyngeal carcinomas have remained poor. Approximately two-thirds of patients develop a second recurrence on average 9 months after salvage resection [6,8]. Moreover, tissue damage induced by previous therapy with intense fibrosis and reduced vascularity may interfere with subsequent salvage surgery and repair of tissue defects, leading to a high incidence of perioperative M. N. Elsheikhmorbidity.…”

“…This may be difficult to achieve in previously irradiated patients as the extent of disease may be difficult to evaluate even with ''state of the art'' imaging studies. Although recent advances in reconstructive procedures have increased the feasibility of larger resections for recurrent HNSCCs, these procedures are associated with significant morbidity [1,6,7] and economic costs [1,8]. These issues are important in consideration of cost-effectiveness.…”

“…In these circumstances quality of life issues usually become the patient's main primary concerns. Quality of life often declines precipitously immediately after major surgery for treatment of HNSCC, and frequently takes a full year to recover to preoperative level [1,6,9]. In patients with limited life expectancy, these issues should be considered in the decisions on treatment so as to restrict reoperative procedures to patients who may achieve meaningful survival.…”

“…Patients with poor performance status may be unable to endure salvage surgery and subsequent morbidity, even if their tumors are technically curable. In addition, the presence of comorbidities, preexisting organ dysfunction, poor cognitive function, lack of social support, low reported quality of life, and continued tobacco/alcohol use are adverse prognostic factors [1,4,6,8,17].…”