The Current Role of Salvage Surgery in Recurrent Head and Neck Squamous Cell Carcinoma

Abstract

Chemoradiotherapy has emerged as a gold standard in advanced squamous cell carcinoma of the head and neck (SCCHN). Because 50% of advanced stage patients relapse after nonsurgical primary treatment, the role of salvage surgery (SS) is critical because surgery is generally regarded as the best treatment option in patients with recurrent resectable SCCHN. Surgeons are increasingly confronted with considering operation among patients with significant effects of failed non-surgical primary treatment. Wide local excision to achieve clear margins must be balanced with the morbidity of the procedure, the functional consequences of organ mutilation, and the likelihood of success. Accurate selection of patients suitable for surgery is a major issue. It is essential to establish objective criteria based on functional and oncologic outcomes to select the best candidates for SS. The authors propose first to understand preoperative prognostic factors influencing survival. Predictive modeling based on preoperative information is now available to better select patients having a good chance to be successfully treated with surgery. Patients with a high comorbidity index, advanced oropharyngeal or hypopharyngeal primary tumors, and both local and regional recurrence have a very limited likelihood of success with salvage surgery and should be strongly considered for other treatments. Following SS, identifying patients with postoperative prognostic factors predicting high risk of recurrence is essential because those patients could benefit of adjuvant treatment or be included in clinical trials. Finally, defining HPV tumor status is needed in future studies including recurrent oropharyngeal SCC patients.

Outcome in patients with isolated regional recurrence after primary radiotherapy for head and neck cancer

“…Even in experienced surgical teams, the likelihood of achieving clear surgical margins must be balanced with the morbidity of the procedure, as the complication rates can be high and the side effects can be severe 9 . About half of the patients with local and/or regional recurrences are suitable for salvage treatment, 4,10 but the majority of patients experience renewed progression and ultimately failure, consistent with a 5‐year overall survival (OS) of 21% to 61% 11 . A number of factors have been associated with a successful outcome of salvage treatment, including low primary T‐classification, 7,12,13 disease‐free interval greater than one year, 14 and tumor located in the larynx 15,16 .…”

High-risk pathological features at the time of salvage surgery predict poor survival after definitive therapy in patients with head and neck squamous cell carcinoma

“…We assessed for common patient factors known to influence survival in patients undergoing salvage therapy including comorbidities using Charlson Comorbidity Index[10] minor and major surgical complications [11] adjuvant treatment including radiation after salvage, and type of salvage surgery performed. The average Charlson Comorbidity Score was 4.5 with a median score of 4.…”

Current Role of Surgery in the Management of Oropharyngeal Cancer

“…Despite the changing role of surgery in the last two decades, it remains the backbone of salvage therapy for recurrent OPSCC. Although the emergence of organ preservation strategies has decreased the role of primary surgery in advanced OPSCC, up to 60% of patients with advanced-stage tumors still develop recurrent disease and thus surgery is generally considered the treatment of choice for resectable tumors (64). However, because the vast majority of patients with OPSCC receive radiation therapy (either primary or adjuvant) at some point in their treatment, the sequelae associated with this treatment pose many challenges for successful salvage surgery, including tissue edema, necrosis, and chondritis.…”

“…However, because the vast majority of patients with OPSCC receive radiation therapy (either primary or adjuvant) at some point in their treatment, the sequelae associated with this treatment pose many challenges for successful salvage surgery, including tissue edema, necrosis, and chondritis. Patients treated with prior radiotherapy have more postoperative complications after salvage surgery and poorer wound healing (64).…”