Surgery for Recurrent Disease
Surgery has shifted from being a primary modality for the treatment of oropharynx and larynx cancer to being a salvage modality for recurrent disease. More patients are being treated with radiation or chemoradiation, and this is especially so in U.S. tertiary centers, said Randal Weber, MD, professor and department chair of head and neck surgery at M.D. Anderson Cancer Center. "So it's important that we select our patients very carefully for salvage, and that we appropriately apply the resources to care for these patients, because it can be quite intensive getting them through this safely," he said.
When it comes to salvage surgery, the pro is the results while the con is that many patients are not even eligible. Dr. Weber outlined the checklist he goes through to decide if a patient can undergo surgery.
Presented by DR. RANDAL WEBER
|•||Candidates for favorable surgical salvage should have a disease-free interval after initial therapy and no recurrent neck disease.|
|•||Tumors must be completely extricated on salvage surgery because margins can impact long-term disease control.|
|•||For patients with recurrent laryngeal cancer after radiation or chemoradiation, surgical resection is preferable to re-irradiation. For recurrence in the oropharynx, re-irradiation is generally the first line of treatment.|
"Performance status here is very important," he said. "You really must exclude patients with serious, comorbid conditions. These operations are associated with a 3% to 5% mortality rate, prolonged hospitalization, and wound problems." Another issue to consider is cure vs palliation: Surgery may extend survival but patients may also experience functional problems such as difficulties with swallowing and speech, he said.
Also, can the disease be completely resected? "Do not do debulking procedures. If you don't think that you can completely resect the tumor with microscopically clear margins, you're not going to achieve a long-term disease control in those patients," Dr. Weber said.
Finally, consider whether the patient will require reconstruction. The majority of patients will need reconstruction so the plastic surgeon should be consulted preoperatively. "The emphasis here is that these patients really need a multidisciplinary approach, and we frequently present them in our tumor conference before we embark on the salvage," he said.
A retrospective review by Mark E. Zafereo, MD, Dr. Weber, and colleagues, looked at 1,681 patients of which 199 had locally or recently recurrent disease without distant metastasis. Only 41 of these were considered candidates for surgical salvage, Dr. Weber explained.
The patients who were recommended for surgery tended to have a longer disease-free interval, early primary tumor stage, and early recurrent tumor and overall stage (Cancer 115:5723-5733, 2009). "So you can see that the overall recurrence rate after we treat oropharyngeal cancer is fairly low, and in those that do recur locally, only a small fraction are even considered for surgery," he said.
Dr. Weber led the RTOG trial 91-11, and in a secondary analysis, the researchers sought to determine the success of salvage for persistent disease or recurrence following organ preservation therapy, determine the impact of initial treatment modality, and assess the morbidity and mortality of salvage surgery. The trial had three arms: treatment with cisplatin(Drug information on cisplatin)/5-FU, followed by surgery and/or radiation therapy for nonresponders (arm I); radiotherapy with concurrent cisplatin (arm II); or radiation therapy alone (arm III).
Of the 517 patients, 25% underwent salvage laryngectomy. Of this group, 5% experienced toxicity that required laryngectomy, while 95% had the procedure for recurrence or persistent disease (Arch Otolaryngol Head Neck Surg 129:44-49, 2003).
Dr. Weber called attention to the laryngectomy group. Survival was lower for patients who had salvage surgery than for those who remained continuously disease free at the primary site.
In the trial, the disease control rate of salvage laryngectomy was 56% in arm I, 72% in arm II, and 69% in arm III. Local-regional control was achieved in 74% of patients in arms I and II, and 90% of those in arm III. After the first failure requiring laryngectomy, there was a 10% decrement in survival.
"If you select the wrong [initial] treatment for the patient, if you try to extend organ preservation to those who perhaps aren't candidates (those with major tongue invasion, gross cartilage destruction, tumor in the soft tissues), they are more likely to fail," he said. "And when they do fail, they're going to trade off about a 10% chance for survival vs laryngectomy alone."
Complications in RTOG 91-11 included a high rate of pharyngocutaneous fistula although the figures were was not outside the norm: 25% in arm I, 29.6% in arm II, and 15% in arm III, Dr. Weber said.
"Patients with the highest risk of fistula were those who got concurrent therapy," he explained, adding that managing fistulas in these patients was very difficult. "You have poor tissue healing and you have debilitated patients; these [factors] can extensively prolong hospitalization and even require a trip back to the operating room for reconstruction."
With regard to reconstruction, the question is whether it decreases morbidity after salvage laryngectomy. A group at New York's Memorial Sloan-Kettering Cancer Center assessed the utility of the pectoralis major muscle flap (PMMF) in patients undergoing salvage total laryngectomy: 64% of the PMMF patients had chemoradiation therapy as the initial definitive treatment vs 25% in the non-PMMF group.
The authors determined that chemoradiation was the only independent predictor of pharyngocutaneous fistula formation (relative risk, 1.82; P = .02). Still, the fistula rate was similar in the PMMF (27%) group and the non-PMMF (24%) group, they said (Arch Otolaryngol Head Neck Surg 135:1019-1023, 2009).
Dr. Weber's take-home message: Avoiding salvage surgery is the best bet, but if it needs to be done, then selecting patients carefully is crucial for surgical success.
"With a multidisciplinary approach and a low threshold for reconstruction, you offer some of these patients a chance for survival," he said.