Salvage Surgery in Head and Neck Cancers

by Tom Collins •

Factors affecting resectability include carotid resection and reconstruction, infiltration of the skin, deep neck musculature involvement, brachial cranial neuropathy, and invasion of the mandible.

In one study of 943 patients with primary head and neck tumors, 95 had isolated neck recurrences—49 ipsilaterally, 36 contralaterally, five bilaterally, and two unknown (J Oncol. 2012;154303). Salvage surgery attempts were made in about half the patients, with re-irradiation when possible. Overall control was achieved for 31%—25% on the ipsilateral side and 37% on the contralateral side.

“Patient selection is critical,” Dr. Kraus said. “Surgical management is dependent on the prior treatment. It’s critical that we have a surgical roadmap for planning these cases …. Ultimately, there is an overall poor outcome for this population of patients.”

Nonsurgical Options

Recurrent head and neck cancer is a major challenge because patients have received so much radiation already, said Cherie-Ann Nathan, MD, chair, professor, and director of head and neck surgical oncology and cancer research at Louisiana State University’s Feist-Weiller Cancer Center in Shreveport. Chemotherapy is really the gold standard, with response rates between 10% and 40% but a “dismal” overall survival of just five to nine months, she said.

With re-irradiation plus chemotherapy, the median overall survival is 11 to 12 months, regardless of the combination of agents used. Radiation performed in the post-operative setting following resection yields significant improvement in local and regional control when compared with resection alone. But, surprisingly, it yields no difference in overall survival.

A study from Sloan-Kettering found that intensity-modulated radiation therapy (IMRT) brings a better progression-free probability compared with non-IMRT treatment (Int J Radiat Oncol Biol Phys. 2006;64:57-62). A 2007 study of cetuximab as a single agent in patients with disease progression on platinum therapy found survival probability was improved by about two months when compared with cetuximab plus platinum combination regimens (J Clin Oncol. 2007;25:2171-2177).

“The question we should ask is, although there’s a significant difference in many of these trials, does five months versus seven months make a difference?” Dr. Nathan said. If not, then palliative care should be strongly considered. Factors to think about are events the patient may want to attend, quality of life, and symptoms. “We have this big divide between curative care and palliative care, but those lines are now crossing.”

Thomas Collins is a freelance medical writer based in Florida.

Take-Home Points

  • Salvage surgery shouldn’t be considered as a do-over back-up plan, because outcomes are often not good after initial surgery fails.
  • Imaging is crucial to surveillance, because it provides clinicians with the “new normal.”
  • Patient selection is key in deciding on salvage surgery for both local and regional recurrence.
  • Nonsurgical options exist, but palliative care should often be considered.