Carbon dioxide laser microsurgery for early glottic carcinoma

OBJECTIVES: To define the oncologic efficacy of transoral endoscopic CO2 laser surgery in early glottic carcinoma. METHODS: A retrospective study of 103 patients with glottic carcinoma (14 Tis, 68 pT1a, 14 pT1b, and 7 pT2) treated from October 1993 to June 2001. Surgical treatment included endoscopic CO2 laser cordectomies according to the classification of the European Laryngological Society. RESULTS: According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery alone was 100% for the Tis, 96.05% for the T1, and 100% for the T2. Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03%. The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100%. Laryngeal preservation was achieved in 100% of the cases. CONCLUSIONS: According to the present series, endoscopic CO2 laser surgery is an effective treatment for early glottic cancer. EBM RATING: C-4.     

CO(2) laser surgery in the treatment of glottic cancer

BACKGROUND: The aim of the study was to assess the effectiveness of CO(2) laser endoscopic surgery in the treatment of glottic carcinoma limited to the true vocal cords or involving the adjacent regions. METHODS: Seven hundred nineteen patients (687 men and 32 women; mean age, 60.4 years; range, 33-86 years) with glottic carcinoma (432 T1N0M0, 236 T2N0M0, 51 T3N0M0) underwent CO(2) laser surgery (mean follow-up, 5 years; range, 2-17 years). Statistical comparison was carried out with Wilcoxon test, considering p < .05 the minimum significance value. RESULTS: Overall actuarial survival, adjusted actuarial survival, and percentage of patients with no evidence of disease at 5 years were 85%, 97%, and 85%, respectively, in patients with T1a disease; 84%, 96%, and 83% in those with T1b disease; 77%, 86%, and 61% in those with T2 unilateral tumors; 77%, 88%, and 55% in those with T2 bilateral tumors; and 64%, 72%, and 60% in those with T3 disease. The statistical analysis showed the following: significant differences in the comparison of T1 versus T2 and T2 versus T3 tumors (p < .01), with the exception of no evidence of disease in the comparison of T2 versus T3 (p > .05); and no significant differences in the comparison of unilateral and bilateral tumors (p > .05). Actuarial local control, actuarial nodal control, and actuarial distant metastasis control at 5 years were 85%, 98%, and 99%, respectively, in patients with T1 disease; and 66%, 82%, and 91% in patients with T2 disease; and 66%, 83%, and 95% in patients with T3 disease. The laryngeal preservation rate was 97.3% in the T1 group, 82.5% in the T2 group, and 80.5% in T3 group. CONCLUSIONS: CO(2) laser endoscopic surgery is effective in the treatment of glottic carcinoma not infiltrating the cartilaginous skeleton; the results achieved are competitive with those of open conservative operations, if we take into account the possibilities afforded by salvage surgery and the rate of laryngeal preservation achieved in the study patients.     

Quality of life and voice in patients after laser cordectomy for Tis and T1 glottic carcinomas

BACKGROUND: Laser cordectomy is gaining popularity for treatment of early glottic carcinoma, but little is known about vocal and quality of life (QOL) outcomes as a function of extent of resection. We prospectively examined QOL and vocal function of patients with carcinoma in situ (Tis) or T1 glottic carcinomas after laser cordectomy. METHODS: Patients (n = 75) were grouped into those who underwent unilateral subepithelial or subligamental resection (group A, n = 45); those who underwent unilateral transmuscular or total cordectomy (group B, n = 17); and those who underwent extended or bilateral cordectomy including the anterior commissure (group C, n = 19). The European Organization for Research and Treatment of Cancer head and neck cancer specific module (QLQ-H&N35), voice handicap index (VHI), and objective vocal function were examined before and 1 year after cordectomy and compared among the groups. RESULTS: No major complications were encountered, but local recurrence occurred in 10 patients, with group C showing the highest rate (6/19, 31.6%). Patient-reported speech and social contact scores of QOL questionnaire and VHI scores after surgery were higher in groups B and C than in group A (p < .05). The scores and perceptual and acoustic data were generally improved in all groups after surgery, but were statistically significant only in group A (p < .03). CONCLUSION: Our data suggest that early glottic cancers with a limited extent and infiltration depth have improved outcomes, both oncologically and functionally, compared to those lesions requiring extensive laser resection.     

Partial laryngectomy after irradiation failure.

INTRODUCTION: Radiation therapy is often the first method of treating patients with early cancer of the glottis. There is a substantial failure rate among these patients. Total laryngectomy has usually been the means of treating patients with failure after radiation. In recent decades, partial laryngectomy has been used for salvage in such patients. This article will discuss the use of partial laryngectomy for radiation failure both from the oncologic result as well as the morbidity. PATIENTS AND METHODS: Between 1984 and 1995, 27 patients with early-stage laryngeal carcinoma underwent salvage partial laryngectomy after irradiation failure. Vertical laryngectomy was performed in 18 patients (13 with T1 N0 and 5 with T2 N0) and horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 with T2 N0, and 5 with T2 N1). The mean follow-up was 4.1 years. RESULTS: Local control was obtained in 77.7% of patients with glottic lesions (T1: 84.6%; T2: 60%, P = NS) and in 55.5% of patients with supraglottic lesions (T1: 66.6%; T2: 50%; P = NS). There was no regional recurrence in the vertical laryngectomy group, whereas the regional control rate in the horizontal-supraglottic laryngectomy group was 77.7%. Distant control was achieved in 94.4% of patients with glottic disease and in 77.7% of patients with supraglottic disease. The overall survival rate for glottic lesions was 88.8% (T1: 92.3%; T2: 80%; P = NS) versus 66.6% for supraglottic lesions (T1: 100%; T2: 50%; P = NS). CONCLUSION AND SIGNIFICANCE: Vertical laryngectomy was not associated with an increased complication rate. Morbidity in the horizontal-supraglottic laryngectomy group was higher, but a satisfactory functional outcome was obtained in all cases. Therefore, in early laryngeal cancer (glottic T1-T2, supraglottic T1) partial laryngectomy can be performed with good expectation of cure and satisfactory laryngeal function. In T2 supraglottic lesions, the oncologic results are less satisfactory; further research is required for developing more efficient complimentary or alternative treatments modalities.     

Stage I (T1 N0 M0) squamous cell carcinoma of the laryngeal glottis: therapeutic results and voice preservation

BACKGROUND: The therapeutic outcomes for voice preservation in Stage I (T1 N0 M0) glottic carcinoma, treated with conservation surgery, radiation therapy, and endoscopic resection, are controversial. METHODS: A retrospective tumor registry retrieval of data on patients treated with curative intent at Washington University Medical Center-Barnes Hospital between January 1971 and December 1990 for the surgical group, January 1971 to December 1985 for the low-dose radiation group, and January 1986 to January 1995 for the high-dose radiation group, was performed. RESULTS: The 659 patients with Stage I (T1 N0 M0) glottic carcinoma treated with curative intent were subdivided into four groups: (1) 90 patients received low-dose radiation (mean dose 58 Gy, range 55-65 Gy, daily fractionation 1.5-1.8 Gy); (2) 104 patients received high-dose radiation (mean dose 66.5 Gy, range 65-70 Gy, daily fractionation 2-2.25 Gy); (3) 404 patients underwent conservation surgery; and (4) 61 patients had endoscopic resection. T1A (85%) and T1B (15%) disease was equally distributed among the groups. The anterior commissure was involved in 38 patients in the radiation therapy groups and 56 patients in the surgical groups. The overall local control was 89%. The overall local salvage was 84%. The overall unaided laryngeal voice preservation was 90%. The overall 5-year disease specific and actuarial survival rates were 95% and 81%, respectively. Prevalence of 2% regional metastases, 1.2% distant metastases, and 14% second primary malignancies were documented. The cure rate was 69% for regional metastases, 13% for distant metastases, and 44% for second primary malignancies. There were 5 complication deaths (0.1%), and 38 (6%) patients died of intercurrent disease. The use and dose of tobacco products was significantly increased in patients who died of intercurrent disease (p = 0.004) or developed second primary malignancies (p = 0.024). No significant difference was observed among the four therapeutic groups in the 5-year cause-specific survival rate (p, 0.68). Actuarial survival was significantly decreased in the low-dose radiation therapy group as compared with the other three therapeutic groups (p = 0.04). Initial local control was poorer for the endoscopic (77%) and low-dose radiation (78%) groups as compared with the high-dose radiation (89%) and conservation surgery (92%) groups (p = 0.02) but significant differences were not found for ultimate local control following salvage treatment. Unaided laryngeal voice preservation was similar for high-dose radiation (89%), conservation surgery (93%) and endoscopic resection (90%), but significantly poorer for low-dose radiation (80%; p = 0.02). T1B disease (N = 94) had similar local control and voice preservation with conservation surgery (87%) and high-dose radiation (88%) but lower results with low-dose radiation and endoscopic resections (67% unaided laryngeal voice preservation; p = 0.02). CONCLUSION: (1)The four therapeutic groups achieved similar rates of disease specific survival and ultimate local control. (2) Low-dose radiation was associated with significantly lower overall actuarial survival and unaided laryngeal voice preservation. (3) Endoscopic resection was associated with a significantly lower initial local control rate, but following salvage therapy achieved equivalent results to the other treatment methods. (4) Patients with (T1 N0 M0) glottic carcinoma had similar survival, local control, and unaided laryngeal voice preservation rates with high-dose radiation, conservation surgery, and endoscopic resections, but not with low-dose radiation therapy. (c) 1999 John Wiley & Sons, Inc. Head Neck 21: 707-717, 1999.     

Voice quality after CO2 laser cordectomy—What can we really expect?

BACKGROUND: Endoscopic management of laryngeal carcinoma has gained popularity among laryngologists based on the good oncologic and functional results. We evaluated the voice quality after laser cordectomy for early glottic cancer in a variety of vocal situations and its relation with the extension of resection and the age. METHODS: We conducted a cross-sectional study of voice quality in 42 consecutive male patients treated for T1 glottic carcinoma with laser cordectomy. Patients were compared with 21 controls. Voice quality was self-assessed by the patients. Perceptual analysis was done by a speech pathologist on a running speech sample [GRBAS (grade, roughness, breathiness, asthenicity, strain)]. Acoustic analysis included fundamental frequency (F0), jitter, shimmer, noise to harmonic ratio (N/H), and maximum phonation time (MPT) on the sustained vowels /a/ and /i/, and on various running speech voice samples. RESULTS: Distribution of the patients included in the study by T classification was as follows: Tis, n = 2 (4.8%); T1a, n = 35 (83.3%); and T1b, n = 5 (11.9%). Cordectomy types were: (I), 14%; (II), 26%; (III), 21%; and (V), 38%. Voice improved in almost 60% of patients, returning to normal in 45%. GRBAS showed significant differences between patients and controls and correlated with type of cordectomy. Acoustic analysis showed significant differences in F0, and jitter, with smaller differences in shimmer, N/H, and MPT. CONCLUSION: Voice quality after laser cordectomy differs from controls, but improves in a majority of patients after the surgery, with almost 50% of patients with subjective normal or near normal voice. Voice quality depends on type of cordectomy.     

Endoscopic laser surgery in the treatment of radiation failure of early laryngeal carcinoma

BACKGROUND: This study was undertaken to analyze the local control rates and survival of patients undergoing endoscopic laser surgery for squamous cell carcinoma of the larynx as a salvage procedure for recurrent tumors after radiotherapy. METHODS: Twenty-four patients underwent endoscopic laser surgery for radiation failure at our hospital from 1988 to 1995. All patients were men, between 45 and 88 years old. The localization of the recurrence was in the supraglottis in 3 cases and in the glottis in 21 cases. The postirradiation recurrences were staged rT1 in 18 patients and rT2 in 6 patients. RESULTS: Local recurrence after laser surgery developed in six patients (25%) who had a total laryngectomy. Voice preservation was thus achieved in 75% of patients. No patient died because of the laryngeal cancer, and the observed 5-year survival rate was 76%. CONCLUSIONS: These results indicate that in selected cases, endoscopic laser surgery may be used successfully for treating radiation failure of early laryngeal carcinomas.     

Transoral carbon dioxide laser microsurgery for recurrent glottic carcinoma after radiotherapy

BACKGROUND: Transoral laser microsurgery is successfully performed in the treatment of primary laryngeal carcinomas. Few publications deal with the application in patients with recurrent glottic carcinomas after radiation failure. Our study aims to review our experience with transoral laser microsurgery in these patients. METHODS: Thirty-four patients with early and advanced recurrent glottic carcinoma after full-course radiotherapy (rT1, n = 11; rT2, n = 10; rT3, n = 10; rT4, n = 3) had CO(2) laser treatment with curative intent between 1987 and 1998. RESULTS: Twenty-four patients (71%) were cured with one or more laser procedures. In nine patients, recurrences could not be controlled by laser microsurgery: six patients underwent total laryngectomy and three palliative treatment. One patient received total laryngectomy because of chondronecrosis after laser treatment. With a median follow-up interval of 38.6 months, the 3-year and 5-year disease-specific survival was 86%. The overall 3-year survival rate was 74%; the corresponding 5-year survival rate was 53%. No major complications occurred. In three cases, temporary tracheostomy was needed. CONCLUSIONS: In early-stage and advanced-stage recurrent glottic carcinomas after radiotherapy, CO(2) laser treatment can successfully be used as a curative organ-preserving procedure. Compared with salvage laryngectomy, results are superior with respect to preservation of laryngeal function. Great expertise is required, especially in resections of advanced-stage recurrent carcinomas.     

Management of stage II (T2N0M0) glottic carcinoma by radiotherapy and conservation surgery

BACKGROUND: The best therapeutic approach for the treatment of stage II (T2N0M0) glottic carcinoma is controversial. METHODS: A retrospective tumor registry data retrieval of patients with stage II glottic carcinoma treated with curative intent at Washington University Medical Center-Barnes Hospital between January 1971 and December 1989 (surgery) and December 1995 (radiotherapy) was performed. RESULTS: Among 134 patients with stage II glottic carcinomas treated with curative intent and function preservation, there were 47 patients treated with low dose radiotherapy (median dose, 58.5 Gy at 1.5-1.8 Gy daily fractions), 16 patients with high dose radiotherapy (67.5-70 Gy) at higher daily fractionation doses (2-2.25 Gy), and 71 patients underwent conservation surgery. The overall local control rate was 85%. The overall salvage rate was 68%. The 5-year actuarial and disease specific survivals were 81.5% and 92%, respectively. Unaided phonation was achieved in 84.4% of the patients. An incidence of 10.4% regional metastases, 2.2% distant metastases, and 6% second primary tumors was documented. There were no statistical differences in local control, voice preservation, and 5-year actuarial and disease specific cure rates between conservation surgery and high dose radiation (p = .89). Low dose radiation had statistically lower local controls, 5-year survival, and voice preservation (p = .014). In advanced T2B disease, treating the ipsilateral neck nodes reduced regional metastases (p = .02). CONCLUSIONS: High dose and daily fractionation (70 Gy at 2 Gy daily fraction doses) radiation achieved results equivalent to those of conservation surgery in 5-year local control, survival, and voice preservation. In advanced T2B disease, treatment of the ipsilateral neck nodes by radiotherapy or functional neck dissection reduced regional metastases.     

Twice-a-day radiotherapy for T3 squamous cell carcinoma of the glottic larynx

Between March 1978 and April 1986, 21 previously untreated patients with T3 squamous cell carcinoma of the true vocal cord received radical courses of twice-a-day radiotherapy (120 cGy twice daily) to total doses of 7,440-7,680 cGy. The rate of local control at the primary site was 67% after radiotherapy. The ultimate control rate after salvage surgery was 83%. Five-year absolute and cause-specific survival rates were 59% and 81%, respectively. It is concluded that radiotherapy is a rational approach for many patients with T3 glottic cancer.     

Supracricoid partial laryngectomy as salvage surgery after radiation failure

BACKGROUND: Radiotherapy is often chosen as the definitive treatment for early stage laryngeal carcinoma. Total laryngectomy is the main procedure for failures. Endoscopic treatment of recurrences by CO(2) laser has found limited application. Partial laryngectomy through an external approach has been proposed as salvage surgery, and the vertical partial laryngectomy (VPL) is the most mentioned surgical technique in the literature, although there are, to date, very few reports regarding the use of the supracricoid partial laryngectomy (SCPL) as salvage surgery after radiation failure. OBJECTIVES: The aim of the study is to check the feasibility of SCPL with cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP) in patients with laryngeal recurrence after radiation failure and to evaluate the oncologic results, morbidity, and functional outcome. METHODS: Fifteen consecutive patients were treated with salvage intent by SCPL from January 1992 to December 1998. CHEP and CHP were performed in 11 and 4 patients, respectively. Five patients underwent homolateral surgical neck dissection, and one underwent bilateral neck dissection. All patients had a temporary tracheostomy, and two patients required percutaneous endoscopic gastrostomy (PEG) to ensure feeding. Functional rehabilitation started 2 weeks after the operation. RESULTS: The results have been evaluated in terms of oncologic outcome and functional preservation. Twelve patients are alive with a minimum follow-up of 36 months and 3 patients died after 36 days, 6 and 14 months after surgery, the first and second patient from heart failure and the third from lung metastasis. Respiratory function was recovered in all cases. Oral intake began 12 days after surgery, and in 14 cases satisfactory swallowing was recovered 30 days after surgery. An acceptable quality of the voice was achieved by most patients, and a high rate of local immediate complications was solved in all cases. CONCLUSIONS: SCPL represents an effective technique as salvage treatment of laryngeal cancer after exclusive radiotherapy; there is a good functional recovery with acceptable morbidity and good oncologic long-term control.     

An objective assessment of voice production after radiation therapy for stage I squamous cell carcinoma of the glottis

Radiation therapy has been the primary treatment for early glottic carcinoma, especially when restoration of normal voice is essential; yet objective evidence of the status of vocal function after treatment is lacking. The purpose of this study was to assess vocal characteristics of patients with glottic carcinoma after they had undergone radiation therapy. Twenty males, who had previously been treated with external beam irradiation for T1N0M0 squamous cell carcinoma with no subsequent evidence of recurrence, volunteered for this study. Laryngovideostroboscopic, acoustic, aerodynamic, and perceptual measures of vocal function were used to determine the characteristics of voice production. Acoustic indices were compared to those of a normal group of 30 age-matched volunteers, and the other measures were compared to established values reported in the literature. On acoustic analysis, the study group was characterized by significantly worse voice production than their counterparts. A high degree of intersubject variability was noted that could not be accounted for in terms of variables in treatment and medical history. The aerodynamic, spectral, and video-stroboscopic findings correlated well; this indicated a poor vibratory source, characterized by diffuse stiffness. Further work is necessary in order to compare vocal function after endoscopic laser and conventional conservative excision.     

Transoral robotic surgery of the vocal cord

The standard endoscopic surgical approach in the management of laryngeal lesions is by the use of a laryngoscope, microscope, and laser. This requires the surgeon to work within the confines of the laryngoscope. At times, it requires repositioning of the laryngoscope and microscope to gain access to a specific area. The surgery also requires line-of-sight observation to complete the operation. The introduction of transoral robotic surgery in head and neck surgery brings the advantages of three-dimensional magnification, increased degrees of freedom with the effector arms, and an articulating distal end that mimics hand movements. To date, transoral robotic surgery of vocal cord surgery requires the use of a tracheostomy in patients. Here we report the use of a CO(2) laser fiber and the Da Vinci robotic platform (Intuitive Surgical) for the surgical management of a T1 glottic squamous cell carcinoma.     

Treatment of the N0 neck during salvage surgery after radiotherapy of head and neck squamous cell carcinoma

BACKGROUND: The morbidity and mortality rates of salvage surgery in patients with local recurrence of head and neck squamous cell carcinoma (HNSCC) after radiotherapy are high. The aim of this study was to determine the rate of occult neck node metastasis and the surgical morbidity of patients after salvage surgery for local relapse after definitive radiotherapy. METHODS: Thirty patients who underwent salvage surgery with a simultaneous neck node dissection for a local relapse after definitive radiotherapy for HNSCC between 1992 and 2000 were included in this study. The primary tumor sites were oral cavity in six patients, oropharynx in 17, supraglottic larynx in three, and hypopharynx in four. Initially, seven patients had T2 disease, eight had T3, and 15 had T4. RESULTS: Twelve patients (40%) experienced postoperative complications, including two deaths. There was no cervical lymph node metastasis (pN0) in 29 of the 30 patients. Fifteen patients (50%) had a recurrence after salvage surgery, including 11 new local recurrences and four patients with distant metastasis. CONCLUSIONS: The risk of neck node metastasis during salvage surgery for local recurrence in patients treated initially with radiation for N0 HNSCC is low. Neck dissection should be performed in only limited area, depending on the surgical procedure used for tumor resection.     

Current trends in the treatment of cancer of the larynx.

The case histories of 250 patients with cancer of the larynx presenting to the Peter MacCallum Hospital, the Alfred Hospital and the Royal Melbourne Hospital in the ten-year period 1966 to 1975 have been reviewed to determine: The results of primary irradiation treatment of T1N0 and T2N0 glottic cancer; The comparative results of primary irradiation plus salvage surgery as compared with primary radical surgery for T3N0 glottic and supraglottic cancer; and The surgical morbidity of secondary salvage laryngectomy following irradiation as compared with that of primary total laryngectomy. These findings are compared with those of a previous study of cancer of the larynx for the period 1956 to 1965.     

The endoscopic management of early squamous carcinoma of the vocal cord with the carbon dioxide surgical laser: clinical experience and a proposed subclassification

Sixteen patients with T1 vocal cord squamous cell carcinoma were treated with endoscopic laser excision during a 4-year period. Laser excision was the initial treatment in 11 patients, and it was used to treat 5 patients who had recurrence after radiotherapy. Postoperatively, 13 (81%) of the 16 patients had normal voices. Two patients with persistent postoperative hoarseness had had anterior commissure lesions and previous radiotherapy; the other patient had a subtotal cordectomy. One patient developed a subsequent new lesion 27 months after the initial laser treatment; he was successfully managed with a second endoscopic laser excision. Involvement of the anterior commissure or involvement of the vocal process with minimally invasive disease proved not to be a contraindication to laser excision. The overall results in this small series suggest that laser excision of T1 vocal cord carcinoma is an excellent method of treatment.     

Management of stage T3 and T4 glottic carcinomas

Between 1959 and 1979, 242 patients with T3 and T4 lesions of the vocal cords were treated at our institution. Treatment consisted of total laryngectomy in all patients. Different modalities of regional node dissections were performed on 187 patients. In addition, 50 patients received irradiation with cobalt-60 postoperatively for specific features of the disease. In the group of 192 patients whose treatment consisted of surgery alone, 28 (14 percent) had recurrence in the neck and 10 (5 percent) had stomal recurrence. Of the patients treated with combined therapy, three (6 percent) had ipsilateral neck recurrences and one (2 percent) had stomal recurrence. For lesions staged N0, failure rates above the clavicles were 16 percent and 31 percent for patients with T3 and T4 lesions, respectively, in the group treated by surgery alone, 9 percent and 6 percent for patients with T3 and T4 lesions, respectively, in the combined therapy group. The rate of failure above the clavicles for lesions staged N+ was 32 percent in the group treated with surgery alone and 8 percent in the combined therapy group. In this study, a correlation was made between the failure rates above the clavicles and different clinical and histologic characteristics of the tumor, surgical findings, and the different modalities of cervical node dissection used. From analysis of the data, recommendations have been made for the selective treatment of patients with advanced glottic carcinomas.     

Management of T3 N0 and T4 N0 glottic carcinomas: results of a national survey.

OBJECTIVE: A survey was undertaken to document the clinical management of T3 and T4 pure glottic primary carcinomas and the management of the N0 neck by otolaryngologists and radiation oncologists. STUDY DESIGN AND SETTING: This study represents the results of a national survey of 250 otolaryngologists and 250 radiation oncologists regarding management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. RESULTS: Of the surveys sent, 208 completed questionnaires were received. Results of this survey suggest that 87% and 90% will treat the neck for a T3 N0 M0 and T4 N0 M0 glottic tumor, respectively, with a large number choosing to perform a radical neck dissection. CONCLUSIONS: A significant percentage of otolaryngologists perform neck dissections in the management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. Given the relatively low risk of occult metastasis, potentially high morbidity associated with overtreatment, and the lack of a well-designed outcome study investigating treatment alternatives, a prospective randomized study is needed to address the issue.     

Salvage surgery after radical accelerated radiotherapy with concomitant boost technique for head and neck carcinomas

BACKGROUND: Definitive radiotherapy (RT) for head and neck cancer is increasingly used to preserve organ function, whereas surgery is reserved for treatment failure. However, data are sparse regarding the feasibility of salvage surgery, particularly for unselected patients after accelerated RT. METHODS: From 1991 to 2001, 297 patients, most with stage III to IV cancer (Union Internationale Contre le Cancer) were treated with concomitant boost RT (median dose, 69.9 Gy in 41 fractions) with or without chemotherapy (in 33%, usually cisplatin with or without 5-fluorouracil). The 75 patients seen with local and/or regional failure were studied. We analyzed the factors influencing the decision to attempt surgical salvage, the oncologic outcome, and the associated complications. RESULTS: Seventeen (23%) of the 75 patients had a salvage operation. This included all five patients with laryngeal cancers but only 16% to 20% of patients with tumors in other locations. Most patients could not be operated on because of disease extension (40%) and poor general condition/advanced age (30%). Patients with low initial primary T and N classification were more likely to undergo surgery (p = .002 and .014, respectively). Median post-recurrence survival was significantly better for patients who had salvage operations than for those without surgical salvage treatment (44 vs 11 months, p = .0001). Thirteen patients were initially seen with postoperative complications (mostly delayed wound healing and fistula formation). CONCLUSIONS: After definitive accelerated RT with the concomitant boost technique, only a minority of patients with local or regional recurrence underwent salvage surgery. Disease stage, tumor location, and patient's general condition at the initial diagnosis seemed to be the main factors influencing the decision to attempt surgical salvage. For patients with initially resectable disease who undergo radical nonsurgical treatment, more effective follow-up is needed to favor early detection of treatment failure, which may lead to a timely and effective salvage surgery.