Incidence and significance of myocardial injury after surgical treatment of head and neck cancer

OBJECTIVE/HYPOTHESIS: To review the incidence of, and risk factors for myocardial injury after head and neck surgery to help optimize patient care and develop perioperative cardioprotective strategies. STUDY DESIGN: Observational cohort study. METHODS: Records of 65 patients surgically treated for upper aerodigestive tract squamous cell carcinoma between 2005 and 2006 were reviewed. Information about cardiovascular history, tumor characteristics, details of surgery, and postoperative complications were recorded. Patients had troponin assays on the third postoperative day. Logistic regression was used to identify risk factors for postoperative myocardial injury. RESULTS: The average age at presentation was 62+/-12 years. There were 46 (71%) males and 19 (29%) females. Troponin-positive and -negative groups were matched for age, sex, cardiovascular risks, comorbidity, site, tumor-node-metastasis status, and duration of the operations. Sixteen (25%) patients had postoperative myocardial injury including five clinical myocardial infarctions. Factors identified as independent predictors of postoperative myocardial injury were blood pressure level (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.04-1.31; P<.02), intraoperative heart rate variability (OR 1.33; 95% CI 1.04-1.71; P<.02), and the degree of postoperative inflammatory response (OR 1.07; 95% CI 1.02-1.13; P<.001). CONCLUSIONS: Postoperative myocardial injury is a known independent predictor of cardiovascular prognosis. Its incidence in head and neck patients could potentially be reduced through stringent blood pressure management, tight intraoperative heart rate control, and dampening of the postoperative inflammatory response. Troponin testing is a valuable screening tool, and patients who have elevated levels postoperatively should be closely monitored and referred to a cardiologist for optimization of cardiovascular care.     

Role of planned postchemoradiotherapy selective neck dissection in the multimodality management of head and neck cancer

OBJECTIVE/HYPOTHESIS: To assess the oncologic efficacy and functional outcome of selective postchemoradiotherapy neck dissection for stage IV head and neck squamous cell carcinoma. METHODS: Retrospective review of patients with N2-3 cervical metastases at presentation who underwent planned neck dissection after complete biopsy-proven clearance of primary site mucosal disease with chemoradiotherapy between 2000 and 2006. RESULTS: There were 31 males and 10 females. The average age at presentation was 57 +/- 9 years. The oropharynx was the most common primary site (n = 23; 56%). Forty-nine hemineck dissections were performed, including six bilateral and two revision procedures. Sixteen (39%) patients had residual viable postchemoradiotherapy neck disease. Patient weight did not deteriorate after neck dissection (P > .4). Two patients had persistently worsened postoperative swallowing. Ten patients required shoulder physiotherapy, of whom eight were treated with conservative measures. Five-year hemineck disease control and disease-specific survival rates were 92% and 64%, respectively. Presence of viable postchemoradiotherapy neck disease was the only independent predictor of regional control (P < .001; hazard ratio 0.00; 0.00-0.40) and disease-specific survival (P < .02; hazard ratio 0.23; 0.04-0.55). Surgery was twice more likely to confer therapeutic benefit than to cause a significant, albeit in most cases, transitory, complication. CONCLUSIONS: Neck dissection is a safe and effective procedure and a necessary component of the multimodality management of all head and neck cancer patients with N2-3 disease. It should be performed soon after satisfactory demonstration of primary site disease clearance. Universal deployment of radical surgery appears unnecessary and should, when possible, be abandoned in favor of more selective procedures to lessen morbidity.