- Email: [email protected]
Results of surgical salvage for radiation failures of laryngeal carcinoma
Results of surgical salvage for radiation failures of laryngeal carcinoma ANTHONYPO WING YUEN,FRCSE,FRCSG,DLO,WILLIAM IGNACEWEI, MS, FRCSE,FACS,DLO,and CHIU MING HO, FRCSE,FRACS,Hong Kong The results of surgicai salvage of radiation failures of laryngeal carcinoma were reviewed. There were 167 stage T3 and T4 patients. The operative mortality was 7%. The complication rates were 8% wound infection, 13% chest complication, and 25% anastomotic leakage. After the first salvage operation, pharyngeal recurrence developed in 28 (18%) patients. Seven (25%) patients were feasible for second salvage operation, and none of them had turther Iocal recurrence. There were 9 [5%] tracheostomal recurrencesù Of the 126 N0 patients, 23 (I 8%) had nodai recurrence, and only 5 of the nodal recurrences were teasibie for salvage by radicaJ neck dissection. All 41 hode-positive patients underwent radical neck dissection, and 9 (23%] had nodal recurrence. Of the 12ö node-negative patients, 19 (15%] had distant metastasls. Of the 41 node-positive patients, 18 [44%] had distant metastasis. The node-positive patients had a significantly high distant failure rate despite Iocoregional control of tumor. The adjusted 5-year survival rate of T3-4NOM0 was 45%, and that of T3-4 N + M0 was 22%. [©T©~RYNG©LHEAD NECK $URG 1995;I 12:405-9,)
Early
T1 and T2 laryngeal carcinomas can be treated equally effectively with either radiotherapy or partial laryngectomy with preservation of laryngeal function. 1,2 Radiotherapy is more commonly used because the voice is better after radiotherapy than after partial laryngectomy. The treatment policy for advanced laryngeal carcinoma remains controversial. Surgery, radiotherapy, and chemotherapy are used in various combinations by different centers. 3-9 Although surgery can achieve better local control of advanced stage tumor, it has the disadvantage of loss of the larynx. The resulting disability may not be acceptable by the patients. Many patients still prefer radiotherapy as the initial treatment to preserve their laryngeal functions. However, up to 20% of early tumors and more than 60% of advanced laryngeal carcinomas fail with the radiotherapy, and these patients require surgical
From the Department of Surgery,The Universityof Hong Kong, Queen Mary Hospital. This study was supported by Committeeon Research and Conference Grants of The University of Hon~ Kong grant no. 337/048/0014. Received for publication June 29, 1994; accepted Sept. 30, 1994. Reprint requests: Dr. Anthony P. W. Yuen, Department of Surgery, University of Hong Kong, Quee~LMary Hospital, Pokfulam Road, Hong Kong. Copyright© 1995by the American Academyof OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/95/$3.00 + 0 23/1/61)950
salvage, ml Although some patients stil1 have eariy disease on recurrence, most patients present with advanced locoregional recurrence after radiotherapy. The progress of early to advanced disease on recurrence may be due to the inadequacy of clinical assessment and follow-up of these patients, but more important is the difficulty of detection of early recurrence of the irradiated larynx even by direct laryngoscopy and biopsy. With the increasing popularity of organ preservation by treatment with combination chemotherapy and radiotherapy, with surgery in reserve for all stages of disease, it is necessary to provide more information on the prognosis of these patients when radiotherapy fails. It has been reported that early recurrence of stage T1 and T2 has good results by surgicat salvage. 12,1sThere is no large series documenting the long-term results of surgical salvage for radiation failure when the recnrrence is of advanced T3 and T4 stage. This article aims at the analysis of our 20 years of clinical experience of surgical salvage for recurrent advanced laryngeal carcinoma after radiotherapy failnre. PATIENTS AND METHODS
This is a review of the clinical experience of surgical salvage for radiation failures of laryngeal carcinoma in the Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong. All records of salvage operations between 405
406
Otolaryngology Head and Neck Surgery March t995
YUENet al.
Table t, Operative complications Complications
Operative mortality Wound infection Chest complication Anastomotic leak
1971-1980 (n = 74)
10 9 15 23
(14%) (12%) (20%) (31%)
January 1971 and December 1990 for radiation failures of laryngeal squamous cell carcinoma were reviewed. All patients were included when the recurrences were clinically determined to be T3 and T4 (UICC 1982) at the time of salvage operation, regardless of the preradiotherapy stage. These patients had either fixed vocal cords or extralaryngeal spread of tumor at the time of salvage operation. All patients with planned combined radiotherapy with surgery or nonsquamous cell carcinoma were excluded. The follow-up excluding patients with hospital mortality ranged from 2 to 181 months, with a median of 20 months. RESULTS
A total of 167 consecutive patients who had documented clinical stage T3 or T4 squamous cell carcinoma of larynx after radiotherapy failure were operated on during this period; all were included in this review. There were 153 men and 14 women, and their ages ranged from 33 to 79 years, with a median of 61 years. There were 33 T3N0, 7 T3N+ (4 N1, 3 N3), 93 T4N0, and 34 T4N+ (14 N1, 3N2, 17 N3). There were 77 supraglottic, 44 infraglottic, and 46 transglottic tumors. The dose of prior radiotherapy ranged from 39 to 66 Gy, with a median 64 Gy. All 167 patients underwent total laryngectomy. Further resection of pharynx, tongue, esophagus, and neck skin were performed as necessary in the presence of extralaryngeal spread. The resultaut pharyngeal defect was closed primarily in 99 (59%) patients. Reconstruction of the pharyngeal defect was carried out by pectoralis major myocutaneous fläp (PMF) in 14 (8%) patients, by pharyngolaryngoesophagectomy and gastric pull-up (PLO) in 53 (32%) patients, and by deltopectoral flap in 1 patient. Of the 53 PLO operations, 43 were done before 1981, and 10 were done after 1981. All PMF reconstructions were done after 1981. The operative mortality and complications are shown in Table 1. There was significant reduction of
1981-1990 [n = 93]
1 5 7 18
(1%) (5%) (8%) (19%)
TOTAL[n = 167)
11 14 22 41
(7%) (8%) (13%) (25%)
30-day operative mortality, from 14% in the first decade to 1% in the second decade (chi-squared test, p < 0.01). Although the mortality of the 53 patients with PLO was 15%, all 14 patients who underwent PMF were discharged from the hospital with no operative mortality. There was also significant reduction of both wound infection and chest complications (chi-squared, p < 0.05). Although there was a trend of reduction of incidence of anastomotic leakage from 31% in the first decade to 19% in the second decade, it was not statistically significant (chi-squared, p > 0.05). After the first salvage operation, 28 (17%) patients had pharyngeal recurrence. Of these 28 patients, 7 (25%) were able to undergo a second salvage operation with circumferential pharyngectomy and reconstruction. Of these 7 pharyngectomy patients requiring reconstruction, 3 underwent PMF, 2 gastric pull-up, 1 colon transposition, and 1 free jejunum transfer. None of the 7 patients had pharyngeal recurrence at the last follow-up. At the last follow-up, 21 (13%) patients had died of local recurrence. There were 9 (5%) tracheostomal recurrences after the first salvage operation. Two patients underwent a second salvage operation with manubrium and tracheal resection; both patients again had recurrence. All patients with tracheostomal recurrence died of tumor. Of the 126 patients with clinically NO neck tumors, 23 (18%) had nodal recurrence. Second salvage operations for nodal recurrence with radical neck dissection were feasible in only 5 patients, and 1 patient had neck recurrence again after the salvage neck dissection. Of the other 41 clinically nodepositive patients, all had radical neck dissection, and 9 (23%) had nodal recurrence. At the last follow-up, 28 (17%) patients had died of neck lymph node recurrence. At the last follow-up, 37 (22%) patients had distant metastasis. Of the 126 node-negative patients, 19 (15%) had distant metastasis. Of the 4I nodepositive patients, 18 (44%) had distant metastasis. The node-positive patients had a significantly higher
Otoloryngology Head and Neck Surgery Votume t12 Number 3
YUEN et ai,
407
100 m
NO 80
a N +
60
Survival 40
v.
20
0
vA
¢-
---0-
vA
¢
J
l
i
t
I
I
I
F
1
2
3
4
5
6
7
8
¢
9
-~
10
Year Fig. t. Acliusted actuarial survivat of NO a n d N + patients.
incidence of distant metastasis (chi-squared, p < 0.05). The adjusted actuarial survival rates of all 167 patients were calculated by the life table method and are shown in Fig. 1. The 5-year actuarial survival rate of N0 patients was 45%, and that of N + patients was 22% (N1, 22%; N2, 33%; N3, 27%). The 5-year actuarial survival rates of the different stages of the first decade (1971-1980) were T3N0, 50%; T4N0, 27%; and T4N +, 21%. The 5-year actuarial survival rates of the second decade (1981-1990) were T3N0, 65%; T4N0, 55%; and T4N +, 14%. The number of patients with T3N+ was too small for separate survival analysis; the 7 patients in the two periods had 56% 5-year actuarial survival. No statistically significant difference was found in the survival between the two decades in all stages (Lee-Desu, p > 0.05). DISCUSSION
Surgmy alone was our treatment modality for the salvage of radiotherapy failures of laryngeal carcinoma. A significant reduction of surgical complication rates was found during this time because of the improvement of perioperative care and the advancement of surgical techniques. Before 1981, large pharyngeal defect had to be reconstructed with stomach pull-up, and thus PLO was required. > The pectoralis major myocutaneous flap was first reported in 1979 for reconstruction of head and neck defects. ~»Since then, defects after partial pharyngectomy have been reconstructed with patch pectoralis major myocutaneous flaps. 16 More extensive involvement of the
pharynx required circumferential pharyngectomy, and the resultant defect was reconstructed with a tubed pectoralis major myocutaneous flap. ~7 The need for PLO decreased gradually after 1981, and it became necessary only when the cervical esophagus was involved. ~8As a result of the change in options of reconstruction, only 10 PLO operations were performed in the period from 1981 to 1990. Because laryngeal carcinoma rarely involves the esophagus even in the advanced stage, it is now rarely necessary to perform PLOs for laryngeal cancer. As a result of the decrease of PLO, there was a large reduction of the mortality and morbidity of these patients during the last decade, as shown in this review. PLO had high mortalit7 because of the high incidence of cardiopulmonary complication. The use of patch or tubed pectoralis major myocutaneous flap to replace PLO with stomach pull-up for pharyngeal reconstruction decreased chest complications by avoiding laparotomy and mediastinal dissection. In the presence of anastomotic leakage, PMF also had lower mortality compared with PLO because most infections in PMF were confined to the heck, whereas infection would easily have tracked down to the mediastinum in PLO. In contrast to the significant reduction of the incidence of wound infection and chest complications in the period from 1981 to 1990, the incidence of pharyngeal anastomotic leakage was still high regardless of the method of pharyngeal closure, be it primary closure, PMF, or stomach pull-up. The irradiated pharynx had impaired healing, which accounted for the high incidence of anastomotic leak-
Otolaryngology Head and Neck Surgery 408
YUEN e t a l .
age compared with the incidence in patients without prior irradiation. The use of PMF did not decrease the high leakage rate compared with that of PLO with stomach pull-up. Although PMF did not decrease the leakage rate, all anastomotic leakage healed spontaneously. In contrast, the leakage after PLO had high mortality because of the associated chest and mediastinum sepsis. Therefore PLO should be reserved only for extensive tumor with esophageal involvement. Thus far, anastomotic leakage is still the most common operative complication in these patients after radical radiotherapy. The local recurrence rate of tumor was 17% after the initial surgical salvage and decreased to 13% after second salvage. No significant improvement was seen in the local control of the tumor during these years. The local control of tumor cannot be reduced further simply by resecting more mucosa of the pharynx and esophagus because the main failure is probably residual tumor at the deep margin, as shown by the absence of tumor in all of our mucosal resection margins of both frozen section and paraffin section. The improvement of surgical reconstruction techniques decreased the operative mortality and morbidity, but it did not significantly affect the tumor recurrence rate. Local control of tumor was more related to the extent of tumor infiltration and margin of resection rather than reconstruction methods. When the tumor has infiltrated the pharynx without involvement of the esophagus, total pharyngolaryngectomy with reconstruction by the pectoralis major myocutaneous flap is an adequate procedure, and preservation of the esophagus will not compromise local control of tumor at the lower resection margin of the phary n x . 19 Although second surgical salvage is possible with good results, the number of patients feasible for the second operation was small because of the difficulty in the early detection of the recurrence. It taust be emphasized that these patients must be followed up closely, and endoscopy should be done at the earliest symptoms of swallowing and neck discomfort. It is not known whether it is worthwhile to perform regular endoscopic screening of the pharynx of these patients during the first 2 years after operation in view of the good results of second surgical salvage. There was 18% nodal recurrence of the clinically node-negative neck after the surgical salvage for local recurrence. Elective heck dissection was not routinely performed in our patients because of the belief that the subclinical nodal metastasis had been adequately treated by the prior radiotherapy. The
March 1995
high incidence of nodal recurrence in this review indicates that tumor can reside in the neck lymph nodes on local recurrence after radiotherapy. A1though radiotherapy is effective in the treatment of subclinical nodal metastasis, it cannot be used again as adjuvant therapy after prior radiotherapy failure. Most patients in this review were not feasible for surgical salvage on nodal recurrence because early detection of nodal recurrence was difficult in the irradiated neck; therefore we recommend elective neck dissection to improve the nodal control. Despite the good locoregional control of tumor by surgery, the incidence of distant metastasis was significantly higher in the T4N+ group. These patients had the worst prognosis after surgical salvage, with 22% 5-year survival even when most patients had their locoregional tumor eradicated. The poor prognosis of these patients indicated that surgery alone was not adequate in the treatment of patients with nodal metastasis. The high incidence of distant recurrence despite locoregional control of tumor indicated that many of them had already had distant micrometastasis at the time of salvage operation. Because distant micrometastasis could not be eradicated by surgery alone, the value of other modalities of cancer therapy should be further studied in this group of T4N+ patients. Further improvement of treatment results awaits the finding of other useful modalities of cancer therapy. In conclusion, the advancement of surgical techniques and perioperative care of patients significantly reduced the surgical mortality and complication rates during the last 20 years. Surgery had satisfactory results in the locoregional control of the advanced laryngeal carcinoma after radiotherapy failure. Patients without nodal metastasis had satisfactory prognosis. The presence of nodal metastasis indicated poor prognosis, and most patients eventually died of nodal and distant metastasis. Despite the prior radiotherapy of the neck, we recommend elective neck dissection for the clinically node-negative neck to improve control of nodal recurrence. Surgery alone is inadequate in the treatment of patients with nodal metastases because of the high distant failure rate. There has been no significant improvement in long-term survival of these patients during the last 20 years despite the significant reduction of surgical mortality and complications. The combination of surgery with other modalities of cancer therapy is worth further study, particularly for patients with nodal metastasis.
Otolaryngology Head and Neck Surgery
YUEN et Qi,
Volume 112 Number3
REFERENCES
1. Lederman M. Radiotherapy of cancer of the larynx. J Laryngol Otol 1970;84:867-96. 2. Harwood AR. Cancer of the larynx- the Toronto experience. J Otolaryngol 1982;ll(suppl):l-21. 3. Bogaert WVD, Ostyn F, Schueren EVD. The primary treatment of advanced vocal cord cancer-laryngectomy or radiotherapy? Int J Radiat Oncol Biol Phys 1983;9:329-34. 4. Mendenhall WM, Million RR, Sharkey DE, Cassisi NJ. Stage T3 squamous cell carcinoma of the glottic larynx treated with surgery and/or radiation therapy. Int J Radiat Oncol Biol Phys 1984;10:357-63. 5. Woodhouse RJ, Quivey JM, Fu KK, et al. Treatment of carcinoma of the vocal c o r d - a review of 20 years experience. Laryngoscope 1981;91:1155-62. 6. Fu KK, Eisenberg L, Dedo HH, Phillips TL. Results of integrated management of supraglottic carcinoma. Cancer 1977;40:2874-81. 7. Karim ABMF, Kralendonk JH, Njo KH, et al. Radiation therapy for advanced (T3T4N0-N3M0) laryngeal carcinoma: the need for a change of strategy: a radiolherapeutic viewpoint. Int J Radiat Oncol Biol Phys 1987;13:1625-33. 8. The Department ofVeterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324:1685-90. 9. Croll GA, Gerritsen GJ, Tiwari RM, Snow GB. Primary radiotherapy with surgery in reserve for advanced laryngeal carcinoma-results and complications. Eur J Surg Oncol 1989;15:350-6.
10. DeSanto LW. T3 glottic cancer: options and consequences of the options. Laryngoscope 1984;94:1311-5. 11. Yuen A, Medina JE, Goepfert H, Fletcher G. Management of stage T3 and T4 glottic carcinoma. Am J Surg 1984;143: 467-72. 12. Sorensen H, Hansen HS, Thomsen KA. Partial laryngectomy following irradiation. Laryngoscope 1980;90:1344-9. 13. Shah JE Loree TR, Kowaiski Ic. Conservation surgery for radiation-failure carcinoma of the glottic larynx. Head Neck 1990;12:326-31. 14. Lam KH, Wong J, Lim STK, Ohg GB. Pharyngogastric anastomosis following pharyngolaryngoesophagectomy-analysis of 157 cases. World J Surg 1981;5:509-16. 15. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and heck. Plast Reconstr Surg 1979;63:73-81. 16. Lam KH, Wei WI, Wong J. The pectoralis major myocutaneous flap in head and heck reconstruction. Asian J Surg 1984;7:159-64. 17. Lau WF, Lam KH, Wei WI. Reconstruction of hypopharyngeal defects in cancer surgery: do we laave a choice? Am J Surg 1987;154:374-80. 18. Lam KH, Choi TK, Wei WI, et al. Present status of pharyngogastric anastomosis following pharyngola~ngo-oesophagectomy. Br J Surg 1987;74:122-5. 19. Ho CM, Lam KH, Wei WI, et al. Squamous cell carcinoma of the hypopharynx-analysis of treatment resutts. Head Neck 1993;15:405-12.
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Early
T1 and T2 laryngeal carcinomas can be treated equally effectively with either radiotherapy or partial laryngectomy with preservation of laryngeal function. 1,2 Radiotherapy is more commonly used because the voice is better after radiotherapy than after partial laryngectomy. The treatment policy for advanced laryngeal carcinoma remains controversial. Surgery, radiotherapy, and chemotherapy are used in various combinations by different centers. 3-9 Although surgery can achieve better local control of advanced stage tumor, it has the disadvantage of loss of the larynx. The resulting disability may not be acceptable by the patients. Many patients still prefer radiotherapy as the initial treatment to preserve their laryngeal functions. However, up to 20% of early tumors and more than 60% of advanced laryngeal carcinomas fail with the radiotherapy, and these patients require surgical
From the Department of Surgery,The Universityof Hong Kong, Queen Mary Hospital. This study was supported by Committeeon Research and Conference Grants of The University of Hon~ Kong grant no. 337/048/0014. Received for publication June 29, 1994; accepted Sept. 30, 1994. Reprint requests: Dr. Anthony P. W. Yuen, Department of Surgery, University of Hong Kong, Quee~LMary Hospital, Pokfulam Road, Hong Kong. Copyright© 1995by the American Academyof OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/95/$3.00 + 0 23/1/61)950
salvage, ml Although some patients stil1 have eariy disease on recurrence, most patients present with advanced locoregional recurrence after radiotherapy. The progress of early to advanced disease on recurrence may be due to the inadequacy of clinical assessment and follow-up of these patients, but more important is the difficulty of detection of early recurrence of the irradiated larynx even by direct laryngoscopy and biopsy. With the increasing popularity of organ preservation by treatment with combination chemotherapy and radiotherapy, with surgery in reserve for all stages of disease, it is necessary to provide more information on the prognosis of these patients when radiotherapy fails. It has been reported that early recurrence of stage T1 and T2 has good results by surgicat salvage. 12,1sThere is no large series documenting the long-term results of surgical salvage for radiation failure when the recnrrence is of advanced T3 and T4 stage. This article aims at the analysis of our 20 years of clinical experience of surgical salvage for recurrent advanced laryngeal carcinoma after radiotherapy failnre. PATIENTS AND METHODS
This is a review of the clinical experience of surgical salvage for radiation failures of laryngeal carcinoma in the Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong. All records of salvage operations between 405
406
Otolaryngology Head and Neck Surgery March t995
YUENet al.
Table t, Operative complications Complications
Operative mortality Wound infection Chest complication Anastomotic leak
1971-1980 (n = 74)
10 9 15 23
(14%) (12%) (20%) (31%)
January 1971 and December 1990 for radiation failures of laryngeal squamous cell carcinoma were reviewed. All patients were included when the recurrences were clinically determined to be T3 and T4 (UICC 1982) at the time of salvage operation, regardless of the preradiotherapy stage. These patients had either fixed vocal cords or extralaryngeal spread of tumor at the time of salvage operation. All patients with planned combined radiotherapy with surgery or nonsquamous cell carcinoma were excluded. The follow-up excluding patients with hospital mortality ranged from 2 to 181 months, with a median of 20 months. RESULTS
A total of 167 consecutive patients who had documented clinical stage T3 or T4 squamous cell carcinoma of larynx after radiotherapy failure were operated on during this period; all were included in this review. There were 153 men and 14 women, and their ages ranged from 33 to 79 years, with a median of 61 years. There were 33 T3N0, 7 T3N+ (4 N1, 3 N3), 93 T4N0, and 34 T4N+ (14 N1, 3N2, 17 N3). There were 77 supraglottic, 44 infraglottic, and 46 transglottic tumors. The dose of prior radiotherapy ranged from 39 to 66 Gy, with a median 64 Gy. All 167 patients underwent total laryngectomy. Further resection of pharynx, tongue, esophagus, and neck skin were performed as necessary in the presence of extralaryngeal spread. The resultaut pharyngeal defect was closed primarily in 99 (59%) patients. Reconstruction of the pharyngeal defect was carried out by pectoralis major myocutaneous fläp (PMF) in 14 (8%) patients, by pharyngolaryngoesophagectomy and gastric pull-up (PLO) in 53 (32%) patients, and by deltopectoral flap in 1 patient. Of the 53 PLO operations, 43 were done before 1981, and 10 were done after 1981. All PMF reconstructions were done after 1981. The operative mortality and complications are shown in Table 1. There was significant reduction of
1981-1990 [n = 93]
1 5 7 18
(1%) (5%) (8%) (19%)
TOTAL[n = 167)
11 14 22 41
(7%) (8%) (13%) (25%)
30-day operative mortality, from 14% in the first decade to 1% in the second decade (chi-squared test, p < 0.01). Although the mortality of the 53 patients with PLO was 15%, all 14 patients who underwent PMF were discharged from the hospital with no operative mortality. There was also significant reduction of both wound infection and chest complications (chi-squared, p < 0.05). Although there was a trend of reduction of incidence of anastomotic leakage from 31% in the first decade to 19% in the second decade, it was not statistically significant (chi-squared, p > 0.05). After the first salvage operation, 28 (17%) patients had pharyngeal recurrence. Of these 28 patients, 7 (25%) were able to undergo a second salvage operation with circumferential pharyngectomy and reconstruction. Of these 7 pharyngectomy patients requiring reconstruction, 3 underwent PMF, 2 gastric pull-up, 1 colon transposition, and 1 free jejunum transfer. None of the 7 patients had pharyngeal recurrence at the last follow-up. At the last follow-up, 21 (13%) patients had died of local recurrence. There were 9 (5%) tracheostomal recurrences after the first salvage operation. Two patients underwent a second salvage operation with manubrium and tracheal resection; both patients again had recurrence. All patients with tracheostomal recurrence died of tumor. Of the 126 patients with clinically NO neck tumors, 23 (18%) had nodal recurrence. Second salvage operations for nodal recurrence with radical neck dissection were feasible in only 5 patients, and 1 patient had neck recurrence again after the salvage neck dissection. Of the other 41 clinically nodepositive patients, all had radical neck dissection, and 9 (23%) had nodal recurrence. At the last follow-up, 28 (17%) patients had died of neck lymph node recurrence. At the last follow-up, 37 (22%) patients had distant metastasis. Of the 126 node-negative patients, 19 (15%) had distant metastasis. Of the 4I nodepositive patients, 18 (44%) had distant metastasis. The node-positive patients had a significantly higher
Otoloryngology Head and Neck Surgery Votume t12 Number 3
YUEN et ai,
407
100 m
NO 80
a N +
60
Survival 40
v.
20
0
vA
¢-
---0-
vA
¢
J
l
i
t
I
I
I
F
1
2
3
4
5
6
7
8
¢
9
-~
10
Year Fig. t. Acliusted actuarial survivat of NO a n d N + patients.
incidence of distant metastasis (chi-squared, p < 0.05). The adjusted actuarial survival rates of all 167 patients were calculated by the life table method and are shown in Fig. 1. The 5-year actuarial survival rate of N0 patients was 45%, and that of N + patients was 22% (N1, 22%; N2, 33%; N3, 27%). The 5-year actuarial survival rates of the different stages of the first decade (1971-1980) were T3N0, 50%; T4N0, 27%; and T4N +, 21%. The 5-year actuarial survival rates of the second decade (1981-1990) were T3N0, 65%; T4N0, 55%; and T4N +, 14%. The number of patients with T3N+ was too small for separate survival analysis; the 7 patients in the two periods had 56% 5-year actuarial survival. No statistically significant difference was found in the survival between the two decades in all stages (Lee-Desu, p > 0.05). DISCUSSION
Surgmy alone was our treatment modality for the salvage of radiotherapy failures of laryngeal carcinoma. A significant reduction of surgical complication rates was found during this time because of the improvement of perioperative care and the advancement of surgical techniques. Before 1981, large pharyngeal defect had to be reconstructed with stomach pull-up, and thus PLO was required. > The pectoralis major myocutaneous flap was first reported in 1979 for reconstruction of head and neck defects. ~»Since then, defects after partial pharyngectomy have been reconstructed with patch pectoralis major myocutaneous flaps. 16 More extensive involvement of the
pharynx required circumferential pharyngectomy, and the resultant defect was reconstructed with a tubed pectoralis major myocutaneous flap. ~7 The need for PLO decreased gradually after 1981, and it became necessary only when the cervical esophagus was involved. ~8As a result of the change in options of reconstruction, only 10 PLO operations were performed in the period from 1981 to 1990. Because laryngeal carcinoma rarely involves the esophagus even in the advanced stage, it is now rarely necessary to perform PLOs for laryngeal cancer. As a result of the decrease of PLO, there was a large reduction of the mortality and morbidity of these patients during the last decade, as shown in this review. PLO had high mortalit7 because of the high incidence of cardiopulmonary complication. The use of patch or tubed pectoralis major myocutaneous flap to replace PLO with stomach pull-up for pharyngeal reconstruction decreased chest complications by avoiding laparotomy and mediastinal dissection. In the presence of anastomotic leakage, PMF also had lower mortality compared with PLO because most infections in PMF were confined to the heck, whereas infection would easily have tracked down to the mediastinum in PLO. In contrast to the significant reduction of the incidence of wound infection and chest complications in the period from 1981 to 1990, the incidence of pharyngeal anastomotic leakage was still high regardless of the method of pharyngeal closure, be it primary closure, PMF, or stomach pull-up. The irradiated pharynx had impaired healing, which accounted for the high incidence of anastomotic leak-
Otolaryngology Head and Neck Surgery 408
YUEN e t a l .
age compared with the incidence in patients without prior irradiation. The use of PMF did not decrease the high leakage rate compared with that of PLO with stomach pull-up. Although PMF did not decrease the leakage rate, all anastomotic leakage healed spontaneously. In contrast, the leakage after PLO had high mortality because of the associated chest and mediastinum sepsis. Therefore PLO should be reserved only for extensive tumor with esophageal involvement. Thus far, anastomotic leakage is still the most common operative complication in these patients after radical radiotherapy. The local recurrence rate of tumor was 17% after the initial surgical salvage and decreased to 13% after second salvage. No significant improvement was seen in the local control of the tumor during these years. The local control of tumor cannot be reduced further simply by resecting more mucosa of the pharynx and esophagus because the main failure is probably residual tumor at the deep margin, as shown by the absence of tumor in all of our mucosal resection margins of both frozen section and paraffin section. The improvement of surgical reconstruction techniques decreased the operative mortality and morbidity, but it did not significantly affect the tumor recurrence rate. Local control of tumor was more related to the extent of tumor infiltration and margin of resection rather than reconstruction methods. When the tumor has infiltrated the pharynx without involvement of the esophagus, total pharyngolaryngectomy with reconstruction by the pectoralis major myocutaneous flap is an adequate procedure, and preservation of the esophagus will not compromise local control of tumor at the lower resection margin of the phary n x . 19 Although second surgical salvage is possible with good results, the number of patients feasible for the second operation was small because of the difficulty in the early detection of the recurrence. It taust be emphasized that these patients must be followed up closely, and endoscopy should be done at the earliest symptoms of swallowing and neck discomfort. It is not known whether it is worthwhile to perform regular endoscopic screening of the pharynx of these patients during the first 2 years after operation in view of the good results of second surgical salvage. There was 18% nodal recurrence of the clinically node-negative neck after the surgical salvage for local recurrence. Elective heck dissection was not routinely performed in our patients because of the belief that the subclinical nodal metastasis had been adequately treated by the prior radiotherapy. The
March 1995
high incidence of nodal recurrence in this review indicates that tumor can reside in the neck lymph nodes on local recurrence after radiotherapy. A1though radiotherapy is effective in the treatment of subclinical nodal metastasis, it cannot be used again as adjuvant therapy after prior radiotherapy failure. Most patients in this review were not feasible for surgical salvage on nodal recurrence because early detection of nodal recurrence was difficult in the irradiated neck; therefore we recommend elective neck dissection to improve the nodal control. Despite the good locoregional control of tumor by surgery, the incidence of distant metastasis was significantly higher in the T4N+ group. These patients had the worst prognosis after surgical salvage, with 22% 5-year survival even when most patients had their locoregional tumor eradicated. The poor prognosis of these patients indicated that surgery alone was not adequate in the treatment of patients with nodal metastasis. The high incidence of distant recurrence despite locoregional control of tumor indicated that many of them had already had distant micrometastasis at the time of salvage operation. Because distant micrometastasis could not be eradicated by surgery alone, the value of other modalities of cancer therapy should be further studied in this group of T4N+ patients. Further improvement of treatment results awaits the finding of other useful modalities of cancer therapy. In conclusion, the advancement of surgical techniques and perioperative care of patients significantly reduced the surgical mortality and complication rates during the last 20 years. Surgery had satisfactory results in the locoregional control of the advanced laryngeal carcinoma after radiotherapy failure. Patients without nodal metastasis had satisfactory prognosis. The presence of nodal metastasis indicated poor prognosis, and most patients eventually died of nodal and distant metastasis. Despite the prior radiotherapy of the neck, we recommend elective neck dissection for the clinically node-negative neck to improve control of nodal recurrence. Surgery alone is inadequate in the treatment of patients with nodal metastases because of the high distant failure rate. There has been no significant improvement in long-term survival of these patients during the last 20 years despite the significant reduction of surgical mortality and complications. The combination of surgery with other modalities of cancer therapy is worth further study, particularly for patients with nodal metastasis.
Otolaryngology Head and Neck Surgery
YUEN et Qi,
Volume 112 Number3
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