Japanese Journal of Clinical Oncology Advance Access originally published online on February 12, 2008
Japanese Journal of Clinical Oncology 2008 38(3):167-171; doi:10.1093/jjco/hym177
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© The Author (2008). Published by Oxford University Press. All rights reserved
Planned Simultaneous Cervical Skin Reconstruction for Salvage Total Pharyngolaryngectomy
1 Department of Otolaryngology, University of Tokyo, Tokyo Japan
2 Department of Plastic and Reconstructive Surgery, University of Tokyo, Tokyo, Japan
For reprints and all correspondence: Kenta Watanabe, Department of Otolaryngology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: Quentaw{at}aol.com
Received October 1, 2007; accepted December 17, 2007
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Abstract |
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 TOP Abstract INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONReferences |
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Background: Salvage surgery after definitive radiotherapy with or without chemotherapy is still controversial, especially in cases of hypopharyngeal cancer because of the poor prognosis and surgical complications. Irradiation of the skin results in loss of flexibility of the skin and impairment of the normal healing processes, thereby increasing the risk of wound infections, which could be potentially life-threatening. In an attempt to diminish the risk of major complications, we performed planned cervical skin replacement with salvage total pharyngolaryngectomy (TPL).
Methods: From 2005 to 2006, six patients underwent salvage TPL and cervical reconstruction with a deltopectoral flap at our hospital. The cervical skin replacement was determined pre-operatively and not according to the intraoperative status.
Results: There were no major post-operative complications. Both the prolongation of the operation time and of the duration of hospitalization were within acceptable limits.
Conclusion: Planned cervical skin reconstruction appears to be an appropriate and acceptable procedure with salvage pharyngolaryngectomy to avoid major complications.
Key Words: hypopharyngeal cancer • reconstruction • chemoradiotherapy • salvage surgery • complication
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INTRODUCTION |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONReferences |
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Remarkable improvements have been achieved in the treatment of head and neck squamous cell carcinoma (HNSCC) in recent years, owing to the advances in the radio- and chemoradiotherapeutic techniques employed. In the case of hypopharyngeal cancer, concurrent chemoradiotherapy has been shown to yield good complete response rates (1) and radiation combined with induction chemotherapy has been reported to be equivalent in therapeutic effect to surgery-based therapy which causes loss of voice (2,3). As organ preservation is very important for patients, more and more patients have begun to prefer radiation-based treatments. Unfortunately, in cases with locoregional control failure, surgical intervention is often considered as a salvage measure. However, the rationale of salvage surgery for locally recurrent hypopharyngeal cancer is still controversial in view of the high incidence of post-operative complications and the poor prognosis (4). Irradiation may cause radiodermatitis and fibrosis, with the resultant scarring producing loss of flexibility of the cervical skin and subcutaneous soft tissues, which poses surgical difficulties during subsequent salvage surgery. In addition to the intraoperative difficulties, the risk of post-operative complications, some of which can be life-threatening, e.g. carotid artery rupture, is also significantly increased (4–6). Wound healing is delayed and the normal processes of healing are impaired, which increase the risk of dehiscence and the chances of bacterial infection (7). Therefore, we were prompted to attempt replacement of the irradiated cervical skin with non-irradiated skin during salvage surgery. In this study, we report the usefulness of ‘preoperatively planned’ cervical skin reconstruction with a deltopectoral (DP) flap in cases undergoing salvage total pharyngolaryngectomy (TPL) after intensive radiotherapy or concurrent chemoradiotherapy, for the prevention of major post-operative complications.
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PATIENTS AND METHODS |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONReferences |
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From February 2005 to December 2006, a total of six Japanese patients underwent salvage TPL and planned cervical reconstruction with a DP flap at the University of Tokyo Hospital, Tokyo, Japan. All patients were males, with a mean age of 61 years (range 54–64 years). Of the six patients, five had hypopharyngeal cancer and one had cervical esophageal cancer. Pathologically, the primary lesion was squamous cell carcinoma in all the cases. The patients had previously received radiation therapy or concurrent chemoradiotherapy, as described in Table 1, however, local recurrence necessitated salvage surgery. The chemotherapeutic regimen for concurrent chemoradiotherapy was intravenous cisplatin, pirarubicin hydrochloride and fluorouracil, administered either singly or in combination. The mean interval from the primary therapy to the salvage surgery for local recurrence was 12.5 months (range 2–30 months). The TNM stages at recurrence (rTNM) are also shown in Table 1.
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All patients gave informed consent for the surgical procedure after obtaining a thorough understanding of the risks of the salvage surgery. TPL with pharyngeal tube reconstruction using a free jejunal flap was performed for locally recurrent disease in all cases, and neck dissection was also undertaken where possible. Simultaneous cervical skin reconstruction with a DP flap, after sacrificing the irradiated anterior cervical skin, was performed with epidermization of the donor site of the flap with a graft from the femoral area (Fig. 1). Prophylactic antibiotics (cefotiam hydrochloride or cefazolin sodium) were given to all patients for 4–6 post-operative days. This procedure was determined pre-operatively in all the cases of this series according to the comprehensive physical condition of the irradiated cervical skin, i.e. its flexibility, color and the thickness of the subcutaneous fat tissue. The peri- and post-operative courses of all the cases were evaluated retrospectively to determine the incidence of complications and the prognoses. The severity of the complications was classified according to the scheme proposed by Weber et al (8).
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RESULTS |
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The surgical procedure was as mentioned above, and a schema is shown in Table 2. Bilateral level II–IV neck dissection was also performed in the majority of the cases. Neck dissection was omitted in one case due to the strong inflammatory adhesions that had developed following the development of a cervical abscess, and unilateral dissection was performed in another case due to previous neck dissection on the opposite side. The mean operation time was 12 h 13 min (range 10 h 15 min–14 h 3 min). The mean intraoperative hemorrhage volume was 398 ml (range 250—500 ml). Two cases required intraoperative blood transfusion. The mean time to oral intake after the operation was 12.5 days (range 10–15 days). The mean duration of hospitalization after operation was 28 days (range 22–40 days).
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None of the cases developed any major acute post-operative local complications, such as flap necrosis, salivary fistula formation and life-threatening major vessel crisis, or systemic complications. Therefore, during hospitalization, no further surgical procedures were necessitated in any of the cases and there were no surgery-related mortalities. In two cases, wound infection (peri-tracheostoma infection) occurred as an acute minor post-operative complication, which was treated by intravenous antibiotic administration. In two cases, stenosis of the tracheostoma was observed because of the coverage of the stoma by the sagging DP flap; this was treated by tube insertion or pulling up of the sagging skin with a tape after hospitalization (Fig. 2). During the follow-up period, two of the six patients died of the disease: one died due to recurrence in the parapharyngeal space and skin metastasis 6 months after the surgery, and another due to recurrence in the supraclavicular region 12 months after the surgery (Table 2). One patient died of other causes 7 months after the surgery, although he had lung metastasis at that time. The remaining three patients are alive at the time of writing, without evidence of disease recurrence (follow-up period range 14–31 months).
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DISCUSSION |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONReferences |
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Intensive radiotherapy and concurrent chemoradiotherapy are becoming increasingly preferred strategies for the treatment of HNSCC. Previous studies have reported better survival rates with altered fractionated radiotherapy, including hyperfractionated and accelerated radiotherapy, than with conventional radiotherapy (9,10). Also, concurrent chemoradiation methods are now commonly chosen for advanced-stage head and neck cancers based on the equivalent or superior survival, locoregional control and organ preservation rates (1,11). Soo et al. (12) reported that there was no significant difference in the survival rate between advanced HNSCC patients treated by surgery and those treated by concurrent chemoradiotherapy. Recently, hyperfractionated or accelerated hyperfractionated concurrent chemoradiotherapy has also been evaluated for very advanced HNSCC (13,14). In cases of hypopharyngeal cancer, radiotherapy combined with induction chemotherapy has been reported to yield equivalent outcomes to surgery combined with post-operative radiation (2,3). As organ preservation, especially laryngeal preservation, may be expected to improve the quality of life, the aforementioned treatments have come to be increasingly preferred as compared to conventional surgery combined with post-operative radiation in patients with HNSCC (15).
On the other hand, in those cases with failure of organ preservation therapy, surgical procedures often need to be considered for salvage. The usefulness of salvage surgery is still controversial and such a surgery is regarded as a ‘high stake’ surgery, because of the poor prognosis, high risk of complications and also even the low cost–benefit ratio of the treatment (4–6,16). The disease-specific 5-year survival rate of salvage surgery has been reported to be only 20%, especially in cases of hypopharyngeal cancer, and it has, therefore, been suggested that in these cases, salvage surgery should be performed only in very carefully selected cases (4). Not only minor complications, but also major ones, such as fistula formation and flap necrosis, are often reported in cases undergoing salvage surgery, which can sometimes directly lead to life-threatening carotid artery rupture (4–6). Although Proctor et al. (17) reported that patients treated by chemoradiation did not seem to be any significantly increased risk of acute post-salvage surgery complications, they did not include cases undergoing free tissue transfer in their study series. Meticulous attention should be paid to the operative procedure during salvage TPL, because the carotid arteries of both sides are exposed during the surgery. We, however, believe that salvage surgery should not be unduly restricted, except in unresectable cases and high-risk surgical cases because of poor general conditions, as better survival would be expected in cases with a favorable TNM stage at recurrence and a negative tumor resection margin (18); furthermore, even if the prognosis is poor, successful surgery without any major complications might still prolong the patients' time spent at home.
From January 2003 to 2005, we treated eight cases of salvage TPL with free jejunal transfer at our hospital, in none of which we performed skin reconstruction. We encountered major post-operative complications in four out of the eight cases, including one case of anastomotic leak that necessitated a second operation and three cases of carotid rupture. Therefore, the incidence rate of major complications was as high as 50%. Retrospective analysis of these cases has revealed that in the cases with the carotid rupture, the complication had developed consequent to wound infection caused by skin flap necrosis or seroma caused by poor vascularization and loss of flexibility of the irradiated skin, even in the absence of salivary fistula formation or jejunal flap necrosis. Irradiation damages the skin and subcutaneous tissue in terms of impairing wound healing (7). Impairment of fibroblast function by irradiation effects atrophy, contraction and fibrosis, leading to impaired wound healing (7), and surgeons often encounter surgical difficulties while operating on the irradiated tissue (6). It is recommended that all possible dead spaces be filled and that wounds be drained well and closed without tension to avoid the formation of seromas or hematomas which could cause wound infection (7,19). The effect of irradiation on wound healing is clearly dependent on the radiation dose (20) and organ damage occurs more frequently in patients undergoing concurrent chemoradiotherapy than in those undergoing radiotherapy alone (21). It has also been reported that surgery after induction chemotherapy was associated with a higher risk of post-operative complications in patients with HNSCC (22). Therefore, in this report, we have suggested a new surgical procedure, namely ‘preoperatively planned’ reconstruction of cervical skin with salvage TPL after radio- or chemoradiotherapy using non-irradiated, flexible and well-vascularized DP flaps. We have performed this procedure in cases needing salvage TPL at our hospital since February 2005, and have noted that the complication rate is indeed lower than that in the cases in which skin reconstruction is not undertaken after radio- or chemoradiotherapy. Reconstruction with flexible skin allows easy drainage and wound healing, reducing the risk of infections following the formation of seromas or hematomas. While there are some reports which suggest a high complication rate with the use of DP flaps and sacrifice of donor site, such as conspicuous scar deformity in the upper chest region (23), the DP flap remains a major useful candidate for neck reconstruction, especially as a salvage option (24), and indeed, we did not encounter any major complications in our series. The vascularization of the DP flaps, which we used only for covering the anterior neck region in this series, was maintained well, when the several perforators of the internal thoracic artery were preserved appropriately. Although superselective or selective neck dissection in salvage surgery and no elective neck dissection in recurrent N0 cases have been advocated (25,26), we suppose that replacement of cervical skin makes performance of neck dissection combined with TPL safer and also improves locoregional control. Although we have not yet determined definite criteria for this procedure, we think that it is especially valid for cases treated by concurrent chemoradiotherapy or altered fractioned radiotherapy, because the cervical skin in these cases seems calloused and poorly vascularized. During the same period, we encountered only two cases of salvage TPL without skin reconstruction which resulted in just a minor anastomotic leak and in no post-operative trouble, respectively, but they were cases of failure of conventional radiotherapy alone.
In this series, the operation time, time to oral intake and the duration of hospitalization all tended to be longer than those after TPL with a free jejunal flap reconstruction performed as first-line treatment at our hospital, although the data were not strictly comparable. The prolongation of the operation time was attributed to the surgical difficulties encountered during the manipulations in the irradiated area and the extra time required for elevation of the DP flap and epidermization at the donor site. Furthermore, the prolongation of hospitalization was attributed to the extreme caution required in monitoring the wound condition and hesitation against early start of oral intake post-operatively because of anxiety about salivary fistula formation, which was reported to occur in about 20% of cases undergoing salvage surgery in a previous study (5), and the long time required for epithelialization at the donor site of the DP flap and the skin grafting. We do not believe that these are too problematic, and also from the medical economics point of view, this procedure might prove to be more cost-beneficial than managing potential major complications following surgery which might necessitate other expensive medical interventions. As minor complications, we encountered stenosis of the tracheostoma in two cases, which did not deteriorate the quality of life of the patients. In this report, although we have presented only a small number of trial cases, the results suggest that the survival prognosis might be as poor as that reported previously (4), because half of the cases died within the very short follow-up period. On the other hand, all of the patients could be discharged from the hospital without major complications and could spend their last days at home without any medical intervention, with a good locoregional control rate. Recently, Fung et al. (27) reported a new surgical technique to avoid major wound complications, involving the use of a free vascularized flap placed at the pharyngeal closure at the time of salvage laryngectomy after chemoradiotherapy. They report that the technique ‘converts’ major wound complications into minor ones. Although we also do, of course, believe that salvage TPL is not a very safe surgical procedure and that the indications should be considered very carefully after obtaining informed consent, the procedure described in this report, even though the number of cases in which it was tried was small, could reduce the risk of major complications as suggested by Fung et al (27), and appears to be acceptable. A greater number of cases should be accumulated and followed up for complications to validate the usefulness of this preventative procedure for salvage surgery, to establish definite criteria for the procedure and to develop even safer surgical techniques.
Conflict of interest statement
None declared.
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References |
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