Salvage Laryngectomy. after R T Failure Indications, Complications and Results. Aug

Transcription

1 Salvage Laryngectomy after R T Failure Indications, Complications and Results Aug

2 Acknowledgments I am grateful to the following individuals who have allowed me to use their slides during this presentation: Piero Nicolai, Brescia, Italy Fernando Dias, Rio de Janeiro, Brasil Andrew Trotti, Tampa, USA.

3 Salvage Surgery following: Previous Surgery Previous Radiotherapy Previous Chemo +Radiotherapy Previous multiple treatments

4 Salvage Surgery Issues Incidence of initial treatment failure Proportion of Patients suitable for Surgery Complexity of Surgery Complications of Surgery Prevention of Complications Outcomes: Local / Regional Control Survival Quality of Life

5 Salvage Surgery Are there patients who could be identified as those with high probability of failure after chemo radiotherapy?

6 Salvage Surgery after Concomitant Chemoradiation in Head and Neck Squamous Cell Carcinomas Stratification for Postsalvage Survival Possible Pre-Salvage Predictors Age Ganly I et al. Arch Otolaryngol Head Neck Surg Initial Tumor Site Arnold DJ et al. Semin Radiat Oncol 2004 > 1 Tumor Sites Stoeckli S.J., Arch Otol H N Surg Initial Tumor Stage Taussky D. et al. Head Neck 2005 Presalvage (Recurrent) Stage Goodwin WJ, Jr. Laryngoscope 2000, Lee SC, Curr Opin Otol HN Surg Time to Treatment Failure Agra IM et al. Head Neck 2006 N3 Disease Richey LM et al. Otolaryngol H N Surg, 2007 Tan H K et al, Head & Neck, 2010

7 Outcomes of Chemoradiotherapy in Head and Neck Cancer Indication for Chemo/RT Response Rates Need for Salvage Surgery Larynx 60-84% 16-34% Hypopharynx 35% 65% Oropharynx 48% 52% Nasopharynx 90% ~10% Advanced disease T 4 N 3 etc. <20%?

8 Risk of Complications Following Salvage Surgery Depends On: The initial stage of disease The type of initial treatment The stage of recurrent disease The state of the patient The extent of salvage surgery The type of reconstructive surgery

9 Salvage Surgery What is the Morbidity and Mortality of complications from Salvage Surgery? What is the cost of Management of Complications following salvage Surgery? What is the impact of Complications of Salvage Surgery on the patient s Quality of Life?

10 Results of Salvage Surgery for Patients with Recurrent Head & Neck Cancer AUTHOR / YEAR N PTS. PRIM SITE RECURREN T DISEASE SALVAGE NO SALVAGE YES COMPLICATI ONS DEATH SURVIVAL AFTER SALVAGE PARSONS L / RT 46 (22%) 30 (26LT 4LNT) (65%) 11 (37%) 0 5y 29% (30) SASSLER CP /QT- >RT 39 (46% ) 21 18(46%) 11 (61%) 0 - GOODWI N L + HF + BOCA /CIR RT - QT (100%) 24 (22%) 2 (1.8% ) 2y 44% (48) STOECKLI * L + HF / RT L 44 (40 % ) HF 33 (59% ) L(88.6%) 15TL(45.5%) L 11 (28 %) HF 6 (40 % ) 1 (1.8% ) L5y 63 % (25) HF5y 20%(3) AGRA* CP / CIR + RT +QT-RT 124 _ 124 (100%) 66 (53,2 %) 4 (3.2%) WEBER L / QT RT QT RT RT 122 ( 23,3% ) 7 (1,3%) ASP / NEC _ 129 TL 100% 72 (55,8%) 1 (0.7%) 2y 45,5% (55) TENAN CP / RT HF 69 (57%) (33%) 10 (62,5%) 2 (15.5%) 2y12,5% (2) LAVERTÚ CP / QT-RT RT 54 ( 54 %) 54 (54%) 15 (27,8%) 0 RICHEY (26.9%) (69%) 9 (24%) 0 2-yOS 26.7% 2-yDSS 27.5% 2-y ELRC 41.5% TAN OC/OP/HP /L 93 (35.2%) (40.8%) 24 (63.2%) 3 (7.8%) 2y OS 43.4% INCA L / HP/OP QT-RT 131 (50.7%) (54.2%) 41 (57.7%) 5 (7.04%) 5-y L 42.5% 5-y OP 33.3% 5-y HP 27% TOTAL (48%) 323 (50.6%) 210 (65 %) * T1-T4 12 (3.7%) 2-y 12.5%/45.5% 5-y 20%/63%

11 Salvage Surgery after RT for Early Stage Glottic Carcinoma To analyze the outcome of salvage surgery for recurrent early stage squamous cell carcinoma of the glottic larynx after radiotherapy. To identify patient and tumor related predictors of outcome of salvage surgery.

12 Clinical T stage prior to RT (n=43) T1b 8% T1a 33% T2 59%

13 Salvage surgery (n=43) 21(49%) suitable for salvage partial laryngectomy (SPL) 22 (51%) required salvage total laryngectomy (STL)

14 Type of salvage partial laryngectomy Supracricoid laryngectomy 2 (10%) Endoscopic laser 1 (5%) Frontolateral PL 11 (52%) Cordectomy/laryngofissure 7 (33%)

15 Disease specific survival Proportion Surviving SPL 93% All 72% STL 51% Time interval from salvage surgery (months) SPL patients had better DSS compared to STL (93% vs 51%, p=0.002)

16 Total Laryngectomy Complications Comparison of complications following, Primary Total Laryngectomy, Salvage Total Laryngectomy after Radiotherapy alone and after Chemo-Radiotherapy

17 Patients and methods 662 patients were treated for squamous cell carcinoma of larynx at MSKCC between 1984 to patients- Total laryngectomy (TL) 113 patients-primary total laryngectomy (PTL) 70 patients-salvage total laryngectomy (STL). 32 (46%) had prior radiotherapy (STL-RT) 38 (54%) had prior chemoradiotherapy (STL-CTRT)

18 Postoperative complications Overall complication rate= 39% Overall mortality rate = 0.5% (1/183;PTL patient)

19 Overall Postoperative Complications Complication % of patients Local 28.4% Swallowing 2.7% Airway 7.1% Systemic 10.4%

20 Overall Postoperative Complications Overall Complication % of patients Pharyngocutaneous fistula 16.9% Chyle leak 1.6% Carotid rupture 2.2%

21 Primary versus salvage laryngectomy Overall complications 60% 50% 52% 40% 30% 20% 10% 36% 34% 0% PTL S TL-RT S TL-CTRT p= 0.08

22 Primary versus salvage laryngectomy Local complications 45% 45% 40% 35% 30% 25% 20% 25% 22% 15% 10% 5% 0% PTL S TL-RT S TL-CTRT p= 0.02

23 Primary versus salvage laryngectomy Pharyngocutaneous fistula 35% 30% 32% 25% 20% 15% 16% 10% 12% 5% 0% PTL STL-RT STL-CTRT p= 0.01

24 Local Complications Effect of Chemoradiation 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 24% No 45% Yes Multivariate analysis RR = 2.7; 95% CI = ; p=0.016

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32 Salvage Surgery What Pre Operative measures should one take to prevent complications from Salvage Surgery: Hyper Alimentation Hyperbaric Oxygen Blood Transfusion Pulmonary Exercises Antibiotics

33 Salvage Surgery What Intra Operative measures should be used to prevent Post Operative complications: Avoid Hypotension Blood Transfusion Antibiotics Vascularized Regional or Free flaps

34 Salvage Total Laryngectomy Role of the Pectoralis Muscle Flap Gil Z, Gupta A, Kummar B, Cordeiro PG, Shah JP, Patel SG. The Role of Pectoralis Major Muscle Flap in Salvage Total Laryngectomy. Arch Otolaryngol Head Neck Surg Oct;135(10): PMID

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39 Pectoralis Major Myofascial Flap N pts: 60 Prevalence of PCF: 23/60 (38%) Prevalence of PCF with pectoralis major: 23% Prevalence of PCF without pectoralis major: 50% p=0.06 Total laryngectomy extended to the pharynx (p=0.03) and poor nutritional status (p=0.05) resulted risk factors for PCF Righini et al, Eur Arch Otorhinolaryngol 262:357-61; 2005

40 Prevention of Complications After TL Use of Free Flaps Fasciocutaneous forearm free flap with Montgomery prosthesis Fascial foream free flap