Organ and Function Preservation: The Role of Surgery as the Optimal Primary Modality or as Salvage After Chemoradiation Failure

https://doi.org/10.1016/j.semradonc.2008.09.004Get rights and content

The treatment for squamous cell carcinoma (SCC) of the head and neck has advanced considerably with the use of multimodality therapy including radiation, chemotherapy, and surgery. Efforts to achieve greater rates of disease control and survival have been coupled with attempts to reduce acute and chronic toxicity and preserve function. In the setting of advanced-stage disease, these goals have typically been achieved via the use of combined radiation and chemotherapy. Although very effective, (chemo)radiation does not always succeed and may not offer benefits to the patient equal to those achieved with surgical resection and reconstruction. This article discusses the issues involved in the selection of surgical therapy both for the primary treatment of SCC of the head and neck and for salvage of disease persistence or recurrence after chemoradiation.

Section snippets

Surgery as the Primary Modality Therapy

In making the decision to recommend surgery as the primary treatment modality, the main technical consideration must be whether or not the tumor and any regional metastasis are amenable to complete resection. Resectability should not be confused with operability. Many patients may have tumors that can be effectively removed, but the patient's overall health or expectations for recovery and function may not be appropriate to warrant using surgical treatment. Likewise, advances in surgical and

The Oral Cavity and Oropharynx

The management of oral cavity and oropharynx cancers is most dependent on the extent of the involvement of the oral tongue, the base of the tongue, or the hard and soft palates. Treatment by either surgical resection or chemoradiation has the potential to lead to impairment in speech, deglutition, taste, salivary flow, and intraoral sensation. In most cases of resectable disease, surgical therapy should be considered when the amount of resected tissue will not lead to significant functional

Larynx and Hypopharynx

The goals of surgical therapy for larynx cancer are similar to those for primary chemoradiation including cure the cancer, preserve voice, maintain or improve swallowing, allow normal respiration, and, if possible, avoid a tracheostomal airway. Unfortunately, this will not be possible for all patients, irrespective of the primary treatment used. Patients with T4 cancers have overall good survival rates after primary treatment, ranging from 40% to 50%,1, 3, 23 but this is usually at the expense

Salvage Surgery After Chemoradiation Failure

The failure of primary chemoradiotherapy for head and neck SCC does not mean that ultimate oncologic control and cure is unattainable, but the long-term rates of locoregional control, disease-free status, and ultimately survival are certainly affected by whether the situation is one of tumor persistence or recurrence. Surgical salvage in the setting of cancer persistence, usually considered as a tumor present at the primary site or regional lymph nodes within 6 months of initial therapy, can be

Outcomes From Salvage Surgery

The efficacy of salvage surgery for persistent and recurrent disease is site and stage specific. Patients with recurrent tumors developing from early-stage primary cancers tend to have better rates of oncologic control and survival, as do recurrent laryngeal cancers even when originally staged T3 and T4.

Total laryngectomy has been the standard approach to salvage for recurrent laryngeal carcinoma. Use of this strategy, regardless of original tumor stage, yields 5-year survival rates of 45% to

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