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OBJECTIVES: Patients with recurrent squamous cell carcinoma of the head and neck (HNSCC) have a poor prognosis and limited therapeutic alternatives. While reirradiation is feasible, it is usually associated with high treatment toxicity and is not yet considered the standard of care. Based on current NCCN guidelines, in the context of very advanced head and neck cancer (recurrent and/or persistent disease), surgical intervention is explored initially with/without adjuvants while unresectable disease is approached with radiation and/or systemic therapies. Specific and reliable prognostic indicators for both -oncologic and functional outcomes- have yet to be defined for this population. METHODS: Retrospective chart review of 54 patients treated with reirradiation at a tertiary academic institution between January of 1998 and January of 2024. Only patients with non-metastatic recurrent, and second primary HNSCC were included in the series. Demographics, staging, radiation dose and technique, additional therapy, histopathologic variables, EORTC toxicity, pre- and post-treatment PEG/tracheotomy dependency and oncologic outcomes were retrieved. RESULTS: The study cohort consisted of 54 patients (37 males, 17 females) with HNSCC, averaging 62.7 years in age. Initial tumors were locally advanced in over 42 % of cases, with 58 % being node-negative. The head and cutaneous regions (24.5 %) and tongue (20.8 %) were the most common tumor sites. Primary surgical resection and adjuvant radiation were performed in 47.2 % of cases, and concurrent chemotherapy was used in 40.7 %. Reirradiation was mainly for local or regional recurrence (88.9 %), often following salvage surgery (68.5 %), with a mean dose of 5623 Gy over 52.5 fractions. Positive surgical margins were present in 29.4 % of cases, and extracapsular spread in 59.5 %. No significant differences were found between the salvage surgery and definitive reirradiation groups except for tumor site (P = 0.022). Median follow-up was 52.6 months, with 27 deaths reported. Lymphovascular invasion was significantly correlated with overall survival (P = 0.017), while initial tumor T-stage and neck disease involvement were linked to local-regional control (P = 0.030 and P = 0.033, respectively). Reirradiation increased tracheotomy and PEG-tube dependency by 20 % (P = 0.011) and 23 % (P = 0.003), respectively. CONCLUSIONS: Reirradiation is a feasible therapeutic alternative in recurrent head and neck SCC. Oncologic outcomes observed in this series compare favorably to most published reports. Complete response and perineural invasion were independent prognostic factors for survival and locoregional control. While no mortality directly associated with treatment was observed in this series, reirradiation had a significant impact in functional outcomes in terms of increased risk of tracheotomy and peg tube dependency. Further studies are required to define the role of this treatment in head and neck cancer.
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Introduction Head and neck cancer with mandibular invasion often necessitates composite resection, leading to defects requiring reconstruction. Microvascular fibula free flap (FFF) surgery is a common approach for this purpose. In this study, we focus on our experience with condyle sacrifice, emphasizing treatment outcomes and functional results. Additionally, we highlight a contemporary perspective by discussing surgical techniques and radiographic outcomes based on a 3D analysis of neo-condyle placement on CT imaging. Methods We studied 23 patients who had undergone segmental mandibulectomy requiring FFF reconstruction between 2009 and 2020. These were all performed by the same surgeon (M.M.) at an academic tertiary care center. Twenty-three reconstructions included condyle sacrifice. Retrospective chart review was performed with a focus on treatment, functional outcomes, and surgical technique. Results A total of 23 patients were included in the study group (13 females and 10 males) with a mean age of 58.1 years. The most common surgical indication was for oncologic purposes (n=9; 39.1%). Twenty (87%) patients required tracheostomy, and all were decannulated. In terms of surgical complications, two (8.7%) patients had a degree of arterial insufficiency and two (8.7%) developed delayed infections. The average inpatient stay was 5.61 days, with a subsequent average clinic follow-up after 16.9 days. CT or MRI imaging was available for 21 (91.3%) patients, showing 14 (66.7%) neo-condyles within the glenoid fossa. Fifteen (71.4%) patients had some element of anterior displacement (average=6.27 mm), and seven (33.3%) patients had a component of lateral displacement (average=2.23 mm). Three (13%) patients died during the follow-up period. Eighteen (90%) of the surviving patients returned to an oral diet within an average of 24.9 days. All patients returned to normal interincisal distance by 12 months. All FFFs, with and without complications, remained viable. Conclusion We achieved favorable oral function outcomes in the majority of our patients. Intriguingly, although radiographic evidence revealed anterior and/or lateral displacement of the neo-condyle, there was no observed correlation with the resumption of oral diet, trismus, or crossbite among these patients.