Recommendations for surgical management of recurrent nasopharyngeal carcinoma during COVID-19 pandemic.

Nasopharyngeal carcinoma is endemic in southern parts of China including Hong Kong. Primary treatment entails radiotherapy ± chemotherapy depending on disease stage at presentation. Surgery is offered as a means of salvage for persistent and recurrent disease. Comprehensive preoperative work-up, careful patient selection, attention to details perioperation and multidisciplinary approach is essential in ensuring optimal outcomes after salvage surgery for recurrent nasopharyngeal carcinoma patients. Since the COVID-19 outbreak, we are faced with unprecedented challenges with priorities of care and resources being shifted to combat the virus. These include patient selection and timing of treatment, while preventing disease transmission to heath care providers. Practices and recommendations made in this document are intended to support safe clinical practice and efficient use of resources during this challenging time.

Surgical salvage of recurrent T3 nasopharyngeal carcinoma: Prognostic significance of clivus, maxillary, temporal and sphenoid bone invasion.

BACKGROUND: To study the efficacy of surgery for recurrent T3 nasopharyngeal carcinoma (NPC) and to determine the prognostic significance of various skull base bone invasion. METHOD: Retrospective view of the surgical outcome for recurrent T3 NPC. Kaplan Meier and log rank tests were used to determine the 5-year overall and disease specific survival. Multivariate analysis was used to identify significant independent prognostic factors that affect the surgical outcome. RESULTS: Between 1990 and 2017, 208 patients with recurrent T3 NPC were recruited. Salvage surgery was performed via the endoscopic endonasal approach (n = 22, 10.6%), endoscopic transpterygoid approach (n = 63, 30.3%) and the maxillary swing approach (n = 123, 59.1%). Thirty-eight (18.3%) patients required vascular bypass. The skull base bone involved by the tumours included: maxillary sinus (n = 13), clivus (n = 36), pterygoid process (n = 61), sphenoid sinus (n = 30), petrous part of the temporal bone (n = 42) and a combination of the above (n = 26). The mean follow-up duration was 41.7 months. Multivariate analysis identified tumours involving with both cortexes of the clivus and the lateral wall of the sphenoid sinus, as well as positive bone resection margins as the significant independent prognostic factors for surgical outcome. CONCLUSION: Outcome of surgical salvage is significantly worse for tumours that involve multiple bones at the skull base, particularly when both cortexes of the clivus and the lateral wall of the sphenoid sinus are invaded. Indication of aggressive surgery in such circumstances is controversial.

Real time indocyanin green near infrared lymphangiography for the reduction of drainage volume after neck dissection.

BACKGROUND: To investigate the role of indocyanine green (ICG) lymphangiography in the reduction of drainage after neck dissection. METHODS: Patients with oral cavity squamous cell carcinoma were randomized into Group A (study group) and Group B (control). In the study group, upon the completion of neck dissection, a total of 2.5 mg of ICG was injected submucosally at the four quadrants around the tumour. Another 2.5 mg of ICG was injected subdermally in the groin bilaterally. The neck was screened using Near Infrared fluorescence. The presence of lymphatic leakage was noted and plicated with silk stitches. The total drainage volume of post-operative day 1, day 2 and the total accumulated volume until drain removal was measured. RESULTS: Twenty-two patients (Group A, n = 12; Group B, n = 10) were recruited. All patients in Group A had at least one site of lymphatic leakage identified. One patient in Group B developed chylous fistula and was excluded from analysis. The mean total drain output for day 1 and 2 after surgery, as well as the mean total output before drain removal, were significantly lower in Group A (22.4 ml vs. 86.2 ml [p = .02]; 14.2 ml vs. 72.8 ml [p = .02]; and 58.4 ml vs. 392 ml [p = .01], respectively), allowing earlier drain removal (2.2 days vs. 7.2 days, p = .02). CONCLUSIONS: Intra-operative ICG lymphangiography is useful in the reduction of drainage volume after neck dissection for caners in the head and neck region.

Stage II recurrent nasopharyngeal carcinoma: Prognostic significance of retropharyngeal nodal metastasis, parapharyngeal invasion, and carotid encasement.

BACKGROUND: The purpose of this study was to assess the predictability of the American Joint Committee on Cancer (AJCC) staging system on patients with stage II recurrent nasopharyngeal carcinoma (NPC). METHOD: We conducted a retrospective review of the surgical outcome for patients with recurrent NPC and retropharyngeal lymph node (RLN) metastasis (group I), recurrent NPC and parapharyngeal space (PPS) invasion (group II), and recurrent NPC and internal carotid artery (ICA) encasement (group III). RESULTS: Between 1990 and 2013, 145 patients received an operation for stage II recurrent NPC (group I, n = 62; group II, n = 65; and group III, n = 18). The rate of local tumor recurrence was significantly higher in groups II and III. The rate of systemic metastasis was significantly higher in group III (16.7%). Accordingly, the 5-year overall survival was significantly worse for patients in group III (group I: 81.2%; group II: 68.4%; and group III: 48.5%). CONCLUSION: The significantly worse prognosis of recurrent NPC encasing the ICA warrants an upstage to the T3 classification in the current AJCC staging system.

Three-dimensional endoscopy for endoscopic salvage nasopharyngectomy: Preliminary report of experience.

BACKGROUND: Prospective, observational study to assess the efficacy of salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma (NPC) via the endoscopic endonasal approach using a three-dimensional (3D) high-definition endoscopic system. METHODS: Between 2016 and 2017, 30 patients with recurrent NPC were recruited. Patient demographics, tumor characteristics, and perioperative data were recorded. Instrument ergonomics and perceived advantages were assessed by the operating, assisting, and observing surgeons. RESULTS: The majority (70%) of patients received radiotherapy alone as the initial treatment for NPC, and tumor recurred after a mean interval of 16.8 months. The tumor (T) classifications of the recurrent (R) tumors were: RT1: 46.7%; RT2: 33.3%; and RT3: 20.0%. The mean operative time was 293.3 minutes, and no conversion to open approach was necessary. Internal carotid artery dissection was required in nine patients, and the resection and repair of dura was required in six patients. The most common method of reconstruction was free vastus lateralis flap (46.7%). Microscopically clear resection margins were achieved in 73.3% of patients. The mean hospital stay was 6.8 days. There was no hospital mortality. One patient developed minor secondary hemorrhage, whereas the other developed transient contralateral vocal cord paralysis. On quantitative assessment, surgeons noticed a significant advantage of the 3D system with regard to depth and size perception, anatomy identification, and hand-eye coordination, whereas there was no significant difference in terms of strain sensation and dizziness. CONCLUSION: The 3D high-definition endoscopic system improves the precision of endoscopic nasopharyngectomy, particularly when dissection of the internal carotid artery and dura is required. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1386-1391, 2018.

Transoral robotic total laryngopharyngectomy and free jejunal flap reconstruction for hypopharyngeal cancer.

BACKGROUND: To report on the feasibility of total laryngopharyngectomy and free jejunal flap transfer for patient with hypopharyngeal cancer via the transoral robotic surgery (TORS) approach. MATERIAL AND METHODS: A patient with hypopharyngeal cancer involving the post-cricoid region is used for demonstration of the TORS total laryngopharyngectomy and free jejunal flap reconstruction. RESULTS: The procedure starts with a cruciate incision for terminal tracheostomy. The trachea and cervical esophagus is exposed and transected, making sure that the resection margins are adequate. This is followed by the transoral dissection using the robotic surgical system. The laryngopharyngectomy specimen is delivered and the free jejunal flap is replaced transorally. Jejuno-oesophageal suturing and the microvascular anastomosis are performed through the tracheostomy wound. The remaining pharyngo-jejunal anastomosis is performed transorally via the TORS approach. CONCLUSION: TORS total laryngopharyngectomy and free jejunal flap reconstruction is feasible and provides and alternative option to the traditional transcervical approach.

The clinical association of programmed cell death protein 4 (PDCD4) with solid tumors and its prognostic significance: a meta-analysis.

BACKGROUND: Programmed cell death protein 4 (PDCD4) is a novel tumor suppressor protein involved in programmed cell death. Its association with cancer progression has been observed in multiple tumor models, but evidence supporting its association with solid tumors in humans remains controversial. This study aimed to determine the clinical significance and prognostic value of PDCD4 in solid tumors. METHODS: A systematic literature review was performed to retrieve publications with available clinical information and survival data. The eligibility of the selected articles was based on the criteria of the Dutch Cochrane Centre proposed by the Meta-analysis Of Observational Studies in Epidemiology group. Pooled odds ratios (ORs), hazard ratios (HRs), and 95% confidence intervals (CIs) for survival analysis were calculated. Publication bias was examined by Begg's and Egger's tests. RESULTS: Clinical data of 2227 cancer patients with solid tumors from 23 studies were evaluated. PDCD4 expression was significantly associated with the differentiation status of head and neck cancer (OR 4.25, 95% CI 1.87-9.66) and digestive system cancer (OR 2.87, 95% CI 1.84-4.48). Down-regulation of PDCD4 was significantly associated with short overall survival of patients with head and neck (HR: 3.44, 95% CI 2.38-4.98), breast (HR: 1.86, 95% CI 1.36-2.54), digestive system (HR: 2.12, 95% CI 1.75-2.56), and urinary system cancers (HR: 3.16, 95% CI 1.06-9.41). CONCLUSIONS: The current evidence suggests that PDCD4 down-regulation is involved in the progression of several types of solid tumor and is a potential marker for solid tumor prognoses. Its clinical usefulness should be confirmed by large-scale prospective studies.

MicroRNA 744-3p promotes MMP-9-mediated metastasis by simultaneously suppressing PDCD4 and PTEN in laryngeal squamous cell carcinoma.

MicroRNA controls cancer invasion by governing the expression of gene regulating migration and invasion. Here, we reported a novel regulatory pathway controlled by miR-744-3p, which enhanced expression of matrix metallopeptidase 9 (MMP-9) in laryngeal squamous cell carcinoma (LSCC). We profiled the differential micoRNA expression pattern in LSCC cell lines and normal epithelial cultures derived from the head and neck mucosa using microRNA microarray. MiR-7-1-3p, miR-196a/b and miR-744-3p were expressed differentially in the LSCC cell lines. Subsequent validation using real-time PCR revealed that high miR-744-3p level was positively correlated with regional lymph node metastasis of LSCC. Real-time cellular kinetic analysis showed that suppressing miR-744-3p could inhibit migration and invasion of LSCC cell lines and reduce the number of lung metastatic nodules in nude mice modules. In silico analysis revealed that miR-744-3p targeted 2 distinct signaling cascades which eventually upregulated MMP-9 expression in LSCC. First, miR-744-3p could suppress programmed cell death 4 (PDCD4), a direct suppressor of NF-κB (p65). PDCD4 could also prevent AKT activation and suppress MMP-9 expression. Further, suppressing miR-744-3p expression could restore phosphatase and tensin homolog (PTEN) expression. PTEN could inhibit AKT activation and inhibit MMP-9 expression in LSCC cells. The results revealed that suppressing miR-744-3p was effective to inhibit LSCC metastasis by inactivating AKT/mTOR and NF-κB (p65) signaling cascade. Targeting miR-744-3p could be a valuable therapeutic intervention to suppress the aggressiveness of LSCC.

Extracranial/intracranial vascular bypass and craniofacial resection: New hope for patients with locally advanced recurrent nasopharyngeal carcinoma.

BACKGROUND: The purpose of this study was to investigate the oncologic outcome and quality of life after surgical treatment of locally advanced (rT3-rT4) recurrent nasopharyngeal carcinoma (NPC) using the staged extracranial/intracranial vascular bypass and combined craniofacial approach. METHODS: We conducted a prospective study. RESULTS: Between 1998 and 2013, 28 patients with rT3 to rT4 tumors were treated with the proposed surgical protocol. Clear resection margin was achieved in 46.4%. The median follow-up was 42.6 months. The rate of local recurrence was 17.8%. The 5-year overall survival was 52%. There was no change in the mean global health system score after the extensive surgery, although the physical functioning scores deteriorated significantly. The most common symptoms experienced by patients were speech and swallowing problems. CONCLUSION: The proposed surgical treatment for locally advanced recurrent NPC was associated with satisfactory local tumor control and survival. Quality of life after surgery was reasonable, although multidisciplinary training was required to maximize the postoperative speech and swallowing function. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1404-E1412, 2016.

Impact of resection margin status on outcome after salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: The purpose of this study was to present the postoperative local tumor control and survival with regard to the different resection margin statuses during salvage nasopharyngectomy. METHODS: We conducted a whole-organ study of nasopharyngectomy specimens. RESULTS: Between 2005 and 2010, 126 patients underwent maxillary swing nasopharyngectomy. The T classification of the recurrent tumor was: T1, 23.8%; T2, 41.3%; T3, 28.6%; and T4, 6.3%. The chance of clear, close, and involved resection margins at nasopharyngectomy was 44.4%, 31.0%, and 24.6%, respectively. At follow-up, the corresponding risk of local tumor recurrence after surgery was 10.7%, 38.5%, and 67.7%, respectively. The local tumor control was significantly worse in patients with involved margins compared with those with close margins (p = .01), which was, in turn, significantly worse than those with clear margins (p = .04). CONCLUSION: The primary objective of salvage nasopharyngectomy is to achieve clear resection margins. Close and involved margins result in significantly inferior local tumor control and overall survival. © 2015 Wiley Periodicals, Inc. Head Neck 38: E594-E599, 2016.

Shoulder Dysfunction after Selective Neck Dissection in Recurrent Nasopharyngeal Carcinoma.

OBJECTIVE: To investigate the incidence of occult nodal metastasis and severity of shoulder dysfunction after selective neck dissection (SND) for recurrent nasopharyngeal carcinoma (NPC) with N0 status. STUDY DESIGN: Prospective, single-group, pre/post test design. SETTING: Academic medical center. SUBJECTS AND METHODS: Between 1998 and 2012, 46 patients who had recurrent NPC and N0 status were recruited. They subsequently received salvage nasopharyngectomy and SND, removing ipsilateral level I to III and V lymphatics. The incidence of occult nodal metastasis was noted. All patients underwent standardized physiotherapy after surgery. Postoperative shoulder function was measured using the Disability of Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: The incidence of microscopic nodal metastasis was 15.2%. For first year posttreatment, the mean DASH score was 44.2. With time, there was no improvement in shoulder function despite targeted physiotherapy (P = .09), and the second postoperative year mean DASH score was 46.3. The degree of daily activity affected was rated as moderate to very limited, and 30% of the patients had at least moderate shoulder pain at rest. CONCLUSION: Shoulder dysfunction after SND for recurrent NPC is significant and persistent. Given the low incidence of microscopic nodal metastasis in such circumstances, routine SND is not recommended.

The role of Epstein-Barr virus-encoded microRNA BART7 status of resection margins in the prediction of local recurrence after salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: Local recurrence is the major cause of treatment failure in patients who undergo surgical salvage of recurrent nasopharyngeal carcinoma (NPC) after radiotherapy. The authors investigated the role of Epstein-Barr virus (EBV)-encoded Bam HI-A rightward transcript 7 microRNA (BART7) status in resection margins in the identification of a subgroup of patients who may benefit from adjuvant reradiation after surgery. METHODS: One hundred two consecutive patients who had histologically clear resection margins after undergoing nasopharyngectomy for recurrent NPC were studied. The status of EBV microRNA BART7 in resection margins was investigated and correlated with the pattern of subsequent disease recurrence. RESULTS: After a median follow-up of 64 months, 20 patients (19.6%) developed local recurrence after surgery despite histologically uninvolved margins. The risk of local recurrence in patients with histologically close (<5 mm) and clear (≥5 mm) margins was 31.6% and 12.5%, respectively. In patients with clear histologic margins, those with margins that were positive for EBV microRNA BART7 has a significantly higher chance of developing local tumor recurrence (P = .016) than those with negative molecular margins. The difference was not significant when the histologic clearance at the resection margins was <5 mm. CONCLUSIONS: Tissue EBV microRNA BART7 is useful for identifying a subgroup of patients with histologically clear margins who are at increased risk of subsequent local tumor recurrence. Postoperative adjuvant treatment is warranted for these patients.

Indocyanine green fluorescence mapping of sentinel lymph node in patients with recurrent nasopharyngeal carcinoma after previous radiotherapy.

BACKGROUND: The purpose of this study was to present the feasibility of indocyanine green (ICG) mapping of sentinel lymph node in recurrent nasopharyngeal carcinoma (NPC). M1ETHODS: Peritumoral injection of 5-mg ICG solution and real-time mapping of the sentinel lymph nodes in the neck was performed during surgery. The sentinel lymph node identified was excised and sent separately for laboratory analysis. Selective neck dissection was then performed. The number and level of the sentinel lymph nodes, their signal-to-background ratio, and the histopathology of the sentinel lymph nodes and the neck dissection specimens were studied. RESULTS: A total of 5 patients were recruited into this study, of which 9 sentinel lymph nodes were identified. The majority of them were located in level II. The mean detection time after ICG injection was 288 seconds. The sentinel lymph nodes in 3 patients tested positive for malignancy. None of the selective neck dissection specimens harbored microscopic tumor deposits. CONCLUSION: ICG mapping of sentinel lymph nodes in locally recurrent NPC is potentially feasible. It offers a better nodal staging in patients with clinically N0 disease status.

Morbidities after maxillary swing nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: The purpose of this study was to investigate the complications after maxillary swing nasopharyngectomy. METHODS: Salvage nasopharyngectomy was performed for 338 patients during 1990 to 2012. Patient and tumor characteristics, perioperative and intraoperative information, and long-term morbidities were analyzed. RESULTS: There were significantly more patients with locally advanced tumors (rT3 and rT4) operated during the recent study period (2002-2012). However, the mean operative time and blood loss was significantly lower than in the earlier period (1990-2001). There was no hospital mortality. There was a significant reduction in the postoperative trismus and palatal fistula formation. Patients with locally advanced tumor, particularly those who required adjuvant chemoradiation, had a higher chance of facial numbness, nasal blockage, and swallowing problems after surgery. CONCLUSION: Salvage nasopharyngectomy via the maxillary swing approach is safe with acceptable long-term morbidities. Prevention of complications associated with surgery, particularly for patients with locally advanced tumors, is crucial to ensure the best outcome of surgery.

Trans-oral brush biopsies and quantitative PCR for EBV DNA detection and screening of nasopharyngeal carcinoma.

OBJECTIVES: To evaluate a newly developed noninvasive ambulatory, quantitative polymerase chain reaction (Q-PCR) Epstein-Barr virus (EBV) DNA detection and screening system (NP Screen™) for nasopharyngeal carcinoma (NPC). STUDY DESIGN: Correlation of the nasopharyngeal epithelial EBV-DNA levels and clinical findings by nasopharyngoscopy and final pathologic diagnosis of NPC with biopsy. SETTING: Multicenter ENT/Oncology clinics in Hong Kong (Radiation Oncology Clinic at the Queen Elizabeth Hospital and Radiation Oncology Clinic and Head and Neck Clinic, Queen Mary Hospital, University of Hong Kong) and in Toronto, Canada (the Otolaryngology-Head and Neck Clinic at the Rouge Valley Health System and 2 large ENT practices in Toronto). METHODS: A single-use trans-oral brush was used for rapid, nontraumatic nasopharyngeal (NP) epithelial cells DNA harvest in 600 Chinese patients, combined with a preservation and shipping kit for remote, real-time Q-PCR EBV DNA determinations. RESULTS: All 600 patients had NP brushings using NP Screen in an ambulatory environment, and no adverse events or complications were recorded. A final 578 patients were included with sufficient amount of DNA for completion of the Q-PCR assay. Of these 578 patients, 94 were confirmed positive for NPC histologically. The study yielded a sensitivity of 98.9%, specificity of 99.3%, positive predictive value (PPV) of 96.9%, and negative predictive value (NPP) of 99.7% for NP Screen in detecting NPC. Endoscopy had a sensitivity of 94%, specificity 97.1%, PPV 85%, and NPP 98.9%. CONCLUSIONS: The trans-oral brushing system fulfills the characteristics of a noninvasive, sensitive, specific detection method suitable for routine, large-scale ambulatory NPC risk assessment for high-risk NPC populations.

Multivariate analysis of prognostic factors for salvage nasopharyngectomy via the maxillary swing approach.

BACKGROUND: The purpose of this study was to investigate the prognostic factors for salvage nasopharyngectomy. METHODS: A retrospective review was conducted on maxillary swing nasopharyngectomy performed between 1998 and 2010. Univariate and multivariate analyses identified prognostic factors affecting actuarial local tumor control and overall survival. RESULTS: The median follow-up duration was 52 months. Among the 268 patients, 79.1% had clear resection margins. The 5-year actuarial local tumor control and overall survival was 74% and 62.1%, respectively. On multivariate analysis, tumor size, resection margin status, and gross tumor in the sphenoid sinus were independent prognostic factors for local tumor control. For overall survival, resection margin status, synchronous cervical nodal recurrence, and cavernous sinus invasion had a negative influence on overall survival after surgery. CONCLUSION: Extent of nasopharyngectomy should be tailored to the individual tumor to achieve clear resection margins. Cavernous sinus invasion is associated with poor survival outcome, and detailed counseling and meticulous surgical planning is crucial in such circumstances.

Radiation-induced squamous cell carcinoma of the nasopharynx after radiotherapy for nasopharyngeal carcinoma.

BACKGROUND: The purpose of this study was to investigate the treatment outcome of radiation-induced squamous cell carcinoma (SCC) of the nasopharynx after radiotherapy (RT) for nasopharyngeal carcinoma (NPC). METHODS: We conducted a retrospective review of patients who underwent radiation therapy for NPC, which resulted in radiation-induced SCC of the nasopharynx. RESULTS: Between 1998 and 2011, 24 patients had radiation-induced SCC of the nasopharynx. The median age of diagnosis was 68.2 years. The majority of patients (66.7%) presented with early-stage NPC initially, and they were treated with RT alone (n = 18) or concurrent chemoradiation (n = 6). The mean latency period for the second malignancy was 10.5 years. All the patients were treated with maxillary-swing nasopharyngectomy. Clear resection margin was achieved in 66.7%, and 75% of those with involved margin received adjuvant RT. The mean follow-up duration was 48.2 months. The overall 5-year actuarial local tumor control was 56% and the overall 5-year disease-free survival was 38%. CONCLUSION: Radiation-induced SCC of the nasopharynx is rare after RT for NPC. The prognosis remained poor despite aggressive surgery and adjuvant RT.

Stenting of the eustachian tube to prevent otitis media with effusion after maxillary swing approach nasopharyngectomy.

OBJECTIVES/HYPOTHESIS: Our previous report recommended that the management of ipsilateral otitis media with effusion (OME) after maxillary swing nasopharyngectomy was observation. The idea of introducing a stent into the eustachian tube (ET) at the nasopharyngeal side after nasopharyngectomy may prevent postoperative OME. The purpose of this study was to examine the feasibility of intraoperative ET stenting and the efficacy of preventing ipsilateral OME formation. STUDY DESIGN: Prospective cohort study. METHODS: From 2009 to 2011, 28 patients with nasopharyngectomy via the maxillary swing approach were recruited. Patients with curative resection were recruited (n = 21). ET stenting was performed intraoperatively using a 16-gauge Angiocath (BD Medical Systems, Franklin Lakes, NJ) with dimensions of 1.7 mm × 30 mm. The stent stays inplace indefinitely. The otologic status was evaluated using otoscopy, pure-tone audiogram, and tympanogram at 3 months, 6 months, and 1 year after the surgery. The outcomes were analyzed and compared with historical control. RESULTS: There were 9 (43%) patients with no OME at 6 months after surgery, and 15 (71%) patients had no OME at 1 year postoperatively. The results were statistically significant (P < .0001) when compared with our historical control of no ET stenting. There was no incidence of adverse effects of the stenting, such as acute otitis media, dislodgement of the stent, otalgia, and nasal pain. CONCLUSIONS: ET stenting was feasible after nasopharyngectomy. ET stenting prevented a significant number of patients from suffering from ipsilateral OME and alleviated the symptoms of unilateral aural fullness and unilateral conductive hearing impairment up to at least 1 year after the surgery. ET stenting is recommended in all patients after maxillary swing nasopharyngectomy.

Surgical salvage for recurrent retropharyngeal lymph node metastasis in nasopharyngeal carcinoma.

BACKGROUND: The purpose of this study was to analyze the surgical management of recurrent retropharyngeal lymph node metastasis after radiotherapy for nasopharyngeal carcinoma (NPC). METHODS: We conducted a prospective analysis of preoperative imaging, surgical approach, and oncological results. RESULTS: Between 1990 and 2011, 82 patients were included. The mean size of the retropharyngeal lymph node on MRI was 1.6 cm, and the mean standardized uptake value maximum (SUVmax) on positron emission tomography (PET) scan was 6.8. All the retropharyngeal lymph nodes were resected via the maxillary swing approach. Among the resected retropharyngeal lymph nodes, 87.8% contained viable tumor cells. The rate of microscopic extracapsular spread was 30.6%. The mean follow-up duration was 38 months. The 5-year actuarial tumor control and the overall disease-free survival of patients who underwent surgeries for isolated recurrent retropharyngeal lymph node metastasis was 79.6% and 59%, respectively. CONCLUSION: A PET scan is potentially useful in diagnosing persistent or recurrent retropharyngeal lymph node after previous radiotherapy for NPC. The maxillary swing approach allows surgical resection with clear margins in order to achieve the best oncological outcome.

Quality of dying in head and neck cancer patients: the role of surgical palliation.

To study the role of surgery for symptom palliation in patients with advanced head and neck malignancy. Between 2000 and 2011, patients with locoregionally advanced cancer in the head and neck region, who chose surgical palliation for symptom control, were studied retrospectively. During the study period, 52 patients were included. The index tumour included carcinoma of the maxilla (23.1 %), tongue (19.2 %), larynx/hypopharynx (15.4 %), post-radiation sarcoma (11.5 %), primary sarcoma (11.5 %), carcinoma of the lower alveolus (11.5 %), nasal mucosal melanoma (3.9 %) and metastatic tumour in the head and neck region (3.9 %). The major symptoms included bleeding (53.9 %), tumour pain (19.2 %), dysphagia (11.5 %), non-healing ulcerations (7.7 %), airway obstruction (5.8 %) and pathological fracture of the mandible (1.9 %). Ligation of the carotid artery was performed in 10 patients, complete resection of tumour in 35, and surgical debulking of the tumour in 7 patients. Mean survival of the patients was 5.6 months. The majority of the patients achieved satisfactory and persistent control of symptoms. One patient died from pneumonia during the hospital stay, and the rest were discharged after a mean duration of 16.4 days. In selected patients, surgery is effective in palliating symptoms which are otherwise difficult to manage. Detailed planning and good communication is the key to success in improving the quality of dying.