Open Journal of Stomatology, 2011, 1, 189-194
doi:10.4236/ojst.2011.14029 Published Online December 2011 ( OJST
Published Online December 2011 in SciRes.
Salvage surgery after failure of non-surgical therapy for
advanced head and neck cancer
Didier Dequanter1, N. Vercruysse2, M. Shahla1, P. Paulus1, P. Lothaire1
1Department of Head and Neck Surgery, CHU Charleroi, Montigny le Tilleul, Belgium;
2Department of Plastic Surgery, CHU Charleroi, Montigny le Ti lleul, Belgium.
Received 25 July 2011; revised 2 September 2011; accepted 15 September 2011.
Introduction: for organ and function preservation,
chemoradiotherapy is ga ining popularity for primary
treatment of advanced head and neck cancer, re-
serveing surgery for salvage. Methods: Retrospective
outcome analysis to determine the results of salvage
surgery after failure of primary treatment of advan-
ced head and neck cancer by chemora d iothe rapy. 104
patients with advanced head and cancer were initially
treated by chemoradiotherapy. Follow-up was evalu-
ated in 27 patients undergoing salvage surgery for re-
current tumor (larynx n = 13; oral cavity n = 9; hypo-
pharynx n = 5). The initial tumor is stage T3 in 11
cases and T4 in 16 cases. 10 patients had primary
tumors stage III and 17 patients had tumors stage IV.
Results: One postoperative death occured following
surgery. The overall incidence of complications was 9/
27 (%). Recurrent disease developed at the primary
initially treated in 25 cases and in the neck in 2 cases
after a mean follow-up of 11 months (3 - 136 months).
After salvage surgery, loco-regional recurrence and/
or distant disease developed in 10/27 patients after a
mean follow- up of 4 mo nths . 6/10 (60 %) pa tient s died
after re-recurrence despite salvage chemotherapy.
Conclusion: Salvage surgery after failure of initial
chemoradiotherapy is burdened with high morbi-
dity and bad oncological outcome. We demonstrated
that it is difficult to salvage locally recurrent head
and neck cancer especially at more advanced T-st ages
or when tumor recur. The limited effect of surgical
salvage for recurrent tumor need to be addressed
when choosing the initial treatment plan.
Keywords: Head and Neck Cancer; Salvage Surgery;
Advanced Disease
Chemoradiation therapy is gaining popularity for pri-
mary treatment of advanced head and neck cancer, re-
serving surgery for salvage. Chemoradiotherapy is in-
creasingly used for organ and function preservation. In a
substantial amount of patients, chemoradiation failure is
seen. Approximatively, 13% - 24% of patients will, in
reality, requ ire salvage surgery [1].
Data about outcome after salvage surgery is necessary
to assess its value as a second line tool. The two main
aspects for an analysis concern the oncological outcome
on one hand and the morbidity on the other hand. Both
have been reported with broad variation in results among
different groups [1 -4].
This study aims to examine the outcome of salvage
surgery as an additional treatment option in a determined
104 patients initially treated by chemoradioth erapy were
retrospectively reviewed in order to determine the clini-
cal course of patients treated by salvage surgery after
failure of primary treatment. In presence of a locoregio-
nal recurrence, the option of salvage surgery was ana-
lyzed. Absence of distant metastases and feasibility of
complete surgical resection with acceptable postoperative
functional outcome are premises for the indication of
salvage surgery. In case of local recurrence, the surgical
strategy depends on the result of microlaryngoscopy and
CT scan. If possible, partial laryngectomy is taken in to
consideration, otherwise total (pharyngo) laryngectomy
is indicated. The neck was treated simultaneously by
neck dissection of the levels II-V in all cases of local
recurrence. In presence of a persisting neck mass and
radiological suspicious lymph nodes, microlaryngos-
copy and CT scan of the neck are performed in order to
exclude oral, laryngeal or hypopharyngeal recurrence.
Then, neck dissection of the levels II-V was performed
based on the clinical suspicion and without further pre-
operative lymph node biopsy. The patients with previ-
ously untreated T3 and T4 head and neck tumor were
D. Dequanter et al. / Open Journal of Stomatology 1 (2011) 189-194
treated for curative intent by chemoradiotherapy. Suc-
cessful surgical salvage was defined as no evidence of
recurrent cancer at 2 years after salvage surgery and con-
tinuously thereafter. All patients undergoing salvage sur-
gery were analyzed for postoperative morbidity.
104 patients with advanced head and neck cancer re-
ceived concomitant chemoradiotherapy (CRT) as an ini-
tial treatment. At the end of the follow-up, loco-regional
recurrence was observed in 32 patients. 5 patients with
non-responding tumors the proposal salvage surgery.
To determine the significance of clinical factors (such
as age, gender, primary tumor site, TN stage, pTN stage
on the recurrence, the chi-square test was used. A p <
0.05 was considered statistically significant.
Of the 104 patients, 27 patients with recurrent head and
neck cancer tumor were reviewed. The primary site was
the larynx in 13 cases, the oral cavity in 9 cases and the
hypopharynx in 5 cases. The T stage at initial pr e sen t at io n
was T3 in 11 cases, T4 in 16 cases. 10 patients were
stage III and stage IV in 17 cases (Table 1). One postop-
erative death occured following salvage surgery. The
patient died from hepatic disease without showing evi-
dence of tumor.
Recurrence developed at the primary in 25 cases (lar-
ynx in 13 cases, or al cavity in 7 cases and hypopharynx
in 5 cases) and at the neck in 2 cases after a mean fol-
low-up of 11 mont hs (3 - 13 6 months).
Total laryngectomy was needed in 11 cases, a partial
laryngectomy in only 2 cases, a pharyngolaryngectomy
in 3 cases, a buccopharyngectomy in 7 cases and a pha-
ryngectomy in 2 cases. A radical neck dissection as sal-
vage treatment was done in 2 cases. The overall inci-
dence of complications was 9/27 (37.5%). Among the 9
patients, eight patients (who underwent complete (phary-
ngo) laryngectomy developed a pharyngocutaneous fis-
tula. In four cases, the fistula closed spontaneously. In 5
Table 1. Patient characteristics.
Characteristics No. patients
Gender Mal e/Female 22/5
Age (years)
30 - 50 8
51 - 70 16
71+ 3
III 10
IV 17
Primary tumor location
Pyriform sinus 5
Larynx 13
Oral cavity 9
cases, surgical closure of the fistula was needed.
The last patient developed a cervical abcess that re-
solved spontaneously.
After the salvage treatment, loco-regional recurrence
and/or distant metastases developed in 10/27 (42%) pa-
tients after a mean follow-up of 4 months. Recurrence
was diagno sed in the neck and the pr imary site in 2 cases,
in the neck alone in 3 cases, in the neck and with distant
metastases in one case, at the primary site in 4 cases.
Among the 10 patients who developed recurrence af-
ter salvage surgery, 6 patients (60%) died despite salvage
Concomitant chemoradiation (CRT) is gaining popular-
ity for primary treatment of advanced head and neck
cancer, reserving surgery for salvage. However, it has
been reported that the feasibility of salvages therapies
following tumor recurrence is generally low. In his series,
Taki et al. [5] reported that the local recurrence rate of
hypopharyngeal cancer was 43.7% in patients with T2 -
T4 disease after treatment with RT (CT) but salvage
surgery is often the only curative option for recurrent
Patients undergoing salvage surgery can be divided into
two groups: patients with local recurrences on one hand
and patients with persistent lymph node metastases but no
evidence of persistent primary tumor on the other hand.
One the hand, surgical therapy of local recurrence re-
quires radical removal with or without neck dissection.
In our study, the tumor recurrence seemed suitable for
partial laryngectomy in only two cases while in 11 cases
complete laryngectomy was indicated. On one hand, this
is due to the initially advanced tumor stage and one the
other hand, the diagnosis of recurrence is delayed by the
oedema occurring after irradiation.
However, in recent decades, partial laryngectomy has
been used successfully in such patients [3,4]. There is
evidence that salvage surgery following (chemo) radio-
therapy for early stage laryngeal carcinoma gives better
survival rates and enables more often partial resections
than in the presence of advanced initial stages [5-9].
But considering the bad overall survival for salvage
surgery in advanced laryngeal and hypopharyngeal can-
cer, total laryngectomy must be considered the main
procedure for failure after CRT [10]. In our study, partial
pharyngolaryngectomy with or without reconstruction
was done for 11 patients. Of the 11 patients, recurrences
were seen in patients with tumors of the pyriform sinus.
We think that advanced tumor stage with metastatic
spread, h ypopharyngeal localisation and previou s radical
radiochemotherapy have contributed significantly to the
unsatisfying results of salvage surgery. Thereby, an ear-
lier detection of persistent and growing tumor tissue
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D. Dequanter et al. / Open Journal of Stomatology 1 (2011) 189-194 191
after completion of (chemo) radiotherapy might improve
the prognosis of salvage surgery.
Simultaneous neck dissection has been recommended
in the literature because of neck recurrence in previously
unsuspicious neck [11,12]. However, the oncological
value of simultaneous neck dissection in the absence of
suspect lymph nodes has also been questioned [13]. Te-
mam et al. [2] found lymph nodes metastases only in on e
of the 30 patients undergoing salvage surgery for local
recurrence of initially irradiated carcinoma of the head
and neck with cN0 necks. They therefore recommend li-
mitation of neck dissection according to the in itial N sta-
tus. In our series, mostly, the N status after salvage su rge-
ry for local recurrences including neck dissection was
congruent with the N status before chemorad iotherap y in
cases while in one case an initial cN2b stage turned into
a pN0 stage after salvage surgery. This data suggest a
coherence of initial clinical lymph nod es status with that
in case of local recurrence after CRT in most cases. Thus,
less radical neck surgery in absence of initial and preop-
erative lymph nodes metastases has to be discussed.
On the other hand, neck dissection (ND) for persistent
cervical lymph nodes may be judged an overtreatment
for the majority of our patients when no vital tumor
could be found in the neck specimen. None of our pa-
tients with N0 neck developed regional recurrence dur-
ing the follow-up. The indication for neck dissection
(ND) is based upon the clinical suspicion the main pro-
blem in preoperative verification of a metastasis relies in
the difficulty to distinguish scarred lymph node tissue
from nodes containing vital tumor cells. Patients with
histologically confirmed persistent cervical metastases
had a high tendency of further regional recurrences and
distant metastasis. In the literature, neck dissection after
chemoradiotherapy yielded unfavourable results for his-
tologically proven N+ situations. On the other hand, ND
seems to be inappropiate if no vital tumor tissue is de-
tected after excision of suspicious residual nodes. Some
authors advocate a wait and see policy for persistent ly-
mph nodes in head an neck cancer as long as a decrease
in size can be demonstrated after chemoradiotherapy
[14]. Others are in favor of an immediate ND after RC-
HT for all patient with initial N2-N3 [15] or only in N3
[16-19] neck disease even in presence of complete re-
sponse. We believe that salvage ND for suspicion of re-
sidual disease is of low morbidity and should therefore
be recommended in regard to individual tumor control.
Performance of radical instead of selective ND must be
discussed in this context and shou ld examined further.
But not only the type of salvage surgery must be dis-
cussed, but also the selection of patients candidate to sal-
vage surgery is an important issue.
In our series, 10 of the 27 patients with advanced head
and neck cancer presented locoregional recurrence and/
or distant metastases.
Most patients (8/10) who developed a recurrence had
a tumor staged T4. Clearly, the tumor extension should
be an important factor in the selection of patients candi-
date to salvage surgery. Indeed, Schwartz et al. in his
series [20], showed that individuals with stage I-II pri-
mary tumors had significantly improved salvage time
and total survival time compared with those with stage
III-IV primary tumors (p < 0.005 and p < 0.001). Con-
versely, the stage of the recurrent tu mor was not predict-
tive of either improved salvage time and total survival
time. Patients who underwent salvage surgery had signi-
ficantly improved salvage time and total survival time
compared with those who received chemotherapy and/or
radiation therapy (p < 0.001 and p < 0.002). Neither the
stage of the primary or recurrent tumors nor the type of
salvage treatment received significantly correlated with
an improved cure rate. Patients most likely to benefit
from retreatment are those who have primary tumors
stage I-II, recur greater than 6 months after theri initial
treatment and develop recurrences that are amenable to
salvage surgery. In his series, Gleich [21] confirmed the
limited potential for survival in patients who have a re-
currence after treatment for advanced (T3 or T4) pri-
mary site head and neck cancer. 48 patients underwent
salvage therapy for recurrence. The median time to re-
currence was 14 months and the median survival time
was 26.2 months. Among the 28 patients treated for pri-
mary site recurrence, the mean time for recurrence was
12.6 months and the mean survival time was 27.3
months. Only the 5 of the 28 patients had prolonged sur-
vival. The stage of recurrent disease did not influence
the outcome. Among the 20 patients treated for neck
recurrence, the mean time to recurrence was 14 months
and the mean time survival time was 25 months. Six of
the 20 patients had prol o nged survival.
In our study, among the patients treated for neck re-
currence, the mean time to recurrence was 8 months and
the mean time survival time was 18 months.
In his series, Kim et al. [22] determined the factors
predicting the outcome after salvage surgery with mi-
crovascular flap reconstruction for recurr ent sq ua m ou s c e ll
cancer of the head and neck. They concluded that pa-
tients with early cancers are the best candidates for sal-
vage surgery but patients with T3 and T4 and who con-
tinue to smoke after initial diagnosis and treatment are
poor candidate s to unde rgo sal vage surgery.
For Wong et al. [23], surgical salvage is only feasible
for early recurrent tumor. In this series, published by
Goodwin et al. [24], median disease free survival was
17.9 months in 109 patients, and this correlated strongly
with recurrent stage, weakly with recurrent site, and not
at all with time to presalvage recurrence.
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D. Dequanter et al. / Open Journal of Stomatology 1 (2011) 189-194
Therefore, Yom et al. [25] proposed for patients with
T3 T4 tumors a planned clinical, radiographic, and
pathologic restaging at 1 to 2 months after initial treat-
ment. This practice produces improved overall local
control and survival rates compared with the literature
reports for delayed attempted salvage with timing base
don the findings of routine clinical surveillance.
In addition, the chance for salvage surgery was more
limited in patients with hypopharyngeal cancers. In this
series [5], when the recurrence became unequivocal,
most T3 and T4 patients were considered unsuitable to
receive surgical salvage. Only two patients of 18 patients
(11%) who experienced local recurrence achieved long
term survival after surgical salvage. All T4 patients died
within 19 months after the local recurren ce was detected.
By contrast, laryngeal cancer offers more chance to un-
dergo salvage surgery for recurrence [26,27].
Finally, some studies report an acceptable frequency
of postoperative complications such as pharyngo-cuta-
neous fistulas after CRT [4,26].
However, some authors report that preoperative che-
moradiotherapy as a cause of increased postoperative
morbidity in laryngeal and hypopharyngeal surgery as
compared to the primary surgery has been postulated [1,
Clark et al. [29] showed that irradiation increased the
incidence of postoperative pharyngo-cutaneous fistula
from 24% to 38% while Wakisaka [30] et al. noted that
although the frequency of pharyngocutaneous fistula
after RT or CRT was not high, fistula closure tended to
be delayed. In their series, Taki et al. [5] experienced
severe postoperative complications including pharyngo-
cutaneous fistulas in 25% of patients who underwent
laryngopharyngectomy. Such complications could seve-
rely diminish the quality of life for patients.
However, the frequency of published pharyngocuta-
neous fistulas in salvage surgery ranges from 14% to 92%
[28] depending the applied dose [31] the tumor stage and
localisation [14] and ti me from initial therapy [28]. As a
comparison, pharyngocutaneous fistulas after larynge-
ctomy without previous therapy occurred in about 11%
for hypopharyngeal [32] and in 4% for laryngeal carci-
nomas [33].
However, salvage surgery can be performed with ac-
ceptable rate of postoperative complications. In his se-
ries, Agra et al. [34] after analyzing the frequency and
risk factors for postoperative complications after salvage
surgery for recurrent head and neck cancers demon-
strated that salvage surgery can be performed with ac-
ceptable rates of complications Post operative complica-
tions occurred in 66 patients (53.2%). 53 patients (42.7%)
had minor complications and 23 patients (18.5%) had
major ones. There were 4 postoperative deaths (3.2%)
The major factor associated with the overall occurrence
of postoperative complications was the clinical stage of
the recurrent tumor (p = 0.02) the occurrence of minor
complications correlated with the previous treated site,
with complications occurring more often in patients un-
dergoing locoregional versus local treatment (p = 0.004)
major complications were associated with the time be-
tween initial treatment and salvage surgery (p = 0.05).
Although most patients had good functional outcome
only a select group of patients with recurrent SCC achi-
eved long term survival after salvage surgery. In the lit-
erature, only a few articles have been published that
discuss the treatment of patients with rerecurrence.
In our series, rerecurrence was diagnosed in 10 of the
24 patients. After a short follow up, 6 of the 10 patients
Patients with rerecurrence seems not to be candidate
for salvage treatment and are at a high risk for death.
Indeed, patients with rerecurrence who have under-
gone all modalities of therapy, the chances for salvage
are limited.
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