Outcome of Salvage Therapy in Isolated Regional Recurrence in Head and Neck Squamous Cell Carcinoma

Abstract

Objectives/Hypothesis Head and neck squamous cell carcinoma (HNSCC) has a high tendency for regional lymphatic spreading. Nevertheless, isolated regional lymph node recurrences are rare, and only limited data regarding its management are available. The aim of this study was to describe treatment modalities and outcomes, and to identify prognostic factors. Study Design Retrospective cohort study. Methods The records of all patients (n = 498) with tumor persistence or recurrence after curatively intended treatment for HNSCC were retrospectively reviewed. Patients with synchronous secondary tumors at initial presentation, tumor persistence, local or locoregional recurrence, and systemic metastases were excluded. Results A total of 76 patients were included. The rate of occult additional metastasis in radiologically uninvolved neck compartments during salvage neck dissection was 25%. The salvaged patients showed a 37.5% 5‐year recurrence‐free survival (RFS). Multivariate analysis revealed initial stage IVA‐B (hazard ratio [HR]: 4.16, P < .01), extracapsular spread (HR: 3.71, P = .04), higher involved/total lymph node ratio (HR: 6.79, P < .01), and soft‐tissue infiltration (HR: 3.27, P < .01) as independent adverse prognostic factors for RFS. Moreover, univariate data analysis identified recurrent stage rcN2‐3; clinical involvement of the neck levels IV, V and/or VI; and smoking as adverse risk factors for RFS. Conclusions This study identifies initial stage IVA‐B, extracapsular spread, higher involved/total lymph node ratio, and soft‐tissue infiltration as independent adverse prognostic factors for RFS following isolated regional recurrences. The incidence of occult additional metastasis of radiologically uninvolved levels during salvage neck dissections was high (25%). Therefore, superselective or selective neck dissection would not have been the adequate type of salvage surgery. Level of Evidence 4 Laryngoscope, 131:67–72, 2021

Salvage neck dissection for isolated neck recurrences in head and neck tumors: Intra and postoperative complications

“…Our results are in accordance with the recent literature 24–26 . Giger et al 25 reported advanced rcN stage in up to 60% of isolated neck recurrences, despite there being 56.6% of cN0 detection at the primary tumor diagnosis; a mean interval of 18.1 months was observed between initial tumor treatment and histological/cytological diagnosis of the IRR.…”

“…Our results are in accordance with the recent literature 24–26 . Giger et al 25 reported advanced rcN stage in up to 60% of isolated neck recurrences, despite there being 56.6% of cN0 detection at the primary tumor diagnosis; a mean interval of 18.1 months was observed between initial tumor treatment and histological/cytological diagnosis of the IRR. Similarly, Léon et al 24 previously recorded rcN2/3 in 97 of 123 IRRs (78.86%) with 66.7% of ENE+, even though no regional involvement of primary tumor was detected in 60.98% of cases; moreover, those authors did not find any relationship between the presence of nodes with extracapsular spread and the local or regional extension of the primary tumor, the initial therapy, or time to regional recurrence on multivariate analysis.…”

“…Finally, in comparison to previous studies on survival in salvage ND in HNSCC patients, our study showed a slightly poorer outcome with a lower OS and DFS (3‐year and 5‐year OS and DFS of 47.31%, 27.04% and 45.22%, 38.76%, respectively) 23–26,32,37,38 . This difference might be due to the high rate of LNR > 10% (47.06%) recorded in our series; this agrees with Ding et al 22 who indicated that the LNR was the most important prognostic factor for OS and DFS in salvage treatment HNSCC patients, having a significant relationship with advanced stage of recurrent disease.…”

“…Despite the advanced nodal stage at presentation, surgery represents the gold standard for treatment in these patients, eventually followed by adjuvant therapy 6,23,25,27–32 . However, salvage ND could be challenging and potentially dangerous in pretreated neck because of the structural changes in tissues undergoing radio(chemo)therapy and/or surgery.…”

Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines, Sixth Edition

“…The reported overall survival outcome for isolated nodal recurrence treated with salvage neck dissection varies from 25 per cent to 56 per cent. 1104,1105 Favourable prognostic factors for survival include p16-positive SCC, complete margins, no extra-nodal extension, low-volume disease, no previous neck treatment and a disease-free interval of greater than six months. 1106 Current evidence suggests regional recurrence occurs generally in the previously treated involved neck levels, regardless of whether the initial modality was surgery or (chemo)radiotherapy.…”