Perils of Salvage Surgery

The term “salvage (or ‘rescue’) surgery” has been used to refer to surgical treatment after failure of initial treatment in various scenarios including treatment of delayed neck metastasis, recurrent primary tumors, or even lung metastasis. Undergoing definite RTCT, patients can have two different outcomes: many will achieve a complete response after non-surgical therapy and will not need further treatment, while some of them will have a partial response needing a treatment, to “rescue” them from the failure of the first treatment. But now Salvage surgery is no longer limited to patients who failed radiotherapy or radio chemotherapy, but also includes patients who previously underwent surgical treatment for tumors located from the base of the skull to the lower neck areas (including thyroid cancer).

Merrian-Webster dictionary defines salvage as “the act of saving something (such as a building, a ship, or cargo) that is in danger of being completely destroyed” or “to remove (something) from a place so that it will not be damaged, destroyed, or lost” If neoadjuvant CT is given to downstage the disease (T4b), surgery after NACT is not salvage but a part of a predefined protocol. The term “salvage surgery” is currently used for both: a second attempt after definitive treatment, or a final attempt to cure.

In nutshell Salvage surgery is a “double-edged sword.” It is the best option for many patients with recurrent cancer when original therapy included irradiation, yet it may provide only modest benefit at high personal cost to the patient. The stakes are high because alternatives are of limited value.

Age > 70 years, initial stage IV, disease-free interval< 12 months, and loco-regional recurrence are strong independent pre-operative predictors of poor outcome in patients undergoing salvage surgery. Patients with two or more of these factors should be informed about the low success rate after salvage surgery and alternative treatments may be considered.

The clinical diagnosis of persistent or recurrent squamous cell carcinoma after chemoradiation is often challenging. Radiation and chemotherapy induced changes in mucosa and soft tissue can mimic many of the worrisome signs and symptoms of local recurrence. For example, treatment induced mucositis, pain, edema, dysphagia and hoarseness can be significant and prolonged. Tumor necrosis can leave residual ulceration that is difficult to distinguish from malignancy. Radionecrosis of the mandible and the larynx can occur late after treatment, and present with ulceration, pain and edema. This is often difficult to distinguish from tumor recurrence. Palpation of lymphadenopathy is often problematic because of postradiation neck fibrosis (woody neck).

 Most tumor recurrences occur in the first 2 years after therapy. It is for this reason that clinical guidelines suggest frequent follow-up visits in the head and neck cancer population. Obtaining imaging studies is often the first step in evaluating the patient with suspected tumor persistence of recurrence. Comparison of these images with prior imaging is essential. Interpretation of CT and MRI is challenging in the presence of postradiation changes. If performed 12 weeks after the completion of chemotherapy, PET scanning has been shown to be beneficial in evaluating the presence of persistent disease both at the primary site and in the neck. In the the face of clinical suspicion or positive PET scan, biopsies of suspicious areas should be performed. It is important to remember that biopsies performed less than 10 weeks after the completion of treatment can be erroneously positive because tumor regression continues even after the completion of radiotherapy. It is also important to remember that biopsy of recurrent disease can yield false-negative results. If the clinician maintains a high index of suspicion despite a negative biopsy, it is prudent to continue very close follow up with repeat biopsies of suspicious areas. Over all accuracy of FNA in detecting persistent or recurrent neck disease is only 57%.

The extent of resection required to extirpate tumor in the case of persistent or  recurrent head and neck carcinoma following chemoradiation is unclear. Some authors would advocate tailoring the extent of resection to pretreatment tumor size with appropriate margins, even if the posttreatment tumor is significantly smaller in size. Others would argue that the chemoradiation reduces tumor load, and thus resection margins should encompass only presently active disease, thereby reducing morbidity and the need for extensive reconstruction. This follows the concept that unresectable tumors can be “downstaged” with chemoradiation to make them operable.

The tumors may appear clinically, endoscopically and radiologically smaller in size, it may not be on histologic analysis. Recurrent tumors are often submucosal and difficult to detect on clinical examination, especially among surrounding radiation-induced edema, fibrosis and inflammation. On histology recurrent tumor is much more likely to have perineural spread, contralateral spread and cricoid cartilage invasion. Recurrent tumors tend to be multifocal rather than follow a concentric growth pattern. It is important to remember that preoperative endoscopy and imaging are not always reliable.  Resecting only visible disease  may leave behind microscopic nests of tumor cells. This emphasizes the need for strict frozen section control, even with wide margins of resection. Given the uncertainties involved, the accurate planning of surgery is difficult. The extirpative surgeon, reconstructive surgeon and the patient should always be prepared for a larger than anticipated resection.

In patients with persistent neck disease, there is no doubt that the neck needs to be addressed surgically. The extent of neck dissection, however, is still under debate. A radical or modified neck dissection is certainly efficacious to eradicate persistent neck disease. “Superselective” neck dissection may also be a feasible option.

Salvage surgery has classically been associated with an increased rate of surgical complications. In particular, wound complications such as breakdown and fistula, pharyngoesophageal stenosis and carotid rupture have been reported with increased frequency. With the increased use of free reconstruction, however, the incidence of surgical complications in salvage surgical procedures is decreasing. Regional flap reconstruction, particularly the pectoralis major myocutaneous flap, has been used successfully in salvage surgical reconstruction, especially for large defects involving the oral cavity and oropharynx.

Traditionally, head and neck radiation oncologists have been reluctant to offer re-irradiation as adjuvant therapy for fear of unacceptable toxicity and morbidity.  IMRT has allowed repeat course of radiation to be delivered while minimizing lifetime doses to critical structures such as the spinal cord and brainstem.

Salvage surgery should not be done by every surgeon. Salvage is a difficult and tricky dissection. Salvage should be done by experienced surgical oncologist with judicious use of flaps for covering raw areas.

Dr. A.K. Dewan
Director – Surgical Oncology