Surgical management for residual or recurrent diseases in the neck after radiotherapy in nasopharyngeal carcinoma

Abstract

To investigate the surgical managements for residual or recurrent diseases in the neck after radiotherapy in nasopharyngeal carcinoma. Seventy-eight cases of neck masses (39 cases for unilateral residual diseases, 9 for bilateral residual diseases and 30 for recurrent diseases) after radiotherapy in nasopharyngeal carcinoma who were treated surgically between January 1990 and December 2005 were retrospectively analyzed. There were 56 males and 22 females. Their ages ranged from 28 to 65 years (median 41 years). There were 27 patients with skin involvement. After preoperative imaging assessment, 17 patients whose common carotid arteries or internal carotid arteries were difficult to separate routinely attained the carotid balloon occlusion test which confirmed that 15 cases of cerebral arterial circle open to compensation, however, two cases of poor compensation. Surgical procedures included expanded neck mass resection (21 cases), unilateral radical neck dissection (49 cases) and bilateral radical neck dissection (8 cases). Of them 5 patients were with unilateral internal carotid artery resection. Neck defects were repaired with pectoralis major muscle flaps (15 cases), free anterolateral femoral skin flaps (9 cases) and trapezius muscle flaps (3 cases). Of the 78 patients, 13 with microscopic positive diseases and 2 with residual diseases in internal carotid artery walls underwent postoperative radiotherapy, with the doses of 45 to 50 Gy. All patients were closely followed-up more than 5 years. Three- and five-year survival rates were 46.2% and 28.3% respectively. Neck defects were successfully repaired with skin flaps immediately after resecting diseases in 27 cases, only one patient with delayed healing. Of 51 patients without skin flap repair, neck wounds healed successfully in 45 patients and with delayed healing in 6 patients. Pathological positive rates of lymph nodes located in the level I, II, III, IV and V were 10.5%, 61.4%, 10.5%, 1.8% and 28.1% respectively. Preoperative balloon occlusion test is required to assess the function of Willis' ring before determining ligation or resection of internal carotid artery. Residual or recurrent diseases commonly exist in level II, VA and III, which should be included in neck dissection. Pectoralis major muscle flap and free anterolateral femoral skin flap are recommended for the repair of neck defect.