Salvage Nasopharyngectomy Research Articles

The application of temporalis muscle flap in the salvage nasopharyngectomy for advanced recurrent nasopharyngeal carcinoma

Objective: To summarize the application of temporalis muscle flap in the salvage nasopharyngectomy for advanced recurrent nasopharyngeal carcinoma (rNPC), and to provide guidance for the repair of extensive skull base defects in salvage rNPC. Methods: A total of 54 patients with the application of temporalis muscle flap in the salvage nasopharyngectomy for advanced rNPC were retrospectively analyzed, including 42 males and 12 females, aging from 29 to 71 years. There were 36 patients with rT3 and 18 patients with rT4. The surgical methods of temporalis muscle flap repair were summarized. The general situation, survival time and postoperative complications of patients were recorded, and the advantages and disadvantages of temporalis muscle flap were discussed. Results: The temporal muscle flap could completely cover the defect area of nasopharynx and skull base, without the need for other autologous repair materials. The follow-up period was 2 to 28 months. The survival rate of temporalis flap was 98.1% (53/54). The 1-year overall survival rate was 84.5% while 1-year progression-free survival rate was 49.0%. None of the patients had facial nerve injury. Three patients (5.6%) had necrosis of the cranial membrane required surgical intervention and four patients (7.4%) required a chonoplasty due to severe chonostril stenosis or chonostril atresia. Eleven cases (20.4%) had mouth opening restriction, chewing weakness, dysphagia and other eating difficulties. Conclusions: Temporalis muscle flap is an alternative flap for the salvage nasopharyngectomy for advanced rNPC. Temporal muscle flap shows high survival rate and wide coverage, but the surgeon should apprehend the possible complications and reduce the occurrence of them.

Open nasopharyngectomy—Facial translocation approach

Salvage nasopharyngectomy has become the mainstay of treatment after radiotherapy failure for nasopharyngeal carcinoma. However, surgical access to the nasopharynx has always been a challenge to head and neck surgeons. Various surgical approaches to the nasopharynx includes transpalatal, transmaxillary, midline mandibulotomy, transpterygoid, facial translocation, and infratemporal fossa approaches. The facial translocation approach is based on the principle of disassembling of vascularized midfacial composite units, permitting wide access for the treatment of tumors at nasopharynx, anterior skull base, paranasal sinuses, pterygomaxillary and infratemporal fossa, and the orbit. The facial translocation approach offers previously unavailable wide and direct exposure and allows extensive resection of tumors in the above areas. Facial translocation also preserves critical structures through approximation and fixation of the facial fragments after the operation, with a potential for immediate reconstruction of the complex region of the nasopharynx and cranial base.

The Management of rNPC: Salvage Surgery vs. Re-irradiation.

Treatment failure, in the form of either persistence or local recurrence, occurs in 10 to 30% of nasopharyngeal carcinoma patients after initial radiotherapy (RT). Early detection of persistent or recurrent disease aids in the recognition of tumors that can be candidates for salvage nasophayngectomy or re-irradiation. There is no consensus till now on the indications or selection of the above two salvage treatment. In recent years, there has been a paradigm shift from open to endoscopic approach for nasopharyngectomy, which carries nearly no complications. For salvage re-irradiation, intensity-modulated radiotherapy (IMRT) is the most commonly indicated modality. Compared to IMRT, salvage endoscopic nasopharyngectomy may be more beneficial in terms of prolonging survival, improving quality of life, and minimizing treatment-related complications and medical costs in a selected subset of recurrent nasopharyngeal carcinoma (rNPC) patients. Salvage nasopharyngectomy should be the mainstay of treatment for rNPC.

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

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. 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. 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. The 3D high-definition endoscopic system improves the precision of endoscopic nasopharyngectomy, particularly when dissection of the internal carotid artery and dura is required. 4. Laryngoscope, 128:1386-1391, 2018.

Reconstructive Flaps After Salvage Nasopharyngectomy

Reconstructive Flaps After Salvage Nasopharyngectomy

Analysis of clinical efficacy and the quality of life after endoscopic nasopharyngectomy for residual or recurrent nasopharyngeal carcinoma

To explore the clinical efficacy of patients who underwent endoscopic salvage nasopharyngectomy for residual or recurrent nasopharyngeal carcinoma (rNPC) after irradiation failure, and examine the quality of life (QOL) of them who were at different tumor stage and given different postoperative treatment. Ninety-six patients who underwent endoscopic salvage nasopharyngectomy for rNPC between June 2009 and March 2015 were retrospectively reviewed. rTNM stage: 20 cases were at stage I, 16 at stage II, 44 at stage III, 16 at stage IV; rT1 22 cases (22.9%), rT2 16 cases (16.7%), rT3 42 cases (43.8%), rT4 16 cases (16.7%); rN0 92 cases (95.8%), rN1 2 cases (2.1%), rN2 2 cases (2.1%); No with distance metastasis. All the patients underwent endoscopic resection of lesions, and four cases with cervical metastasis received neck dissection at the same time.Postoperatively the self-reported, health-related QOL questionnaires were used to assess and compare the QOL of survival patients.SPSS 19.0 software was used to analyzed the data. The overall 1 year survival rates (SR), 2 year SR, 3 year SR were 83%, 68%, 63%, respectively. The median follow-up was 43 months. Cox regression analysis indicated the complete resection for rNPC and pathology were two independent factors affecting survival. The QOL of patients who received endoscopic salvage nasopharyngectomy only were better than the patients who received concurrent chemoradiation therapy or chemotherapy. The patients who underwent endoscopic salvage nasopharyngectomy for rNPC had a good survival rates and QOL.

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

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. We conducted a whole-organ study of nasopharyngectomy specimens. 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). 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.

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. Prospective, single-group, pre/post test design. Academic medical center. 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. 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. 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.

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. 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. 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. 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.

Surgical salvage of recurrent nasopharyngeal carcinoma.

Nasopharyngeal carcinoma is a unique tumour which is endemic in southern China including Hong Kong. Whilst the treatment results for the primary cancer has been encouraging, management of recurrent tumours has been challenging. Compared to other surgical approaches, the maxillary swing operation provides wide access to the bilateral nasopharynx and the ipsilateral parapharyngeal space, allowing resection of tumours with adequate margins. Among the 312 patients who had received salvage nasopharyngectomy via the maxillary swing approach, the chance of achieving microscopically clear resection margins was 79.5 %. The overall local recurrence rate after surgery was 13.1 %. Multivariate analysis showed that resection margin status, synchronous nodal recurrence and cavernous sinus invasion were independent prognostic factors for overall survival. For small tumours located in the posterior wall, endoscopic resection, or more recently, the transoral robotic (TORS)-assisted approach, can be performed. Every effort should be made to ensure microscopic clearance of disease as well as to minimize the potential complications of surgery that may adversely affect the subsequent quality of life.

Management of Nasopharyngeal Carcinoma: State of the Art

Program Description: Nasopharyngeal carcinoma (NPC) is a distinct and important cancer of the head and neck. As the incidence is rare in Whites, diagnosis can be challenging. However, ear, nose, and throat specialists should be able to manage NPC; therefore, the aim is to provide the attendee a great opportunity to be familiar with some of the current knowledge of the management of NPC, including using Epstein-Barr virus (EBV) as a biomarker to diagnose and monitor NPC, evolution of treatment guidelines of NPC, and salvage nasopharyngectomy for local recurrence in this miniseminar. Educational Objectives: (1) Use EBV as a biomarker to diagnose and monitor patients with NPC. (2) Recognize the evolution and treatment guideline of NPC. (3) Explain the rationale and the various approaches for salvage NPC (open/endoscopic), treatment results, and prognosticators.

Morbidities and Quality of Life after Maxillary Swing Nasopharyngectomy for Recurrent Nasopharyngeal Carcinoma

Background: The maxillary swing approach provides a good access that allows maximal resection of recurrent NPC. The aim of the current study was to report the morbidities and quality of life of patients after surgery. Methods: A prospective study of the early and late morbidities after surgery was performed. A longitudinal investigation of the quality of life before and 1 year after surgery was performed using the self-reported, EORTC questionnaire. Results: Salvage nasopharyngectomy was performed for 338 patients during 1990 to 2012. There was no hospital mortality. The morbidities were actively prevented by modifications of surgical techniques, leading to a significant reduction in the incidence of postoperative trismus (42.1 vs. 9.2%, p = 0.01) and palatal fistula formation (24.0 vs.3.7%, p = 0.01). Patients with locally advanced tumor, particularly those who required adjuvant chemoradiation, had higher chance of facial numbness, nasal blockage, and swallowing problem after surgery. There was no significant change in the mean global health system score after surgery, except those after palliative resection requiring adjuvant chemoradiation. Social functioning had the lowest scores among the five functioning scales in all groups of patients. Palatal fistula significantly affected social eating and weight loss, and osteoradionecrosis caused more pain and nasal discharge, severely affecting the social life of the patients. Conclusions: QOL of patients after salvage nasopharyngectomy.

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

The purpose of this study was to investigate the prognostic factors for salvage nasopharyngectomy. 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. 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. 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.

The role of plasma Epstein‐Barr virus DNA in the management of recurrent nasopharyngeal carcinoma

To study the role of plasma Epstein-Barr virus (EBV) DNA in patients with recurrent nasopharyngeal carcinoma (NPC) after previous chemoradiation. Prospective. Sixty patients with recurrent NPC were recruited, and their plasma EBV DNA was checked preoperatively, 1 week postoperatively, and 6 months thereafter. In a pilot group of 30 patients, further testing was performed at 60 minutes after tumor resection. The plasma EBV DNA level was correlated with tumor T classification, resection margin status, and subsequent relapse. The mean preoperative plasma EBV DNA reflected the tumor load (T1: 48 copies/mL, T2: 316 copies/mL, T3: 890 copies/mL, P = .03). It was significantly higher in patients with positive margins at the time of surgery (722 vs. 126 copies/mL, P = .02) and in those with subsequent systemic metastasis (668 vs. 92 copies/mL, P = .01). However, it failed to predict local recurrence after surgery. Postoperative plasma EBV DNA was undetectable in all patients with positive resection margins. Serial measurements were able to identify 87.5% of local recurrences and 100% of distance metastases. In patients with recurrent NPC requiring salvage nasopharyngectomy, preoperative plasma EBV DNA identifies patients at high-risk of subsequent distant failure after surgery. Serial measurements of plasma EBV DNA after surgery, especially for those with high preoperative levels, is crucial to allow early detection of local of distant failure.

Critical appraisal of maxillary swing approach for nasopharyngeal carcinoma

Background: The aim of the current study was to report results of salvage nasopharyngectomy using the maxillary swing approach for persistent or recurrent nasopharyngeal carcinoma after primary treatment.Methods: Between 1989 and 2011, Nasopharyngectomies were performed in 312 patients. Data were composed of retrospective review of records of the first 72 patients followed by a prospective collection of data for the remaining patients.Results: Among the patients, 41 (13.1%) had persistent tumours and 271 (86.9%) had recurrent disease. Curative resection was achieved in 248 (79.5%) patients. All patients survived the operations. The median follow up duration was 34 months. The overall 5-year actuarial local tumour control was 74% and the overall 5-year disease-free survival was 56%. Those with negative resection margins on frozen section and tumour size less than 1.5 cm in diameter had significantly better local tumour control in the nasopharynx as well as disease-free survival.Conclusions: Maxillary swing nasopharyngectomy is an effective salvage procedure for small, persistent or recurrent tumour in the nasopharynx after primary therapy.

Quality of life of patients after salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma

The objective of this study was to examine the quality of life (QOL) of patients who underwent salvage nasopharyngectomy for residual or recurrent nasopharyngeal carcinoma and to justify the value of the procedure. A self-reported, health-related QOL questionnaire was used to assess the QOL of patients after salvage nasopharyngectomy. The effects of potential complications after surgery also were evaluated. Between 2003 and 2011, 185 patients underwent salvage nasopharyngectomy using the maxillary swing approach. Curative resection was achieved in 80% of patients. There were no significant changes in mean global health system scores after surgery, except after palliative resection requiring postoperative adjuvant chemoradiation. Social functioning scores were the lowest of the 5 functioning scales in all patient groups. Palatal fistula significantly affected social eating and weight loss, and osteoradionecrosis caused more pain and nasal discharge, severely affecting the social life of patients. The QOL of patients after maxillary swing salvage nasopharyngectomy was good. The current results indicated that attention must be paid to the factors that adversely affect QOL after surgery, such as palliative resection, and complications like trismus, palatal fistula and osteoradionecrosis.

Surgical salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma: A multivariate analysis of prognostic factors

The purpose of this study was to identify independent prognostic factors that influenced local relapse-free survival (LRFS) and overall survival (OS) of patients who underwent salvage surgery for residual or recurrent nasopharyngeal carcinoma (NPC). Ninety-seven patients who had been treated with radiotherapy or chemoradiotherapy for NPC underwent a nasopharyngectomy for a residual or recurrent local tumor between November 1987 and June 2007. The subsequent minimum follow-up was 2 years. Univariate and multivariate analyses were performed to identify prognostic factors for LRFS and OS. The 5-year LRFS and OS was 46.7% and 51.9%, respectively. On multivariate analysis for LRFS and OS, respectively, recurrent regional disease (hazard ratio [HR], 3.245; p = .008) and (HR, 4.990; p = .001), and positive surgical margins (HR, 5.963; p = .000), and (HR, 4.912; p = .000) were independent prognostic factors. In patients undergoing surgical salvage nasopharyngectomy for residual or recurrent NPC, positive surgical margins have an independent negative influence on LRFS and OS.

Surgical salvage of persistent or recurrent nasopharyngeal carcinoma with maxillary swing approach — Critical appraisal after 2 decades

The purpose of this study was to report on our experience on salvage nasopharyngectomy using the maxillary swing approach for persistent or recurrent nasopharyngeal carcinoma after primary treatment. Over the past 2 decades, we have performed salvage nasopharyngectomies for 246 patients. Thirty-seven patients (15%) had persistent disease and 209 (85%) had recurrent tumors. All patients survived the operation with minimal morbidity. Negative resection margins were achieved in 191 patients (78%), and 55 patients (22%) had microscopic residual disease. The median follow-up was 38 months. The 5-year actuarial control of disease in the nasopharynx was 74%. The 5-year disease-free survival was 56%. Cox regression model identified the negative resection margin and the size of the tumor as 2 independent factors that affected local control of disease and survival. Maxillary swing nasopharyngectomy is an effective salvage procedure for a small, persistent, or recurrent tumor in the nasopharynx after primary therapy.

Nasopharyngectomy: Does the approach to the nasopharynx influence survival?

To investigate whether the approach used to the nasopharynx to perform a salvage nasopharyngectomy for recurrent or residual nasopharyngeal carcinoma influences survival. A retrospective case series. Eighty patients underwent a nasopharyngectomy via a transpalatal, maxillary swing, or midfacial degloving approach. Local progression-free, locoregional progression-free, and overall survival rates were calculated for each approach. For the whole group (N = 80), there were no significant differences in the survival rates between the three approaches. For the subgroup of patients with recurrent T1 and T2 tumors (n = 68), the local progression-free and locoregional progression-free survival rates were significantly better when a maxillary swing approach was used than when a midfacial degloving approach was used. The maxillary swing approach is associated with significantly better survival rates than the midfacial degloving approach when used to perform a salvage nasopharyngectomy for residual or recurrent T1 and T2 nasopharyngeal carcinoma.

Nasopharyngectomy for recurrent nasopharyngeal carcinoma: a review of 53 patients and prognostic factors

Conclusions. Salvage surgery is a justified treatment for primary recurrence of nasopharyngeal carcinoma (NPC). Skull base surgery can play a role in rescuing patients with more advanced local recurrence of NPC. Objectives. The purpose of this study was to report the local control and overall survival outcome of patients with (NPC) with local failure who received salvage nasopharyngectomy and to identify prognostic factors. Patients and methods. Fifty-three consecutive patients who had primary recurrence of NPC and underwent salvage surgery with curative intention from July 1993 to December 2006 were retrospectively reviewed. The follow-up time ranged from 5.1 to 142.2 months. The numbers of cases of recurrent NPC stage were as follows: stage I, 26; stage II, 9; stage III, 10 and stage IV, 8. Fifty patients had one course of radiation therapy while 3 had two courses of radiation therapy before the salvage surgery. For the nasopharyngectomy, 2 patients underwent endoscopic approach and 33 underwent facial translocation, while 18 had craniofacial resection. Postoperative adjuvant treatment included radiation therapy, 4 cases; radiosurgery, 8 cases; concurrent chemoradiation therapy, 7 cases; and chemotherapy, 2 cases. Results. The 5-year local control rates were T1, 58.3%; T2, 27.8%; T3, 53.3%; T4, 75.0%; and all stages, 53.6%. The 5-year overall survival rates were stage I, 64.8%; stage II, 38.1%; stage III, 25.9%; stage IV, 46.9%; and all stages, 48.7%. Multivariate analysis revealed that gender, margin status, adjuvant treatment type and parapharyngeal space involvement were significant impact factors of local control, whereas dura or brain involvement, local recurrence and adjuvant treatment type were significant impact factors of survival.