Salvage Neck Dissection Research Articles

Extent of salvage neck dissection for residual or recurrent cervical nodal disease.

Extent of salvage neck dissection for residual or recurrent cervical nodal disease.

Salvage neck dissection following definitive radiation

Salvage neck dissection describes removing cervical lymph nodes and disease following definitive radiation. Unique challenges include a fibrotic field with disease that is frequently more advanced than surgery in the primary setting. The surgical approach may vary depending on the extent of locoregional disease. Review of clinical data is necessary to design a surgical plan. Special considerations include having a reconstructive plan, if needed, for soft tissue reconstruction and great vessel coverage.

FGD-PET/CT three months after (chemo)radiotherapy for head and neck squamous cell carcinoma spares considerable number of patients from a salvage neck dissection

PurposeIn the last decades FDG-PET/CT is increasingly used in combination with the standard diagnostic modalities (MRI + US-FNA) to identify residual neck disease (RND) after (chemo)radiotherapy for head-and-neck squamous cell carcinoma (HNSCC). The purpose of the current study is to identify the impact of increasing use of FDG-PET/CT on the accuracy of patient selection for salvage neck dissection (SND). Materials and methodsBetween 2008 and 2022, 908 consecutive patients with node-positive HNSCC were treated with (chemo)radiotherapy in our institution. Primary endpoint: positive predictive value (PPV) of FDG-PET/CT for pathologic-confirmed RND (pRND) after SND, compared to the standard of care; MRI + US-FNA. Secondary endpoints: oncologic outcomes. ResultsOf the entire group, 130 patients (14 %) received SND. Of them only 53 patients (41 %) had pRND at the SND-specimens. The PPV of FDG-PET/CT for the detection of pRND was considerably better, compared to MRI + US-FNA; 89 % and 65 %, respectively. If FDG-PET/CT showed metabolic CR, these patients did not undergo SND. The NPV was 97.5 %, as only 2.5 % of these patients developed delayed regional failure.FDG-PET/CT considerably improved the accuracy of patient selection for SND, as significantly more patients treated in the second period, compared to first period of the study (n = 454 each) still had vital tumor at SND-specimen (53 % and 31 %, p = 0.008). Regional recurrence free-survival, DFS, OS and HNSCC-death were significantly worse in patients with pRND (p < 0.05) ConclusionsIncorporating FDG-PET/CT into the diagnostic pathway for the response evaluation after (chemo)radiotherapy significantly improved the accuracy of patient selection for SND and spared considerable number of patients (>20 %) from unnecessary SND. For patients with metabolic CR, SND can safely be omitted while for patients with no metabolic CR, SND is strongly advocated.

When should patients with T1N0 oral squamous cell carcinoma be considered for elective neck dissection?

To identify adverse pathological features (APF) predicting nodal failure in clinically node negative T1 oral squamous cell carcinoma (OSCC). This study evaluated patients with T1N0 (≤5 mm depth of invasion (DOI) and ≤2 cm diameter) oral cancers from a prospectively maintained database between 1988 and 2020. All patients underwent surgical excision of the primary lesion without neck dissection. Patients underwent three monthly clinical surveillance and salvage neck dissection was performed if nodal relapse was diagnosed. Overall, 141 patients were included. Nodal relapse was reported in 16/141 (11.3%) patients. Factors impacting regional recurrence-free survival were DOI ≥3 mm (HR: 2.4, P < 0.001), maximum tumour diameter ≥12 mm (HR: 1.1, P = 0.009), perineural invasion (PNI) (HR 7.5, P = 0.002) and poor differentiation (HR 5.3, P = 0.01). Rates of nodal relapse increased from 2% amongst patients with no APFs to 100% for those with four APFs. Patients with two or more APFs had significantly poorer 5-year regional recurrence-free survival (94.8% vs. 56.3%, P < 0.001). Patients with T1N0 OSCC with two or more APFs (DOI ≥3 mm, diameter ≥12 mm, PNI or poor differentiations) should be considered for elective neck dissection.

Long-term outcomes of patients with oral cavity cancer receiving postoperative radiotherapy after salvage neck dissection for cervical lymph node recurrence.

We aimed to clarify the outcomes of postoperative radiotherapy (PORT) after salvage neck dissection for cervical lymph node (LN) recurrence in oral cavity cancer. We retrospectively evaluated overall survival (OS), recurrence-free survival (RFS), recurrence patterns, and adverse events of 51 patients with high-risk features receiving PORT after salvage neck dissection between 2009 and 2019. After a median follow-up of 7.4 years from PORT initiation, the 7-year OS and RFS rates were 66.3% (95% CI: 54.0-81.3) and 54.6% (95% CI: 42.1-70.9), respectively. Age <70 years and isolated LN recurrence were significantly associated with longer OS and RFS. Among the 22 patients who experienced recurrence, 14 experienced recurrence within the radiation field. PORT-related grade 3 acute mucositis (35%) and late adverse events (osteoradionecrosis [4%] and laryngeal stenosis [2%]) were observed. PORT after salvage neck dissection for cervical LN recurrence achieved good survival with acceptable toxicity.

Value of PET imaging in head and neck cancer

The combination of positron-emission tomography (PET) with cross-sectional imaging in particular is becoming increasingly important in the diagnosis of head and neck tumors because, in addition to pure anatomy, the metabolic activity of tissue can be visualized and assessed. The combination of PET and computed tomography (CT) is already an established procedure in head and neck tumor patients in some indications, e.g., for primary tumor detection in cancer of unknown primary (CUP) syndrome or also after completed primary radio(chemo)therapy for evaluation of response, especially also with regard to nodal status. In some cases, salvage neck dissection can thus be avoided in the case of PET-negative findings. In the context of primary diagnosis, PET/CT imaging can be used primarily to evaluate distant metastasis. According to current guidelines, PET-based imaging is not (yet) of value in determining the local extent at initial diagnosis. Achallenge is the still limited reimbursement by health insurance companies, which currently allow only certain indications, and the still lack of nationwide coverage.

Results of salvage neck dissection after chemoradiation in locally advanced head and neck squamous cell carcinoma.

Salvage surgery is mandatory when regional persistence/recurrence after chemoradiation. The aim of this study is to describe the outcomes of salvage surgery. A retrospective study was conducted in patients with locally advanced head and neck squamous cell carcinoma that were primarily treated with chemorradiation and underwent salvage neck dissection (ND) with suspected recurrent/persistent nodal disease. All patients had a response evaluation at 12weeks through clinical examination and computed tomography-positron emission tomography. Decision for ND was taken in case of suspected persistence or if there was suspicion of recurrence, histologically confirmed. There were 40 patients included. 32/40 (80%) ND were done because of confirmed/suspected persistence and 8/40 (20%) were done because of recurrences. Persistence was confirmed histologically in 14/32 (43.8%) cases and recurrence in 6/8 (75%) cases. Median survival from diagnosis was 39months (95% CI 28.162-49.838). Significant differences were observed between patients who had viable tumour cells in the sample and those who did not, but the differences were only significant when only deaths due to tumour progression were considered (p = 0.014). 14/32 (43.8%) patients with suspected or confirmed persistence developed a recurrence after the ND and 3/8 (37.5%) patients with suspected or confirmed recurrence developed a new recurrence. New recurrences were more frequent in cases that had viable tumor in the specimen. Patients with nodal persistence/recurrence have a poor prognosis, even after salvage surgery. However, in a substantial number of patients the disease is controlled after ND, so it should be offer to these patients.

Disease Control and Toxicity Outcomes after Intraoperative HDR Brachytherapy for Neck Recurrences in Patients Previously Irradiated Head and Neck Cancer

Despite recent advances in local and systemic therapies for head and neck squamous cell carcinomas (HNSCC), the most common types of treatment failure remain local and regional. Patients with HNSCC also have a higher risk of developing secondary head and neck tumors due to a field cancerization phenomenon. Treatment of these recurrences poses a challenge, particularly in patients having previously received full dose external beam radiotherapy (EBRT) to the head and neck region. This study evaluates the clinical outcomes of intraoperative Harrison-Anderson-Mick applicator (HAM) HDR brachytherapy (BT) after salvage neck dissection for neck recurrences in patients previously irradiated for HNSCC. All patients having received HAM BT for HNSCC neck recurrences at a single institution were identified. Demographic, treatment, disease control and toxicity data were collected retrospectively. Toxicity was graded as per Common Terminology Criteria for Adverse events version 5. The Kaplan Meier method was used to assess overall survival (OS) and ipsilateral regional control (IRC) from the time of HAM BT. Nineteen patients with regional recurrence of HNSCC were treated with HAM BT Ir-192 between July 2006 and June 2022, with a median follow-up for survival of 51.4 months (range: 2.5-186.7). The median BT dose was 12.5 Gy delivered intraoperatively at 5 mm tissue depth/1 cm from source. Fifteen patients (78.9%) also received postoperative EBRT to a median dose of 46 Gy in 23 fractions and 13 (68.4%) received systemic therapy. Six patients (31.6%) developed ipsilateral neck recurrences (4 who had adjuvant EBRT and 2 who did not), 2 patients had primary site recurrences and 5 patients developed distant metastases. In terms of acute toxicity, 4 patients had grade 3 dysphagia requiring feeding tube (FT) placement and one patient required surgical intervention for wound necrosis. In terms of late toxicity, 2 additional patients required FT placement and 1 was able to have it removed. No grade 4+ late toxicities were noted. The IRC at the site of HAM BT at 1 year was 71.5% and 63.6% at 5 years. The 1-year OS was 81.3% and 5-year OS was 40.9%. Intraoperative HAM BT resulted in favorable rates of IRC with acceptable toxicity in the reirradiation setting for HNSCC.

Tailoring Radiation to the Contralateral Neck for Midline HPV-Mediated Oropharyngeal Squamous Cell Carcinoma (p16+ OPSCC)

De-intensification strategies for locally advanced p16+ OPSCC are under active investigation, including omission of contralateral neck radiation (RT) for well-lateralized T1-2N0-2a. This study evaluates the outcomes of omitting contralateral neck nodal levels for p16+ OPSCC that are not well-lateralized. A retrospective review was done of 134 consecutive patients with non-metastatic p16+ OPSCC that were not well-lateralized (< 1 cm from midline or ≥ 1 cm extension to soft palate or base of tongue) who were treated with definitive chemoradiation from 2013 to 2019. IMRT to an EQD2 6364-6735 cGy (200-220 cGy per fraction) was used to treat the primary tumor and ipsilateral or bilateral neck, with tailored nodal level coverage and dose, and with concurrent paclitaxel and carboplatin. Contralateral neck RT was tailored in 121 patients: omitted in 11, limited to level II in 9, and limited to level II and III in 101 (contralateral lower neck omitted); the remaining 13 had bilateral level II-IV neck RT. Local and regional recurrences were evaluated. Median follow up was 45.34 months. Local and/or regional recurrence was noted in 9/134 (6.7%). 3 (2%) recurred in the contralateral neck in unirradiated tissue (out-of-field). All three were salvaged. The remaining 6 recurrences (4%) were in-field; one was at the primary site and 5 were nodal (all ipsilateral). 4 of the 5 regional recurrences were in a location that was treated to EQD2 7000 cGy (all had PET avid nodal disease upfront that was included in the high dose level); the other region of recurrence was treated to an EQD2 6353 cGy (the only recurrence in a never smoker). 4 of the 5 neck recurrences underwent neck dissection; one further underwent adjuvant RT to 5940 cGy in 33 fractions and remains disease-free. 2 of those who underwent salvage neck dissection alone subsequently developed distant metastases. The majority of first recurrences were distant, 19.4% (26/134). 3-year progression free survival (PFS) was 74.41% (95% CI, 65.63-81.26). Taken together, regional recurrence rate in the contralateral, unirradiated neck was 2.5% (3/121) and ultimate locoregional control was 99% (132/134). Our tailored approach demonstrates a contralateral neck local control of 97.5% (118/121) regardless of tumor lateralization; those who recurred in unirradiated cervical lymph nodes were successfully salvaged. Limiting this analysis is moderate sample size and retrospective nature, but it raises important alternative de-escalation strategies (RT volume reduction) for p16+ OPSCC aside from dose reduction, which is under active investigation in phase II/III trials. Improved systemic therapies are needed to combat distant metastases. Prospective randomized clinical trials are needed for further evaluation of nodal omission for definitive chemoradiation of non-well-lateralized p16+ OPSCC.

Value of PET imaging in head and neck cancer

The combination of positron-emission tomography (PET) with cross-sectional imaging in particular is becoming increasingly important in the diagnosis of head and neck tumors because, in addition to pure anatomy, the metabolic activity of tissue can be visualized and assessed. The combination of PET and computed tomography (CT) is already an established procedure in head and neck tumor patients in some indications, e.g., for primary tumor detection in cancer of unknown primary (CUP) syndrome or also after completed primary radio(chemo)therapy for evaluation of response, especially also with regard to nodal status. In some cases, salvage neck dissection can thus be avoided in the case of PET-negative findings. In the context of primary diagnosis, PET/CT imaging can be used primarily to evaluate distant metastasis. According to current guidelines, PET-based imaging is not (yet) of value in determining the local extent at initial diagnosis. Achallenge is the still limited reimbursement by health insurance companies, which currently allow only certain indications, and the still lack of nationwide coverage.

Survival outcome of patients undergoing salvage surgery for hypopharyngeal cancer after failure of primary curative treatment: a retrospective study

ObjectivesSalvage surgery for hypopharyngeal cancer remains a major challenge, and only a few studies have been conducted. In this study, we review our 10 years of experience in treating patients with hypopharyngeal cancer. The main aim of this study is to analyze survival outcomes in patients who underwent salvage surgery compared with those who had complete remission or inoperable residual tumors.MethodsChart reviews were performed for all patients with hypopharyngeal squamous cell carcinoma who underwent curative treatment at a tertiary care hospital between 2009 and 2019. Data on survival, clinical course, and complications were analyzed.ResultsSalvage surgery was performed in 15 of the 34 patients with residual hypopharyngeal cancer. Of these, 10 patients with isolated residual neck disease underwent salvage neck dissection, and five patients with residual primary tumors underwent salvage total or partial laryngopharyngectomy.The overall 3-year survival rate of patients who underwent salvage surgery was 33.3%. Patients who underwent salvage neck dissection alone had significantly better survival rates than those who received palliative treatment, with median survival times of 21 and 12 months, respectively. The median survival time of patients who underwent laryngopharyngectomy for residual primary tumors was 14 months, which was not significantly different from that of patients who received palliative treatments.ConclusionSalvage surgery was associated with improved survival in patients with hypopharyngeal cancer and isolated residual neck disease. Nevertheless, the survival benefit of salvage surgery in patients with residual primary disease remains unclear.

WPOI-4/5 Correlates With Lymph Node Recurrence and Poor Prognosis in Early-stage Tongue Squamous Cell Carcinoma.

Neck management in patients with early-stage tongue cancer remains controversial. The worst pattern of invasion (WPOI) of the primary tumor has been associated with the incidence of regional metastasis. We investigated the prognostic role of WPOI, especially in relation to regional lymph node recurrence and disease-specific survival (DSS). We retrospectively reviewed medical records and evaluated tumor specimens of 38 patients with early-stage tongue cancer who underwent primary tumor resection without elective neck dissection. Regional lymph node recurrence rates were significantly higher in patients with WPOI-4/5 compared with WPOI-1 to -3. The 5-year DSS rates were significantly higher for WPOI-1 to -3 than for WPOI-4/5. Notably, patients with WPOI-1 to -3 achieved a 100% 5-year DSS rate with salvage neck dissection and postoperative treatment, even those with cervical lymph node recurrence, whereas patients with WPOI-4/5 had a poorer prognosis. Patients with WPOI-1 to -3 tumors can be followed up without neck dissection until regional lymph node recurrence is detected, with a good course after salvage treatment. In contrast, patients with WPOI-4/5 tumors who are followed up until the appearance of regional lymph node recurrence have a poor prognosis, even with adequate treatment for recurrent disease.

Histopathological Analysis of Nodal Disease After Chemoradiation Reveals Viable Tumor Cells as the most Important Prognostic Factor in Head and Neck Squamous Cell Carcinoma

BackgroundIn head and neck squamous cell carcinoma (HNSCC), salvage neck dissection (ND) is required after primary chemoradiation in case of residual nodal disease. Upon histopathological examination, viability of tumor cells is assessed but little is known about other prognostic histopathological features. In particular, the presence of swirled keratin debris and its prognostic value is controversial. The aim of this study is to examine histopathological parameters in ND specimens and correlate them with patient outcome to determine the relevant parameters for histopathological reporting.Materials and MethodsSalvage ND specimen from a cohort of n = 75 HNSCC (oropharynx, larynx, hypopharynx) patients with prior (chemo) radiation were evaluated on H&E stains for the following parameters: viable tumor cells, necrosis, swirled keratin debris, foamy histiocytes, bleeding residues, fibrosis, elastosis, pyknotic cells, calcification, cholesterol crystals, multinucleated giant cells, perineural, and vascular invasion. Histological features were correlated with survival outcomes.ResultsOnly the presence / amount (area) of viable tumor cells correlated with a worse clinical outcome (local and regional recurrence-free survival, (LRRFS), distant metastasis-free survival, disease-specific survival, and overall survival, p < 0.05) in both the univariable and multivariable analyses.ConclusionWe could confirm the presence of viable tumor cells as a relevant negative prognostic factor after (chemo) radiation. The amount (area) of viable tumor cells further substratified patients with worse LRRFS. None of the other parameters correlated with a distinctive worse outcome. Importantly, the presence of (swirled) keratin debris alone should not be considered viable tumor cells (ypN0).

PD-0399 Timing of Response Assessment PET CT in OPSCC Post Treatment and Salvage Neck Dissection Rates

PD-0399 Timing of Response Assessment PET CT in OPSCC Post Treatment and Salvage Neck Dissection Rates

The role of liquid biopsy in management of the neck with indeterminate response on post-treatment imaging following non-surgical management of oropharyngeal cancer.

This study aimed to determine if post-treatment HPV cell-free DNA (cfDNA) can assist in the decision-making process for salvage neck dissection in patients following non-surgical treatment of oropharyngeal squamous cell carcinoma (OPSCC) with a partial response in the neck on imaging at 12 weeks post-treatment. 86 patients who completed treatment were prospectively recruited through the regional multidisciplinary team (MDT). Treatment response was categorised as complete response (CR), partial response (PR) or progressive disease on 12-week post-treatment imaging. Pre- and post-treatment blood samples were assessed for HPV cfDNA through droplet digital PCR (ddPCR). Eight patients had an isolated partial response in the neck. One (12.5%) had detectable HPV cfDNA (22.96 copies/ml) at ∼12 weeks post-treatment with positive disease on subsequent neck dissection (positive predictive value; PPV=100%). Of the seven patients with undetectable HPV cfDNA, two patients had evidence of regional disease recurrence at 23.9 and 27.4 months respectively (negative predictive value; NPV=71%). The detection of HPV cfDNA may help target salvage therapy in patients with a partial response in the neck. Follow-up studies in larger cohorts would be required to further validate the use of post-treatment HPV cfDNA in the management of OPSCC.

Surgical site complications of isolated salvage neck dissection post-radiotherapy and post-chemoradiotherapy – A cohort analysis (1997–2017)

IntroductionThis study aims to quantify surgical site complications (SSC) after isolated salvage neck dissection (ND) compared with primary ND. Patients and methodsBetween 1997 and 2017 in the Netherlands Cancer Institute - Antoni van Leeuwenhoek, a total of 323 isolated NDs were performed in 308 patients: primary ND (n = 144), post-radiotherapy (RT) ND (n = 53) and post-chemoradiotherapy (CRT) ND (n = 126). Patient, tumor and therapy characteristics were recorded. SSCs were scored according to the Clavien-Dindo Classification (CDC). Results101 NDs (31%) were complicated by at least one SSC. In total, 189 different SSCs occurred. Translated to CDC, 45 complications were grade 2, 25 grade 3a and 31 grade 3b. No significant difference in occurrence of SSC (CDC >1) was found between all groups. However, post-CRT, selective (SND) and modified radical ND and radical ND (MRND/RND) (p = 0.005), resection of sternocleidomastoid muscle (SCM) (p = 0.039) and duration of super selective ND surgery (p = 0.048) were significantly associated with more SSC. SCM muscle removal was associated with more surgical site infection (p = 0.045) and necrosis (p = 0.036). From week 10 post-RT/CRT, no difference in complication frequency with primary ND was seen. ConclusionPost-CRT SND, MRND/RND and SCM muscle resection were associated with an increased incidence of SSCs. If oncologically possible, limit the extent of ND and when an MRND is inevitable, preserve the SCM muscle for optimal prevention of SSC. Concerning SSC, optimal timing of salvage ND is minimal 10 weeks after RT/CRT.

Post-Treatment Neck Dissection of Tonsillar and Base of Tongue Squamous Cell Carcinoma in the Era of PET-CT, HPV, and p16.

Human-papillomavirus (HPV)-positive tonsillar and base of tongue carcinomas (TSCC/BOTSCC) are rising in incidence and treatments with radiotherapy, chemoradiotherapy (RT/CRT), and neck dissections (NDs) have several side effects. Therefore, an improved selection of patients needing salvage NDs would be beneficial. We examined the prevalence and localisations of viable tumour cells in neck lymph nodes in patients post-RT/CRT, identified by fluorodeoxyglucose positron-emission tomography with computer-tomography (FDG PET-CT), with a focus on HPV-associated tumours. Patients with 217 TSCC/BOTSCC with tumours assessed for HPV-DNA and p16INK4a undergoing FDG PET-CT 12 weeks after treatment and/or an ND were included. The FDG PET-CT data were compared with the findings in the pathology report after the ND. In total, 36/217 (17%) patients were selected for an ND due to positive findings in post-treatment FDG PET-CT. Of these, 35/36 were HPV-associated, 10/36 (28%) had viable tumour cells in the pathology reports of the neck specimen, and 8/10 (80%) were consistent with the FDG PET-CT findings, while 2/36 (5%) were missed by FDG PET-CT. We conclude that FDG PET-CT 12 weeks after RT/CRT is useful, but not completely reliable for finding all the metastases of HPV-associated TSCC/BOTSCC. Nonetheless, our data indicate that an ND could be more selectively guided by FDG PET-CT.

ME03 How to treat recurrent or metastatic nasopharyngeal cancer?

Locoregional recurrence of NPC is uncommon in the era of Intensity Modulated Radiation Therapy (IMRT). Salvage surgery should be considered and salvage neck dissection is preferred in isolated regional relapse. Re-irradiation is associated with significant morbidities but local control rates of greater than or equal to 50% can be obtained at 1-2 years. In patients with oligometastatic disease, local treatments with stereotactic body RT, metastasectomy and radiofrequency ablation can be used. The prognosis of recurrent metastatic (R/M) NPC is heterogeneous.

Clinical outcomes of high-risk cutaneous squamous cell carcinomas treated with Mohs surgery alone: An analysis of local recurrence, regional nodal metastases, progression-free survival, and disease-specific death

BackgroundThe incidence of cutaneous squamous cell carcinoma (cSCC) continues to increase, and it is now predicted that the number of deaths from cSCC will surpass that of melanoma within the next 5 years. Although most cSCCs are successfully treated, there exists an important subset of high-risk tumors that have the highest propensity for local recurrence (LR), nodal metastasis (NM), and disease-specific death (DSD). ObjectiveWe investigated the clinical outcomes of high-risk cSCCs treated with Mohs surgery (MS) alone, analyzing LR, NM, distant metastasis, and DSD. In addition, we analyzed progression-free survival and DSD in patients who underwent salvage head/neck dissection for regional NMs. MethodsRetrospective review of all high-risk cSCC treated in our clinics between January 1, 2000, and January 1, 2020, with follow-up through April 1, 2020. SettingTwo university-affiliated, private-practice MS referral centers. ResultsIn total, 581 high-risk primary cSCCs were identified in 527 patients, of which follow-up data were obtained for 579 tumors. The 5-year disease-specific survival was 95.7%, with a mean survival time of 18.6 years. The 5-year LR-free survival was 96.9%, the regional NM-free survival was 93.8%, and the distant metastasis–free survival was 97.3%. The 5- and 10-year progression-free survival rates from metastatic disease were 92.6 and 90.0%, respectively. In patients who experienced regional NMs and underwent salvage head and neck dissection with or without radiation, the 2-year disease-specific survival was 90.5%. ConclusionOur cohort, which is the largest high-risk cSCC cohort treated with MS to date, experienced lower rates of LR, NM, and DSD than those reported with historical reference controls using both the Brigham and Women’s Hospital and American Joint Committee on Cancer, Eighth Edition, staging systems. We demonstrated that MS confers a disease-specific survival advantage over historical wide local excision for high-risk tumors. Moreover, by improving local tumor control, MS appears to reduce the frequency of regional metastatic disease and may confer a survival advantage even for patients who develop regional metastases.

Occult Metastases During Salvage Oral Cavity and Oropharyngeal Free Flaps: Oncologic Outcomes.

To define rates of occult metastases in salvage oral cavity and oropharyngeal cancer resection requiring free flap, to examine the location of occult metastases, and to determine associations between occult metastasis and survival. Retrospective cohort study. Two tertiary care referral centers. We identified previous cases of irradiation with recurrent or second primary oral cavity or oropharyngeal squamous cell carcinoma that had no evidence of regional metastasis and required free tissue transfer reconstruction of the primary site. Patients who underwent elective neck dissection or exploration were reviewed. The main outcome measures were the presence and location of occult nodal metastasis. Disease-free survival and overall survival were measured. Odds ratios and hazard ratios were used for analysis. A total of 83 patients were included: 52 with oral cavity primary tumors and 31 with oropharynx. An overall 78 (94%) underwent elective salvage neck dissection. Occult metastases were found in 9 (11.5%) patients. The most common nodal station for occult metastasis was level 2. Neither elective neck dissection nor the presence of occult metastasis was significantly associated with regional disease-free or overall survival. Oropharyngeal primary tumors were associated with higher risk of occult metastasis (odds ratio, 1.38; P < .01) and worse overall survival (hazard ratio, 2.09; P = .01). There is a low incidence of occult metastasis in postradiated recurrent or second primary oral cavity and oropharyngeal tumors. Elective neck dissection and occult nodal metastases were not associated with regional or overall survival. This series may help surgeons make decisions regarding the extent of neck surgery after prior radiation, especially when free flap reconstruction is required.