European Archives of Oto-Rhino-Laryngology

, Volume 271, Issue 8, pp 2277–2283

Time interval between primary radiotherapy and salvage laryngectomy: a predictor of pharyngocutaneous fistula formation

  • William J. Scotton
  • I. J. Nixon
  • T. F. Pezier
  • R. Cobb
  • A. Joshi
  • T. Guerrero Urbano
  • R. Oakley
  • J. P. Jeannon
  • R. S. Simo
Head and Neck

Abstract

Salvage laryngectomy (SL) is associated with high levels of morbidity. Rates of pharyngocutaneous fistulae (PCF) are as high as 35 % in some series. Patients at highest risk of such complications may be candidates for altered surgical management in terms of additional tissue transfer, or delayed tracheoesophageal puncture. This study investigates the relationship between the time from primary radiotherapy (RT) to salvage surgery and the development of PCF. 26 consecutive patients who underwent SL between 2000 and 2010 were identified from our institutional database. Demographic, staging, treatment and complication data were collected. Subgroup analysis was performed using the Student’s t test or Mann–Whitney U test for continuous variables and either Chi-squared test or Fisher’s Exact test for categorical variables. 26 patients underwent SL between October 2003 and July 2010. Of these, 15 (58 %) developed a PCF. On analysis of the time between pre-operative RT and surgery, a significant difference was seen, with a mean time of 19.5 months in those who developed a PCF versus 47.0 months in those who did not (p = 0.02). Patient characteristics, treatment, and pathology results were comparable between the two groups. There was no significant difference in distribution of the other covariates between the PCF and non-PCF groups. We reported a high rate of PCF and identified an association between PCF and a short time from primary treatment to salvage surgery. Identifying factors associated with higher rates of post-operative morbidity allows surgeons to adapt surgical planning in an attempt to minimize rates of PCF.

Keywords

Laryngectomy Laryngeal carcinoma Pharyngocutaneous fistulae Radiotherapy Chemotherapy Time interval 

References

  1. 1.
    Wolf et al (1991) Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med 324(24):1685–1690CrossRefGoogle Scholar
  2. 2.
    Vokes EE, Kies MS, Haraf DJ et al (2000) Concomitant chemoradiotherapy as primary therapy for locoregionally advanced head and neck cancer. J Clin Oncol 18:1652–1661PubMedGoogle Scholar
  3. 3.
    Forastiere AA, Zhang Q, Weber RS et al (2013) Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol 31:845–852PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Lagha A, Chraiet N, Labidi S et al (2013) Larynx preservation: what is the best non-surgical strategy? Crit Rev Oncol Hematol. doi:10.1016/j.critrevonc.2013.05.005. [Epub ahead of print]
  5. 5.
    Grau C, Johansen LV, Hansen HS et al (2003) Salvage laryngectomy and pharyngocutaneous fistulae after primary radiotherapy for head and neck cancer: a national survey from DAHANCA. Head Neck 25:711–716PubMedCrossRefGoogle Scholar
  6. 6.
    Scotton W, Cobb R, Pang L et al (2012) Post-operative wound infection in salvage laryngectomy: does antibiotic prophylaxis have an impact? Eur Arch Otorhinolaryngol 269:2415–2422PubMedCrossRefGoogle Scholar
  7. 7.
    Poole ME, Sailer SL, Rosenman JG et al (2001) Chemoradiation for locally advanced squamous cell carcinoma of the head and neck for organ preservation and palliation. Arch Otolaryngol Head Neck Surg 127:1446–1450PubMedCrossRefGoogle Scholar
  8. 8.
    Sassler AM, Esclamado RM, Wolf GT (1995) Surgery after organ preservation therapy. Analysis of wound complications. Arch Otolaryngol Head Neck Surg 121(2):162–165PubMedCrossRefGoogle Scholar
  9. 9.
    Penel N, Lefebvre D, Fournier C et al (2001) Risk factors for wound infection in head and neck cancer surgery: a prospective study. Head Neck 23:447–455PubMedCrossRefGoogle Scholar
  10. 10.
    Weber RS, Berkey BA, Forastiere A et al (2003) Outcome of salvage total laryngectomy following organ preservation therapy: the Radiation Therapy Oncology Group trial 91-11. Arch Otolaryngol Head Neck Surg 129:44–49PubMedCrossRefGoogle Scholar
  11. 11.
    Aarts MCJ, Rovers MM, Grau C et al (2010) Salvage laryngectomy after primary radiotherapy: what are prognostic factors for the development of pharyngocutaneous fistulae? Otolaryngol Head Neck Surg 144(1):5–9CrossRefGoogle Scholar
  12. 12.
    Paydarfar JA, Birkmeyer NJ (2006) Complications in head and neck surgery. Arch Otolaryngol Head Neck Surg 132:67–72PubMedCrossRefGoogle Scholar
  13. 13.
    Ganly I, Patel S, Matsuo J et al (2005) Postoperative complications of salvage total laryngectomy. Cancer 103:2073–2081PubMedCrossRefGoogle Scholar
  14. 14.
    Patel UA, Moore BA, Wax M et al (2013) Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg, pp 1–6Google Scholar
  15. 15.
    Girod DA, McCulloch TM, Tsue TT, Weymuller EA (1995) Risk factors for complications in clean-contaminated head and neck surgical procedures. Head Neck 17:7–13PubMedCrossRefGoogle Scholar
  16. 16.
    Johnson JT, Myers EN, Thearle PB, Sigler BA, Schramm VL Jr (1984) Antimicrobial prophylaxis for contaminated head and neck surgery. Laryngoscope 94(1):46–51PubMedCrossRefGoogle Scholar
  17. 17.
    Papazoglou G, Doundoulakis G, Terzakis G, Dokianakis G (1994) Pharyngocutaneous fistula after total laryngectomy: incidence, cause, and treatment. Ann Otol Rhinol Laryngol 103(10):801–805PubMedGoogle Scholar
  18. 18.
    Overgaard J, Alsner J, Eriksen J, Horsman MR, Grau C (2000) Importance of overall treatment time for the response to radiotherapy in patients with squamous cell carcinoma of the head and neck. Rays 25(3):313–319PubMedGoogle Scholar
  19. 19.
    Virtaniemi JA, Kumpulainen EJ, Hirvikoski PP, Johansson RT, Kosma VM (2001) The incidence and etiology of postlaryngectomy pharyngocutaneous fistulae. Head Neck 23(1):29–33CrossRefGoogle Scholar
  20. 20.
    Tabet JC, Johnson JT (1990) Wound infection in head and neck surgery: prophylaxis, etiology and management. J Otolaryngol 19(3):197–200PubMedGoogle Scholar
  21. 21.
    Head and Neck Cancer. Multidiscplinary Management Guidelines September 2011. ENT UK. http://www.bahno.org.uk/docs/head_and_neck_cancer.pdf
  22. 22.
    Klozar J, Cada Z, Koslabova E (2011) Complications of total laryngectomy in the era of chemoradiation. Eur Arch Otorhinolaryngol 269:289–293PubMedCrossRefGoogle Scholar
  23. 23.
    Weber RS, Forastiere A, Rosenthal DI, Laccourreye O (2004) Controversies in the management of advanced laryngeal squamous cell carcinoma. Cancer 101:211–219PubMedCrossRefGoogle Scholar
  24. 24.
    Agra IMG, Carvalho AL, Pontes E et al (2003) Postoperative complications after en bloc salvage surgery for head and neck cancer. Arch Otolaryngol Head Neck Surg 129:1317–1321PubMedCrossRefGoogle Scholar
  25. 25.
    Kao J, Garofalo MC, Milano MT et al (2003) Reirradiation of recurrent and second primary head and neck malignancies: a comprehensive review. Cancer Treat Rev 29:21–30PubMedCrossRefGoogle Scholar
  26. 26.
    Cacicedo J, Navarro A, Alongi F et al (2013) The role of re-irradiation of secondary and recurrent head and neck carcinomas. Is it a potentially curative treatment? A practical approach. Cancer Treat Rev. doi:10.1016/j.ctrv.2013.08.002. [Epub ahead of print]
  27. 27.
    Janot F, de Raucourt D, Benhamou E et al (2008) Randomized trial of postoperative reirradiation combined with chemotherapy after salvage surgery compared with salvage surgery alone in head and neck carcinoma. J Clin Oncol 26:5518–5523PubMedCrossRefGoogle Scholar
  28. 28.
    Ho AS, Kraus DH, Ganly I et al (2013) Decision making in the management of recurrent head and neck cancer. Head Neck pp 1–8. doi:10.1002/hed.23227
  29. 29.
    Mouttet-Audouard R, Gras L, Comet B, Lartigau E (2012) Evidence based and new developments in re-irradiation for recurrent or second primary head and neck cancers. Curr Opin Otolaryngol Head Neck Surg 20(2):137–141PubMedCrossRefGoogle Scholar
  30. 30.
    Tsou Y, Hua C, Lin M, Tseng H (2010) Comparison of pharyngocutaneous fistula between patients followed by primary laryngopharyngectomy and salvage laryngopharyngectomy for advanced hypopharyngeal cancer. Head Neck, pp 1494–1501Google Scholar
  31. 31.
    Chee N, Siow JK (1999) Pharyngocutaneous fistula after laryngectomy—incidence, predisposing factors and outcome. Singapore Med J 40(3):130–132PubMedGoogle Scholar
  32. 32.
    Natvig K, Boysen M, Tausjø J (1993) Fistulae following laryngectomy in patients treated with irradiation. J Laryngol Otol 107(12):1136–1139PubMedCrossRefGoogle Scholar
  33. 33.
    Ikiz AO, Uça M, Güneri EA, Erdağ TK, Sütay S (2000) Pharyngocutaneous fistula and total laryngectomy: possible predisposing factors, with emphasis on pharyngeal myotomy. J Laryngol Otol 114(10):768–771PubMedCrossRefGoogle Scholar
  34. 34.
    Cummings CW, Johnson J, Chung CK, Sagerman R (1977) Complications of laryngectomy and neck dissection following planned preoperative radiotherapy. Ann Otol Rhinol Laryngol 86:745–750PubMedGoogle Scholar
  35. 35.
    Van der Putten L, de Bree R, Kuik DJ et al (2011) Salvage laryngectomy: oncological and functional outcome. Oral Oncol 47:296–301PubMedCrossRefGoogle Scholar
  36. 36.
    Basheeth N, O’Leary G, Sheahan P (2013) Pharyngocutaneous fistula after salvage laryngectomy: impact of interval between radiotherapy and surgery, and performance of bilateral neck dissection. Head Neck. doi:10.1002/hed.23337
  37. 37.
    Stenson KM, Haraf DJ, Pelzer H, Recant W, Kies MS, Weichselbaum RR, Vokes EE (2000) The role of cervical lymphadenectomy after aggressive concomitant chemoradiotherapy. Arch Otolaryngol Head Neck Surg 126:950–956PubMedCrossRefGoogle Scholar
  38. 38.
    Goguen LA, Chapuy CI, Li Y, Zhao SD, Annino DJ (2010) Neck dissection after chemoradiotherapy. Arch Otolaryngol Head Neck Surg 136:1071–1077PubMedCrossRefGoogle Scholar
  39. 39.
    Rabalais AG, Walvekar R, Nuss D et al (2009) Positron emission tomography-computed tomography surveillance for the node-positive neck after chemoradiotherapy. Laryngoscope 119:1120–1124PubMedCrossRefGoogle Scholar
  40. 40.
    Ong SC, Schöder H, Lee NY et al (2008) Clinical utility of 18F-FDG PET/CT in assessing the neck after concurrent chemoradiotherapy for locoregional advanced head and neck cancer. J Nucl Med 49:532–540PubMedCrossRefGoogle Scholar
  41. 41.
    Wang Y, Liu R, Chu P, Chang F (2009) Positron emission tomography in surveillance of head and neck squamous cell carcinoma after definitive chemoradiotherapy. Head Neck 31(4):442–451PubMedCrossRefGoogle Scholar
  42. 42.
    Nayak JV, Walvekar RR, Andrade RS et al (2007) Deferring planned neck dissection following chemoradiation for stage IV head and neck cancer: the utility of PET-CT. Laryngoscope 117(12):2129–2134PubMedCrossRefGoogle Scholar
  43. 43.
    Vedrine P-O, Thariat J, Hitier M et al (2008) Need for neck dissection after radiochemotherapy? A study of the French GETTEC Group. Laryngoscope 118(10):1775–1780PubMedCrossRefGoogle Scholar
  44. 44.
    Ernst-stecken A, Brunner T, Grabenbauer GG et al (2003) Neck dissection following radiochemotherapy of advanced head and neck cancer—for selected cases only? Radiother Oncol 66:57–63PubMedCrossRefGoogle Scholar
  45. 45.
    Marx RE, Johnson RP (1988) Problem wounds in oral and maxillofacial surgery: the role of hyperbaric oxygen. In: Davis JC, Hunt TK (eds) Problem wounds: the role of oxygen. Elsevier Science Inc., New York, pp 65–123Google Scholar
  46. 46.
    Hopewell JW, Campling D, Calvo W et al (1986) Vascular irradiation damage: its cellular basis and likely consequences. Br J Cancer Suppl 7:181–191PubMedCentralPubMedGoogle Scholar
  47. 47.
    Jeannon J, Orabi A, Manganaris A, Simo R (2011) Methicillin resistant Staphylococcus aureus infection as a causative agent of fistula formation following total laryngectomy for advanced head & neck cancer. Head Neck Oncol 2:14CrossRefGoogle Scholar
  48. 48.
    Pang L, Jeannon J-P, Simo R (2011) Minimizing complications in salvage head and neck oncological surgery following radiotherapy and chemo-radiotherapy. Curr Opin Otolaryngol Head Neck Surg 19:125–131PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • William J. Scotton
    • 1
  • I. J. Nixon
    • 2
  • T. F. Pezier
    • 3
  • R. Cobb
    • 4
  • A. Joshi
    • 3
  • T. Guerrero Urbano
    • 3
  • R. Oakley
    • 3
  • J. P. Jeannon
    • 3
  • R. S. Simo
    • 3
  1. 1.Academic Neurosciences Foundation ProgrammeAddenbrookes HospitalCambridgeUK
  2. 2.Head and Neck ServiceMemorial Sloan Kettering Cancer CenterNew YorkUSA
  3. 3.Head and Neck Unit, Guy’s HospitalGuy’s and St. Thomas’ NHS Foundation TrustLondonUK
  4. 4.Academic Surgical Foundation Programme, St George’s HospitalLondonUK

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