Pectoralis Major Transposition Allows for Immediate Delivery of High Dose Rate Brachytherapy In Previously Irradiated Patients with Recurrent Head and Neck Cancer

Background: Cervical recurrences of previously-irradiated head and neck cancer (H&NC) represent a formidable therapeutic and reconstructive challenge.  Brachytherapy (BT) is frequently utilized in this setting to increase local control following radical resection. However, without bringing healthy, vascularized tissue to the operative bed, such aggressive local treatment of tissues compromised by previous radiation is likely to predispose the patient to wound healing complications, ranging from cervical skin flap loss to carotid blowout. We therefore sought to review our experience with pectoralis flap reconstruction and subsequent high dose rate (HDR) BT for salvage of recurrent cervical lymphadenopathy due to H&NC.

Methods: A retrospective review was performed of all patients who underwent HDR BT for recurrent H&NC at a single institution from 2007 to 2009. Charts were reviewed for patient demographics, surgical interventions, a history of chemotherapy or radiation therapy (RT), and outcome. 

Results: Five patients with 6 flaps were included in the study (1 with metachronous bilateral disease). There were 4 primary and 2 secondary recurrences. All patients had previously underwent primary cisplatin-based chemotherapy and external beam RT (60-70 Gy). Two patients had previous neck dissections.  In this series, the surgical approach consisted of radical (n=5) or extended radical (n=1) neck dissection, placement of after-loading HDR catheters, and coverage of the tumor bed and catheters with a pedicled pectoralis major flap. An average of 3 catheters were placed at each surgical site. RT with iridium-192 was started within 48 hrs of surgery in all patients. Median BT dose was 2000 cGy in 200 cGy fractions delivered BID. Following completion of therapy, catheters were removed at the bedside. All flaps were fully viable within a 3-month follow-up period. One patient developed a 1cm area of superficial wound dehiscence that resolved with local wound care. One patient who underwent floor-of-mouth resection with concomitant radical neck dissection developed an orocutaneous fistula, which healed following primary repair.  There were no other recipient site complications.

Discussion: Pectoralis flap reconstruction of oncologic defects in previously irradiated fields not only provides reliable coverage of HDR BT catheters but allows for immediate high dose irradiation (within 24-48 hrs of surgery) without adversely affecting wound healing or flap survival.  These data may serve to guide future treatment of complicated H&NC recurrences.