Reconstructive Outcomes in Head and Neck Salvage Surgery With Interstitial Brachytherapy

Introduction:  Treatment of head and neck cancers with surgical resection, chemotherapy, and external beam radiation therapy (EBRT) is the standard for treatment of advanced-stage tumors.    However, loco-regional recurrence is common, overall survival rates range from 10% to 25% at 2 years, and secondary treatment options are limited.  Ablative surgery combined with interstitial brachytherapy (IBT) has demonstrated curative potential and improved survival in recalcitrant disease.  Reconstructive surgery and outcomes of these challenging patients have not been described.  The purpose of this study was to review outcomes of head and neck reconstruction in salvage patients undergoing cervical tumor ablation combined with IBT, and further to identify patient characteristics and reconstructive options predictive and/or protective for complications.

Methods:  All patients who underwent head and neck salvage surgery with simultaneous IBT between 1994 and 2012 were identified from a prospectively maintained patient database.  Patients’ records were then reviewed for demographics, medical co-morbidities, adjunct therapies, reconstruction, complications, and outcomes.

Results:56 consecutive patients underwent head and neck salvage surgery and reconstruction with simultaneous IBT during the study period (average follow up: 25.2 ± 11.2 months).  All patients had received preoperative XRT and 32% had undergone previous ablative surgery.  Complication rates included all complications (37.5%), surgical complications (33.9%), and medical complications (8.9%).   Most common complications included delayed wound healing (14.3%), infection (5.4%), hematoma (5.4%) and fistula (5.4%).  Reconstructions included local skin flaps (17.9%), pedicled muscle flaps (73.2%), and free flaps (8.9%).  There were no total flap losses and 2 (3.6%) partial flap losses. Complication rates of local skin flaps (50%) were not significantly greater than flap reconstructions (34.8%, p=0.48).  Recurrence of disease was 30.4%.

Conclusions:  Head and Neck salvage patients commonly have extensive soft tissue invasion, carotid and/or jugular vessel involvement, and significant radiation sequelae, which can create a hostile environment with limited reconstructive options.  In select patients, reconstruction with muscle flaps may be superior to skin flaps for reconstruction of cervical defects.  Salvage surgery with IBT is an aggressive treatment paradigm for recurrent head and neck cancers and results in improved disease-free survival and overall survival.  Proper multidisciplinary planning and execution of reconstruction is essential to decrease operative morbidity.