Relapsing HNSCC: Salvage loco-regional treatment: Surgeon‘s view

Christian SimonService d´ORLCHUV/UNILLausanne

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DISCLOSURE:

- PFIZER: TRIAL STEERING COMMITTEE- MERCK: CONSULTANT

Incidence of loco-regional recurrent operable HNSCCs:

15%

Gana et al. Eur Arch Otorhinolaryngol 2016

Survival of patients with recurrent operable HNSCC

Janot et al. JCO 2008

Toxicity

Janot et al. JCO 2008

Salvage surgery: For which patient?

Summary of prognosticators in recurrent OPSCC

• Initial and recurrent stage• Tumor site (larynx vs. others)• Concurrent regional failure• Disease-free interval• T-stage• Tobacco status• Comorbidities• HPV/p16-status• Post-operative margins• Post-operative complications

Agra et al., Head and Neck, 2006

Hamoir et al., Oral Oncology, 2017

Zafereo et al. Cancer 2009

Tan et al; Head and Neck; 2010

Kim et al. JAMA OtolaryngolHead Neck Surg 2007

Joseph et al. Head and Neck 2015

Guo et al., Cancer 2015

Fakhry et al., J Clin Oncol 2014

Salvage surgery: How?

Approach to the oropharynx through a median mandibulotomy

Harvesting of a RFFF and ALT

Salvage laryngo-pharyngectomieswith free-flap reconstruction

Reconstruction in the irradiated/operated field

Urken M. 2012

Corlett-loop

Flow-through flaps in case of vessel depletion

Gaggl 2007

TORS in the recurrent setting

White et al. JAMA;2013

Salvage surgery: For what price?

• Most patients surpass pretreatment functional thresholds by 1 years (Goodwin et al., Laryngoscope 2000)

• Median DFS is approximately 8 months (Janotet al., Kim et al, Zafereo et al., List et al.)

Thank you for your attention

Loco-regional HNSCC recurrence

• The incidence of loco-regional recurrences after treatment of operable HNSCCs is app. 25% after 2 years (Lefebvre, 1996; Mantz, 2001; Forastiere, 2003)

• More than 50% of these patients will die within the following 2 years despite treatment for their recurrent disease (Goodwin, 2000)

Individualized approach

NCCN-guidelines for loco-regional failure

OS depends on clinical stage and disease free interval

Agra et al., Head and Neck, 2006

OS depends on disease free interval and T-stage

Zafereo et al. Cancer 2009

OS after salvage depends on stage and concurrence of loco-regional failure

Tan et al; Head and Neck; 2010

OS depends on tobacco status

Kim et al. JAMA Otolaryngol Head Neck Surg 2007

OS depends on comorbidity score

Kim et al. JAMA Otolaryngol Head Neck Surg 2007

OS depends on HPV-status

Joseph et al. Head and Neck 2015

OS depends on HPV-status

Guo et al., Cancer 2015

OS depends on p16-status

Fakhry et al., J Clin Oncol 2014