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Background: Surgery after (chemo)radiation (RCTX/RTX) is felt to be plagued with a high incidence of wound healing complications reported to be as high as 70%. The additional use of vascularized flaps may help to decrease this high rate of complications. Therefore, we examined within a retrospective single-institutional study the peri– and postoperative complications in patients who underwent surgery for salvage, palliation or functional rehabilitation after (chemo)radiation with regional and free flaps. As a second study end point the Karnofsky performance status (KPS) was determined preoperatively and 3 months postoperatively to assess the impact of such extensive procedures on the overall performance status of this heavily pretreated patient population. Findings: 21 patients were treated between 2005 and 2010 in a single institution (17 male, 4 female) for salvage (10/21), palliation (4/21), or functional rehabilitation (7/21). Overall 23 flaps were performed of which 8 were free flaps. Major recipient site complications were observed in only 4 pts. (19%) (1 postoperative haemorrhage, 1 partial flap loss, 2 fistulas) and major donor site complications in 1 pt (wound dehiscence). Also 2 minor donor site complications were observed. The overall complication rate was 33%. There was no free flap loss. Assessment of pre- and postoperative KPS revealed improvement in 13 out of 21 patients (62%). A decline of KPS was noted in only one patient. Conclusions: We conclude that within this (chemo)radiated patient population surgical interventions for salvage, palliation or improve function can be safely performed once vascularised grafts are used. Keywords: head and neck cancer, radiation, free flap, regional flap, Karnofsky performance status * Correspondence: Christian.Simon@med.uni-heidelberg.de University of Heidelberg, Department of Otolaryngology - Head and Neck Surgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany Full list of author information is available at the end of the article © 2011 Simon et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Simon et al. Radiation Oncology 2011, 6:109 Page 2 of 7 http://www.ro-journal.com/content/6/1/109 procedures including free flap and/or regional flap Findings reconstruction in (chemo)radiated patients undergoing Surgery after (chemo)radiation (RCTX/RTX) therapy is surgical salvage for recurrent disease, surgical functional felt to be plagued with a high incidence of wound compli- rehabilitation or palliation. Given that such extensive cations as the consequence of radiation induced wound procedures as free and regional flaps may compromise bed changes . Major peri- and postoperative complica- the performance status of the patients, we added an tions upon surgery after RCTX or RTX are reported to be assessment of the pre- and postoperative Karnofsky per- up to 73% for i.e. salvage laryngectomies . The use of formance status (KPS) as a second endpoint to this regional and free tissue transfer appears to decrease these study. complications. However studies on the incidence of major All patients were treated at the University of Heidel- peri-and postoperative complications after procedures that berg Medical Center between 2005 and 2010. All include using vascularized tissue transfer still display (chemo)radiated patients that received a vascularized highly variable rates that range between 10%  and 66% transplant within this interval and were operated on by (for doubly irradiated patients) . For salvage laryngec- the authors C.S. and P. A. F. The institutional review tomies with reinforcement of the pharyngeal closure using board at UHMC approved this retrospective analysis vascularized tissue transfer the incidence of fistula forma- and the study has therefore been performed in accor- tion is reported to be between 18%  and 29%  and dance with the ethical standards laid down in the 1964 there is still debate whether or not flaps help to decrease declaration of Helsinki. All patients gave their informed the incidence of such fistulas [7-10]. Thus, there remains a consent prior to their inclusion in the study. Surgical question on the safety of performing surgical procedures intervention was chosen as per the treating physician on (chemo)radiated patients and the role of vascularized discretion. Free flap reconstruction was used on the tissue transfer within this patient population. basis of the surgeon’s preference (Table 1). We therefore undertook a retrospective chart review If radiation treatment took place in Heidelberg, radio- on our own patient population in order to assess the therapy was performed in all cases as intensity modulated incidence of peri- and postoperative complications after Table 1 Patients characteristics and treatment categories: Treatment categories are divided into salvage and palliative procedures, procedures to improve function, closure of a fistula, and management of a radiation induced wound healing complication. Number Age Diagnosis Gender Treatment category 1 59 OC (T2N0M0) 98, Hypopharynx-/Larynx(T4N2cM0) 10/06, Hypoharynx-/Larynx recurrence 11/07 male salvage 2 59 OC 97, Hypopharynx (T2N1M0) 04, hypopharynx recurrence 9/07 male fistula 3 56 oropharynx (T3N2bM0) 03/07, oropharynx recurrence 12/07 male salvage 4 47 OC (T2N1M0) 02/06, oropharynx 03/07 male salvage 5 79 Ear SSC 04/04 (T1N3M0), SCC recurrence with involvement of temporal bone, parotid gland male palliative 12/05 6 72 SCC temple region (T4N0M0) 08/06, recurrence 11/07 male palliative 7 62 Ear basosquamous CC (T4N0M0) 01/01, recurrence with cerebral infiltration 03/06 male palliative 8 66 Larynx-SCC (T4N0M0) 97, regional recurrence 06 male palliative 9 60 Hypopharynx-SCC (T3N1M0) 02/94 male functional 10 52 CUP-Syndrom (T0N2bM0) 85, Oropharynx SCC (T4N0M0) 11/04 male salvage 11 56 CUP-Syndrom (T0N2bM0) 85, Oropharynx SCC (T4N0M0) 11/04, Larynx SCC (T4N0M0) 12/07 male salvage 12 58 Oropharynx SCC (T3N0M0) 11/04, Hypopharynx SCC (T4N0M0) 08/06, Rektumkarzinom female salvage (T3N2M1) 09/07 13 66 Hypopharynx SCC (T1N2M0) 07/06 female functional 14 48 Larynx SCC (T4N2M0) 06/07 male postradiation wound healing complication 15 64 Nose SCC 05/08 (T2N0M0), recurrence (T4N0M0) 01/09, recurrence (T4N0M0) 07/09 male salvage 16 55 Oropharynx SCC (T2N2BM0) 05/09 male functional 17 52 Larynx SCC (T3N1M0) 07/03 male functional 18 68 CUP-Syndrom (T0N2bM0) 07/04, OC-SCC (T3N0M0) male salvage 19 51 ACC parotid (T3N0M0) 01/07, recurrence 01/08, recurrence 03/08, recurrence 10/08, female salvage recurrence 02/09, recurrence 06/09, recurrence 09/09, recurrence 12/09 20 37 OC-SCC (T1N0M0) 09/08, regional recurrence 04/09, regional recurrence 09/09 female salvage 21 61 Oropharynx-SCC (T2N0M0) 04/09 male functional Simon et al. Radiation Oncology 2011, 6:109 Page 3 of 7 http://www.ro-journal.com/content/6/1/109 radiotherapy (IMRT) or at least as a 2D/3-D planned reinforce closure as described elsewhere . The medi- radiotherapy. The applied total doses ranged between 60 cal records of the patients were reviewed and analyzed and 70.4Gy in a single dose of 1.8 to 2.0Gy. Radioche- with respect to tumor stage, treatment history, radiation motherapy was realized as a combination of 5-FU and dose, peri- and postoperative complications, KPS, flap cisplatin in the first and last treatment week or of cispla- performed, and comorbidities. KPS was determined 3 tin once a week during radiotherapy (Table 2). months after surgery as per literature . Statistical Free and regional flap insetting was in all cases per- analysis was performed using Kaplan Meier and Fisher’s formed with 3.0 Vicryl. In cases of pharyngeal closure exact test. Overall 10 out of the 21 patients underwent salvage the flap was inset into the defect and sutured to the sur- rounding mucosa. The flaps were NOT just used to procedures, 4 were treated for palliation, and 7 patients Table 2 Type of reconstruction, peri-operative complications, Karnofsky-performance status (KI or KPS), no data available (n Number Indication for Type of recon- RTX versus 2/3D Postoperative Pharyngo- Karnofsky Karnofsky surgery struction RCTX/dose versus complications tomy index index IMRT preop postop 1 hypopharynx pec major RCTX/90,9Gy 2D + 3D 0 1 50 60 recurrence Boost 2 Fistula after salvage pec major RTX/60Gy 2D 0 1 50 60 laryngectomy 3 oropharynx recurrence pec major RCTX/70Gy n.d. 1(hemorrhage) 1 40 40 4 oropharynx recurrence pec major and RCTX/70Gy 2D + 3D 0 1 70 80 deltopectoral and Boost trapezius 5 SCC recurrence lat dorsi RCTX/70Gy n.d. 0 0 60 70 temporal bone 6 SCC recurrence lat dorsi RCTX/70Gy 3D 1(partial flap 050 50 temporal bone loss) 7 BSCC recurrence lat dorsi RTX/ND (>2*60Gy) n.d. 0 0 60 40 temporal bone 8 Regional recurrence pec major RCTX/60Gy n.d. 0 0 60 70 debulking 9 Esophageal stenosis forearm RTX/60Gy n.d. 0 1 60 70 10 Oropharynx SCC forearm RTX/62Gy n.d. 0 1 60 70 11 Larynx SCC pec major RTX, RCTX/62Gy n.d. 1(fistula) 1 60 60 +ND (>60Gy) 12 hypopoharynx pec major RTX/60Gy IMRT 0 1 50 60 recurrence 13 dysphagia forearm RTX/ND (>60Gy) n.d. 0 1 50 60 14 wound healing deltopectoral RCTX/70,4Gy 2D 0 0 50 60 complication tracheostoma 15 Nasal dorsum SCC forearm RCTX/60Gy IMRT 1(fistula) 1 50 60 recurrence 16 dysphagia due to soft forearm RCTX/65,8Gy IMRT 0 1 50 60 palate defect 17 Radiochondronecrosis pec major RCTX/ND (>60Gy) n.d. 1(wound 140 60 of larynx dehiscence donor site) 18 OC-SCC after CUP forearm RTX/ND (>60Gy) n.d. 1(wound 160 60 dehiscence donor site 19 parotid recurrence scapula RTX/60Gy IMRT 1(wound 060 60 dehiscence donor site) 20 regional recurrence lat dorsi RCTX/70,4Gy IMRT 0 0 60 60 21 exposed mandibular forearm RTX/66Gy IMRT 0 1 80 80 bone after RCTX Simon et al. Radiation Oncology 2011, 6:109 Page 4 of 7 http://www.ro-journal.com/content/6/1/109 were operated on to improve function or close fistulas received RTX. All 4 recipient site complications and treat wound healing complications after radiation occurredinthe RCTX patientpopulation(Table2). (Table 1). However, this was not found to be statistically signifi- Radiation induced wound healing problems are antici- cant (Fisher exact, two sided, p = 0.09). Neither age nor pated to occur at the recipient site. Interestingly we preoperative status of comorbidities correlated with the observed only 4 recipient site complications (1 hemor- incidence of recipient site or donor site complications rhage from the tracheostomy site, 1 partial flap loss of a within this series of patients. Median KPS prior to the operation was 60%. Improve- regional flap, 1 pharyngeal fistula, 1 fistula in the melo- ment of KPS was observed in 13 out of 21 patients and labial region after nasal reconstruction) (19%). We observed three donor site complications (1 wound declined in one patient (Table 2). Looking at the treat- dehiscence requiring a rotational flap for closure, 1 ment categories 50% of the patients treated for salvage small wound dehiscences in the scapula flap harvest improved with respect to their KPS (5/10). Out of 4 region and one in the forearm harvest region, requiring patients treated with palliative intention also 50% no further surgical intervention). In total 7 out of 21 improved, one patient had a similar index after treat- patients had a complication (33%) (Table 2). Of these 7 ment but in one patient the index declined. In contrast complications 5 were major complications (24%) and 2 80% of the patients treated to improve their functional were minor complications (small wound dehiscences status improved with respect to their KPS and only one that healed via secondary intention and did not require patient had a similar index after the procedure. Both a surgical intervention). Overall 13 pharyngotomies/ patients treated for a fistula and a post-radiation wound pharyngeal closures were performed and only 1 fistula healing complication improved with respect to their was observed (8%). It occurred in a patient who received KPS. adjuvant radiation therapy twice up to a cumulative Within this study 19% (4 patients) of the patients dose of >122Gy. Overall 8 free flaps (7 radial forearm developed recipient site complications. Out of the 4 flaps (Figure 1, 2), 1 scapula flap) and 15 regional flaps patients there was only 1 fistula, one tracheostomy (8 pectoralis major, 4 latissimus dorsi (Figure 3), 2 del- bleeding, one partial flap failure of a regional flap and a topectoral (Figure 4a, b), 1 trapezius (Figure 4c, d)) were wound dehiscence requiring additional management. performed. No free flap failure occurred but one partial While the fistula an wound dehiscence may be a conse- flap loss was observed in the group of patients that had quence of radiation-induced recipient site tissue received a regional flap with a latissimus dorsi flap. changes, this is less likely the case for the tracheostomy bleeding and complication of a regional flap. We there- There was no significant association between the inci- dence of complications and the use of any particular fore believe that the incidence of wound healing compli- flap. 12 patients received RCTX versus 11 patients that cations that may be a consequence of radiation is only 2 Figure 1 Reconstruction of the entire anterior tongue (Pt. 18). A: For this reconstruction a transoral approach without temporary mandibulotomy was used. B, C, D: Residual mobility preserved through preservation of the base-of-tongue. Simon et al. Radiation Oncology 2011, 6:109 Page 5 of 7 http://www.ro-journal.com/content/6/1/109 Figure 2 Reconstruction of a pharyngeal stenosis with a free radial forearm flap (Pt.8). A: Flap design with monitor portion. B: Status after flap insetting, monitor visible. C: Postoperative result. D, E: Barium swallow after surgery documenting adequately resolved pharyngeal stenosis after the procedure. Figure 3 Reconstruction of the neck with a regional latissimus dorsi flap after radical neck dissection revision and carotid resection with Gore-Tex allotransplant interposition (Pt.20). A: Status after resection and Gore-Tex allotransplant interposition. B: Outlines of the flap. C: Harvesting of the flap on the thoracodorsal vessels. D: Status after insetting. Simon et al. Radiation Oncology 2011, 6:109 Page 6 of 7 http://www.ro-journal.com/content/6/1/109 Figure 4 Reconstruction of the neck after radical extended neck revision with partial pharyngectomy (Pt.4). A, B: Reconstruction of the anterior neck with a deltopectoral flap. C, D: Reconstruction of the residual circumference of the neck with a trapezius flap. outof21patients(9.5%). This suggeststhatifproper indicate that 62% of our patients had an improved KPS. surgical technique is used, operating in the radiated field The preoperative KPS ranged between 40% and 80%, the in the head and neck is likely to be safe. Only 1 patient majority of patients had a KPS between 50% and 70%. A developed fistula after pharyngeal closure with a regio- KPS improvement from 50% to 60% indicating to regain the ability to function mostly independent of help in all nal or free flap. This also compares favorably with key areas of live, was observed in 8 out of 21 patients published data on fistula formation after salvage laryn- gectomy, that are reported to be as high as 18% to 29% (38%). An improvement from a KPS of 60% to 70% was [5,6]. This data supports in our opinion the conclusion observed in 4 out of 21 patients (19%) indicating an that surgery can be safely performed after radiation improvement towards being entirely independent of help once vascularized tissue transfer is used as an adjunct without being able to work. The KPS declined in only one technique. patient. The data suggest that 3 months after surgery It is also noteworthy that we did not encounter any when the KPS was assessed the patients had recovered flap failures with our free flaps despite having to per- very well from surgery despite the extent of the procedure. form vascular anastomosis in preirradiated and pre- In summary our data indicate that surgical treatment viously operated fields suggesting that free flaps can also of patients after RTX or RCTX is feasible with an accep- be safely performed. tablerateofcomplications,if free or regional flaps are All recipient site complications occurred in patients included in the operative strategy. that were treated with RCTX. This finding however was not statistically significant. This trend however is consis- Author details tent with published data, indicating a high rate of peri- University of Heidelberg, Department of Otolaryngology - Head and Neck operative complications after RCTX . Surgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. University of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld In order to assess the potential hazard of an extension of 400, 69120 Heidelberg, Germany. theprocedurebyacomplicated flap surgery on the patient’s postoperative performance, we measured the pre- Authors’ contributions CS designed and coordinated the study, participated in the data acquisition and postoperative KPS based on a chart review. It certainly and analysis, and helped to draft the manuscript, CB participated in the data would have been better to undertake quality-of-life studies acquisition and analysis, MWM and KL both participated in the data in this patient population. However this was not possible acquisition and analysis, and helped to draft the manuscript, ZB and SS and duetothe retrospectivenatureofthe study. Ourdata SL participated in the data acquisition and analysis, PKP and PAF helped to Simon et al. Radiation Oncology 2011, 6:109 Page 7 of 7 http://www.ro-journal.com/content/6/1/109 coordinate the study and draft the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 9 March 2011 Accepted: 6 September 2011 Published: 6 September 2011 References 1. Schultze-Mosgau S, Grabenbauer GG, Radespiel-Troger M, Wiltfang J, Ries J, Neukam FW, Rodel F: Vascularization in the transition area between free grafted soft tissues and pre-irradiated graft bed tissues following preoperative radiotherapy in the head and neck region. Head Neck 2002, 24:42-51. 2. Relic A, Scheich M, Stapf J, Voelter C, Hoppe F, Hagen R, Pfreundner L: Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas. Eur Arch Otorhinolaryngol 2009, 266:1799-1805. 3. 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Med Clin North Am 1950, 34:439-458, illust. doi:10.1186/1748-717X-6-109 Cite this article as: Simon et al.: Assessment of peri- and postoperative complications and Karnofsky-performance status in head and neck cancer patients after radiation or chemoradiation that underwent surgery with regional or free-flap reconstruction for salvage, palliation, or to improve function. Radiation Oncology 2011 6:109. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color ﬁgure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit
Radiation Oncology – Springer Journals
Published: Sep 6, 2011
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