SURGICAL SALVAGE AFTER RADIOTHERAPY FOR ADVANCED LARYNGOPHARYNGEAL CARCINOMA

Objective: To comment on the use of surgery after the failure of radio therapy in patients with advanced laryngeal, oropharyngeal, and hypoph aryngeal carcinomas. Design: Randomized, controlled, clinical trial, w ith a mean follow-up period of 3.1 years. Setting: The Princess Margar et Hospital, Toronto, Ontario. Patients: Patients with advanced laryng opharyngeal carcinoma (T3 or T4 or N+).Intervention: Three hundred thi rty-six patients who met the eligibility criteria were enrolled in a r andom randomized, controlled, clinical trial and treated with primary radio therapy using either the standard fractionation regimen or the h yperfractionation regimen. One hundred eight patients with recurrent d isease underwent salvage surgery and were observed prospectively, with careful documentation of surgical and tumor data, complications, recu rrences, and survival. Main Outcome Measures: Surgical complication ra te and survival. Results: Of the 108 patients who underwent surgery, 2 9 (27%) had complications. One third of these had multiple complicatio ns. There was no statistical difference between the surgical complicat ion rates of the 2 radiotherapy groups (16 patients [28%] in the stand ard fractionation radiotherapy group and 13 [25%] in the hyperfraction ation radiotherapy group). Survival after surgery was statistically co rrelated with the TNM system for the stage of the recurrent tumor, the pathologic nodal status, and the surgical margin status, The overall 3-year survival rate, which was calculated from the date of surgery, f or the group of patients who underwent: surgery was 22%. Conclusions: In this patient population, the hyperfractionation regimen was not ass ociated with a higher surgical complication rate. Using the policy of primary radiotherapy and reserving surgery for the management of failu res of radiotherapy, 140 patients (71%) at highest risk (laryngeal and hypopharyngeal primary tumor sites) retained an intact larynx until t he end of the study or death. Since it is the stage of the recurrent t umor that correlates with survival rather than the stage of the tumor at initial presentation, we suggest that tumors be restaged at the tim e of recurrence.