Salvage surgery for recurrent or persistent advanced laryngeal or hypopharyngeal squamous cell cancer: systematic review

INTRODUCTION: The common use of non-surgical protocols implies the possible indication for salvage surgery in irradiated tissue in case of recurrent or new primary carcinomas after radiotherapy or chemo-radiotherapy. Surgery in form of salvage total laryngectomy/pharyngo-laryngectomy is the main curative treatment in patients with advanced recurrent or persistent laryngeal or hypopharyngeal squamous cell carcinoma. EVIDENCE ACQUISITION: All studies reporting oncologic outcomes and complication rate of patients who underwent total laryngectomy with or without subtotal or circular pharyngectomy for advanced-stage (stage III and IV) squamous cell carcinoma of the larynx or hypopharynx, as a salvage procedure after failure of radiotherapy with or without chemotherapy were included. EVIDENCE SYNTHESIS: Ten studies (547 patients) were included in the review. The full text of the included studies was reviewed with extraction of patient number, tumor site, TNM stage, primary treatment, salvage treatment, incidence of salivary fistula, and 5-year oncological outcomes. Comparison of survival and incidence of salivary fistula for laryngeal and hypopharyngeal cancer was performed. CONCLUSIONS: Local control should be the most important value when choosing the treatment modality for advanced-stage primary squamous cell carcinoma of the larynx and hypopharinx since failures after non-surgical organ preservation therapy are burdened by a bad prognosis despite rescue treatment. Recurrences without pharyngeal extension have better outcomes compared to the hypopharyngeal recurrence (5-year OS, DSS and DFS of 47.3%, 47% and 46.4% vs. 39.3%, 23.6%, and 36.3% respectively). Salivary fistula is the most frequent postoperative complication, mainly observed in patients with hypopharyngeal relapse (36% vs. 26.7% observed in patients exclusive laryngeal relapse) and after primary chemo-radiotherapy (36.2% vs. 23.6% in patients who relapsed after radiotherapy alone). Free and pedicled flaps have a major role in salvage surgery for recurrent advanced laryngeal or hypopharyngeal squamous cell carcinoma.