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PubMed2001

Salvage surgery.

Salvage surgery is an essential method in the armamentarium of the surgeon caring for the severely injured patient. The patient in unstable condition with multiple abdominal injuries is a challenge, even to the most experienced trauma surgeon. The first priority should be to control major vascular injuries and other sources of bleeding that are immediately life-threatening. Often after massive blood loss, the deadly triad of hypothermia, acidosis, and coagulopathy is present. Additional time in the operating room often worsens these physiologic parameters and patient outcome. Once surgically correctable bleeding has been addressed, such patients are best served by cessation of the operation, packing of the abdomen, and transfer to the intensive care unit. Resuscitative steps should then be taken. Once the physiologic derangement has been corrected, the patient can undergo definitive operative procedures.

Abdominal Injuries↗

PubMed1998

Salvage surgery or salvage radiotherapy for locally recurrent prostate cancer.

OBJECTIVES: To evaluate the efficacy and toxicity of salvage radiation or surgery for locally recurrent tumor after initial treatment for clinically localized prostate cancer. METHODS: The treatment records of 70 patients with local treatment failure after definitive therapy for clinically localized prostate cancer were reviewed. Initial treatment consisted of external beam radiation therapy (RT) in 27 patients and radical retropubic prostatectomy (RP) in 43 patients. RESULTS: The mean serum PSA levels were similar in both groups before initial treatment: 8.5 and 10.5 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.09). However, at the time of salvage treatment, the mean serum PSA levels were 9.1 and 1.1 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.0001). The mean time from tumor recurrence to salvage treatment was 15.6 months for the salvage RP group and 4.9 months for the salvage RT group (P = 0.0001 ). Although there was no statistical difference in the disease-free survival rate (P = 0.38), a trend for better disease control in the salvage RT group was evident (74.4% versus 44.4%). Patients treated with salvage RP had a higher rate of urinary incontinence than those undergoing salvage RT: 63% and 32.6%, respectively (P = 0.01). CONCLUSIONS: The disease-free survival rate was similar between patients receiving salvage RP or RT, despite the significantly higher serum PSA levels at the time of treatment and the delay in time to treatment for the salvage RP patients. Salvage RP is associated with a high rate of urinary incontinence. Earlier identification of tumor recurrence after RT may improve the efficacy and safety of salvage RP.

Follow-Up Studies↗

PubMed1991

The nursing role in limb salvage surgery.

Limb salvage surgery has proven itself as a valuable option for sarcoma patients. The reconstruction options are vast and include metallic implants, allografts, and a combination of both. The nursing implications for these patients are unlimited. The patient needs to be educated and assessed closely for complications such as infections, nonunion of the allograft, and limited mobility. Although the nursing care is more complicated, the rewards with working with these patients are great.

Bone Neoplasms↗

PubMed2000

Salvage surgery after failure of nonsurgical therapy for carcinoma of the larynx and hypopharynx.

BACKGROUND: For larynx preservation, radiotherapy is gaining popularity for primary treatment of laryngeal and hypopharyngeal cancer, reserving surgery for salvage. OBJECTIVE: To analyze the outcome of salvage surgery after failure of primary radiotherapy. DESIGN: Nine-year retrospective outcome analysis. SETTING: University referral center. PATIENTS: Fifty-four patients with squamous cell carcinoma of the larynx (n = 39) or hypopharynx (n = 15). RESULTS: For laryngeal cancer, mean interval from radiation to detection of recurrence was 14.5 months (range, 2-66 months). Twenty-three patients (59%) presented with a more advanced tumor stage after radiation than at the initial evaluation. Total laryngectomy was needed in 36 patients (92%). Disease-specific 5-year survival rate was 63%. Survival of patients with small recurrent tumors was statistically significantly better than those with advanced tumors (P =.004). For hypopharyngeal cancer, mean interval from radiation to detection of the recurrence was 10.6 months (range, 3-40 months). Total laryngopharyngectomy was needed in 8 of 9 patients with local recurrrence; neck dissection, in 6 patients with regional recurrence. Disease-specific 5-year survival rate was only 20%. Recurrent tumor and node stages did not influence the outcome. Patients with regional recurrences did no better than those with local ones. CONCLUSIONS: Salvage surgery in laryngeal cancer achieves good results, especially for small recurrences. Because of tumor progression, larynx preservation is seldom possible at the time of salvage. Salvage surgery in hypopharyngeal cancer shows poor survival regardless of tumor stage and despite radical surgical procedures, and can be recommended only for carefully selected patients. Arch Otolaryngol Head Neck Surg. 2000;126:1473-1477

Carcinoma, Squamous Cell↗

PubMedDate not supplied

Special problems in limb-salvage surgery.

Limb-salvage surgery is a safe and effective treatment for malignancies of the musculoskeletal system. Careful evaluation and planning are necessary to avoid both early and late complications. Biopsy must be carefully performed to avoid unnecessary contamination and to obtain adequate tissue for an accurate diagnosis. Pathologic fractures present both a diagnostic and a therapeutic challenge, and evaluation strategies depend on the age of the patient. Treatment of a pathologic fracture depends on the location and the histology of the lesion and many host factors. Limb salvage may or may not be indicated. Instability is another problem with certain limb-salvage situations, e.g., when it is necessary to resect the scapula. Various approaches may obviate the problem. The salvage of failed limb-salvage procedures requires careful evaluation and planning. Patients with infections and local recurrences often require amputation surgery. Correctable problems following failed allograft reconstructions include collapse of the articular cartilage, joint instability, nonunion, and fracture of the allograft. Correctable problems following prosthetic arthroplasty include aseptic loosening, prosthetic fracture, and polyethylene wear. Approximately two thirds of patients with failed limb-salvage procedures will obtain a functional limb following revision surgery. Attention to these special problems may allow for greater success with limb-salvage surgery.

Biopsy↗

PubMed2005

Improved survival associated with postoperative wound infection in dogs treated with limb-salvage surgery for osteosarcoma.

BACKGROUND: Limb-salvage surgery and adjuvant chemotherapy are performed as a treatment of appendicular osteosarcoma in dogs. Approximately 50% of dogs that undergo limb-salvage surgery develop postoperative surgical wound infections. Postoperative surgical infections may affect survival in cancer patients. The purposes of this study were to examine the effect of surgical wound infection on survival, local recurrence, and metastasis in relation to other prognostic factors for dogs with spontaneous osteosarcoma treated with limb-salvage surgery. METHODS: Forty-seven client-owned dogs with osteosarcoma of the distal radius were treated with limb-salvage surgery and adjuvant chemotherapy--either carboplatin or carboplatin and doxorubicin. Hazard ratios were estimated by using the Cox proportional hazard model, and survival functions were estimated by using the Kaplan-Meier product-limit life-table method. RESULTS: Of the 47 dogs in this study, 32 (68%) developed a postoperative wound infection. Infection, dog weight, and extent of the primary tumor (percentage of length) significantly affected survival, and infection and percentage of length significantly affected time to metastasis. None of the variables considered in this study affected local recurrence. Dogs that were diagnosed with an infection were less likely to die (hazard ratio, .446), and dogs with greater body weight and greater percentage length involvement were more likely to die (hazard ratios of 3.37 and 3.66, respectively). CONCLUSIONS: In dogs with osteosarcoma treated with limb-salvage surgery, infection has a positive influence on survival, as does a smaller initial length of radius involved and lower body weight.

Animals↗

PubMed2006

Factors affecting the prognosis of patients with esophageal cancer undergoing salvage surgery after definitive chemoradiotherapy.

BACKGROUND AND OBJECTIVES: Although salvage surgery after definitive chemoradiotherapy (CRT) is common, the safety and indication has not yet been established. METHODS: We retrospectively compared the mortality and morbidity of 24 patients who underwent salvage surgery with those of historical controls treated with neoadjuvant CRT followed by planned esophagectomy during the same period, and analyzed the prognostic factor of salvage surgery. RESULTS: Preoperative serum albumin (3.7 vs. 4.1 g/dl, P = 0.0157) and lymphocyte count (763 vs. 964/mm(3), P = 0.0111) in the salvage group were significantly lower than those in the neoadjuvant group. A significant difference was also observed in operation time (567 vs. 474 min, P = 0.0381), C-reactive protein (CRP) on postoperative day 1 (11.2 vs. 8.7 mg/dl, P = 0.0021), and postoperative systemic inflammatory response syndrome (SIRS) duration (3.5 vs. 2.9 days, P = 0.0486). There were three hospital deaths in the salvage group, whereas no patient died in the neoadjuvant group. Multivariate analysis showed curability (R0 vs. R1 + R2) to be the strongest prognostic factor of salvage surgery (P = 0.0064). R1 + R2 operation was more frequently performed in the salvage group (33% vs. 13%), and the reason for all cases was unresectable T4, which had been underestimated preoperatively. CONCLUSIONS: Salvage surgery is a highly invasive and morbid operation, which is performed on immunocompromised hosts. The indication must be carefully considered, with care taken to avoid non-curative surgery.

Aged↗

PubMed1992

Primary childhood osteosarcoma: the role of salvage surgery.

The overall results of salvage surgery for lung metastases were evaluated on 174 consecutive patients with primary osteosarcoma below the age of 20, resected in Milan between 1970 and 1988. Seventy-two children treated in the years 1970-1981 were compared with 102 children treated in the years 1982-1988. In the latter period, adjuvant chemotherapy was replaced by neo-adjuvant programs and salvage surgery was applied systematically to all patients with resectable lung metastases through median sternotomy. During the last period, the overall 5 year survival improved significantly from 35% to 58% (P less than 0.001), while the disease free survival rose from 38% to 45% (median 15 vs. 33 months, P = 0.3). The proportion of patients with completely resected lung metastases rose from 17% (7/42) to 55% (27/49), without operative mortality, and the overall survival from detection of lung metastases (including unresected cases) improved from 0 to 28% at 5 years (P less than 0.001). The survival benefit was observed only in the group of children with resected metastases. These data indicate that systematic bilateral pulmonary resection, combined with neoadjuvant chemotherapy, has contributed to improve the final cure rate of childhood osteosarcoma.

Adolescent↗

PubMed2000

Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means?

OBJECTIVES/HYPOTHESES: Salvage surgery is widely viewed as a "double-edged sword." It is the best option for many patients with recurrent cancer of the upper aerodigestive tract, especially when original therapy included irradiation, yet it may provide only modest benefit at high personal cost to the patient. The stakes are high because alternatives are of limited value. The primary objective of this study was to fully assess the value of salvage surgical procedures in the treatment of local and regional recurrence. The following hypotheses were developed to focus the study design and data analysis. 1) The efficacy of salvage surgery correlates recurrent stage, recurrent site, and time to presalvage recurrence. 2) The economic and noneconomic costs of salvage surgery increase with higher recurrent stage. 3) Information relating the value of salvage surgery to recurrent stage and recurrent site will be useful to these patients and the physicians who treat them. STUDY DESIGN: Two complimentary methods of investigation were used: a meta-analysis of the published literature and a prospective observational study of patients undergoing salvage surgery for recurrent cancer of the upper aerodigestive tract. METHODS: The meta-analysis combined 32 published reports to obtain an estimate of average treatment effect for salvage surgery with regard to survival, disease-free survival, surgical complications, and operative mortality. The prospective observational study included detailed data in 109 patients who underwent salvage surgery. In addition to parameters studied in the meta-analysis, we obtained baseline and interval quality of life data (Functional Living Index for Cancer [FLIC] scores), baseline and interval performance status evaluations (Performance Status Scale for Head and Neck Cancer Patients [PSS head and neck scores]), length of hospital stay, and hospital and physician charges, and related this data primarily to recurrent stage, recurrent site, and time to presalvage recurrence. RESULTS: The weighted average of 5-year survival in the meta-analysis was 39% in 1,080 patients from 28 different institutions. In the prospective study, median disease-free survival was 17.9 months in 109 patients, and this correlated strongly with recurrent stage, weakly with recurrent site, and not at all with time to presalvage recurrence. Noneconomic costs for patients and economic costs correlated with recurrent stage, but not with site. Baseline FLIC and PSS head and neck scores correlated with recurrent stage, but not with site. After salvage surgery the percentage of patients reaching or exceeding baseline was 51% for FLIC scores, and this differed significantly with recurrent stage. Postoperative interval "success" in PSS head and neck subscale scores for diet and eating in public also correlated with recurrent stage. CONCLUSIONS: Overall, the expected efficacy for salvage surgery in patients with recurrent head and neck cancer was surprisingly good, but success was limited and costs were great in stage III and, especially, in stage IV recurrences. A strong correlation of efficacy and noneconomic costs with recurrent stage allowed the creation of expectation profiles that may be useful to patients. Additional systematic clinical research is needed to improve results. In the end, the decision to undergo salvage surgery should be a personal choice made by the patient after honest and compassionate discussion with his or her surgeon.

Carcinoma, Squamous Cell↗

PubMed2005

Patterns of local disease failure and outcome after salvage surgery in patients with anal cancer.

BACKGROUND: Salvage surgery for anal cancer is usually reserved for local disease failure, but issues relating to the prediction of local failure and surgical outcome are ill defined. METHODS: Between 1988 and 2000, 254 patients with non-metastatic anal epidermoid carcinoma were treated at a regional cancer centre with radiotherapy (n = 127) or chemoradiotherapy (n = 127). RESULTS: There were 99 local disease failures (39.0 per cent), all but five occurring within 3 years of initial treatment. Increasing age (P < 0.001, Cox model), total radiation dose (P = 0.004) and tumour stage (P = 0.010) were independent predictors of local failure. The overall 3- and 5-year survival rates after local disease failure were 46 and 29 per cent; the corresponding rates after salvage surgery (73 patients) were 55 and 40 per cent. A positive resection margin was the strongest negative predictor of survival after salvage surgery (P = 0.008, log rank test). Of 52 patients treated before the routine consideration of primary plastic reconstruction, delayed perineal wound healing occurred in 22 (42 per cent). CONCLUSION: In the management of anal cancer, local disease failure is a major clinical problem requiring early detection followed by radical surgery, often accompanied by plastic reconstruction. By implication, these factors favour the centralization of treatment for this uncommon cancer to a multidisciplinary oncology team.

Adult↗

PubMedDate not supplied

[Recurrence after radiotherapy and/or surgery of carcinoma of the oropharynx and the pharynx. Possibilities of salvage surgery].

Forty-seven laryngeal and 21 oropharyngeal recurrences were treated with salvage surgery alone or combined with radiotherapy at the ENT Clinic and Radiotherapy Division of the University of Turin, Italy. Primary tumors had been treated with surgery alone in 10 cases (larynx) and in 21 cases (oropharynx), with combined surgery and radiotherapy in 2 and 8 patients, and with radiotherapy alone in 9 and 18 cases. We observed 26/47 (larynx) and 12/21 (oropharynx) recurrences at the site of primary tumor, 20/47 and 9/21 in loco-regional nodes, and 9/47 and 3/21 in locations adjacent to the primary tumor. Salvage treatment employed surgery alone in 12 (oropharynx) and 16 (larynx) cases; radiotherapy was combined in 9 and 31 cases. Five-year actuarial NED survival was 45.5% for laryngeal and 24% for oropharyngeal cancer patients. After salvage surgery, 50% of laryngeal lesions and only 25% of oropharyngeal recurrences were completely cured. In our series, in 2 cases only the complications caused the patient's death, while in the extant cases a prolonged postoperative hospitalization was necessary. Our study was aimed at investigating the curative potentials of secondary therapy for recurrent carcinomas. A review of the literature on the subject is reported. The small amount of published data prevents "universal" treatment protocol from being assessed. The authors suggest the opportunity of employing a multimodal treatment policy for recurrences of head and neck cancers.

Adult↗

PubMed2001

Locally recurrent rectal cancer: predictors and success of salvage surgery.

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.

Disease-Free Survival↗

PubMed2005

Salvage surgery for radiorecurrent prostate cancer: contemporary outcomes.

PURPOSE: We present a 30-year experience with performing salvage surgery in patients with persistent prostate cancer (PCA) after definitive radiotherapy. MATERIALS AND METHODS: Patients with biopsy proven PCA following definitive radiotherapy who underwent salvage surgery were identified retrospectively (1967 to 2000). Prostate specimens were evaluated by a single pathologist. Progression-free survival (PFS) and cancer specific survival (CSS) estimates were made with multivariate analysis of outcome predictors. Complications were reviewed. RESULTS: Sufficient information was available on 199 patients, including 138 with retropubic prostatectomy (RP) and 61 with cystoprostatectomies (CP). Median followup was 7.0 years. Rectal injury rates (5% for RP and 10% for CP) remained stable, while transfused units of blood decreased. Urinary extravasation (15% of cases) and bladder neck contracture (22%) were the most common complications. Urinary continence (0 pads) improved from 43% to 56% of patients (p = 0.17) with an additional 20% requiring 1 or fewer pad daily. Overall 10-year CSS in all patients undergoing salvage surgery was 65%. Patients undergoing RP fared better than those needing CP (10-year CSS 77% vs 38%, p <0.001 and median PFS 8.7 vs. 4.4 years, p <0.001). Tumor ploidy, percent 4/5 Gleason grade and pathological stage were strong predictors of outcome, while margin status and preoperative prostate specific antigen had minimal predictive strength. CONCLUSIONS: Significant PFS and CSS can be expected following salvage surgery for radioresistant PCA. Several pathological features of the removed prostate are predictive of survival. The surgical risks of salvage surgery are now defined. Morbidity rates, including continence, have moderately improved with time.

Aged↗

PubMed2005

Treatment of the N0 neck during salvage surgery after radiotherapy of head and neck squamous cell carcinoma.

BACKGROUND: The morbidity and mortality rates of salvage surgery in patients with local recurrence of head and neck squamous cell carcinoma (HNSCC) after radiotherapy are high. The aim of this study was to determine the rate of occult neck node metastasis and the surgical morbidity of patients after salvage surgery for local relapse after definitive radiotherapy. METHODS: Thirty patients who underwent salvage surgery with a simultaneous neck node dissection for a local relapse after definitive radiotherapy for HNSCC between 1992 and 2000 were included in this study. The primary tumor sites were oral cavity in six patients, oropharynx in 17, supraglottic larynx in three, and hypopharynx in four. Initially, seven patients had T2 disease, eight had T3, and 15 had T4. RESULTS: Twelve patients (40%) experienced postoperative complications, including two deaths. There was no cervical lymph node metastasis (pN0) in 29 of the 30 patients. Fifteen patients (50%) had a recurrence after salvage surgery, including 11 new local recurrences and four patients with distant metastasis. CONCLUSIONS: The risk of neck node metastasis during salvage surgery for local recurrence in patients treated initially with radiation for N0 HNSCC is low. Neck dissection should be performed in only limited area, depending on the surgical procedure used for tumor resection.

Adult↗

PubMed2003

Postoperative complications after en bloc salvage surgery for head and neck cancer.

OBJECTIVE: To analyze the frequency of and risk factors for postoperative complications after en bloc salvage surgery for head and neck cancer. DESIGN: Retrospective cohort study. SETTING: Patients were evaluated from February 7, 1990, to November 17, 1999, in a tertiary cancer center hospital. PATIENTS: Consecutive sample of 124 patients from the hospital database. Only patients with recurrent head and neck squamous cell carcinoma undergoing en bloc salvage resection were eligible for the study. MAIN OUTCOME MEASURES: We analyzed the frequency of and risk factors for complications after salvage surgery. RESULTS: The tumor location was the lip in 6 patients, oral cavity in 55, oropharynx in 31, larynx in 24, and hypopharynx in 8. Previous treatment was surgery alone in 20 patients, radiotherapy alone in 68, surgery and radiotherapy in 21, and radiotherapy and chemotherapy in 14. An additional patient received chemotherapy alone before salvage surgery. The clinical stage of the recurrent tumor was I or II in 23 patients and III or IV in 101 patients. Postoperative complications occurred in 66 patients (53.2%). Fifty-three patients (42.7%) had minor complications, and 23 patients (18.5%) had major ones. There were 4 postoperative deaths (3.2%). The major factor associated with the overall occurrence of postoperative complications was the clinical stage of the recurrent tumor (P =.02). The occurrence of minor complications correlated with the previously treated site, with complications occurring more often in patients undergoing locoregional vs local treatment (P =.04). Major complications were associated with the time between initial treatment and salvage surgery (P =.05). CONCLUSIONS: Salvage surgery can be performed with acceptable rates of postoperative complications. The clinical stage of the recurrent tumor and the previous site treated were the 2 major factors associated with the occurrence of postoperative complications.

Adolescent↗

PubMed1992

Prognosis of osteosarcoma treated by limb-salvage surgery: the ten-year intergroup study in Japan.

We report the prognoses for 107 patients treated by limb-salvage surgery and 147 treated by amputation or disarticulation, during the period 1980-1985, at 22 university hospitals, cancer centers and national hospitals in Japan. In this multi-institute non-randomized study, the five-year cumulative survival rate was 70% for the former group and 49% for the latter. The prognosis was more favorable among patients who responded to preoperative chemotherapy than among those who did not. Limb-salvage surgery was feasible for most of the surgical stage IIB patients with small extraosseous tumor extensions who had responded to preoperative chemotherapy. Local tumor recurrences were seen in 15 (14%) of the 107 patients in the limb-salvage surgery group, nine of whom died of the metastasis. While limb-salvage surgery is being increasingly used in Japan, present indications show the procedure not to reduce survival rate for osteosarcoma patients. The survival rate of patients with wide-with-marginal margins was similar to that of patients with wide margins. Taking into account the long-term survival of osteosarcoma patients, limb-salvage surgery can be recommended when the osteosarcoma responds to preoperative chemotherapy.

Adolescent↗

PubMed2006

Case reports: polymethylmethacrylate lung embolus after limb-salvage surgery of the distal femur.

Limb-salvage surgery for malignant tumors frequently involves reconstruction with an endoprosthesis anchored to bone by using third-generation cementing techniques. A 10-year-old boy with osteosarcoma had a pulmonary embolus caused by polymethylmethacrylate after having limb-salvage surgery that used high-pressure cementing techniques. He experienced transient postoperative chest pain, and a new wedge-shaped radiodense pulmonary lesion appeared on a computed tomography scan of the chest. A thoracotomy for resection of suspected metastatic osteosarcoma revealed a pulmonary infarct caused by cement embolization. Awareness of this potential complication should prompt investigation of possible pulmonary embolism and may prevent unnecessary thoracotomy.

Biopsy↗

PubMedDate not supplied

Salvage surgery after radiotherapy failure in T1-T2 squamous cell carcinoma of the glottic larynx.

BACKGROUND: This study was undertaken to analyze the clinical course of patients who developed local (primary) recurrence after high-dose irradiation of T1 -T2 squamous cell carcinoma of the glottic larynx. METHODS: Between May 1977 and December 1989, 247 patients with previously untreated T1 and T2 invasive squamous cell carcinoma of the glottic larynx were treated for curative intent with radiotherapy. Local recurrence occurred in 26 of 247 patients (11%). Successful surgical salvage was defined as no evidence of recurrent cancer for at least 2 years after salvage surgery and continuously thereafter. RESULTS: Two patients refused to undergo salvage surgery and one patient had unresectable disease. Of 23 patients who underwent salvage surgery, 19 had a total laryngectomy and 4 had a voice-sparing procedure. One patient who was continuously free of disease, died less than 24 months after salvage surgery; this patient was excluded from all local control and survival analyses, leaving 22 patients available for analysis. Successful salvage was achieved initially in 13 (59%) of the 22 patients. Two patients with local failure after voice-sparing salvage surgery underwent completion laryngectomy; one was salvaged, so that 14 of 22 (64%) were ultimately salvaged. The rate of successful salvage did not correlate with preirradiation T stage, time to failure after irradiation, or time from clinical suspicion of recurrence to histologic proof. In a subgroup of patients (those with positive margins, tumor extension into the soft tissues of the neck, or two or more adverse histologic features), the risk of local-regional recurrence after salvage laryngectomy was 80%. CONCLUSION: There are few data in the literature regarding the clinical outcome of patients whose tumors are not controlled by initial radiotherapy. This series and previous publications from other institutions indicate that most patients who develop primary failure undergo salvage surgery, which is successful in approximately 50-80% of the patients. The rate of surgical complications is acceptable and is related to radiotherapy dose. At our institution, most patients who had recurrence after radiotherapy underwent total laryngectomy. More than 50% of the patients who experienced recurrence after irradiation originally had tumors of such extent that they would have required total laryngectomy if surgery had been recommended instead of radiotherapy for the initial treatment. It is reasonable to consider reirradiation in patients with a very high risk of local-regional recurrence after salvage laryngectomy.

Biopsy↗