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110

KUANetal.

TABLE XIII.1 (Continued)

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusion

Yaoet al. 423

LR

1. For patients who have no evidence of residual lymphadenopathy and a

2005 4

Retrospective case series

53N + patients with

head and neck SCC treated with CRT, followed by surveillance PET/CT and salvage neck dissection for (1) persistent N + and positive PET or (2) persistent N + and negative PET

negative FDG PET scan 12 weeks after definitive radiation, neck dissection can be safely withheld 2. In cases with residual lymphadenopathy on exam and negative PET/CT, neck dissection may be withheld

Abbreviations: CRT, chemoradiation therapy; CT, computed tomography; FDG, fluorodeoxyglucose; LR, locoregional recurrence; ND, neck dissection; PET, positron emission tomography; SB, skull base; SCC, squamous cell carcinoma; SN, sinonasal.

deemed untreatable and did not undergo salvage therapy, and, of the remaining 14 patients, seven were deceased by the end of the study period. Aggregate grade of evidence : C (Level 3: three studies; Level 4: four studies) B Role of salvage surgery Salvage surgery is typically recommended for patients with more favorable histological subtypes where surgical resec tion can be safely performed without injury to critical neurovascular structures (Table XIII.2). A study performed with a hospital-based US database showed that patients with SNM undergoing salvage surgery had significantly longer postoperative hospital stays and increased rates of 30- and 90-day mortality compared to patients undergoing primary surgery. 378 Based on their analysis of 42 patients with recurrent SNM, Kaplan et al. reported prognostic factors that negatively affected survival. These included high-risk histologic subtypes (melanoma, SNUC, ade nocarcinoma, SNEC, sarcoma, SCC), high-grade/poorly differentiated tumors, and tumors with orbital and skull base involvement. 417 For recurrent tumors with these features and not located in the ethmoid sinus, they recom mended against salvage surgery. A retrospective study of 118 patients undergoing salvage surgery for recurrent SNM reported a 5-year OS of 56%, with 57% achieving negative margins. 432 Two recent studies, both from Japan, have assessed the role of salvage surgery for the treatment of local persis tent/recurrent advanced maxillary sinus SCC treated ini tially with RADiation and intraarterial cisPLATin (RAD PLAT). In both series, patients in whom negative sur gical margins could be achieved with SS had a signifi cant improvement in their 2- and 5-year survival rates and local disease control. 433,434 However, salvage treat

ment of advanced epithelial malignancies involving other sinonasal sites seems less effective. Orlandi et al., in a series of 69 locally advanced (T3 and T4) sinonasal epithelial carcinomas (keratinizing and nonkeratinizing SCC, SNEC, SNUC) treated with multimodal therapy consisting of IC followed by surgery and RT or definitive CRT, observed that 44 patients presented with recurrences after primary treatment. Forty-eight percent were local and 45% had dis tant metastases with or without locoregional recurrence. Median OS after recurrence was 13 months and patients who underwent salvage surgery had a median survival of 29.5 months compared to 4.6 months for those who did not undergo salvage surgery (i.e., received chemotherapy alone). 435 Gore et al. performed a systematic review and pooled analysis of 678 patients with ONB from 35 surgical series. They reported a local recurrence rate of 28.5% after primary treatment. Of the 101 patients who underwent salvage treatment for local recurrence, the success of salvage treatment, defined as a DFS of at least 1 year following treatment, was 42.6% with no observed difference between the different treatment modalities of salvage surgery, reir radiation, or a combination of both. Most documented failures were locoregional (23/28) with only a small per centage (5/28) failing with distant metastases. 436 These results need to be interpreted with caution, however, given the low sample size. The largest analysis for the role of salvage surgery for the treatment of neck recurrence was for regionally recur rent ONB. In a pooled analysis performed by Gore et al. of 678 patients from 35 studies, the rate of overall cervical metastases was 20.2%, with a 12.4% rate of late neck metas tases. Salvage surgery was only attempted in 45 patients presenting with late neck metastases, with a 1-year DFS of 31.2% posttreatment. The addition of RT to salvage surgery conferred a statistically significant increase in the rate of successful salvage in patients with late neck metastases. 437