Open surgical salvage procedures for nasopharyngeal carcinoma

Abstract

Due to the relative inaccessibility of the nasopharynx and the high radiosensitivity of the nasopharyngeal carcinoma (NPC), NPC is primarily treated nonsurgically with radiotherapy. However, in residual or recurrent disease, additional radiotherapy may not be feasible or may be associated with increased morbidity. In such cases, salvage surgery can be considered. Open nasopharyngectomy usually requires transgressing a large amount of normal tissue while endoscopic approach offers similar local control with less morbidities. For more advanced tumors, open nasopharyngectomy still has the advantage of better manipulation of tissue and less risk of vascular injury. Approaches to the nasopharynx include the inferior approach via transpalatal approach; inferio-lateral approach via transcervico-manibulo-palatal approach; anterior approach via midfacial degloving approach; anterio-lateral approach via maxillary swing approach; and lateral approach via the infratemporal fossa approach. Each approach has advantages and disadvantages. The maxillary swing approach has the most research in the literature and has been shown to be superior to the midfacial degloving approach. For salvage of nodal failures, standard surgery is radical neck dissection. With improving imaging techniques leading to better delineating of the extent of the disease, a less-than-radical neck dissection surgery has recently been advocated. For more extensive disease, additional local radiotherapy via after-loading brachytherapy can be delivered via plastic tubes placed over tumor bed during surgery. In summary, even with high rate of cure of modern chemoradiotherapy for NPC, open surgery for salvage is occasionally required and should be advocated in patients suffering from loco-regional failures not suitable for minimally invasive surgery.