Importance: Patients with recurrent or second primary oropharyngeal cancer can achieve survival benefit from surgical salvage, and often require simultaneous free tissue transfer reconstruction in this setting. Resection and reconstruction can have significant impact on function, leading to long-term tube dependence.
Objective: Primary objective: describe rates of tracheostomy and gastrostomy tube dependence one year after oropharyngeal resection and free flap reconstruction among patients with prior head and neck radiation. Secondary objective: evaluate for patient, tumor, and treatment factors associated with tube dependence.
Design: Retrospective, multi-institutional cohort study. Patients treated from August 2003 - June 2020. Average follow-up 21.4 months.
Setting: Five tertiary care referral centers.
Participants: Adult patients undergoing resection and simultaneous free flap reconstruction for oropharyngeal squamous cell carcinoma after prior head and neck radiation. Consecutive sample of 89 patients were included.
Main Outcome and Measures: Primary outcomes were gastrostomy tube dependence and presence of tracheostomy or tracheostoma one year after surgery. Univariable and multivariable logistic regression performed to identify patient, tumor, and treatment factors associated with tube dependence as binary outcomes.
Results: All patients underwent oropharyngectomy and free flap reconstruction; 9 (10%) underwent segmental mandibulectomy and 18 (20%) underwent total laryngectomy as part of their tumor extirpation. After surgical salvage and free flap reconstruction, 51 patients (57%) were alive at 12 months, with median overall survival 23.9 months. Among patients alive at 12 months, 22 (43%) were at least partially-dependent on gastrostomy tube, and 15 (29%) had either tracheostomy tube or tracheostoma. On multivariable logistic regression analysis, patients undergoing total laryngectomy were significantly association with long-term gastrostomy tube (OR 7.74, 95% CI 1.32-66.0, p=0.033). Long term tracheostomy or tracheostoma was significantly associated with preoperative gastrostomy (OR 7.12, 95% CI 1.67-36.9, p=0.011).
Conclusions and Relevance: Even among long-term survivors after salvage oropharyngeal resection and free flap reconstruction, rates of tube dependence are significant. This multi-institutional review is the largest such study to date, and may help inform patient discussions and shared decision making in this challenging patient population.