Carotid artery replacement in conjunction with resection of recurrent cancer of the neck: midterm results with quality of life assessment

Objectives: The management of patients with recur- rent cervical cancer invading the carotid artery is difficult and controversial. The purpose of this study was to evaluate the overall survival rate, primary patency of the vascular re- constructions, and quality-adjusted life-years (QALY) after en bloc resection of the carotid artery and tumor with in- line polytetrafluoroethylene (PTFE) carotid grafting, fol- lowed by radiotherapy. Methods: From 2000 to 2014, 31 consecutive pa- tients with recurrent neck cancer invading the carotid ar- tery underwent en bloc resection and simultaneous carotid artery reconstruction with a PTFE graft, completed with a myocutaneous flap in 18 cases. The primary tumor was a squamous cell carcinoma of the larynx in 17 patients, of the hypopharynx in 7, an anaplastic tumor of the thyroid in 3, and an undifferentiated carcinoma of unknown origin in 4. Postoperatively all the patients received radiotherapy (50-70 Gy). Ten patients received also chemotherapy (doxorubicin and cisplatin). Results: None of the patients died or sustained a stroke in the postoperative period. Postoperative morbidity consisted of 6 transitory dysphagia, 3 vocal cord palsies, 2 wound dehiscences, 1 transitory mandibular claudication, and 1 partial myocutaneous flap necrosis. No graft infec- tion occurred during follow-up. Fifteen patients (48%) died of metastatic disease during a median follow-up period of 45.4 months (8-175 months). None of the patients showed evidence of local recurrence, stroke, or thrombosis of the carotid reconstruction. The 5-year survival rate was 49% 6 10%. The overall QALYs was 3.12 (95% confidence interval, 1.87-4.37) with a significant difference between patients without metastasis at time of redo surgery (n ¼ 25; QALYs, 3.74) and those with metastasis (n ¼ 6; QALYs, 0.56). QALYs were also significantly better for pa- tients with cancer of the larynx (n ¼ 17; QALYs, 4.69) compared with patients presenting with other tumors. Conclusions: Aggressive en-bloc resection of recur- rent neck cancer with PTFE grafting can be curative, particularly in patients without metastasis at time of redo surgery. In this subset of patients, extensive neck surgery with carotid artery replacement allows an excellent local control of the disease with an improved quality of survival