Extracapsular lymph node spread in recurrent nasopharyngeal carcinoma

To study the efficacy of combined neck dissection and brachytherapy for nodal metastasis with extracapsular spread (ECS) in recurrent nasopharyngeal carcinoma (NPC).

Prospective.

Between 1990 and 2010, we recruited patients who had regional recurrent NPC after radiotherapy. The prevalence of ECS, the type of treatments, and the postoperative complications were noted. Nodal tumor control and disease-free survival were compared between patients with or without ECS.

Macroscopic ECS was seen in 25.9% of our series of 158 patients. They were treated by extended radical neck dissection (RND) followed by brachytherapy. The rest of the patients without ECS were treated by RND alone. Median follow-up duration was 62 months. With such aggressive treatment, there was no significant difference in the 5-year actuarial nodal control (62% and 65%, P = .18) and 5-year disease-free survival (38% and 44%, P = .08) between those with or without ECS. Regional flaps were employed (deltopectoral flap: 24 patients; pectoralis major flap: 17 patients) to prevent wound necrosis and carotid blowout after brachytherapy. The rate of delayed vagal and hypoglossal nerve palsy after brachytherapy was 2.4% and 4.8%, respectively. None of our patients developed cerebral ischemia secondary to accelerated atherosclerosis from brachytherapy after previous external radiotherapy.

With combined surgery and brachytherapy, satisfactory results can be achieved in patients with ECS in recurrent NPC. Reconstruction with regional flaps is mandatory to prevent serious complications like wound necrosis and carotid artery blowout.