Familial Nasopharyngeal Carcinoma 6

Surgery for Recurrent Nasopharyngeal Carcinoma 259DPFig. 20.10. Five empty nylon tubes are placed over the tumorbed (arrows) so that after-loading brachytherapy sourcescan be insertedthe brachytherapy source. The skin overlying thebrachytherapy source is irradiated during the initialtreatment, and might not be able to tolerate this additionalbrachytherapy. The area of neck skin lying onthe brachytherapy source has to be removed with thespecimen during radical neck dissection. The cutaneousdefect should be reconstructed with nonirradiatedskin from the chest wall, such as the deltopectoralflap or the pectoralis major myocutaneous flap (Fig.20.11). Brachytherapy could start on seventh or eighthpostoperative day, when the neck wound has healedand the nylon tubes could be removed after completionof brachytherapy.When this adjuvant therapy was administered forpatients with extensive recurrent or residual neckdisease after radical neck dissection, a similar localtumor control rate could be achieved when comparedto when the radical neck dissection was carried outfor less-extensive neck disease (Wei et al. 2001).20.4Management of Recurrent Carcinomain the Nasopharynx20.4.1Local Recurrence of Nasopharyngeal CarcinomaAs NPC is radiosensitive, the primary treatment ofNPC is radiotherapy or concurrent chemoradiotherapy.Despite the fact that most of the tumor can beeradicated, in some patients the tumor might eitherpersist or recur at the nasopharynx. It is still possibleto manage the residual or recurrent tumor with aFig. 20.11. Deltopectoral flap (DP) is planned to cover thecutaneous defect overlying the neck lymph node (arrows)after resectionsecond course of external radiotherapy, usually at agreater dose than the initial course. A salvage rate of32% together with a cumulative incidence of latepostreirradiation sequelae of 24% and a treatmentmortality of 1.8% has been reported (Lee et al. 1993).The problems associated with the second course ofexternal radiotherapy affects significantly the qualityof life of these patients.To avoid this high incidence of significant complicationsresulting from the second course ofirradiation, alternative salvage measures have beenintroduced. The surgical contributions in this aspectinclude the introduction of brachytherapy sourceinto the tumor or surgical resection of the pathology.These treatment options are applicable when theresidual or recurrent tumor is of limited size and islocalized in the nasopharynx.20.4.2BrachytherapyBrachytherapy is most effective when the radiationsource is inserted directly into the tumor. The