Radyoterapi Sonrası Baş Boyun Cerrahisinde Zorluklar
Özet
Baş boyun kanserlerinde küratif amaçlı radyoterapi (RT) sonrasında hastaların %30-50'sinde lokorejyonel nüks gelişmekte veya %40'a varan oranlarda ikinci bir metakron primer tümör ortaya çıkabilmektedir. Bu tür durumlarda en etkili tedavi seçeneği kurtarma cerrahisi olmakla birlikte, daha önce ışınlanmış dokularda ameliyat yapmak cerrahlar için ciddi teknik zorlukları ve yüksek peroperatif riskleri beraberinde getirmektedir. RT, kasları, sinirleri ve kemikleri besleyen kan damarlarına kalıcı hasarlar vererek ilerleyici bir "radyasyon fibrozisi sendromu" yaratır. Dokularda gelişen odunsu sertlik ve fibrozis; operasyon sürelerinin uzamasına, peroperatif komplikasyon riskinin artmasına ve beslenmesi bozulan dokularda ciddi yara iyileşmesi problemlerine yol açar. Ayrıca çiğneme kaslarının etkilenmesiyle oluşan trismus, takibi ve cerrahi görüşü zorlaştırırken; faringoözefageal stenoz, karotis arter hasarları, osteoradyonekroz ve yumuşak doku nekrozu gibi geç yan etkiler de rekonstrüksiyon ihtiyacını artırarak büyük maliyetlere neden olur. Hayatta kalan popülasyonda IMRT gibi modern tekniklere rağmen sigara kullanımıyla da ilişkili olarak sekonder kanser gelişme riski yüksek olduğundan, tedavi sonrası multidisipliner yaklaşımla yakın klinik sürveyans, egzersizler ve profilaktik ağız bakımı hayati önem taşımaktadır.
In head and neck cancers, locoregional recurrence develops in 30-50% of patients after curative radiotherapy (RT), or a second metachronous primary tumor occurs in up to 40%. Although salvage surgery is the most effective treatment option in such cases, operating on previously irradiated tissues brings serious technical difficulties and high perioperative risks for surgeons. RT causes permanent damage to blood vessels supplying muscles, nerves, and bones, resulting in progressive "radiation fibrosis syndrome". Woody stiffness and fibrosis in tissues lead to prolonged operation times, increased risk of perioperative complications, and severe wound healing problems in malnourished tissues. Additionally, trismus caused by the involvement of masticatory muscles complicates follow-up and surgical exposure, while late side effects such as pharyngoesophageal stenosis, carotid artery damage, osteoradionecrosis, and soft tissue necrosis increase the need for complex reconstruction, causing significant clinical costs. Since the risk of developing secondary cancers is high in the surviving population due to smoking history despite modern techniques like IMRT, close clinical surveillance with a multidisciplinary approach, stretching exercises, and prophylactic oral care are of vital importance.
Referanslar
Lo Nigro C, Denaro N, Merlotti A, et al. Head and neck cancer: improving outcomes with a multidisciplinary approach. Cancer Manag Res, 2017;9: 363−371.
de Bree R, Leemans CR. Recent advances in surgery for head and neck cancer. Curr Opin Oncol. 2010;22(3):186−193.
Argiris A, Karamouzis MV, Raben D, et al. Head and neck cancer. Lancet. 2008;371:1695−1709.
Bussink J, van Herpen CM, Kaanders JH, et al. PET-CT for response assessment and treatment adaptation in head and neck cancer. Lancet Oncol. 2010;11: 661−669.
Blanchard P, Baujat B, Holostenco V, et al. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): a comprehensive analysis by tumour site. Radiother Oncol. 2011;100(1):33−40.
Goodwin WJJr. Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means? Laryngoscope. 2000;110(93):1−18.
Elicin O, Nisa L, Dal Pra A, et al. Up-front neck dissection followed by definitive (chemo)-radiotherapy in head and neck squamous cell carcinoma: Rationale, complications, toxicity rates, and oncological outcomes – A systematic review. Radiotherapy and Oncology. 2016; 119; 185-193.
Bonner JA, Harari PM, Giralt J, et al. Radiotherapy plus cetuximab for locoregionally advanced head and neck cancer: 5-year survival data from a phase 3 randomised trial, and relation between cetuximab-induced rash and survival. Lancet Oncol. 2010;11: 21–28.
Thariat J, Hamoir M, Garrel R, et al. Management of the neck in the setting of definitive chemoradiation: is there a consensus? A GETTEC study. Ann Surg Oncol. 2012;19: 2311–2319.
Pignon JP, le Maître A, Maillard E, et al. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): an update on 93 randomised trials and 17,346 patients. Radiother Oncol. 2009;92: 4–14.
Brook I. Late side effects of radiation treatment for head and neck cancer. Radiation Oncology Journal. 2020;38(2):84-92.
Tolentino Ede S, Centurion BS, Ferreira LH, et al. Oral adverse effects of head and neck radiotherapy: literature review and suggestion of a clinical oral care guideline for irradiated patients. J Appl Oral Sci. 2011;19: 448-454.
Stubblefield MD. Clinical evaluation and management of radiation fibrosis syndrome. Phys Med Rehabil Clin N Am. 2017;28: 89-100.
Sroussi HY, Epstein JB, Bensadoun RJ, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6: 2918-2931.
Straub JM, New J, Hamilton CD, et al. Radiation-induced fibrosis: mechanisms and implications for therapy. J Cancer Res Clin Oncol. 2015;141:1985-1994.
Stubblefield MD, Levine A, Custodio CM, et al. The role of botulinum toxin type A in the radiation fibrosis syndrome: a preliminary report. Arch Phys Med Rehabil. 2008;89: 417-421.
Ortigara GB, Schulz RE, Soldera EB, et al. Association between trismus and dysphagia-related quality of life in survivors of head and neck cancer in Brazil. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;128:235-242.
Urken ML, Jacobson AS, Lazarus CL. Comprehensive approach to restoration of function in patients with radiation-induced pharyngoesophageal stenosis: report of 31 patients and proposal of new classification scheme. Head Neck. 2012;34: 1317-1328.
Shah-Becker S, Pennock M, Sinoway L, et al. Baroreceptor reflex failure: review of the literature and the potential impact on patients with head and neck cancer. Head Neck. 2017;39: 2135-2141.
Grandhi R, Brasiliense LB, Williamson R, et al. Delayed pipeline embolization of a ruptured true internal carotid artery aneurysm presenting with epistaxis: case report and review of the literature. World Neurosurg. 2019;125:273-276.
Fernandez-Alvarez V, Lopez F, Suarez C, et al. Radiation-induced carotid artery lesions. Strahlenther Onkol. 2018;194:699-710.
Giannopoulos S, Texakalidis P, Jonnalagadda AK, et al. Revascularization of Radiation-Induced Carotid Artery Stenosis With Carotid Endarterectomy vs. Carotid Artery Stenting: A Systematic Review and Meta-Analysis. Cardiovasc Revasc Med. 2018;19: 638-644.
Ajila V, Hegde S. Osteoradionecrosis - a review of clinical features and management. Gulhane Med J. 2020;62: 213-223.
Curi MM, Cardoso CL, Benites AFC, et al. Delayed tongue necrosis simultaneous with bilateral osteoradionecrosis of the jaw secondary to head and neck irradiation. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;123: 28-32.
Piccin A, Di Pierro AM, Tagnin M, et al. Healing of a soft tissue wound of the neck and jaw osteoradionecrosis using platelet gel. Regen Med. 2016;11: 459-463.
Beech A, Farrier J. Use of the Integra skin regeneration system in an intraoral mandibular defect in osteoradionecrosis. Int J Oral Maxillofac Surg. 2016; 45: 1159-1161.
Rathy R, Sunil S, Nivia M. Osteoradionecrosis of mandible: Case report with review of literature. Contemp Clin Dent. 2013;4: 251-253.
Garg H, Ramaraj PN, Palekar MG, et al. Changing trend in management of Osteo radio necrosis of the mandible: A case report. IJADS. 2018;4: 271-274.
Chronopoulos A, Zarra T, Ehrenfeld M, et al. Osteoradionecrosis of the jaws: definition, epidemiology, staging and clinical and radiological findings. A concise review. International Dental Journal. 2018;68: 22-30.
Chen JA, Wang CC, Wong YK, Wang CP, Jiang RS, Lin JC, et al. Osteoradionecrosis of mandible bone in patients with oral cancer—associated factors and treatment outcomes. Head Neck. 2016;38: 762–768.
Nadella KR, Kodali RM, Guttikonda LK, et al. Osteoradionecrosis of the Jaws: Clinico-Therapeutic Management: A Literature Review and Update. J Maxillofac Oral Surg. 2015;14: 891-901.
Haubner F, Ohmann E, Pohl F, et al. Wound healing after radiation therapy: Review of the literature. Radiation Oncology. 2012;7: 162.
Tang Y, Shen Q, Wang Y, et al. A randomized prospective study of rehabilitation therapy in the treatment of radiation-induced dysphagia and trismus. Strahlenther Onkol. 2011;187: 39–44.
Lee S, Thiele C. Factors associated with free flap complications after head and neck reconstruction and the molecular basis of fibrotic tissue rearrangement in preirradiated soft tissue. J Oral Maxillofac Surg. 2010:68:2169–2178.
Dormand EL, Banwell PE, Goodacre TE. Radiotherapy and wound healing. Int Wound J. 2005;2: 112–127.
Thom SR. Hyperbaric oxygen: its mechanisms and efficacy. Plast Reconstr Surg. 2011;127(1):131–141.
Lee YH, Kim YS, Chung MJ, Yu M, Jung SL, Yoo IR, et al. Soft tissue necrosis in head and neck cancer patients after transoral robotic surgery or wide excision with primary closure followed by radiation therapy. Medicine (Baltimore), 2006;95:e2852.
Kim JH, Jenrow KA, Brown SL. Mechanisms of radiation-induced normal tissue toxicity and implications for future clinical trials. Radiat Oncol J. 2014;32: 103–115.
Stone HB, Coleman CN, Anscher MS, McBride WH. Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol. 2003;4: 529–536.
Brenner DJ, Curtis RE, Hall EJ, et al. Second malignancies in prostate carcinoma patients after radiotherapy compared with surgery. Cancer. 2000;88: 398–406.
Hall EJ, Wuu CS. Radiation-induced second cancers: the impact of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys. 2003;56: 83–88.
