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ORIGINAL ARTICLE
AIRWAY MANAGEMENT BEFORE CHEMORADIATION FOR
ADVANCED HEAD AND NECK CANCER
Alexander Langerman, MD,1 Riddhi M. Patel, MD,1 Ezra E. W. Cohen, MD,2,3
Elizabeth A. Blair, MD,1,3 Kerstin M. Stenson1,3
1
Department of Surgery, Section of Otolaryngology–Head and Neck Surgery, University of Chicago Medical Center,
Chicago, IL. E-mail: [email protected]
2
Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
3
University of Chicago Comprehensive Cancer Center, University of Chicago Medical Center, Chicago, IL
Accepted 14 December 2010
Published online 7 March 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hed.21729
Abstract: Background. Patients with upper aerodigestive
tract tumors can have development of airway compromise
both before and during chemoradiotherapy (CRT). Tracheotomy is the classic method for securing a safe airway, but tumor debulking may also be used.
Methods. This was a retrospective review of locoregionally
advanced tumors of the base of tongue, larynx, or hypopharynx undergoing CRT between 1995 and 2007.
Results. Forty-two of the 109 patients presented with signs
or symptoms of airway obstruction. Of these, 28 underwent tracheotomy before CRT, and 11 had tumor debulking. Two of
the 11 patients who underwent debulking required tracheotomy within 1 year after CRT for persistent edema and fibrosis.
Larynx tumors were more likely to require tracheotomy or
debulking than other tumors (p ¼ .01).
Conclusions. Debulking is a safe and effective alternative
to tracheotomy in select patients with tumor-related airway
obstruction before CRT. Patients who undergo debulking
should be monitored closely for recurrence of airway comproC 2011 Wiley Periodicals, Inc.
mise during and after CRT. V
Head Neck 34: 254–259, 2012
Keywords: Chemotherapy; radiation; tracheostomy; airway
management; debulking
Patients with upper aerodigestive tract tumors can
have airway compromise develop both before and after
the initiation of chemoradiation. Tracheotomy is the
classic method for securing a safe airway in patients
with obstruction, but tumor debulking may also be used
to decrease the obstruction and improve the airway.
Concerns have been raised in the literature
regarding the risk of ‘‘seeding’’ the upper aerodigestive tract with tumor cells during tracheotomy,1 and
proposals have been made to preferentially perform
debulking of obstructing airway lesions either as a
stabilization procedure before definitive surgery2 or
Correspondence to: K. M. Stenson
Presented at the American Head and Neck Society Meeting at the
Combined Otolaryngology Section Meetings, May 30, 2009, Phoenix,
AZ.
C 2011 Wiley Periodicals, Inc.
V
254
Airway Management Before Chemoradiation
as a palliative measure.3 No study has yet examined
the role of debulking before chemoradiotherapy
(CRT).
MATERIALS AND METHODS
We retrospectively reviewed patients undergoing CRT
for primary treatment of head and neck squamous
cell carcinoma as part of prospectively designed trials
between 1995 and 2007. Review was limited to those
patients most likely to have airway compromise, specifically those with T3 or T4 tumors of the base of
tongue, larynx, or hypopharynx. Data on tumor characteristics, presenting symptoms and physical findings, airway interventions both before and during
CRT, treatment outcome (defined as partial versus
complete response to CRT at first posttreatment evaluation), and follow-up disease, tracheotomy, and oral
intake status were abstracted from preexisting trial
databases. Data points were confirmed by review of
operative notes and clinic records.
All chemotherapeutic regimens involved concomitant CRT, with or without induction chemotherapy.
Agents included 5-fluorouracil and hydroxyurea, with
paclitaxel, docetaxel, carboplatin, cisplatin, or others
as a third agent. For radiation, two-dimensional
treatment planning was used before 1998, at which
point 3-dimensional treatment planning ensued with
the use of the computed tomography simulator. Conventional radiotherapy was used before 2000. After
2000, intensity-modulated radiotherapy was used.
High-risk microscopic disease received between 51 Gy
and 60 Gy, depending on the protocol. Gross disease
received 75 Gy. For patients treated with surgical
debulking, treatment planning was based on postdebulking tumor volume.
Data for this study were entered into an
Excel spreadsheet (Microsoft Corp., Redmond, WA).
Two-tailed Student’s t test was used to compare
rates of airway intervention between different tumor
sites and T classification, as well as incidence of
HEAD & NECK—DOI 10.1002/hed
February 2012
FIGURE 1. Debulking of a patient presenting with a T3 supraglottic cancer and signs and symptoms of airway obstruction. Tumor
reduction was performed with a microdebrider and cold instruments under telescopic magnification. The patient subsequently underwent chemoradiation and did not require further airway intervention. Image from clinic via flexible fiberoptic laryngoscopy (A) demonstrates a critical airway (arrow). Intraoperative images before (B) and after debulking with (C) and without (D) endotracheal tube in
place demonstrate creating of an adequate airway with preservation of the glottis.
pulmonary metastasis and response to chemoradiation between intervention groups. The statistical significance threshold was defined as p ¼ .05. This study
was conducted under the University of Chicago Institutional Review Board approval for the parent trials.
RESULTS
One-hundred seventeen patients from 6 trials were
identified with T3 or T4 tumors of the base of
tongue larynx, or hypopharynx. Of the 117, eight
patients had airway management with tracheotomy
before referral to our hospital and were excluded
from subsequent analysis, leaving 109 patients.
Mean time of laryngoscopy to initiation of treatment
was 14.7 days (range, 1–50 days). Seventy-six
patients (70%) had induction chemotherapy, and
33 (30%) went immediately to concurrent chemoradiation, according to the protocol in which they
were enrolled.
Forty-two (39%) of these patients presented with
symptoms of airway obstruction (stridor or increasing
shortness of breath) or laryngoscopic evidence of a
compromised airway (Figure 1). Twenty-eight (67%)
Airway Management Before Chemoradiation
of the 42 underwent tracheotomy before starting
treatment, and 11 (26%) had tumor debulking
(Figures 1 and 2). Three patients with symptoms or
signs of airway obstruction did not have any airway
intervention before starting treatment. Emergency
laryngectomy was not performed on any of these
patients and was not performed at our institution
during the time period of this study.
Two (7%) of the 28 patients with tracheotomy
experienced minor complications during CRT (peristomal cellulitis) that required antibiotic therapy. Of the
three patients who presented with signs of airway
compromise but no pretreatment airway intervention,
one of these, a patient with a T4 supraglottic tumor,
required an urgent tracheotomy after induction chemotherapy and during concurrent chemoradiation for
airway edema.
Sixty-seven (61%) of the 109 patients did not
have evidence of airway compromise. Of these 67
patients, only 3 (5%) required tracheotomy during
treatment (1 for postoperative edema after staging
panendoscopy and 2 during CRT). For the 2 patients
who underwent tracheotomy during CRT, one had a
T3 supraglottic tumor and the other had a T4
HEAD & NECK—DOI 10.1002/hed
February 2012
255
FIGURE 2. Contrast-enhanced coronal (top) and axial (bottom) CT scans of a patient before (pre) and after (post) debulking of a T4
laryngeal cancer. The ‘‘post’’ image was obtained before chemoradiation for other reasons but allows radiographic demonstration of
the changes caused by debulking. Arrow indicates level of tumor-related obstruction.
hypopharynx tumor. The time to treatment after laryngoscopy for these 2 patients was 13 days and 16
days, similar to the overall cohort. Both of these
patients underwent induction chemotherapy; however, both required tracheotomy during the concurrent chemoradiation portion of therapy, and both as
a result of edema with airway compromise.
Within the first year of completing CRT, five
patients underwent tracheotomy for persistent edema
and fibrosis resulting in an inadequate airway. Four
of the patients had T4 supraglottic cancers, and 1
had a T4 hypopharyngeal cancer. Two of these
patients treated with late tracheotomy had undergone
debulking before chemoradiation (the only 2 patients
with T4 supraglottic cancers for whom debulking was
attempted). All of these patients had deep extension
of tumor into cartilage and surrounding neck tissue.
The 2 patients who underwent debulking also had a
considerable exophytic portion that was the target of
debulking.
256
Airway Management Before Chemoradiation
Advanced laryngeal tumors were more likely to
require tracheotomy or debulking than base of
tongue or hypopharyngeal tumors (43% vs 24%,
respectively, p ¼ .01). T3 tumors were more often
successfully debulked than T4 tumors (14% vs 5%,
respectively, p ¼ .08), and as mentioned previously,
both T4 supraglottic cancer debulking attempts
ultimately failed in the post-CRT period. However,
overall rates of airway intervention were similar
for T3 and T4 tumors (30% vs 41%, p ¼ .26). Tracheotomy or tumor debulking did not affect
response to CRT (88% complete response in intervention group versus 90% complete response in no
intervention group, p ¼ .98). Within 1 year after
CRT, the rates of pulmonary metastases were similar in both groups (7% in intervention group versus 8% in no intervention group, p ¼ .45).
However, 1 of the patients with tracheotomy did
have development of a recurrence at his stoma
1 year after CRT.
HEAD & NECK—DOI 10.1002/hed
February 2012
Table 1. Airway intervention and follow-up data by tumor site and T classification for 109 patients treated with
chemoradiation for advanced head and neck cancer.
Glottic T3
Debulking
Tracheotomy
No intervention
Glottic T4
Debulking
Tracheotomy
No intervention
Supraglottic T3
Debulking
Tracheotomy
No intervention
Supraglottic T4
Debulking
Tracheotomy
No intervention
Base of tongue T3
Debulking
Tracheotomy
No intervention
Base of tongue T4
Debulking
Tracheotomy
No intervention
Hypopharynx T3
Debulking
Tracheotomy
No intervention
Hypopharynx T4
Debulking
Tracheotomy
No intervention
Summary data
All debulking
All tracheotomy
All no intervention
All patients
No. of
patients
No. with >2-y
follow-up
6
1
1
4
7
2
3
2
23
2
3
18
31
2
15
14
9
1
3
5
19
1
2
16
5
2
0
3
9
0
1
8
5
1
1
3
4
2
1
1
15
2
2
11
20
1
9
10
6
0
2
4
7
0
1
6
5
2
—
3
2
—
0
2
3
0
0
3
4
2
1
1
14
2
2
10
16
1
8
7
6
11
28
70
109
8
16
40
64
No. NED
(%)
No. salvage
laryngectomy (%)
1
(100%)
(100%)
(100%)
(100%)
(100%)
(93%)
(100%)
(100%)
(91%)
(80%)
(100%)
(89%)
(70%)
(100%)
—
(100%)
(100%)
(86%)
—
(100%)
(83%)
(100%)
(100%)
—
(100%)
(50%)
—
—
(50%)
—
0
0
1 (20%)
0
—
1 (33%)
1 (50%)
—
—
1 (50%)
—
0
0
1 (14%)
—
0
1 (17%)
0
0
—
0
1 (50%)
—
—
1 (50%)
7
14
34
55
(88%)
(88%)
(85%)
(86%)
0
1 (6%)
5 (13%)
6 (9%)
0
3 (19%)
7 (18%)
10 (16%)
0
3 (19%)
8 (20%)
11 (17%)
1
5
5
2
3
1
0
0
No. NPO
(%)
1 (20%)
0
1 (100%)
0
0
0
0
0
1 (7%)
0
0
1 (9%)
3 (15%)
0
0
3 (30%)
0
—
0
0
0
—
0
0
0
0
—
0
1 (50%)
—
—
1 (50%)
2
4
6
(60%)
No. tracheotomy
dependent (%)
—
0
0
0
0
0
5
0
1
4
3
0
2
1
0
(33%)
(50%)
(36%)
(15%)
(22%)
(10%)
—
0
0
0
1
0
1
0
0
0
0
0
5
0
0
5
3
0
2
1
0
(20%)
(100%)
(33%)
(46%)
(15%)
(22%)
(10%)
NED ¼ Alive, no evidence of disease; NPO ¼ nothing by mouth and therefore feeding tube dependent.
Follow-up data are given as status at last follow-up.
Within the first 2 years of completing CRT, 3
patients had died of disease, and 2 patients had died
of other causes. For the remaining 104 patients,
follow-up data at 2 years or greater was available for
64 (62%), with a mean follow-up of 71 months and a
range of 24 to 162 months, including 8 patients who
had undergone debulking before CRT, 16 patients
who underwent tracheotomy before or during CRT,
and 40 patients who did not undergo airway intervention before CRT (the Table provides follow-up data
broken down by airway intervention status). Of these
64 patients, seven were alive with disease at last
follow-up, 2 had died of other causes than cancer, and
the remaining 55 patients had no evidence of disease.
There were no additional cases of pulmonary metastases in these patients with longer follow-up.
Tracheotomy and oral intake status for patients
with at least 2 years of follow-up are also presented
in the Table. None of the patients treated with
Airway Management Before Chemoradiation
debulking required long-term tracheotomy, and all
were taking at least some nutrition by mouth (definitive gastrostomy tube status was not available). Of
the 16 patients who underwent tracheotomy before
or during CRT, 1 (6%) patient had laryngectomy,
3 (19%) patients have remained tracheotomy
dependent (2 have active disease), and 12 (75%)
patients have undergone decannulation. Thirteen
(81%) of the 16 patients are able to take at least
some nutrition orally. Of the 40 patients with no
pre-CRT airway intervention, 5 (13%) underwent
laryngectomy, 3 (8%) had a tracheotomy during a different salvage surgery, 5 (12.5%) underwent
tracheotomy for persistent airway inadequacy as a
complication of chemoradiation (1 underwent subsequent decannulation), and the remaining 27 (68%)
have not required an airway intervention. Thirty-two
(80%) of the 40 patients are able to take at least
some nutrition orally).
HEAD & NECK—DOI 10.1002/hed
February 2012
257
FIGURE 3. Proposed algorithm for airway management before chemoradiation. *Observation requires close follow-up with the head
and neck surgeon during treatment.
DISCUSSION
Respiratory compromise is a common presenting sign
and symptom of advanced upper airway tumors
and occurred in 39% of the patients in this series.
Classically, all or most of these patients would have
undergone tracheotomy or emergency laryngectomy.
In an era of cancer treatment focused on organ preservation and quality of life, emergency laryngectomy
may be inappropriate, and safe airway management
should be balanced with an earnest effort to minimize
the use of tracheotomy. In these series 26% of the
patients who presented with airway compromise
underwent debulking in an effort to avoid a tracheotomy, and although all of these patients completed
CRT without needing tracheotomy, ultimately 82% of
these patients were able to completely avoid tracheotomy during and after treatment.
In contrast, most of the patients who presented
with airway compromise did undergo tracheotomy
before CRT, and it proved to be a safe, definitive airway throughout treatment. As our experience grows
with surgical debulking, more patients may be considered appropriate candidates for debulking as a bridge
to definitive CRT. However, it must be emphasized the
importance of regular evaluation by the head and neck
surgeon and assessment of reliability and compliance
of patients when considering debulking over tracheotomy (Figure 3). At this time, patients with T4 supra-
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Airway Management Before Chemoradiation
glottic and other cancers with deep tumor extension
are not optimal candidates for debulking and should
be monitored carefully during CRT and follow-up.
During chemoradiation, tumor and soft tissue
swelling, as well as difficulty with secretion management, can transform a serviceable airway into a
critical airway. Even while patients are under the
primary care of the medical and radiation oncologists during therapy, it is critical that the head and
neck surgeon remain involved to monitor for and
address airway and other complications.4 In this
series, a small number of patients (5%) without initial signs or symptoms of airway compromise ultimately required airway intervention during CRT as
a result of acute toxicity. In these patients, surgical
debulking was not considered. Currently, there are
no data to support debulking during active treatment. Operative intervention in an actively radiated
field carries many difficulties and hazards, and
debulking would alter the radiation target. Such
patients should undergo tracheotomy for definitive
airway management.
This study demonstrates that debulking before
treatment does not interfere with a patient’s ability to
undergo subsequent CRT, nor does it impact their
response to treatment. Long-term ability to maintain
oral intake, lack of tracheotomy dependence, and disease status in this group also compared favorably
HEAD & NECK—DOI 10.1002/hed
February 2012
with patients undergoing tracheotomy or not requiring intervention. Surgical debulking was directed
only at the exophytic portion of patients’ tumors, with
an effort to spare any anatomic areas (eg, the true
vocal cords) that may contribute to function, even if
grossly involved with tumor. This is in keeping with
the overall goal of organ preservation.
This study suffers from the usual drawbacks of a
retrospective analysis. Additionally, data-specific
swallowing function, including aspiration and stricture formation, as well as gastrostomy tube retention,
was not available. The vast majority of patients
underwent tracheotomy or debulking before the initiation of chemotherapy, and it is therefore difficult to
comment on what effect, if any, induction chemotherapy may have had in reducing airway compromise.
CONCLUSION
Debulking is a safe and effective alternative to tracheotomy in select patients with tumor-related airway
Airway Management Before Chemoradiation
obstruction prior to undergoing chemoradiation. Tracheotomy continues to be the definitive airway. Neither
method resulted in an increased incidence of pulmonary metastasis, although 1 patient with tracheotomy
had stomal recurrence. Patients treated with debulking
should be monitored closely for recurrence of airway
compromise during and after chemoradiation.
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