Postoperative radiation of free jejunal autografts in patients with advanced cancer of the head and neck

Abstract

Background: Free jejunal autografts increasingly are being used to repair the pharynx after resections of head and neck carcinomas. Doses of greater than 45 Gy are generally considered to be above the tolerance of the small bowel, whereas the dose range for effective postoperative radiotherapy of advanced head and neck cancers is between 57.6 Gy and 63 Gy. Between July 1988, and December, 1992, 29 patients at the M. D. Anderson Cancer Center were treated with a combination of resection of the advanced head and neck cancer, reconstruction with free jejunal autograft, and postoperative radiation. Planned reductions in postoperative doses due to the presence of the jejunum within the field were not made. This retrospective study analyzes the outcome of these patients with attention to survival, local-regional control, and complications.

Methods: Twenty-seven of the 29 study patients had squamous cell carcinoma of the larynx or pharynx; 24 of these patients had Stage III or Stage IV disease. Two patients had recurrent papillary thyroid carcinoma. The median number of days from surgery to the start of radiation was 34. Radiation doses to the tumor bed ranged from 50 Gy to 72 Gy. The median doses to the tumor bed and the jejunal autograft were both 63 Gy. Surviving patients were followed from 12 to 68 months (median, 20 months) from the time of their surgery.

Results: The actuarial 2-year survival rate was 51%. Nine patients had local or regional recurrences above the clavicles. The 2-year local-regional control and freedom from relapse rates were 71 and 50%, respectively. The most severe complication during radiation was confluent mucositis in greater than 50% of the treated area, which developed in two patients. No patient developed a late complication related to the jejunal autograft.

Conclusions: Postoperative radiation to free jejunal autografts used for pharyngeal reconstruction can be delivered safely. Doses in this setting of 57.6 Gy to 63 Gy depending on the anticipated risk of recurrence based on clinical, surgical, and pathologic findings are recommended. The presence of a free jejunal autograft did not require a reduction of the desired doses used for patients with postoperatively irradiated head and neck cancer.