Balancing Improved Survival and Long-term Outcomes After Surgical Treatment of Pediatric Head and Neck Cancer

With a high density of critical structures which may include muscle, bone, or skin, the head and neck region presents distinct reconstructive challenges for microsurgeons. From 1973 to 2010, head and neck cancers accounted for 11.9% of all pediatric cancer diagnoses, of which 19.7% were sarcomatous in origin.1 For pediatric patients, the reconstruction of head and neck cancer (HNC) is further complexed by the priority to preserve future bone growth and optimize functionality while maintaining low morbidity. Even when complete remission is achieved, the physical side effects of radiation therapy and resection in the head and neck region can lead to facial disfigurement, neural dysfunction, and vascular injuries.2 Current resection of HNC and adjuvant therapy predisposes patients to severe long-term complications, motivating the surgeon to assess the balance between survivability and quality of life. This study aims to examine the survival, complications, and functional outcomes characteristic to pediatric HNCs. A retrospective analysis was conducted evaluating patients that underwent HNC treatment between 2000 and 2017. Patients with index surgery outside of Children’s Hospital Los Angeles, incomplete data, lesions outside of the head and neck, or less than 5 years of follow-up were excluded. Patient medical history, demographics, disease stage, margin classifications, and long-term outcomes were abstracted from medical charts. Wilcoxon, chi-squared, and Kaplan Meier analyses were performed for statistical analysis. Of 77 pediatric patients with HNC, the average age of diagnosis was 5.9 ± 5.6 years old with malignant connective tissue neoplasms as the most common type of HNC (n = 52; 67.5%). Among the 56 patients that underwent tumor resection by the plastic and maxillofacial service, 27 (48.2%) had negative margins (R0), of which 15 (26.8%) received adjuvant therapy. The remainder of the resections were limited with anticipated positive margins given the tumor's proximity to critical structures and to avoid significant morbidity. The overall survival was 85.7% with significantly higher rates of death among patients who did not undergo any surgical intervention compared to those who did (28.6% vs 7.7%, P = .028). Among patients who underwent R0 resection, those who did not undergo chemoradiation had a higher predicted 5-year survival compared to those who did (65.0% vs 95.0%, P = .004). The incidence of deglutition dysfunction and chronic infection respectively were significantly higher in patients receiving surgery and chemotherapy (0.0% vs 25.0%, P = .022, 0.0% vs 25.0%, P = .022), chemoradiation (0.0% vs 33.3%, P = .007; 0% vs 25.0%, P = .022), and any adjuvant therapy (0.0% vs 29.2%, P = .029, 0.0% vs 25.0% P = .043) compared to surgery alone. In contrast to adult HNC, pediatric HNC are commonly malignant sarcomatous tumors, and early and aggressive surgical intervention provides balance in survivability and morbidity. Our data suggests that chronic dysfunctions may be a sequela of additional therapies. Deglutition and mastication dysfunction was more common among patients who received any adjuvant therapies, potentially secondary to chronic mucositis associated with these therapies. Particularly, radiation therapy confers an increased risk for poor functional outcomes and should be prescribed with caution.