Surgery and/or radiotherapy with or without concurrent chemotherapy has been established as a primary treatment for all newly diagnosed SCCHN. Nevertheless, loco(regional) failure occurs in up to 50% of patients, and for these lasts, salvage surgery is considered the best treatment option [3]. Even after aggressive multimodal therapy, many patients have persistent or recurrent disease due to their multiple risk factors and induced field cancerization. Salvage surgery represents the optimal approach in this category of patients, but it is not always easy to identify the ideal candidate for surgical approach, and moreover, salvage surgery may not be performed in all patients. With persistence/recurrence rates as high as 40% to 50%, and only 20% to 30% of these patients eligible for curative salvage therapy [7,8], it is clearly important to determine which factors predict successful salvage.

Matoscevic et al., performed a descriptive analysis of 176 patients with SCCHN, who relapsed after the primary curative treatment. Patients with a previous diagnosis of primaries arising from the oral cavity, larynx, oropharynx, and hypopharynx and who were treated with upfront surgery or in alternative radiation therapy were enrolled. Salvage surgery was the most frequently chosen modality of salvage treatment, being performed in 67.2% of patients affected by laryngeal cancer, 45.3% of those with oropharyngeal cancer, 56.5% of patients with hypopharyngeal carcinoma, and 37.8% of those affected by oral cavity cancer. The salvage rate was significantly better in patients affected by larynx and oral cavity recurrent tumors, while those suffering for oropharynx and hypopharynx recurrences had worser outcome. The authors also highlighted that lower initial T and N stage, developing local relapse in larynx and oral cavity have the best chances for salvage [9].

Elbers et al., used salvage surgery in 189 patients with a diagnosis of recurrent SCCHN carcinoma, previously treated with radiotherapy alone or chemoradiotherapy as an upfront approach. Oral cavity primaries were excluded from the analysis, upfront surgery being in this case the best option in site of radiation therapy. The authors found that larynx carcinomas were associated with more favorable local and locoregional control than pharyngeal (both oropharynx and hypopharynx) carcinomas. Overall, surgery reached a five-year overall survival (OS) of 33%, and a median OS of 18 months. Moreover, a sharp distinction was made between the “local” disease (recurrence on T) and “locoregional” disease (recurrence upon T and/or N), and interestingly, survival following salvage surgery for locoregional disease was significantly worse if compared with those obtained in local disease. In patients with locoregional recurrence, due to the higher tumor burden, prognosis was significantly worse. In this category of patients, the authors also found that rpT stage and ASA (American Society of Anesthetists) score were independent predictors for worse DFS [10].

Most data from the literature have highlighted that salvage surgery for laryngeal and oral cavity tumor recurrences does result in better survival, if compared to other subsites (hypopharynx and oropharynx), and this may be due to the major difficulty in resecting pharyngeal recurrences due to nearby anatomical structures (e.g., carotid artery and skull base) [8,9,10]. Nevertheless, salvage surgery may be taken into account, especially in high expertise centers, as modality of choice also in recurrent pharyngeal cancers. When choosing surgery as salvage strategy is important to acknowledge some important features, mainly the site of recurrence and then the extent of recurrent disease (pT), the ASA score, the disease-free interval, the feasibility of postoperative radiation, and the previous radiotherapy received, the performance status of the patient and the family and social environment.