Postoperative radiation therapy for head and neck cancer in the setting of orocutaneous and pharyngocutaneous fistula

Due to concerns of radiation-related toxicity and hindered wound healing, the presence of a fistulous tract from the aerodigestive airway to the skin is commonly considered a contraindication for the initiation of postoperative radiation therapy (RT). Seventeen patients with an orocutaneous (9 patients) or pharyngocutaneous (8 patients) fistula underwent postoperative RT for head and neck cancer to a median dose of 60 Gy (range, 60-70 Gy). The median time period from surgical resection to the first day of RT was 39 days (range, 23-77 days). All patients were irradiated over an open orocutaneous or pharyngocutaneous fistula using intensity-modulated (10 patients) or conventional (7 patients) techniques. The median size of the fistula at the initiation of RT was 2 cm (range, 0.5-5 cm). All 17 patients completed postoperative RT without any treatment breaks. However, 4 patients developed serious complications within 3 months after completion of treatment (1 osteomyelitis requiring intravenous antibiotics; 1 flap necrosis requiring surgical debridement; 1 oral commissure dihiscence requiring reconstruction; 1 tracheoesophageal fistula) resulting in a 24% rate of grade 3+ acute toxicity. Closure of the fistulous tract eventually occurred either spontaneously (9 patients) or after additional surgical intervention (8 patients). Late complications included 1 case of severe trismus requiring permanent gastrostomy tube and 1 case of osteoradionecrosis. Postoperative RT in the setting of orocutaneous and pharyngocutaneous fistula should be considered after judiciously weighing the potential benefits and risks. Since excessive delays in starting postoperative RT can portend worse oncologic outcomes, however, this treatment approach seems warranted in selected cases.