We encountered two patients who developed treatment-related myelodysplastic syndrome (MDS) and neck infection after chemoradiotherapy for head and neck squamous cell carcinoma (HNSCC), in whom we had difficulty in treating the neck infection and pharyngocutaneous fistula formation.
Case 1: 73-year-old male. The patient had undergone total pharyngo-laryngo-esophagectomy, bilateral neck dissection, and free jejunal flap reconstruction after neo-adjuvant chemotherapy (nedaplatin, 5-FU) 14 years earlier for left pyriform sinus squamous cell carcinoma (SCC) pT4aN2cM0. After surgery, he had received adjuvant chemoradiotherapy (docetaxel, 58 Gy) and adjuvant chemotherapy (oral fluorouracil agents). He was hospitalized thereafter due to necrosis of the free jejunal flap. After surgical debridement, a staged reconstruction strategy was considered for the defect. Reconstructions using a left deltopectoral (DP) flap, left pectoralis major myocutaneous flap, and right DP flap were attempted, but failed, with residual fistula formation due to marginal or total necrosis of the flaps. Finally, it took 67 weeks before we succeeded in closing the fistula using a migrating tube flap from the right DP flap. The patient was diagnosed as having MDS while he was hospitalized and this was thought to be responsible for his delayed wound healing.
Case 2: 76-year-old male. The patient had undergone neo-adjuvant chemotherapy (nedaplatin, S-1) and chemoradiotherapy (docetaxel, 60 Gy) 12 years earlier for left pyriform sinus SCC pT2N1M0. He had been diagnosed 3 years earlier as having MDS. He was hospitalized for deep neck infection. In spite of prompt surgical drainage and antibiotic therapy, he developed septic shock 7 weeks after admission. Although his condition began to improve and the fistula started to become smaller after the second surgery for debridement, his deep neck infection progressed to cervical vertebral osteomyelitis 30 weeks after admission and the patient died 39 weeks after admission.
In conclusion, physicians should be keenly aware that infection in a HNSCC patient who develops treatment-related MDS after chemoradiotherapy can be a life-threatening event, and close attention needs to be paid to wound healing in these patients.
