Commentary on “Major complications in deceased patients with advanced recurrent nasopharyngeal carcinoma who underwent salvage surgery: a long-term follow-up cohort study”

Dear Editor, We read with great interest the recent multicenter prospective cohort study by Peng et al that evaluated mortality patterns after salvage skull base surgery for advanced recurrent nasopharyngeal carcinoma (NPC)[1]. The authors reported that internal carotid artery (ICA) rupture and tumor recurrence accounted for 26.67% of deaths, while malnutrition contributed 23.33%. The authors highlighted clinically actionable perioperative priorities beyond oncological control[1,2]. We offer two focused considerations that may strengthen interpretation and facilitate translation into risk-stratified care pathways. This communication is compliant with the TITAN Guidelines 2025 – governing declaration[3]. First, stratifying survival by the eventual cause of death warrants careful interpretation in the presence of competing risks: ICA rupture, recurrence, malnutrition-related decline, and other events are mutually exclusive terminal outcomes, and their hazards may interact. Presenting cause-specific cumulative incidence estimates (accounting for competing events) alongside regression approaches using subdistribution hazard models could provide more clinically interpretable absolute risks over time for each endpoint and clarify which perioperative factors (e.g., radiological ICA involvement, vascular management strategies, or nutritional parameters) are most strongly associated with each outcome. Such reporting may also help clinicians balance vascular protection with intensified surveillance for recurrence when counselling high-risk patients. Second, the observation that routine preoperative blood indices did not differ between deceased and surviving patients despite frequent malnutrition-related conditions during follow-up suggests that nutritional vulnerability may not be captured by laboratory testing at a single time point alone[1]. Contemporary frameworks recommend a multi-domain, repeated assessment (weight loss, low body mass index, reduced muscle mass, and functional status) rather than relying on isolated laboratory tests[4,5]. Incorporating standardized screening at baseline and at pre-specified postoperative intervals, paired with early, protocolized nutritional intervention (including enteral support when indicated), could improve comparability across centers and allow evaluation of whether timely escalation modifies downstream risks such as wound complications, treatment tolerance, and late catastrophic hemorrhage. In conclusion, this study provides valuable insights into the non-recurrence drivers of mortality after salvage surgery for advanced recurrent NPC[1]. Future studies that report competing-risk-aware estimates for cause-specific death and adopt standardized, dynamic nutritional assessment may further refine perioperative decision making and identify the most effective levers to improve outcomes in this vulnerable population.