Prognostic significance of clinically false positive cervical lymph nodes in patients with laryngeal carcinoma

Nodal metastasis in surgically treated laryngeal squamous cell carcinoma

BACKGROUND

Management of the neck in laryngeal squamous cell carcinoma (LSCC) is essential to oncologic control and survival. We aim to describe patterns and rates of clinical/pathologic lymph node disease, elective neck dissection (END), and occult lymph node metastasis (LNM) in patients with surgically-managed LSCC.

METHODS

Retrospective cohort study of patients in the National Cancer Database (NCDB) diagnosed with LSCC between January 2004 and December 2016 who underwent primary surgery.

RESULTS

Seven thousand eight hundred and seventy-six patients met inclusion criteria. For cN0 patients, the rates of END and occult LNM both increased with tumor stage and were highest for supraglottic tumors. Predictors of occult LNM included supraglottic site, pathologic T3 and T4 stage, positive margins, and presence of lymphovascular invasion (p < 0.05).

CONCLUSIONS

The propensity for cervical LNM in surgically-managed LSCC varies based on primary tumor site and stage, and a variety of disease factors increase risk of occult LNM.

[Functional outcome after transmandibular resection and primary chemoradiation in advanced oropharyngeal squamous cell carcinoma]

Ziel der Arbeit

In dieser Studie wurden die funktionellen Ergebnisse nach transmandibulärer Resektion und Rekonstruktion mittels mikrovaskulär anastomosiertem Radialistransplantat (TMR+Tx) gegenüber einer primären Radiochemotherapie (pRCT) bei fortgeschrittenen orophayngealen Plattenepithelkarzinomen (OPSCC) verglichen.

Methoden

Es erfolgte ein Vergleich zwischen 50 OPSCC-Patienten mit TMR+Tx und 50 OPSCC-Patienten mit pRCT. Die Wasserschluckzeit war als primärer Endpunkt definiert. Der Saxon-Test, die maxillomandibuläre Distanz, der Mallampati-Score, der Quotient aus Körpergröße zu Gewicht, eine nasale Penetration, das Vorhandensein einer Ernährungssonde/Tracheostomie sowie 4 validierte Fragebögen (Visuelle Analogskala zur Mundtrockenheit, Sicca VAS; MD Anderson Dysphagia Inventory, MDADI; Voice Handicap Index, VHI; European Organization for Research and Treatment of Cancer Quality of Life Questionnaire – Head and Neck Cancer – 35 Items, QLQ-H&N35) dienten als sonstige Endpunkte zur Beurteilung der Funktion und Lebensqualität.

Ergebnisse

Die Gesamtkohorte an operierten Patienten zeigte eine erhöhte Rate an nasaler Penetration (p < 0,0001), was mit einer verlängerten Wasserschluckzeit verbunden war (p < 0,05). Durch eine modifizierte Rekonstruktion des Weichgaumens wurde die nasale Penetration in der chirurgisch therapierten Gruppe im Vergleich zur klassischen Rekonstruktion signifikant reduziert (p = 0,0001). Patienten mit pRCT litten signifikant stärker an einer Xerostomie (Saxon-Test) als Patienten nach TMR+Tx und Adjuvanz (p = 0,001). In den Fragebögen zur Funktionalität und Lebensqualität zeigte sich kein Unterschied zwischen den Gruppen.

Schussfolgerung

Die TMR+Tx mit modifizierter Rekonstruktion und adjuvante Therapie zeigte gegenüber der pRCT vergleichbare funktionelle Ergebnisse.

T4a laryngeal cancer survival: retrospective institutional analysis and systematic review

OBJECTIVES/HYPOTHESIS

To assess the survival outcomes of a homogeneous group of pT4a laryngeal cancer patients treated at our institution by primary total laryngectomy and neck dissection with adjuvant therapy when indicated, and to systematically review studies reporting overall survival outcomes in T4a laryngeal cancer.

STUDY DESIGN

Systematic review of PubMed and Embase databases.

METHODS

Records of 108 laryngeal cancer patients treated by total laryngectomy were reviewed. pT4a cases treated by primary total laryngectomy between 1998 and 2010 were included. Overall and disease-free survival at 2 and 5 years were reported. A systematic review was performed including all published studies reporting overall survival outcomes by treatment modality in T4 laryngeal cancer patients.

RESULTS

Thirty cases met the inclusion criteria. At 2 years, overall and disease-free survival were 81.3% and 78%, respectively. The 5-year overall and disease-free survival rates were 60%. The systematic review retrieved 24 articles. Overall survival at 2 years ranged from 12% to 21.2% with radiotherapy, <30% to 65% with chemoradiotherapy, and from 30% to 100% with surgery. At 5 years, it ranged from 0% to 75% with radiotherapy, 16% to 50.4% with chemoradiotherapy, and 10% to 80.9% with surgery.

CONCLUSIONS

Primary total laryngectomy provides a high survival rate for pT4a laryngeal cancer patients. Randomized controlled trials including homogenous patients are still needed before shifting to organ preservation protocols in these patients.

LEVEL OF EVIDENCE

NA.

Can the lymph node reactivity pattern in the pN0 neck analysis provide any additional prognostic information in patients with laryngeal squamous cell carcinoma?

OBJECTIVE

To evaluate the influence of lymph node reactivity on recurrence and survival rates in a population of pT3 or pT4 pN0 patients with laryngeal squamous cell carcinoma.

METHODS

Between 2002 and 2005, 105 patients with LSSC underwent total laryngectomy with bilateral selective neck dissection including levels II, III and IV. Most (69) received PO radiotherapy. All pathological specimens were either pT3 or pT4, and all necks were pN0. All lymph nodes were analyzed and their reactivity status were classified as the following four patterns: follicular hyperplasia associated with humoral response, paracortical hyperplasia associated with cellular response, sinus histiocytosis with no association with specific immune response, or normal lymph node. Only the first two patterns were considered stimulated, whereas the last two were considered non-stimulated. The most prevalent pattern in a particular neck specimen was considered for the analysis of recurrence and survival.

RESULTS

The total number of lymph nodes studied was 3,648, with an average of 34.7 lymph nodes/neck specimens. The most frequent lymph node reactivity patterns were sinusal histiocytosis (50 cases), paracortical hyperplasia (35 cases), and follicular hyperplasia (20 cases). There was no statistical association of these individual patterns with recurrence rate (p = 0.98) or mortality (p = 0.49). However, there was a statistically significant association between paracortical hyperplasia pattern (related to cellular lymph node immunity) and improved five-year survival (76 versus 60%; log-rank = 0.05).

CONCLUSIONS

There was a positive correlation between stimulated cellular lymph node pattern and improved 5-year survival rate in patients with pN0 laryngeal squamous cell carcinoma, suggesting the indication of adjuvant treatment for those individuals with decreased immune response, even in the absence of pathologic metastases detected by the usual methods.

Morphological changes of regional lymph node in squamous cell carcinoma of the oral cavity

BACKGROUND

Regional immune responses with various types of cancer have been studied histopathologically, however, the prognostic value remains conflicting. The aim of this study was to evaluate morphological changes related to lymph node metastasis and the prognostic value for oral cavity squamous cell carcinoma.

METHODS

With histopathologic whole architecture of 430 lymph nodes, gross area, germinal center (GC) area, paracortical area (PA), and tumor area were measured.

RESULTS

Metastatic node had significantly lower distribution ratio of PA to lymphoarea than that of tumor-free node. GC area was not constantly associated with lymph node metastasis. In Cox multivariate analysis, the mean ratio of PA to gross area/lymphoarea was an independent prognostic factor.

CONCLUSIONS

The proportion of PA to gross/lymph area was associated with lymph node metastasis and long-term survival and may be useful in stratification of those patients for a requirement of adjuvant treatments.

Development or existence of non-metastatic lymph nodes in the previously operated neck: a good prognostic sign for oromaxillary squamous cell carcinoma?

The aim of this study is to clarify the clinicopathological features of patients having non-metastatic lymph nodes in the previously operated neck for oromaxillary squamous cell carcinoma (OSCC). The clinicopathological factors of 9 such patients were comparatively analyzed with those of 78 other patients who underwent neck dissection (ND). The following observations were elicited from the data: (1) These 9 patients were alive and without OSCC for periods ranging from 1 year to 15 years and 9 months since their initial cancer treatments. (2) The interval between ND and clinical and/or imaging recognition of newly developed lymph nodes with suspicion of recurrence was significantly longer in these 9 patients. (3) The initially removed lymph nodes tended to be in a less advanced stage of disease. (4) Retrospectively, discrimination of non-metastatic lymph nodes from metastatic nodes was difficult in only one patient. (5) Each of the extirpated lymph nodes from 7 of the 9 patients showed a varying grade of reactive lymphadenitis on histopathology. In conclusion, the occurrence of benign hyperplastic lymph nodes in the previously operated neck region suggested favorable prognosis, though the immunological mechanism is not understood.

Prognostic significance of microscopic and macroscopic extracapsular spread from metastatic tumor in the cervical lymph nodes

It has been established that the presence or absence of cervical node metastases in patients with head and neck squamous cell carcinoma (HNSCC) is a powerful prognostic indicator. This report reviews the evolution of thinking over the past 70 years with regard to the import and detection of cervical nodal metastases which exhibit spread of tumor beyond the confines of the original encompassing nodal capsule. In the process, this discussion touches upon clinical examination, gross and microscopic pathologic examination, and radiographic imaging studies. In particular, the distinction between gross nodal extracapsular spread of tumor and microscopic nodal extracapsular spread of tumor has been drawn in recent reports; this raises the possibility that identification of microscopic breaching of the nodc capsule by tumor might provide clinically significant information which is not provided by the gross observation of an intact lymph node capsule. While it remains to be seen whether microscopic extracapsular spread alone will prove to be an important prognostic factor, it is recommended that selective neck dissection continue to be offered even in those patients with clinically negative necks; further studies should aid in defining the import of microscopic extracapsular tumor spread in patients with positive cervical nodes.

Evaluation of cervical lymph node metastasis of 1400 patients with cancer of the larynx

OBJECTIVE

The main goal of the paper was to evaluate the results of surgical treatment of patients with laryngeal carcinoma, among whom cervical lymph node metastases were observed. The results of treatment were assessed after prior analysis of the following factors localization of laryngeal carcinoma, local and regional advancement, number of lymph nodes affected by metastases, the incidence of 'occult metastases', the presence of metastases in the pre-laryngeal node, the regions of the neck which were most frequently affected by metastases and supplementary irradiation treatment.

METHODS

An analysis of a group of 1400 patients who underwent surgery for laryngeal carcinoma in the period 1948-1992, was carried out. In all of the cases, a partial or total laryngectomy accompanied by a unilateral or bilateral surgery of the cervical lymph node system was performed. The results of the above treatment were assessed over a 5-year survival period.

RESULTS

In patients among whom metastases to the lymph nodes were observed, it is the following factors that exert an influence on survival chances: supraglottic and glottic localization of the tumor, an increase of regional and organ advancement of the tumor, number of lymph nodes affected by metastases, the presence of metastases in the 'pre-laryngeal' node and the level of the neck affected by metastases.

CONCLUSION

The incidence of metastases in regional lymph nodes is a prognostic factor in the treatment of patients suffering from laryngeal carcinoma.

[Cervical lymph node involvement in laryngeal carcinoma: a retrospective study of 430 cases]

Cervical lymph node involvement in laryngeal tumors could be a market impact on the disease prognosis. We performed a retrospective study of 430 patients who underwent surgery to treat laryngeal carcinoma in our center over a 10-year period. The objective was to correlate clinical and pathological lymph node involvement with the site of origin and size of the tumor, the treatment and its impact on patient survival. We observed a significantly greater incidence of lymph node involvement in tumors originating from supraglottis, with a rate of occult lymph node metastases of 31%. Patients with lymphadenopathy that remained undetected in the absence of surgical treatment and those with nonmetastatic lymphadenopathy presented similar 5-year survival rates, 83% y 98% respectively. However, the 5-year survival decreased to 24% in the presence of metastatic lymph node involvement. These results support the proposal that treatment of laryngeal carcinoma should include the region of the cervical nodes as well.

Prognostic factors and relative risk for survival in N1-3 oral squamous cell carcinoma: a multivariate analysis using Cox's hazard model

The records of 136 patients with N1-3 oral squamous cell carcinoma treated by surgery were investigated retrospectively, with the aim of finding out which factors were predictive of survival on multivariate analysis. Four independent factors significantly influenced survival in the following order: pN stage; T stage; histological grade; and N stage. The most significant was pN stage, the five-year survival for patients with pN0 being 91% and for patients with pN1-3 41%. A further study was carried out on the 80 patients with pN1-3 to find out their prognostic factors for survival and the independent factors identified by multivariate analysis were T stage and presence or absence of extracapsular spread to metastatic lymph nodes.

Vascularization of reactively enlarged lymph nodes analyzed by color duplex sonography

PURPOSE

This study involved a prospective evaluation of the reliability of sonography, and especially duplex sonography, in confirmation of the benign nature of enlarged cervical lymph nodes.

PATIENTS AND METHODS

In 53 untreated patients with enlarged cervical lymph nodes, B-mode, plain, and d-galactose-enhanced color duplex sonography were performed. The B-mode sonomorphology was analyzed for the structure of vascularization. Quantitative parameters such as maximum flow velocity, pulsatility index, and resistive index were also assessed. The benignity of the lymph nodes was confirmed by microscopic analysis.

RESULTS

The B-mode showed 20 homogeneous lymph nodes, 23 with a central echogenoic line covering less than one third, and 10 with a distinct hilus sign extending to more than one third of the lymph node diameter. Microscopically, the least fibrotic or chronic inflammatory changes in the parenchyma were observed in the homogeneous lymph nodes, whereas those with central echogeneoity had fibrotic and lipoid hilus changes. Histologically, all lymph nodes had normal afferent and efferent hilus vessels. In 37 lymph nodes, the vessel structure could be reliably visualized by both plain and enhanced color duplex sonography, whereas in 16 it could only be demonstrated after the use of signal enhancement. Nine of 53 lymph nodes had Solbiati-(L/T-) indices below 2, which were suggestive of malignancy. Quantitative flow parameters did not provide useful information.

CONCLUSION

Color duplex analysis of enlarged lymph nodes is a useful method for assessment of benignity, especially after application of a signal-enhancing agent.

Assessment of vascularity in reactive lymph nodes by means of D-galactose contrast-enhanced Doppler sonography

RATIONALE AND OBJECTIVES

A prospective study in signal-enhanced Doppler sonography of lymph nodes that were assumed pretherapeutically to be benign was performed to investigate characteristic sonomorphologic features and vascularity of reactively enlarged lymph nodes.

METHODS

Thirty-four patients with enlarged superficial lymph nodes of the neck were examined first by B-scan sonography then by Doppler sonography before and after administration of an ultrasound signal-enhancing agent. In B-scan sonography, lymph nodes were classified into three groups according to their sonomorphologic features: (1) homogeneous parenchyma, (2) a centrally located echogenoic line, and (3) a echogenoic "hilus reflex." In conventional and contrast-enhanced Doppler sonography, peak flow rate, pulsatility index, and resistive index were assessed. Sonomorphologic criteria were compared with histologic findings.

RESULTS

Reactively enlarged lymph nodes showed characteristic sonomorphologic patterns correlating to their histologic features. Echogenicity of the hilus corresponded to fibrosis (centrally located echogenoic line in 13 nodes; 38.2%) or fatty involution of the hili (echogenoic hilus reflex in 15 nodes; 44.1%). Administration of the galactose-based ultrasound contrast enhancer facilitated the assessment of hilar vessels, which projected to the echogenoic hili, respectively, actually additionally visualized a hilar vascularity in 10 of the 34 lymph nodes compared with conventional Doppler. Measured Doppler indices gave not a significant clue for identifying reactive lymph nodes or for differential diagnosis.

CONCLUSIONS

Qualitative sonomorphologic assessment of characteristic sonomorphologic features of reactive lymph nodes may serve as a valuable tool for examining reactively enlarged lymph nodes. Administration of an ultrasound echo enhancer allows the assessment of a characteristic nodal vascularity in reactive lymph nodes and were superior to conventional B-mode and conventional Doppler sonography.

Prognostic significance of lymph node reactivity in the control of pathologic negative node squamous cell carcinomas of the oral cavity

BACKGROUND

Identification of high-risk patients and defining prognostic factors may be useful in the treatment of head and neck cancer. The role of the lymph node reactivity is still obscure. The value of the node reactivity pattern as a predictor of tumor control in oral cavity cancer was analyzed.

METHODS

Retrospective analysis of patients with oral cavity squamous cell carcinoma (OCSCC), submitted to tumor resection and neck dissection, with pathologic negative lymph nodes (pN0). Dominant node reactivity pattern was defined as lymphocytic predominance (LP), germinal centers (GC), normal (NL), sinus hystiocytosis (SH), and lymphocytic depletion (LD). Clinical and pathological characteristics of patients free of disease (DF) were compared with those of patients with control failure (CF), which included local, regional, and distant recurrences.

RESULTS

Of the 26 patients with pN0 OCSCC, prevalence of SH was found in 10 cases, GC in 13, and LD, NL and PL in 1 case each. Comparing CF and DF groups, there was no significant statistical difference regarding: age, gender, performance status index, weight loss, smoking and drinking habits, complementary treatment, average follow-up, tumor grade or thickness, margins, or tumor inflammatory and desmoplastic reaction. Although there was a higher proportion of perineural invasion and larger tumors in the CF group, the difference was not statistically significant either. Germinal centers or LP were noted in only 27% of the CF group and in 73% of the DF group. Collectively, NL, SH, or LD patterns were observed in 73% of CF. This incidence was statistically different from 27% of the DF group (P <0.05).

CONCLUSIONS

Lymph node reactivity pattern seems to be a prognostic index in pN0 OCSCC patients. Prospective analysis is advised to confirm these results. Prophylactic neck dissection as a staging procedure could select high-risk patients even when no metastasis is found.

Treatment of the clinically negative neck in laryngeal cancer patients

BACKGROUND

Elective treatment of the NO neck in patients with laryngeal cancer remains a controversial issue. We reviewed our experience with patients who had neck dissection for NO laryngeal carcinoma with occult metastases in order to compare elective lymphadenectomy results with those achieved with therapeutic neck dissection performed subsequently when occult disease became clinically evident.

METHODS

We retrospectively analyzed 150 NO laryngeal cancer patients who after a neck dissection had histologically positive lymph nodes and 5-year minimum follow-up. This population was divided in two subsets, including: 54 NO patients with occult neck metastases who had an elective neck surgery (ED); 96 initially NO patients who had a subsequent therapeutic neck dissection when nodal involvement became clinically detectable (STD). The two groups were compared with respect to the pattern of nodal metastasis and sites of treatment failures and also in terms of absolute, determinate, and actuarial survival.

RESULTS

Overall absolute survival was 72.2% in the elective dissected (ED) group, compared with 54.1% in the group of subsequent therapeutic dissected (STD) patients (p = 0.075). Determinate survival was 74.0% after ED and 59.3% after STD (p = 0.17). Actuarial curves by the Kaplan-Meier method did not show any statistically significant differences among the two groups analyzed (logrank test, p = 0.54). Accordingly, Cox multivariate analysis confirmed that neck treatment policy had no prognostic impact on survival in our NO laryngeal cancer patients. However, a higher proportion of STD patients died of metastases at distant sites compared with ED patients (21.9% vs 7.4%, respectively) (p = 0.02).

CONCLUSIONS

Elective lymphadenectomy does not significantly improve survival in NO laryngeal cancer patients with occult disease compared with those undergoing a therapeutic neck dissection when metastases subsequently appear.

A model of focal cancer in rabbit lymph nodes

RATIONALE AND OBJECTIVES

We sought to develop a model of focal cancer in the rabbit lymph node.

METHODS

Under computed tomography (CT) guidance, 4-5 million VX2 cells were directly injected into the popliteal nodes of 14 anesthetized New Zealand White rabbits. Fifteen to 18 days later, percutaneous lymphography was performed with CT scanning using radiopaque nanoparticulates and massage. Histologic correlation also was obtained.

RESULTS

In 12 of the 14 animals, focal lesions were successfully created within (n = 6) and adjacent (n = 6) to the node, and all animals appeared to be healthy when euthanized. Within 15 min after massage, CT lymphography showed homogeneous enhancement of normal node regions and no enhancement of cancer. There was good agreement between histology and lymphography.

CONCLUSION

This method is suitable as a model to test for diagnostic and therapeutic interventions.