The distribution of lymph node metastases in supraglottic squamous cell carcinoma: therapeutic implications

Development and validation of a diagnostic model for predicting cervical lymph node metastasis in laryngeal and hypopharyngeal carcinoma

Objectives

The lymph node status is crucial for guiding the surgical approach for patients with laryngeal and hypopharyngeal carcinoma (LHC). Nonetheless, occult lymph node metastasis presents challenges to assessment and treatment planning. This study seeks to develop and validate a diagnostic model for evaluating cervical lymph node status in LHC patients.

Materials and methods

This study retrospectively analyzed a total of 285 LHC patients who were treated at the Department of Otolaryngology Head and Neck Surgery, Daping Hospital, Army Medical University, from January 2015 to December 2020. Univariate and multivariate logistic regression analyses were employed to construct the predictive model. Discrimination and calibration were used to assess the predictive performance of the model. Decision curve analysis (DCA) was performed to evaluate the clinical utility of the model, and validation was conducted using 10-fold cross-validation, Leave-One-Out Cross Validation, and bootstrap methods.

Results

This study identified significant predictors of lymph node metastasis in LHC. A diagnostic predictive model was developed and visualized using a nomogram. The model demonstrated excellent discrimination, with a C-index of 0.887 (95% CI: 0.835-0.933). DCA analysis indicated its practical applicability, and multiple validation methods confirmed its fitting and generalization ability.

Conclusion

This study successfully established and validated a diagnostic predictive model for cervical lymph node metastasis in LHC. The visualized nomogram provides a convenient tool for personalized prediction of cervical lymph node status in patients, particularly in the context of occult cervical lymph node metastasis, offering valuable guidance for clinical treatment decisions.

Impact of lymph node ratio and number of lymph node metastases on survival and recurrence in laryngeal squamous cell carcinoma

INTRODUCTION

The aim of this study is to assess the impact of lymph node ratio (LNR) and number of positive lymph nodes (NPLN) on mortality and recurrence rates in patients with laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

We conducted a retrospective multicenter international study involving 24 Otorhinolaryngology-Head and Neck Surgery divisions. Disease-specific survival (DSS) and disease-free survival (DFS) were evaluated as the main outcomes. The curves for DSS and DFS according to NPLN and LNR were analyzed to identify significant variations and establish specific cut-off values.

RESULTS

2507 patients met the inclusion criteria. DSS and DFS were significantly different in the groups of patients stratified according to LNR and NPLN. The 5-year DSS and DFS based on LNR and NPLN demonstrated an improved ability to stratify patients when compared to pN staging.

CONCLUSION

Our data demonstrate the potential prognostic value of NPLN and LNR in laryngeal squamous cell 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.

Assessment of Occult Nodal Micrometastases to the Clinically Negative Contralateral Neck in Locally Advanced Supraglottic Squamous Cell Carcinoma

The aim of this study is  to study the incidence of occult nodal micrometastases (ONM) in the contralateral neck and compare it to the laterality of the primary tumor. Retrospective analysis of the medical records of patients with locally advanced supraglottic squamous cell carcinoma and Clinically negative contralateral neck (cN0-CLN) - who had concurrent total laryngectomy and bilateral neck dissection as their primary treatment at the Otolaryngology Department, Al Kas Al Ainy School of Medicine-Cairo University between 2015 and 2020 - was conducted. Patients were divided into 3 groups according to the extent of the primary tumor. 28 patients met the inclusion criteria. Patients with well-lateralized tumors were 14 (Group A), tumors abutting the midline were 4 (Group B) and tumors significantly involving the contralateral side were 14 (Group C). There was no statistically significant difference in age of patients among the three groups. Eleven patients had cervical lymphadenopathy in the final pathology reports. Seven patients had ONM, all of whom were among group C patients (7/14; 50%). The degree of tumor differentiation was not associated with the presence of ONM. Treatment of the cN0-CLN is justified in locally advance supraglottic carcinoma significantly crossing the midline. The total number of patients with ONM in the cN0-CLN exceeds the threshold for observation, however the authors could not recommend or refute the practice of routine prophylactic treatment of the cN0-CLN as none of the patients-in this study-with well-lateralized tumors or tumors just abutting the midline showed ONM.

Delineation of neck node levels for patients with locally advanced supraglottic cancer receiving radical intensity-modulated radiotherapy: a cross-sectional study in Mainland China

Background: To survey the diversity of clinical target volumes (CTVs) for locally advanced supraglottic cancer (LA-SGC) with radical radiotherapy in mainland China. Methods: Radiation oncologists from 30 provinces and four representative cases (T2N1, T3N2b, T4N0, T4N2c) were included. Results: High risk (HR)-CTV included involved and the lower adjacent level was followed by most physicians (n = 160, 97.6%). In the N0-1 stage, whether contralateral levels II-III should be included in HR- or low risk (LR)-CTV was controversial. In the N2 stage, the bilateral levels II-IVb were included in LR-CTV (75-92.5% agreement). Levels Ib, V or VIb were included in CTV requiring certain conditions. Conclusion: Involved and lower adjacent levels were as HR-CTV. Whether bilateral levels II-IV are included in HR- or LR-CTV remain controversial.

A Predictive Nomogram for Lymph Node Metastasis in Supraglottic Laryngeal Squamous Cell Carcinoma

Purpose

Lymph node metastasis (LNM) has a negative impact on the survival of patients with laryngeal squamous cell carcinoma (LSCC). Supraglottic LSCC is the most common cause of cervical lymph node metastases due to the extensive submucosal lymphatic plexus. The accurate evaluation of LNM before surgery can inform improved decisions in the clinic. In this study, we aimed to construct a nomogram to predict LNM in primary supraglottic LSCC patients.

Methods

The data from 314 patients with clinico-pathological confirmed supraglottic LSCC who underwent partial or total laryngectomy in our department from 2016 to 2020 were retrospectively analyzed (243 cases in the training set and 71 cases in the validation set). A multivariate logistic regression model was used to screen out independent risk factors and a nomogram was established. The accuracy and discrimination ability of the nomogram was evaluated using a consistency index and calibration curves.

Results

Tumor size, tumor differentiation degree and LMR (lymphocyte-monocyte ratio) were selected to construct the nomogram. The C-index was 0.731 in the training set and 0.707 in the validation set. The calibration curves of the training and validation group both exhibited close agreement between the predicted and the actual presence of LNM.

Conclusions

A nomogram was established based on routinely measured pretreatment variables and the predicted results improved the management of patients with LNM.

Improving Survival of T3cN0M0 Glottic Squamous Cell Cancer With Elective Neck Dissection

OBJECTIVES/HYPOTHESIS

This study aimed to elucidate the role of elective neck dissection (END) in improving the outcome of T3cN0M0 glottic squamous cell cancer (GSCC).

STUDY DESIGN

Retrospective population-based database analysis.

METHODS

Patients with T3cN0M0 GSCC in the Surveillance, Epidemiology, and End Results database (SEER) were extracted and stratified into END and non-END cohorts. Propensity score matching (PSM) was used to eliminate the baseline variations. The Kaplan-Meier method was performed to access the association between END and survival.

RESULTS

We retrospectively analyzed 1,589 T3cN0M0 GSCC patients in the SEER database from 2004 to 2015, and found that only 22% to 58% T3cN0M0 GSCC were performed with END. After PSM, END cohort had better overall survival (OS) (median survival time: 93 vs. 55 months, respectively; P = .0047) and cancer-specific survival (CSS) (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.29-0.77, P = .003) than non-END cohort. In addition, Subgroup analysis also indicated END cohort had better OS or CSS than non-END cohort.

CONCLUSION

This study demonstrated that in patients with T3cN0M0 GSCC, END significantly associated with better survival outcomes compared with non-END.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Efficacy of superselective neck dissection (IIA and III) for supraglottic laryngeal cancer with clinically negative neck

OBJECTIVES

The purpose of this study was to determine the safety and efficacy of superselective neck dissection(SSND) (levels IIA and III) for patients with supraglottic squamous cell carcinoma (SCC) of the larynx and clinically negative (N0) neck.

STUDY DESIGN

This was a prospective analysis of consecutive patients.

METHODS

A prospective analysis of 60 patients with SCC of the supraglottic larynx and N0 neck who underwent surgical treatment of the primary lesion with simultaneous SSND (levels IIA and III). The incidence of occult metastasis in the lymph nodes, regional recurrence, survival rate, and spinal accessory nerve function were evaluated.

RESULTS

Ninety-eight superselective neck dissection (levels IIA and III) procedures were performed for 60 patients. The occult metastasis rate was 20% (12 of 60). Four patients (6.7%) developed regional recurrence, none of them was in level IIB. The 5-year overall, cancer-specific and disease-free survival rate was 82.8%, 87.6%, and 80.7%, respectively. Spinal accessory nerve function was maintained in all patients.

CONCLUSION

Superselective neck dissection removing lymph nodes in levels IIA and III was safe and effective for supraglottic SCC of the larynx with clinically negative neck. The spinal accessory nerve function was maintained without compromising clinical outcome.

Occult lymph node metastasis in patients with laryngeal cancer and relevant predicting factors: a single-center experience

OBJECTIVE

To reveal the incidence and predictive parameters of occult cervical lymph node metastasis (LNM) in patients with cN0 laryngeal squamous cell cancer (LSCC) who underwent surgery as definitive treatment.

METHODS

Patients with cN0 laryngeal cancer who had undergone elective neck dissection together with partial or total laryngectomy between January 2006 and November 2020 were retrospectively analyzed. Clinical and histopathologic predictors of occult metastasis were also analyzed. Follow-up data were used to obtain recurrence and survival analysis.

RESULTS

A total of 86 patients with a mean age of 62.5 years were included in the study. Occult LNM was detected in 15 (17.4%) patients. Tumor grade, pT stage, thyroid cartilage invasion, and extralaryngeal extension were found to predict occult neck metastasis in univariate analysis. The mean follow-up time was 60.7 months and in the survival/recurrence analysis, pT stage, tumor location, tumor grade, presence of occult metastasis, pre-epiglottic space involvement. and extralaryngeal extension were found to predict poorer outcome.

CONCLUSION

Overall occult LNM is low (17.4%) in N0 laryngeal cancer, but the presence of LNM is a poor prognostic factor. Correct determination of the neck status and proper treatment is crucial. The incidence of LNM is very low in T1-T2 stages and well-differentiated tumors. The "wait and see" strategy may be applied in T1-T2 cases as well as selected T3 cases with well-differentiated tumors.

pT3 N0 Laryngeal Squamous Cell Carcinoma: Oncologic Outcomes and Prognostic Factors of Surgically Treated Patients

Objectives/Hypothesis

To assess the disease control, survival rates, and prognostic factors of exclusive surgical treatment for patients with pT3 N0 laryngeal squamous cell carcinoma (LSCC).

Study Design

Multicentric retrospective cohort study.

Methods

Multicentric retrospective case series of previously untreated patients with pT3 R0N0 LSCC, who received exclusive surgery between 2011 and 2019. Tumor location; subsite involvement; grading; and lymphatic, vascular, and perineural invasion were reported. Overall survival (OS), disease‐specific survival (DSS), and disease‐free survival (DFS) were measured.

Results

Fifty‐four patients (mean age 67.1; male sex 83.3%; mean follow‐up period 37 months) underwent total laryngectomy (48.1%) or partial laryngectomy (51.9%). Ipsilateral or bilateral neck dissection was performed in 46 (85.2%) cases. Perineural invasion was more frequent in case of supraglottic involvement than glottic involvement (85.7% vs. 14.3%, P = .03). Five (9.3%) patients experienced recurrence (3 local recurrences, 1 nodal recurrence, 1 distant recurrence). Rate of recurrence differed between glottic (0%), supraglottic (80%), and transglottic (20%) tumors (P = .01), with a lower risk yielded by glottic involvement (odds ratio [OR], 0.05, 95% confidence interval [95% CI], 0.01–0.56, P = .01). A higher risk was recorded in case of perineural invasion (OR, 66.0, 95% CI, 1.41–3085.3, P = .03). The OS, DSS, and DFS were 79.6%, 96.3%, and 90.7%, without differences regarding the type of surgery. The DFS was lower in case of supraglottic involvement when compared to purely glottic LSCC (83.9% vs. 100%, P = 0.02).

Conclusions

Exclusive surgery is a safe option for patients with pT3 R0N0 LSCC. Adjuvant treatments or closer follow‐up monitoring might be considered in case of supraglottic involvement or perineural invasion.

Level of Evidence

4 Laryngoscope, 131:2262–2268, 2021

[Current diagnostic imaging and treatment planning for laryngeal cancer]

CLINICAL/METHODICAL ISSUE

Laryngeal cancer is the third most common malignancy in the head and neck region. Endoscopic laryngoscopy with assessment of vocal fold function, microlaryngoscopy with biopsy and computed tomography (CT)/magnetic resonance imaging (MRI) remain the cornerstones of diagnostic workup. Thus, in the context of therapy planning, consideration of individual functional and socioeconomic aspects is of major importance.

STANDARD RADIOLOGICAL METHODS

Due to the short acquisition time and the possibility to perform functional maneuvers, CT is the tool of choice. MRI allows better soft tissue differentiation, but is more susceptible to movement artifacts and is complicated by disease-specific symptoms. The choice of examination method therefore depends on the patient's physical resilience.

PERFORMANCE

Depending on the study, the information on the sensitivity of CT with regard to the question of cartilage infiltration varies between 62 and 87% with a specificity between 75 and 98%. For MRI, sensitivity between 64 and 95% and specificity between 56 and 88% are stated.

ACHIEVEMENTS

The synthesis of the findings from endoscopy, biopsy and imaging is prerequisite for initiation of stage-appropriate treatment. For image interpretation, knowledge of the anatomical landmarks is essential. However, the assessment of posttherapeutic changes also poses a challenge for the radiologist.

PRACTICAL RECOMMENDATIONS

Regular interdisciplinary dialogue between radiologists, otorhinolaryngologists and radiotherapists in the context of primary diagnostics, therapy planning and aftercare is essential.

The survival benefit of lymph node dissection in resected T1-2, cN0 supraglottic cancer: A population-based propensity score matching analysis

BACKGROUND

The survival benefit of clinically negative cervical lymph nodes (cN0) in patients with T1-2 supraglottic cancer (SC) remains unclear. This study aimed to comprehensively evaluate the prognostic value of lymph node dissection (LND) in patients with T1-2, cN0 SC.

METHODS

We included 1036 confirmed T1-2, cN0 SC patients with clinicopathological characteristics between 2004 and 2015, based on the Surveillance, Epidemiology, and End Results program (SEER) database. The association between LND and overall survival (OS) was investigated by the Kaplan-Meier method.

RESULTS

Before propensity score matching (PSM), patients selected for LND had better OS, compared to patients did not receive LND (5-year OS: 62.6% vs 51.2%, respectively; p = 0.011). After PSM, the LND group also present significant improvement in prognosis (5-year OS: 64.3% vs 51.7%, respectively; p < 0.01).

CONCLUSIONS

LND was significantly associated with a more favorable prognosis compared with non-LND in patients with T1-2, cN0 SC.

Patterns of Cervical Lymph Node Metastasis in Locally Advanced Supraglottic Squamous Cell Carcinoma: Implications for Neck CTV Delineation

Objective

To investigate the prevalence and distribution of cervical lymph node metastasis (LNM) in locally advanced supraglottic squamous cell carcinoma (LASCC) and guide the delineation of clinical lymph node target volumes.

Materials and Methods

We reviewed patients defined as LASCC from January 2000 to December 2017 in our hospital. The primary tumor was operated on using partial or total laryngectomy, and all patients underwent bilateral neck dissection (levels II–IV at least). Univariate and multivariate logistic regressions were used to find risk factors associated with LNM.

Results

A total of 206 patients were enrolled. In the whole group, the rate of ipsilateral metastasis (IM) was 60.9% (67 patients), whereas contralateral metastasis was 25.5% (28 patients). Only positive ipsilateral lymph nodes contributed to contralateral metastasis (p = 0.001). Seventy-six cases were diagnosed with clinical positive lymph nodes (cN⁺). IM of primary lesions mainly located within the unilateral sites (n = 49 patients) was detected in levels II, III, and IV with lymph node metastasis ratios of 73.5% (36 patients), 63.3% (31 patients), and 20.4% (10 patients), respectively, and contralateral metastasis of 36.7% (18 patients), 16.3% (8 patients), and 6.1% (3 patients), respectively. Involvement of level II or III was associated with metastasis of level IV. No one developed contralateral level IV involvement without metastasis of contralateral levels II and III. A total of 130 cases had clinically negative neck lymph nodes (cN0). The prevalence of occult metastasis (OM) was 35.4%. Among 62 patients with unilateral lesions, the rates of OM to ipsilateral neck levels II, III, and IV were 21, 11.1, and 1.6%, respectively, whereas contralateral neck levels were 6.3, 4.8, and 0%, respectively. In terms of the risk factors, histopathological differentiation was related to OM (p = 0.003). Two of 25 people were with level VIb metastasis, and both of them were with subglottic involvement.

Conclusion

Neck levels II to IV are most frequently involved and should be included in clinical target volume (CTV) in cN⁺ patients. Contralateral IV may be omitted when contralateral levels II and III are negative. In cN0 patients, ipsilateral levels II and III are suggested to be included in the CTV, whereas whether contralateral levels II and III should be included needs further research.

Incidence of Occult Lymph Node Metastasis in Primary Larynx Squamous Cell Carcinoma, by Subsite, T Classification and Neck Level: A Systematic Review

Background: Larynx cancer is a common site for tumors of the upper aerodigestive tract. In cases with a clinically negative neck, the indications for an elective neck treatment are still debated. The objective is to define the prevalence of occult metastasis based on the subsite of the primary tumor, T classification and neck node levels involved. Methods: All studies included provided the rate of occult metastases in cN0 larynx squamous cell carcinoma patients. The main outcome was the incidence of occult metastasis. The pooled incidence was calculated with random effects analysis. Results: 36 studies with 3803 patients fulfilled the criteria. The incidence of lymph node metastases for supraglottic and glottic tumors was 19.9% (95% CI 16.4–23.4) and 8.0% (95% CI 2.7–13.3), respectively. The incidence of occult metastasis for level I, level IV and level V was 2.4% (95% CI 0–6.1%), 2.0% (95% CI 0.9–3.1) and 0.4% (95% CI 0–1.0%), respectively. For all tumors, the incidence for sublevel IIB was 0.5% (95% CI 0–1.3). Conclusions: The incidence of occult lymph node metastasis is higher in supraglottic and T3–4 tumors. Level I and V and sublevel IIB should not be routinely included in the elective neck treatment of cN0 laryngeal cancer and, in addition, level IV should not be routinely included in cases of supraglottic tumors.

Rational choice of neck dissection in clinically N0 patients with supraglottic cancer

BACKGROUND

The mainstay treatment of the neck for clinically negative neck (cN0) supraglottic laryngeal carcinoma (SGLC) is neck dissection. However, the optimal extent remains controversial. This study's purpose is to determine whether ipsilateral level II-III neck dissection is appropriate for cN0SGLC patients.

METHODS

The records of 220 consecutive untreated cN0SGLC patients were retrospectively reviewed. Relevant factors related to occult and contralateral neck metastasis were analyzed and the distribution of metastasis was described.

RESULTS

Seventy-seven and 143 patients underwent unilateral and bilateral neck dissection, respectively. The rate of occult neck metastases was 21.4%. The histologic differentiation was an independent risk factor for occult neck metastasis. In the bilateral neck dissection group, the incidence of contralateral neck metastasis of patients with noncentral tumors was 0.7%. Moreover, only 1.7% of patients had positive nodes at level IV, and no isolated nodal metastases existed in level IV.

CONCLUSION

Ipsilateral level II-III neck dissection is feasible for patients with noncentral cN0SGLC.

The Extent of Neck Dissection Among Patients Who Receive Adjuvant Radiotherapy for HNSCC and Its Effect on Disease-Specific and Overall Survival

The study objective was to assess if the extent of neck dissection among patients who receive adjuvant radiotherapy affects regional recurrence and survival. This was a retrospective study of patients who had clinical metastatic mucosal primary squamous cell carcinoma (SCC) to cervical lymph nodes done at Roswell Park Comprehensive Cancer Center, Buffalo, New York from 2004 to 2015. Patients with previous radiotherapy and/or chemotherapy were excluded. All patients had surgery to the primary tumor and the neck followed by adjuvant (chemo) radiation. Patients have been divided into 2 groups according to type of neck dissection as either selective neck dissection (SND) or comprehensive neck dissection (CND). The extent of neck dissection was determined by surgeon preference. All patients received postoperative radiotherapy to the primary tumor bed and to the neck with or without chemotherapy. Main outcomes were measured in regional recurrence and overall survival. In our study, 74 patients were included. Among the 2 groups of patients, 3-year outcomes for regional recurrence occurred in 4 (7.1%) of 56 patients in the SND group and 2 (11.1%) of 18 patients in the CND group. Overall survival was 29 (51.8%) of 56 patients in the SND group and 11 (61.1%) of 18 patients in the CND group ( P = .497). Among patients who died in each cohort, disease-specific death was 20 (74.1%) of 27 patients in the SND group and 5 (71.4%) of 7 patients in the CND group ( P = .79).The overall and disease-specific survival differences between the SND and CND cohorts were not statistically significant. In conclusion, SND, combined with proper adjuvant treatment, achieved regional control and survival rates comparable to CND.

CO2 Transoral Microsurgery for Supraglottic Squamous Cell Carcinoma

The present study analyzed the results of the endoscopic approach to T1, T2 and selected T3 supraglottic carcinoma with the aim of reviewing functional and oncologic outcomes after different types of endoscopic supraglottic laryngectomies. This is a retrospective clinical study of 42 consecutive patients (mean age of 61.8 years, 33 males, 9 females) treated by the senior author for supraglottic squamous cell carcinoma with a transoral CO₂ laser approach and reviewed from November 2010 to September 2017. Surgical procedures were classified according to the European Laryngological Society. In addition to the standardized transoral supraglottic laryngectomies, we introduced a modified type IVb by sparing the inferior third of the arytenoid if not directly involved in the tumor. Swallowing was evaluated with the Swallowing Performance Status Scale reported by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. Survival probabilities were estimated using Kaplan-Meier curves. Two type I, 2 type IIa, 2 type IIb, 3 type IIIa, 12 type IIIb, 13 type IVa, 3 type modified IVb, and 5 type IVb supraglottic laryngectomies were performed. Twenty-one patients (50%) underwent primary neck dissection. The pathologic TNM classification according to the 8th edition of the American Joint Committee on Cancer system was as follows: 9 pT1cN0, 2 pT1N0, 1 pT1N1, 7 pT2cN0, 1 rypT2cN0, 9 pT2N0, 4 pT2N1, 2 ypT2N1, 2 pT3cN0, 2 rypT3cN0, 1 pT3N1, and 2 pT3N2b. Mean follow-up was 3.4 years (range of 9 months to 6 years). According to the Kaplan-Meier analysis, 5-year disease-specific survival, local-relapse-free survival, nodal-relapse-free survival, overall laryngeal preservation and overall survival of patients without previous head and neck radiotherapy/open surgery were 100%, 95.2%, 87.8%, 100%, and 64.6%, respectively. Patients who underwent type I, IIa, and IIb resections (n = 6) started oral feeding the day after surgery, patients who underwent type III-IVb modified resections (n = 31) started oral feeding 3-4 days after surgery, and patients who underwent standard type 4b resections (n = 5) started oral feeding 7 days after surgery. Three months after surgery, patients without a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed significantly better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing in 8 and 66.7% of cases, respectively (p = 0.006072); patients with a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed not statistically significant better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing at 3 months in 16.7% and 50% of cases, respectively (p = 0.23568). Transoral CO₂ laser supraglottic laryngectomy is an oncologic sound alternative to traditional open neck surgery and chemo-radiotherapy. Recovery of swallowing is significantly worsened after total resection of the arytenoid. Modified type IVb procedure leaving intact, when possible, the inferior third of the arytenoid and consequently the glottic competence, improves functional outcome.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Survival of T4aN0 and T3N+ laryngeal cancer patients: a retrospective institutional study and systematic review

OBJECTIVE

We aim to assess the correlation of tumor and nodal staging to survival in pT3N+ and T4aN0 laryngeal cancer with subgroup analysis within stage IVa (pT4N0 and pT3N2).

STUDY DESIGN

Retrospective cohort study with systematic review of the literature.

SETTING

Hotel Dieu de France University Hospital (tertiary referral center).

SUBJECTS AND METHODS

Laryngeal cancer patients' registries were reviewed from 1998 to 2012 selecting pT3N+ and pT4aN0 patients treated by primary total layngectomy. Overall survivals were compared using Log rank and Kaplan-Meier analysis. A systematic review was performed by 2 reviewers including all the articles reporting the outcome of these categories of patients. Online databases, including PubMed and EMBASE, were used. Reference sections of identified studies were examined for additional articles.

RESULTS

Thirteen T3N+ patients and 19 T4aN0 patients treated by primary total laryngectomy were included. Five-year overall survival for T3N+, T3N2 and T4aN0 was respectively 33%, 32.1% and 73.7%. Due to the small sample, the difference was not significant. The systematic review revealed three articles reporting overall survival outcome for the T4N0 group and 6 articles for the T3N+. At 5years, the survival ranged from 62.5% to 73% in T4N0 and from 32.2% to 77% in T3N+.

CONCLUSION

In advanced stage laryngeal cancer, T4aN0 tends toward a better survival than T3N+ especially when compared to T3N2 although they are grouped in the same TNM stage IVa.

Epstein-Barr virus infection is strictly associated with the metastatic spread of sinonasal squamous-cell carcinomas

BACKGROUND

Sinonasal squamous-cell carcinomas (SNSCC) are relatively rare. Thus, data regarding the rate of lymph node metastases are inconsistent in contrast with well-known high metastasis rates in squamous-cell carcinomas of the head and neck (HNSCC) (oral cavity, pharynx and larynx). Hence, the indication for elective neck dissection is difficult in SNSCC. The aim of this study was to assess common genetic alterations and EBV and HPV status as a function of metastasis in SNSCC and HNSCC.

METHODS

We retrospectively analyzed 44 SNSCC and 65 HNSCC for TP53, EGFR, KRAS, PIK3CA and BRAF mutations using a high-resolution melting analysis followed by Sanger sequencing. EBV and HPV detection was performed using in situ hybridization for virus encoded RNA. Tumor-associated p16(INK4a) expression was visualized by immunohistochemistry and correlated with HPV infection. The mutation data, EBV and HPV status were statistically compared with the clinical data in SNSCC and HNSCC.

RESULTS

TP53 mutations were exclusively associated with shorter survival in SNSCC (p=0.048). All the other markers had no effect on the metastasis rate and survival. In total, 20 of 44 SNSCC were EBV-positive. Only these EBV positive tumors developed lymph node or distant metastases (p=0.008). LMP1 was positive in 14/44 patients. When combining both methods significance for a correlation between EBV/LMP1 positive patients and metastases was even higher (p=0.001).

CONCLUSION

In SNSCC, the presence of EBV is strictly associated with metastasis. We recommend an elective neck dissection in patients with EBV-positive SNSCC.

The effect of midline crossing of lateral supraglottic cancer on contralateral cervical lymph node metastasis

CONCLUSION

The degree of midline crossing of lateral supraglottic cancer does not significantly change its rate of contralateral cervical metastasis. The rate of occult metastasis is too high to take the risk of contralateral regional recurrence. We support routine bilateral neck dissection even in lateral supraglottic cancers with no or minimal midline crossing.

OBJECTIVES

Data on the rate of contralateral cervical metastasis of laterally located supraglottic cancer, the effect of its degree of midline crossing on contralateral cervical metastasis, and its treatment are still controversial.

METHODS

This was a retrospective cohort, chart review involving 305 surgically treated patients with T1-3 squamous cell carcinoma of the supraglottic larynx. In all, 184 patients had bilateral neck dissection; 86 N0 contralateral necks were followed up. Thirty-five patients who needed postoperative radiation therapy because of the primary tumor or ipsilateral neck dissection specimen also received radiation therapy to the contralateral neck. The degree of midline crossing at the epiglottis was measured on a laryngectomy specimen with a ruler and expressed as 'no,' '<5 mm' or '≥5 mm.'

RESULTS

The rates of occult and overall contralateral metastasis in our series were 16% and 28%, respectively. There was no statistically significant difference between contralateral neck metastasis and recurrence rates in the neck dissection, follow-up, and irradiation groups according to the degree of midline crossing.

An orthotopic mouse model of laryngeal squamous cell carcinoma

OBJECTIVE

This study aimed to create a reliable and reproducible orthotopic mouse model of laryngeal malignancy that recapitulates its biologic behavior, local invasiveness, and spread as seen in patients.

METHODS

Via direct laryngoscopy, human squamous cell carcinoma line FaDu (ATCC HTB-43) was implanted in the larynx (supraglottis and glottis) in nu/nu mice (n = 31). Animals were monitored with direct laryngoscopy and ultrasound for tumor growth and survival. Specimens of larynxes, neck lymphatics, livers, and lungs were removed for histopathologic evaluation to assess tumor extension, thyroid cartilage invasion, and nodal spread.

RESULTS

Thirty-one successful direct laryngoscopies were performed. Supraglottic and glottic tumor uptake was 100% and 25%, respectively. Median survival for the animals with supraglottic tumors was 35 days. Histopathologic evaluation revealed pre-epiglottic extension, paraglottic extension, thyroid cartilage invasion, and lymph node metastasis.

CONCLUSION

We describe the first orthotopic model for laryngeal cancer. Our model faithfully recapitulates the phenotype and malignant behavior that reproduces its natural biologic behavior as seen in laryngeal cancer patients. This model offers an opportunity to identify and specifically target therapy for larynx squamous cell carcinoma.

Lymph node ratio for postoperative staging of laryngeal squamous cell carcinoma with lymph node metastasis

BACKGROUND

Lymph node metastasis has a significant impact on laryngeal cancer prognosis. The role of lymph node ratio (LNR, ratio of metastatic to examined nodes) in the staging of laryngeal cancer was not reported.

PATIENTS AND METHODS

Records of laryngeal cancer patients with lymph node involvement from Surveillance, Epidemiology, and End Results database (SEER, training set, N = 1963) and Fudan University Shanghai Cancer Center (FDSCC, validating set, N = 27) were analyzed for the prognostic value of LNR. Kaplan-Meier survival estimates, the Log-rank χ² test and Cox proportional hazards model were used for univariate and multivariate analysis. Optimal LNR cutoff points were identified by X-tile.

RESULTS

Optimal LNR cutoff points classified patients into three risk groups R1 (≤0.09), R2 (0.09-0.20) and R3 (>0.20), corresponding to 5-year cause-specific survival and overall survival in SEER patients of 55.1%, 40.2%, 28.8% and 43.1%, 31.5%, 21.8%, 2-year disease free survival and disease specific survival in FDSCC patients of 74.1%, 62.5%, 50.0%, and 67.7%, 43.2%, 25.0%, respectively. R3 stratified more high risk patients than N3 with the same survival rate, and R classification clearly separated N2 patients to 3 risk groups and N1 patients to 2 risk groups (R1-2 and R3).

CONCLUSIONS

R classification is a significant prognostic factor of laryngeal cancer and should be used as a complementary staging system of N classification.

Levels II and III neck dissection for larynx cancer with N0 neck

The removal of level II, III, and IV metastases has gained importance in the treatment of squamous cell carcinomas (SCC) of the neck and larynx. This study assessed the possibility of removing level II and level III metastases only, given the low likelihood of occurrence of metastatic lymph nodes on level IV in SCCs of the larynx.

Objective

This study aimed to analyze the prevalence rates of metastatic lymph nodes on level IV in laryngeal SCC patients.

Methods

This prospective study enrolled consecutive patients with laryngeal SCC submitted to neck lymph node dissection. Neck levels were identified and marked for future histopathology testing.

Results

Six percent (3/54) of the necks had level IV metastatic lymph nodes. All cN0 necks (42) were free from level IV metastasis. Histopathology testing done in the cN (+) necks (12) revealed that 25% of the level IV specimens were positive for SCC. The difference between cN0 and cN (+) necks was statistically significant (p = 0.009). Level IV metastases never occurred in isolation, and were always associated with level II or level III involvement (p = 0.002).

Conclusion

The prevalence rate for lymph node metastasis in cN0 necks was 0%. Level IV metastatic lymph nodes were correlated to cN (+) necks. Level IV metastasis was associated with the presence of metastatic lymph nodes in levels II or III.

Lymph node metastasis in sinonasal squamous cell carcinoma treated with IMRT/3D-CRT

OBJECTIVES

To analyze the patterns of neck and retropharyngeal lymph nodes (RPLNs) metastases with magnetic resonance imaging (MRI) in patients with sinonasal squamous cell carcinoma (SCC), and to explore the patterns of treatment failure treated with intensity modulated radiotherapy (IMRT) or three-dimensional conformal radiotherapy (3D-CRT). We also attempt to discuss the role of elective neck irradiation (ENI) in the treatment of cervical negative patients.

MATERIALS AND METHODS

Between July 2004 and February 2011, 59 patients with histopathologically proven sinonasal SCC were treated with curative intent at our hospital. Among them, 18 (30.5%) patients had neck or RPLN lymph node involvement at diagnosis. RPLN, level Ib, and level IIa were the most common sites of initial nodal involvement. All patients received IMRT or 3D-CRT, while 19 patients further received surgical resection, and other 40 patients received cisplatin based chemotherapy. Median follow-up durations were 28 months (range, 6-81 months) for the entire patient population and 40 months (range, 7-81 months) among the surviving patients, respectively.

RESULTS

The estimated 3-year local-regional control rate, distant-metastasis free survival rate, disease-free survival rate, and overall survival rate were 63.3%, 81.9%, 60.1%, and 68.9%, respectively. On multivariate analysis, old age (>60 years) significantly influenced the overall survival rate(HR=9.428, p=0.000). As for the pattern of treatment failures developed in 26 patients in the follow-up time, local failure, neck recurrence, and distant metastases were seen in 18, 7, and 9 patients, respectively. Level Ib and level IIa were the most common sites of cervical nodal recurrence. None of the 11 patients who received ENI developed failure in the neck.

CONCLUSION

For sinonasal SCC patients treated with IMRT or 3D-CRT, our results were generally consistent with findings of other studies, local failure still remain the predominant pattern of treatment failure. However, RPLN metastasis occurred more frequently than previously recognized through detection by MRI in our study. ENI seems to have effectively prevented regional relapse. We recommend ipsilateral level Ib and level IIa neck irradiation for T3-4 sinonasal SCC patients.

Management of the clinically negative neck in early-stage head and neck cancers after transoral resection

The decision regarding treatment of the clinically negative neck has been debated extensively. This is particularly true with early-stage tumors for which surgery is the treatment of choice, and the tumor has been resected transorally without a cervical incision. Elective neck dissection in this situation is an additional procedure with potential associated morbidity. The alternative strategy for the clinically negative neck is to "wait and watch." Both an elective neck dissection policy and a "watchful waiting" policy have their proponents. The purpose of this article was for us to review the literature about this subject to try to answer the following question: if the tumor has been resected transorally, should an elective treatment of the neck be performed or is a "watchful waiting" policy safe and adequate? We conclude that, currently, the best available evidence suggests that elective neck dissection does not seem to be superior to the policy of observation without neck surgery, with regard to survival and control of neck disease. This review highlights the need for further well-designed prospective studies that will provide more reliable answers to the debatable issue of the management of the clinically negative neck in such cases.

[Occult metastases in patients with supraglottic larynx cancer]

The treatment of patients with supraglottic laryngeal cancer still remains a controversal issue. The study comprised 193 patients with a supraglottic laryngeal carcinoma treated in the period 1986-2003. All patients had primary surgery. They all had clinically and ultrasonografically negative findings in the neck (N0). Bilateral selective neck dissection at the level II-III was performed in all patients at the time of primar surgery. Postoperative radiotherapy was given to all patients with verified occult metastases (60 Gy). The occult cervical node metastases were found in 18% (35/193). Ipsilateral occult metastases were more common (77%, 27/35), but both bilateral and contralateral spread was also seen (14%, 5/35 and 9%, 3/35, respectively). Only in two (1%) did metastases develop subsequently. The 5-years survival rate was 86%.

Primary and salvage total laryngectomy

Treatment of laryngeal cancer has evolved, and newer methods of laryngeal conservation, both surgical and nonsurgical, are the primary treatment of choice. Nevertheless, total laryngectomy is not extinct and still plays an important role in primary therapy for advanced stage laryngeal cancers and as salvage therapy for failures of organ preservation strategies.

Is dissection of levels 4 and 5 justified for cN0 laryngeal and hypopharyngeal cancer?

CONCLUSION

Dissecting levels 2 and 3 and sparing the dissection of level 4 and the contralateral neck when frozen section results are negative are reasonable options for the selective dissection of cN0 necks. Our findings show that dissection of level 5 is considered unnecessary, unless there is overt metastasis.

OBJECTIVE

The level of node involvement and recurrence rates were assessed in cN0 laryngeal and hypopharyngeal carcinoma patients in order to develop appropriate guidelines for the treatment of the neck.

MATERIALS AND METHODS

A total of 328 cN0 necks operated with selective dissection were reviewed retrospectively. Patients were monitored for at least 24 months and regional recurrences were evaluated.

RESULTS

The prevalence of level 4 occult metastases was 3.4%; 1.5% of them were isolated to level 4. We observed regional recurrence in 5.6% of the necks. No case of metastasis or regional relapse was observed in level 5.

Is routine bilateral neck dissection absolutely necessary in the management of N0 neck in patients with supraglottic carcinoma?

The supraglottic larynx has a rich lymphatic network that places patients with supraglottic laryngeal carcinomas at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, elective neck treatment of clinically N0 neck in patients with supraglottic carcinomas is widely accepted as a standard approach. However, the issue whether elective neck treatment should routinely be directed on both sides of the neck is still controversial. The present study is aimed at determining whether T2-T4 stage supraglottic carcinomas require bilateral neck dissection in the management of N0 necks. We designed a prospective study on 72 patients with N0 supraglottic laryngeal carcinoma. Patients were divided into three groups according to the site and extension of the primary tumors. Group I consisted of 21 patients with lateralized (clear lateral) lesion reaching but not crossing the midline. Group II comprised 25 patients with cancer largely involving one side and crossing to the midline. Group III included 26 patients with carcinoma equally involving both sides of the larynx or growth into the midline larynx. All patients underwent bilateral lateral neck dissection in conjunction with various types of laryngectomies selected to the status of the primary. Of the 72 patients, 16 were found to have occult regional metastases in pathologic examination (9 pN1, 4 pN2b, 3 pN2c). The prevalence of occult metastases proportionally increased with T stage from 8.3 to 22.7 and 31.2%, respectively, for T2, T3 and T4. Bilateral neck metastases were found in 2 of 26 patients (7.7%) with central lesions. There was only one patient (4%) with both ipsilateral and contralateral lymph node metastasis in group II. None of the 21 patients with lateral lesion (group I) had contralateral neck metastasis. Routine bilateral elective neck dissection may not be a part of the surgical procedure in all supraglottic laryngeal carcinoma patients. Bilateral neck dissection should be preferred for cases with central tumors and lateral tumors with positive nodes in the ipsilateral side of the neck.

Cranial location of level II lymph nodes in laryngeal cancer: Implications for elective nodal target volume delineation

PURPOSE

To analyze the cranial distribution of level II lymph nodes in patients with laryngeal cancer to optimize the elective radiation nodal target volume delineation.

METHODS AND MATERIALS

The most cranially located metastatic lymph node was delineated in 67 diagnostic CT data sets. The minimum distance from the base of the skull (BOS) to the lymph node was determined.

RESULTS

A total of 98 lymph nodes were delineated including 62 ipsilateral and 36 contralateral lymph nodes. The mean ipsilateral and contralateral distance from the top of the most cranial metastatic lymph node to the BOS was 36 mm (range, -9-120; standard deviation [SD], 17.9) and 35 mm (range, 14-78; SD 15.0), respectively. Only 5% and 12% of the ipsilateral and 3% and 9% of the contralateral metastatic lymph nodes were located within 15 mm and 20 mm below the BOS, respectively. No significant differences were found between patients with only ipsilateral metastatic lymph nodes and patients with bilateral metastatic lymph nodes. Between tumors that do cross the midline and those that do not, no significant difference was found in the distance of the most cranial lymph node to the BOS and the occurrence ipsilateral or contralateral.

CONCLUSIONS

Setting the cranial border of the nodal target volume 1.5 cm below the base of the skull covers 95% of the lymph nodes and should be considered in elective nodal irradiation for laryngeal cancer. Bilateral neck irradiation is mandatory, including patients with unilateral laryngeal cancer, when elective irradiation is advised.

Selective neck dissection in patients with upper aerodigestive tract cancer with clinically positive nodal disease

OBJECTIVES

We evaluated the efficacy of the application of selective neck dissection to cases of clinically node-positive disease.

METHODS

We performed a retrospective review at the University of Pittsburgh Head and Neck Cancer Database. A database of 65 patients was followed for an average of 36 months (range, 2 to 128 months) after they underwent selective neck dissection for clinically node-positive regional disease.

RESULTS

Regional failure occurred in 8 patients (12.3%). In-field failure was experienced in 4 patients (6.1%), and failures outside the field of dissection occurred in 4 patients (6.1%). The overall incidence of extracapsular spread was 33.8% (22 of 65). Only 2 of 8 regional recurrences were associated with extracapsular spread at the initial neck dissection; however, both recurrences were in the contralateral, undissected side of the neck. Four regional failures were salvaged with surgery, with eventual overall regional control in the neck of 93.9%. Only 1 of 4 ipsilateral recurrences (25%) was successfully salvaged. In contrast, 3 of 4 contralateral failures (75%) were successfully salvaged. In our study population, 21 of 65 cases (32%) that were initially staged as clinically node-positive had no evidence of nodal metastases on pathologic examination.

CONCLUSIONS

The application of selective neck dissection and postoperative irradiation in patients with clinically Nl and limited N2 clinical disease appears to be oncologically efficacious. Clinical overstaging occurred frequently in this sample, and may put patients at risk for more morbid surgical procedures.

Predictive Value of Lymph Node Metastases and Extracapsular Extension for the Risk of Distant Metastases in Laryngeal Carcinoma

OBJECTIVE

The objective of this retrospective chart analysis was to determine the prognostic value of the lymph node status and extracapsular lymph node extension (ECE) of the neck for the development of distant metastases in squamous cell carcinoma of the larynx.

METHODS

One hundred sixty-five patients treated for laryngeal carcinoma with a neck dissection with histologic evaluation were included. Primary study end point was distant metastasis-free survival. Univariate analysis with the Kaplan-Meier method was used to calculate distant metastasis-free survival and overall survival for the whole group and for groups according to ECE/lymph node status. Patients were classified as 1) no metastatic lymph nodes, 2) metastatic lymph nodes without ECE, or 3) metastatic lymph nodes with ECE. Univariate Cox regression was performed with outcome distant metastasis-free survival.

RESULTS

The median overall survival for the whole group was 5.1 years and the 5-year survival rate was 51%. The median distant metastasis-free survival for the whole group could not be calculated and the 5-year metastasis-free survival rate was 78%. The hazard ratio was 3.4 (95% confidence interval [CI] = 1.0-12.1) for patients with positive nodes and without ECE and 10.5 (95% CI = 3.6-30.8) for the patients with metastatic nodes and with ECE compared with the patients without metastatic lymph nodes.

CONCLUSION

The presence of ECE in metastatic lymph nodes augments the risk of distant metastasis by nine times in laryngeal carcinoma. Metastatic lymph nodes without ECE show a risk three times greater.

Current opinion in diagnosis and treatment of laryngeal carcinoma

Laryngeal carcinoma is the 11th commonest form of cancer in men world-wide, with 121,000 new cases in 1985. More than 95% of all laryngeal malignancies are squamous cell carcinomas. Treatment indications in cancer of the larynx are often controversial, since there are few comparative studies of different available therapeutic approaches. Surgery and radiotherapy are both widely used, and the choice between these two procedures is the most common therapeutic decision which has to be taken. Laryngeal function preservation has gained more and more weight in the last decades and chemotherapy is also a significant component of several curative approaches. In the last decades, several organ-preserving surgical techniques have become available and consequently total laryngectomy results less applied. Regardless of the treatment modality, Tis, T1, T2 laryngeal carcinomas have an 80-90% probability of cure, whereas for more advanced tumours this is approximately 60%. The most effective approach to laryngeal cancer remains prevention and early diagnosis when this cancer is curable with function preserving treatments.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

Purpose

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials.

Methods

A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors.

Results

Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated.

Recommendations

All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Molecular assessment of neck dissections supports preserving level IIB lymph nodes in selective neck dissection for laryngeal squamous cell carcinoma with a clinically negative neck

OBJECTIVES

It was the aim of this study to determine whether level IIB lymph nodes can be saved in elective neck dissection as a treatment for patients with squamous cell carcinoma (SCC) of the larynx. We present a prospective analysis of a case series.

METHODS

Thirty-one patients with SCC of the larynx and without palpable lymph nodes at the neck who underwent an elective neck dissection were prospectively studied. The incidence of micrometastasis to level IIB lymph nodes after performing elective neck dissection was evaluated by nested reverse transcription polymerase chain reaction for cytokeratin (CK)19 and CK20 as well as by pathological examination.

RESULTS

Nested reverse transcription polymerase chain reaction for CK19 and CK20 mRNA presented similar results but differed from the pathological examination. Of the 31 patients, 6 (19%) by pathological analysis and 9 (29%) by molecular analysis had lymph nodes positive for metastatic SCC. By molecular analysis, only 1 of the 31 patients had involvement of level IIB lymph nodes.

CONCLUSIONS

This region may be preserved in elective neck dissection in patients with SCC of the larynx, so that accessory nerve dysfunction can be minimized and operative time can be saved.

Efficacy of routine bilateral neck dissection in the management of the N0 neck in T1–T2 unilateral supraglottic cancer

BACKGROUND

The treatment of the clinically negative (N0) neck in supraglottic laryngeal cancer continues to be an area of controversy. The aim of this study was to analyze the long-term efficacy of routine bilateral neck dissection compared with ipsilateral neck dissection in T1-T2 N0 lateral supraglottic carcinomas.

METHODS

A retrospective review of 108 patients who underwent surgery for T1-T2 supraglottic squamous cell carcinoma was performed. Forty-eight had undergone ipsilateral functional neck dissection, and 60 had undergone bilateral functional neck dissections. None of these patients received adjuvant radiotherapy.

RESULTS

No significant differences (p = .78) in regional recurrence were observed between the patients treated with bilateral neck dissection (13%) and those treated with ipsilateral neck dissection (17%). The 5-year survival rates were 73% and 80% for the patients who received a bilateral and ipsilateral neck dissection, respectively (p = .51).

CONCLUSIONS

This study suggests that routine bilateral neck dissection may not be necessary in the surgical treatment of all supraglottic cancers.

Is dissection of level IV absolutely necessary in elective lateral neck dissection for clinically N0 laryngeal carcinoma?

A prospective study of 73 previous untreated consecutive patients with clinically N0 laryngeal squamous cell carcinoma (SCC) from January 1997 to October 2002 was undertaken to determine whether level IV lymph nodes can be saved in elective lateral neck dissection (LND) performed as a treatment for the N0 neck. The incidence of pathological metastases to level IV lymph nodes was evaluated, as were the incidence of regional recurrence after elective LND, and postoperative complications such as chylous leakage and phrenic nerve paralysis. A total of 142 LNDs were enrolled in this prospective study. The mean number of harvested lymph nodes by level was as follows; 13.1 in level II, 7.1 in level III, and 9.2 in level IV. Pathologic examination revealed nodal involvement in 25 neck specimens (17.6%, 25 of 142). Five necks had lymph nodes which were positive for microscopic metastasis in level IV (3.5%, 5 of 142). These necks were all ipsilateral (6.8%, 5 of 73) and none of the 69 contralateral neck specimens had level IV lymph node metastasis (0%, 0 of 69). With regard to T stage, 3.3% (1 of 30) of ipsilateral necks of T2 tumors exhibited occult metastasis in level IV lymph nodes, 5.9% (2 of 34) for T3 tumors, and 33.3% (2 of 6) for T4 tumors. There were no cases of T1 (n = 3). Separate skip metastasis in level IV lymph nodes was observed in two necks (1.4%, 2 of 142). Four cases of regional recurrence (5.5%, 4 of 73) were observed. Postoperative chylous leakage and phrenic nerve paralysis occurred in four cases (5.5%, 4 of 73) and two cases (2.7%, 2 of 73), respectively. The results of the present study demonstrate the rare incidence of level IV occult lymph node metastasis, as well as infrequent nodal recurrence after elective LND in the treatment of clinically N0 laryngeal SCC. Therefore, dissection of level IV lymph node pads, especially in the ipsilateral neck of early T staged tumors or the contralateral neck, may be unnecessary for the treatment of laryngeal SCC patients with a clinically N0 neck.

Radiothérapie postopératoire des cancers laryngés classés N0

PURPOSE

A retrospective study to re-assess the indications for postoperative radiation therapy in squamous cell carcinoma of the larynx staged N0 after gross resection.

PATIENTS AND METHODS

Between January 1975 and December 2000, 166 patients with squamous cell carcinoma of the larynx were treated by total laryngectomy with or without neck dissection. Surgery was completed by external radiotherapy delivering 45 to 65 Gy to the tumour bed and 45 to 50 Gy to cervical lymphatic chains. Minimal follow-up was 36 months and median follow-up was 98 months.

RESULTS

The rate of nodal recurrence was 6% (median time for relapse was 9 months). The survival rates at 1, 2, 3 and 5 years were 93.5, 84, 80 and 69% respectively, with a 8 year 3 month median survival. The univariate analysis showed 4 parameters, which significantly increased the risk of local recurrence: the medical necessity for immediate tracheotomy, the subglottic involvement, the involvement of the whole larynx and the presence of lymphatic embols in the neck dissection. There was no statistically significant difference between the patients with or without a neck dissection. Fifty-nine secondary cancers were observed, 15 of them occurring in the head and neck area. The late complications consisted of cervical subcutaneous fibrosis (7%), oesophageal stricture (4%), oeso-tracheal fistula (l%), hypothyroidism (3%), bone necrosis (1%).

CONCLUSION

Prophylactic cervical radiotherapy in laryngeal cancers resulted in 6% cervical node recurrence rate. This value may represent the maximal rate to accept if one would favour new therapeutic strategies based on restricted indications for radiotherapy.

Intraoperative lymphatic mapping in cases of midline squamous cell carcinoma

OBJECTIVE

To analyze the value of intraoperative lymphatic mapping in cases of midline primary head and neck squamous cell carcinoma (HNSCC) in clinically staged N0 necks.

MATERIAL AND METHODS

Eleven patients with HNSCC of the epiglottis (2 T1, 6 T2, 3 T3), all of whom were staged with a neck status of N0 using sonography and CT, underwent intraoperative peritumoral (99m)Tc-nanocoll injection (4 sites; 45 MBq), radiolabeled detection and analysis of up to 3 hot sentinel nodes (SNs) during elective neck dissection.

RESULTS

Gamma probe use revealed bi- and unilateral intranodal tracer uptake in 6/11 and 5/11 patients, respectively. In 2/6 patients with bilateral intranodal tracer uptake an SN with an isolated metastasis was found at one neck site while the other four patients were tumor-free in the SNs. Of the five patients with unilateral intranodal tracer uptake, three had radiolabeled SNs containing isolated metastases whereas two had no cancer detected, giving a total occult cancer rate of 45% (5/11). No cancer was found in non-labeled nodes.

CONCLUSIONS

Intraoperative lymphatic mapping correctly identified the stage of metastatic disease. Unilateral tracer uptake represented the pathway of occult metastatic spread in 3/5 patients and the disease-free neck status of both neck sites in 2/5 patients. No patient had occult bilateral cancer. Future investigations should be done to determine whether intraoperative lymphoscintigraphy can guide the indication for unilateral only or bilateral neck dissection in these patients.

Selective neck dissection for clinically N0 neck in laryngeal cancer: is dissection of level IIb necessary?

The most common morbidity associated with selective neck dissection (SND; II-IV) is spinal accessory nerve dysfunction and related shoulder disability. Nerve dysfunction is usually attributed to stretching of the nerve during clearance of lymph nodes lying posterior and superior to the spinal accessory nerve (level IIb). If these lymph nodes were left in place and not removed, stretching of the spinal accessory nerve during neck dissection and postoperative shoulder disability could be avoided. 113 SNDs (II-IV) performed on clinically N0 necks of patients with laryngeal carcinoma were enrolled in this prospective study. During SND, level IIb was separately removed and processed. Mean number of lymph nodes in level IIb was 6.26 (range, 0-19). In none of the 113 SND (II-IV) specimens did level IIb contain metastases, thus providing an oncological basis that leaving these lymph nodes in place is an oncologically safe approach, probably avoiding postoperative shoulder disability.