Elective neck dissection in the treatment of T3/T4 N0 squamous cell carcinoma of the larynx

The role of central neck dissection and adjuvant treatment in pT4aN0 laryngeal carcinoma treated with open partial horizontal laryngectomy

PURPOSE

The study aimed to identify parameters that could predict oncological and functional outcomes in patients with pT4aN0 laryngeal squamous cell carcinoma (LSCC) who underwent open partial horizontal laryngectomy (OPHL). The role of paratracheal neck dissection (PTND) was analyzed as the primary outcome. Additionally, the study compared the outcomes of patients who underwent postoperative radio/chemotherapy (PORT/PORCT) with those who refused or did not adhere to adjuvant treatments.

METHODS

Twenty-nine OPHL patients whose pathological exam was consistent with pT4aN0-x disease were enrolled and their clinical charts were retrospectively reviewed. The study analyzed oncological outcomes, such as local, regional, and distant recurrence rates (RR), overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS). Additionally, functional results were analyzed, including decannulation rate, hospitalization time, and postoperative complication rate.

RESULTS

The study revealed and overall recurrence rate of 27%. The final rates for OS and DSS were 68% and 79%, respectively. Based on the univariate analysis the PTND was significantly associated with longer DFS. No significant differences inoncological outcomes were observed between pT4a patients who underwent adjuvant radio/radiochemotherapy and those who did not, in terms of RR, DFS, DSS or OS. However, adjuvant treatment was found to significantly increase decannulation time.

CONCLUSIONS

In a properly super-selected subgroup of patients with pT4aN0 LSCC, OPHL may beconsidered as a conservative surgical option even without adjuvant treatment. However, for optimal oncological outcomes, it is strongly recommended to consider a central compartment dissection in cases of hypoglottic and anterior extra-laryngeal tumor extension.

ALCAM is a biomarker of tumor aggressiveness and worse prognosis in glottic laryngeal squamous cell carcinoma

BACKGROUND

Laryngeal squamous cell carcinoma (LSCC) is the second most frequent head and neck tumor. Prognosis of patients with LSCC has not improved in recent decades, showing a need for the identification of prognostic biomarkers and new therapeutic targets. Recently, we showed that ALCAM overexpression was associated with glottic LSCC prognosis.

OBJECTIVES AND METHODS

Aiming to validate the prognostic value of ALCAM, we evaluate the ALCAM protein levels by immunohistochemistry in 263 glottic LSCC surgically treated with neck dissection.

RESULTS

ALCAM was expressed in 48.7% and overexpressed in 36.5% of glottic LSCC samples. ALCAM overexpression was associated with lymph node metastasis (p = 0.030), lymphovascular involvement (p = 0.0002), high-grade tumors (p = 0.025), and tumor relapse (p = 0.043). Multivariate survival analyses showed an overfitting between ALCAM overexpression and lymph node metastasis as a prognostic variable.

CONCLUSIONS

High ALCAM expression was associated with an aggressive glottic LSCC profile.

Comparative Survival Function in Patients with Positive Surgical Margins Following Laryngectomy

Aims: This study aims to make a comparative analysis of disease-free survival (DFS) and overall disease-specific survival (OS) in patients with laryngeal carcinoma. Materials and methods: The study was designed retrospectively. Sixteen patients with postoperative PSM and 30 with negative surgical margins (NSM) were included. Survival analysis and Long-Rank comparisons was performed for DFS and OS between groups. Results: PSM was a significant independent risk factor for loco-regional recurrence and disease-related mortality (p = 0.004, HR: 1.6, p = 0.002, HR: 3.2, respectively). DFS and OS were significantly longer in NSM group (p = 0.001 and 0.003, respectively). For PSM group, 2- and 5-year DFS rates were 57%; OS rates were 80% and 34% respectively. In NSM group, 2- and 5-year DFS rates were 96% and 83%; OS rates were found to be 96%. Conclusion: PSM had significant relation with poor prognosis.

Salvage Surgery

The Department of Veterans Affairs Laryngeal Cancer Study propelled the combination of chemotherapy and radiation therapy to the forefront of strategies used for the management of locally advanced laryngeal cancer. The organ preservation rate was 84%. However, over the past 30 years that these approaches have been in place, there have been concerns regarding long-term survival and high failure rates requiring salvage. Furthermore, salvage laryngectomy, if feasible when considering increased morbidity after CRT, is fraught with a higher risk of wound complications including fistula, longer hospitalization, and reduced quality of life.

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.

Occult Metastasis in Laryngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

The incidence of occult metastasis (OM) in laryngeal squamous cell carcinoma (SCC) is still widely debated. In this systematic review, we aim to determine the rate of OM in laryngeal SCC, its impact on recurrence, and the role of elective neck dissection (END) in the management of the clinically negative neck.

METHODS

A systematic review of the English-language literature in Web of Science, PubMed, MEDLINE, and Cochrane Library databases on occult metastasis in laryngeal SCC from 1977 to 2018 was conducted. Studies evaluating occult metastasis (OM) in patients with laryngeal SCC with clinically negative necks undergoing surgery were included. Studies evaluating other head and neck subsites, clinically node positive, and salvage patients were excluded.

RESULTS

Twenty-one articles with a total of 5630 patients were included. The overall rate of OM was 20.5% and was 23% and 12.2% in supraglottic and glottic tumors, respectively. The OM rate in T1-T2 tumors was 13% and 25% in T3-T4 tumors. T3-T4 tumors had significantly greater odds of developing OM compared to T1-T2 tumors (Odds Ratio [OR] = 2.61, 95% Confidence Interval [CI] = 1.92-3.55, P < .00001). Patients with OM were more likely to develop distant metastasis (OR = 5.65, 95% CI = 3.36-9.51, P < .00001).

CONCLUSIONS

Patients with advanced T-stage laryngeal SCC should undergo elective neck treatment. More aggressive treatment for patients with history of OM should be considered due to the risk of subsequent regional and distant metastasis.

LEVEL OF EVIDENCE

II.

[Determination of pathological margin of hypopharyngeal cancer by terahertz time-domain spectroscopy system]

Objective:To investigate the accuracy of the terahertz system in differentiating hypopharyngeal cancer from normal tissue and its role in determining the pathological incised margin of hypopharyngeal cancer. Method:The transplantation model of hypopharyngeal cancer in 5-week-old male BALB/c nude mice were established by subcutaneous injection. The obtained transplanted tumor specimens were pathologically diagnosed to determine the extent of tumor tissue. Tumor tissue, normal tissue and paracellular tissue of transplantation tumor were scanned by terahertz time-domain spectroscopy. The differential spectral data were obtained through the detection of frozen tissue sections and paraffin tissue sections, respectively. The results were compared by t-test. Result:The tarahertz absorption coefficient of tumor tissues was higher than that of normal tissues, and the difference was statistically significant when the detection frequency was greater than 0.48 THz in frozen sections（P<0.05）. In the paraffin sections, the difference was statistically significant within the effective spectrum range of 0.2-1.6 THz（P<0.01）. The difference of refractive index between tumor tissue and normal tissue was significant in specimens treated in two ways（P<0.01）. The absorption coefficient of adjacent tissue felt between that of normal tissue and tumor tissue. Conclusion:Terahertz technology can distinguish tumor tissues and normal tissues accurately, and can detect the spectral changes in adjacent tissues sensitively. Therefore, terahertz technology may become another tool for the judgment of pathologic margin.

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.

Metastatic lymph node burden predictive of survival in patients undergoing primary surgery for laryngeal and hypopharyngeal cancer

PURPOSE

Metastatic lymph node (LN) burden is one of the most important prognosticators in human solid cancers, but has rarely been examined in laryngeal and hypopharyngeal cancers (LHC). We evaluated the nodal factors predictive of recurrence and survival in patients with LHC.

METHODS

This study included 141 consecutive patients who underwent primary surgery and neck dissection for previously untreated LHC at our tertiary referral centre. Nodal factors included the presence of pathological LN metastasis, number of positive LNs, LN ratio, and extra-nodal extension (ENE). Our proposed N classification was analysed by recursive partitioning analysis and compared with the AJCC and other N classifications using the c-index. Univariate and multivariate Cox proportional hazard regression analyses were used to define significant predictors of post-treatment disease-free survival (DFS) and overall survival (OS).

RESULTS

Of the 141 patients, 66 (46.8%) had positive LNs, and 27 (19.1%) had ENE. In multivariate analyses, the number of positive LNs was strongly associated with DFS and OS outcomes (P < 0.01). Our new N classification was proposed with four categories, such as N0 (0 LN +), N1 (1 LN +), N2 (2-4 LN + or ENE) and N3 (≥ 5 LN +). The C-index of our new N classification improved the OS prediction (0.718) compared with the AJCC and the other N classifications (0.704-0.713).

CONCLUSION

Metastatic LN burden is an important predictor of survival in patients with LHC. A proposed N classification using the number of positive LNs and ENE might improve the LHC survival prediction.

A novel prognostic score model incorporating CDGSH iron sulfur domain2 (CISD2) predicts risk of disease progression in laryngeal squamous cell carcinoma

Background

The role of CDGSH iron sulfur domain 2 (CISD2) in laryngeal squamous cell carcinoma (LSCC) remains unclear.

Results

CISD2 were up-regulated in LSCC tissues compared with adjacent noncancerous tissues both at mRNA and protein levels. CISD2 was significantly correlated with T stage, lymph node metastasis, clinical stage and disease progression. A prognostic model (C-N model) for PFS was subsequently constructed based on independent prognostic factors including CISD2 and N classification. This model significantly divided LSCC patients into three risk subgroups and was more accurate than the prediction efficacy of TNM classification in the training cohort (C-index, 0.710 vs 0.602, P = 0.027) and validation cohort (C-index, 0.719 vs 0.578, P = 0.014).

Methods

Real-time PCR and Western blotting were employed to examine the expression of CISD2 in eight fresh paired LSCC samples. Immunohistochemistry was performed to assess CISD2 expression in 490 paraffin-embedded archived LSCC samples. A prognostic model for progression-free survival (PFS) was built using independent factors. The concordance index (C-Index) was used to evaluate the prognostic ability of the model.

Conclusions

CISD2 was up-regulated in LSCC. The novel C-N model, which includes CISD2 levels and N classification, is more accurate than conventional TNM classification for predicting PFS in LSCC.

Clinical and histopathological prognostic factors in locoregional advanced laryngeal cancer

Objective:

To evaluate the clinical and histopathological factors affecting the prognosis of patients with squamous cell locoregional advanced laryngeal cancer.

Methods:

A retrospective chart review was conducted of 121 patients with locoregional advanced laryngeal cancer, primarily treated with surgery from 2007 to 2011. Disease-free survival and overall survival rates were analysed as oncological outcomes. Prognostic variables, namely gender, pharyngeal invasion, pathological assessment of tumour and nodal stage, adjuvant therapy, margin status, nodal extracapsular extension, tumour differentiation, lymphovascular and perineural invasion, and predominant growth pattern, were also analysed.

Results:

One-year and three-year disease-free survival rates were 81.3 per cent and 63.5 per cent, respectively. One-year and three-year overall survival rates were 88.3 per cent and 61.4 per cent, respectively. Multivariate analysis showed that nodal extracapsular extension (p < 0.05) and an infiltrative growth pattern (p < 0.05) were associated with disease progression. Nodal extracapsular extension (p < 0.05) was associated with higher mortality.

Conclusion:

Nodal extracapsular extension and an infiltrative growth pattern were the main prognostic factors in locoregional advanced laryngeal cancer. The presence of pharyngeal invasion, pathologically confirmed node-positive stage 2–3 disease, close or microscopic positive margins, and lymphovascular and perineural invasion have a negative impact on prognosis.

Occult Nodal Disease Prevalence and Distribution in Recurrent Laryngeal Cancer Requiring Salvage Laryngectomy

OBJECTIVES

The indications for neck dissection concurrent with salvage laryngectomy in the clinically N0 setting remain unclear. Our goals were to determine the prevalence of occult nodal disease, analyze nodal disease distribution patterns, and identify predictors of occult nodal disease in a salvage laryngectomy cohort.

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary academic center.

SUBJECTS

Patients with persistent or recurrent laryngeal squamous cell carcinoma (LSCC) after radiation/chemoradiation failure undergoing salvage laryngectomy with neck dissection.

METHODS

We analyzed a single-institution retrospective case series of patients between 1997 and 2014 and identified those who had clinically N0 (cN0) necks (n = 203). Clinical and pathologic data, including nodal prevalence and distribution, were collected and statistical analyses performed.

RESULTS

Overall, cN0 necks had histologically positive occult nodes in 17% (n = 35) of cases. Univariate predictors of occult nodal positivity included recurrent T4 stage (34% T4 vs 12% non-T4; P = .0003) and supraglottic subsite (28% supraglottic vs 10% nonsupraglottic; P = .0006). Histologically positive nodes associated with supraglottic primaries were most frequently positive in ipsilateral levels II and III (17% and 16%). Positive nodes for glottic LSCC were most frequently positive in the ipsilateral and contralateral paratracheal nodes (11% and 9%).

CONCLUSION

Histologically positive occult nodes are identified in 17% of cN0 patients undergoing salvage laryngectomy with neck dissection. Occult nodal disease varies in frequency and distribution based on tumor subsite. Predictors of high (>20%) occult nodal positivity include T4 tumors and supraglottic subsite. In glottic LSCC, the most frequent sites of occult nodal disease are the paratracheal nodal basins.

Long-term outcomes after surgical or nonsurgical initial therapy for patients with T4 squamous cell carcinoma of the larynx: A 3-decade survey

BACKGROUND

The current study was conducted to evaluate long-term disease control, survival, and functional outcomes after surgical and nonsurgical initial treatment for patients with T4 larynx cancer.

METHODS

Demographics, disease stage, and treatment characteristics were reviewed for 221 sequential patients treated for T4 laryngeal squamous cell cancer at a single institution between 1983 and 2011. Survival and disease control outcomes were calculated.

RESULTS

The median follow-up time was 47 months (71 months for patients still alive at the time of analysis). The overall 5-year and 10-year overall survival rates were 52% and 29%, respectively, and the corresponding disease-free survival rates were 57% and 48%, respectively. Overall 5-year and 10-year locoregional control rates were 78% and 67%, respectively, and the corresponding rates for freedom from distant metastasis were 76% and 74%, respectively. On both univariate and multivariate analyses, lymph node-positive disease at the time of presentation was associated with overall mortality (P<.0001). Patients treated with laryngectomy followed by postlaryngectomy radiotherapy (161 patients) achieved better initial locoregional control than patients treated with a laryngeal preservation (LP) approach (60 patients) throughout the follow-up period (log-rank P<.007) yet the median overall survival times were equal for both groups (64 months; 95% confidence interval 47-87 months and 38-87 months, respectively [P =.7]). Patients treated with an LP approach had a tracheostomy rate of 45% and an any-event aspiration rate of 23%. Rates of high-grade dysphagia at the time of last follow-up were worse for patients treated with an LP approach (P<.01).

CONCLUSIONS

Surgery and postoperative radiotherapy can produce substantial long-term cancer control and survival rates for patients with T4 larynx cancer. Caution should be taken when selecting patients for initial nonsurgical treatment because of significant rates of functional impairment despite survival equivalence.

Postoperative irradiation in patients with pT3-4N0 laryngeal cancer: results and prognostic factors

Approximately 60 % of patients with locally advanced laryngeal cancer (LALC) treated primarily with surgery require adjuvant radiotherapy. In the available literature predominate series of patients were with pathologically confirmed node-positive status. Subgroups of pN0 patients with LALC are scarce. The aim of the study is to evaluate the efficacy of postoperative radiotherapy in patients with pathological stage T3-4N0M0 and identification of prognostic factors in this group. Between 1975 and 2005, 138 patients with squamous pT3-4N0 laryngeal cancer were irradiated postoperatively. Primary surgical treatment consisted of total laryngectomy and cervical lymphadenectomy. The median time between surgery and the implementation of radiotherapy was 56 days. The median total dose was 60 Gy (range 40–70 Gy). Five-year disease-free survival (DFS5) was achieved in 76 % of patients. Cancer recurrence was observed in 34 patients. In 28 (82 %) cases it was locoregional failure. DFS5 rates for pT3 and pT4 were 92 and 69 %, for margin status R0, R1 and R2 were 82, 72 and 67 %, respectively. The pharyngeal invasion was related to a decrease in DFS5 from 80 to 59 %. Postoperative irradiation in patients with pT3-4N0 LALC is an effective treatment method. The main reason of the failure is local recurrence. The following independent prognostic factors were identified in this group of patients: pT stage, surgical margin status and pharyngeal invasion.

The role of elective neck dissection in patients undergoing salvage laryngectomy

BACKGROUND

We investigated the risk of neck metastases in patients undergoing salvage total laryngectomy in association with previous radiotherapy.

METHODS

The medical records of 42 patients (51 neck specimens) with clinical N0 classification who underwent salvage total laryngectomy in 2 cancer centers were reviewed. Fourteen patients had previous radiotherapy to the central neck and 28 to the central and lateral neck.

RESULTS

Staging before salvage total laryngectomy was similar in both groups. The risk of neck metastases in the central and central/lateral radiation groups was 12% and 18%, respectively (p = .69). Subgroup analysis revealed that 4 of 8 patients initially presenting with clinically N+ had neck metastases before surgery, versus 2 of 26 for those with clinically N0 (p = .015; relative risk [RR] = 4.67). The risk or metastases in the contralateral neck was 0 of 9.

CONCLUSION

The risk of neck metastases in patients who undergo either central or central/lateral neck radiotherapy is similar. Elective neck dissection seems appropriate in patients undergoing SLR.

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.

Total laryngectomy and T3-T4 laryngeal cancer without other adverse histopathology

OBJECTIVE

We sought to determine the postoperative management, incidence of tumor recurrence in the neck, and outcome in laryngeal cancer patients whose risk for tumor relapse is not clear.

STUDY DESIGN AND SETTING

Thirty patients (27 of whom had transglottic tumors) met the study criteria (resected T3-T4 laryngeal cancer, histologically negative cervical nodes, and no other adverse histopathology). A group of 12 patients who underwent surgery alone was compared with a second group of 18 patients with similar characteristics but who received postoperative radiotherapy.

RESULTS

Overall survival at five years was 50% in the surgery alone group and 61% in the combined therapy group (P=0.63). Among the 28 evaluable patients with a median follow-up of 44 months, the relapse rate in the neck was 25% in the surgery alone group and was 0% in the postoperatively irradiated group (P=0.07). Recurrences in the neck remained uncontrolled in two of the three patients at the time of death.

CONCLUSION AND SIGNIFICANCE

Postoperative radiotherapy deserves consideration in selected cases of T3-T4 laryngeal cancer without adverse histopathology.

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.

Elective lateral neck dissection for laryngeal cancer in the clinically negative neck

BACKGROUND

Despite the introduction of modern imaging techniques, it is still difficult to detect microscopic disease in neck nodes. The purpose of this study is to evaluate the efficacy of the lateral neck dissection (LND) for elective treatment of the clinically node negative neck (cN0) in laryngeal squamous cell carcinoma (SCC).

METHODS

The clinical records of 110 cN0 patients with laryngeal SCC treated in this hospital from January 1997 to December 2002 were reviewed retrospectively.

RESULTS

One hundred ten patients received 145 elective LND. Occult metastasis was detected in 22 (20.0%) of this group of patients. The distribution of the 37 positive nodes was as follows: Level II 56.8%; Level III 37.8%; Level IV 5.4%. The 3-year neck recurrence rate estimated by the Kaplan-Meier approach for all cN0 patients (n = 110) was 5.4% [95% CI: 0.0%; 12.5%]. No significant difference in 3-year lymph node recurrence was found between node negative and node positive groups, between supraglottis and glottis groups, or between surgery alone and combined therapy groups.

CONCLUSION

The lateral neck dissection is effective in elective treatment of the neck in patients with laryngeal carcinoma.

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.

[Distribution of cervical metastases from carcinoma of the cervicofacial region]

The primary goal in the therapy of patients with cervico-facial cancers has been always the control of loco-regional disease. It is more difficult to control metastasis than primary tumor. According to numerous authors, metastases to cervical lymphonodus reduce the survival of patients with planocellular cancer of the upper aero-digestive pathways for about 50%. Precise classification of primary tumor and regional lymphonodus is highly significant for adequate and timely treatment of patients with cancers of cervico-facial region. The objective of our study was to make clinical classification of cervico-facial tumors and to establish the distribution of nodes according to node groups and cervical levels. In our series of 319 subjects, T2 category of primary tumors was most prevalent accounting for 40.44%. Clinically palpable lymphonodes were found in 87.15%, with most prevalent N1 category accounting for 42.95%. The incidence of clinically negative cervical nodus (N0) was reported in 12.85%. The nodes of the upper, medium and lower jugular group were most frequent in cancers of the larynx and pharynx. In cancer of the oral cavity, submental and submandibular nodes were the most commonly involved. In distribution of nodes based on oncological cervical levels, 45.86% of nodes at level II of the neck were found in laryngeal cancer, while 40% the neck level I was involved in the cancer of the oral cavity. In epipharyngeal cancer, 3.15% of cervical metastases were detected in the posterior triangle of the neck. The incidence of cervical metastases in specific primary localizations has a significant role for indications of one of the dissections of the neck.

Prognostic Value of Resection Margins in Supracricoid Laryngectomy

OBJECTIVES

The objective was to assess the prognostic value of surgical margin involvement in patients treated for squamous cell carcinoma of the larynx.

STUDY DESIGN

Retrospective study.

METHODS

A review was made of 253 patients treated with supracricoid laryngectomy between 1984 and 2001. A histopathological study on the surgical resection margins was performed in all cases. The incidence of local recurrence was correlated with the histological features of resection margins.

RESULTS

Forty patients (15.8%) were identified as having positive margins: 29 had invasive carcinoma and 11 had dysplastic lesions. The remaining 213 patients (84.2%) had negative margins. Subsequent follow-up showed that 19 of 253 patients developed local recurrence and 3 patients developed regional recurrence. Nine of these patients had positive resection margins (six with invasive carcinoma and three with dysplastic lesions), and 10 had negative resection margins. Overall survival at 3 years was significantly higher for patients without recurrence than for patients with local or regional failure (89.9% vs. 45.5% [P <.05]).

CONCLUSION

According to results of the study, patients with positive resection margins developed local recurrence more frequently than those with clear resection margins (P <.05).

Total laryngectomy and postoperative radiotherapy for T4 laryngeal cancer: a 14-year review

OBJECTIVE

The most appropriate treatment of locally advanced carcinoma of the larynx remains to be ascertained. Management of T4 laryngeal cancer patients with postoperative radiotherapy after total laryngectomy is generally advocated and not often debated. However, the effects of this combined treatment approach are poorly documented. We reviewed the oncologic outcome and long-term survival of individuals treated by total laryngectomy and postoperative radiotherapy (TLPR) for T4 carcinoma of the larynx.

METHODS

Twenty-eight patients with a pathologic diagnosis of T4 laryngeal cancer treated by TLPR during a 14-year period were studied retrospectively. Median follow-up from treatment until the end of observation was 36 months (range 6 to 123 months).

RESULTS

The overall actuarial and disease-free survival rates at 7 years were 43% and 30%, respectively. Local recurrence, regional relapse, and distant metastasis developed in 4%, 4%, and 7% of the cases, respectively. Later esophageal stricture, dental caries, or carotid artery disease in 3 patients (11%) was successfully managed. Multivariate analysis showed patient age, bilateral true vocal cord-anterior commissure involvement by laryngeal cancer (horse-shoe lesion), and any type of treatment failure to be the most predictive variables affecting prognosis.

CONCLUSION

Long-term disease control and survival is achievable by TLPR with minimal late toxicity in patients with T4 carcinoma of the larynx.

Functional neck dissection for the clinically negative neck: effectiveness and controversies

This study was performed to evaluate the effectiveness of functional neck dissection in controlling metastasis to the clinically negative (cN0) neck, focusing on recurrences in the pathologically negative (pN0) neck and the role of extracapsular spread in the cN0 neck. A series of 172 patients (253 dissected fields) treated for cN0 laryngeal or hypopharyngeal cancer with a 5-year minimum follow-up is presented. Occult metastasis was observed in 30% of the patients. Extracapsular spread was present in 39% of the positive nodes. The neck recurrence rate was 5.2%. Surgical specimens from cases of neck recurrence in pN0 necks were reevaluated for micrometastasis by immunostaining with antibody for cytokeratins. The immunohistochemical findings were positive in 1 of 4 cases. Functional neck dissection provides good neck control and survival rates for the cN0 neck. The accurate prognostic significance of extracapsular spread in cN0 necks is still unknown. Micrometastasis alone may be insufficient to explain recurrences in pN0 necks.

Laringectomia supracricóide (chep) para câncer glótico

OBJETIVOS: Com a intenção de se avaliar os resultados funcionais e terapêuticos da laringectomia supracricóide com crico-hióide-epiglote-pexia (CHEP) foram estudados 50 casos de pacientes com carcinoma epidermóide da glote classificados como T2/T3 submetidos a esta técnica em nossa instituição. MÉTODOS: Foi realizada uma análise retrospectiva entre 1996 e 1999. Classificamos 18 pacientes como T2N0M0 e 32 pacientes como T3N0M0. Quarenta e um pacientes foram submetidos a esvaziamento cervical seletivo lateral bilateralmente, quatro foram submetidos ao mesmo esvaziamento unilateralmente, e cinco não foram esvaziados. Analisamos as complicações e a sobrevida livre de doença pelo método de Kaplan-Meyer. RESULTADOS: Dez pacientes tiveram complicações pós-operatórias, dois foram tratados com complementação da laringectomia. Os 48 pacientes restantes mantiveram a via aérea normal, deglutição e a voz. Três pacientes no grupo submetido a esvaziamento cervical apresentaram linfonodo metastático. Quatro pacientes tiveram recidiva da doença, três com recidiva local, sendo dois tratados com laringectomia total e estão vivos e sem doença, o outro com doença avançada alcançou o óbito pela doença. O paciente que teve recidiva no pescoço foi tratado com esvaziamento cervical mais radioterapia e morreu com doença. Dois pacientes tiveram um segundo tumor primário em orofaringe, sendo um tratado com radioterapia paliativa e morreu com doença e o outro tratado com cirurgia está vivo e sem doença. A sobrevida livre de doença em três anos foi de 88% para pacientes T2 e 72% para pacientes T3. CONCLUSÕES: Esta técnica é útil no tratamento de casos selecionados de carcinoma epidermóide da glote T2/T3 sempre se considerando a extensão da doença. A incidência de complicações necessitando laringectomia total de resgate não compromete a funcionalidade desta técnica. A sobrevivência é comparável aos pacientes submetidos a laringectomia total e laringectomia "near-total".

[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.

Supracricoid laryngectomy with CHEP: functional results and outcome

OBJECTIVES

To assess whether supracricoid laryngectomy with cricohiodoepiglottopexy could successfully reach the cure and preserve the voice in glottic laryngeal cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with cricohiodoepiglottopexy.

STUDY DESIGN

A retrospective analysis has been carried out between 1995 through 1997. We classified 11 patients as T2N0M0 and 16 patients as T3N0M0. Nineteen patients had bilateral selective lateral neck dissection, 3 patients had unilateral lateral neck dissection, and 5 patients had undissected neck. Survival was analyzed under the Kaplan-Meyer method.

RESULTS

Five patients had postoperative complications, 2 were treated with a total laryngectomy. The remaining 25 patients kept the normal airway, swallowing, and speech. None of the patients in the neck dissection group had neck metastasis. Two patients had recurrences, 1 with local recurrence was treated with a total laryngectomy and is alive without disease; the other patient had neck recurrence, was treated with radical neck dissection plus radiotherapy, and is dead of the disease. One patient had a second tumor in oropharynx treated with palliative radiotherapy and is dead of the disease. Three years disease-free survival was 75% for T2 and 79% for T3.

CONCLUSIONS

This technique is useful in the treatment of selected cases of T3/T2 glottic cancer regarding the extent of disease. The incidence of complications in need of a complete laryngectomy does not compromise the functionality of this technique. The survival is comparable to patients who submitted to total laryngectomy and near-total laryngectomy, regarding the extent of the lesion.

Role of multimodal treatment in oropharynx, larynx, and hypopharynx cancer

Due to recent advances in radiation fractionation, radiochemotherapy, and conservative surgical techniques, the concept of multimodal therapy in head and neck cancer is currently changing. The recently published RTOG Phase III trial 9003, with 1,113 patients accrued, showed that hyperfractionation and accelerated fractionation with concomitant boost are more efficacious than standard fractionation for locally-advanced head and neck cancer. Acute, but not late, toxicity was also increased. Three meta-analyses have suggested that the impact of chemotherapy in head and neck cancer is small but is highly associated with the timing of therapy. Concomitant administration of radiation therapy and chemotherapy led to an absolute benefit in 5-year survival of about 10%. This finding has been further supported by recently published randomized prospective trials comparing concomitant radiochemotherapy with radiotherapy alone in advanced head and neck cancer. There is now clear evidence that radiochemotherapy provides a substantial and statistically significant improvement in survival and local-regional control, as compared to radiotherapy alone. Radiochemotherapy should be considered an accepted standard of care in cancers of the oropharynx, particularly for patients with locally-advanced disease who have a good performance status. Two randomized studies conducted by the Department of Veterans' Affairs and the EORTC, with a total of 534 patients accrued, showed that induction chemotherapy followed by radiotherapy of responders yields survival rates equal to those of total laryngectomy with postoperative radiotherapy. After 4 years, one-half to two-thirds of survivors of the chemotherapy arm retained a functional larynx. Larynx preservation using induction chemotherapy can now be regarded as feasible but still investigational. Current phase II studies show excellent larynx preservation rates using a primary concomitant radiochemotherapy with an altered fractionation regimen. More clinical and laboratory research is required to further evaluate the different treatment options of the multimodality concept, and to develop prognostic models that will allow individualization of the therapy.

Neck-dissection surgical specimens treated by lymph node revealing solution

The detection of metastatic lymph nodes in cancer patients is essential for determining the cancer stage, and thus, the therapeutic modalities. However, very small lymph nodes can easily be missed during routine examination. We described a "Lymph Node Revealing Solution" (LNRS) that helps to detect tiny lymph nodes in neck dissection specimens. Twenty-one consecutive specimens of neck-dissection were investigated. The entire surgical specimen, fixed at first in formalin, was searched for lymph nodes by the traditional method. These were excised and sent for processing. The remaining tissue was immersed for 24 hours in LNRS. The lymph nodes stood out as white chalky nodules on the background of the yellow fat. They were then excised, and examined. A total of 227 lymph nodes were detected by the traditional method; 38 (17%) were positive for metastasis. Using the LNRS method, an additional 72 nodes were identified, among them 8 (11%) were positive for metastases and 2 cases were upstaged. LNRS is an inexpensive and easy method of detecting tiny lymph nodes; it enhances significantly the yield of normal and metastatic nodes of neck-dissection specimens and helps to establish a more accurate staging.

Comparing treatment outcomes of radiotherapy and surgery in locally advanced carcinoma of the larynx: a comparison limited to patients eligible for surgery

PURPOSE

The use of radical radiotherapy and surgery for salvage (RRSS) in locally advanced squamous cell carcinoma (SCC) of the larynx is controversial. In the absence of randomized studies, it is unclear if RRSS can match the rates of locoregional control and survival reported for primary surgery in this setting. The aim of this study was to compare treatment outcomes of radiotherapy and surgery in comparable patients with CS III-IV SCC of the larynx.

METHODS AND MATERIALS

Eighty-two patients with untreated T2N+M0 or T3T4NM0 SCC of the larynx were treated with a policy RRSS at the Toronto-Sunnybrook Regional Cancer Centre between June 1980 and December 1990. The medical records at presentation were reviewed independently by a panel of three surgical oncologists blinded as to treatment outcome to determine patient suitability for laryngectomy and neck dissection using eligibility criteria adopted by recent clinical trials. Treatment outcomes for surgery-eligible patients were compared to results of comparably staged patients in the surgical literature since 1980.

RESULTS

Sixty-three patients (77%) were eligible for study. With a median follow-up of 3 years, radiotherapy controlled the primary in 8/20 evaluable glottic primaries and 21/41 evaluable supraglottic primaries. Forty-five percent of patients surviving 5 years retained a functional larynx. Sixteen of 29 relapsing patients were salvaged with surgery. Disease above the clavicles was controlled in 65% of T3T4N0N+ glottic primaries (compared to a published range of 53% to 79%) and 82% of T3N0 glottic primaries (compared to a published range of 69% to 84%). The 5-year overall survival of patients with T3T4 glottic cancer was 54% compared to a published range of 50% to 63%. The cause-specific survival (CSS) of patients with T3N0 glottic primaries (86% at 1 year and 73% at 2 years) was identical to the only published report of CSS in the surgical literature.

CONCLUSION

A policy of RRSS offers a good chance of laryngeal conservation without compromising ultimate locoregional control or survival when compared to primary laryngectomy and neck dissection in patients with locally advanced carcinoma of the larynx meeting the surgical eligibility of clinical trials.

The role of neck dissection in head and neck mucosal squamous cancer

The most clinically useful system of classification of neck lymph nodes is grouping into levels I-V. Anatomical, clinical and pathological studies demonstrate that although generally lymphatic flow is from above downwards, level I is often bypassed and level V is seldom involved. Neck dissection is classified into radical, modified radical, selective and extended radical neck dissections. Recent studies demonstrate that elective neck dissection is beneficial to the outcome of oral cancer patients, but not necessarily to laryngeal and pharyngeal cancer patients. Modified radical neck dissection is as effective as radical neck dissection when performed in the elective situation. Selective neck dissection in the form of supra-omohyoid neck dissection is useful as a staging procedure. Modified radical neck dissection is acceptable for the N1 neck provided postoperative radiotherapy is given.

Management of N0 neck in T1-T2 unilateral supraglottic cancer

Early-stage supraglottic cancers (stage I and II) are treated with several different programs. Previously reported data have led us to design a therapeutic protocol in treatment of patients with early-stage squamous cell carcinoma of the supraglottic larynx. From 1991 to 1996, 39 patients with unilateral supraglottic carcinoma were treated according to this protocol. All patients underwent unilateral functional neck dissection and resection of the primary carcinoma in an en bloc fashion. Histopathologic studies showed that 9 (23%) of them had positive nodes, and they received planned adjuvant radiotherapy. None of the 30 patients with histopathologically NO necks received either adjuvant irradiation or contralateral neck dissection. The mean follow-up period was 34 months. All patients are alive, and none have developed any recurrence in either dissected or undissected sides of the neck. This treatment policy seems satisfactory and will avoid unnecessary therapeutic interventions. Routine bilateral neck dissection may not be necessary in the surgical treatment of all supraglottic laryngeal cancers.

Definitive radiotherapy for 114 cases of T3N0 glottic carcinoma: influence of dose-volume parameters on outcome

BACKGROUND AND PURPOSE

Assuming that the dose-response curve for T3N0M0 glottic carcinoma is steep and that the rate of occult lymph node metastases is low, it should be possible to employ high biological tumour doses to modest target volumes and thereby maximise laryngeal control without compromising final neck control. Within the constraints of a retrospective study we aim to examine this policy with respect to local control, incidence of nodal relapse and late complications.

MATERIALS AND METHODS

One hundred and fourteen patients with T3N0M0 glottic carcinoma who received a 3-week schedule of radical radiotherapy between 1986 and 1994 were analysed. The median age was 67 years (range, 34-85 years) and the median follow-up for living patients was 4.8 years (1.9-8.9 years). There were no strict selection criteria for those patients treated with radiotherapy.

RESULTS

The 5-year overall survival was 54%. The 5-year local control with radiotherapy and the ultimate loco-regional control following salvage laryngectomy were 68 and 80%, respectively. Nine patients (8%) suffered a regional nodal relapse but only three of these (3% overall) occurred in the absence of local failure. Four patients (3.5%) developed serious late complications requiring surgical intervention (three received 55 Gy and one 52.5 Gy).

CONCLUSIONS

It is possible to employ maximum tolerable doses to specific target volumes and thereby exploit the dose response demonstrated and minimise major late effects. The use of modest target volumes resulted in only 3% of patients requiring surgery that might have been avoided had prophylactic neck irradiation been employed.

Upper neck (level II) dissection for N0 neck supraglottic carcinoma

OBJECTIVES

Elective neck dissection for the N0 neck in head and neck surgery is still controversial. This prospective nonrandomized study of N0 supraglottic carcinoma was designed to find an appropriate method of neck management.

STUDY DESIGN

Anatomical studies show that the first echelon of lymphatic drainage from the supraglottic larynx is toward the upper jugular nodes (level II). An upper neck dissection (UND) was applied and all the lymph nodes were sent for frozen section. If the subclinical metastasis was found, a modified neck dissection was performed. If the nodes harbored no foci of cancer, the patients were observed after surgery on the supraglottic lesions.

METHODS

Patient records of 142 patients with supraglottic laryngeal cancer (T1-4N0M0) were reviewed, with special attention paid to neck recurrences and survival rates. The cases were treated between 1976 and 1990 and all were observed for at least 5 years after the operation or until the time of death.

RESULTS

The UND specimens of 142 patients were negative for metastasis. The 5-year survival rate for this group after surgery was 80.8%, according to the life table analysis. Fifteen of the 142 patients (10.6%) had neck recurrences during the period of observation within 5 years. The recurrence rate of this series with limited dissection on the neck was comparable with those reported in the literature after neck dissection, either radical or modified.

CONCLUSIONS

There is no need for a comprehensive neck dissection for N0 supraglottic laryngeal cancer. A selective neck dissection such as UND (level II) or a supraomohyoid neck dissection (sparing the submandibular region) of level II and III will serve the purpose of radical neck treatment for the supraglottic cancer.

The significance of DNA flow cytometry in predicting survival and delayed clinical manifestation of occult lymph node metastasis to the untreated neck in patients with oral squamous cell carcinoma

A total number of 116 clinically neck-negative patients with squamous cell carcinoma of the oral cavity who underwent radical primary tumour surgery without simultaneous neck treatment were entered into this prospective study. The 5 year overall survival rate was 87% for patients with flow cytometrically diploid tumours and 58% for the aneuploid group (P < 0.05). By multivariate survival analysis, tumour stage (P < 0.05) and DNA ploidy (P < 0.05) were significantly associated with the outcome. The cumulative 3 year rate of delayed clinical manifestation of lymph node metastasis to the previously untreated neck was 12.6% for patients with flow cytometrically diploid tumours and 41.3% for the aneuploid group (P < 0.01). By multivariate analysis, the DNA ploidy status of the primary tumour was the only factor among tumour stage, localization and degree of histological differentiation predictive of occult metastasis development (P < 0.05). Also, patients with T1 tumours who frequently are not considered to benefit from elective neck dissection were at high risk of subclinical lymph node involvement if the primary tumours were aneuploid (47%), whereas only 10% of the diploid T1 sample showed occult neck disease. Particularly in patients with less extensive oral carcinomas, DNA aneuploidy is therefore an important decisive factor in elective neck dissection.

Diagnostic evaluation of the neck

Modern imaging for neck node metastases has increased our ability to predict the presence of palpably occult metastases and predict the resectability of large metastases. The accuracy of CT scans, MR imaging, but especially US-FNAC, has increased to such an extent that clinical consequences are being attached to negative radiologic findings in a clinically N0 neck. As not all palpably occult metastases can be detected, especially when they are micrometers, follow-up should be strict, with use of US-FNAC in the neck observed instead of treated electively.

Nodal disease in purely glottic carcinoma: is elective neck treatment worthwhile?

OBJECTIVE

Although there is a generalized understanding of the relatively low overall incidence of nodal disease from purely glottic carcinoma, the exact role for elective neck treatment in the management of this disease remains controversial. The purpose of this study was to identify the incidence of occult nodal disease (including paratracheal) in patients who have glottic carcinoma without significant extraglottic extension and to identify which patients are at risk for this. A retrospective chart review of 92 such patients who had either undergone neck dissection or been observed for a minimum of 2 years was performed.

RESULTS

For the 92 patients, neck treatment consisted of observation in 68 patients, paratracheal node dissection in four, unilateral neck dissection in four, unilateral neck dissection and excision of paratracheal nodes in 14, and bilateral neck dissection with paratracheal node excision in two. Of the 24 nodal dissections performed, four were positive for occult metastatic disease. No patient in the observation group developed nodal disease.

CONCLUSION

The incidence of occult nodal disease in NO glottic carcinoma is low, 0% in early stage disease (T1-T2) and 19% in late stage disease (T3-T4). Nodes at highest risk included only the paratracheal, level II, and level III. Elective neck treatment should only be undertaken for advanced (T3-T4) disease and even then is of questionable benefit. If undertaken, it should have a low potential morbidity, such as selective neck dissection or radiation. Computed tomography was not useful in staging the neck for this subset of patients.

Near-total laryngectomy for treatment of advanced laryngeal cancer

BACKGROUND

In order to assess whether near-total laryngectomy (NTL) could successfully reach the cure and preserve the voice in advanced laryngeal cancer, we studied 28 patients with T3/T4 squamous cell carcinoma of the larynx treated with NTL in our institution.

METHODS

A retrospective analysis has been carried out from 1990 through 1994. We classified 24 patients as Stage III and 4 patients as Stage IV. All patients had lateral neck dissection. Survival was analyzed under the Kaplan-Meier method.

RESULTS

Twenty-six patients achieved voice preservation. Two patients in the bilateral neck dissection group had a metastatic lymph node on the opposite side. No patient had local recurrence. Three patients died of the disease, and 1 patient was salvaged with neck dissection. Three-year disease-free survival was 85%.

CONCLUSION

This technique is useful in the treatment of selected cases of advanced laryngeal cancer and achieves local control of the lesion in all cases. The survival is comparable with that of patients submitted to total laryngectomy, regarding the extent of lesion. Voice preservation can be achieved in most cases.