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

Surgical Treatment of Early Glottic Cancer

The incidence of all head and neck malignancies is rising worldwide, with carcinoma of the larynx constituting approximately 1% of all cancers. Early glottic cancer responds quite favorably to surgical intervention due to its early presentation, coupled with the low rate of regional and distant metastases. This article focuses on various approaches to the surgical treatment of early glottic cancer. Details include the clinical and radiological evaluation of laryngeal cancer, the goals of treatment, current surgical options for early disease, approach to surgical resection margins and management of nodal disease, and complications associated with each treatment modality.

Elective neck dissection for T3-T4N0 laryngeal carcinoma: evidence from Japan's National Head and Neck Cancer Registry

BACKGROUND

Although total laryngectomy is the standard treatment for advanced laryngeal cancer, the significance of elective neck dissection (END) for N0 laryngeal cancer remains unclear in Japan, which is an aging society.

METHODS

We conducted a retrospective nationwide observational study on patients with T3-T4N0 laryngeal squamous cell carcinoma treated with curative total laryngectomy from 2011 to 2018 in Japan.

RESULTS

A total of 1,218 patients were analyzed. The median patient age was 72 years, with 735 cases of T3N0 and 483 cases of T4N0. END was performed on the affected side in 850 patients (70%) and on the contralateral side in 502 patients (41.2%). END on the affected side was omitted in patients aged > 80 years (40.4%) and in patients with an advanced performance status. The occult lymph-node metastasis rate did not differ by age (18.8%-19.6%); it tended to increase chronologically from 2011 (11.1%) and was higher in cT4a (22.5%) and pT4a (24.3%) cases. In this study, coherent clinical information and follow-up data were available for 252 patients. Both univariate and multivariate analyses showed no significant prognostic factors for overall survival or recurrence-free survival for either affected or contralateral END. Older age and subglottic location were poor prognostic factors, but death due to factors other than laryngeal cancer could not be ignored in older patients.

CONCLUSION

Omission of END during laryngectomy for T3-T4N0 laryngeal cancer is acceptable for older patients who want their operation to be completed in a short time.

Imaging Recommendations for Diagnosis, Staging and Management of Larynx and Hypopharynx Cancer

We discussed the imaging recommendations for diagnosis, staging, and management of larynx and hypopharynx cancer. Carcinoma of the larynx is a common cancer, with males being affected more. Hypopharyngeal carcinoma is less common than laryngeal malignancies. Squamous cell carcinoma is the most common histological type. Nonsquamous cell malignant lesions are rare and mostly submucosal lesions. Clinical examination and endoscopy play an integral role in its detection and staging. Imaging also plays a major role in its staging, including local disease extent, nodal and distant metastatic status, as well as to assess response to therapy. Follow-up of treated cases and differentiation of recurrence from post treatment changes can be done on imaging. Early stage disease is treated with single modalities such as radiotherapy or surgery. Advanced disease is treated with multimodality of either chemoradiotherapy or surgery followed by adjuvant radiotherapy with or without concurrent chemotherapy.

Management of clinically node-negative glottic squamous cell carcinoma patients according to risk-scoring model for occult lymph node metastases

Background

Glottic squamous cell carcinoma (GSCC) is the most prevalent type of laryngeal carcinoma. The value of prophylactic lymph node dissection (LND) in resected GSCC remains controversial. This study aims to quantitatively assess the probability of occult lymph node metastasis (LNM) for GSCC patients and devise individualized postoperative radiotherapy strategies.

Methods

A total of 1319 patients with GSCC were retrospectively analyzed.

Results

GSCC patients with T1-T2 stages showed significantly lower LNM rate than those with T3-T4 stages. For patients with T3-T4 GSCC, multivariate logistic analyses indicated that three factors-maximum tumor diameter (MTD) of more than 2.0 cm, relatively low differentiation, and tumor invasive depth of no less than 1.0 cm-were independent risk factors for the existence of LNM. A predictive nomogram was established based on these factors. The accuracy and validity of our model were verified by 0.716 and remained at 0.717 after 1000 bootstrapping. The calibration curve was also plotted and showed a favorable agreement. The patients were stratified into two groups based on their individual LNM risk points. Possible LNM rates for low-risk and high-risk subgroups were 4.7% and 25.2%, respectively.

Conclusions

A new post-operative strategy selection flow chart was established based on our newly created nomogram which can effectively predict the individualized possibility of occult LNM for GSCC patients. For clinical T3-4N0 patients in the high-risk subgroup, prophylactic dose post-operative radiation therapy is recommended. However, for all those clinically diagnosed as T1-2N0 stage, regular follow-up is sufficient in view of the low occult LNM rate.Level of Evidence: 2a.

Pre-Treatment Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios as Predictors of Occult Cervical Metastasis in Clinically Negative Neck Supraglottic and Glottic Cancer

Background. Among patients with diagnosis of Laryngeal Squamous Cell Carcinoma (LSCC), up to 37.5% of cases may have occult metastasis (OM), and this feature is linked to poor prognosis and high rate of local recurrence. The role of elective neck dissection (END) in clinically negative neck (cN0) LSCC remains controversial. It is of great value to search for low-cost and easily detectable indicators to predict the risk of OM in laryngeal cancer. Recent reports have shown that high values of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) represent a negative prognostic factor in head and neck cancers. The aim of our study has been to investigate the value of pre-treatment NLR and PLR with regard to predicting occult cervical metastasis in cN0 supraglottic and glottic LSCC. Materials and methods. Data of patients affected by LSCC, who had been surgically treated by means of laryngectomy (total, horizontal partial and supracricoid) and END between January 2006 and January 2021, were retrospectively reviewed, using information retrieved from a database dedicated to such procedures in a single tertiary care referral institute. Results. A total of 387 patients were treated for LSCC at our Institute from 2006 to 2021, but only 108 of them met the inclusion criteria. The median age at the time of diagnosis was 64 years (range, 39–89 years). All the tumors were treated with a laryngectomy and an END. A total of 27.7% of patients were found positive for neck node metastasis (the pN+ group), while 78/108 (72.3%) patients were found to be negative for the presence of neck metastasis (the pN0 group). High values of NLR, but not PLR, significantly correlated with the probability of OM, and according to the iterative algorithm of Newton–Raphson, an NLR value of 2.26 corresponds to a probability of OM of 20%. Conclusion. Our analysis revealed a statistical correlation between high NLR pre-treatment values and positive neck OM in patients with LSCC.

Occult Lymph Node Metastasis in Early-Stage Glottic Cancer in the National Cancer Database

OBJECTIVES

Early-stage glottic cancer (cT1-T2 cN0) may be treated by primary surgery or radiation. Elective treatment of the neck in clinically N0 disease is usually not performed due to low rates of regional lymph node metastasis. This study examines the role of elective neck dissection (END) and rate of occult nodal metastasis in cT1-T2 cN0 glottic cancer treated with primary surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

The National Cancer Database was used to identify patients treated for early-stage glottic cancer. Demographic variables, disease characteristics, and overall survival were compared between the subgroups of patients who did and did not receive END. Factors predictive of occult lymph node metastasis were also identified using a multivariate logistic regression model.

RESULTS

Thirty-eight percent of the 991 patients in this cohort underwent END. Younger age, treatment at an academic facility, advanced T-stage, and higher tumor grade were associated with receiving END. Sixteen percent of the 372 patients undergoing END had occult nodal metastasis. Higher tumor histopathologic grade was associated with occult metastasis (P = .004). While undergoing END did not affect significantly survival, those with occult metastasis had poorer survival (P < .001).

CONCLUSIONS

END should be considered in cT1-T2 N0 glottic cancers with poorly differentiated or undifferentiated tumor histopathology. While END itself may not improve overall survival, identification of occult nodal metastasis is an important finding for prognostication.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 131:E1139-E1146, 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.

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.

Surgical Therapy of T1 and Selected Cases of T2 Glottic Carcinoma: Cordectomy, Horizontal Glottectomy and CO2 Laser Endoscopic Resection

Aims and background

Among the different laryngeal neoplasms, glottic carcinoma is known to be one of the most suitable for functional management. Nevertheless, the best treatment for T1 and T2 glottic carcinoma, whether an open neck procedure, endoscopy or radiotherapy, with reference to recurrence, survival, and functional results, has long been debated.

Study design

From February 1983 to September 1997, 83 patients with well to undifferentiated glottic carcinoma (48 pT1a, 14 pT1b, and 21 selected cases of pT2 with impairment of vocal cord mobility) were submitted to surgery at the Otorhinolaryngologic Section of the Department of Surgical Sciences and Organ Transplantations of Cagliari University. Surgical treatment included 30 laryngofissures with simple or enlarged cordectomy, 22 horizontal glottectomies and 31 endoscopic laser resections. A retrospective review of the records of the patients was performed in order to obtain a better understanding of the outcome of the three different surgical procedures in our institution.

Results

According to the Kaplan-Meier method, the probability of remaining free of local recurrence 3 years after primary surgery was 0.90 for the T1 group and 0.85 for the T2 group. The distribution of recurrences for cordectomy, glottectomy and CO2 laser at 3 years showed a cumulative probability of remaining free of disease after primary surgery of 0.86, 0.85 and 0.88. The probability of remaining free of local recurrence 3 years after salvage surgery was 0.96 for the T1 group and 0.95 for the T2 group. Analyzing the phenomena for type of surgical procedure, local control at 3 years after salvage surgery for cordectomy, glottectomy and exclusive CO2 laser was 0.93, 0.90 and 0.92, respectively. In the endoscopic group, local control rate after any type of salvage therapy modified the percentage at 3 years to 100%. Anterior commissure spread (AC1-AC2) resulted in a difference (not statistically significant) in local control between the group of patients without and with anterior commissure involvement. Laryngeal preservation was achieved in 93.7% (45/48) of patients who survived after salvage surgery following open neck procedures and in 100% of patients originally submitted to the endoscopic approach.

Conclusions

In our experience, although open laryngeal procedures can be still considered a valid option in the treatment of T1 and selected cases of T2 glottic carcinoma, endoscopic laser excision offered an oncologically adequate alternative to the traditional techniques, with minimum discomfort for the patient and satisfactory preliminary functional results.

A novel classification scheme for advanced laryngeal cancer midline involvement: implications for the contralateral neck

PURPOSE

There are insufficient data concerning risk factors for contralateral regional metastases in laryngeal cancer. The aim of this study was to investigate the frequency and risk factors for contralateral lymph node metastases and their dependence on midline involvement of the primary tumor in patients with advanced laryngeal squamous cell carcinoma.

METHODS

58 consecutive patients (8 females, 50 males; mean age 64.2 ± 9.8 years; AJCC stage III disease in 43.1%, IVA disease in 54.4%) undergoing primary total laryngectomy with bilateral neck dissection between 2002 and 2016 have been retrospectively investigated at one of the largest university medical centers in Europe. Preoperative staging computed tomography (CT) scans were analyzed for midline involvement of the primary laryngeal cancer. As a result, a classification scheme has been established (type A: clear, type B: involved, type C: exceeded, and type D: bilateral/origin side indeterminable).

RESULTS

Contralateral lymph node metastases (pN2c necks) were found in six cases (10.3%), from which four were diagnosed with type D (23.5% of type D cases), and one each with type B and type C midline involvement. In cases with no midline involvement (type A), a risk ratio reduction of 100% was seen. CT-based midline typing resulted in fourfold increased sensitivity for predicting contralateral metastases compared to conventional staging. Positive nodal status (pN+) significantly reduced overall and disease-free survival (HR 2.706, p < 0.05).

CONCLUSIONS

As a consequence, for type A category, a contralateral neck dissection might be avoidable accompanied by a reduction in surgical complications and operating time.

AHNS Series - Do you know your guidelines? Principles of treatment for glottic cancer: A review of the National Comprehensive Cancer Network guidelines

This article is a continuation of the "Do You Know Your Guidelines" series, an initiative of the American Head and Neck Society's Education Committee to increase awareness of current best practices pertaining to head and neck cancer. The National Comprehensive Cancer Network (NCCN) guidelines for primary and adjuvant treatment of cancer of the glottic larynx are reviewed here in a systematic fashion according to stage.

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.

Carbon Dioxide Laser Microsurgery for Early Glottic Carcinoma

OBJECTIVES: To define the oncologic efficacy of transoral endoscopic CO2 laser surgery in early glottic carcinoma.

METHODS: A retrospective study of 103 patients with glottic carcinoma (14 Tis, 68 pT1a, 14 pT1b, and 7 pT2) treated from October 1993 to June 2001. Surgical treatment included endoscopic CO2 laser cordectomies according to the classification of the European Laryngological Society.

RESULTS: According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery alone was 100% for the Tis, 96.05% for the T1, and 100% for the T2. Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03%. The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100%. Laryngeal preservation was achieved in 100% of the cases.

CONCLUSIONS: According to the present series, endoscopic CO2 laser surgery is an effective treatment for early glottic cancer.

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.

Primary surgical treatment of T3 glottic carcinoma: long-term results and decision-making aspects

OBJECTIVES/HYPOTHESIS

The aim of this study was to assess the efficacy of primary surgical treatment in the management of T3 glottic carcinomas.

STUDY DESIGN

Retrospective clinical study.

METHODS

A retrospective evaluation of the records for all patients treated with primary surgery for T3 glottic carcinomas at a tertiary referral center between 1980 and 2005 was carried out. Data for the 5-year disease-specific survival (DSS) were assessed, as well as local control rates in relation to vocal cord immobility, N classification, choice of surgical modality, and adjuvant therapy. Patients who underwent partial laryngectomy were also evaluated in relation to organ preservation and the rate of permanent tracheotomies.

RESULTS

The 5-year DSS in the 120 patients was 78.3%. Positive neck disease was shown to be a significant negative prognostic factor. Organ preservation was achieved in 90.1% of the patients who underwent partial laryngectomy and in 50% of the overall patient group. The occult metastasis rate was 14%.

CONCLUSIONS

Primary surgical treatment is an effective modality against T3 glottic carcinomas. Partial laryngectomy is a reliable method in carefully selected cases. Low complication rates can be expected.

Diversity of treatment of T2N0 glottic cancer of the larynx: lessons to learn from epidemiological cancer registry data

CONCLUSION

Neither elective selective neck dissection nor any conservative treatment option in pT2cN0 glottic cancer showed a significant advantage on survival. This should be the basis for future treatment standardization. Obligatory documentation of the R status and cause of death in the cancer registries will improve the data interpretation in the future.

OBJECTIVES

Optimal adjuvant treatment of pT2cN0 glottic cancer is not well defined. The impact of neck dissection or radio(chemo)therapy for better outcome is unknown.

METHODS

In a retrospective cancer registry study we analyzed the survival of 73 patients with pT2cN0 glottic cancer in Thuringia, Germany, treated surgically between 1996 and 2005.

RESULTS

In all, 35 patients had undergone elective neck dissection, the remaining 38 patients had not. Histopathology revealed occult lymph node metastasis in three patients. Adjuvant radiotherapy was delivered to 17 patients and radiochemotherapy to 4. Overall, 52 patients received an adjuvant treatment. The 5-year recurrence-free survival rate was 60.8% and the 5-year overall survival rate was 56.5%. Multivariate but not univariate analysis revealed age >62 years (p = 0.05) and neck dissection (p = 0.033) as significant negative risk factors for tumor recurrence. Looking at overall survival, the site of primary surgery and radiotherapy were significant univariate risk factors, whereas multivariate analysis did not reveal any independent risk factor. No adjuvant treatment or combinations of adjuvant treatment resulted in better recurrence-free or overall survival (p = 0.253; p = 0.279).

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.

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.

What the clinician wants to know: surgical perspective and ultrasound for lymph node imaging of the neck

Imaging of lymph node metastases in the neck can have two major indications: (1) prognosis and assisting with choice of treatment; (2) staging and detection of clinically occult metastases in different levels of the neck. Both indications are discussed. The role and limitations of US and US-guided fine-needle aspiration cytology are also reviewed.

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.

[Selective neck dissection in the treatment of pN1/2 lymph node metastases in the neck]

INTRODUCTION

As yet there is no single reliable and accurate method for detection of neck lymph node metastases. Therapeutic approaches differ from one author to other. The aim of this paper was to establish the extent to which, with good control of primary process, we can control spreading of malignant disease by means of selective neck dissection.

MATERIAL AND METHOD

This retrospective study included 595 surgically treated patients in the period 1990-1998. There were 525 patients with malignant laryngeal tumors, and 70 patients with malignant hypopharyngeal tumors. Preoperative diagnostics of enlarged lymph nodes was based on palpation of the neck, without CT, US, NMR diagnostics. With all risky N0 patients, selective neck dissection was performed for presence of occult metastases. Intraoperative frozen section analysis was not performed. Adjuvant radiatitherapy was performed in all patients in whom presence of neck lymph node metastases was histologically proved.

RESULTS

Selective lateral neck dissection was performed in 389 (65.4%) patients. In 78 (20%) patients, lymph node metastases were pathohistologically detected. In 5 (6.4%) transitional cellular cancer was histologically diagnosed, and the remaining 73 (93.6%) presented with squamous cell cancer. Postoperative radiation therapy was applied in 54 patients (69.2%) while 24 (30.8%) were not irradiated. 5-year survival was achieved in 18 (23.1%), and 3-year survival was achieved in 15 (19.2%) patients. Out of 45 patients who lived less than tree year, 18 (40%) presented with metastatic relapse and fatal outcome. Relapse of neck metastases appeared in 12 (11.9%) on the side and in the zones of lymph nodes which were included in neck dissection. Recurrence of neck metastases appeared in 8.3% of patients who were not irradiated postoperatively and in 32.1% of cases irradiated postoperatively.

DISCUSSION

This study includes comparison of our results with results of literature data.

CONCLUSION

Neck lymph node metastases point to advanced malignant process of the third or forth stage of the disease when results are the worst and 5-year survival decreases with or without adjuvant radiotherapy.

Management of T3 N0 and T4 N0 glottic carcinomas: results of a national survey

OBJECTIVE

A survey was undertaken to document the clinical management of T3 and T4 pure glottic primary carcinomas and the management of the N0 neck by otolaryngologists and radiation oncologists.

STUDY DESIGN AND SETTING

This study represents the results of a national survey of 250 otolaryngologists and 250 radiation oncologists regarding management of T3 N0 M0 and T4 N0 M0 glottic carcinomas.

RESULTS

Of the surveys sent, 208 completed questionnaires were received. Results of this survey suggest that 87% and 90% will treat the neck for a T3 N0 M0 and T4 N0 M0 glottic tumor, respectively, with a large number choosing to perform a radical neck dissection.

CONCLUSIONS

A significant percentage of otolaryngologists perform neck dissections in the management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. Given the relatively low risk of occult metastasis, potentially high morbidity associated with overtreatment, and the lack of a well-designed outcome study investigating treatment alternatives, a prospective randomized study is needed to address the issue.