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

Oncological Feasibility of Limited Neck Dissection in cN0 Supraglottic Laryngeal Cancer

BACKGROUND

Supraglottic squamous cell carcinoma (SCC) is a significant portion of head and neck cancers, with the management of clinically negative necks (cN0) through selective neck dissection (SND) being debated due to potential morbidities and low metastasis rates in levels IIb and IV.

METHODS

This study is a retrospective, multicenter examination of the potential feasibility of limited neck dissection (LND), including only levels IIa and III in cN0 supraglottic SCC patients. It analyzed occult metastasis rates and explored relapse occurrences alongside potential predictors of lymph node metastasis.

RESULTS

Among 425 patients, predominantly male (85.6%) with a mean age of 63 years, the occult metastasis rate was 28.9%, and 13.7% experienced relapses during a mean follow-up of 52 months. Advanced clinical stage, higher grading, and other risk factors emerged as predictors of occult lymph node metastasis at level IIb.

CONCLUSIONS

The study supports LND potential feasibility for cN0 supraglottic SCC, suggesting level IIb dissection can be omitted in specific early-stage cases to reduce morbidity without affecting outcomes.

Prevalence and risk factors of postoperative laryngeal edema in patients undergoing neck dissection

PURPOSE

Postoperative laryngeal edema (PLE) is a common complication in patients undergoing head and neck surgery, leading to symptoms such as odynophagia, dysphagia, or potential airway obstruction. However, the prevalence and risk factors of PLE in patients undergoing neck dissection (ND) have not been well investigated.

METHODS

A retrospective analysis was conducted in three steps. Initially, a pilot study of 50 consecutive ND patients revealed a preliminary PLE prevalence of 0.34. Then, the medical records of an additional 295 ND patients were reviewed to estimate the prevalence of PLE with a total width of 95% confidence interval (CI) of ± 5%. Finally, multivariable logistic regression analyses were performed to identify risk factors for PLE (n = 343).

RESULTS

PLE occurred in 29.4% [95%CI 24.4-34.4%] of patients undergoing any type of ND, with the most common symptoms of odynophagia (75.0%) and dyspnea (11.1%). Hospital stay was just one day longer in PLE patients, responding well with short-term steroid treatment (p = 0.0057). In multivariable analyses, no significant association was found between PLE occurrence and airway management. However, body mass index and the American Society of Anesthesiologists classification correlated with PLE. More importantly, surgery for oro-hypopharynx or supraglottis tumors (odds ratio, OR = 3.019, [95%CI 1.166-7.815]) and lymph node level 2(3) ND (OR = 4.214 to 5.279, [95%CI 1.160-20.529]) were significant risk factors for PLE.

CONCLUSIONS

PLE developed in approximately 30% of ND patients, causing uncomfortable symptoms. Early diagnosis and intervention of PLE in high-risk patients can improve patient care and outcomes.

Total Laryngectomy: A Review of Surgical Techniques

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.

Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

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.

FDG-PET/CT and Pathology in Newly Diagnosed Head and Neck Cancer: ACRIN 6685 Trial, FDG-PET/CT cN0

OBJECTIVE

FDG-PET/CT (fluorodeoxyglucose-positron emission tomography/computed tomography) is effective to assess for occult neck nodal disease. We report risks and patterns of nodal disease based on primary site and nodal level from data on the dissected cN0 per the results from ACRIN 6685.

STUDY DESIGN

Prospective nonrandomized enrollment included participants with first-time head and neck squamous cell carcinoma and at least 1 cN0 neck side to be dissected.

SETTING

Twenty-four ACRIN-certified centers internationally (American College of Radiology Imaging Network).

METHODS

A total of 287 participants were enrolled. Preoperative FDG-PET/CT findings were centrally reviewed and compared with pathology. Incidence, relative risk, pattern of lymph node involvement, and impact upon neck dissection were reported.

RESULTS

An overall 983 nodal levels were dissected (n = 261 necks, n = 203 participants). The highest percentages of ipsilateral positive nodes by primary location and nodal level were oral cavity (level I, 17/110, 15.5%), pharynx (level II, 6/30, 20.0%), and larynx (level VI, 1/3, 33.3%).

CONCLUSION

Levels at greatest risk for nodal disease in cN0 in terms of ipsilateral neck dissection are level I (oral cavity), II (pharynx), and VI (larynx). These data should be considered when treating patients presenting with cN0. This is the first study to comprehensively report the incidence, location, and risk of metastases in cN0 in the FDG-PET/CT era.

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.

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.

The Sensitivity of Preoperative Scanning in Regional Recurrence of Papillary Thyroid Cancer

BACKGROUND: The treatment of patients with regionally recurrent papillary carcinoma of the thyroid is a matter of controversy. Radioactive nodal picking was proposed as an alternative to neck dissection in these patients.

METHODS: We analyzed neck dissection specimens in 20 patients with PTC and compared the results to preoperative total-body scan (TBS) following a therapeutic dose of I131 and ultra-sonographic findings.

RESULTS: Eighteen patients underwent paratracheal neck dissection and 10 patients had a lateral neck dissection. Preoperative TBS detected the correct number of positive nodes in only 1 patient (5%) and the correct number of patients with positive nodes in 6/20 (30%) of the patients. US detected 32/98 positive nodes (36%) and 20/20 (100%) of the patients. Prediction of the number of positive nodes for both TBS and US was low (5% and 10%, respectively).

CONCLUSIONS: Preoperative TBS and/or US cannot satisfactorily predict metastatic lymph node involvement and cannot safely delineate limited surgery to replace formal neck dissection in patients with regionally recurrent PTC.

Reappraisal of metastatic lymph node topography in head and neck squamous cell carcinomas

Objective

To analyze the lymphatic distribution of metastatic carcinomatous cells in cervical lymph nodes in head and neck squamous cell carcinoma (HNSCC).

Study Design and Setting

We retrospectively reviewed 119 patients treated in our hospital for HNSCC (1999-2004). Topography of the neck dissection specimens was prospectively classified according to the classification of Robbins. The 4000 lymph nodes were analyzed by optical microscopy using hematoxylin-eosin-safran (HES) staining. In cases of negative results in level II, cytokeratin (AE1/AE3) immunodetection was performed.

Results

Metastases were visualized using HES in 6.4% of lymph nodes for oral cavity, and 4.7% of oropharyngeal, 4.4% of hypopharyngeal, and 1.3% of endolaryngeal cancers. The highest incidence of nodal metastasis was observed in level IIa ( P < 0.01). In eight patients (6.7%) with lymph node metastases, level II was spared. In these patients, all 134 nodes histologically negative on HES were confirmed to be negative by IHC.

Conclusions

Level IIa is the main level involved in regional metastases of HNSCC, regardless of the primary site of cancer. However, in eight (6.7%) patients, level II was spared, as confirmed by IHC. In these cases, level II did not represent the first step of drainage from the tumor. The sentinel lymph node technique in HNSCC is discussed in light of these results.

Is routine inclusion of level IV necessary in neck dissection for clinically N0 supraglottic carcinoma?

Objective

Elective level II to IV dissection has become a common practice for patients with N0 neck and supraglottic laryngeal carcinoma. Several authors have questioned the necessity of dissecting level IV and the possible risk of associated morbidities such as chyle leak and phrenic nerve injury.

Study Design and Setting

We reviewed 58 patients who underwent elective functional and lateral neck dissection for supraglottic carcinoma. Node levels were delineated just after the removal of the specimens. The patients were followed at least 3 years postoperatively or until the time of death; recurrence rates and levels were evaluated.

Results

Occult lymph node metastases were determined in 14 cases. Level II was the most involved zone (7 patients). Isolated level IV lymph node metastasis was not established.

Conclusion

We think that routine level IV dissection is not necessary in the management of clinically and radiologically N0 necks in patients with supraglottic laryngeal carcinoma.

Accuracy of microRNAs as markers for the detection of neck lymph node metastases in patients with head and neck squamous cell carcinoma

BACKGROUND

The presence of metastatic disease in cervical lymph nodes of head and neck squamous cell carcinoma (HNSCC) patients is a very important determinant in therapy choice and prognosis, with great impact in overall survival. Frequently, routine lymph node staging cannot detect occult metastases and the post-surgical histologic evaluation of resected lymph nodes is not sensitive in detecting small metastatic deposits. Molecular markers based on tissue-specific microRNA expression are alternative accurate diagnostic markers. Herein, we evaluated the feasibility of using the expression of microRNAs to detect metastatic cells in formalin-fixed paraffin-embedded (FFPE) lymph nodes and in fine-needle aspiration (FNA) biopsies of HNSCC patients.

METHODS

An initial screening compared the expression of 667 microRNAs in a discovery set comprised by metastatic and non-metastatic lymph nodes from HNSCC patients. The most differentially expressed microRNAs were validated by qRT-PCR in two independent cohorts: i) 48 FFPE lymph node samples, and ii) 113 FNA lymph node biopsies. The accuracy of the markers in identifying metastatic samples was assessed through the analysis of sensitivity, specificity, accuracy, negative predictive value, positive predictive value, and area under the curve values.

RESULTS

Seven microRNAs highly expressed in metastatic lymph nodes from the discovery set were validated in FFPE lymph node samples. MiR-203 and miR-205 identified all metastatic samples, regardless of the size of the metastatic deposit. Additionally, these markers also showed high accuracy when FNA samples were examined.

CONCLUSIONS

The high accuracy of miR-203 and miR-205 warrant these microRNAs as diagnostic markers of neck metastases in HNSCC. These can be evaluated in entire lymph nodes and in FNA biopsies collected at different time-points such as pre-treatment samples, intraoperative sentinel node biopsy, and during patient follow-up. These markers can be useful in a clinical setting in the management of HNSCC patients from initial disease staging and therapy planning to patient surveillance.

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.

[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%.

Efficacy of diagnostic upper-node procedures during laryngectomy for glottic carcinoma

BACKGROUND

Regional recurrence of glottic squamous cell carcinoma was evaluated in patients with a clinically N0 neck who underwent selective upper-node dissection (SUND) or selective upper-node inspection (SUNI; surgical visualization and palpation of jugular lymph nodes at levels II and III) during (salvage) laryngectomy.

METHODS

In 152 patients, 291 clinically N0 (139 bilateral and 13 contralateral) necks were evaluated for occult neck metastases by SUNI or SUND during (salvage) laryngectomy.

RESULTS

Occult neck metastases were identified with SUNI or SUND in 7% of the necks (21 of 291). In 4% (n = 11) of the remaining 270 necks, regional recurrence was detected during follow-up evaluation. Thus, in these 8 patients, SUNI or SUND seemed to have failed.

CONCLUSIONS

SUND or SUNI of levels II and III during (salvage) laryngectomy identified the vast majority of patients who needed extensive neck treatment. In the N0 necks, these techniques led to less morbidity than elective neck dissection.

Detection of occult carcinomatous diffusion in lymph nodes from head and neck squamous cell carcinoma using real-time RT-PCR detection of cytokeratin 19 mRNA

The aim of the present study was to evaluate the occult lymph node carcinomatous diffusion in head and neck squamous cell carcinoma (HNSCC). A total of 1328 lymph nodes from 31 patients treated between 2004 and 2005 were prospectively evaluated by routine haematoxylin–eosin–safran (HES) staining, immunohistochemistry (IHC) and real-time Taqman reverse–transcriptase polymerase chain reaction (real-time RT–PCR) assay. Amplification of cytokeratin 19 (CK19) mRNA transcripts using real-time RT–PCR was used to quantify cervical micrometastatic burden. The cervical lymph node metastatic rates determined by routine HES staining and real-time RT–PCR assay were 16.3 and 36.0%, respectively (P<0.0001). A potential change in the nodal status was observed in 13 (42.0%) of the 31 patients and an atypical pattern of lymphatic spread was identified in four patients (12.9%). Moreover, CK19 mRNA expression values in histologically positive lymph nodes were significantly higher than those observed in histologically negative lymph nodes (P<0.0001). These results indicate that real-time RT–PCR assay for the detection of CK19 mRNA is a sensitive and reliable method for the detection of carcinomatous cells in lymph nodes. This type of method could be used to reassess lymph node status according to occult lymphatic spread in patients with HNSCC.

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.

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.

Resection and replacement of the carotid artery in metastatic head and neck cancer: literature review and case report

Metastases of advanced tumours of the oral cavity sometimes affect the cervical segments of the carotid arteries. The situation is worse in the 5-10% of cases in which the metastasis involves the common or internal carotid to such an extent that resection and replacement of the artery become necessary. Following clinical, CT/NM, and angiographic examinations, a surgical plan for the resection and reconstruction of the affected vascular segment is formulated. In preparing a treatment plan, emphasis must be placed on the expected quality of life, and careful consideration must be given to the extent of the operation.A survey of the international literature reveals that the reported mean 1-year complaint free survival rate after resection and reconstruction varies between 0 and 44%. In our experience, the wall of the carotid vessels is very resistant to tumour invasion in a large majority of patients. When radical surgery and reconstruction are carried out in the same session, does this increase the long-term cure rate and lengthen patient survival? A number of authors agree that radical interventions do not alter the survival indices significantly, but may improve the quality of life and regional control of the disease. The controversy over this topic is illustrated by means of a case report.

Routine inclusion of level IV in neck dissection for squamous cell carcinoma of the larynx: Is it justified?

BACKGROUND

Dissection of levels II-IV as part of an elective or therapeutic neck dissection is common practice during laryngectomy for laryngeal squamous cell carcinoma (SCC). The necessity of routine dissection at level IV has recently been questioned. The purpose of this study was to find the incidence of level IV metastases in patients with transglottic and supraglottic SCC who underwent neck dissections.

METHODS

The charts of 71 suitable patients were reviewed. Forty-two had supraglottic primary cancers, and 29 had transglottic primary tumors. Levels II-IV had been removed in them all, and their neck specimens were marked according to the levels of the neck. The surgical specimens were pathologically diagnosed.

RESULTS

Of 43 patients who underwent elective lateral neck dissection, the only one (2.3%) with level IV metastases also showed metastases at level II. Nine (32%) of the other 28 patients with clinical adenopathy had level IV metastases.

CONCLUSIONS

Dissection of level IV as part of a therapeutic neck dissection for supraglottic and transglottic SCC is recommended for patients with clinically enlarged lymph nodes, but its necessity in the absence of detectable adenopathy is challenged.

Tratamiento del cuello no en el cáncer supraglótico

INTRODUCTION

Occult regional metastases in supraglottic cancer NO are the object of classical controversies. The aim of our study is to provide our experience in order to determine how neck treatment affects on regional recurrence of NO supraglottic cancer.

METHODS

A retrospective study of 246 patients with NO supraglottic cancer treated in our service between 1977 to 1999 is presented.

RESULTS

11.4% of patients did not have any cervical treatment, with a 23% of neck recurrence amongst the evolution. 66.7% of patients were treated with a modified radical neck dissection, 24% of these presented occult metastases in the histopathological study. Global regional recurrence was 2.9% in early stages (T1/T2) and 13.1% in advanced stages (T3/T4). In pN+ patients, 85% underwent postoperative radiotherapy, with a regional recurrence of 8.8%. Postoperative clinical control without any other treatment in pN0 patients showed a neck recurrence of 6.1%. We performed a unilateral neck dissection in those patients with clear-lateral tumours. In these cases the clinical control of the contralateral neck gave a 5.5% recurrencies on that side. Patients treated with elective primary radiotherapy suffered a 5.5% of regional recurrence.

DISCUSSION/CONCLUSIONS

Neck treatment of the NO supraglottic cancer is recommended. We treat neck in the same way of primary tumour (surgery or radiotherapy) with good control of regional recurrencies, less than 10%. In case of a negative pathological study of the neck careful, watching is the elective attitude. In the positive pathological study of the neck (pN+), radiotherapy is the elective treatment in those with three or more affected nodes or capsular breakdown in any of them.

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

BACKGROUND

The treatment of the neck in cancer of the upper aerodigestive tract is still a matter of controversy, even though nowadays there is a trend in the literature toward elective surgery in the N0 neck when the probability of occult lymph node metastasis is greater than 20%. In the elective setup, every effort is made for preservation of uninvolved nonlymphatic structures in positive neck. The aim of this study is to analyze in a large cohort of patients treated for supraglottic carcinoma the prevalence of lymph node metastases and their distribution through various neck levels to redefine our policy of neck treatment.

METHODS

A retrospective review of 402 consecutive patients, who underwent surgery in the Department of Otolaryngology of the University of Brescia (Italy) for supraglottic squamous cell carcinoma in a 14-year period, has been performed. The prevalence of neck metastases was assessed by pT category and site (marginal vs vestibular) of the primary tumor. The side(s) of neck disease was related to the side of the primary tumor, whether lateral or central. The distribution of involved lymph nodes through the neck levels was determined.

RESULTS

Overall lymph node metastases accounted for 40%; their prevalence rate increased with pT category from 10% to 57% (p =.0001). Occult metastases were found in 26% of N0 patients from 0% in pT1 to 40% in pT4 (p =.02). There was no difference in metastases rate between marginal vs vestibular, and central vs lateral neoplasms, whereas bilateral metastases were more frequent in central tumors (20% vs 5%; p <.0001). Level IV was involved only in association with level II and/or level III. Levels I and V were rarely involved when overt metastases were present and never by occult metastases.

CONCLUSIONS

Elective lateral neck dissection (levels II-IV) is recommended in T2-T4 N0 supraglottic cancers; clearance of both sides of the neck is indicated whenever the lesion is not strictly lateral. We still perform a selective neck dissection including levels II-V whenever there is clinical, radiologic, or intraoperative evidence of metastases at any level.

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.