Involvement of level I neck lymph nodes in advanced squamous carcinoma of the larynx

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

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

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.

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 diagnosis and treatment of oral cavity cancer

BACKGROUND

About 10,000 persons are diagnosed as having carcinoma of the oral cavity or the throat in Germany every year. Squamous-cell carcinoma accounts for 95% of cases.

METHODS

We systematically reviewed the pertinent literature on predefined key questions about these tumors (which were agreed upon by a consensus of the investigators), concerning imaging, the removal of cervical lymph nodes, and resection of the primary tumor.

RESULTS

246 clinical trials were selected for review on the basis of 3014 abstracts. There was only one randomized, controlled trial (evidence level 1-); the remaining trials reached evidence levels 2++ to 3. Patients with mucosal changes of an unclear nature persisting for more than two weeks should be examined by a specialist without delay. The diagnosis is made by computed tomography or magnetic resonance imaging along with biopsy and a standardized histopathological examination. Occult metastases are present in 20% to 40% of cases. Advanced disease (stages T3 and T4) should be treated by surgery followed by radiotherapy, with or without chemotherapy. 20% of the patients overall go on to have a recurrence, usually within 2 to 3 years of the initial treatment. The 5-year survival rate is somewhat above 50%. Depending on the radicality of surgery and radiotherapy, there may be functional deficits, osteoradionecrosis, and xerostomia. The rate of loss of implants in irradiated bone is about 10% in 3 years.

CONCLUSION

The interdisciplinary planning and implementation of treatment, based on the patient's individual constellation of findings and personal wishes, are prerequisites for therapeutic success. Reconstructive measures, particularly microsurgical ones, have proven their usefulness and are an established component of surgical treatment.

Relevance of level I and IIB neck dissection in laryngeal cancer

OBJECTIVES

Dissection of neck levels I and IIB is time-consuming and can cause comorbidity. This study aimed to determine whether level I and IIB neck dissection was necessary in patients with laryngeal cancer and clinically detectable or nondetectable neck nodes.

PATIENTS AND METHODS

This was a retrospective review of 73 patients with laryngeal cancer. Essential clinical data were obtained and analysed to determine the incidence of neck node metastasis in levels I and IIB.

RESULTS

Of the 48 patients with no clinically apparent neck nodes, none had level I metastases and only one had level IIB metastases. Of the patients with clinically detectable neck nodes, three of 21 patients had level I metastases and three of 25 patients had level IIB metastases; these six patients also had additional metastases in level IIA.

CONCLUSION

Dissection of neck levels I and IIB is justifiable in laryngeal cancer patients with clinically detectable neck nodes and suspicious lymph nodes in the respective level or level IIA. However, in patients without clinically detectable neck nodes, preservation of levels I and IIB is oncologically safe, economical and reduces the risk of comorbidity.

Guidelines for delineation of lymphatic clinical target volumes for high conformal radiotherapy: head and neck region

The success of radiotherapy depends on the accurate delineation of the clinical target volume. The delineation of the lymph node regions has most impact, especially for tumors in the head and neck region. The purpose of this article was the development an atlas for the delineation of the clinical target volume for patients, who should receive radiotherapy for a tumor of the head and neck region. Literature was reviewed for localisations of the adjacent lymph node regions and their lymph drain in dependence of the tumor entity. On this basis the lymph node regions were contoured on transversal CT slices. The probability for involvement was reviewed and a recommendation for the delineation of the CTV was generated.

Management of the N0 neck in moderately advanced squamous carcinoma of the larynx

OBJECTIVE

To assess the oncological efficacy of selective neck dissection (SND) in patients with T3-4 N0 laryngeal squamous carcinoma.

SUBJECTS AND METHODS

A total of 327 patients underwent 654 neck dissections; each side of the neck was individually evaluated.

RESULTS

Three percent of patients who had SND developed regional recurrence (RR) in comparison with 11.7 percent of patients who underwent modified radical neck dissection (MRND) (P=0.005). Only 3 (0.9%) patients developed RR outside the field of SND. The presence of extracapsular extension (P=0.002) in node-positive (pN+) group and of microvascular invasion (P=0.007), together with the type of neck dissection (ND) (P=0.0003) in node-negative (pN0) group had statistical impact on RR. The development of RR significantly affected disease-specific survival (P=0.0001). Equivalent rates of RR were found in pN+ (2.6%) or pN0 (3.2%) patients treated with SND (P=0.98) as well as in pN+ patients who underwent SND (2.6%) or MRND (4.7%) (P=0.85).

CONCLUSION

This study confirmed the adequacy of SND as a satisfactory staging and therapeutic procedure, and suggests its use in the treatment of limited node-positive (N+) neck.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Management of cervical metastasis

Cervical metastasis from head and neck cancer is a common occurrence. Despite improvements in diagnostic modalities and treatment options, survival in this group of patients has not changed appreciably over the past few decades. Cervical metastasis portends a poor prognosis and also presents a diagnostic and treatment dilemma for the head and neck oncologist. This article reviews the current state of the art in the diagnosis and treatment of this difficult group of patients and the literature on the topic.

Neck dissection: current concepts and future directions

For individuals diagnosed with head and neck cancer, neck dissection may be performed for therapy or disease staging. The classification of neck dissection and the definition of precise anatomic landmarks have allowed for this operation, and its many variations, to become standardized world-wide. SLNBX shows promise in its ability to accurately stage NO head and neck cancer and may allow patients with no micro metastatic disease to avoid neck dissection. Before this technique becomes adopted into routine clinical practice, however, it must first be prospectively scrutinized in large patient populations. Regardless of the future role of SLNBX in the management of head and neck cancer, currently it is only through a complete understanding of the clinical, theoretic, and technical aspects of neck dis-section that surgeons may benefit individual patients and the head and neck cancer patient population as a whole.

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.