Elective Paratracheal Lymph Node Dissection in Salvage Laryngectomy

Occult neck metastasis in salvage laryngectomy: a road map for super-selective neck dissection

OBJECTIVE

This study aimed to solve the debate over the role and extent of neck dissection to treat any occult nodal metastasis in patients undergoing salvage laryngectomy for recurrent and/or residual squamous cell carcinoma of larynx.

METHODS

This was a retrospective study over a time frame of 6 years (2016-2022) of 74 patients who underwent bilateral neck dissection and salvage laryngectomy for recurrent or persistent disease with N0 neck. We calculated the incidence of occult nodal metastasis in ipsilateral and contralateral neck.

RESULTS

Incidence of ipsilateral neck disease was calculated as 8.11 per cent and it was 0 per cent in contralateral neck. Regarding ipsilateral nodal level distribution, level II was the highest at 6.76 per cent, followed by level III at 5.41 per cent. There was 0 per cent metastasis in levels IV and IIb.

CONCLUSION

In patients undergoing salvage laryngectomy with N0 neck, ipsilateral super selective neck dissection is considered a convenient and oncologically safe option to treat the neck.

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.

Elective Neck Dissection in Patients Undergoing Salvage Laryngectomy: Outcomes, Complications, and Considerations

Objective In this study, we sought to identify the predictors for occult nodal disease (OND) and compare oncologic outcomes in patients undergoing elective neck dissection (END) at the time of salvage laryngectomy (SLE) versus the observation group. Methods A retrospective chart review was conducted involving all patients with clinically node-negative (cN0) necks who underwent SLE at a tertiary academic center over 12 years. A total of 58 patients met the inclusion criteria and were divided into two groups: END (n=39) and observation (n=19). Primary endpoints were OND, regional recurrence-free survival (RRFS), and disease-specific survival (DSS). Univariate analysis was performed to establish the association between variables with Fisher's exact test and Mann-Whitney U test. Survival analysis was performed with the log-rank test. Results The cohort comprised 46 (79.3%) males and 12 (20.7%) females, with a mean age of 60 years. Pathological nodal disease was identified in five of 71 (7%) examined neck dissection specimens, with positive nodes found in levels II through IV. The only statistically significant predictor of OND was the rT3/rT4 stage (p=0.017). There were no differences in perioperative complications, RRFS (p=0.216), or DSS (p=0.298) between the END and observation groups. Conclusions In cN0 necks, the advanced recurrent T-stage (rT3-rT4) is a predictor for OND. As OND was found involving levels II, III, and IV in this study's specimens, formal lateral neck dissection should be the procedure of choice if END is to be performed alongside SLE. While END did not show a significantly higher morbidity profile versus conservative management in this cohort, the procedure did not improve loco-regional control or survival, even when stratifying by tumor stage.

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Extent of thyroidectomy and paratracheal lymph node dissection in total pharyngolaryngectomy for pyriform sinus cancer, and recurrence, survival, and postoperative hypoparathyroidism: A multicenter retrospective study

BACKGROUND

Total pharyngolaryngectomy (TPL) is standard treatment for hypopharyngeal cancer. However, extensive thyroidectomy and paratracheal nodal dissection (PTND) can cause hypoparathyroidism. We sought to determine the optimum extent of resection.

METHODS

We analyzed the clinicopathological information of 161 pyriform sinus cancer patients undergoing TPL from 25 Japanese institutions. Rates of recurrence and risk factors for hypoparathyroidism, as well as incidence of pathological contralateral level VI nodal metastasis and stomal recurrence, were investigated.

RESULTS

The extent of thyroidectomy and nodal dissection were not independent risk factors for recurrence. Incidences of contralateral level VI nodal involvement and stomal recurrence were 1.8% and 1.2%, respectively. Patients undergoing hemithyroidectomy/ipsilateral PTND did not develop stomal recurrence and had the lowest incidence of hypoparathyroidism. Prognosis in patients without tracheostomy prior to hemithyroidectomy/ipsilateral PTND was comparable to that with more extensive resections.

CONCLUSIONS

Hemithyroidectomy/ipsilateral PTND may be sufficient for pyriform sinus cancer cases without tracheostomy.

Peristomal recurrence following primary total laryngectomy: the enigma of the central compartment neck lymph nodes

PURPOSE OF REVIEW

The practice of primary total laryngectomy (TL) for advanced laryngo-hypopharyngeal cancer has significantly declined in the developed countries. The treatment options most frequently adopted have changed from open surgery to transoral laser or robotic approaches or nonsurgical (bio-chemo-) radiotherapy. Primary TL remains the treatment of choice in the developing world where healthcare resources are limited, especially for the treatment of cancer.

RECENT FINDINGS

Peristomal recurrence (PSR) is quite a serious complication, with an incidence of 6.6% from the published literature (mainly concerning the developed world), most diagnosed within 2 years, and associated with >80% mortality. The major risk factors include pretreatment tracheostomy, specific primary tumor subsites, positive surgical margins, and presence of nodal metastasis. The treatment options are limited and most success has been observed with surgery, especially when PSR is diagnosed at an early-stage, which is uncommon. Treatment of advanced-stage disease is usually palliative. Reduction and/or prevention of the known risk factors for PSR remain the goal when performing TL. In particular, central compartment (para- and pretracheal) lymph nodes dissection in case of large tumors with extra-laryngeal and/or subglottic extension or pretreatment tracheotomy plays a paramount role in PSR prevention.

SUMMARY

Research is required to conclude the formulation of guidelines for proper dissection of the central compartment (level VI) lymph nodes as indicated either prophylactically or therapeutically during TL for preventing PSR.

Central Compartment Neck Dissection in Laryngeal and Hypopharyngeal Squamous Cell Carcinoma: Clinical Considerations

Metastatic lymph node involvement represents the most relevant prognostic factor in head and neck squamous cell carcinomas (HNSCCs), invariably affecting overall survival, disease-specific survival, and relapse-free survival. Among HNSCCs, laryngeal and hypopharyngeal cancers are known to be at highest risk to metastasize to the central neck compartment (CNC). However, prevalence and prognostic implications related to the CNC involvement are not well defined yet, and controversies still exist regarding the occult metastasis rate. Guidelines for the management of CNC in laryngeal and hypopharyngeal cancers are vague, resulting in highly variable selection criteria for the central neck dissection among different surgeons and institutions. With this review, the authors intend to reappraise the existing data related to the involvement of CNC in laryngeal and hypopharyngeal malignancies, in the attempt to define the principles of management while highlighting the debated aspects that are lacking in evidence and consensus. Furthermore, as definition and boundaries of the CNC have changed over the years, an up-to-date anatomical-surgical description of the CNC is provided.

Paratracheal lymph node dissection during total (pharyngo-)laryngectomy: A systematic review and meta-analysis

OBJECTIVES

The objective of this review was to determine the rate and risk factors of paratracheal lymph node (PTLN) involvement during total laryngectomy (TL) or total pharyngolaryngectomy (TPL). In addition, we aimed to assess its prognostic significance in terms of survival and peristomal recurrence.

METHODS

A comprehensive electronic search was performed on PubMed, EMBASE, and CENTRAL databases. We searched for studies reporting outcomes of PTLN dissection during radical laryngeal surgery for squamous cell carcinoma of the larynx, hypopharynx or cervical oesophagus.

RESULTS

We included a total of ten studies (838 patients). The overall rate of PTLN dissection positivity was 18.6% (20.7% for primary TL, 8.7% for salvage TL). Random-effects meta-analysis identified T4 stage, N+ stage of the lateral neck, subglottis involvement and primary tumour arising from the hypopharynx or cervical oesophagus as significant risk factors for PTLN involvement.

CONCLUSIONS

This meta-analysis allowed to better define the risk of PTLN involvement during TL or TPL, in a bid to guide indication for PTLN dissection. There is a need for further large studies reporting rigorously the outcomes of PTLN dissection in order to establish stronger evidence-based recommendations.

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.

Twenty-year experience with salvage total laryngectomy: lessons learned

OBJECTIVE

The purpose of this study was to evaluate the outcome of salvage total laryngectomy and identify areas for further improvement.

METHOD

A retrospective analysis of all patients who underwent salvage total laryngectomy between January 1999 and December 2018 was performed.

RESULTS

Thirty-one patients were identified. The most common primary tumour site was the glottis (83.8 per cent). Early stage (T1-T2) disease was identified in 83.9 per cent of cases. Overall survival at 2 and 5 years post-salvage total laryngectomy was 71 per cent and 45 per cent, respectively. Disease-free survival at 2 and 5 years post-salvage total laryngectomy was 65 per cent and 42 per cent, respectively. The rate of post-salvage total laryngectomy pharyngocutaneous fistula was 29 per cent.

CONCLUSION

More than half of patients will not survive beyond five years after salvage total laryngectomy. Regional recurrence was the most common form of failure and death. From this study, elective lateral and central neck dissection is advocated in patients with early laryngeal cancer who present with an advanced recurrence.

Systematic review of incidence, risk factors, prevention and treatment of post-laryngectomy hypoparathyroidism

Purpose

Post-laryngectomy hypoparathyroidism is associated with significant short- and long-term morbidities. This systematic review aimed to determine incidence, risk factors, prevention and treatment of post-laryngectomy hypoparathyroidism.

Methods

Medline, EMBASE and the Cochrane library were searched for relevant articles on hypocalcaemia and/or hypoparathyroidism after laryngectomy or pharyngectomy. Two authors independently screened titles and abstracts from the search. Data from individual studies were collated and presented (without meta-analysis). Quality assessment of included studies was undertaken. The review protocol was registered in the PROSPERO database (CRD42019133879).

Results

Twenty-three observational studies were included. The rates of transient and long-term hypoparathyroidism following laryngectomy with concomitant hemi- or total thyroidectomy ranged from 5.6 to 57.1% (n = 13 studies) and 0 to 12.8% (n = 5 studies), respectively. Higher transient (62.1–100%) and long-term (12.5–91.6%) rates were reported in patients who had concomitant oesophagectomy and total thyroidectomy (n = 4 studies). Other risk factors included bilateral selective lateral neck dissection, salvage laryngectomy and total pharyngectomy. There is a lack of data on prevention and management.

Conclusion

Hypoparathyroidism occurs in a significant number of patients after laryngectomy. Patients who underwent laryngectomy with concomitant hemithyroidectomy may still develop hypoparathyroidism. Research on prevention and treatment is lacking and needs to be encouraged.