The role of elective neck dissection during salvage surgery in head and neck squamous cell carcinoma

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.

Oncologic Outcomes After Clinically Node-Negative Salvage Laryngectomy

Importance

Controversy exists regarding management of the clinically node-negative neck in patients with recurrent larynx or hypopharynx cancers who received total laryngectomy after definitive radiation with or without chemotherapy.

Objective

To explore clinical and oncologic outcomes after elective neck dissection vs observation in patients who received clinically node-negative salvage total laryngectomy.

Design, Setting, and Participants

This cohort study was performed from January 2009 to June 2021 at a single, high-volume tertiary care center. Follow-up was conducted through June 2021 for all patients. Survival outcomes were based on at least 2 years of follow-up. Patients aged 18 years or older with recurrent, clinically node-negative larynx or hypopharynx tumors after definitive nonsurgical treatment who were treated with a salvage total laryngectomy were included. Data were analyzed from October 2021 through September 2022.

Exposures

Elective neck dissection.

Main Outcomes and Measures

Presence and location of occult nodal metastasis in electively dissected necks, along with differences in fistula rates and overall and disease-free survival between patients receiving elective neck dissection vs observation.

Results

Among 107 patients receiving clinically node-negative salvage total laryngectomy (median [IQR] age, 65.0 [57.8-71.3] years; 91 [85.0%] men), 81 patients underwent elective neck dissection (75.7%) and 26 patients underwent observation (24.3%). Among patients with elective neck dissection, 13 patients had occult nodal positivity (16.0%). Recurrent supraglottic (4 of 20 patients [20.0%]) or advanced T classification (ie, T3-T4; 12 of 61 patients [19.7%]) had an occult nodal positivity rate of 20% or more, and positive nodes were most likely to occur in levels II and III (II: 6 of 67 patients [9.0%]; III: 6 of 65 patients [9.2%]; VI: 3 of 44 patients [6.8%]; IV: 3 of 62 patients [4.8%]; V: 0 of 4 patients; I: 0 of 18 patients). There was a large difference in fistula rate between elective neck dissection (12 patients [14.8%]) and observed (8 patients [30.8%]) groups (difference, 16.0 percentage points; 95% CI, -3.4 to 35.3 percentage points), while the difference in fistula rate was negligible between 50 patients undergoing regional or free flap reconstruction (10 patients [20.0%]) vs 57 patients undergoing primary closure (10 patients [17.5%]) (difference, 2.5 percentage points; 95% CI, -12.4 to 17.3 percentage points). Undergoing elective neck dissection was not associated with a clinically meaningful improvement in overall or disease-free survival compared with observation. Recurrent hypopharynx subsite was associated with an increased risk of death (hazard ratio, 4.28; 95% CI, 1.81 to 10.09) and distant recurrence (hazard ratio, 7.94; 95% CI, 2.07 to 30.48) compared with glottic subsite.

Conclusions and Relevance

In this cohort study, patients with recurrent supraglottic or advanced T classification tumors had an increased occult nodal positivity rate, elective neck dissection was not associated with survival, and patients with recurrent hypopharynx subsite were more likely to have a distant recurrence and die of their disease. These findings suggest that underlying disease pathology rather than surgical management may be associated with survival outcomes in this population.

Proposal for an algorithm to avoid neck dissection during salvage total laryngectomy. A GETTEC multicentric study

OBJECTIVES

To identify the factors related to the presence of occult metastases before salvage total laryngectomy (STL) in rcN0 patients and to propose an algorithm to identify patients who do not require neck dissection (ND).

PATIENTS AND METHODS

This multicentric retrospective study included five centers with recruitment from 2008 to 2018. Inclusion criteria were: i) having been treated for laryngeal squamous cell carcinoma in first intention by radiotherapy (either alone or potentiated or preceded by induction chemotherapy), ii) having received STL with or without ND, iii) having an rcN0 neck at the time of STL.

RESULTS

120 patients met the inclusion criteria. The overall rate of occult metastases was 9.1 %. The rate was significantly higher in patients with an initial positive cN+ lymph node status (p < 0.005) and in advanced stages with rcT3-T4 lesions at recurrence (p < 0.005). Patients with occult metastases recurred earlier than those without (p = 0.002). The overall survival of patients was the same with or without ND (p = 0.16). There were significantly more healing complications requiring revision surgery in the group with ND than in the group without (p = 0.048).

CONCLUSION

ND does not confer a net survival benefit and is associated with significant complications. Patients without initial lymph node metastases who are rcT1-T2 at recurrence or rcT3-T4 with a recurrence period of more than 12 months could benefit from STL without ND. This decisional algorithm, which needs to be validated, would help avoid 58 % of ND procedures and their proven morbidity.

DISCIPLINE

Head and neck surgery.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Elective neck dissection during salvage surgery after radiotherapy in patients with head and neck squamous cell carcinoma

SUMMARY

Elective neck dissection in patients with recurrent head and neck squamous cell carcinoma (HNSCC) without evidence of neck disease (crN0) is poorly defined. A retrospective review was carried out on 165 crN0 patients treated with salvage surgery and elective neck dissection. Multivariate Cox analysis and recursive partitioning analysis were used to evaluate prognostic factors. The frequency of occult neck node metastases in the neck dissection (rpN+) was 16.4%. The risk of occult metastases for glottic rpT1-T2 recurrences was 5.9%, for glottic rpT3-T4 recurrences 13.2%, for non-glottic rpT1-T2 recurrences 16.1% and for locally advanced (rpT3-T4) non-glottic recurrences 31.1%. Patients with occult neck node metastases (rpN+) had a 5-year adjusted survival rate of 38.1%, while patients without nodal disease (rpN0) had a 5-year adjusted survival rate of 71.1% (p = 0.0001). Elective neck dissection can be omitted in crN0 patients with rT1-T2 glottic recurrence. We consider it advisable to perform elective neck dissection in all other situations.

Complications and oncologic outcomes following elective neck dissection with salvage laryngectomy for the N0 neck

PURPOSE

To investigate the difference in survival and complication outcomes between patients with a clinically and radiologically N0 neck who received an elective neck dissection at the time of salvage total laryngectomy compared to those who had salvage total laryngectomy alone.

MATERIALS AND METHODS

A retrospective chart review was performed on 125 salvage total laryngectomy patients who were clinically and radiologically N0 preoperatively. Performance of an elective neck dissection and other factors were tested for associations with various postoperative complications, disease-free survival, and overall survival.

RESULTS

Ninety-eight patients underwent elective neck dissection, of which ten had positive nodal pathology. Elective neck dissection was not significantly associated with complications or survival outcomes. Positive nodal disease was associated with worse disease-free and overall survival on multivariate analysis.

CONCLUSIONS

In patients with clinically and radiologically N0 necks undergoing salvage total laryngectomy, an elective neck dissection can provide prognostic information but does not appear to be significantly associated with increased complications or improved survival.

Success of salvage treatment: a critical appraisal of salvage rates for different subsites of HNSCC

OBJECTIVE

Despite advances in interdisciplinary treatment protocols, the chance of cure for recurrent head and neck squamous cell carcinoma (HNSCC) following failed primary therapy is poor and often entails a high morbidity. Recurrence rates vary widely in the literature depending on tumor localization, primary tumor stage, and treatment modality, and only a minority of patients can be salvaged.

STUDY DESIGN

Historical cohort study.

SETTING

This study valuates the outcomes of patients treated for recurrent squamous cell carcinoma of the larynx, pharynx, and oral cavity in the largest tertiary referral center of Switzerland to find predictors for survival in salvage surgery with curative intent.

SUBJECTS AND METHODS

Included were 176 consecutive patients with recurrent disease after primary curative treatment of HNSCC, in locations mentioned previously. Kaplan-Meier survival analyses with log-rank testing were performed depending on T and N stage, gender, treatment, and location of first relapse to evaluate the impact on overall survival, disease specific survival, and recurrence free survival.

RESULTS

Overall successful salvage rates were 49.2% for laryngeal recurrence, 35.1% for oral cavity, 32.7% for oropharyngeal, and a mere 17.4% for hypopharyngeal recurrences. Predictive factors for better outcome were location of recurrence, female gender, lymph node status, and extent of salvage treatment.

CONCLUSION

In case of recurrent disease, laryngeal cancers showed the best salvage rates, whereas in hypopharyngeal relapses, very few patients could be successfully salvaged. Patients therefore should be carefully selected and counseled for salvage treatment according to patient motivation, age, type of previous treatment, surgical resectability, and exclusion of distant recurrence.

Recurrent and second primary squamous cell carcinoma of the head and neck: when and how to reirradiate

BACKGROUND

Local and/or regional recurrence and metachronous primary tumor arising in a previously irradiated area are rather frequent events in patients with head and neck squamous cell carcinoma (HNSCC). Re-treatment is associated with an increased risk of serious toxicity and impaired quality of life (QOL) with an uncertain survival advantage.

METHODS

We analyzed the literature on the efficacy and toxicity of photon/electron-based external beam reirradiation for previously irradiated patients with HNSCC of non-nasopharyngeal origin. Studies were grouped according to the radiotherapy technique used for reirradiation. Patient selection criteria, target volume identification method, tumor dose, fractionation schedule, systemic therapy administration, and toxicities were reviewed.

RESULTS

In addition to disease-related factors, current comorbidities and preexisting organ dysfunction must be considered when selecting patients for reirradiation. As morbidity from re-treatment may be considerable and differ depending on which mode of re-treatment is used, it is important to give patients information on potential morbidity outcomes so that an informed choice can be made within a shared decision-making context. With improved dose distribution and adequate imaging support, including positron emission tomography-CT, modern radiotherapy techniques may improve local control and reduce toxicity of reirradiation. A reirradiation dose of ≥60 Gy and a volume encompassing the gross tumor with up to a 5-mm margin are recommended. Concomitant administration of systemic therapeutics and reirradiation is likely to be of similar benefit as observed in large randomized studies of upfront therapy.

CONCLUSION

Reirradiation, administered either with or without concurrent systemic therapy, is feasible and tolerable in properly selected patients with recurrent or a new primary tumor in a previously irradiated area of the head and neck, offering a meaningful survival (in the range of 10% to 30% at 2 years). Whenever feasible, salvage surgery is the method of choice for curative intent; patients at high-risk for local recurrence should be advised that postoperative reirradiation is expected to increase locoregional control at the expense of higher toxicity and without survival advantage compared to salvage surgery without reirradiation. © 2014 Wiley Periodicals, Inc. Head Neck 37: 134-150, 2015.