Elective neck dissection during salvage total laryngectomy – a beneficial prognostic effect in locally advanced recurrent tumours

Hilly, Ohad; Gil, Ziv; Goldhaber, Danny; Amit, Moran; Biadsee, Ameen; Popovtzer, Aron; Shvero, Jacob; Cohen, Jacob T.; Fliss, Dan M.; Feinmesser, Raphael; Bachar, Gideon

doi:10.1111/coa.12309

Cited by 33 publications

(41 citation statements)

References 14 publications

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“…Of the four included studies with these data, only one of 14 patients with a regional recurrence after an observed neck had long‐term survival (5‐year OS = 7%) . Other included studies showed equivalent rates of regional recurrence between END and observed necks, or even greater rates in END patients, without report of their survival …”

Section: Discussionmentioning

confidence: 99%

Elective neck dissection during salvage laryngectomy: A systematic review and meta‐analysis

Gross

Vila

Simón³

et al. 2019

The Laryngoscope

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Objectives The primary objective was to determine the rate of occult cervical nodal metastasis in patients undergoing elective neck dissection (END) during salvage laryngectomy. The secondary objective was to compare survival and postoperative complication rates between patients undergoing END versus observation. Methods A medical librarian performed a comprehensive search for END outcomes in laryngeal cancer patients undergoing salvage laryngectomy after primary chemoradiation therapy. Seventeen retrospective studies and 1 prospective study met inclusion criteria, with a total of 1,141 patients (799 END, 350 observed). Results The rate of nodal positivity was 11% among patients who underwent END during their salvage laryngectomy. Three studies and 155 patients were included in a 5‐year overall survival (OS) analysis with no significant difference in OS (95% confidence interval [CI]: 0.82‐2.22). After inclusion of six studies and 494 patients (249 END, 245 observed), the risk of fistula formation was not statistically different (95% CI: 0.61‐2.56). Due to significant heterogeneity between studies and inadequate data, most patients could not be included in the meta‐analysis of outcomes. Conclusion Salvage laryngectomy patients undergoing END have an occult nodal positivity rate of 11%. Meta‐analysis showed no statistically significant differences in 5‐year OS between patients undergoing END versus observation. Laryngoscope, 130:899–906, 2020

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Section: Discussionmentioning

confidence: 99%

Elective neck dissection during salvage laryngectomy: A systematic review and meta‐analysis

Gross

Vila

Simón³

et al. 2019

The Laryngoscope

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“…They performed 42 ipsilateral NDs and 9 bilateral NDs and found no occult nodal metastases in the contralateral neck, similarly no contralateral neck disease was found in a recently published cohort . A total of 3 studies reported occult nodal metastases in hemidissected necks (unilateral and bilateral NDs), however, did not comment on whether they occurred in the contralateral neck. Pennings et al reported results based on patients who had lymph nodes at levels II and III visually and manually inspected intraoperatively; any suspicious lymph nodes were removed by selective upper node dissection, and if either inspection or dissection was positive for neck metastases a modified radical ND of levels I‐V was performed on the affected side .…”

Section: Discussionmentioning

confidence: 85%

“…In 3 studies, END appears to offer increased DFS over no ND, especially in the situation of late T classification at recurrence . However, there was no significant difference in pooled 5‐year DFS between those who received END and those who had no ND (OR = 0.76, CI = 0.49‐1.17, P = 0.21, I 2 = 10%; summarized in Figure ).…”

Section: Resultsmentioning

confidence: 97%

“…The laryngeal subsite of recurrence was documented in 6 studies (290/1141, 25.4% of patients) that contained patients who were cN0 and received END (164 glottic, 81 supraglottic, 43 transglottic, 2 subglottic). Unilateral and/or bilateral ND was noted in 7 studies . The treatment categories are summarized in Table .…”

Section: Resultsmentioning

confidence: 99%

“…The description of unilateral and/or bilateral NDs in the included studies was limited to 7 studies with great heterogeneity in the reported data between each study. Central (level VI) ND was performed as a standardized procedure in all patients in 4 studies . Of those, only Birkeland et al reported occult nodal disease in the paratracheal nodal basins which were dissected; and found 15% ipsilateral paratracheal nodal disease in recurrent supraglottic tumors, and in recurrent glottic tumors 11% and 9% paratracheal nodal disease was present ipsilaterally and contralaterally, respectively.…”

Section: Discussionmentioning

confidence: 99%

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Elective neck dissection in patients with radio‐recurrent and radio‐residual squamous cell carcinoma of the larynx undergoing salvage total laryngectomy: Systematic review and meta‐analysis

et al. 2019

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Background Approximately 30% of nonsurgically treated patients with laryngeal squamous cell carcinoma will suffer recurrence, and many will be clinically N0; the indication for elective neck dissection (END) remains uncertain. We aimed to determine whether END is indicated during salvage laryngectomy. Methods Systematic review and meta‐analysis. Results A total of 1141 patients were identified from 17 studies. Occult nodal positivity was 13.7% (106/775) confidence interval (CI) 11.3%‐16.1%; higher in supraglottic than glottic disease (17.8%, CI 10.3%‐25.3% vs 12%, CI 7.1%‐16.9%, P = .18). No significant difference existed between END vs observation in 5‐year disease free survival (odds ratio [OR] = 0.76, CI = 0.49‐1.17, P = .21, I2 = 10%) and overall survival (OS; OR = 0.96, CI = 0.65‐1.41, P = .82, I2 = 54%). Conclusions No significant survival advantage was found for END vs observation. Individual studies trended towards improved survival with END in supraglottic and locally advanced tumors. These factors should be considered when deciding on END in salvage laryngectomy.

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Oncologic Outcomes After Clinically Node-Negative Salvage Laryngectomy

Gross

Patel

Switchenko

et al. 2023

JAMA Otolaryngol Head Neck Surg

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ImportanceControversy 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.ObjectiveTo explore clinical and oncologic outcomes after elective neck dissection vs observation in patients who received clinically node-negative salvage total laryngectomy.Design, Setting, and ParticipantsThis 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.ExposuresElective neck dissection.Main Outcomes and MeasuresPresence 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.ResultsAmong 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 RelevanceIn 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.

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Elective neck dissection during salvage total laryngectomy – a beneficial prognostic effect in locally advanced recurrent tumours

Abstract: Elective neck dissection during salvage total laryngectomy seems to improve survival in patients with advanced local disease at recurrence. The role of neck dissection in the treatment of smaller tumours awaits further studies.

Cited by 33 publications

References 14 publications

Elective neck dissection during salvage laryngectomy: A systematic review and meta‐analysis

Elective neck dissection during salvage laryngectomy: A systematic review and meta‐analysis

Elective neck dissection in patients with radio‐recurrent and radio‐residual squamous cell carcinoma of the larynx undergoing salvage total laryngectomy: Systematic review and meta‐analysis

Oncologic Outcomes After Clinically Node-Negative Salvage Laryngectomy

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