Elective neck dissection for salvage total laryngectomy: A systematic review, meta‐analysis and “decision‐to‐treat” approach

Abstract

IntroductionThe authors provide an updated, systematic and comprehensive summary of the literature concerning management of the N0 neck in patients for whom primary irradiation for squamous cell carcinoma of the larynx has been unsuccessful and salvage surgery in the form of total laryngectomy (TL) advocated.MethodsBibliographic databases MEDLINE, Cochrane, PubMed and Embase were searched from inception to April 2019, with no language restrictions. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed. Risk of bias was defined using the Joanna Briggs Institute guidelines. Outcome measures were defined as the impact of END on locoregional control, complication rate, disease‐specific and overall survival (DSS and OS).ResultsThe primary search identified 19 eligible articles, comprising 1353 patients, (1552 ENDs). The overall risk of occult metastases was 14% (9% of ENDs). The relative risk (RR) of developing complications was 1.29 when END was performed, compared to observation of the neck (CI 0.86‐1.92). Contrariwise, patients in whom the neck was managed with neck dissection had a decreased risk of developing regional recurrence (RR 0.62, CI 0.35‐1.08). There was no statistically significant variation between DSS and OS between END and neck observation groups, respectively.SummaryEND during salvage TL may reduce the rate of regional recurrence, but not at the expense of improving DSS or OS. Rates of occult metastases, regional recurrence and “cure” through salvage neck dissection are not equivalent. Significant bias in all collated manuscripts should encourage the reader to interpret conclusions with caution. Patients should be fully involved in the decision‐making process and their performance status and co‐morbidities taken carefully into account when deciding to increase the extent of surgery, which we believe should remain limited to TL in the majority of cases.

Neck Dissection in Salvage Surgery for Larynx Cancer: National Cancer Database Review

“…In previously published reports, the rate of positive lymph nodes in all salvage laryngeal cases inclusive of cN0 and cN+ patients at the time of salvage has a broad range from 0% to 46%. 7-10 In one of the largest single-institution studies of neck dissection outcomes in laryngeal salvage, Birkeland et al 27 reported a 24% rate of identifying positive lymph nodes in patients undergoing salvage surgery, compared to 26% in the present study. Rates of occult metastasis for cN0 patients at the time of salvage surgery in individual studies range from 0% to 31%.…”

“…There is considerable variability in reported nodal metastasis rates in patients undergoing neck dissection (ND) during salvage laryngeal surgery, ranging from 0% to 46% amongst all patients and from 0% to 31% in cN0 patients undergoing elective ND. 7-10 Many authors have shown low yield of positive lymph nodes, higher complication rates, and ultimately no improvement in regional control or survival outcomes. 10-14 Still, some authors who have shown a higher rate of nodal metastasis or survival benefit advocate for neck dissection in the salvage setting either routinely or in selected cases.…”

“…7-10 Many authors have shown low yield of positive lymph nodes, higher complication rates, and ultimately no improvement in regional control or survival outcomes. 10-14 Still, some authors who have shown a higher rate of nodal metastasis or survival benefit advocate for neck dissection in the salvage setting either routinely or in selected cases. 10,15-17 These studies are based on single institution experiences and are limited by small patient numbers.…”

“…10-14 Still, some authors who have shown a higher rate of nodal metastasis or survival benefit advocate for neck dissection in the salvage setting either routinely or in selected cases. 10,15-17 These studies are based on single institution experiences and are limited by small patient numbers. A survey of multiple institutions is necessary to enhance these studies.…”

Rational surgical neck management in total laryngectomy for advanced stage laryngeal squamous cell carcinomas

“…In contrast, several previous retrospective studies showed no significant influence of elective neck dissection (END) on survival in advanced laryngeal cancers (Ketterer et al 2020;Shi et al 2019;Kennedy et al 2017;Djordjevic et al 2016;Canis et al 2012). For salvage TL cases, END is not generally recommended, because, although it reduces the rate of regional recurrence, it does not provide a survival benefit as stated in a recent meta-analysis (Davies-Husband et al 2020).…”