Occult Nodal Disease Prevalence and Distribution in Recurrent Laryngeal Cancer Requiring Salvage Laryngectomy

Abstract

Objectives The indications for neck dissection concurrent with salvage laryngectomy in the clinically N0 setting remain unclear. Our goals were to determine the prevalence of occult nodal disease, analyze nodal disease distribution patterns, and identify predictors of occult nodal disease in a salvage laryngectomy cohort. Study Design Case series with planned data collection. Setting Tertiary academic center. Subjects Patients with persistent or recurrent laryngeal squamous cell carcinoma after radiation/chemoradiation failure undergoing salvage laryngectomy with neck dissection. Methods We analyzed a single-institution retrospective case series of patients between 1997–2014 and identified those who had clinically N0 necks (n = 203). Clinical and pathologic data, including nodal prevalence and distribution were collected, and statistical analyses were performed. Results Overall, cN0 necks had histologically positive occult nodes in 17% (n=35) of cases. Univariate predictors of occult nodal positivity included recurrent T4 stage (34% T4 vs. 12% non-T4; p=0.0003), and supraglottic subsite (28% supraglottic vs. 10% non-supraglottic; p=0.0006). Histologically positive nodes associated with supraglottic primaries were most frequently positive in ipsilateral level II and III (17% and 16%). Positive nodes for glottic SCC were most frequently positive in the ipsilateral and contralateral paratracheal nodes (11% and 9%). Conclusion Histologically positive occult nodes are identified in 17% of cN0 patients undergoing salvage laryngectomy with neck dissection. Occult nodal disease varies in frequency and distribution based upon tumor subsite. Predictors of high (>20%) occult nodal positivity include T4 tumors and supraglottic subsite. In glottic SCCs, the most frequent sites of occult nodal disease are the paratracheal nodal basins.

Elucidation of salvage laryngectomy pathologic and clinical variables to guide further treatment intensification investigation

“…Although some authors have argued against routine neck dissection in the salvage setting when there is no clinical evidence of disease because of morbidity concerns, we performed neck dissections on the majority of the patients (82%), and most were bilateral neck dissections encompassing levels 2 to 4, medial 5, or extended when clinical disease was evident. The pathologic findings did show node positivity in 25% of the patients after the neck dissections, consistent with other reports in the literature showing a concern for occult nodal disease in patients with failed laryngeal preservation who underwent surgical salvage, particularly if the supraglottis or transglottic subsites were observed …”

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

“…The application of this decision tree to the salvage setting is more unclear, however. Looking specifically at the included studies by Birkeland et al, Wax and Touma, Yao et al, and Koss et al, they report a ≥20% risk of occult nodal disease with recurrent supraglottic tumors and advanced tumor (T) stage (T3–T4) tumors and therefore recommend END for those subsets . Based on the existing standard and the above data, it may be reasonable to observe the necks of a recurrent laryngeal cancer unless it is an advanced T stage or of supraglottic subset.…”

Positron emission tomography–CT prediction of occult nodal metastasis in recurrent laryngeal cancer

“…This technology has proven useful in initial staging, assessing treatment response, monitoring for recurrence, and identifying distant metastasis in patients with head and neck cancer . Although PET‐CT has been shown to have increased sensitivity when compared to CT or MRI, the role of PET‐CT in guiding treatment of the neck, especially in the salvage setting, is evolving …”

“…Supraglottic tumors and advanced T classification tumors have been associated with an even higher occult nodal metastasis rate . When taken together, patients with T4 supraglottic tumors have a 50% risk of occult nodal disease . Efforts have been made to predict the likelihood of nodal metastases in these patients.…”