Surgical Treatment of the Neck in Cancer of the Larynx

Abstract

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher.The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal ‘skip’ metastases.The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.

Paratracheal lymph node dissection does not negatively affect thyroid dysfunction in patients undergoing laryngectomy

“…Usually a PTLN dissection is performed in advanced laryngeal and hypopharyngeal carcinomas with subglottic involvement [8,12]. It still remains to be identiWed in which patients PTLN dissection is really indicated [9].…”

“…The reported incidence of PTLN metastases varies between 9 and 36% depending on the site and stage of the primary tumor [10][11][12][13].…”

Detection of occult carcinomatous diffusion in lymph nodes from head and neck squamous cell carcinoma using real-time RT–PCR detection of cytokeratin 19 mRNA

“…According to Ferlito et al (2000), selective neck dissection in HNSCC provides important information for prognostic purposes and therapeutic decisions. In the present study, occult micrometastases were detected in 13 out of 31 patients, and if these findings were taken into account, they would have changed the patients' nodal status and nine pN0 patients would have been mN-upstaged.…”

The relationship between the frequency of cervical metastases and tumor related factors in laryngeal cancer and outcome of surgical treatment in these cases

“…37,38 Ayrıca ışık mikroskobu ile gösterilemeyen mikrometastatik hastalığın immunohistokimyasal ve moleküler çalış-malar ile %5 oranında gösterilebildiği unutulmamalıdır. 39,40 Ayrıca yapılan bir çalışmadada, ipsilateral boyun disseksiyonu yapıldığı halde metastaz tespit edilmeyen %5.5 oranında bir hasta gurubunda kontralateral tarafta ileriki dönemlerde nüks geliş-miştir. 17 Bizim çalışmamızda da boyun disseksiyonu yapıldığı halde metastaz tespit edilmeyen hastaların 12'sinde ileriki dönemlerde servikal nüsle karşı-…”