Effectiveness of therapeutic (N1, N2) selective neck dissection (levels II to V) in patients with laryngeal and hypopharyngeal squamous cell carcinoma

Feasibility of Salvage Selective Neck Dissection after Primary Irradiation of Pharyngeal and Laryngeal Carcinoma

INTRODUCTION

The concept of neck dissection (ND) in the management armamentarium of head and neck squamous cell carcinoma has evolved throughout the years. Nowadays, ND becomes more functional.

METHODOLOGY

A retrospective study of 865 patients was performed at Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital to investigate the feasibility of selective ND (SND). All patients with squamous cell carcinoma of the pharynx and larynx who received primary radiation and underwent salvage ND were included in the study.

RESULT

A total of 29 NDs were analyzed. In 17 neck sides, viable metastases were found (58%), whereas in the other 12 specimens there were no viable metastases. In 16 of the 17 necks (94%), the metastases were located either in level II, III, or IV or in a combination of these 3 levels. Level V was involved in only 1 case (6%).

CONCLUSION

It is well justified to perform a salvage SND (levels II, III, and IV) for pharyngeal and laryngeal carcinoma after primary radiation. In carefully selected cases of supraglottic and oropharyngeal carcinoma, a superselective ND also appears as an efficient option.

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

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Contralateral Cervical Lymph Node Metastases in Pyriform Sinus Carcinoma

OBJECTIVE: We designed a retrospective study to evaluate the incidence of contralateral neck metastases in squamous cell carcinoma of the pyriform sinus.

STUDY DESIGN AND SETTING: Sixty-three patients with strictly unilateral squamous cell carcinoma of the pyriform sinus who underwent bilateral neck dissection at the time of primary surgery were included in this study. The medical records of all patients were reviewed. A multivariate statistical analysis was performed, considering some clinical and histologic parameters of T stage and N stage in relation to contralateral neck metastases.

RESULTS: Contralateral neck metastases were histopathologically confirmed in more than 20% of the cases examined (13 out of 63 patients), of whom 3 were clinically staged as N2c, 2 N2b, 5 N2a, 2 N1 and 1 N0. The percentage of occult contralateral neck metastases was 77% (10/13 cases). Poorly differentiated tumors ( P = .02) and the involvement of the lateral wall ( P= .036) showed a statistically significant correlation with stage pN2c. Also T size and ipsilateral N stage were associated with the presence of contralateral neck metastases.

CONCLUSIONS: Our data suggest that elective bilateral neck dissection is recommended in patients with locally advanced squamous cell carcinoma of the pyriform sinus.

Selective neck irradiation for supraglottic cancer: focus on Sublevel IIb omission

OBJECTIVE

To estimate selective neck irradiation omitting surgical Sublevel IIb.

METHODS

Bilateral necks of 47 patients (94 necks) were subjected to definitive radiotherapy for supraglottic cancer. Sixty-nine and 25 necks were clinically node negative (cN-) and clinically node positive (cN+), respectively. We subdivided Sublevel IIb by the international consensus guideline for radiotherapy into Sublevel IIb/a, directly posterior to the internal jugular vein, and Sublevel IIb/b, which was behind Sublevel IIb/a and coincided with surgical Sublevel IIb. Bilateral (Sub)levels IIa, III, IV and IIb/a were routinely irradiated, whereas Sublevel IIb/b was omitted from the elective clinical target volume in 73/94 treated necks (78%).

RESULTS

Two patients presented with ipsilateral Sublevel IIb/a metastases. No Sublevel IIb/b metastasis was observed. Five patients experienced cervical lymph node recurrence; Sublevel IIb/a recurrence developed in two patients, whereas no Sublevel IIb/b recurrence occurred even in the cN- necks of cN+ patients or cN0 patients. The 5-year regional control rates were 91.5% for Sublevel IIb/b-omitted patients and 77.8% for Sublevel IIb/b treated patients.

CONCLUSIONS

Selective neck irradiation omitting Sublevel IIb/b did not compromise regional control and could be indicated for cN- neck of supraglottic cancer.

Lymphatic drainage patterns from melanomas on the shoulder or upper trunk to cervical lymph nodes and implications for the extent of neck dissection

Purpose

To determine the incidence and pattern of cervical lymphatic drainage in patients with melanomas located on the upper limb or trunk, and to evaluate our current neck dissection protocol for those patients with a N+ neck.

Methods

Of 1192 melanoma patients who underwent sentinel node biopsy, 631 were selected with a primary tumor on the upper limb or trunk. All lymphoscintigrams, SPECT/CT images and operative reports were reviewed to determine the exact locations of sentinel nodes visualized preoperatively and dissected during operation.

Results

Thirty-nine (6.2 %) of 631 patients with a melanoma on the upper limb or trunk showing cervical lymph node drainage were identified. In 34 (87 %) of 39 patients, sentinel nodes were excised from level IV or Vb, and in 30 of those 39 patients simultaneous from the axilla. In the remaining five patients (13 %), sentinel nodes were collected from level IIb, level III or the suboccipital region. All collected sentinel nodes were located in the intended dissection area for N+ patients. Thirteen patients (33 %) had a total of 22 tumor-positive sentinel nodes in either the axilla (n = 10), level IV (n = 2), Vb (n = 9) or suboccipital (n = 1).

Conclusions

Only a minority of the patients with upper limb or trunk melanomas demonstrated lymphatic drainage to cervical lymph node basins, with preferential drainage to levels IV and Vb. Our current dissection protocol of levels II–V, with or without extension to the suboccipital region, in those patients with involved cervical sentinel nodes seems sufficient.

Therapeutic selective neck dissection (level II-V) for node-positive hypopharyngeal carcinoma: is it oncologically safe?

CONCLUSIONS

Our study suggests that routine level I dissection may not be necessary in the surgical management of clinically N + hypopharyngeal squamous cell carcinoma (SCC) in patients who do not have a positive lymph node in neck level I.

OBJECTIVE

To determine whether level I lymph node dissection can be saved in patients with clinically N + hypopharyngeal SCC.

PATIENTS AND METHODS

Retrospective analysis of 64 consecutive clinically N + patients with untreated hypopharyngeal SCC between 1994 and 2006. Forty-seven patients underwent level I lymph node dissection and the remaining 17 did not. Forty-five of the 64 patients were followed for a minimum of 2 years, if alive, or until death. Of these 45 patients, 35 underwent ipsilateral level I dissection of the neck.

RESULTS

The incidence of occult metastases to level I was 6% (3 of 47). Six (17%) of 35 patients with level I dissection and 1 (10%) of 10 patients without level I dissection experienced regional recurrence (p>0.05). The 2-year disease-specific survival in 47 patients undergoing level I neck dissection was 44% compared with 37% in 17 patients who did not undergo level I neck dissection (p>0.05).

Selective neck dissection in patients with upper aerodigestive tract cancer with clinically positive nodal disease

OBJECTIVES

We evaluated the efficacy of the application of selective neck dissection to cases of clinically node-positive disease.

METHODS

We performed a retrospective review at the University of Pittsburgh Head and Neck Cancer Database. A database of 65 patients was followed for an average of 36 months (range, 2 to 128 months) after they underwent selective neck dissection for clinically node-positive regional disease.

RESULTS

Regional failure occurred in 8 patients (12.3%). In-field failure was experienced in 4 patients (6.1%), and failures outside the field of dissection occurred in 4 patients (6.1%). The overall incidence of extracapsular spread was 33.8% (22 of 65). Only 2 of 8 regional recurrences were associated with extracapsular spread at the initial neck dissection; however, both recurrences were in the contralateral, undissected side of the neck. Four regional failures were salvaged with surgery, with eventual overall regional control in the neck of 93.9%. Only 1 of 4 ipsilateral recurrences (25%) was successfully salvaged. In contrast, 3 of 4 contralateral failures (75%) were successfully salvaged. In our study population, 21 of 65 cases (32%) that were initially staged as clinically node-positive had no evidence of nodal metastases on pathologic examination.

CONCLUSIONS

The application of selective neck dissection and postoperative irradiation in patients with clinically Nl and limited N2 clinical disease appears to be oncologically efficacious. Clinical overstaging occurred frequently in this sample, and may put patients at risk for more morbid surgical procedures.

Elective and therapeutic selective neck dissection

Selective neck dissection is a modification of the more comprehensive modified radical or radical neck dissection that is designed to remove only those nodal levels considered to be at risk for harboring nodal metastases. The role of selective neck dissection continues to evolve: while initially designed as a staging and diagnostic procedure for patients without clinical evidence of nodal disease, a growing body of literature suggests that selective neck dissection has a therapeutic role in patients with clinical and histologic evidence of nodal metastases. The rationale behind selective neck dissection, its application in the clinically negative but histologically node-positive neck and the extended application of selective neck dissection in patients with clinical evidence of nodal disease are discussed.