Prediction of occult neck disease in laryngeal cancer by means of a logistic regression statistical model

[Current diagnostic imaging and treatment planning for laryngeal cancer]

CLINICAL/METHODICAL ISSUE

Laryngeal cancer is the third most common malignancy in the head and neck region. Endoscopic laryngoscopy with assessment of vocal fold function, microlaryngoscopy with biopsy and computed tomography (CT)/magnetic resonance imaging (MRI) remain the cornerstones of diagnostic workup. Thus, in the context of therapy planning, consideration of individual functional and socioeconomic aspects is of major importance.

STANDARD RADIOLOGICAL METHODS

Due to the short acquisition time and the possibility to perform functional maneuvers, CT is the tool of choice. MRI allows better soft tissue differentiation, but is more susceptible to movement artifacts and is complicated by disease-specific symptoms. The choice of examination method therefore depends on the patient's physical resilience.

PERFORMANCE

Depending on the study, the information on the sensitivity of CT with regard to the question of cartilage infiltration varies between 62 and 87% with a specificity between 75 and 98%. For MRI, sensitivity between 64 and 95% and specificity between 56 and 88% are stated.

ACHIEVEMENTS

The synthesis of the findings from endoscopy, biopsy and imaging is prerequisite for initiation of stage-appropriate treatment. For image interpretation, knowledge of the anatomical landmarks is essential. However, the assessment of posttherapeutic changes also poses a challenge for the radiologist.

PRACTICAL RECOMMENDATIONS

Regular interdisciplinary dialogue between radiologists, otorhinolaryngologists and radiotherapists in the context of primary diagnostics, therapy planning and aftercare is essential.

Gamma Probe Accuracy in Detecting the Sentinel Lymph Node in Clinically No Squamous Cell Carcinoma of the Head and Neck

The sentinel node, which is not always located at the first-echelon nodal area close to the primary tumor, is the initial recipient of possible metastasis. In order to verify the usefulness of the sentinel lymph node technique in the staging of head and neck cancers, we studied 31 untreated patients with squamous cell carcinoma of the upper airways by injecting them around the primary tumor with technetium 99m albumin microcolloid (99mTc) and submitting them to selective neck dissection with en bloc tumor removal. The nodes were examined after γ-probe identification of the sentinel node(s). No patients were found to have microscopic tumor spread outside the level(s) containing the γ-probe-identified sentinel node(s). In only 1 case was the metastatic node not the γ-probe-posi-tive one, but an adjacent one. Lymphoscintigraphy with 99mTc seems reliable in identifying the sentinel node(s) and might contribute to the reduction of surgical morbidity by reserving therapeutic neck dissection for cases with histologically confirmed nodal metastasis.

The Relationship between the Localization, Size, Stage and Histopathology of the Primary Laryngeal Tumor with Neck Metastasis

OBJECTIVE

In this study we aimed the investigate the laryngectomy (partial and total) and neck dissection (functional, radical) in patients undergoing larynx identified as a result of the operation of primary tumour localization, size, stage and histopathology of the relationship between neck metastasis.

MATERIALS AND METHODS

The files of 118 patients who has had operation of laryngectomy (partly, total) and neck dissection (functional, radical) because of larynx cancer in the Ear Nose and Throat (ENT) Clinic in the last ten years (1997-2007) have been evaluated retrospectively.

RESULTS

116 of them were male and 2 of them were female. Age average was 56+/-22. 189 neck dissections have been applied to 118 patients. While in supraglottic tumours, 55.2% cervical metastasis and 28.9% occult metastasis have been determined, in transglottic tumours 35.1% cervical metastasis and 18.9% occult metastasis have been determined. It has been seen that while the cervical metastasis ratio of tumours bigger than 4 cm is 55.8%, the tumours smaller than 4 cm is 27.27% (p=0.002). The cervical metastasis rate has been determined as 26.3% in T1 cases, 25.8% in T2 cases, 40.6% in T3 cases and 58.3% in T4 cases. In tumours with advanced T stage, the rate of cervical metastasis has been seen more than the ones with early T stage (p=0.027). Cervical metastasis has been determined as 27.3% in good differential (G1) tumours, 53.4% in medium differential (G2) tumours, and 74.1% in bad differential (G3) tumours (p=0.005).

CONCLUSION

Considered in the light of clinical parameters specified in the cervical lymph node metastasis, N0 patients with laryngeal cancer, tumour, according to the anatomical location as unilateral or bilateral elective neck dissection should be performed and histopathological specimens taken in the event of a positive detection of metastases concluded that postoperative radiotherapy should be performed.

Radiothérapie postopératoire des cancers laryngés classés N0

PURPOSE

A retrospective study to re-assess the indications for postoperative radiation therapy in squamous cell carcinoma of the larynx staged N0 after gross resection.

PATIENTS AND METHODS

Between January 1975 and December 2000, 166 patients with squamous cell carcinoma of the larynx were treated by total laryngectomy with or without neck dissection. Surgery was completed by external radiotherapy delivering 45 to 65 Gy to the tumour bed and 45 to 50 Gy to cervical lymphatic chains. Minimal follow-up was 36 months and median follow-up was 98 months.

RESULTS

The rate of nodal recurrence was 6% (median time for relapse was 9 months). The survival rates at 1, 2, 3 and 5 years were 93.5, 84, 80 and 69% respectively, with a 8 year 3 month median survival. The univariate analysis showed 4 parameters, which significantly increased the risk of local recurrence: the medical necessity for immediate tracheotomy, the subglottic involvement, the involvement of the whole larynx and the presence of lymphatic embols in the neck dissection. There was no statistically significant difference between the patients with or without a neck dissection. Fifty-nine secondary cancers were observed, 15 of them occurring in the head and neck area. The late complications consisted of cervical subcutaneous fibrosis (7%), oesophageal stricture (4%), oeso-tracheal fistula (l%), hypothyroidism (3%), bone necrosis (1%).

CONCLUSION

Prophylactic cervical radiotherapy in laryngeal cancers resulted in 6% cervical node recurrence rate. This value may represent the maximal rate to accept if one would favour new therapeutic strategies based on restricted indications for radiotherapy.

Resultados funcionales de la laringectomía supraglótica láser

OBJECTIVES

To analyse the functional outcome of patients with supraglottic carcinomas treated by transoral laser surgery.

METHODS

The clinical records of 55 patients who underwent transoral laser surgery were reviewed. Swallowing capacity, surgical complications, requirements for tracheotomies, percentage of decannulations, laryngeal paralysis, stenosis, aspiration associated pneumonia, time to remove the nasogastric tube and postsurgical stay in hospital were the studied variables.

RESULTS

52% of the patients had a normal or within functional limits swallowing performance. 18% suffered aspiration pneumonia. 13% developed a laryngeal stenosis. 7% suffered of laryngeal palsy. 18 tracheostomies were performed, of them 10 could be reverted. The mean time to remove the nasogastric tube was 9 days. The mean hospital stay was 23 days.

CONCLUSIONS

The main functional advantages of transoral laser surgery for supraglottic carcinoma, when compared with the conventional approach, are a lower incidence of temporary tracheotomies, a faster removal of the nasogastric feeding tube, and a lower incidence of pharyngocutaneous fistulas (0%).

Cervical cystic metastasis of squamous cell carcinoma: a case report with an unusual presentation

Cervical cystic masses may be a diagnostic challenge, especially in patients older than 40 years. We present the case of a 62-year-old male patient with a large cystic metastasis of squamous cell carcinoma to the neck and discuss this rare condition regarding diagnostic, pathologic and therapeutic features.

Functional outcomes of transoral laser surgery of supraglottic carcinoma compared with a transcervical approach

BACKGROUND

Several functional advantages have been described for the transoral laser supraglottic laryngectomy as compared with open techniques. However, comparative studies have been rarely performed.

METHODS

Functional results in 26 patients treated with a transoral approach were retrospectively compared with those of a comparable series of 26 patients who underwent a transcervical approach.

RESULTS

The only significant differences found between the two groups were a lesser number of temporary tracheotomies and a shorter time of removal of the nasogastric tube in the laser group. No significant differences were found in the incidence of postoperative complications, hospital stay, and swallowing capacity.

CONCLUSIONS

The rate of functional problems after transoral laser surgery did not greatly decrease compared with the rate after the conventional procedure. The mayor advantage of the transoral approach was the lower incidence of temporary tracheotomies.

Carcinoma of the larynx: the Dutch national guideline for diagnostics, treatment, supportive care and rehabilitation

PURPOSE

This evidence based guideline aims to facilitate proper management and to prevent diverging views concerning diagnosis, treatment and follow-up of carcinoma of the larynx between the major referral centers for head and neck cancer in The Netherlands.

METHOD

A multidisciplinary committee was formed representing all medical and paramedical disciplines involved in the management of laryngeal cancer and all head and neck oncology centers in The Netherlands. This committee reviewed the literature and formulated statements and recommendations based on the level of evidence and consistency of the literature data. Where reliable literature data were not available, recommendations were based on expert opinion.

RESULTS

Strict criteria have been proposed for the radiological diagnostic procedures as well as for the pathology report. For carcinoma in situ and severe dysplasia, microsurgery, preferably by laser, is proposed. For all other stages of invasive carcinoma, a full course of radiotherapy as a voice conserving therapy is the treatment of choice. Only in cases with massive tumor volumes with invasion through the laryngeal skeleton, primary surgery is inevitable. For rehabilitation and supportive care, minimal criteria are described. Due to the complexity of therapy and relative rarity of larynx carcinoma, all patients should be seen at least once in a dedicated head and neck clinic.

CONCLUSION

This guideline for the management of larynx carcinoma was produced by a multidisciplinary national committee and based on scientific evidence wherever possible. This procedure of guideline development has created the optimal conditions for nationwide acceptance and implementation of the guideline.

Radiologic evaluation of neck metastases: the otolaryngologist's perspective

Imaging of the neck for the assessment of nodal metastases can be used to detect occult metastases or to assess operability of palpable metastases. The detection of small occult metastases has limitations, as micrometastases cannot be depicted. However, imaging can diminish the risk of occult metastases and thus influence management; for this purpose a very sensitive technique is necessary. The currently used radiologic criteria are not sensitive enough to accomplish enough reduction in the risk of occult metastases. Therefore, more sensitive CT and MRI criteria, but especially ultrasound guided aspiration, should be used to assess the clinically negative neck.

Diagnostic evaluation of the neck

Modern imaging for neck node metastases has increased our ability to predict the presence of palpably occult metastases and predict the resectability of large metastases. The accuracy of CT scans, MR imaging, but especially US-FNAC, has increased to such an extent that clinical consequences are being attached to negative radiologic findings in a clinically N0 neck. As not all palpably occult metastases can be detected, especially when they are micrometers, follow-up should be strict, with use of US-FNAC in the neck observed instead of treated electively.

Endoscopic Laser Resection of Supraglottic Carcinoma

Forty-six patients with infiltrating supraglottic carcinoma were treated prospectively for cure between 1986 and 1992 with transoral laser resection of the primary. Nine primaries were classified as T1, and 37 as T2. Thirty-three had staged unilateral or bilateral neck dissections, and 16 had postoperative radiotherapy. All patients were followed up for 2 to 8 years unless they died. Of the 46 patients, 33 are alive without disease, 8 died with disease, and 5 died of intercurrent disease. Among the 8 patients who died with disease, 4 had uncontrollable local or regional recurrences, and 4 had distant metastases but were free of local or regional recurrence. Calculated overall survival was 59% and adjusted survival was 72% after 5 years. Four patients had tracheostomies perioperatively, and 2 required temporary postoperative tracheostomies. The remaining 40 patients needed no artificial airway other than orotracheal intubation for the endolaryngeal intervention. Thirty-seven patients relearned undisturbed deglutition within 2 weeks from surgery, and 4, within 4 weeks. However, 5 (10.9%) patients failed to relearn swallowing and consecutively underwent “completion” total laryngectomy. Among them were the two patients who had previously had unsuccessful surgical or radiologic treatment of their primaries and the patient with a history of oral cavity carcinoma. This study confirms that transoral laser resection can effectively control early supraglottic carcinoma. Tracheostomies are not routinely required, and phonatory function is not compromised. However, transoral laser resection could not steadily preserve undisturbed deglutition in the patients included In this study. Patients with histories of unsuccessful attempts of other larynx-sparing therapeutic modalities or of previous major head and neck interventions were not successfully managed with transoral laser resection in this series. Criteria for patient selection remain to be established.

Elective neck dissection in the treatment of T3/T4 N0 squamous cell carcinoma of the larynx

BACKGROUND

This study analyzed pathologic findings of clinically occult cervical lymph nodes of T3/T4 N0 squamous cell laryngeal carcinoma and their impact on locoregional failures and overall survival.

PATIENTS AND METHODS

A retrospective analysis of 76 patients with T3/T4 N0 laryngeal carcinoma was carried out between 1981 and 1989. Sixty-seven patients had transglottic tumor, 31 patients had extralaryngeal spread, 56 patients were T3 N0, and 20 patients were T4 N0. Seventy-five patients had total laryngectomy and 1 had near total laryngectomy. All patients had bilateral elective neck dissection. The chi-square test was applied to factors related to neck metastasis and locoregional failure. Survival was analyzed using the Kaplan-Meier actuarial method; differences were tested using the Wilcoxon signed-rank test.

RESULTS

Eighteen patients had positive surgical margins. Occult neck metastasis was observed in 30%. Univariate analysis showed that cancer stage and cartilage status were not significant to predict neck metastasis. Locoregional recurrence was observed in 28% of patients. Surgical margins, cervical metastasis, lesion extension, and cartilage invasion had significant impact on disease-free survival. The 5-year overall survival was 52%; disease-free survival was 57%.

CONCLUSION

The elective bilateral neck dissection performed in T3/T4 N0 patients yielded a 30% incidence of occult neck metastasis. Classification of transglottic carcinomas into endolaryngeal and exolaryngeal provides a better parameter for predicting neck metastasis than does T status. Disease-free and overall survival were significantly affected by neck metastasis, T stage, exolaryngeal tumor, cartilage infiltration, and surgical margins.