Central compartment dissection (of levels VI and VII) for carcinoma of the larynx, hypopharynx, cervical esophagus, and thyroid

Abstract

Lymphatic spread to the paratracheal and upper mediastinal nodes most often arises from tumors of the hypopharynx, larynx, cervical esophagus, and thyroid. The paratracheal and upper mediastinal lymph nodes are within the described lymphatic drainage pathways for tumors arising in these sites. Failure to address these lymphatics can lead to central compartment recurrence after thyroidectomy in cases of differentiated thyroid cancer or stomal recurrence after total laryngectomy in cases of squamous carcinoma of the larynx, hypopharynx, and cervical esophagus. We briefly review the lymphatic drainage to the central compartment (levels VI and VII), and we describe the operative techniques for appropriate lymphadenectomy. Rouviere’s 1,2 classic description of the lymphatic drainage of the larynx was expanded by the more contemporary work of Welsh et al, 3 who used injection of radioactive tracers to define lymphatic pathways. Interestingly, these injection studies demonstrated that supraglottic laryngeal lymphatics drain primarily to the ipsilateral upper and midjugular lymph nodes. However, small areas of uptake also were found in the contralateral side of the neck, and the tracer was demonstrated in the ipsilateral thyroid lobe and the paratracheal lymph nodes. Subglottic injections drained to the paratracheal and upper mediastinal lymph nodes. The cervical esophagus is richly supplied with lymphatics, and primary tumors at this site drain to the paratracheal, upper mediastinal, and retropharyngeal lymph nodes. The efferent hypopharyngeal lymphatics drain into the anterior pathway that pierces the thyrohyoid membrane, terminating in the superior and midjugular lymph nodes, whereas the posterior pathway drains the inferior hypopharynx and proceeds to the paratracheal, retroesophageal, and internal jugular lymph nodes. 4 Lymphatic drainage from the thyroid gland follows multiple routes and is routinely bilateral. The primary echelon of nodal drainage from the thyroid is to the cricothyroid (“Delphian”) lymph node, the paratracheal nodes, and the upper mediastinal lymph nodes.