Routine Elective Neck Dissection Research Articles

Factors Influencing Lymph Node Metastasis From Supraglottic Laryngeal Carcinoma

In patients with supraglottic carcinoma (SGLC), lymphatic metastasis is frequent and can cause a significant reduction in local control rate and survival. Currently, the preferred method of neck treatment in patients with supraglottic cancer is prophylactic bilateral neck dissection that could result in overtreatment in at least two thirds of patients. The purpose of this study is to evaluate factors influencing neck metastasis and to determine whether routine elective neck dissection is necessary for the management of all SGLCs. 66 patients with SGLCs who underwent transoral laser surgery and neck dissection were included in this study. The rate of overall and occult lymphatic involvement was 29% and 20%, respectively. The most common involvement site was level II, and factors such as T category, tumor grade, epilarynx involvement, and extension of tumor to the medial wall of pyriform sinus were significantly related to cervical lymph node metastasis. In conclusion, our results suggest that in selected patients with SGLC (such as small T1 or lateralized tumors), elective neck treatment could be ignored, and instead, close follow-up be considered.

Cervical Lymph Node Metastasis in Adenoid Cystic Carcinoma of the Larynx: A Collective International Review.

Adenoid cystic carcinoma (AdCC) of the head and neck is a well-recognized pathologic entity that rarely occurs in the larynx. Although the 5-year locoregional control rates are high, distant metastasis has a tendency to appear more than 5 years post treatment. Because AdCC of the larynx is uncommon, it is difficult to standardize a treatment protocol. One of the controversial points is the decision whether or not to perform an elective neck dissection on these patients. Because there is contradictory information about this issue, we have critically reviewed the literature from 1912 to 2015 on all reported cases of AdCC of the larynx in order to clarify this issue. During the most recent period of our review (1991–2015) with a more exact diagnosis of the tumor histology, 142 cases were observed of AdCC of the larynx, of which 91 patients had data pertaining to lymph node status. Eleven of the 91 patients (12.1%) had nodal metastasis and, based on this low proportion of patients, routine elective neck dissection is therefore not recommended.

The role of elective neck dissection during surgical salvage for recurrent nasopharyngeal carcinoma

Background:To study the incidence of microscopic tumour deposit in the neck in patients with recurrent nasopharyngeal carcinoma (NPC) and hence, the role of routine elective neck dissection during nasopharyngectomy. Methods:Retrospective review of the pathology report of the selective neck dissection specimens in patients with recurrent NPC and clinically N0 status. Results:Between 2000 and 2012, 38 patients presented with recurrent NPC requiring maxillary swing nasopharyngectomy and free flap reconstruction. The initial T-classification of the tumour was T1, 15.8%; T2, 52.6%; and T3, 31.6%, and the N-classification was N0, 26.3%; N1, 47.4%, N2, 15.8%; and N3, 10.5%. Concurrent chemoradiation was given in 57.9% of the subjects. All patients in the series had complete response after the initial treatment, and the mean time to develop local tumour recurrence was 22.3 months. Among these patients, only 1 (2.6%) demonstrated microscopic tumour metastasis in 1 lymph node removed during selective neck dissection. Conclusions: Given the low incidence of microscopic tumour metastasis in patients with recurrent NPC and clinically N0 status, routine elective neck dissection is not indicated.

Is there a role for elective neck dissection with salvage laryngectomy? A decision‐analysis model

Elective neck dissection for the clinically negative neck is often a matter of debate. A decision-analysis model that was published in 1994 established the widely accepted principle that neck dissection is warranted when the risk for occult metastases is higher than 20%. The aim of the present study was to build a specific and up-to-date decision-analysis model to determine the need for elective neck dissection during salvage laryngectomy after chemoradiation failure and to identify the variables that effect the decision. Decision-analysis model. A decision-analysis model was performed to compare the outcome of patients after salvage total laryngectomy with and without an elective neck dissection. Probabilities and expected utilities were derived from available literature to construct the model. Monte Carlo simulation and sensitivity analysis were used to calculate our models' outcomes and to identify the variables that influence the model most, respectively. When calculating our model results with published data, we found that elective neck dissection is not warranted during salvage total laryngectomy. Optimal decision was found to be sensitive by two variables: 1) the probability for cure with neck dissection, and 2) the probability for regional-only recurrence after salvage laryngectomy without neck dissection. In multiway sensitivity analysis, only when cure rate with neck dissection exceeded 82%, adding neck dissection was the preferred decision. In practice, cure rates for patients after salvage total laryngectomy are around 50% to 65%. Based on our decision-analysis model, we do not recommend routine elective neck dissection during salvage total laryngectomy after failure of chemoradiation.

Sentinel node biopsy for early oral and oropharyngeal squamous cell carcinoma

The appearance of lymph node metastases represents the most important adverse prognostic factor in head and neck squamous cell carcinoma. Therefore, accurate staging of the cervical nodes is crucial in these patients. The management of the clinically and radiologically negative neck in patients with early oral and oropharyngeal squamous cell carcinoma is still controversial, though most centers favor elective neck dissection for staging of the neck and removal of occult disease. As only approximately 30% of patients harbor occult disease in the neck, most of the patients have to undergo elective neck dissection with no benefit. The sentinel node biopsy concept has been adopted from the treatment of melanoma and breast cancer to early oral and oropharyngeal squamous cell carcinoma during the last decade with great success. Multiple validation studies in the context of elective neck dissections revealed sentinel node detection rates above 95% and negative predictive values for negative sentinel nodes of 95%. Sentinel node biopsy has proven its ability to select patients with occult lymphatic disease for elective neck dissection, and to spare the costs and morbidity to patients with negative necks. Many centers meanwhile have abandoned routine elective neck dissection and entered in observational trials. These trials so far were able to confirm the high accuracy of the validation trials with less than 5% of the patients with negative sentinel nodes developing lymph node metastases during observation. In conclusion, sentinel node biopsy for early oral and oropharyngeal squamous cell carcinoma can be considered as safe and accurate, with success rates in controlling the neck comparable to elective neck dissection. This concept has the potential to become the new standard of care in the near future.

Unilateral, clinically T2N0, squamous cell carcinoma of the tongue: surgical outcome analysis

To determine the survival rate and analyse the predicting factors of recurrence in patients with unilateral, clinically T2N0 squamous cell carcinoma (SCC) of the tongue which does not cross the midline, a retrospective analysis of 32 such consecutive, previously untreated, cases was performed. All patients were initially treated by surgery between January 1992 and May 2004. All patients had neck dissections: 12 continuous, 20 discontinuous, 24 bilateral and 8 unilateral. Fourteen patients (44%) received adjunctive postoperative radiotherapy. Occult metastatic rates were 34% and 4% in ipsilateral and contralateral neck, respectively. Patients with pN0 cancer had a better 5-year disease-specific survival rate than those with pN+ cancer (85% versus 41%, P = 0.005). Twelve patients (38%) had recurrences after the initial treatment. The recurrence rate was significantly higher in patients with pathologic nodal metastasis, peroral resection of the primary tumour or discontinuous neck dissection. The results suggest that the most effective surgical methods for treating unilateral T2N0 SCC of the tongue which does not cross the midline are: pull–through approach for primary lesion instead of peroral approach; continuous rather than discontinuous neck dissection and ipsilateral elective rather than bilateral routine elective neck dissection.

Elective neck dissection versus observation in primary parotid carcinoma

To evaluate the efficacy of elective neck dissection in the clinically negative neck of patients with primary carcinoma of the parotid gland. Study design and setting A retrospective analysis was undertaken at a university Department of Otorhinolaryngology-Head and Neck Surgery on 83 previously untreated patients with primary carcinoma of the parotid gland and a clinically negative neck. The reliability of fine needle aspiration cytology, frozen section, and the clinico-pathologic findings of patients with occult neck metastases were analyzed. The regional recurrence rate and the outcome were compared among 2 groups; one with elective neck dissection (N = 41) and one without elective neck dissection (N = 42). The diagnosis of malignancy was known preoperatively in 59 (71%) cases, the exact histologic tumor type in 36 (43%) and the grade in 37 (44%) of 83 cases. Occult metastases were detected in 8 (20%) of 41 cNO patients, in 5 cases associated with a high-grade and in 3 cases with a low-grade carcinoma. Recurrence of disease developed in 5 (12%) patients in the elective neck dissection group and in 11 (26%) patients in the observation group. All of the 7 neck recurrences occurred in the observation group. The 5-year actuarial and disease-free survival rate was 80% and 86% for patients with elective neck dissection and 83% and 69% for patients without neck dissection. Conclusion and significance A routine elective neck dissection is suggested in all patients with primary carcinoma of the parotid gland. The efficacy of elective neck dissection, nevertheless, has never been evaluated prospectively.

Predictors of survival in early oral cancer.

Despite the substantial rate of neck conversion reported among patients with early oral cancer, a policy of routine elective neck dissection has been criticized on the grounds that it confers little survival advantage while subjecting many to potentially avoidable morbidity. However, the identification of factors predictive of survival may allow for the identification of those patients who are more likely to benefit from elective neck treatment. The clinical and histologic material of 71 patients with stage I or II squamous carcinoma of the oral cavity were reviewed. Patients were followed up for a minimum of 3 years after their surgery, and the impact of these variables on 3-year survival was assessed. Increased tumor thickness was significantly predictive of decreased survival (P = 0.030). Although having no prognostic value alone, when combined with thickness, both pattern of invasion and gender increased the significance of the latter in predicting outcome. Conclusion and significance Measuring tumor thickness and pattern of invasion in patients with early oral cancer may allow for the identification of those patients with more aggressive disease who are more likely to benefit from elective neck treatment.

Predictors of survival in early oral cancer

Objective Despite the substantial rate of neck conversion reported among patients with early oral cancer, a policy of routine elective neck dissection has been criticized on the grounds that it confers little survival advantage while subjecting many to potentially avoidable morbidity. However, the identification of factors predictive of survival may allow for the identification of those patients who are more likely to benefit from elective neck treatment. Study design and setting The clinical and histologic material of 71 patients with stage I or II squamous carcinoma of the oral cavity were reviewed. Patients were followed up for a minimum of 3 years after their surgery, and the impact of these variables on 3-year survival was assessed. Results Increased tumor thickness was significantly predictive of decreased survival ( P = 0.030). Although having no prognostic value alone, when combined with thickness, both pattern of invasion and gender increased the significance of the latter in predicting outcome. Conclusion and significance Measuring tumor thickness and pattern of invasion in patients with early oral cancer may allow for the identification of those patients with more aggressive disease who are more likely to benefit from elective neck treatment.

Carcinoma of the parotid gland

Background The low incidence and heterogeneity of histiotypes of primary parotid carcinomas makes these tumors histologically and epidemiologically difficult to evaluate. The present study reviews a single institution’s experience in the treatment of primary parotid carcinomas during the last 10 years. Methods The charts of 98 consecutive patients who had a primary parotid carcinoma and who received primary curative treatment were analyzed retrospectively. The tumors were grouped into high-grade and low-grade malignancies. The effect of treatment modalities on locoregional control, the incidence of locoregional recurrences and distant metastases, and survival rates are evaluated and compared between high- and low-grade malignancies. Results High- and low-grade malignant tumors were observed in 50 and 48 cases, respectively. Lymph node metastases were detected in 25 of 98 (25%) patients, of whom 8 of 22 (22%) clinically NO staged patients underwent elective neck dissection. In 24 of 26 resected facial nerves, a histologic tumor infiltration was confirmed, in 14 high-grade and 10 low-grade tumors. Local recurrence developed in 13 patients and was associated in 7 with high-grade and in 6 with low-grade tumors. All but 1 of the low-grade malignancies with local recurrence did not receive postoperative irradiation. Regional recurrence developed in 11 patients and distant metastases developed in 10, 3 in combination with a neck recurrence and 1 with a local recurrence. The survival rate at 5 years for low- and high-grade carcinomas was 87% and 56% and the disease-free survival rate 72% and 48%, respectively. Conclusions The incidence of occult metastases in clinically N0-elective neck dissection was 22%. A routine elective neck dissection in all N0 parotid carcinomas is suggested. There is no statistically significant difference between low- and high-grade tumors as for the rate of local recurrence and, as all except one of the low-grade malignancies with local recurrence did not receive postoperative irradiation, postoperative irradiation is not only suggested for high-grade carcinomas but also for T2 to T4 low-grade carcinomas.

Carcinoma of the Larynx: Selective Approach to the Management of Cervical Lymphatics

Our experience with the surgical management of 472 patients with squamous cell carcinoma of the larynx suggests that more aggressive management of the N0 neck is effective in managing patients with laryngeal carcinoma. Only 3% of patients developed recurrence at the primary site. Patients with T3 and T4 carcinoma of the glottic larynx and all patients treated surgically for carcinoma of the supraglottic larynx should undergo routine elective neck dissection of the N0 neck. This is undertaken on the ipsilateral side for T3 and T4 glottic lesions. Selective neck dissection is undertaken bilaterally for patients with carcinoma of the supraglottic larynx irrespective of the side of the primary tumor. Distant metastasis develops as a sole site of recurrent disease in 9% of patients overall. Additionally, 14% of patients developed a second primary carcinoma sometime during the postoperative period. Strategies to prevent and manage these problems are the challenge for the future.