Rational surgical neck management in total laryngectomy for advanced stage laryngeal squamous cell carcinomas

Abstract

Purpose: Controversies exist in regard to surgical neck management in total laryngectomies (TL). International guidelines do not sufficiently discriminate neck sides and sublevels, or minimal neck-dissection nodal yield (NY).

Methods: Thirty-seven consecutive primary TL cases from 2009 to 2019 were retrospectively analyzed in terms of local tumor growth using a previously established imaging scheme, metastatic neck involvement, and NY impact on survival.

Results: There was no case of level IIB involvement on any side. For type A and B tumor midline involvement, no positive contralateral lymph nodes were found. Craniocaudal tumor extension correlated with contralateral neck involvement (OR: 1.098, p = 0.0493) and showed increased involvement when extending 33 mm (p = 0.0134). Using a bilateral NY of ≥ 24 for 5-year overall survival (OS) and ≥ 26 for 5-year disease-free survival (DFS) gave significantly increased rate advantages of 64 and 56%, respectively (both p < 0.0001).

Conclusions: This work sheds light on regional metastatic distribution pattern and its influence on TL cases. An NY of n ≥ 26 can be considered a desirable benchmark for bilateral selective neck dissections as it leads to improved OS and DFS. Therefore, an omission of distinct neck levels cannot be promoted at this time.

Keywords: Advanced laryngeal cancer; HNSCC; Level IIB; Neck dissection; Nodal yield; Total laryngectomy.

Fig. 1

Neck level involvement using a simplified topographical scheme. Bold face: level name; top line: no. cases of positive node(s) from pathology/no. cases dissected; bottom line: no. mean positive nodes/mean nodal yield. Level “II” cases lacked a sublevel distinction into A or B on pathology reports

Fig. 2

Midline involvement scheme* and case distribution. For types A and B, no contralateral neck involvement was detected on pathology. A significant uneven distribution for midline type and contralateral involvement became evident (p = 0.025). For grouped imaging-based midline types, a risk of 4.0% for contralateral involvement in type A + B and 37.14% for type C + D cases was calculated (p = 0.1565). *According to Ref. (Böttcher et al. 2017)

Fig. 3

Risk estimation for contralateral lymph-node involvement depending on craniocaudal tumor extension. Craniocaudal extension exerted a significant influence on the appearance of contralateral lymph-node development on histology with an odds ratio of 1.098 (CI 1.000–1.205, p = 0.0493) per mm of growth

Fig. 4

Survival estimation with regard to regional lymph-node involvement. Kaplan–Meier curves depicting overall survival (OS) (a) and disease-free survival (DFS) (b) for pN0 necks compared to ipsilateral and bilateral pN + necks. There is a significant median DFS advantage of 49.7 months for pN0 necks compared to bilateral neck involvement and 34.9 months for pN0 necks compared to ipsilateral neck involvement (p = 0.049)

Fig. 5

Survival estimation with regard to neck-dissection nodal yield. Kaplan–Meier curves depicting overall survival (OS) (a) and disease-free survival (DFS) (b) for a nodal yield cut-off at n < / ≥ 50, including pN0 cases. Trends towards advantages for a NY ≥ 50 in 5-year OS and DFS rates are evident, but lack statistical significance (17%, p = 0.17, and 22%, p = 0.098, respectively)

Fig. 6

Survival estimation with regard to optimized NY. Cut-off point calculation of n = 24 for overall survival (OS) (a) and n = 26 for disease-free survival (DFS) (b). Significant survival advantages are evident leading to an increased median DFS of 62.8 months for a NY > 26 compared to 2.4 months for a NY < 26 (p < 0.0001)