Considerations in the treatment of the node-negative (N0) neck in glottic carcinomas

Abstract

Treatment of lymph node negative (N0) glottic carcinoma has raised numerous controversy for decades. Prevention is one of the oldest axioms in medicine. On the other hand, overtreatment can cause unnecessary harm to patients. This retrospective study was performed in 206 patients having glottic cancers with clinically node-negative (N0) necks. The aim of this assessment is to deal with the diagnosis, predictive factors and surgical therapy of occult metastases of squamous cell cancers originating from the glottic region. The examinations were performed in three phases. Preoperative clinical, histological - and in selective cases - imaging were carried out to separate high-risk patients. Intraoperative cases of open surgery after U-shaped skin preparation up to the hyoid bone with direct inspection of jugular lymph node chain (JLNCh) where the neck was staged. The enlarged suspicious nodes were submitted for immediate frozen section. The types of neck dissection were based on the size, shape, number and histological diagnosis of regional nodes. The postoperative additional management was decided according to the results of definitive pathological findings from serial sections of the dissected specimen. Endolaryngeal LASER surgery was carried out in 87 patients based on clinical, histological and imaging criteria. In the course of two years follow-up 2 occult metastases became clinically apparent. At 119 cases open surgery were performed. In 51 patients we could not see enlarged lymph nodes (N< 2 mm) with direct examination, and thus the JLNCh remained intact. In 68 patients elective neck dissections (END) were carried out. In cases of extracapsular spread (ECS) and/or multiple nodal involvements additional radiotherapy was given.

Incidence of Occult Lymph Node Metastasis in Primary Larynx Squamous Cell Carcinoma, by Subsite, T Classification and Neck Level: A Systematic Review

“…All the studies were case series, except the case control study by Djordjevic et al [45]. Eight studies were prospective [20,25,27,29,36,39,42,45]; fifteen studies analyzed the larynx without specification of occult metastasis by subsite [10,13,15,20,[24][25][26][27]29,34,37,39,40,43,46]; nineteen analyzed supraglottic tumors [10,12,14,16,18,19,22,23,28,[30][31][32][33]35,36,38,42,44,45]; and six, glottic tumors [10,17,21,23,31,41]. Katilmis et al included a small number of hypopharynx tumors (13/213)…”

“…Five of 105 patients (4.8%) had occult metastasis. It was impossible to calculate a pooled incidence as Elo et al [21], Pinilla et al [23] and Lim et al [29] did not observe any event in this category.…”

“…From the six studies that specified glottic tumors [10,17,21,23,31,41] approximately two thirds (65.6%) were classified as T1-2. They reported a pooled incidence for occult metastasis of 8.0% (95% CI 2.7-13.3, I2 = 81%) ( Figure S1).…”

“…Five studies reported data on the T1 stage [16,21,23,29,31]. Five of 105 patients (4.8%) had occult metastasis.…”

“…Fourteen studies reported data on the T3 stage [10,[14][15][16][17]21,23,28,29,[31][32][33]42,44]. For the subgroup of glottic tumors [10,17,21,23,31], the pooled incidence was 14.4% (95% CI 6.9-21.8, I2 = 11%).…”