Paratracheal lymph node dissection in cancer of the larynx, hypopharynx, and cervical esophagus: The need for guidelines

Abstract

In laryngeal, hypopharyngeal, and cervical esophageal carcinomas, the paratracheal lymph nodes (PTLN) may be at risk for lymph node metastasis. The presence of PTLN metastasis is an important prognostic factor for the development of mediastinal and distant metastases, stomal recurrence, and disease-free and overall survival. Studies on PTLN metastasis are scarce. In most studies, PTLN dissection has not been routinely performed, and selection criteria for PTLN dissection are usually not well defined. Therefore, in most reported studies, selection bias is present and results are difficult to compare. The reported prevalence of PTLN metastases varies according to the site and stage of the primary tumor: subglottic cancer, transglottic cancer, and glottic cancer with subglottic extension have a higher risk of PTLN metastases. Diagnostic imaging is not sufficiently reliable to detect occult PTLN metastases and avoid unnecessary PTLN dissections. PTLN dissection is associated with limited morbidity, but damage to major vessels may occur, and because of exposure of these vessels PTLN may increase the morbidity of fistulae that can occur after total laryngectomy. The dissection may produce hypocalcemia, if performed bilaterally. Nevertheless, the limited morbidity and high rate of metastasis in specific laryngeal, hypopharyngeal, and cervical esophageal carcinomas argue in favor of routine elective PTLN treatment for these tumors. Large prospective studies are needed to identify the patients at risk with primary tumors in more detail. Moreover, improved diagnostic imaging is needed to detect (occult) PTLN metastases more reliably. Based on future studies, clinical guidelines have to be developed to avoid undertreatment and overtreatment.

Subtotal laryngectomy: outcomes of 469 patients and proposal of a comprehensive and simplified classification of surgical procedures

“…In case of subglottic extension, homo-or bilateral paratracheal lymph node dissection should be performed considering the high prevalence of occult metastases [22].…”

Elective superior mediastinal dissection for laryngeal carcinoma involving subglottis

“…Although the suprasternal notch is considered a constant anatomic landmark separating the paratracheal and superior mediastinal compartments, the boundaries of these compartments cannot be determined precisely due to the variable anatomic conformation of the thoracic inlet in different patients [8]. Therefore, the extent of the PTLND and superior mediastinal dissection is controversial and varies according to each surgeon's preference [8,9].…”

“…Therefore, the extent of the PTLND and superior mediastinal dissection is controversial and varies according to each surgeon's preference [8,9]. Regarding the recent studies analyzing the role of PTLND in laryngeal carcinomas, it can be seen that there are no standardized data, especially on the inferior limit of PTLND [10,11].…”

Optimal Treatment for Early Glottic Carcinoma

“…No significant difference in local control or survival has been seen on comparing open CLS or TOLMS and radiation therapy [16][17][18][19]. T2 tumors with impaired vocal fold mobility have local control rates lower than with normal mobility, whether the treatment is radiation therapy, TOLMS, or open CLS [9,15,17,[20][21][22][23]. Local control rates falling as low as 50% has been reported.…”

“…Tumors with deep extension into the paraglottic space had a much lower rate of local control, disease-free survival, and larynx preservation than more superficial T2 tumors. Significant subglottic extension is not only contraindication to the conservative procedures but also has higher risk of paratracheal node metastases [22]. Globally, the use of open surgery has been declining, as TOLMS has taken over as the main surgical approach, but this does not mean that open surgery is not a legitimate option.…”