Indian J Otolaryngol Head Neck Surg
https://doi.org/10.1007/s12070-021-02470-7
ORIGINAL ARTICLE
Role of Neck Dissection in Organ-Preservation for Glottic
Squamous Cell Carcinoma
Kuauhyama Luna-Ortiz1,2 • Nancy Reynoso-Noverón3 • Luis C. Zacarı́as-Ramón1 •
Zelik Luna-Peteuil4 • Dorian Y. Garcı́a-Ortega5
Received: 18 January 2021 / Accepted: 16 February 2021
Ó Association of Otolaryngologists of India 2021
Abstract The surgical approach to the neck in laryngeal 87.3%. The 60-month disease-specific survival was 97.1%.
cancer depends on the tumor site and stage. Clinical Bilateral neck dissection and Delphian node dissection
practice guidelines recommend elective neck dissection showed a low rate of metastasis (2.8%). Radical neck
in C T2 N0 and all supraglottic cancers; however, there is dissection may thus represent overtreatment; however, this
no evidence supporting these recommendations. The surgical procedure could be justified to prevent regional
objective is to evaluate the results of bilateral elective neck recurrences.
dissection in patients with glottic cancer who underwent
supracricoid partial laryngectomy (SCPL) with cricohyoi- Keywords Glottis Organ preservation Neck dissection
doepiglottopexy (CHEP). Thirty-five patients diagnosed Supracricoid partial laryngectomy
with C T2 N0 laryngeal squamous cell carcinoma (LSCC) Cricohyoidoepiglottopexy Cancer Delphian lymph node
in a single-center retrospective study. Right-sided neck
dissections yielded 900 lymph nodes, none of which were
positive for metastatic disease. Left-sided neck dissections Introduction
yielded 949 lymph nodes, one of which was positive for
malignancy. Prelaryngeal (Delphian) neck dissection was The surgical approach to the neck in laryngeal cancer
performed in all patients. Out of 50 lymph nodes removed; depends on the tumor site and stage. Accurate staging in
one was positive for malignancy. Median overall survival cN0 patients leads to appropriate management of early
was 172 months, and the 60-month overall survival was supraglottic cancer (which has a 30% chance of spreading
to the lymph nodes) or advanced glottic cancer. For
cN ? patients, neck management depends on the treatment
& Kuauhyama Luna-Ortiz
kuauhyama@yahoo.com.mx
used for the primary tumor, especially in larynx-preserva-
tion strategies. Organ preservation treatment includes open
1
Department of Head and Neck Surgery, Instituto Nacional de or transoral laser microsurgery, radiotherapy, chemora-
Cancerologia (Mexico), Av. San Fernando # 22, Col. Sección diotherapy, or induction chemotherapy followed by surgi-
XVI, 14080 Tlalpan Mexico CDMX, Mexico
cal resection [1, 2]. Out of 500 patients with laryngeal
2
Department of Surgery (Head and Neck Surgey), Hospital cancer at different sites and stages that we identified in our
General Manuel Gea Gonzalez (Mexico), Mexico City,
Mexico
cancer center, 66% were cN0 [3].
3
Clinical practice guidelines recommend elective neck
Basic and Clinical Research, Instituto Nacional de
Cancerologı́a (Mexico), Av. San Fernando #22, Col. Sección
dissection in C T2 cN0 cases and all supraglottic cancers.
XVI, 14080 Tlalpan, Mexico City, Mexico However, these recommendations arise from studies
4 assessing total laryngectomy as the surgical procedure
Universitatea de Medicinâ Si Farmacie Grigorie T. Popa IASI
(visitor medical student), Mexico City, Mexico [1, 4–6]. The extent of neck dissection includes levels II–
5 VI; however, some authors have suggested a less extensive
Surgical Oncology, Instituto Nacional de Cancerologı́a
(Mexico), Av. San Fernando #22, Col. Sección XVI, 14080 surgery of just II–IV [7–10]. Even though bilateral or
Tlalpan, Mexico City, Mexico central neck dissection in patients with laryngeal cancer
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Indian J Otolaryngol Head Neck Surg
has not been thoroughly studied, some guidelines recom- Statistical Analysis
mend procedures that are yet to be fully supported by
evidence from clinical trials [11, 12]. We aimed to evaluate We performed a descriptive analysis of demographic and
the results of elective neck dissection in glottic cancer clinical characteristics. We used measures of central ten-
patients treated with larynx-preservation surgery, specifi- dency and dispersion to perform an inferential analysis and
cally supracricoid partial laryngectomy (SCPL) with determine the overall and disease-specific survival
cricohyoidoepiglottopexy (CHEP). according to the Kaplan–Meier estimator. We used STATA
v14.2 for statistical analysis.
Material and Methods
Results
A single-center, retrospective, cohort study was conducted
by identifying all consecutive patients treated with SCPL- Cohort of Patients
CHEP during a 20-year period (January 2000–December
2019). This study was reviewed and approved by the Demographic and clinicopathological data of all 35
Institutional Review Board and registered under the num- patients are shown in Table 1.
ber IRB 2019/0116.
A total of 85 patients were identified, and 35 were Neck Dissection
included for final assessment. All patients included were
diagnosed with laryngeal squamous cell carcinoma Right-sided dissection yielded 900 lymph nodes; none of
(LSCC). Staging was determined with physical examina- which was positive for metastasis. Left-sided dissection
tion and nasolaryngoscopy before treatment. A computed yielded 949 lymph nodes; one of them had metastasis (no
tomography scan was performed in most patients. Patients extranodal extension was found). Fifty Delphian lymph
with C T2 and cN0 were included in the study. At the nodes were dissected, and one of them had metastasis. Two
beginning of the period covered in the study, laser surgery patients (5.7%) at high risk of recurrence (surgical margin
was not available at our cancer center, which is the current close to malignancy and a sarcomatoid variant of SCC)
treatment of choice; therefore, some T2 patients were received adjuvant treatment. No patient reported lymph
treated with SCPL-CHEP (our procedure of choice for T2 node recurrence during follow-up. Five patients (14.3%)
glottic cancer at the time). Another criterion for choosing experienced local recurrence, three (8.6%) underwent total
this surgical procedure was poor visualization during direct laryngectomy, and two received radiotherapy. Thirty-two
laryngoscopy. All 35 patients included were treated with patients (91.4%) preserved their larynx throughout follow-
either SCPL-CHEP, bilateral, radical, or modified neck up. Three deaths (8.6%) were attributable to laryngeal
dissection including levels II–V. Delphian lymph nodes cancer. Median follow-up was 89.6 months (1.4 – 202).
were deliberately dissected in all patients because this is Median overall survival was 172 months. The probability
the standard management of laryngeal cancer patients of survival at 60, 120, and 180 months was, respectively,
treated with SCPL at our center. Head and neck cancer 87.3%, 72%, and, 40.6%. Additionally, the disease-specific
specialists evaluated the surgical specimens and defined survival was 97.1% at 60 months and 83.7% at both 120
positive lymph nodes as those where neoplastic cells were and 180 months. Overall and disease-specific survival are
found. shown (Kaplan–Meier plot) in Figs. 1 and 2.
We excluded patients who had a histologic diagnosis
other than SCC in the final pathology report, supraglottic or
subglottic epicenters, T1 tumors, or who had previously Discussion
received other treatment (e.g., radiotherapy, chemoradio-
therapy, neoadjuvant/induction chemotherapy). Patients SCPL-CHEP is an open larynx-preserving surgery recom-
who had undergone radiotherapy limited to the larynx were mended by several clinical practice guidelines as the pre-
not excluded. The results of bilateral neck dissection and ferred organ-preserving surgery for some T3 tumors [1, 13]
Delphian lymph node dissection were analyzed. Dissected and T2 laryngeal tumors unsuitable for laser resection. Our
lymph nodes and positive lymph nodes were reported. study only included C T2 glottic tumors; therefore, it can
be assumed that surgery was appropriate and adhered to
international guidelines. Most patients with T1–T2 laryn-
geal cancer are currently treated with laser transoral sur-
gery at our center. Patients deemed unsuitable for laser
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Indian J Otolaryngol Head Neck Surg
Table 1 Clinical and follow-up data Table 1 continued
n = 35 N (%) n = 35 N (%)
Age (mean) 56 (50–65) Total lymph nodes dissected 900
Sex Mean lymph nodes dissected 25.7
Male 33 (94.3) Range 12–57
Female 2 (5.7) Positive lymph nodes 0
Comorbidities Left neck dissection
None 34 (97.14) Neck dissections 35 (100)
Diabetes mellitus 0 (0) Total lymph nodes dissected 949
Thyroid cancer 1 (2.86) Mean lymph nodes dissected 27.1
Previous treatment Range 9–61
Induction chemotherapy 0 (0) Positive lymph nodes 1 (2.8%)
None 32 (92.8) Delphian node dissection
Radiotherapy 1 (2.86) Delphian node dissections 35 (100)
Transoral laser surgery 2 (5.7) Patients with identifiable Delphian lymph nodes 30 (85.7)
Site Number of patients according to 22 (62.9)
Glottis 31 (88.6) Delphian nodes resected
Glottis ? supraglottis 1 (2. 9) 1 LN 3 (8.6)
Glottis ? subglottis 3 (8.6) 2 LN 1 (2.9)
Histology 3 LN 2 (5.7)
Conventional squamous cell carcinoma 33 (94.29) 4 LN 1 (2.9)
Sarcomatoid carcinoma 2 (5.71) 5 LN 1 (2.9)
(spindle cell squamous cell carcinoma) Total Delphian nodes dissected 50
Histologic grade Mean Delphian nodes dissected 1.4
GX 0 (0) Range 0–6
G1 19 (54.3) Positive Delphian nodes 1 (2.9)
G2 13 (37.1) Tracheostomy (days) 8.8 (6–8)
G3 3 (8.6) NGT (days) 18.2 (13–19)
cT Hospital stay (days) 10.1 (3–45)
T2 14 (40) Adjuvant treatment
T3 17 (48.6) None 31 (88.5)
T4 4 (11.4) Radiotherapy 4 (11.4)
cN Follow-up
N0 35 (100) Alive and recurrence-free 11 (31.43)
cM Lost and recurrence-free 12 (34.29)
M0 35 (100) Lost with recurrence 0 (0)
Clinical stage Deceased and recurrence-free 9 (25. 7)
I 0(0) Deceased with recurrence 3 (8.6)
II 13 (37.1) Recurrence
III 19 (54.3) No 30 (85.71)
IV 3 (8.6) Local recurrence 5 (14.29)
pN Survival
N0 33 (94.3) Yes 23 (65.71)
N1 1 (2.86) No 12 (34.29)
N2 1 (2.86)
Preserved arytenoids
1 9 (25.7) resection, often due to inadequate exposure, are advised to
2 26 (74.3) undergo cordectomy through laryngofissure or SCPL-
Right neck dissection CHEP.
Neck dissections 35 (100) International guidelines have yet to standardize elective
neck dissection for laryngeal cancer. Our case series of 500
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Indian J Otolaryngol Head Neck Surg
fully agree given that in our study only 3.4% of early
glottic tumors (T1–T2) had lymph node metastasis [3].
Based on the Brazilian Head and Neck Cancer Study
Group (BHNCSG), neck dissection is recommended in [
T2 glottic cancer and all tumors with supraglottic exten-
sion, even without clinical lymph node disease. In 1999,
the BHNCSG described 26% of occult lymph node disease
in supraglottic and transglottic cancers [8]. In our study,
only three cases out of 35 showed invasion of other
laryngeal sites. UK guidelines [5] suggest elective neck
dissection in C T2b tumors but with no supporting clinical
data. In our study, no T2 patients showed metastatic lymph
nodes. Shi et al. [15] reported occult lymph node disease in
15% of glottic cancer patients, while Riviere et al. [16]
Fig. 1 Overall survival according to Kaplan–Meier found occult lymph node disease in 14% of patients with
T3 laryngeal cancer who underwent total laryngectomy and
in 70% of T4 patients; however, they included patients
with supraglottic tumors. Our cancer center previously
reported 75% and 50% of pN0 after neck dissection in T3
and T4 glottic cancer patients, respectively [3]. The present
study shows an incidence of nodal metastatic disease of
only 2.8% for T2–T4 tumors.
Neck dissection should be ipsilateral for primary glottic
tumors, limiting a bilateral approach to larger glottic
tumors. The management of supraglottic tumors has
apparently been established. Weber et al. [17] suggested
bilateral neck dissection in patients with supraglottic can-
cer, based on their results of decreasing lymph node
recurrence by 11% when compared with unilateral neck
dissection. Since the introduction of SCPL-CHEP, bilateral
Fig. 2 Disease-specific survival according to Kaplan–Meier
neck dissection has been the standard procedure at our
center. We follow Prof. Laccourreye’s instructions, who
laryngeal cancer patients included 308 glottic tumors, of
promotes this procedure to avoid technical difficulties in
which 242 (78.5%) were classified as cN0. The proportion
case of recurrence. Furthermore, high-volume centers
of cN0 cases to their respective T status was: 51/55 (92%)
agree that neck dissection has become a relatively safe
for T2, 91/132 (75%) for T3, and 29/58 (50%) for T4.
procedure with low morbidity. [18] Contralateral elective
Some studies clearly indicate neck dissection in T3 and T4
neck dissection is less frequently justified in patients with
patients [3]; however, they are retrospective studies.
glottic cancer, and its performance depends on the degree
Moreover, not all patients underwent imaging studies (ul-
of local extension and Delphian node status [19]. Our
trasound, CT scan, MRI), which could have led to over-
findings could result in two distinct clinical approaches: a
staging. Myers et al. [13] stated that even with these
conservative ‘‘watch and wait’’ approach restraining from
imaging studies added to the work-up, the size threshold
performing contralateral neck dissection while considering
for considering a lymph node as suspicious for malignancy
that neck recurrence will significantly affect prognosis;
is 10 mm. Gallo et al. [14] reported that despite using fine
conversely, bilateral neck dissection could be justified
needle aspiration cytology, 7–10% of cases may have
based on the absence of recurrence during follow-up and
occult lymph node metastasis. The National Comprehen-
that only 2.8% of patients were pN ? (one T4 patient who
sive Cancer Network (NCCN) guidelines [4] suggest
did not meet the criteria for postsurgical radiotherapy). All
against neck dissection in T1 glottic cancer, but they state
recurrences were local. The five-year overall survival was
that neck dissection in glottic cancer should be done at the
100% and the larynx-preservation rate was 91%. The latter
surgeon’s discretion; and if performed, neck dissection
approach including bilateral neck dissection would be more
should include level VI when appropriate. The American
appropriate for the population at our center due to their
Society of Clinical Oncology (ASCO) [1] advice against
demographic and cultural characteristics.
elective neck dissection in T1–T2 tumors, with which we
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Indian J Otolaryngol Head Neck Surg
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