Occult nodal disease in patients with failed laryngeal preservation undergoing surgical salvage

Abstract

Objectives/hypothesis: The primary objective was to determine the incidence of pathologically positive lymph nodes in clinically N0 larynx cancer patients undergoing salvage surgery following nonsurgical primary therapy. Secondary aims included assessment of the impact of laryngeal subsite and neck dissection on disease status and survival.

Study design: Retrospective chart review.

Methods: Sixty-eight patients with recurrent laryngeal cancer and no evidence of neck disease who underwent salvage laryngectomy and neck dissection after undergoing failed primary radiotherapy or chemoradiation were examined. Main outcome measures included: standard demographics, primary, clinical, radiologic, and pathologic recurrent TNM stage, laryngeal subsite, nodal neck level, surgical intervention, margin status, disease status, survival, and imaging results.

Results: Fifty-three men and 15 women, aged 33 to 88 years (mean=62.7 years) with recurrent laryngeal cancer were included. Overall, 28.3% of patients had pathologic nodal disease, with supraglottic cancer showing the highest rate (60%, P=.02). Survival was not associated with laryngectomy type (P=.35). However, on multivariate analysis, laryngeal subsite was significantly predictive of survival with transglottic recurrences demonstrating decreased mean survival (20.7 months, P=.02), and supraglottic recurrences demonstrating prolonged mean survival (37.1 months, P=.03). Metabolic imaging (negative predictive value=0.86) proved more reliable than anatomic imaging (negative predictive value=0.71).

Conclusions: The incidence of pathologically positive lymph nodes in clinically negative patients with recurrent laryngeal carcinoma following nonsurgical therapy warrants standard selective neck dissection. Subsite of recurrence, specifically supraglottis and transglottis, correlates with pathologic neck node positivity and survival. Metabolic imaging proved more reliable than anatomic imaging in negative predictability for nodal disease.

Level of evidence: 4.

Keywords: N0; Recurrent or persistent larynx cancer; chemotherapy failure; neck dissection; positron emission tomography; radiation failure; salvage surgery.