Upper mediastinal and paratracheal node dissection in total (pharyngo) laryngectomy, it is really indicated?

doi:10.4236/ojst.2011.14028

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Open Journal of Stomatology, 2011, 1, 185-188

doi:10.4236/ojst.2011.14028 Published Online December 2011 (http://www.SciRP.org/journal/ojst/

OJST

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJST

Upper mediastinal and paratracheal node dissection in total

(pharyngo) laryngectomy, it is really indicated?

Didier Dequanter, M. Shahla, P. Paulus, P. Lothaire

Department of Head and Neck Surgery, CHU Charleroi, Montigny le Tilleul, Belgium.

Email: [email protected]

Received 25 July 2011; revised 29 August, 2011; accepted 14 September 2011.

ABSTRACT

Introduction: Advanced laryngeal and hypopharyn-

geal cancers are aggressive tumors with a poor prog-

nosis. Multiple lymph node metastases often occur in

the neck as well as in the upper mediastinum and

thus upper mediastinal dissection is crucial to im-

proving the cure rate. However, excessive mediastinal

dissection can increase postoperative morbidity and

mortality making it important to employ the proper

technique and appropriate extent of dissection. In the

present study, we aimed to determine the need and

the prognostic importance of mediastinal dissection

in patients with advanced carcinoma of the upper

aerodigestive tract. Methods: A retrospective review

of the records of 30 patients who underwent (phar-

ynxgo) laryngectomy for advanced squamous cell

carcinomas was done. 17 patients had laryngeal car-

cinomas, 13 had hypopharyngeal carcinomas. The

mediastinal dissection was designed to remove mainly

the paratracheal and retrooesophageal lymph nodes.

Results: 60 neck dissections and 30 mediastinal dis-

section were performed in 30 patients and yielded

positive nodes were found in 20/30 patients. Neck

nodes were positive in 9/17 of the patients with la-

ryngeal cancer and 11/13 of the patients with hypo-

pharyngeal cancers respectively. Positive nodes were

detected in the neck regardless of T stage. The medi-

astinal nodes were positive in 0% of the patients with

laryngeal cancer. Upper mediastinal metastases were

detected positive in 6/13 of the hypopharyngeal pa-

tients. In these patients, mediastinal metastases were

associated with tumors greater than 35 mm. The ma-

jority of positive paratracheal nodes were less than 1

cm in diameter and appeared negative preoperatively.

0% of the patients had positive paratracheal nodes

alone in a histologically negative cervical neck dissec-

tion Regarding the appropriate extent of dissection,

no major complications were observed. Conclusions:

There is little controversy about neck dissection in

advanced tumors of the (pharyngo) larynx. Laryn-

geal carcinomas showed no positive mediastinal no-

des in this series. The study highlighted the propen-

sity of advanced hypopharyngeal cancers to involve

the paratracheal nodes.

Keywords: Advanced Head and Neck Cancer; Medi-

astinal Dissection; Hypopharynx

1. INTRODUCTION

(Pharyngo) laryngeal squamous cell carcinoma is a very

aggressive cancer that is generally diagnosed at advan-

ced stages and, consequently, has a poor prognosis and

low survival. More than 75% of patients with (pharyn-

go) laryngeal tumors have stage III or IV disease at

presentation [1]. Indeed, cervical metastases are present

in 60% - 80% [2,3] and, often, associated with multiple

lymph nodes metastases that occur in the upper medi-

astinum as well as in the paratracheal area. Although

neck dissection is the surgical standard for the treatment

of cervical lymph spread the upper mediastinal paratra-

cheal nodal group is not routinely included in the dissec-

tion. However, metastases to paratracheal lymph nodes

occur in 30% of patients, mostly with hypopharyngeal

tumors [4]. A 20% frequency of occult metastases to

ipsilateral paratracheal lymph nodes has been reported in

laryngeal cancer patients with postcricoid lesions and in

patients with tumors that involved the pyriform fossa [5].

Moreover, laryngeal/hypopharygeal metastatic disease

involving the paratracheal nodal group has been impli-

cated in recurrent disease, particulary in patients with

peristomal recurrence; this suggest the prognostic sig-

nificance of positive paratracheal metastatic spread [6,7].

The purpose of this study was to analyse the paratra-

cheal nodal yield and frequency of metastases and de-

termine the indications of the upper mediastinal paratra-

cheal dissection.

2. METHODS

The study group consisted of 30 patients that were not

previously treated for advanced squamous cell carcinoma

D. Dequanter et al. / Open Journal of Stomatology 1 (2011) 185-188

186

(SCC) of the (pharyngo) larynx. They underwent surgery

from May 2007 to July 2010. The cases were reviewed

retrospectively. The diagnostic evaluation at presentation

included a complete physical examination, panendo-

scopy, CT and /or MRI scans of the head and neck, chest

X-rays, and laboratory tests. We assessed the CT and/or

the RMN to determine the regional lymph node status.

No patient had radiological evidence of distant metasta-

sis at presentation, and all patients were treated with

curative intent. At our institution in principal the choice

of radical therapy is surgery for advanced tumors and

neck lymph node metastasis is treated by neck dissection.

Additional radio (chemo) therapy in conducted in pati-

ents with multiple lymph node metastasis.

To determine the significance between paratracheal

lymph node metastasis and clinical factors (such as age,

gender, primary tumor site, TN stage, pTN stage, the

chi-square test, Fisher’s exact test, multiple logistic re-

gression analysis, multiple linear regression analysis,

and correlation analysis were used, as appropriate. A p <

0.05 was considered statistically significant.

3. RESULTS

The median age was 58 years (range 43 - 90 years);

there were 25 males and 5 females the follow-up period

ranged from 3 to 41 months with a mean of 27 months.

The site of the original primary tumor was recorded in

all patients and included: 17 patients with a laryngeal

cancer and 13 patients with hypopharyngeal tumor.

Concerning the disease stage of the cervical lymph

nodes, there were 6 N0 patients; 4 N1 patient and 20 N2

patients

Regarding the pathological stage, 14 patients had T3

staged cancers and 16 patients had T4 cancers.

Regarding the cell differentiation, there were 12 well-

differentiated, 9 moderate-differentiated, and 9 poorly

differentiated cases, respectively.

For tumor excision, 17 patients had total laryngec-

tomy and 13 pharyngolaryngectomy. Laryngeal resection

was performed under direct vision based on the invasion

of the tumor. The surgical defects were reconstructed

with pectoralis major myocutaneous flap in 13 cases. All

the patients had neck dissection at the time of the pri-

mary surgery. A modified bilateral radical neck dissec-

tion was performed in all cases. All the patients had a

bilateral paratracheal lymph node dissection. The para-

tracheal node dissection included dissection of all of the

nodes between the carotid artery laterally and the trachea

medially, as far inferior into the superior mediastinum as

possible through the cervical approach. There was no

preoperative mortality.

The rate of ipsilateral paratracheal lymph nodes me-

tastasis was 6/30. No patients had controlateral paratra-

cheal nodes.

The mean number of paratracheal lymph nodes dis-

sected per side was 2.3.

Histological paratracheal metastasis in the clinically

node positive neck were present in patients with pyri-

form sinus cancer. All the patients had a tumor greater

than 35 mm. In the clinically node negative, no paratra-

cheal histological metastases were found.

At the end of the follow-up, 10/30 died. More speci-

fically, 3/6 (50%) of the patients with positive paratra-

cheal nodes died.

We analysed the correlation between paratracheal ly-

mph nodes metastasis and several clinical factors among

the 30 patients (Table 1).

There was a strong but not statistically significant cor-

relation of paratracheal lymph node metastasis with the

primary site. However, there was no significant relation-

ship between age, gender, TN stage and pTN stage and

paratracheal lymph node metastasis.

4. DISCUSSION

Advanced laryngeal and hypopharyngeal carcinomas had

a high tendency to invade cervical lymph nodes. This

nodal extension is a well-known prognostic factor [7-

10].

Table 1. Clinical factors affecting paratracheal lymph node

metastasis in patients with laryngeal and hypopharyngeal car-

cinomas.

Parameters PTN positive

(n= 6)

PTN negative

(n = 24) P value

Age

<60

≥60

3 (17%)

3 (25%)

15 (83%)

9 (75%)

0.57

Gender

Male

Female

6 (24%)

0 (0%)

19 (76%)

5 (100%)

0.54

Primary site

Larynx

Hypopharynx

0 (0%)

6 (38%)

16 (100%)

8 (62%)

0.08

T clinic stage

0 (0%)

6 (26%)

7 (100%)

17 (74%)

0.77

T anapathological

stage

0 (0%)

6 (38%)

14 (100%)

10 (62%)

0.54

N clinic stage

0 (0%)

6 (30%)

6 (100%)

4 (100%)

14 (70%)

0.58

N anapathological

stage

0 (0%)

6 (38%)

9 (100%)

4 (100%)

10 (62%)

0.36

D. Dequanter et al. / Open Journal of Stomatology 1 (2011) 185-188 187

Although neck dissection is the surgical gold standard

for the treatment of cervical lymphatic spread, the upper

mediastinal and paratracheal nodal groups are not rou-

tinely included in the dissection.

However, Welsh et al. [11] initially reported the im-

portance of the paratracheal nodes in lymphatic drainage

of the larynx and hypopharynx. Harrison et al. con-

firmed that carcinomas of the larynx (especially from the

subglottic region), the trachea, and the cervical esopha-

gus are at risk for paratracheal and tracheobronchial

lymph node metastasis and recommended resection of

the manubrium to remove theses lymph nodes and re-

duce the risk for parastomal disease recurrence [5]. We-

ber et al. [7] reported that paratracheal lymph node me-

tastasis were found in 17.6% of the patients with tumors

of the larynx, in 8.3% of the patients with pharyngeal

tumors and, at least, in 71.4% of the patients with tumors

of the esophagus.

Some investigators have suggested that ipsilateral

paratracheal node dissection should be included as part

of a selective neck dissection in all patients with tumors

invading the subglottis, pyriform fossa apex and postcri-

coid region [12].

In our study, all the patients with advanced laryngeal

and hypopharyngeal SCC had a neck dissection extend-

ed to the upper mediastinum. Most patients with hypo-

pharyngeal SCC had positive paratracheal lymph nodes

but only to the ipsilateral side of the primary. All the

patients with hypopharyngeal SCC greater than 35 mm

had paratracheal lymph node metastasis. Furthemore,

paratracheal lymph node metastasis was always associ-

ated with the presence of cervical lymph node metastasis.

In addition, a strong correlation but, unfortunately, not

statistically significant was found between the presence

of paratracheal lymph node metastasis and hypoharyn-

geal tumors.

We recommend that ipsilateral paratracheal node dis-

section should be included as part of a selective neck

dissection in all patients with tumors invading the hypo-

pharynx, certainly in tumors greater than 35 mm.

In terms of survival rates, in a prospective study of 50

patients with carcinoma of the larynx, hypopharynx, and

cervical esophagus, Timon et al. [13] reported that the

rate of paratracheal nodal metastases was 26%. More-

over, they reported that the survival in patients with po-

sitive paratracheal nodes demonstrated a trend towards

poorer survival compared to patients without paratra-

cheal nodal involvement, and concomitant involvement

of both cervical and paratracheal nodal groups was asso-

ciated with the poorest survival propability.

In their study, Weber et al. [7] confirmed that survival

was significantly reduced by the presence of paratra-

cheal lymph nodes. In our study, 50% of the patients

with positive paratracheal nodes died.

In conclusion, there is little controversy about neck dis-

sections in advanced tumors of the larynx and hypo-

pahrynx. A similar situation applies to mediadtinal dis-

section for hypopharyngeal carcinomas, certainly in tu-

mors greater than 35 mm.

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