When salvage laryngectomy is required in the setting of recurrent cancer after primary irradiation or chemoradiation therapy, is elective neck dissection always indicated?
Background: No prospective, randomized studies have been performed on this topic. Other authors report mixed findings. It is generally conceded that a risk of occult metastatic disease in excess of 20% justifies the use of elective neck dissection. In the setting of radio-resistant tumor at the primary site, concern exists that occult disease in the nodes may have been similarly resistant. Additionally, the risk to patients who had been initially node positive may be different from those who were clinically negative at the time of primary irradiation.
Study design: A retrospective study was based on the clinical records of patients who required salvage laryngectomy. All patients were node negative at the time of salvage surgery.
Setting: The study was performed between 1991 and 2011 at two academic medical centers.
Synopsis: Only 42 patients were available for study. At the time of primary treatment, 14 (33%) had previously undergone central neck irradiation, while 28 (67%) had undergone central and lateral neck irradiation. The primary tumor was supraglottic in 16 and glottic in 26 patients. Only eight of the patients were node positive at initial presentation. The overall rate of occult node metastasis was 19%. Subgroup analysis demonstrated that the patients at highest risk were those who had been treated for clinically positive nodes at the time of their initial treatment. The rate of occult node metastasis in the advanced glottic group, excluding patients with N positive disease at initial presentation, was 15%.
Bottom line: Patients who fail primary irradiation or chemoradiation are at highest risk for persistent occult nodal disease if the nodes are positive at presentation. While the study does not provide a definitive answer to the question, it calls attention to the potential need for surgeons to consider elective neck dissection in the lower risk groups, because there is no effective adjuvant therapy in this setting.
Citation: Amit M, Hilly O, Leider-Trejo L, et al. The role of elective neck dissection in patients undergoing salvage laryngectomy. Head Neck. 2013;35:1392-1396.