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Epidermoid carcinoma of the supraglottic larynx
Epidermoid Carcinoma of the Supraglottic Larynx Role of Neck Dissection in Initial Surgical Treatment
Jatin #. Shah, MD, New York, New York H. Randall Tollefsen, MD, New York, New York
Epidermoid carcinoma of the supraglottic larynx is defined as carcinoma that arises on the laryngeal surface of the epiglottis, aryepiglottic folds, arytenoids, ventricular bands, and ventricular cavities. Such tumors may extend inferiorly to involve the vocal cords or subglottic region. More often they spill over the superior margins of the laryngeal box to invade adjacent sites outside the larynx such as the base of the tongue, vallecula, pyriform sinus, and postcricoid region. These tumors may also infiltrate beneath the laryngeal mucosa to involve underlying structures causing fixation of the larynx or even infiltrate deeply to extend outside the larynx. The most common mode of metastases of these tumors is through the lymphatics to cervical lymph nodes. One of the questions that face the clinician is whether lymbhatic metastasis has taken place and, if so, to what extent. On the basis of this information the plan of treatment is formulated. Unfortunately no preoperative tests of any clinical value are available to ascertain the presence of metastases in the absence of palpable cervical lymph nodes, and thus the clinical findings at initial examination must be relied on. It is dbvious that in the presence of clinical cervical metastases there is no controversy as to the type of surgery advocated. However, when the cervical nodes are clinically negative for metastases, the dilemma arises as to whether elective neck dissection should be performed at the time of init,ial surgery of the From the Head and Neck Service, Department of Surgery, Memoiial Sloan-Kettering Cancer Center, New York, New York. Reprint requests should be addressed to Dr H. Randall Tollefsen, 737 Park Avenue, New York, New York.10021. Presented at the Twentieth Annual Meeting of the Society of Head and Neck Surgeons, Honolulu, Hawaii, April 14-17, 1974.
494
primary laryngeal lesion. This study was undertaken to evaluate the role of neck dissection in the surgical treatment of carcinoma of the supraglottic larynx. Also, an attempt was made to ascertain whether any criteria could be established for selecting patients who may benefit from elective neck dissection. Clinical Material
The records of all patients (603) with the diagnosis of carcinoma of the supraglottic larynx seen at Memorial Hospital from 1951 through 1965 were reviewed. However, only 352 of these were new (primary) untreated cases. Fourteen patients had consultation only and no treatment was rendered to them. Nine refused therapy. Thirty-seven patients were treated surgically prior to referral. Seventy patients received radiation therapy elsewhere and were seen at our institution for persistent or recurrent disease. Advanced cancer prohibited surgical treatment in nineteen patients. Sixty-one patients were treated on other services and forty-one patients had nonepidermoid cancer of the supraglottic region. The 352 primary cases were treated by the members of the Head and Neck Service. Four patients were lost to follow-up study but had no evidence of recurrent laryngeal carcinoma at the time of their last examination. Forty-three patients who were free of disease died of causes unrelated to laryngeal carcinoma. These fortyseven indeterminate cases are excluded. Since this study involves the role of cervical lymph node metastases in relation to the primary tumor and their influence on survival, we have excluded the fifteen patients who died postoperatively. These are usually considered to be determinate cases. The remaining 290 patients provide the data for analysis in this study. Age and Sex Distribution. Figure 1 shows the age and sex distribution. Ninety per cent of the patient popula-
The American Journal 01 Surgery
Epidermoid
tion were males (262). The majority of the patients were in the sixth and seventh decade. There were no patients in the first three decades of life. TNM Staging. All the patients in this series were classified by the 1972 revision of the TNM staging systern. Table I shows the “T” and “N” status of these patients. All the patients included in this study had no evidence of distant metastases on admission (MO). The incidence of cervical node metastases was progressively higher as the primary tumor staging advanced. Forty per cent of patients with T1 lesions had cervical lymph node metastases on presentation. When the primary lesion was Tz, the incidence of cervical node metastases was 42 per cent, for T3 lesions, 55 per cent, and for T4 lesions, 65 per cent. Over-all, 51 per cent (149) had clinical cervical metastases on presentation.
l&d -
Carcinoma
Males:
262
90%
Females:
28
10%
of Supraglottic
Larynx
140 ml-
111 -
2
&
loo -
P
80-
101
Ml40
40 -
28
m-
6
I
4
AL
0.10 11-M 21-30 31-4041-50 511X
61-70 71-W
81-90
AGE IN DECADE
Results
The survival rates of patients by TNM staging is shown in Table II. Eighty-three per cent of patients with stage I disease survived five years. When the disease was stage II at the time of presentation, 72 per cent survived five years. However, five year survival dropped to 42 per cent for patients with stage III disease, and none of the three patients with stage IV disease survived five years. Survival in Relation to “T” Status. If only the “T” status of the patient is considered and survival assessed, the results are as shown in Table III. Fifty-three per cent of patients with T1 disease survived five years; 57 per cent with T2, 60 per cent with T3, and 40 per cent with T4 disease were alive and well at five years. Thus, there is no statistically significant correlation between the “T” status of these patients and their prognosis. However, there does exist a direct correlation between the incidence of cervical node metastases and the “T” status of the patient. (Table I.) This probably only means that the prognosis of the patient is directly dependent on the “N” status of the patient rather than the “T” status. There also was no direct correlation between the size of the primary tumor as measured in the pathology laboratory on the surgical specimen and the incidence of clinical cervical metastases. (Table IV.) There is also no striking correlation between the size of the primary tumor and survival. Based on these findings, it can be concluded that neither the “T” status alone nor the actual size of the primary tumor has a direct influence on survival is prognosis. What probably influences the relative incidence of cervical node metastases.
Volune 128, October 1974
Figure 1. Age and sex distribution.
Survival in Relation to “N” Status. The direct influence of cervical lymph node involvement on prognosis is evident, as seen in Table V. Sixty-nine per cent of all patients with no clinical node metastases on admission (No) survived five years; however, only 35 per cent of patients with clinical cervical metastases (N+) survived five years. As one progresses from N1 to N3, the survival rate drops from 39 per cent to zero. This direct relationship of “N” status of the patient to prognosis warrants further scrutiny of data. Figure 2 shows the management and end reTABLE
I
TNM Classification
-~~ Nodes
Tumor
No. of Patients*
No
N,
N?
T1 TP TX TG Total
30 123 42 95 290
18 71 19 33 141
7 38 20 42 107
3 13 3 17 36
* All patients admission. TABLE
Stage I II III IV
II
had
no evidence
-
N+ Na (Nr+N?+ 2 1 0 3 6
of distant
TIN&JO TzNoMo T&J’&, TIZB + TIZB + TIZJJ +
TJW& N,z + Mo Na + Mo NW + MI
12 52 23 62 149
N3)
(40%) (42%) (55%) (65%) (51%)
metastases
Clinical Staging of Disease Five Year Survival
TNM Classification
__~
on
and
No. of Patients
Five Year Survival (%)
18 71 198
83 72 42
3
0
495
Shah and Tollefsen
Survival of Patients by “T” Status
TABLE III “T” Status
No. of Patients
Five Year Survival (%)
T1 T2 T3 T,
30 123 42 95
53 57 60 40
Size of Primary Tumor, Incidence Nodes, and FiveYear Survival
TABLE IV
Size of Primary Lesion* (cm)
No. of Patients
uptol 1.1-2 2.1-3 3.1-4 4.15 5.1-6 6.1-7 7.1-8 8.1 or more * Exact patients.
TABLE V
size
8 54 69 69 31 21 1 1 1 of primary
tumor
Five Year Per cent with Clinical Nodes Survival(%) 50 46 54 52 42 48 100 0 0 not described
75 65 51 42 52 52 0 100 100 in thirty-five
Survival of Patients by “N” Status
“N” Status NO N1 N* NB N +
of Clinical
IN, + Nz +
Nal
No. of Patients
Five Year Survival (%)
141 107 36 6
69 39 28 0
149
35
-
sults of all patients (141) who were “No” on admission. Sixty-five of these had elective radical neck dissection and twenty-two (34 per cent) were found to have histologically positive nodes. The five year survival of these patients with occult metastases is 32 per cent. In contrast, 81 per cent of the forty-three patients who had pathologically negative nodes on elective neck dissection survived five years. Of the other 76 patients who were “No” on admission, cervical metastases requiring neck dissection subsequently developed in 21, 52 per cent (11 of 21) of whom survived five years. The remaining 55 patients never had clinical cervical lymph node metastases develop and 80 per cent survived five years. The results in the second group of 149 patients who presented with clinical cervical metastases (N+) are shown in Figure 3. The clinical impression of cervical lymph node metastases was confirmed by the pathologist in 132 of the 149 patients (89 per cent) and only 27 per cent of these
496
survived five years. In 17 patients the clinically palpable enlarged cervical nodes proved to be histologically benign and 94 per cent of these patients were alive and well at five years. Thus, in the “No” group, elective neck dissection yields a 34 per cent incidence of occult metastases which would favor “elective neck dissection;” however, an improvement in survival by only 5 per cent (32 per cent for occult metastases versus 27 per cent for N+ with positive nodes) questions the value of “elective neck dissection.” The group of twenty-one patients who were classified as Nc initially but later required therapeutic neck dissection for subsequent metastases presents an interestingly high survival rate of 52 per cent. This finding would not favor “elective neck dissection.” From this we are unable to define the role of elective neck dissection based on the information derived only from the status of cervical lymph nodes and survival. Therefore, we have further analyzed our data to study whether the extent of the primary lesion as determined clinically has any influence on nodal metastases, and the relationship of nodal metastases to survival. Extent of Primary Lesion and Incidence of Clinical Cervical Metastases. For the purpose of this analysis we have divided all lesions of the supraglottic larynx into two clinical categories: endolaryngeal and exolaryngeal. (Figure 4.) Endolaryngeal lesions are confined within the laryngeal box. They may involve the free edge of epiglottis, aryepiglottic fold, and/or the arytenoid but do not extend beyond these margins. Inferiorly they may extend to involve the vocal cords. Exolaryngeal lesions also arise within the laryngeal box but spill over the superior margins to extend outside the larynx and invade adjacent sites such as the base of the tongue, vallecula, pyriform sinus, or postcricoid region. When the primary tumor was “endolaryngeal,” 34 per cent of the patients had clinical cervical metastases on admission in contrast to 69 per cent when the primary tumor was exolaryngeal. This relative incidence of clinically palpable cervical metastases is reflected in the five year survival of these two groups of patients. Sixty-six per cent of patients with the primary tumor confined within the larynx survived five years. Conversely, when the primary tumor extended outside the larynx, only 37 per cent survived five years. (Table VI.) The greater the peripheral extent of the primary lesion, the higher the chances of cervical lymph node metastases and the poorer the prognosis. However, to make a case for or against elective neck dissection, further breakdown of these data is
The American Journal of Surgery
EpidermoidCarcinoma of SupraglotticLarynx
necessary. (Figure 5.) As previously mentioned, 34 per cent of the patients with endolaryngeal lesions (50 of 146) had clinical cervical metastases. The remaining ninety-six patients were classified as No on admission. Thirty of these ninety-six underwent elective neck dissection and seven (23 per cent) had occult metastases confirmed on histologic examination. The remaining sixty-six patients did not have elective neck dissection, and in seventeen (26 per cent) of these subsequent cervical metastases developed requiring neck dissection. Of the patients with exolaryngeal lesions, 69 per cent (99 of 144) had clinical cervical metastases on admission. Of the remaining 45 who were classified as No on admission, 35 underwent elective neck dissection and 15 (43 per cent) bad occult metastases on pathologic examination. In 4 of the other 10 (40 per cent) who did not have elective neck dissection subsequent cervical metastases developed requiring neck dissection. Thus, when the primary lesion was “exolaryngeal” 69 per cent were N+ on admission. When elective neck dissection was performed on patients classified as No, 43 per cent had occult metastases. Of the remaining “No” patients who did not have elective neck dissection, subsequent cervical metastases developed in 40 per cent requiring therapeutic neck dissection. These findings seem to favor the need for elective neck dissection in all patients classified as No whose primary lesion is “exolaryngeal.” When the primary lesion was “endolaryngeal,” 34 per cent of patients were N+ on admission. Only 23 per cent of “NO” patients undergoing elective neck dissection proved to have occult metastases, and in 26 per cent of those “No” patients who did not undergo elective neck dissection, subsequent cervical metastases developed requiring therapeutic neck dissection. Thus, the need for elective neck dissection in patients with primary “endolaryngeal” lesions seems to be less favorable.
Unlike most other cancerous lesions arising from the mucosa of the oral cavity, carcinoma of the supraglottic larynx presents a very interesting feature in that the “T” status of the primary tumor alone seems to have little effect on prognosis, provided that it is adequately treated. The most important prognostic factor is the presence or absence of proved cervical node metastases. From our own clinical material we have been able to substantiate two known facts. One, the decline
volume
128,
October
1974
No RND
65
76
I\
J-l
Neg. Nodes
22 (34%)
43
I
I
Subseq. Neck. Mets. RND 21
5 yr. Survivors 61%
5 yr Survivors 52%
Pos. Nodes
5 yr. Survivors 32%
No Neck Mets at all 55
5 yr. S;rvivors 80%
F&we 2. AMpatients with no evkience of cNnka/ cervical metastases. N+ (N,+Nz+N,) 149 \ \
/ Pos. Nodes 132
Neg. Nodes 17
5 yr. Survivors
5 yr. Survivors
27%
94%
Figure 3. All patients wfth cllnkal cervkal metastases.
EXOLARYNGEAL
ENDOLARYNGEAL (Tumor
(Tumor
confined within
Lorynqcol
VI
Anatomic Incidence
Primary Tumor Endolaryngeal (within larynx) Exolaryngeal (spills over margins or extends outside larynx)
extends outside
Larynqeol box1
boa)
Figure 4. Carcinoma of ths supragkftk
TABLE
Comments
Elective RND
iatynx.
Extent of Primary Lesion and of Clinical Cervical Metastases
No. of Patients
Per cent with Cervical Metastases
Five Year Survival (%)
146
34
66
144
69
37
497
Shah and Tollefsen
Endolaryogeal /46\ No 96
Exolarynpeal
N+
/‘441\ No
Ni
xl
45
99
Elective N.D.
No. N.D. 66
30
Pos. Nodes (occult)
Elective N.D. 35
Subseq. No Neck Neck Mets. Mets.
Neg. Nodes 23
17 (26%)
No. N.D. 10
Pos. Nodes ~occull)
Neg. Nodes
15
20
49
(43%)
Climcal on Admission Occult in Elective N.D. Subsequent- Therapeutic N.D.
34% 23% z6%
69% 43% 40%
Pathologic Status of Lymph Nodes and Survival
Node Status Gross metastases Occult metastases Negative nodes Unknown*
No. of Patients
Survival(%)
132 22 60 76
27 32 85 72
l No initial neck dissection. In fifty-five patients neck metastases never developed and 80 per cent survived five years. Twenty-one had subsequent therapeutic neck dissection and 52 per cent survived five years.
498
4
6
VW
in survival rates is directly proportional to the clinical findings (“N” status) of cervical nodes. As one progresses from No to Na, survival rate drops from 69 per cent to zero. (Table V.) Thus, patients with no palpable cervical nodes have the best prognosis and patients with unilateral mobile cervical metastases have a better chance of survival than do those with bilateral metastases or fixed cervical nodes. The second fact, as shown in Table VII, is based on the pathologic findings of cervical lymph nodes. When the nodes are negative, 85 per cent of the patients survive five years. With occult metastases 32 per cent survive five years and with gross metastases 27 per cent survive five years. Based on the “N” status alone, 141 “No” patients could have been considered for elective neck dissection. In our series, as shown in Figures 2 and 3, 65 underwent elective neck dissection and 34 per cent (22/65) had occult metastases. Thus, 66 per cent of patients (43/65) underwent unnecessary neck dissection. The survival rate of patients with occult metastases was 32 per cent compared with 27 per cent for those with N+ on admission in VII
No Neck Mets.
Primary tumor Endolaryngeal Exolaryngeal
Cervical Metastases
TABLE
Subseq. Neck Mets.
Figure 5. Extent of primary lesion and incidence of cervical metasfases.
whom gross metastases were confirmed at therapeutic neck dissection. However, this 5 per cent improvement in survival (occult 32 per cent versus gross 27 per cent) is not significant since only one more patient (5 per cent of 22) was saved by performing 65 elective neck dissections, and 43 of these proved to be unnecessary because the nodes were negative. On the other hand, 76 patients classified as No did not have elective neck dissection, as seen in Figure 2, and in 21 of these subsequent cervical metastases developed requiring therapeutic neck dissection. Eleven of these 21 (52 per cent) survived five years. These findings certainly do not favor the routine performance of elective neck dissection based only on “N” status. In the hopes of selecting patients who may benefit from elective neck dissection we analyzed our clinical data by classifying the primary lesions into endolaryngeal and exolaryngeal categories. (Figure 5.) Patients with primary endolaryngeal lesions have a relatively better prognosis since they have a low incidence of clinical cervical metastases (50/ 146 or 34 per cent). Therefore, a large group (66 per cent) would have to be considered for elective neck dissection. If elective neck dissection is performed in all patients, that is, all “No” patients (96/146 or 66 per cent), the only ones who would benefit from such a procedure would be those who had occult metastases (7) and those in whom subsequent metastases to cervical nodes developed without recurrence at the primary site (17). Therefore, only 25 per cent of patients with primary endolaryngeal lesions (7 + 17 = 24/96) would derive some benefit as a result of elective neck dissection, and the remaining 75 per cent (72/96) would un-
The American
Journal ol Surgery
Epidermoid Carcinoma of Supraglottic Larynx
dergo unnecessary surgery. Since the improvement in survival between occult and gross metastases was merely 5 per cent, only one more patient (5 per cent of 24) was saved and for that 72 unnecessary elective neck dissections were carried out. Therefore, elective neck dissection is not recommended for primary endolaryngeal lesions. Patients with primary exolaryngeal lesions, however, have a relatively poor prognosis since they have a high incidence of clinical cervical metastases (99/144 or 69 per cent) and only a small group (31 per cent) remains to be considered for elective neck dissection. If elective neck dissection is performed in all these patients (45/144 or 31 per cent), that is, all “No” patients, those who would benefit from such a procedure would be those who had occult metastases (15) and those in whom cervical node metastases subsequently developed without recurrence at the primary site (4). Thus, 42 per cent of patients with primary exolaryngeal lesions (15 + 4 = 19/45) would achieve a 5 per cent improvement in survival as a result of elective neck dissection. That means one additional patient would be saved and 58 per cent of the other “NO” patients (26/45) would undergo unnecessary surgery. Therefore, elective neck dissection is not indicated even in patients with primary exolaryngeal lesions. From the foregoing, elective neck dissection does not seem to affect the course of the disease. The improvement in survival is meager, and if one considers the operative mortality, the gain in survival by elective neck dissection would be nullified by the operative deaths. Even though the margin of improved survival between occult metastases and gross metastases is narrow, one should bear in mind that any occult cervical metastases may progress to become N1 or even Na or Ns, with their poor relative survival rates as seen before. Therefore, a close follow-up study of all patients who have undergone surgical treatment of carcinoma of the supraglottic larynx is essential. If and when cervical metastases are suspected, immediate therapeutic neck dissection should be undertaken.
volume 129, October 1974
1. Ninety per cent of patients in this series were males. 2. Seventy-three per cent of all patients were between the ages of fifty and seventy years. 3. Fifty-one per cent of all patients had clinical cervical metastases on admission. 4. Five year survivals are: stage I, 83 per cent; stage II, 72 per cent; stage III, 42 per cent; stage IV, 0 per cent. 5. Neither the “T” status alone nor the actual size of the primary tumor had a significant influence on prognosis. 6. Prognosis is directly influenced by the “N” status and it worsens as it progresses from No to NY. 7. Radical neck dissection is mandatory in the presence of clinical cervical metastases in conjunction with initial surgery of the primary tumor and saves 27 per cent when metastases are histologically confirmed. 8. Elective neck dissection performed in patients classified as No yields a 34 per cent incidence of occult metastases. The survival of this group is 5 per cent better than that of those with gross metastases (32 versus 27 per cent). 9. Patients with endolaryngeal lesions have a better five year survival than do those with exolaryngeal lesions (66 versus 37 per cent). 10. Patients with exolaryngeal lesions in contrast to endolaryngeal lesions have a significantly higher incidence of: (a) N+ on admission (69 versus 34 per cent); (b) occult metastases in elective neck dissection (43 versus 23 per cent); (c) subsequent metastases requiring therapeutic neck dissection (40 versus 26 per cent). 11. Clinical classification of carcinomas of the supraglottic larynx into endolaryngeal and exolaryngeal categories provides a better prognostic index than does the “T” status. 12. Routine elective neck dissection is not recommended in all patients having epidermoid carcinoma of the supraglottic larynx.
499
Jatin #. Shah, MD, New York, New York H. Randall Tollefsen, MD, New York, New York
Epidermoid carcinoma of the supraglottic larynx is defined as carcinoma that arises on the laryngeal surface of the epiglottis, aryepiglottic folds, arytenoids, ventricular bands, and ventricular cavities. Such tumors may extend inferiorly to involve the vocal cords or subglottic region. More often they spill over the superior margins of the laryngeal box to invade adjacent sites outside the larynx such as the base of the tongue, vallecula, pyriform sinus, and postcricoid region. These tumors may also infiltrate beneath the laryngeal mucosa to involve underlying structures causing fixation of the larynx or even infiltrate deeply to extend outside the larynx. The most common mode of metastases of these tumors is through the lymphatics to cervical lymph nodes. One of the questions that face the clinician is whether lymbhatic metastasis has taken place and, if so, to what extent. On the basis of this information the plan of treatment is formulated. Unfortunately no preoperative tests of any clinical value are available to ascertain the presence of metastases in the absence of palpable cervical lymph nodes, and thus the clinical findings at initial examination must be relied on. It is dbvious that in the presence of clinical cervical metastases there is no controversy as to the type of surgery advocated. However, when the cervical nodes are clinically negative for metastases, the dilemma arises as to whether elective neck dissection should be performed at the time of init,ial surgery of the From the Head and Neck Service, Department of Surgery, Memoiial Sloan-Kettering Cancer Center, New York, New York. Reprint requests should be addressed to Dr H. Randall Tollefsen, 737 Park Avenue, New York, New York.10021. Presented at the Twentieth Annual Meeting of the Society of Head and Neck Surgeons, Honolulu, Hawaii, April 14-17, 1974.
494
primary laryngeal lesion. This study was undertaken to evaluate the role of neck dissection in the surgical treatment of carcinoma of the supraglottic larynx. Also, an attempt was made to ascertain whether any criteria could be established for selecting patients who may benefit from elective neck dissection. Clinical Material
The records of all patients (603) with the diagnosis of carcinoma of the supraglottic larynx seen at Memorial Hospital from 1951 through 1965 were reviewed. However, only 352 of these were new (primary) untreated cases. Fourteen patients had consultation only and no treatment was rendered to them. Nine refused therapy. Thirty-seven patients were treated surgically prior to referral. Seventy patients received radiation therapy elsewhere and were seen at our institution for persistent or recurrent disease. Advanced cancer prohibited surgical treatment in nineteen patients. Sixty-one patients were treated on other services and forty-one patients had nonepidermoid cancer of the supraglottic region. The 352 primary cases were treated by the members of the Head and Neck Service. Four patients were lost to follow-up study but had no evidence of recurrent laryngeal carcinoma at the time of their last examination. Forty-three patients who were free of disease died of causes unrelated to laryngeal carcinoma. These fortyseven indeterminate cases are excluded. Since this study involves the role of cervical lymph node metastases in relation to the primary tumor and their influence on survival, we have excluded the fifteen patients who died postoperatively. These are usually considered to be determinate cases. The remaining 290 patients provide the data for analysis in this study. Age and Sex Distribution. Figure 1 shows the age and sex distribution. Ninety per cent of the patient popula-
The American Journal 01 Surgery
Epidermoid
tion were males (262). The majority of the patients were in the sixth and seventh decade. There were no patients in the first three decades of life. TNM Staging. All the patients in this series were classified by the 1972 revision of the TNM staging systern. Table I shows the “T” and “N” status of these patients. All the patients included in this study had no evidence of distant metastases on admission (MO). The incidence of cervical node metastases was progressively higher as the primary tumor staging advanced. Forty per cent of patients with T1 lesions had cervical lymph node metastases on presentation. When the primary lesion was Tz, the incidence of cervical node metastases was 42 per cent, for T3 lesions, 55 per cent, and for T4 lesions, 65 per cent. Over-all, 51 per cent (149) had clinical cervical metastases on presentation.
l&d -
Carcinoma
Males:
262
90%
Females:
28
10%
of Supraglottic
Larynx
140 ml-
111 -
2
&
loo -
P
80-
101
Ml40
40 -
28
m-
6
I
4
AL
0.10 11-M 21-30 31-4041-50 511X
61-70 71-W
81-90
AGE IN DECADE
Results
The survival rates of patients by TNM staging is shown in Table II. Eighty-three per cent of patients with stage I disease survived five years. When the disease was stage II at the time of presentation, 72 per cent survived five years. However, five year survival dropped to 42 per cent for patients with stage III disease, and none of the three patients with stage IV disease survived five years. Survival in Relation to “T” Status. If only the “T” status of the patient is considered and survival assessed, the results are as shown in Table III. Fifty-three per cent of patients with T1 disease survived five years; 57 per cent with T2, 60 per cent with T3, and 40 per cent with T4 disease were alive and well at five years. Thus, there is no statistically significant correlation between the “T” status of these patients and their prognosis. However, there does exist a direct correlation between the incidence of cervical node metastases and the “T” status of the patient. (Table I.) This probably only means that the prognosis of the patient is directly dependent on the “N” status of the patient rather than the “T” status. There also was no direct correlation between the size of the primary tumor as measured in the pathology laboratory on the surgical specimen and the incidence of clinical cervical metastases. (Table IV.) There is also no striking correlation between the size of the primary tumor and survival. Based on these findings, it can be concluded that neither the “T” status alone nor the actual size of the primary tumor has a direct influence on survival is prognosis. What probably influences the relative incidence of cervical node metastases.
Volune 128, October 1974
Figure 1. Age and sex distribution.
Survival in Relation to “N” Status. The direct influence of cervical lymph node involvement on prognosis is evident, as seen in Table V. Sixty-nine per cent of all patients with no clinical node metastases on admission (No) survived five years; however, only 35 per cent of patients with clinical cervical metastases (N+) survived five years. As one progresses from N1 to N3, the survival rate drops from 39 per cent to zero. This direct relationship of “N” status of the patient to prognosis warrants further scrutiny of data. Figure 2 shows the management and end reTABLE
I
TNM Classification
-~~ Nodes
Tumor
No. of Patients*
No
N,
N?
T1 TP TX TG Total
30 123 42 95 290
18 71 19 33 141
7 38 20 42 107
3 13 3 17 36
* All patients admission. TABLE
Stage I II III IV
II
had
no evidence
-
N+ Na (Nr+N?+ 2 1 0 3 6
of distant
TIN&JO TzNoMo T&J’&, TIZB + TIZB + TIZJJ +
TJW& N,z + Mo Na + Mo NW + MI
12 52 23 62 149
N3)
(40%) (42%) (55%) (65%) (51%)
metastases
Clinical Staging of Disease Five Year Survival
TNM Classification
__~
on
and
No. of Patients
Five Year Survival (%)
18 71 198
83 72 42
3
0
495
Shah and Tollefsen
Survival of Patients by “T” Status
TABLE III “T” Status
No. of Patients
Five Year Survival (%)
T1 T2 T3 T,
30 123 42 95
53 57 60 40
Size of Primary Tumor, Incidence Nodes, and FiveYear Survival
TABLE IV
Size of Primary Lesion* (cm)
No. of Patients
uptol 1.1-2 2.1-3 3.1-4 4.15 5.1-6 6.1-7 7.1-8 8.1 or more * Exact patients.
TABLE V
size
8 54 69 69 31 21 1 1 1 of primary
tumor
Five Year Per cent with Clinical Nodes Survival(%) 50 46 54 52 42 48 100 0 0 not described
75 65 51 42 52 52 0 100 100 in thirty-five
Survival of Patients by “N” Status
“N” Status NO N1 N* NB N +
of Clinical
IN, + Nz +
Nal
No. of Patients
Five Year Survival (%)
141 107 36 6
69 39 28 0
149
35
-
sults of all patients (141) who were “No” on admission. Sixty-five of these had elective radical neck dissection and twenty-two (34 per cent) were found to have histologically positive nodes. The five year survival of these patients with occult metastases is 32 per cent. In contrast, 81 per cent of the forty-three patients who had pathologically negative nodes on elective neck dissection survived five years. Of the other 76 patients who were “No” on admission, cervical metastases requiring neck dissection subsequently developed in 21, 52 per cent (11 of 21) of whom survived five years. The remaining 55 patients never had clinical cervical lymph node metastases develop and 80 per cent survived five years. The results in the second group of 149 patients who presented with clinical cervical metastases (N+) are shown in Figure 3. The clinical impression of cervical lymph node metastases was confirmed by the pathologist in 132 of the 149 patients (89 per cent) and only 27 per cent of these
496
survived five years. In 17 patients the clinically palpable enlarged cervical nodes proved to be histologically benign and 94 per cent of these patients were alive and well at five years. Thus, in the “No” group, elective neck dissection yields a 34 per cent incidence of occult metastases which would favor “elective neck dissection;” however, an improvement in survival by only 5 per cent (32 per cent for occult metastases versus 27 per cent for N+ with positive nodes) questions the value of “elective neck dissection.” The group of twenty-one patients who were classified as Nc initially but later required therapeutic neck dissection for subsequent metastases presents an interestingly high survival rate of 52 per cent. This finding would not favor “elective neck dissection.” From this we are unable to define the role of elective neck dissection based on the information derived only from the status of cervical lymph nodes and survival. Therefore, we have further analyzed our data to study whether the extent of the primary lesion as determined clinically has any influence on nodal metastases, and the relationship of nodal metastases to survival. Extent of Primary Lesion and Incidence of Clinical Cervical Metastases. For the purpose of this analysis we have divided all lesions of the supraglottic larynx into two clinical categories: endolaryngeal and exolaryngeal. (Figure 4.) Endolaryngeal lesions are confined within the laryngeal box. They may involve the free edge of epiglottis, aryepiglottic fold, and/or the arytenoid but do not extend beyond these margins. Inferiorly they may extend to involve the vocal cords. Exolaryngeal lesions also arise within the laryngeal box but spill over the superior margins to extend outside the larynx and invade adjacent sites such as the base of the tongue, vallecula, pyriform sinus, or postcricoid region. When the primary tumor was “endolaryngeal,” 34 per cent of the patients had clinical cervical metastases on admission in contrast to 69 per cent when the primary tumor was exolaryngeal. This relative incidence of clinically palpable cervical metastases is reflected in the five year survival of these two groups of patients. Sixty-six per cent of patients with the primary tumor confined within the larynx survived five years. Conversely, when the primary tumor extended outside the larynx, only 37 per cent survived five years. (Table VI.) The greater the peripheral extent of the primary lesion, the higher the chances of cervical lymph node metastases and the poorer the prognosis. However, to make a case for or against elective neck dissection, further breakdown of these data is
The American Journal of Surgery
EpidermoidCarcinoma of SupraglotticLarynx
necessary. (Figure 5.) As previously mentioned, 34 per cent of the patients with endolaryngeal lesions (50 of 146) had clinical cervical metastases. The remaining ninety-six patients were classified as No on admission. Thirty of these ninety-six underwent elective neck dissection and seven (23 per cent) had occult metastases confirmed on histologic examination. The remaining sixty-six patients did not have elective neck dissection, and in seventeen (26 per cent) of these subsequent cervical metastases developed requiring neck dissection. Of the patients with exolaryngeal lesions, 69 per cent (99 of 144) had clinical cervical metastases on admission. Of the remaining 45 who were classified as No on admission, 35 underwent elective neck dissection and 15 (43 per cent) bad occult metastases on pathologic examination. In 4 of the other 10 (40 per cent) who did not have elective neck dissection subsequent cervical metastases developed requiring neck dissection. Thus, when the primary lesion was “exolaryngeal” 69 per cent were N+ on admission. When elective neck dissection was performed on patients classified as No, 43 per cent had occult metastases. Of the remaining “No” patients who did not have elective neck dissection, subsequent cervical metastases developed in 40 per cent requiring therapeutic neck dissection. These findings seem to favor the need for elective neck dissection in all patients classified as No whose primary lesion is “exolaryngeal.” When the primary lesion was “endolaryngeal,” 34 per cent of patients were N+ on admission. Only 23 per cent of “NO” patients undergoing elective neck dissection proved to have occult metastases, and in 26 per cent of those “No” patients who did not undergo elective neck dissection, subsequent cervical metastases developed requiring therapeutic neck dissection. Thus, the need for elective neck dissection in patients with primary “endolaryngeal” lesions seems to be less favorable.
Unlike most other cancerous lesions arising from the mucosa of the oral cavity, carcinoma of the supraglottic larynx presents a very interesting feature in that the “T” status of the primary tumor alone seems to have little effect on prognosis, provided that it is adequately treated. The most important prognostic factor is the presence or absence of proved cervical node metastases. From our own clinical material we have been able to substantiate two known facts. One, the decline
volume
128,
October
1974
No RND
65
76
I\
J-l
Neg. Nodes
22 (34%)
43
I
I
Subseq. Neck. Mets. RND 21
5 yr. Survivors 61%
5 yr Survivors 52%
Pos. Nodes
5 yr. Survivors 32%
No Neck Mets at all 55
5 yr. S;rvivors 80%
F&we 2. AMpatients with no evkience of cNnka/ cervical metastases. N+ (N,+Nz+N,) 149 \ \
/ Pos. Nodes 132
Neg. Nodes 17
5 yr. Survivors
5 yr. Survivors
27%
94%
Figure 3. All patients wfth cllnkal cervkal metastases.
EXOLARYNGEAL
ENDOLARYNGEAL (Tumor
(Tumor
confined within
Lorynqcol
VI
Anatomic Incidence
Primary Tumor Endolaryngeal (within larynx) Exolaryngeal (spills over margins or extends outside larynx)
extends outside
Larynqeol box1
boa)
Figure 4. Carcinoma of ths supragkftk
TABLE
Comments
Elective RND
iatynx.
Extent of Primary Lesion and of Clinical Cervical Metastases
No. of Patients
Per cent with Cervical Metastases
Five Year Survival (%)
146
34
66
144
69
37
497
Shah and Tollefsen
Endolaryogeal /46\ No 96
Exolarynpeal
N+
/‘441\ No
Ni
xl
45
99
Elective N.D.
No. N.D. 66
30
Pos. Nodes (occult)
Elective N.D. 35
Subseq. No Neck Neck Mets. Mets.
Neg. Nodes 23
17 (26%)
No. N.D. 10
Pos. Nodes ~occull)
Neg. Nodes
15
20
49
(43%)
Climcal on Admission Occult in Elective N.D. Subsequent- Therapeutic N.D.
34% 23% z6%
69% 43% 40%
Pathologic Status of Lymph Nodes and Survival
Node Status Gross metastases Occult metastases Negative nodes Unknown*
No. of Patients
Survival(%)
132 22 60 76
27 32 85 72
l No initial neck dissection. In fifty-five patients neck metastases never developed and 80 per cent survived five years. Twenty-one had subsequent therapeutic neck dissection and 52 per cent survived five years.
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4
6
VW
in survival rates is directly proportional to the clinical findings (“N” status) of cervical nodes. As one progresses from No to Na, survival rate drops from 69 per cent to zero. (Table V.) Thus, patients with no palpable cervical nodes have the best prognosis and patients with unilateral mobile cervical metastases have a better chance of survival than do those with bilateral metastases or fixed cervical nodes. The second fact, as shown in Table VII, is based on the pathologic findings of cervical lymph nodes. When the nodes are negative, 85 per cent of the patients survive five years. With occult metastases 32 per cent survive five years and with gross metastases 27 per cent survive five years. Based on the “N” status alone, 141 “No” patients could have been considered for elective neck dissection. In our series, as shown in Figures 2 and 3, 65 underwent elective neck dissection and 34 per cent (22/65) had occult metastases. Thus, 66 per cent of patients (43/65) underwent unnecessary neck dissection. The survival rate of patients with occult metastases was 32 per cent compared with 27 per cent for those with N+ on admission in VII
No Neck Mets.
Primary tumor Endolaryngeal Exolaryngeal
Cervical Metastases
TABLE
Subseq. Neck Mets.
Figure 5. Extent of primary lesion and incidence of cervical metasfases.
whom gross metastases were confirmed at therapeutic neck dissection. However, this 5 per cent improvement in survival (occult 32 per cent versus gross 27 per cent) is not significant since only one more patient (5 per cent of 22) was saved by performing 65 elective neck dissections, and 43 of these proved to be unnecessary because the nodes were negative. On the other hand, 76 patients classified as No did not have elective neck dissection, as seen in Figure 2, and in 21 of these subsequent cervical metastases developed requiring therapeutic neck dissection. Eleven of these 21 (52 per cent) survived five years. These findings certainly do not favor the routine performance of elective neck dissection based only on “N” status. In the hopes of selecting patients who may benefit from elective neck dissection we analyzed our clinical data by classifying the primary lesions into endolaryngeal and exolaryngeal categories. (Figure 5.) Patients with primary endolaryngeal lesions have a relatively better prognosis since they have a low incidence of clinical cervical metastases (50/ 146 or 34 per cent). Therefore, a large group (66 per cent) would have to be considered for elective neck dissection. If elective neck dissection is performed in all patients, that is, all “No” patients (96/146 or 66 per cent), the only ones who would benefit from such a procedure would be those who had occult metastases (7) and those in whom subsequent metastases to cervical nodes developed without recurrence at the primary site (17). Therefore, only 25 per cent of patients with primary endolaryngeal lesions (7 + 17 = 24/96) would derive some benefit as a result of elective neck dissection, and the remaining 75 per cent (72/96) would un-
The American
Journal ol Surgery
Epidermoid Carcinoma of Supraglottic Larynx
dergo unnecessary surgery. Since the improvement in survival between occult and gross metastases was merely 5 per cent, only one more patient (5 per cent of 24) was saved and for that 72 unnecessary elective neck dissections were carried out. Therefore, elective neck dissection is not recommended for primary endolaryngeal lesions. Patients with primary exolaryngeal lesions, however, have a relatively poor prognosis since they have a high incidence of clinical cervical metastases (99/144 or 69 per cent) and only a small group (31 per cent) remains to be considered for elective neck dissection. If elective neck dissection is performed in all these patients (45/144 or 31 per cent), that is, all “No” patients, those who would benefit from such a procedure would be those who had occult metastases (15) and those in whom cervical node metastases subsequently developed without recurrence at the primary site (4). Thus, 42 per cent of patients with primary exolaryngeal lesions (15 + 4 = 19/45) would achieve a 5 per cent improvement in survival as a result of elective neck dissection. That means one additional patient would be saved and 58 per cent of the other “NO” patients (26/45) would undergo unnecessary surgery. Therefore, elective neck dissection is not indicated even in patients with primary exolaryngeal lesions. From the foregoing, elective neck dissection does not seem to affect the course of the disease. The improvement in survival is meager, and if one considers the operative mortality, the gain in survival by elective neck dissection would be nullified by the operative deaths. Even though the margin of improved survival between occult metastases and gross metastases is narrow, one should bear in mind that any occult cervical metastases may progress to become N1 or even Na or Ns, with their poor relative survival rates as seen before. Therefore, a close follow-up study of all patients who have undergone surgical treatment of carcinoma of the supraglottic larynx is essential. If and when cervical metastases are suspected, immediate therapeutic neck dissection should be undertaken.
volume 129, October 1974
1. Ninety per cent of patients in this series were males. 2. Seventy-three per cent of all patients were between the ages of fifty and seventy years. 3. Fifty-one per cent of all patients had clinical cervical metastases on admission. 4. Five year survivals are: stage I, 83 per cent; stage II, 72 per cent; stage III, 42 per cent; stage IV, 0 per cent. 5. Neither the “T” status alone nor the actual size of the primary tumor had a significant influence on prognosis. 6. Prognosis is directly influenced by the “N” status and it worsens as it progresses from No to NY. 7. Radical neck dissection is mandatory in the presence of clinical cervical metastases in conjunction with initial surgery of the primary tumor and saves 27 per cent when metastases are histologically confirmed. 8. Elective neck dissection performed in patients classified as No yields a 34 per cent incidence of occult metastases. The survival of this group is 5 per cent better than that of those with gross metastases (32 versus 27 per cent). 9. Patients with endolaryngeal lesions have a better five year survival than do those with exolaryngeal lesions (66 versus 37 per cent). 10. Patients with exolaryngeal lesions in contrast to endolaryngeal lesions have a significantly higher incidence of: (a) N+ on admission (69 versus 34 per cent); (b) occult metastases in elective neck dissection (43 versus 23 per cent); (c) subsequent metastases requiring therapeutic neck dissection (40 versus 26 per cent). 11. Clinical classification of carcinomas of the supraglottic larynx into endolaryngeal and exolaryngeal categories provides a better prognostic index than does the “T” status. 12. Routine elective neck dissection is not recommended in all patients having epidermoid carcinoma of the supraglottic larynx.
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