Die Rolle der elektiven Neck dissection bei Salvage Laryngektomie – eine retrospektive Analyse

Zusammenfassung

Im Rahmen der Salvage Laryngektomie (SLE) bei Rezidivkarzinomen des Larynx und Hypopharynx wird häufig, wie bei der primären Laryngektomie (LE), eine elektive beidseitige Neck dissection durchgeführt. Der therapeutische Nutzen muss angesichts des potentiell höheren Morbiditätsrisikos nach definitiver Radiochemotherapie gegenüber den Risiken abgewogen werden.

In einer retrospektiven Analyse wurden onkologische Parameter von Patienten erfasst, welche bei Rezidivkarzinomen des Larynx und Hypopharynx nach primärer Radiochemotherapie eine SLE mit beidseitiger Neck dissection erhielten. Zum Vergleich wurden Daten von Patienten mit primärer LE und beidseitiger Neck dissection bei Larynx- und Hypopharynxkarzinomen erfasst.

19 Patienten mit SLE und 83 Patienten mit LE wurden in die Analyse eingeschlossen. Bei der Mehrzahl der Patienten waren sowohl das initiale Tumorstadium als auch das Rezidiv-Tumorstadium vor SLE fortgeschritten. Vor SLE wiesen 5 % der Patienten (n = 1) klinisch metastasensuspekte Lymphknoten auf, vor LE 47 % (n = 39). Bei 17 % (n = 14) der Patienten mit LE wurden okkulte Lymphknotenmetastasen nachgewiesen, bei SLE lediglich bei 5 % der Patienten (n = 1). Insgesamt ergab sich ein pN+ -Stadium in 55 % (LE, n = 44) bzw. 10 % (SLE, n = 2) der Fälle. Die Gesamtzahl der entfernten Lymphknoten bei LE war höher als bei SLE (37,3 vs. 18,7, p < 0,001). Das 5-Jahres-Gesamtüberleben der Patienten lag nach LE bei 50,0 %, nach SLE bei 33,3 %.

Patienten, welche bei Rezidivkarzinomen des Larynx oder Hypopharynx nach primärer Bestrahlung eine SLE erhalten, weisen selten Lymphknotenmetastasen auf. Dennoch kommt es in Einzelfällen zu einer okkulten Metastasierung. Bei der Planung der letzten kurativen Therapieoption sollte dies in Betracht gezogen werden.

Abstract

Elective neck dissection of the N0-neck is routinely performed during salvage laryngectomy (SLE) for recurrent cancer of the larynx or hypopharynx. The therapeutic benefit of additional neck dissection must be weighed against the risk of increased morbidity. In this retrospective analysis, we assessed oncologic parameters of patients who underwent SLE with concurrent bilateral neck dissection for recurrent laryngeal or hypopharyngeal cancer. We compared these data with patients who underwent primary laryngectomy (LE) with bilateral neck dissection for laryngeal and hypopharyngeal cancer.

19 patients who had undergone SLE and 83 patients after LE were included in the analysis. The majority of patients had advanced stage tumors prior to LE or primary radiation therapy, as well as advanced stage recurrent tumors prior to SLE. Prior to SLE, 5 % of all patients (n = 1) had clinically pathologic lymph nodes, compared to 47 % (n = 39) prior to LE. 17 % (n = 14) of patients with LE and bilateral neck dissection had occult lymph node metastases, compared to 5 % (n = 1) of patients who underwent SLE with bilateral neck dissection. Overall, 55 % (n = 44) of patients who underwent LE had positive cervical lymph nodes, compared to 10 % (n = 2) of SLE patients. Lymph node yield was higher in patients with LE than in SLE-patients (37.3 vs. 18.7, p < 0.001). 5-year OS was 50 % after LE and 33 % after SLE. Cervical lymph node metastases are rare in patients who undergo SLE for recurrent cancers of the larynx of hypopharynx. However, occult metastases do occur. Therefore, since SLE is the final curative therapy, additional neck dissection should be taken into consideration.

Schlüsselwörter

Salvage Laryngektomie - Neck dissection - Laryngektomie - okkulte Metastasen - Pectoralis major Lappen

Key words

salvage laryngectomy - neck dissection - occult metastases

• Literatur

• 1 Department of Veterans Affairs Laryngeal Cancer Study G. Wolf GT, Fisher SG. et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The New England journal of medicine 1991; 324: 1685-1690
• 2 Forastiere AA, Goepfert H, Maor M. et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. The New England journal of medicine 2003; 349: 2091-2098
• 3 Weber RS, Berkey BA, Forastiere A. et al. Outcome of salvage total laryngectomy following organ preservation therapy. The Radiation Therapy Oncology Group trial 91–11. Archives of otolaryngology. Head & neck surgery 2003; 129: 44-49
• 4 Ganly I, Patel S, Matsuo J. et al. Postoperative complications of salvage total laryngectomy. Cancer 2005; 103: 2073-2081
• 5 Klozar J, Cada Z, Koslabova E. Complications of total laryngectomy in the era of chemoradiation. European archives of oto-rhino-laryngology 2012; 269: 289-293
• 6 Rothmeier N, Hoffmann TK, Lehnerdt G. et al. [Surgical management of persisting fistulas after salvage-laryngectomy]. Laryngo-rhino-otologie 2013; 92: 236-243
• 7 Candela FC, Kothari K, Shah JP. Patterns of cervical node metastases from squamous carcinoma of the oropharynx and hypopharynx. Head & neck 1990; 12: 197-203
• 8 Rodrigo JP, Shah JP, Silver CE. et al. Management of the clinically negative neck in early-stage head and neck cancers after transoral resection. Head & neck 2011; 33: 1210-1219
• 9 Weiss MH, Harrison LB, Isaacs RS. Use of decision analysis in planning a management strategy for the stage N0 neck. Archives of otolaryngology. Head & neck surgery 1994; 120: 699-702
• 10 Sanabria A, Silver CE, Olsen KD. et al. Is elective neck dissection indicated during salvage surgery for head and neck squamous cell carcinoma?. European archives of oto-rhino-laryngology 2014; 271: 3111-3119
• 11 Freiser ME, Ojo RB, Lo K. et al. Complications and oncologic outcomes following elective neck dissection with salvage laryngectomy for the N0 neck. Am J Otolaryngol 2016; 37: 186-194
• 12 Basheeth N, O‘Leary G, Sheahan P. Elective neck dissection for no neck during salvage total laryngectomy: findings, complications, and oncological outcome. JAMA otolaryngology. Head & neck surgery 2013; 139: 790-796
• 13 Falchook AD, Dagan R, Morris CG. et al. Elective neck dissection for second primary after previous definitive radiotherapy. Am J Otolaryngol 2012; 33: 199-204
• 14 Hilly O, Gil Z, Goldhaber D. et al. Elective neck dissection during salvage total laryngectomy. A beneficial prognostic effect in locally advanced recurrent tumours. Clin Otolaryngol 2015; 40: 9-15
• 15 Birkeland AC, Rosko AJ, Issa MR. et al. Occult Nodal Disease Prevalence and Distribution in Recurrent Laryngeal Cancer Requiring Salvage Laryngectomy. Otolaryngology. Head & neck surgery 2016; 154: 473-479
• 16 Hoffman HT, Porter K, Karnell LH. et al. Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. The Laryngoscope 2006; 116: 1-13
• 17 Ko HC, Harari PM, Chen S. et al. Survival Outcomes for Patients With T3N0M0 Squamous Cell Carcinoma of the Glottic Larynx. JAMA otolaryngology. Head & neck surgery 2017; 143: 1126-1133
• 18 Peller M, Katalinic A, Wollenberg B. et al. Epidemiology of laryngeal carcinoma in Germany, 1998–2011. European archives of oto-rhino-laryngology 2016; 273: 1481-1487
• 19 Dirven R, Swinson BD, Gao K. et al. The assessment of pharyngocutaneous fistula rate in patients treated primarily with definitive radiotherapy followed by salvage surgery of the larynx and hypopharynx. The Laryngoscope 2009; 119: 1691-1695
• 20 Virtaniemi JA, Kumpulainen EJ, Hirvikoski PP. et al. The incidence and etiology of postlaryngectomy pharyngocutaneous fistulae. Head & neck 2001; 23: 29-33
• 21 Natvig K, Boysen M, Tausjo J. Fistulae following laryngectomy in patients treated with irradiation. J Laryngol Otol 1993; 107: 1136-1139
• 22 Dagan R, Morris CG, Kirwan JM. et al. Elective neck dissection during salvage surgery for locally recurrent head and neck squamous cell carcinoma after radiotherapy with elective nodal irradiation. The Laryngoscope 2010; 120: 945-952
• 23 Yao M, Roebuck JC, Holsinger FC. et al. Elective neck dissection during salvage laryngectomy. Am J Otolaryngol 2005; 26: 388-392
• 24 Bohannon IA, Desmond RA, Clemons L. et al. Management of the N0 neck in recurrent laryngeal squamous cell carcinoma. The Laryngoscope 2010; 120: 58-61
• 25 Rothmeier N, Bergmann C, Mattheis S. et al. [The primary use of pectoralis myofascial flap in salvage laryngectomy]. Laryngo-rhino-otologie 2015; 94: 232-238
• 26 Sayles M, Grant DG. Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. The Laryngoscope 2014; 124: 1150-1163
• 27 Guimaraes AV, Aires FT, Dedivitis RA. et al. Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: A systematic review. Head & neck 2016; 38 (Suppl. 01) E2317-2321
• 28 Shvero J, Koren R, Marshak G. et al. Histological changes in the cervical lymph nodes after radiotherapy. Oncol Rep 2001; 8: 909-911
• 29 Johnstone PA, Miller ED, Moore MG. Preoperative radiotherapy decreases lymph node yield of neck dissections for head and neck cancer. Otolaryngology. Head & neck surgery 2012; 147: 278-280