Abstract
Purpose
Patients with surgically treated head and neck cancer and clinical N0 neck with high risk of occult lymph node metastasis undergo elective neck dissection (ND). Late lymph node metastasis may appear in those patients with pN0 neck. The aim of the present study was to analyze the incidence and clinical relevance of late lymph node metastasis in patients with head and neck cancer.
Materials and Methods
The clinical data of 61 patients with head and neck cancer who had undergone elective ND with pN0 neck were retrospectively analyzed. Only patients without local failure, second primary, or radiochemotherapy were included in the study.
Results
Late lymph node metastasis could be observed in 4 (6.5%) cases at the margin or outside the initially dissected lymph node levels. In those patients, the primary tumor was localized in the oral cavity (n = 3) or oropharynx (n = 1) and was classified in all cases as T1 or T2. Lymph node metastasis could be found in levels I (n = 2), II (n = 1), and IV (n = 1), respectively.
Conclusion
Even in the case of pN0 neck after an elective ND, the appearance of late lymph node metastases must be expected. The low proportion of patients with late lymph node metastases after a selective ND in clinical and histologic N0 does not justify an extended form of neck surgery.
1
Introduction
The presence or absence of lymph node metastasis is the most important prognostic factor in head and neck cancer . Neck node involvement may be associated with a significant reduction of the survival rate and a higher risk for development of local recurrence on the primary tumor site and distant metastasis . Beside treatment of the primary tumor, appropriate management of cervical lymph nodes is an important aspect of head and neck cancer therapy.
The individual treatment concept of neck nodes depends on the treatment of the primary cancer and the clinical presence or absence of lymph node metastasis. Although patients with N0 neck may still harbor occult metastases in up to 30% , in particular, the management of occult metastases in clinical N0 neck remains enigmatic. The most accurate method for definitive diagnostic evaluation of the lymph node status is the operative exploration in the sense of an elective neck dissection (ND) and then histologic examination of the neck nodes. Because such an approach may be associated with an increased morbidity for the patients, less invasive procedures such as sentinel lymph node biopsy are increasingly promoted . Despite all criticisms, a selective ND is an established procedure for staging the neck with acceptable functional and esthetic results in patients who have head and neck cancer with a high risk of occult cervical metastasis . However, patients without histologic evidence of lymph node metastases may also develop treatment failure during the follow-up.
In the literature, little attention is paid to the problem of delayed lymph node metastasis of the neck. A review of the literature revealed only few studies on delayed cervical lymph node metastasis in patients with head and neck cancer . The aim of the present study was to analyze clinical characteristics of patients who underwent selective ND with pN0 neck and developed late neck lymph node metastasis.
2
Patients and methods
2.1
Clinical data
The clinical data of 171 patients with T1 to T4 squamous cell carcinoma (SCC) of the head and neck without evidence of neck metastasis who underwent a unilateral or bilateral selective ND at the Department of Otolaryngology, Head and Neck Surgery, Philipp University, Marburg, Germany, in a period of 11 years (from 1998 to 2009) were analyzed. In 29 cases (17.0%), primary tumor was localized in the oral cavity; 41 cases (24.0%), in the oropharynx; 28 cases (16.4%), in the hypopharynx; and 73 cases (42.7%), in the larynx.
All patients were preoperatively staged as N0 via ultrasonography and computed tomography (CT) of the neck. For neck staging in 27 patients (16%), ultrasound-guided fine-needle aspiration cytology (FNAC) was performed, which provided negative results. Selective ND was performed in all cases as a diagnostic procedure.
Inclusion criteria contained a complete resection of the primary tumor with free margins (R0) and without evidence for residual disease. Only patients with a follow-up time of at least 1 year were enrolled in the present study. Patients who received primary or adjuvant radiochemotherapy or patients with local failure in the follow-up were excluded.
In 53 of 171 cases, elective ND was performed after primary radiochemotherapy. Occult cervical spread could be recognized by histologic examination after surgery in another 44 patients, whereas 74 patients were postoperatively classified as pN0. Seven of the remaining 74 patients who developed local failure or a second primary of the head and neck were excluded. Follow-up was less than 1 year in another 6 cases. The remaining 61 patients fulfilled the inclusion criteria, 48 of which were male and 13 were female. The mean age at diagnosis was 60.6 years (range, 29–80 years).
2.2
Follow-up examination of the neck
Follow-up examination contained clinical inspection, palpation, and complete sonographic examination of both neck sides. Sonographic examination was routinely done by using a 7.5-MHz transducer (Sonoline G60 S; Siemens Medical Solutions, Andover, MA). In the first 2 years after diagnosis, the neck was followed up in 4- to 8-week intervals. In the third year, the follow-up period was 3 months; fourth year, 6 months; and fifth year, 12 months. The average follow-up period after selective ND was 1.8 (1.1–10.7) years. Late lymph node metastases were defined as metastases that were diagnosed after performing an elective ND in the initial pN0 neck.
In the case of clinical suspicion for the presence of lymph node metastases, further diagnostics included FNAC of the neck nodes, followed by panendoscopy and CT of the head and neck or positron emission tomography in combination with CT scan.
2.3
Selective neck dissection
Of the 61 patients who met the inclusion criteria, elective ND was carried out in 28 cases (45.9%) on the ipsilateral side and in 33 cases (54.1%) bilaterally. Selective ND of different dimensions and neck levels was performed. In this context, dissection of levels I to III (n = 20) and levels II to IV (n = 44) formed the greatest proportion. The most frequently dissected lymph node levels were level II (n = 73) and level III (n = 83).
Selective ND was performed unilaterally for all tumors without evidence of midline involvement. Regarding the location of the primary tumor, patients with oral or oropharyngeal cancer underwent selective ND including levels I to III. In the case of hypopharyngeal and laryngeal cancer, selective ND included levels II to IV. If the primary tumor was close to the midline (<10 mm) or in the case of midline involvement, bilateral selective ND was carried out. In patients with oral or oropharyngeal cancer close to the midline, the ipsilateral levels I to III and the contralateral levels I and II were dissected. In the case of oral or oropharyngeal cancer and midline involvement, bilateral selective ND including levels I to III was performed. Patients with hypopharyngeal or laryngeal cancer with evidence of midline involvement underwent bilateral selective ND including levels II to IV. Dissection of level I included Ia and Ib with extirpation of the ipsilateral submandibular gland, and dissection of level II included IIa and IIb in all examined cases.
In all of the examined cases, a simultaneous operation on the primary tumor was carried out. The variety of these simultaneous operations arose from the location and the tumor stage of the primary tumor. The larynx was the most common tumor site (n = 29, or 47.5%), followed by oral cavity (n = 20, or 32.8%), oropharynx (n = 9, or 14.7%), and hypopharynx (n = 3, or 4.9%). Pathologic tumor status was classified by histologic examination as T1 in 29 cases (47.5%), T2 in 23 cases (37.7%), T3 in 8 cases (13.1%), and T4 in 1 case (1.6%).
2
Patients and methods
2.1
Clinical data
The clinical data of 171 patients with T1 to T4 squamous cell carcinoma (SCC) of the head and neck without evidence of neck metastasis who underwent a unilateral or bilateral selective ND at the Department of Otolaryngology, Head and Neck Surgery, Philipp University, Marburg, Germany, in a period of 11 years (from 1998 to 2009) were analyzed. In 29 cases (17.0%), primary tumor was localized in the oral cavity; 41 cases (24.0%), in the oropharynx; 28 cases (16.4%), in the hypopharynx; and 73 cases (42.7%), in the larynx.
All patients were preoperatively staged as N0 via ultrasonography and computed tomography (CT) of the neck. For neck staging in 27 patients (16%), ultrasound-guided fine-needle aspiration cytology (FNAC) was performed, which provided negative results. Selective ND was performed in all cases as a diagnostic procedure.
Inclusion criteria contained a complete resection of the primary tumor with free margins (R0) and without evidence for residual disease. Only patients with a follow-up time of at least 1 year were enrolled in the present study. Patients who received primary or adjuvant radiochemotherapy or patients with local failure in the follow-up were excluded.
In 53 of 171 cases, elective ND was performed after primary radiochemotherapy. Occult cervical spread could be recognized by histologic examination after surgery in another 44 patients, whereas 74 patients were postoperatively classified as pN0. Seven of the remaining 74 patients who developed local failure or a second primary of the head and neck were excluded. Follow-up was less than 1 year in another 6 cases. The remaining 61 patients fulfilled the inclusion criteria, 48 of which were male and 13 were female. The mean age at diagnosis was 60.6 years (range, 29–80 years).
2.2
Follow-up examination of the neck
Follow-up examination contained clinical inspection, palpation, and complete sonographic examination of both neck sides. Sonographic examination was routinely done by using a 7.5-MHz transducer (Sonoline G60 S; Siemens Medical Solutions, Andover, MA). In the first 2 years after diagnosis, the neck was followed up in 4- to 8-week intervals. In the third year, the follow-up period was 3 months; fourth year, 6 months; and fifth year, 12 months. The average follow-up period after selective ND was 1.8 (1.1–10.7) years. Late lymph node metastases were defined as metastases that were diagnosed after performing an elective ND in the initial pN0 neck.
In the case of clinical suspicion for the presence of lymph node metastases, further diagnostics included FNAC of the neck nodes, followed by panendoscopy and CT of the head and neck or positron emission tomography in combination with CT scan.
2.3
Selective neck dissection
Of the 61 patients who met the inclusion criteria, elective ND was carried out in 28 cases (45.9%) on the ipsilateral side and in 33 cases (54.1%) bilaterally. Selective ND of different dimensions and neck levels was performed. In this context, dissection of levels I to III (n = 20) and levels II to IV (n = 44) formed the greatest proportion. The most frequently dissected lymph node levels were level II (n = 73) and level III (n = 83).
Selective ND was performed unilaterally for all tumors without evidence of midline involvement. Regarding the location of the primary tumor, patients with oral or oropharyngeal cancer underwent selective ND including levels I to III. In the case of hypopharyngeal and laryngeal cancer, selective ND included levels II to IV. If the primary tumor was close to the midline (<10 mm) or in the case of midline involvement, bilateral selective ND was carried out. In patients with oral or oropharyngeal cancer close to the midline, the ipsilateral levels I to III and the contralateral levels I and II were dissected. In the case of oral or oropharyngeal cancer and midline involvement, bilateral selective ND including levels I to III was performed. Patients with hypopharyngeal or laryngeal cancer with evidence of midline involvement underwent bilateral selective ND including levels II to IV. Dissection of level I included Ia and Ib with extirpation of the ipsilateral submandibular gland, and dissection of level II included IIa and IIb in all examined cases.
In all of the examined cases, a simultaneous operation on the primary tumor was carried out. The variety of these simultaneous operations arose from the location and the tumor stage of the primary tumor. The larynx was the most common tumor site (n = 29, or 47.5%), followed by oral cavity (n = 20, or 32.8%), oropharynx (n = 9, or 14.7%), and hypopharynx (n = 3, or 4.9%). Pathologic tumor status was classified by histologic examination as T1 in 29 cases (47.5%), T2 in 23 cases (37.7%), T3 in 8 cases (13.1%), and T4 in 1 case (1.6%).
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