Impact of nodal yield at a single institution in patients undergoing neck dissection and total laryngectomy

Presentation: C060
Topic: Pharynx / Larynx Cancer
Type: Poster
Date: Thursday, April 19, 2018
Session: 9:00 AM - 7:00 PM
Authors: Michael C Topf, MD, Linda C Magana, PhD, James Metkus, MD, James Hamilton, MD, Larissa Sweeny, MD, William M Keane, MD, Richard A Goldman, MD, Adam Luginbuhl, MD, Joseph M Curry, MD, David M Cognetti, MD
Institution(s): Thomas Jefferson University Hospital

BACKGROUND: There has been recent emphasis on lymph node yield during neck dissection in patients with head and neck squamous cell carcinoma (HNSCC). Previous studies have suggested that lymph node yield should be considered as a measure of surgical quality in head and neck cancer treatment.

OBJECTIVE: To determine the impact of nodal yield in patients undergoing neck dissection at the time of total laryngectomy (TL) at a single institution. 

DESIGN: Retrospective chart review.

SETTING: Tertiary care center.

PARTICIPANTS: Patients undergoing primary or salvage TL with unilateral or bilateral neck dissection between January 2008 and July 2016 were identified. Patients with history of previous neck dissection were excluded.   

EXPOSURE: TL with unilateral or bilateral neck dissection.  

MAIN OUTCOMES AND MEASURES: Lymph node yield (LNY), lymph node ratio (LNR), total number of positive nodes, presence of bilateral nodal metastases, and extracapsular extension (ECE) status were determined for all patients. Primary outcome measures consisted of overall survival (OS) and disease-free survival (DFS).

RESULTS: A total of 232 patients underwent TL with neck dissection and were included in the study. The majority of the patients (n = 131) had no prior history of radiation, while 101 patients underwent salvage laryngectomy. Positive nodes were found in: level 1A (1.3%), level 2A (31.9%), level 2B (4.74%), level 3 (28.5%), level 4 (11.6%), level 5 (1.72%), and level 6 (15.5%). Preoperative radiotherapy significantly decreased mean LNY from 29.6 to 21.9 nodes (p < .001). Eighteen or greater lymph nodes were dissected in 72.4% of necks (84.7% in patients without a history of radiation and 56.4% in patients with prior radiation). Multivariate analysis demonstrated that overall survival was associated with a LNR greater than .026 (HR 2.48; 95% CI, 1.58 – 3.92, p < .001), positive ECE (HR 1.71; 95% CI, 1.12 – 2.63, p = .013), and salvage TL (HR 1.58; 95% CI 1.04 – 2.40, p = .031). Similarly, DFS was associated with LNR greater than .026 (HR 2.70; 95% CI, 1.55 – 4.69, p <.001), positive ECE (HR 2.42 (95% CI, 1.43 – 4.08, p <.001), and salvage TL (HR 2.99; 95% CI, 1.79 – 4.99, p <.001). LNY, total number of positive nodes, and the presence of bilateral nodal metastases had no impact on OS or DFS.

CONCLUSIONS AND RELEVANCE: Within a single institution, the importance of nodal yield during neck dissection is unclear. Previous radiotherapy significantly reduces the nodal yield during total laryngectomy and neck dissection. Lymph node ratio, ECE, and salvage laryngectomy are independent prognostic risk factors for overall survival and recurrence in patients undergoing TL with neck dissection.