NODAL METASTASES FROM LARYNGEAL AND THEIR CORRELATION WITH CERTAIN CHARACTERISTICS OF THE

Kamaljit Kaur ~, Nishi Sonkhya 2, A.S. Bapna 3

Key Words : Carcinoma larynx, nodal metastases.

INTRODUCTION nodal metastases progresses in an orderly manner with of the larynx represents about 2% of the total the first site of being the sentinel node. cancer risk and is the most common (skin excluded). It has been consistently observed by Lymphatic metastasis is the most important mechanism various authors that the status of cervical lymph nodes is in the spread of head and neck squamous carcinoma. the single most important prognostic factor in laryngeal Multiple clinical studies have demonstrated that the carcinoma and the probability of 5 year survival, regardless distribution of cervical lymph node metastases is indeed of the treatment rendered, reduces by 50% once the tumor predictable in patients with previously untreated squamous dissemination to the regional lymph nodes has taken place. cell carcinoma of the upper aerodigestive tract. The rate For this reason, studies dealing with the probability of of metastasis probably reflects the aggressiveness of the nodal metastases are important in making therapeutic primary tumor and is an important prognosticator. Not decisions. only the presence, but also the number of nodal metastases, their level in the neck, the size of the nodes and the presence Although the credit for first injection studies of laryngeal of extra-capsular spread are important prognostic feature. lymphatics goes to Hajek in 1891, it was the monumental study of laryngeal lymphatics by injections of dyes and There is a need to identify pretreatment factors that can radioisotopes by Pressman et al in 1956 that provided differentiate high risk from low risk patients with respect excellent documentation of the anatomical to occult metastases. Several clinical factors (tumor site, compartmentalization and lymphatic flow within the larynx microscopic type, local extent and stage of the primary and afforded considerable insight into the nature of spread tumor) and pathologic ones (grade of histological of cancer within the larynx. Anatomic and radiographic differentiation, thickness, vascular embolization, perineural studies of the lymphatics of the head and neck have invasion) have been correlated to the risk of lymph node demonstrated that the lymphatic drainage of this region metastases in head and neck carcinoma. However, the follows predictable pathways (Fisch, 1964). The concept gold standard for the detection of lymph node metastases of sentinel node approach is based on the knowledge that in the neck is the histological examination of all carefully ~Senior Registrar, 2Assistant Professor, 3professor& Head Department of ENT, SMS Medical College & Hospital, Jaipur 256 Nodal Metastases from Lao,ngeal Carcinoma and their Correlation with Certain Characteristics of the Primar), Tumor

dissected nodes by the pathologist in the specimen of a histopathological examination. Excluding the 5 glottic selective or comprehensive neck dissection. lesions, which were managed by radiotherapy, all the other cases were managed by total laryngectomy and neck This prospective study was undertaken to ascertain the dissection - selective lateral neck dissection (clearance of incidence and pattern of lymph node metastases (both levels II, III and IV) in cases with a clinically negative clinical and occult) and to determine the influence of neck and modified radical neck dissection (sparing the certain characteristics of the primary tumor on the spinal accessory nerve) in cases with a clinically positive incidence of lymph node metastases in 50 cases of neck at the time of presentation. The clinical data, laryngeal carcinoma. peroperative findings and histopathological details were carefully noted and finally all the data was compiled to MATERIALS AND METHODS tabulate the results. The present series includes a clinicopathological study of 50 patients with the clinical diagnosis of laryngeal OBSERVATIONS AND RESULTS carcinoma who were hospitalized in the department of In our study, transglottic constituted 66% ENT, SMS Medical College & Hospital, Jaipur, during the (33 cases) of the total 50 cases, while supraglottic years 2000 and 2001. Those cases of carcinoma larynx malignancies constituted 24% (12 cases) and glottic who had previously undergone radiotherapy were excluded malignancies constituted 10% (5 cases). On studying the from the study. All the patients were evaluated with regard age distribution, the most common age group involved in to detailed history and clinical examination. Subsequently, our series was 51-60 years constituting 50% (25 cases) all the patients were subjected to direct laryngoscopy under of the total 50 cases. The youngest patient in our series general anaesthesia during which the characteristics of was 34 year old while the eldest patient was 78 year old the primary tumor like site, stage, peripheral growth pattern (Table I). etc. were noted and biopsy was taken and sent for It was observed in our study that hoarseness of voice

Table - I : Topographical and age distribution in 50 cases of laryngeal carcinoma

Site of No. of Age group (in yrs.) Carcinoma cases < 40 41-50 51-60 61-70 > 70

Supraglottis 12 (24%) 1 (8.3%) 3 (25%) 7 (58.3%) 1 (8.3%)

Glottis 5 (10%) 2 (40%) 2 (40%) 1 (20%)

Transglottic 33 (66%) 7 (21.2%) 16 (48.5%) 9 (27.3%) 1 (2%)

Total 50 1 (2%) 12 (24%) 25 (50%) 11 (22%) i (2%).

Table - II : Distribution of signs and symptoms in 50 cases of laryngeal carcinoma

Signs / Symptoms No. of cases Supraglottic (n = 12) Glottic (n = 5) Transglottic(n = 33)

Hoarseness 40 (80%) 2 (16.7%) 5 (100%) 33 (100%) Breathlessness 24 (48%) 4 (33.3%) 20 (60.6%) Difficulty in swallowing 18 (36%) 8 (66.7%) 10 (30.3%) Discomfort in throat 14 (28%) 6 (50%) 8 (24.2%) Earache 12 (24%) 4 (33.3%) 8 (24.2%) Hemoptysis 5 (10%) l (8.3%) 4 (12%) Cough 4 (8%) 1 (8.3%) 3 (9.1%) Mass in the neck 21 (42%) 5 (41.7%) 16 (48.5%)

Indian Journal of Otolaryngology and Head and Neck Surgery. Vol. 54 No. 4, October - December 2002 Nodal Metastases from Laryngeal Carcinoma and their Correlation with Certain Characteristics of tile Primary Tumor 257 was the most common symptom (100%) in both glottic positive neck at the time of presentation - 47.6% being in and transglottic malignancies whereas difficulty in N 2 stage, 38.1% in N~ stage and only 14.3% being in N 3 swallowing was the most common symptom (66.7%) in stage (Table III). the case of supraglottic malignancies. 48.5% (16 cases) cases of transglottic presented with a mass in In 29 cases of laryngeal carcinoma with a clinically the neck as compared to 41.7% (5 cases) cases of negative neck at the time of presentation, the overall supraglottic malignancies. Thus the overall incidence of incidence of occult nodal disease was found to be 27.6% nodal metastases in our series was 42% (21 cases) (8 cases) - comprised by 42.8% (3 cases) occult nodes (Table II). in supraglottic lesions and 29.4% (5 cases) occult nodes On studying the N stage in 50 cases of laryngeal carcinoma, in transglottic lesions (Table IV). 58% (29 cases) were found to be N o stage - constituted by 58.3% of the supraglottic lesions, 100% of the glottic In our series of 50 cases of laryngeal carcinoma, 56% lesions and 51.5% of the transglottic lesions. On the other (28 cases) had extralaryngeal spread as compared to 44% hand, 42% (21 cases) were found to have a clinically (22 cases) endolaryngeal lesions. While 100% of the glottic

Table - III : N-stage of primary lesion in 50 cases of laryngeal carcinoma

N Stage Site Total Supra glottis Glottis Transglottis N o 7 (58.3%) 5 (100%) 17 (51.5%) 29 (58%) N 1 2 (I 6.6%) 6 (18.2%) 8 (38.1%) N 2 N2a 2 (16.6%) 3 (9.1%) 10 (47.6%) N2b 1 (8.3%) 3 (9.1%) N2c 1 (3%) N 3 3 (9.1%) 3 (14.3%)

Total 12 5 33 50

Table IV : Occult nodal metastases detected by elective neck dissection

Site No. of Clinically palpable Clinically negative Occult nodal cases nodes neck metastases Supraglottis 12 5 (41.7%) 7 (58.8%) 3 (42.8%) Glottis 5 5 (100%) Transglottic 33 16 (48.5%) 17 (51.5%) 5 (29.4%) Total 50 21 (42%) 29 (58%) 8 (27.6%)

Table V : Correlation between nodal metastases and anatomical extent of the primary

Extent of primary No. of N+ Supra-glottis N+ Glottis N+ Trans-glottic N+ cases Extralaryngeal 28(56%) 15 7 4 21 11 (53.4%) (25%) (57.1%) (75%) (52.4%) Endolaryngeal 22 6 5 1 5 12 5 (44%) (27.3%) (22.7%) (20%) (22.7%) (54.5%) (41.7%) Total 50 21 12 5 5 33 16 (42%) (41.7%) (48.5%)

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 4. October - December 2002 258 Nodal Metastases from Lao'ngeal Carcinoma and their Correlation with Certain Characteristics of the Primary Tumor

Table VI : Correlation between nodal metastases and peripheral growth pattern

Peripheral No. of N+ Supra-glottis N+ Glottis N+ Trans-glottic N+ ~rwoth pattern cases Exophytic 3O ll 8 3 4 18 8 (60%) (36.7% (26.7%) (37.5%) (13.3%) (60%) (44.4%) Endophytic 2O 10 4 2 1 15 8 (40%) (50%) (2O%) (50%) (5%) (75 %) (53.3%) Total 5O 21 12 5 33 16 (42%) (41.7%) (48.5%)

Table VII : Correlation between nodal metastases and

Cellular No. of N+ Supra- N+ Glottis N+ Trans- N+ differentiation cases ~lottis glottic Well 8 (16%) 2(25%) 3 (37.5%1 1.(33.3%) 3(37.5%) 2 (25%) 1 (50%) differentiated Moderately 36 (72%) 15(41.7%3 7(19.4%) 3 (42.8%) 2 (5.6%) 27 (75%) 12 (44.4%) differentiated Poorly 6(12%) 4(66.7%) 2(33.3%) 1(50%) 4(66.7) 3 (75%) differentiated Total 50 21(42%) 12 5(41.7%) 5 33 16(48.5%)

Table VIII : Correlation of T stage with N stage

T Stage No. of cases N Stage NQ N+ N 1 N~ N~

T 1 12 (24%) 11 (91.7%) 1 (8.3%) 1 (lOO%) T 2 5 (10%) 4 (80%) 1(20%) 1 (100%) T 3 16 (32%) 8 (50%) 8 (50%) 2 (25%) 6 (75%) T4 17 (34%) 6 (35.3%) 11 (64.7%) 4 (36.4%) 4 (36.4%) 3 (27.3%)

Total 50 29 (58%) 21 (42%) 8 (38.1%) lO (47.6%) 3 (14.3%)

Table IX : Correlation of T stage with level of nodal metastases

T Stage No. of N+ Level of lymph nodes I Ill II+III II+III+IV cases II i

W 1 12 (24%) 1 (8.3%) 1(100%) T 2 5 (10%) 1 (20%) 1 (100%) T3 16 (32%) 8 (50%) i (12.5%) 1 (12.5%) 4 (50%) 2 (25%) T 4 17 (34%) 11 64.7%) 2 (18.2%) 4 (36.4%) 5 (45.4%) Total 50 21 (42%) 3 (14.3%) 3 (14.3%) 8 (38.1%) 7 (33.3%) / malginancies were endolaryngeal, 58.3% (7 cases) of the metastases, it was observed that 53.4% of the supraglottic and 63.6% (21 cases) of transglottic extralaryngeal lesions had nodal metastases as compared malignancies had extralaryngeal spread. On correlating the to 27.3% of the endolaryngeal lesions showing nodal anatomical extent of the primary lesion with cervical nodal metastases (Table V).

Indian Journal of Otolaryngology and Head and Neck Surge~ Vol. 54 No, 4, October - December 2002 Nodal Metastases from Laryngeal Carcinoma and their Correlation with Certain Characteristics of the Primary. Tumor 259

On studying the peripheral growth pattern, it was observed pattern of nodal metastases and the various tumor that 60% (30 cases) had pushing margins as compared to characteristics that affect them. 40% (20 cases) with infiltrating margins. While 80% of the glottic lesions had pushing borders, 66.7% of the In our study, 66% (33 cases) lesions were transglottic as supraglottic and 54.5% of the transglottic lesions had compared to 24% (12 cases) supraglottic and 10% (5 pushing borders. Correlation between peripheral growth cases) glottic lesions. Although the majority of laryngeal pattern and nodal metastases showed that 50% of the arise in the glottis in the world, there is a endophytic lesions had cervical nodal metastases as preponderance of supraglottic carcinomas in Finland, compared to 36.7% of the exophytic lesions showing nodal Spain, Italy, India and Japan. The majority of lesions in metastases (Table VI). our study were transglottic because the patients presented late with advanced disease. Our study reveals that In our series, 72% (36 cases) were moderately carcinoma larynx most commonly occurs in the 6th decade differentiated squamous cell carcinoma, 16% (8 cases) of life, comprising 50% (25 cases) of all the cases. Similar were well differentiated squamous cell carcinoma and 12% observations have been made by varirus authors. Binnie (6 cases) poorly differentiated squamous cell carcinoma. et al. (1983) reported that the incidence of head and neck While 60% of the glottic malignancies were well cancer parallels with the longevity, multiplicity and intensity differentiated, 58.3% of the supraglottic lesions and 81.8% of carcinogenic exposure so that the peak incidence tends of the transglottic lesions were moderately differentiated. to arise beyond the fifth decade of life. The male : female On correlating the cellular differentiation with cervical ratio in our study was 15.7 : 1 (47 males : 3 females). nodal tuetastases, it was observed that 66.7% of the poorly differentiated lesions were associated with nodal It was observed in the present series that the most metastases as compared to 41.7% of the moderately common symptom of glottic and transglottic carcinomas differentiated and 25% of well differentiated lesion was hoarseness. Supraglottic carcinoma was most showing cervical nodal metastases (Table VII). commonly associated with difficulty in swallowing (66.7%), discomfort in throat (50%) and mass in the neck Correlation of T stage with N stage showed that as the T (41.7%). Besides hoarseness, other symptoms commonly stage advanced, the N stage also correspondingly associated with transglottic carcinoma were breathlessness advanced - 8.3% of the T~ lesions being N+, 20% of the (60.6%), mass in the neck (48.5%) and difficulty in T z lesions being N+, 50% of the T 3 lesions being N+ and swallowing (30.3%). Similar signs and symptoms have 64.7% of T 4 lesions being N+ (Table VIII). been reported by various authors.

On correlating the T stage with level of nodal metastases, In this series, the overall incidence of nodal metastases it was observed in our study that progressively lower levels was found to be 42% (21 cases) so that 58% (29 cases) of cervical nodes are involved with advancing T stage. had a clinically negative neck at the time of presentation. Of the 21 cases with cervical nodal metastases at the time The incidence of nodal metastases in supraglottic lesions of presentation, levels II and III were found to be involved was found to be 41.7% (5 cases out of 12). Shah & in 85.7% (18 cases) whereas multiple levels were involved in 71.4% (15 cases) (Table IX). Tollefson (1974) reported 51% palpable nodal metastases in their series of 290 supraglottic tumors. Kirchner and DISCUSSION Owen (1977) reported an incidence of 48% palpable nodal Laryngeal cancer shares with only few other types of metastases amongst 97 supraglottic tumors. The incidence (such as cutaneous, cervical, lymphomas and of clinically positive neck at the time of presentation in perhaps colonic) a high rate of cure which in certain sub- supraglottic carcinoma is 55% according to Million and sites may reach over 85% and overall exceeds 50% (Powell Cassissi (1994). This high rate of nodal metastases in & Robin, 1983). The prognostic significance of nodal supraglottic lesions can be explained by the extensive metastases in head and neck cancers has long been lymphatic network of the supraglottis. In our study, the recognized. The cure rates drop to nearly V2 with the incidence of nodal metastases in the case of supraglottic involvement of regional cervical lymph nodes. So, the lesions is a bit lower than these reported figures because present study was undertaken to study the incidence and all the advanced T 3 and T 4 supraglottic lesions which are

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 4, October - December 2002 260 Nodal Metastases from Laryngeal Carcinoma and their Correlation with Certain Characteristics of the Primary Tumor associated with a high incidence of nodal metastases were the site and size of the tumor, its and the degree included in the group of transglottic lesions. and type of stromal reaction, the favourable concurrence of all said parameters occurring in 2% cases only. All the 5 cases of glottic lesions in our study had a clinically However, if only clinical parameters i.e. site and size of negative neck at the time of presentation. Leroux-Robert tumor are taken into account, a favourable concurrence (1975) reported 15 metastases in his study of 625 glottic occurs in 18% of cases with an incidence of occult carcinomas (2.5% incidence). According to Million & metastases lower than 2% and these cases are almost Cassissi (1994), the incidence of clinically palpable nodes exclusively represented by T~N0 supraglottic and T~T2No at the time of diagnosis in glottic carcinoma in T~ lesions glottic tumors. is 0%, 2-7% in T 2 lesions and rises to 20% in T 3 • T 4 lesions. Since all the 5 glottic lesions in our study were in Kowalski et al (1995) concluded that the likelihood of T~ stage, the incidence of nodal metastases in our series occult nodal metastases was significantly affected was found to be 0%. Besides the low incidence of nodal exclusively by the tumor site-highest risk being for metastases, other factors responsible for the excellent cure supraglottic lesions. rates in glottic carcinoma are - - the lesions are detected early because anatomical Ferlito and Rinaldo (1998) proposed selective lateral neck distortion of the vocai cord rapidly produces a change in dissection for laryngeal cancers with a clinically negative vocal quality neck because micrometastases can not be detected pre- - the majority of lesions arising on the true vocal cord are operatively and to reduce the recurrence rate. They also well differentiated squamous cell carcinomas that generally reported that selective lateral neck dissection is not only tend to be exophytic. useful to obtain important information for the staging procedure, but is also just as valid as a modified radical The incidence of palpable nodal metastases in the case of neck dissection in the treatment of patients with limited transglottic lesions was found to be 48.5% (16 out of 33 cervical metastases. Although the patients with cancer of cases). The term transglottic was introduced by the larynx are potentially curable, a significant proportion McGavran et al. (1961) to describe tumors that cross the of them develop loco-regional recurrences and many laryngeal ventricle to involve both the true and false cords. subsequently die of their neoplastic disease. So, several In their study of 25 patients with transglottic tumors, 13 institutions are adopting and recommending selective neck (52%) were noted to have a clinically positive neck. dissection as the standard treatment for patients with a Kirschner et al. (1974) found positive cervical nodal clinically negative neck in order to reduce the recurrence metastases in 15 (30%) of their 50 patients with transglottic rate (Spiro et al 1993, Houck and Medina 1995, Clayman lesions. In a study of 152 patients with transglottic and Frank 1998). carcinoma, Mittal et al. (1984) found that 45 (30%) patients had a clinically positive neck at the time of Hicks et al (1999) reported an incidence of 30% occult presentation. nodal metastases in their series of 104 supraglottic tumors. In the case of 17 transglottic lesions with a clinically The incidence of occult modal metastases in the case of negative neck, the incidence of occult nodal metastases various tumors was found by performing an elective neck was found to be 29.4% (5 cases). Overall, out of 29 dissection in patients having a clinically negative neck. laryngeal tumors with a clinically negative neck, 27.6% It was observed in our study that 42.8% (3 cases) of 7 (8 cases) had occult nodal metastases. supraglottic lesions with a clinically negative neck had occult nodal metastases. Shah and Tollefson (1974) In view of this high occult nodal metastatic rate, it seems described 34% occult nodal metastases in their series of prudent to advocate lateral neck dissection to remove the 290 supraglottic tumors. Kirchner and Owen (1977) at risk as well as metastatic nodes from the neck and reported an incidence of 40% occult nodal metastases hence prevent recurrence. Since the pattern of metastases amongst 97 supraglottic tumors. is largely predictable in cancer of the larynx, the application of selective lateral neck dissection represents a well Bocca et al (1984) in their study of 237 cases of laryngeal accepted modality for patients clinically defined as N o. carcinoma without palpable nodes concluded that the Despite meticulous investigations, preoperative assessment frequency of occult metastases is significantly related to of the lymph nodes shows limited levels of accuracy. The

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 4, October - December 2002 Nodal Metastases from Lao'ngeal Carcinoma and their Correlation with Certain Characteristics of the Primao' Tumor 261 detailed histopathological examination of all lymph nodes that 34% (50 cases) of the 146 endolaryngeal lesions and removed during a neck dissection is the most reliable 69% (99 cases) of the 144 extralaryngeal tumors had a method currently available for diagnosing the actual status clinically positive neck at the time of presentation. Similar of the lymph nodes. There is extensive evidence that observations have been made by McGavran etal (1961) micro-metastases cannot be detected by non-invasive and Kashima (1976). Thus, the incidence of nodal methods, so it is essential to dissect the neck in order to metastases increases when the tumor spreads to reduce the rate of regional recurrence and its associated extralaryngeal sites. mortality. It was observed in our study that 66.7% (4 cases) of the Selective lateral neck dissection also serves a prophylactic 6 poorly differentiated lesions had a clinically positive neck role. The application of selective lateral neck dissection at the time of presentation as compared to 41.7% (15 represents an adequate and valid modality for laryngeal cases) of the 36 moderately differentiated lesions and 25% cancer patients provided they have only limited, occult (2 cases) of the 8 well differentiated lesions. McGavran metastatic disease i.e. when their metastases involve 1 or et al (1961) reported an incidence of 49% nodal metastases 2 nodes, small in size, mobile and with no macroscopic with poorly differentiated tumors, 22% with moderately extra capsular extension (Ferlito and Rinaldo, 1998). differentiated tumors and 11% with well differentiated Cervical failures often occur in the undissected neck so tumors. Kirschner and Owen (1971) and Kashima (1976) it seems more advisable to perform selective lateral neck also reported a lower incidence of nodal metastases from dissection. As Myers (1996) pointed out - while it is well differentiated lesions than from moderately certainly true that some patients can be salvaged after differentiated or poorly differentiated lesions. Wang et al recurrence of lymph nodes in the neck, the fact is that (1997) concluded that the incidence of nodal metastases not all patients who have a recurrence can be cured. increased as the histological differentiation of the tumol: Micrometastases are difficult to evaluate and their reported decreased. Thus, it can be concluded that as the anaplasia incidence varies according to the methods used for their increases and the degree of differentiation of the tumor detection (e.g. semi-serial sections and / or histochemistry decreases, the incidence of nodal metastases progressively for cytokerations). Their high incidence in cancer of the increases. larynx would strongly support the use of selective lateral neck dissection (Ferlito and Rinaldo, 1998). In our study, 60% (30 cases) had pushing borders - comprosing 66.7 (8 cases) supraglotticlesions, 80% (4 It was observed in our study that the anatomical extent of cases) glottic lesions and 54% (18 cases) transglottic the primary lesion was extralaryngeal in 56% (28 cases) lesions. On the other hand, 40% (20 cases) had infiltrating of the patients as compared to 44% (22 cases) of the borders comprised by 33.3% (4 cases) supraglottic primary lesions that were endolaryngeal. All the 5 glottic lesions, 20% (1 case) glottic lesiorrs and 45.5% (15 cases) lesions in our study were endolaryngeal. In the case of 12 transglottic lesions. This increased preponderance of supraglottic lesions, 7 (58.3%) were extralaryngeal and 5 exophytic peripheral growth pattern in supraglottic and (41.7%) were endolaryngeal. Of the 33 cases of glottic lesions has also been reported by McGavran et al transglottic lesions, 21 (63.6%) were extralaryngeal as (1961), Micheau et al (1976) and Million and Cassissi compared to 12 (36.4%) which were endolaryngeal. Our (1994). observations are in concordance with those of Norris et al (1970) and Micheau et al (1976) who reported that In this series, it was observed that 36.7% (ll cases) of supraglottic and transglottic lesions had a higher the 30 lesions with pushing borders had nodal metastases preponderance for extralaryngeal spread ascompared to at the time of presentation as compared to 50% (10 cases) glottic lesions. of the 20 lesions with infiltrating borders who had a clinically positive neck at the time of presentation. It was observed in our study that 53.4% (15 cases) of the 28 laryngeal tumors with extralaryngeal spread had McGavran et al (1961) in their study of 96 cases of nodal metastases at the time of presentation. In the case laryngeal carcinoma reported that 25 of the 31 patients of 22 endolaryngeal tumors, only 27.3% (6 cases) had with nodal metastases had infiltrating margins while only clinically palpable nodes at the time of presentation. Shah 6 of the 50 lesions with pushing margins had a clinically and Tollefson (1974) in their study of 290 patients reported positive neck at the time of presentation.

Indian Journal of Otolaryngology and Head and Neck Surgery. Vol. 54 No. 4, October - December,. 2002 262 Nodal Metastases from Laryngeal Carcinoma and their Correlation with Certain Characteristics of the Primary. Tumor

In their study of 40 cases, Wang et al (1997) reported cases with nodal metastases at clinical presentation. that lesions with infiltrating margins were associated with a markedly higher incidence of nodal metastases as Lindberg (1972) reported that level ti (superior jugular compared to lesions with pushing borders. Yilmaz et al lymph node chain) was the most commonly involved level (1998) reported in their study of 94 cases of laryngeal with head and neck cancers. Spiro et al (1974) reported carcinoma that the incidence of regional lymph node that as nodal metastases progressively involve lower levels involvement was much higher in lesions with infiltrating of neck, the prognosis steadily worsens. Kleinsasser margins than in those with pushing margins. Thus, it can (1992) stated that the location within the neck of positive be concluded that the type of growth pattern in cancers lymph node influences the prognosis in laryngeal squamous of the larynx is a very important parameter in determining cell carcinoma. Jones et al (1994) concluded that level II the likelihood of nodal metastases. was the most common level of nodal involvement in squamous celt carcinoma of the head and neck irrespective It was observed in our study that as the T stage of the primary. Kowalski et al (1995) reported that levels progressively advanced, the incidence of nodal metastases II and III were most frequently involved in laryngeal also progressively increased - 8.3% (1 case) showing carcinoma in their study of 103 cases. metastases out of 12 T~ lesions, 20% (1 case) showing nodal metastases out of 5 T 2 lesions, 50% (8 cases) CONCLUSION showing nodal metastases out of 16 T 3 lesions and 64.7% A correlative study was carried out on 50 cases of laryngeal (11 cases) showing nodal metastases out of 17 T 4 lesions. carcinoma to study the incidence and pattern of nodal Moreover, as the T stage of the primary lesion increased, metastases (both clinical and occult) and to determine the the N stage also progressively advanced. Shah and influence of certain characteristics of the primary tumor Tollefsen (1974) reported an incidence of cervical on the incidence of nodal metastases. In our study, 66% metastasis of 40% for TI, 42% for T 2, 55% for T 3 and of the lesions were transglottic as compared to 24% 65% for T 4 lesions in their study of 290 patients. Cachin supraglottic and 10% glottic lesions. The most common (1975) reported a 27% incidence of nodal metastases in age group involved in our series was 51-60 years and the T~ lesions and a 38% incidence of nodal metastases in T 2 male to female ratio was 15.7:1. The most common signs lesions in his study of early supraglottic carcinomas. and symptoms associated with laryngeal carcinoma were hoarseness, difficulty in swallowing, discomfort in throat, The presence of multiple lymph nodes has been correlated mass in the neck and breathlessness. On correlating the with distant metastases, Kalnins et al (1977) noted that cervical nodal metastases with various tumor factors, it the incidence of distant metastases was as high as 70% was found that the incidence of cervical nodal metastases when 3 or more lymph nodes were involved. Leemans et increased when the primary lesions had extralaryngeal al (1993) reported that patients with nodal disease had spread, infiltrating or endophytic peripheral growth pattern, twice as much distant metastases as those without (13.6% poor cellular differentiation and advanced T stage. The versus 6.9%) with the group with more than 3 most common levels of lymph nodes involved in our study histologically positive nodes at most risk (46.8%). Houck were levels II and III, accounting for 85.7% of the cases. and Medina (1995) have also concluded that advanced T Multiple level lymph node involvement was seen in 71.4% stage (T2_ 4 ) is associated with a high risk of nodal of the cases with a clinically positive neck at the time of metastases. presentation.

In this series, it was observed that as the T stage of the The incidence of palpable nodal metastases in our study primary lesion advanced, the level of lymph-nodes involved was found to be 42% while the incidence of occult nodal also advanced and progressively multiple levels were metastases in our study was found to be 27.6% so that involved. The sole nodal metastasis from T 1 and T 2 each the overall nodal metastatic rate was 69.6%. In view of involved level II nodes. On the contrary, nodal metastases this high nodal metastatic rate, it is prudent to advocate from T 3 and T~ lesions involved levels II, III and IV. Levels neck dissection to remove the at risk as well as metastatic II and III were found to be involved in 85.7% (18 cases) nodes from the neck-modified radical neck dissection of the 21 cases with nodal metastases. Involvement of (followed by radiotherapy) in cases with a clinically multiple levels was seen in 71.4% (15 cases) of the 21 positive neck at the time of presentation and selective lateral

Indian Journal of Otolaryngology and Head and Neck Surgery. Vol. 54 No. 4, October - December 2002 Nodal Metastases from Laryngeal Carcinoma and their Correlation with Certain Characteristics of the Primary Tumor 263 neck dissection in cases with a clinically negative neck at cancer. Is it long overdue ? (Proposal for an improved TN the time of presentation. Since the pattern of cervical nodal classification). JLO 106 : 197. metastases is largely predictable in laryngeal carcinoma, 14. Kowalski LP, Franco EL, de Andrade Sobrinho J (1995) : Factors it is appropriate to apply selective lateral neck dissection influencing regional lymph node metastases from laryngeal in patients with a clinically negative neck at the time of carcinoma. Ann. Otol Rhinol Laryngol 104(6) : 442-447. presentation. 15. Leemans CR, Tiwari R, Nauta JP et al (1993) : Regional lymph node involvement and its significance in the development of distant metastases in head and neck carcinoma. 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Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 4, October - December 2002