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Nodal Metastases from Laryngeal Carcinoma and Their Correlation with Certain Characteristics of the Primary Tumor

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Nodal Metastases from Laryngeal Carcinoma and Their Correlation with Certain Characteristics of the Primary Tumor NODAL METASTASES FROM LARYNGEAL CARCINOMA AND THEIR CORRELATION WITH CERTAIN CHARACTERISTICS OF THE PRIMARY TUMOR Kamaljit Kaur ~, Nishi Sonkhya 2, A.S. Bapna 3 Key Words : Carcinoma larynx, nodal metastases. INTRODUCTION nodal metastases progresses in an orderly manner with Cancer of the larynx represents about 2% of the total the first site of metastasis being the sentinel node. cancer risk and is the most common head and neck cancer (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 cell 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 malignancies 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 malignancy 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 differentiation 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.
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