Paratracheal Lymph Node Dissection for Carcinoma of the Larynx, Hypopharynx, and Cervical Esophagus

Abstract

Paratracheal lymph node (PTLN) metastasis has been implicated as an etiologic factor in peristomal recurrence after laryngectomy. To determine the relationship between the primary site, the risk of peristomal recurrence, and the prognostic significance of PTLN metastasis, the medical records of 645 patients who underwent total laryngectomy between 1978 and 1990 for squamous cell carcinoma of the larynx, hypopharynx, and cervical esophagus were reviewed. Criteria for inclusion were the surgeon's description of PTLN dissection and hemi- or total thyroidectomy, as well as gross and microscopic pathologic identification of PTLNs. These requirements were fulfilled in 141 patients, who composed the cohort analyzed. There were 117 males and 24 females, with a median followup of 20 months (range, 1 to 94 months). Fifty-three patients were treated previously; among these, 21 underwent tracheostomy before laryngectomy. The primary site of origin was the larynx in 64.5% of patients, the hypopharynx in 25.5%, and the cervical esophagus in 9.9%. Of the patients with endolaryngeal primary tumors, 33% had subglottic extension. Postoperative stomal irradiation was administered to 61 patients. The mean number of PTLNs removed was 3.9 (range, 1 to 30), and metastasis was present in 29 patients (20.5%). PTLN metastasis by primary tumor site was the cervical esophagus, 10 of 14 (71.4%) (p < 0.001); the larynx, 16 of 91 (17.6%); and the hypopharynx, 3 of 36 (8.3%). Of the 30 patients with subglottic extension, eight (26.7%) had PTLN metastases. Peristomal recurrences developed in six of 141 patients (4%), and metastasis to PTLNs was identified in one third of these patients. No peristomal recurrence developed in any of the patients who received postoperative radiotherapy to the stoma (p = 0.057). Survival was significantly reduced by the presence of PTLN metastases. For patients with neither regional nor PTLN metastasis, the overall survival was 87%, whereas none of those with paratracheal metastasis survived beyond 42 months (p < 0.001). PTLN dissection provides prognostic information in patients who are undergoing total laryngectomy. Patients with carcinomas of the larynx, hypopharynx, and cervical esophagus may harbor occult metastasis in the PTLN, and for this reason we recommend elective dissection of these lymph nodes to reduce the risk of peristomal recurrence.