Conservative neck dissection.

The areolar tissue which fills the laterovisceral spaces of the neck is thought to be in close contact with the limiting muscle and the large vessels and nerves of the neck. The site of lymph nodes and lymphatic vessels in such tissue is not clearly defined. A more profound anatomical study shows that the areolar tissue contains the whole lymphatic system of the neck, limited by a series of aponeuroses. These are derived from the embryonal mesenchyme, surrounding muscles and vessels, giving origin to a series of compartments which are in continuity with each other. These compartments, which contain the lymphatic structures, may be entirely removed en bloc including their limiting aponeurotical membranes, as long as the latter are carefully stripped from the muscular and vascular structures. This technique of neck dissection originating with O. Suarez in Argentina, is as radical as any traditional neck dissection, providing that some technical details are respected and that the nodes are still mobile. By preserving many useful or necessary structures of the neck, which themselves are unrelated to the lymphatic spread of cancer, conservative neck dissection presents important functional and cosmetic advantages as compared with traditional neck dissection.

Supraglottic cancer.

Supraglottic cancer, because of the embryological development of the larynx, and of the arrangement of its lymphatic network, tends to remain limited within the vestibule of the larynx and the pre-epiglottic space also in its advanced stages of evolution. The cancer spread may superiorly involve the epilarynx, the vallecula, the base of the tongue, and the pyriform fossa; however, inferiorly, the invasion of the glottis is quite exceptional (1 percent of cases); therefore, supraglottic laryngectomy is the operation of choice. The lower the location of cancer in the vestibule, the safer the indication. The higher location generally requires an extension of surgical excision toward the tongue, arytenoids and hypopharnx. In view of the high percentage of lymph node metastases, supraglottic laryngectomy should be associated with neck dissection, mainly bilateral, also in cases with no evidence of enlarged lymph nodes. Supraglottic laryngectomy has been performed in 240 cases in the course of the last 14 years and the five-year cure rate has been 79 percent. Five postoperative deaths have been recorded. Rehabilitation time for the breathing and swallowing function has been three weeks as an average. Complications, such as fistula or infection have been exceedingly rare: uneventful recovery followed in all cases.

Functional neck dissection: an evaluation and review of 843 cases.

After briefly reviewing the principles, indications, and merits of functional neck dissection, the results of 1200 neck dissections performed on 843 patients in the period 1961-1979 are presented. They compare very favorably with those reported for classic (radical) neck dissection by other leading authors; however, a retrospective analysis of data derived from material of different origin is hardly possible and has a disputable value. Therefore, we decided to compare our data on functional neck dissections (FND) with those of classic neck dissections (CND) performed by the same surgical team at the same clinic in the period 1948-1960. The clinical material was largely the same in both cases, and the data were collected and analyzed using the same criteria. In both series, neck dissections were divided into elective and curative. It could be demonstrated that the number of neck recurrences observed in the dissected necks is the same for FND and CND in curative dissections, while it is considerably lower for FND in elective neck dissections. This of course does not prove improved radicality in FND, but only proves that a systematic bilateral elective neck dissection in N0 cases affords improved cancerological safety. This radical bilateral approach to regional lymph nodes is made possible routinely by FND which avoids the problems of unnecessary mutilation. The figures produced speak in favor of a wider adoption of FND especially for expanding the indications to elective treatment of regional lymph nodes in cancer of the head and neck. Elective neck dissection is made practically harmless by this newer technique and averts the dreadful appearance of late metastases in N0 cases.

Occult metastases in cancer of the larynx and their relationship to clinical and histological aspects of the primary tumor: a four-year multicentric research.

The authors have tried to verify whether some clinical or pathological features of laryngeal cancer may favor the occurrence of occult metastases in the lymph nodes of the neck in N0 cases. The purpose of the investigation was to define the possible existence of tumors, where elective neck dissection, in the absence of palpable nodes, could be done without, thus contributing to settlement of a long debated problem. Different parameters, both clinical and pathological, have been considered. The result of a cross comparison of such parameters in 237 cases of cancer of the larynx without palpable nodes, submitted to surgery on the primary and elective neck dissection, indicates that, although the frequency of occult metastases is significantly related to the site and size of the tumor, its grading, and the degree and type of stromal reaction, the favorable concurrence of all said parameters occurs in 2% of cases only. However, if only clinical parameters, viz. site and size of tumor, are taken into account, a favorable concurrence occurs in 18% of cases with an incidence of occult metastases lower than 2%. These cases are almost exclusively represented by T1N0 supraglottic and T2N0 glottic tumors. We can conclude by saying that clinical and pathological preoperative findings may offer a useful clue in evaluating the risk of occult metastases, and hence advising, or not, an elective neck dissection in N0 cases. Nevertheless, in the vast majority of cases, an elective functional neck dissection still offers the best guarantee of oncologic safety while avoiding unnecessary mutilation.

Sixteenth Daniel C. Baker, Jr, memorial lecture. Surgical management of supraglottic cancer and its lymph node metastases in a conservative perspective.

Supraglottic laryngectomy combined with functional elective or curative neck dissection is a priceless contribution toward treatment of supraglottic cancer and its lymph node metastases. The history and background of this conservative approach is reviewed. Results related to staging are presented. Irradiation as a combined or alternative therapy is considered.

Supraglottic laryngectomy: 30 years of experience.

A review of 467 cases of supraglottic laryngectomy operated during the last 30 years is presented. Cases have been subdivided into groups according to stage and TNM classification. By far the most numerous in this series were T2 cases. No cases prevailed over N+ by 4:1. Stage II cases represented about 60% of the total. Results are analyzed according to TNM and staging. The average overall 5-year cure rate is 75%. The influence of factors other than TNM and staging upon results is also considered. Supraglottic laryngectomy may be extended to include one arytenoid, the base of the tongue, or both, with approximately equal results. Practically all cases had en bloc bilateral functional or classic neck dissection for threatening or actual lymph node metastases. This may have contributed to a higher number of successes. Combined surgery and radiotherapy is occasionally indicated, but rarely improves the prognosis of severe cases. Site and type of recurrences are considered and their treatment and prognosis are discussed. On the basis of the present study the clinical value of supraglottic laryngectomy is further assessed.

Extended supraglottic laryngectomy. Review of 84 cases.

Extended supraglottic laryngectomy is a surgical procedure by which the boundaries of standard supraglottic laryngectomy are extended to include the base of the tongue and/or pyriform sinus and/or one of the arytenoids, according to the extent of epilaryngeal or extralaryngeal invasion by vestibular cancer. We report the results of 84 extended supraglottic laryngectomies performed by our group from 1970 to 1980. Besides the highly favorable 5-year cure rate (75%), full functional rehabilitation followed in all but three patients, who were therefore submitted to secondary total laryngectomy. Rehabilitation time is often somewhat longer than in standard supraglottic laryngectomy, especially when an ample resection of the base of the tongue is required. Combined resection of the base of the tongue, aryepiglottic fold, and one of the arytenoids may further lengthen the rehabilitation period. We believe that extended supraglottic laryngectomy should be performed more often, not only for actual invasion, but also for suspected invasion of extralaryngeal structures.

Limitations of supraglottic laryngectomy and conservative neck dissection.

Limitations of supraglottic laryngectomy may arise from either the primary location, or secondary spread of the tumor in the vestibule. When a growth reaches the epilarynx a modified supraglottic laryngectomy or a more radical operation must be envisaged. Other limitations include poor bronchopulmonary condition, age of the patient, and previous radiotherapy. All these conditions may jeopardize healing and/or, even more important, functional rehabilitation. New hands to this surgery should know its limitations and should be warned against its risks. On the other hand no limitations exist to conservation neck dissection, except fixed nodes or lymph node metastases following radiation or earlier surgery. The conservative technique is as radical as the traditional technique, but respects essential structures and thus widens instead of limiting the indications for elective bilateral neck dissection.