The Journal of Laryngology & Otology March 2004, Vol. 118, pp. 175–178 Editorial Is dissection of level V necessary in patients with T 2 –T 4 N 0 supraglottic cancer? Alessandra Rinaldo, M.D., Alo Ferlito, M.D., F.R.C.S. (Ed.), F.R.C.S., F.A.S.C.P., Luiz P. Kowalski*, M.D., Miquel Quer † , M.D., Carlos Sua ´ rez ‡** , M.D., Xavier Leo ´n † , M.D., K. Thomas Robbins § , M.D., F.R.C.S.C., F.A.C.S. Nodal status has a greater inuence on the curability of supraglottic cancer than the status of the primary tumour. The proper management of the neck in patients with supraglottic cancer remains a subject of much debate. There is no general consensus of which type of neck dissection is more adequate in patients with supraglottic cancer without clinical, radiologic, or ultrasonic regional lymph node metastasis. Elective dissection of cervical lymph nodes is commonly advocated for the treatment of patients with T 2 –T 4 N 0 supraglottic cancer. The philosophy of radical neck dissection has been replaced by a more selective approach in the absence of clinically obvious metastatic disease. 1 The procedure of choice for elective surgery, until recently, was usually modied radical neck dissec- tion, in particular the ‘type III’ (or functional neck dissection) 2 which removes lymph node levels I, II, III, IV and V and preserves the sternocleidomastoid muscle, the internal jugular vein, the spinal accessory nerve and the submandibular gland. In 1990, Candela et al. 3 retrospectively reviewed 247 con- secutive patients with supraglottic or transglottic squamous cell carcinoma submitted to a comprehen- sive neck dissection. The analysis of the distribution of lymph node metastasis showed a remarkable preference for levels II and III. Levels I and V were rarely involved. Based on these observations, the authors proposed the indication of more selective neck dissections for patients with necks staged as N 0 or N 1 . In 1994, Shah and Andersen 4 retrospectively reviewed the patterns of nodal metastasis in patients who underwent comprehensive dissections in an effort to validate the indication of less extensive surgical procedures in order to reduce post-operative morbidity. They reinforced the rational for the indication of a lateral neck dissection in patients with laryngeal cancer. More recently, complete functional neck dissec- tion has been considered an unnecessarily extensive procedure for treatment of the clinically negative neck as levels I and V are rarely involved, particularly in the absence of clinically or radiologi- cally apparent neck metastases. 5 Thus, selective lateral neck dissection (jugular neck dissection) is a valid option in supraglottic cancer as this procedure preserves levels I and V where laryngeal cancer rarely metastasizes. The dissection of levels II, III and IV as part of an elective or therapeutic neck dissection is a common practice for patients with supraglottic cancer. In 1999, Tu, 6 in a prospective non-randomized study, suggested that a very limited neck dissection, called upper neck (level II) dissection for N 0 neck supraglottic cancer, can be considered a diagnostic as well as a therapeutic modality. In the case of subclinical metastasis on frozen section, a level III neck dissection was also performed. In 1996, Ambrosch et al. 7 mentioned that Steiner advocates performing ‘limited’ selective neck dissec- tion, clearing only levels II and III for cancer of the larynx. In 2001, a retrospective study was published by Steiner’s group. 8 The authors believed that the dissection of levels II and III was sufcient when metastases were not suspected during surgery to level IV, a type of surgery that they had done routinely since 1979. In 2001, Leo ´n et al. 9 published a retrospective revision of 79 patients with laryngeal cancer in which a conservative surgical approach to the clinically negative neck was adopted. Treatment consisted of a neck dissection at levels II and III with intra- operative biopsy of a sample of subdigastric and supraomohyoid nodes. When biopsy specimens were positive, dissection of levels IV and V was com- pleted. In no case were positive nodes found at level V, therefore the authors do not consider it necessary to dissect level V in selective neck dissection. From the Department of Surgical Sciences, ENT Clinic, University of Udine, Udine, Italy, Head and Neck Surgery and Otorhinolaryngology Department*, Centro de Tratamento e Pesquisa Hospital do Cancer A. C. Camargo, Sa ˜o Paulo, Brazil, Department of Otolaryngology † Hospital de Santa Creu i Sant Pau, Barcelona, Spain, Department of Otolaryngology‡, Hospital Universitario Central de Asturias, Oviedo, Spain, Instituto Universitario de Oncologõ ´a del Principado de Asturias**, Oviedo, Spain, Division of Otolaryngology § , SIU School of Medicine, Springeld, IL, USA. 175 https://www.cambridge.org/core/terms. https://doi.org/10.1258/002221504322927919 Downloaded from https://www.cambridge.org/core. IP address: 34.228.24.229, on 01 Jun 2020 at 18:14:51, subject to the Cambridge Core terms of use, available at