Letter to the Editor Regarding Elective Neck Dissection During Salvage Laryngectomy: A Systematic Review and Meta-Analysis Dear Editor: We would like to commend Gross et al. 1 for their sys- tematic review and meta-analysis, on the role of elective neck dissection (END) during salvage laryngectomy. The treatment of advanced laryngeal cancer has seen a radical shift from surgery to organ preservation treatment, with laryngectomy being more of a salvage procedure. In the current analysis, data was collated ret- rospectively over 6 decades. This was the period when newer and safer techniques of radiation techniques were evolving. Unintended poor outcomes have been reported during this transition from 60 Cobalt to the linear accelerator. 2 The concept of electively addressing the neck was based on a mathematical model and not applicable in a salvage setting. 3 The chances of nodal involvement vary with the site and T stage of the primary. The rate of nodal spread is more common and bilateral in sup- raglottic and hypopharyngeal tumors when compared to the glottic lesions. The current review does not include details of the pretreatment nodal status. All the patients in the recurrent arm had clinically negative neck; how- ever, the rate of occult metastasis ranged from 0% to 27%. Similar studies have quoted the mean rate of occult metastasis of 13% to 14%, whereas mean subsite nodal positivity rate was 17% to 24%, especially in supraglottis, and 21% in T3 and T4 lesions. 4,5 The details of the pre- treatment nodal status and factors for deciding an elec- tive neck treatment versus observation in these studies could be crucial to understand the efficacy of treatment and the role of planned neck dissection. These details would help the readers to make better clinical decisions. The majority of the cases that underwent an elective neck dissection were higher T staged as compared to the obser- vation arm. More than two-thirds of the patients under- went unilateral neck dissection; however, the mean occult nodal metastasis was 11%. The patterns of neck metasta- sis get altered post radiotherapy and are no more predict- able. Very few studies were included in the final meta- analysis and it would not be unerring to draw a general- ized conclusion from it. We believe that the addition of an elective neck dis- section while doing a salvage surgery provides an addi- tional layer of safety and associated with lesser morbidity, especially when the laryngectomy is being per- formed simultaneously. NAGARJUNA G. V. REDDY, MS, FHNO ANAND SUBASH, MS, DNB, FHNO VISHAL RAO, US MS FHNO, FRCS Department of Head and Neck Oncology, HCG Cancer Centre, Bangalore, India BIBLIOGRAPHY 1. Gross JH, Vila PM, Simon L, et al. Elective neck dissection during salvage laryngectomy: a systematic review and meta-analysis. Laryngoscope 2020; 130:899–906. 2. Yamazaki H, Suzuki G, Nakamura S, et al. Radiotherapy for laryngeal cancer-technical aspects and alternate fractionation. J Radiat Res 2017; 58:495–508. 3. Weiss MH, Harrison LB, Isaacs R. Use of decision analysis in planning a management strategy for the stage NO neck. Arch Otolaryngol Neck Surg 1994;120:699–702. 4. Lin C, Puram SV, Bulbul MG, et al. Elective neck dissection for salvage lar- yngectomy: a systematic review and meta-analysis. Oral Oncol 2019;96: 97–104. 5. Lin DJ, Lam A, Warner L, et al. Elective neck dissection in patients with radio-recurrent and radio-residual squamous cell carcinoma of the larynx undergoing salvage total laryngectomy: systematic review and meta-anal- ysis. Head Neck 2019;41:1–10. DOI: 10.1002/lary.28901 Laryngoscope 00: 2020 Reddy et al.: Letter to the Editor 1 The Laryngoscope © 2020 The American Laryngological, Rhinological and Otological Society, Inc.