Open Journal of Stomatology, 2011, 1, 185-188
doi:10.4236/ojst.2011.14028 Published Online December 2011 (http://www.SciRP.org/journal/ojst/
OJST
).
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJST
Upper mediastinal and paratracheal node dissection in total
(pharyngo) laryngectomy, it is really indicated?
Didier Dequanter, M. Shahla, P. Paulus, P. Lothaire
Department of Head and Neck Surgery, CHU Charleroi, Montigny le Tilleul, Belgium.
Received 25 July 2011; revised 29 August, 2011; accepted 14 September 2011.
ABSTRACT
Introduction: Advanced laryngeal and hypopharyn-
geal cancers are aggressive tumors with a poor prog-
nosis. Multiple lymph node metastases often occur in
the neck as well as in the upper mediastinum and
thus upper mediastinal dissection is crucial to im-
proving the cure rate. However, excessive mediastinal
dissection can increase postoperative morbidity and
mortality making it important to employ the proper
technique and appropriate extent of dissection. In the
present study, we aimed to determine the need and
the prognostic importance of mediastinal dissection
in patients with advanced carcinoma of the upper
aerodigestive tract. Methods: A retrospective review
of the records of 30 patients who underwent (phar-
ynxgo) laryngectomy for advanced squamous cell
carcinomas was done. 17 patients had laryngeal car-
cinomas, 13 had hypopharyngeal carcinomas. The
mediastinal dissection was designed to remove mainly
the paratracheal and retrooesophageal lymph nodes.
Results: 60 neck dissections and 30 mediastinal dis-
section were performed in 30 patients and yielded
positive nodes were found in 20/30 patients. Neck
nodes were positive in 9/17 of the patients with la-
ryngeal cancer and 11/13 of the patients with hypo-
pharyngeal cancers respectively. Positive nodes were
detected in the neck regardless of T stage. The medi-
astinal nodes were positive in 0% of the patients with
laryngeal cancer. Upper mediastinal metastases were
detected positive in 6/13 of the hypopharyngeal pa-
tients. In these patients, mediastinal metastases were
associated with tumors greater than 35 mm. The ma-
jority of positive paratracheal nodes were less than 1
cm in diameter and appeared negative preoperatively.
0% of the patients had positive paratracheal nodes
alone in a histologically negative cervical neck dissec-
tion Regarding the appropriate extent of dissection,
no major complications were observed. Conclusions:
There is little controversy about neck dissection in
advanced tumors of the (pharyngo) larynx. Laryn-
geal carcinomas showed no positive mediastinal no-
des in this series. The study highlighted the propen-
sity of advanced hypopharyngeal cancers to involve
the paratracheal nodes.
Keywords: Advanced Head and Neck Cancer; Medi-
astinal Dissection; Hypopharynx
1. INTRODUCTION
(Pharyngo) laryngeal squamous cell carcinoma is a very
aggressive cancer that is generally diagnosed at advan-
ced stages and, consequently, has a poor prognosis and
low survival. More than 75% of patients with (pharyn-
go) laryngeal tumors have stage III or IV disease at
presentation [1]. Indeed, cervical metastases are present
in 60% - 80% [2,3] and, often, associated with multiple
lymph nodes metastases that occur in the upper medi-
astinum as well as in the paratracheal area. Although
neck dissection is the surgical standard for the treatment
of cervical lymph spread the upper mediastinal paratra-
cheal nodal group is not routinely included in the dissec-
tion. However, metastases to paratracheal lymph nodes
occur in 30% of patients, mostly with hypopharyngeal
tumors [4]. A 20% frequency of occult metastases to
ipsilateral paratracheal lymph nodes has been reported in
laryngeal cancer patients with postcricoid lesions and in
patients with tumors that involved the pyriform fossa [5].
Moreover, laryngeal/hypopharygeal metastatic disease
involving the paratracheal nodal group has been impli-
cated in recurrent disease, particulary in patients with
peristomal recurrence; this suggest the prognostic sig-
nificance of positive paratracheal metastatic spread [6,7].
The purpose of this study was to analyse the paratra-
cheal nodal yield and frequency of metastases and de-
termine the indications of the upper mediastinal paratra-
cheal dissection.
2. METHODS
The study group consisted of 30 patients that were not
previously treated for advanced squamous cell carcinoma

D. Dequanter et al. / Open Journal of Stomatology 1 (2011) 185-188 186
(SCC) of the (pharyngo) larynx. They underwent surgery
from May 2007 to July 2010. The cases were reviewed
retrospectively. The diagnostic evaluation at presentation
included a complete physical examination, panendo-
scopy, CT and /or MRI scans of the head and neck, chest
X-rays, and laboratory tests. We assessed the CT and/or
the RMN to determine the regional lymph node status.
No patient had radiological evidence of distant metasta-
sis at presentation, and all patients were treated with
curative intent. At our institution in principal the choice
of radical therapy is surgery for advanced tumors and
neck lymph node metastasis is treated by neck dissection.
Additional radio (chemo) therapy in conducted in pati-
ents with multiple lymph node metastasis.
To determine the significance between paratracheal
lymph node metastasis and clinical factors (such as age,
gender, primary tumor site, TN stage, pTN stage, the
chi-square test, Fisher’s exact test, multiple logistic re-
gression analysis, multiple linear regression analysis,
and correlation analysis were used, as appropriate. A p <
0.05 was considered statistically significant.
3. RESULTS
The median age was 58 years (range 43 - 90 years);
there were 25 males and 5 females the follow-up period
ranged from 3 to 41 months with a mean of 27 months.
The site of the original primary tumor was recorded in
all patients and included: 17 patients with a laryngeal
cancer and 13 patients with hypopharyngeal tumor.
Concerning the disease stage of the cervical lymph
nodes, there were 6 N0 patients; 4 N1 patient and 20 N2
patients
Regarding the pathological stage, 14 patients had T3
staged cancers and 16 patients had T4 cancers.
Regarding the cell differentiation, there were 12 well-
differentiated, 9 moderate-differentiated, and 9 poorly
differentiated cases, respectively.
For tumor excision, 17 patients had total laryngec-
tomy and 13 pharyngolaryngectomy. Laryngeal resection
was performed under direct vision based on the invasion
of the tumor. The surgical defects were reconstructed
with pectoralis major myocutaneous flap in 13 cases. All
the patients had neck dissection at the time of the pri-
mary surgery. A modified bilateral radical neck dissec-
tion was performed in all cases. All the patients had a
bilateral paratracheal lymph node dissection. The para-
tracheal node dissection included dissection of all of the
nodes between the carotid artery laterally and the trachea
medially, as far inferior into the superior mediastinum as
possible through the cervical approach. There was no
preoperative mortality.
The rate of ipsilateral paratracheal lymph nodes me-
tastasis was 6/30. No patients had controlateral paratra-
cheal nodes.
The mean number of paratracheal lymph nodes dis-
sected per side was 2.3.
Histological paratracheal metastasis in the clinically
node positive neck were present in patients with pyri-
form sinus cancer. All the patients had a tumor greater
than 35 mm. In the clinically node negative, no paratra-
cheal histological metastases were found.
At the end of the follow-up, 10/30 died. More speci-
fically, 3/6 (50%) of the patients with positive paratra-
cheal nodes died.
We analysed the correlation between paratracheal ly-
mph nodes metastasis and several clinical factors among
the 30 patients (Table 1).
There was a strong but not statistically significant cor-
relation of paratracheal lymph node metastasis with the
primary site. However, there was no significant relation-
ship between age, gender, TN stage and pTN stage and
paratracheal lymph node metastasis.
4. DISCUSSION
Advanced laryngeal and hypopharyngeal carcinomas had
a high tendency to invade cervical lymph nodes. This
nodal extension is a well-known prognostic factor [7-
10].
Table 1. Clinical factors affecting paratracheal lymph node
metastasis in patients with laryngeal and hypopharyngeal car-
cinomas.
Parameters PTN positive
(n= 6)
PTN negative
(n = 24) P value
Age
<60
≥60
3 (17%)
3 (25%)
15 (83%)
9 (75%)
0.57
Gender
Male
Female
6 (24%)
0 (0%)
19 (76%)
5 (100%)
0.54
Primary site
Larynx
Hypopharynx
0 (0%)
6 (38%)
16 (100%)
8 (62%)
0.08
T clinic stage
T3
T4
0 (0%)
6 (26%)
7 (100%)
17 (74%)
0.77
T anapathological
stage
T3
T4
0 (0%)
6 (38%)
14 (100%)
10 (62%)
0.54
N clinic stage
N0
N1
N2
0 (0%)
0 (0%)
6 (30%)
6 (100%)
4 (100%)
14 (70%)
0.58
N anapathological
stage
N0
N1
N2
0 (0%)
0 (0%)
6 (38%)
9 (100%)
4 (100%)
10 (62%)
0.36
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D. Dequanter et al. / Open Journal of Stomatology 1 (2011) 185-188 187
Although neck dissection is the surgical gold standard
for the treatment of cervical lymphatic spread, the upper
mediastinal and paratracheal nodal groups are not rou-
tinely included in the dissection.
However, Welsh et al. [11] initially reported the im-
portance of the paratracheal nodes in lymphatic drainage
of the larynx and hypopharynx. Harrison et al. con-
firmed that carcinomas of the larynx (especially from the
subglottic region), the trachea, and the cervical esopha-
gus are at risk for paratracheal and tracheobronchial
lymph node metastasis and recommended resection of
the manubrium to remove theses lymph nodes and re-
duce the risk for parastomal disease recurrence [5]. We-
ber et al. [7] reported that paratracheal lymph node me-
tastasis were found in 17.6% of the patients with tumors
of the larynx, in 8.3% of the patients with pharyngeal
tumors and, at least, in 71.4% of the patients with tumors
of the esophagus.
Some investigators have suggested that ipsilateral
paratracheal node dissection should be included as part
of a selective neck dissection in all patients with tumors
invading the subglottis, pyriform fossa apex and postcri-
coid region [12].
In our study, all the patients with advanced laryngeal
and hypopharyngeal SCC had a neck dissection extend-
ed to the upper mediastinum. Most patients with hypo-
pharyngeal SCC had positive paratracheal lymph nodes
but only to the ipsilateral side of the primary. All the
patients with hypopharyngeal SCC greater than 35 mm
had paratracheal lymph node metastasis. Furthemore,
paratracheal lymph node metastasis was always associ-
ated with the presence of cervical lymph node metastasis.
In addition, a strong correlation but, unfortunately, not
statistically significant was found between the presence
of paratracheal lymph node metastasis and hypoharyn-
geal tumors.
We recommend that ipsilateral paratracheal node dis-
section should be included as part of a selective neck
dissection in all patients with tumors invading the hypo-
pharynx, certainly in tumors greater than 35 mm.
In terms of survival rates, in a prospective study of 50
patients with carcinoma of the larynx, hypopharynx, and
cervical esophagus, Timon et al. [13] reported that the
rate of paratracheal nodal metastases was 26%. More-
over, they reported that the survival in patients with po-
sitive paratracheal nodes demonstrated a trend towards
poorer survival compared to patients without paratra-
cheal nodal involvement, and concomitant involvement
of both cervical and paratracheal nodal groups was asso-
ciated with the poorest survival propability.
In their study, Weber et al. [7] confirmed that survival
was significantly reduced by the presence of paratra-
cheal lymph nodes. In our study, 50% of the patients
with positive paratracheal nodes died.
In conclusion, there is little controversy about neck dis-
sections in advanced tumors of the larynx and hypo-
pahrynx. A similar situation applies to mediadtinal dis-
section for hypopharyngeal carcinomas, certainly in tu-
mors greater than 35 mm.
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