THE LEVEL OF CERVICAL LYMPH-NODE METASTASES - THEIR PROGNOSTIC RELEVANCE AND RELATIONSHIP WITH HEAD AND NECK SQUAMOUS CARCINOMA PRIMARY SITES

It would seem logical that patients with nodal metastases low in the n eck would fare less well than patients with disease high in the neck. The penultimate UICC classification suggested that neck node level was important although there was no mention of this in the most recent cl assification. In addition, patients with carcinomas at the various sit es would be expected to have different patterns of nodal involvement. Of 3419 patients with head and neck squamous carcinoma on the Liverpoo l University Head and Neck Unit database, 947 had neck node metastases . The neck node levels were coded as (I) sub-mandibular, (II) above th e thyroid notch, (III) below the thyroid notch and (IV) supra-clavicul ar/posterior triangle nodes. Levels II and III contained the deep jugu lar chain. The relationship between node level and site and sub-site a nd survival were analysed with particular emphasis on multivariate met hods. The 5-year survival for the whole group was 51% and survival fel l with decreasing node level (I-IV) being 37% for sub-mandibular nodes , 32% for deep cervical nodes and 25% for lower deep cervical nodes. T he 18-month survival for supra-clavicular and posterior triangle nodes was 21%. The difference in survival was significant (chi3(2) = 24.42, P < 0.001). Multivariate analysis confirmed that as the level of the nodes fell from the sub-mandibular region to the supra-clavicular regi on the prognosis worsened (estimate = -0.3378, P = 0.0003). Level II ( upper deep cervical) nodes were the most commonly involved with regard s to all primary sites and formed 69% of all neck node metastases. Ove r three quarters of laryngeal oropharyngeal and hypopharyngeal metasta ses went to this level whereas only 47% of oral cancers did. Most of t he remainder of these latter lesions metastasized to level 1 (42%). Th ese findings were confirmed by multiple logistic regression. When stud ying survival for lymph node level with regard to site all sites had a reducing prognosis with decreasing node level except for larynx. Mult iple linear regression showed an association between decreasing node l evel and increasing N-stage (P = 0.001) with increasing T-stage (P = 0 .0014) and as the site moved from the mouth to the larynx (P = 0.0047) . The present data support the view that neck node level is important as regards prognosis for most sites in the head and neck. The data con firm the clinical view that deep cervical nodes are most frequently af fected by head and neck cancer with level IV nodes being unusual and c linically tending to herald a non head and neck tumour and that level III nodes are relatively uncommon. This is surprising as one would exp ect at least a proportion of laryngeal carcinomas and quite a high pro portion of hypopharyngeal carcinomas to metastasize to this region.