Fisch, U. P.

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The Journal ofLaryngology and Otology(Founded in 1887 by MORELL MACKENZIE and NORRIS WOLFENDEN)August 1964CERVICAL LYMPHOGRAPHY IN CASES OFLARYNGO-PHARYNGEAL CARCINOMA*By U. P. FISCH (Zurich) fINVOLVEMENT of the cervical lymphatic system is very often the majorproblem in evaluating the therapeutic approach for head and neckmalignancies as the clinical methods available to determine the extent ofmetastatic spread from a particular tumour are limited.The development of a technique for cervical lymphography has provedof great value in the functional study of the lateral cervical lymphaticsystem (Fisch and Sigel, 1964). It was hoped that lymphography wouldalso be of value in the observation of cervical metastases. For this reason,cervical lymphography has been performed in patients with head andneck malignancies and it is the purpose of this paper to describe thelymphographic patterns observed in cases of laryngopharyngealcarcinoma.Method1. Lymphographic techniqueOil-contrast material, lipiodol ultra-fluid, has been injected in adeep retro-auricular lymph vessel using a previously described technique(Fisch and del Buono, 1963a).* Read at the meeting of the Section of Laryngology of the Royal Society of Medicineon February 7th, 1964.j From the Department of Otolaryngology (Head: Professor L. Riiedi) of the Universityof Zurich, Switzerland.715use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofU. P. Fisch2. Selection of patientsCervical lymphography was performed on twenty consecutive patientswith squamous-cell carcinoma of the larynx and hypopharynx prior tosurgical therapy.3. Histologic techniqueNodes filled with Lipiodol were identified by X-ray of the resectedspecimen. Using this X-ray information and careful dissection, all visibleand palpable nodes were removed from the specimen and divided intofour nodal groups (junctional, jugular, supraclavicular and spinal) aspreviously established in non-pathologic cervical lymphograms (Fig. 1).The lymph nodes were imbedded in paraffin and representative sections1 1 JUNCTIONAL NODESOZ JUGULAR NODES&3 SUPRACLAVICULAR NODESSPINAL NODES05 RETROAURICULAR NODESFIG. 1.Schematic'representation of the nodal groups in the cervical lymphatic system as visualizedby lymphography (Fisch and Sigel, 1964).716use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofCervical Lymphography in Laryngo-Pharyngeal Carcinomastained with H. and E., Van-Gieson, Giemsa and Bielschowsky-Gomoritechniques. In instances of questionable findings, serial sections of alymph node were examined.ResultsFrom the twenty cases studied, three patients, illustrating the mainpatterns observed, are presented.Case I. V.W., a 67-year-old white male, attended the O.R.L. Policlinic ofthe University of Zurich on February 14th, 1963, with a 3 month history ofdysphagia. Physical examination revealed an exophytic lesion of the rightaryepiglottic fold and two palpable lymph nodes in the region of the anteriorsuperior border of the right sternocleidomastoid muscle. Direct laryngoscopyand biopsy revealed squamous-cell carcinoma. Cervical lymphography wasperformed prior to a right radical neck dissection—the patient having refusedlaryngectomy. The primary was treated by radiotherapy.The cervical lymphogram (Fig. 2) revealed a complete block in thejugular and spinal chains whereas the junctional and supraclavicularnodal groups exhibited partial filling.A schematic representation of the histologic examination is seen inFig. 3. Four nodes in the upper jugular chain were invaded by carcinoma.In the region of the block, no tumour was present in 29 lymph nodes of thejugular and spinal chains. However, 21 of these 29 lymph nodes revealed amarked hyperplastic reaction either of the lymphatic type, reticular type,or both.Case II. W.E., a 51-year-old white male, attended the O.R.L. Policlinic of theUniversity of Zurich on May 29th, 1963, with a history of progressive hoarsenessover the preceding month. Physical examination revealed an ulcerating lesionof the right false cord. No lymph nodes were palpable. Direct laryngoscopy andbiopsy revealed a squamous-cell carcinoma. Cervical lymphography wasperformed prior to laryngectomy and right radical neck dissection.The cervical lymphogram (Fig. 4) revealed a total block of the rightjugular chain whereas the junctional, supraclavicular and spinal groupswere partially filled. A schematic representation of the histologic examina-tion is seen in Fig. 5. No carcinoma was found in the resected lymphnodes. All the blocked lymph nodes of the jugular chain (13 out of 13)revealed a marked hyperplastic reaction, predominantly of the reticulartype (9 out of 13).The reticular reaction observed consisted in a proliferation of reticulumcells filling entirely the marginal and intermediate sinuses of the nodes(Fig. 6a). Fig. 6b demonstrates the presence of an intricated networkof fibrils around the reticulum cells filling the sinuses.717use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofU. P. Fisch718use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofCervical Lymphography in Laryngo-Pharyngeal CarcinomaCASE 16V.W. MALE,A6E 67DIAS.-SaUAMOUS-CEU. CARCINOMATREATMENT:RADICAL NECK DISSECTION(FEB. 18, 1963)NODCS COUNTED BY:NODAL GROUPSJUNCTIONAL JUGULAR SPINAL CUvicuLARX-RAYHISTOLOGYNOdES SHOMHGCANCERLYMPHATIC HYPER-PLASIA UH.)RETICUUR HYPER-PLASIA CRM.)L.H.+R.H.TOTAL912.;11S21044111042124--114-15_----15494513628FIG. 3.Case I: note the limited extent of the metastases in relation to the blocked lymphnodes.Caselll. C.E., a 41-year-old white male, attended the O.R.L. Policlinic of theUniversity of Zurich on April 16, 1963, with a history of progressive hoarsenessover the preceding seven months. Examination revealed an exophytic tumourof the fixed left vocal cord extending to the anterior commissure. No cervicalnodes were palpable and squamous-cell carcinoma was found on biopsy.Cervical lymphography was done prior to laryngectomy and left radical neckdissection.The cervical lymphogram (Fig. 7) reveals the junctional, spinal andsupraclavicular nodes to be partially filled with contrast material Theenlarged lymph nodes of the jugular chain are completely blocked.However, being surrounded by extravasated Lipiodol, they are recogniz-able by their outline. Sixty-two nodes were removed from the specimenand examined. A schematic representation of the histologic examinationis seen in Fig. 8. Xo carcinoma was found in the cervical lymph nodes. All719use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofU. P. Fisch720use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofCervical Lymphography in Laryngo-Pharyngeal CarcinomaCASE SSW.E.MALE.A6E SIDIAO SOUAMOUS-CELL CARCINOMATREATMENT:LARYNSECTOMY AND RADICALNECK DISSECTION (JULYl. 1963) Qo °oNODES coumro BY-NODAL GROUPSSUPRA- TOTAL NUMBERJUNCTIOHAL JUGULAR SPINAL CLAVICULAR OF NODESX-RAYHiSTOLOsyNODES SHOWINS:CANCERLYMPHATIC HYPER-PLASIA (L HJRETICULAR HYPER-PLAi,IA (R.H)l.H.+R.H.TOTAL83_T3711Sa2035_---5713_5-5_7-7_~15116FIG. 5.Case II; note the absence of metastases in the blocked region.the blocked nodes of the jugular chain (7 out of 7), revealed a folliculartype of hyperplastic reaction. The enormously enlarged secondaryfollicles are seen in Fig. ga.The compression of the marginal sinus by the hyperplastic pulp isdemonstrated in Fig. gb.CommentA block to oil-contrast material in the cervical lymphatic system hasbeen observed in all twenty studied cases of laryngeal and hypopharyngealcarcinoma. In the blocked nodes of the first case, both cancer and a hyper-plastic reaction were found. Cases II and III demonstrate, however, that ablock in the lymphatic system does not necessarily imply the presence ofmetastatic carcinoma as a reticular or lymphatic hyperplasia of thecervical nodes alone produced a block in the lymphatic flow.Even partial filling of a single node, which in the X-ray picture has721use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofU. P. Fisch(a)(b)FIG. 6.Case II: (a) Section of a jugular lymph node with a marked hyperplastic reaction of thereticular type in the intermediate sinuses (H.E. X 25). (b) Fibrillary network aroundproliferating reticulum cells in an intermediate sinus (Bielschowsky-Gomori x 160).been felt to be pathognomonic of cancerous invasion, is observed with thishyperplastic reaction alone (Fisch and del Buono, 1963b).As demonstrated in the silver stains, it is evident that the compactmass of reticulum cells and their fibrils, filling marginal and intermediatesinuses, may serve as sufficient obstacle to lymphatic flow through thelymph node. Compression of the sinuses resulting from the hyperplasticpulp and the diffuse massive lymphocytic infiltration observed in theinstances of lymphatic hyperplasia may also account for this block.It follows that we are not able, from the cervical lymphograms alone,to distinguish which type of pathologic change (tumour or hyperplasticreaction) is present in the blocked nodes.For this reason, cervical lymphography alone cannot be used to provethe presence of metastases. Conversely, an absence of block or fillingdefects may exclude the presence of cancer in the filled nodes.Further studies are necessary to determine the significance of thesefindings. It is interesting that Black and Speer (1958) observed a similar722use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofFIG. 7.n o 3 tr tr 3' n 3 O 3 6Case III: Patient C.E., aged 41; (a) A-P projection; (6) Lateral projection. Note the extravasationof contrast material around the enlarged jugular lymph nodes.use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofU. P. FischCASE 43C.E. MALE.ASE41DIAG. SHUAMOUS-CELL CARCINOMATREATMENT:LARYNBECTOMY AND RADICALNECK DISSECTION /"APRIL 19,19BS)0 UPIODOLO NO LIPIODOL& TUMOURMODAL GROUPSNODES COUNTED ByX-RAYHISTOLOGYNODES SH0WIN6:CANCERLYMPHATIC HYPER-PLASIA (L.H.)RETICULAR HYPER-PLASIA (R.H.)LH + R.H.TOTALJUNCTIONALs6213JUSULAR777SPIHAL2134SUPRA -CLAVICULARa15TOTAL NUMBIROF NODES30626132033IS1732FIG. 8.Case III: no metastases are present in the blocked lymph nodes.type of hyperplastic reaction in axillary nodes removed during radicalmastectomy. It was their feeling that a particular form of reticularhyperplasia (which they referred to as sinus histiocytosis) is a measure ofthe host resistance to cancer growth and spread.At present, a block in the cervical lymphogram in cases of head andneck malignancies should be considered as suspicious for tumour invasion,and on this basis cervical lymphography may already be of clinical help.SummaryThe results obtained in twenty cervical lymphograms on patients withcarcinoma of the larynx and hypopharynx are illustrated by threerepresentative cases.A block to oil-contrast material has been observed in all the studiedcases. This block may be due to:(i) Metastatic carcinoma.724use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofCervical Lymphography in Laryngo-Pharyngeal Carcinoma(a)FIG. g.Case III: (a) Section of a jugular lymph node with follicular hyperplasia (H.E. X 25).(6) Compression of a marginal sinus by the hyperplastic pulp of the same lymph node(Bielschowsky-Gomori x 64).(2) Reticular hyperplasia of the lymph nodes.(3) Lymphatic hyperplasia of the lymph nodes.(4) Any combination of the above three pathologic changes.A block in the cervical lymphogram does not necessarily imply thepresence of metastatic carcinoma.ZusammenfassungDie Resultate von zwanzig cervikalen Lymphographien bei Patientenmit einem Carcinom des Larynx oder Hypopharynx werden anhand vondrei typischen Beispielen demonstriert. In alien untersuchten Fallenwurde ein Block im cervikalen Lymphsystem fiir das olige Kontrastmittelfestgestellt.Der beobachtete Block ist auf folgende Ursachen zuruckzufuhren:(1) Metastasen eines Carcinoms.(2) Reticulare Hyperplasie der Lymphknoten.725use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms ofU. P. Fisch(3) Lymphatische Hyperplasie der Lymphknoten.(4) Die Vereinigung zweier oder der drei obgenannten pathologischenVeranderungen.Beim Vorkommen eines Blockes im cervikalen Lymphogramm kannman nicht ohne weiteres auf das Vorhandensein von Metastasen schliessen.ResumeParmi vingt cas de lymphographies cervicales effectuees chez desmalades presentant un cancer du pharynx ou de l'hypopharynx trois castypiques sont mis en evidence.Un blocage du systeme lymphatique cervical a ete observe dans tousles cas etudies. La cause de ce blocage peut-etre:(1) Une metastase de carcinome.(2) Une hyperplasie reticulaire des ganglions.(3) Une hyperplasie lymphatique des ganglions.(4) La combinaison de deux ou des trois etats sus-mentionnes.On en conclut qu'un blocage observe dans un lymphogramme cervicalne prouve pas necessairement l'existence de metastases cancereuses dansles ganglions du cou.REFERENCESBLACK, M. M., and SPEER, F. D. (1958) Surg. Gynec. Obstet., 106, 163.FISCH, U. P., and DEL BUONO, M. S. (1963a) Schweiz. med. Wschr., 93, 994., and (1963b) Arch. Ohr.-, Nets.-, u. Kehlk.-Heilk., 182, 311., and SIGEL, M. E. (1964) Ann. Otol. (St. Louis) (in press).Dept. of Oto-Laryngology,University of Zurich,Zurich, Switzerland.726use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100062678Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:21:07, subject to the Cambridge Core terms of

Cervical Lymphography in Cases of Laryngo-Pharyngeal Carcinoma

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