AXILLARY METASTASES FROM CARCINOMA OF THE

LARYNX: A 25-YEAR SURVIVAL

William R. Nelson, MD, and Michael Sisk

Axillary metastases from squamous cell carcinomas of the

head and neck are usually considered signs of incurability. A
case is presented in which the patient developed welldifferentiated squamous cell carcinoma in bilateral axillary
nodes following total laryngectorny and radical neck dissection for advanced recurrent squamous cell carcinoma of the
larynx. Bilateral axillary dissection was performed on this
patient followed by a second neck dissection for metastasis.
The patient remained well for 25 years free of disease, dying
of a massive heart attack. One report of this phenomenon
has been found in the literature. The authors conclude that
radical axillary dissection should be considered in selective
cases of well-differentiated carcinoma in axillary nodes from
a controlled primary in the head and neck mucosa when no
other signs of dissemination have been found. A brief review
of cervical and axillary lymphatic anatomy is included.
HEAD Ui NECK 1994;16:83-87
0 1994 John Wiley 8 Sons, Inc.

Distant spread of squamous carcinoma of the

head and neck is traditionally considered incurable. This entity has been defined as any evidence
From the Department of Surgery (Dr. Nelson), PresbyterianlSt. Luke's
Medical Center, Denver, Colorado; and University of Colorado School of
Medicine (Or. Nelson and Mr. Sisk), Denver, Colorado.
Presented at the Annual Meetingof the Colorado Chapter of the American
College of Surgeons, Colorado Springs, Colorado, May 9, 1992.
Acknowledgment:The work of Michael Sisk, fourth year medical student
in a summer fellowship, was supported by the Colorado Division of the
American Cancer Society.
Address reprint requests to Dr. Nelson at I801 Williams, t201,Denver,
CO 80218.
Accepted for publication March 16, 1993.
CCC 0148-6403/94/01083-05
0 1994 John Wiley & Sons, Inc.

Axillary Metastases from Larynx Cancer

of dissemination below the clavicles. In the recent

past, autopsy studies of patient dying of head and
neck cancer have demonstrated spread to distant
sites in a wide range.
Some authors have found spread in lo%,
whereas others have found dissemination in 55%
of cases at autopsy.'-8 The chance of spread is
directly related to the stage of cervical node involvement. NO-N2 cases develop spread in less
than 10% compared with 30% in N2-N3 cases.g
The lung is the most common site, ranging from
52% to 90%. Next in line are liver, bone, and thoracic nodes. Crile" found only 1%distant metastases overall in an era when advanced primaries caused early death. There is mention of
axillary metastases in only two of eight published
autopsy studies.2'8
Gowen and Desuto-Nagy' described findings
at autopsy of 35 patients dying of head and neck
cancer. Fifty-seven percent of patients had distant metastases and 82% of these were pulmonary. Nine percent of patients had positive axillary nodes.
Hoye et a1.2 analyzed autopsy findings in 42
patients dying of the disease. Fifty-five percent of
patients had distant metastasis with lungs being
involved in 96%. One patient had a positive axillary node.
Nonpalpable axillary nodes are rarely dissected at autopsy except possibly in breast and
melanoma patients. There is only one article, a
Russian work," that describes surgery for axillary metastases in a patient previously treated
HEAD & NECK

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83

CASE REPORT

A 57-year-old white man was first seen by the

senior author on December 11, 1964, at Mercy
Hospital in Denver where he had just undergone
an emergency tracheostomy because of laryngeal
obstruction. This patient had completed radiotherapy in May 1964 for a locally advanced carcinoma of the right vocal cord. Recurrent cancer
in the subglottic area was noted during placement of the tracheostomy tube. Laryngoscopy
subsequently demonstrated extensive squamous
carcinoma in the supraglottic larynx as well.
Right middle and upper jugular lymph nodes
were palpable at that time.
On December 15, 1964, a right radical neck
dissection and total laryngectomy were performed with resection of a large portion of skin of
the anterior neck in the region of the tracheostomy. Double-sliding pectoral flaps were used to

FIGURE 1. Microscopic (high power) section of axillary node

(hematoxylin & eosin stain) showing squamous carcinoma
and normal lymphoid tissue.

for larynx cancer by total laryngectomy. Survival

was only 6 months, the patient dying suddenly of
an apparent heart attack. Klotch (in a personal
communication) reports a 1.5-year survival after
resection of an axillary metastasis from carcinoma of the floor of the mouth.
The case presented here survived 25 years after bilateral radical axillary dissection for metastatic laryngeal carcinoma. No such case has been
found in a thorough search of the world literature. The possible mechanism of spread will be
outlined in detail. It is likely that such cases in
the past have been considered incurable and only
palliative treatment was instituted. This report is
to demonstrates a rare phenomenon in head and
neck cancer and records a remarkable result from
aggressive surgery in the treatment of axillary
metastases from squamous cell carcinoma of the
be the first recorded
Of
This may
long-term survival after surgical treatment in
this unusual clinical setting.

84

Axillary Metastases from Larynx Cancer

FIGURE 2. Patient 15 years following total laryngectomy, bilateral radical neck dissection, and bilateral radical axillary
dissection.

HEAD 8 NECK

January/February 1994

close the neck defect around the tracheal stoma.

The pathology report revealed adequate margins
on the primary lesion and extensive right cervical
lymph node involvement. A small pharyngeal fistula developed postoperatively but healed quickly
with wound care.
This patient did well until March 1965, when
he presented with a 4-cm mass in the right axilla
and a 2-cm node in the left axilla. Open biopsy on
the right revealed well-differentiated squamous
cell carcinoma. Extensive workup showed no
other signs of dissemination. A bilateral radical
axillary dissection with removal of thepectoral

muscles on both sides was performed. Metastatic

spread was found bilaterally, one large metastatic mass being present on the right. On the
left, matted nodes in the lower axilla contained
carcinoma and one of three lymph nodes at the
junction of the mid- and upper axillary regions
contained the same tumor (Figure 1).
After an uneventful recovery, he was closely
followed until May 1965, when a mass was discovered in the left lower jugular region. Again,
biopsy revealed squamous carcinoma and a left
radical neck dissection was performed on May 26,
1965. The centrally necrotic mass was 8 x 4 cm.

FIGURE 3. Cervical and axillary lymphatics. (From C. M.Goss: Gray's Anafomy, 29th American
Edition. Philadelphia: Lea & Febiger, 1973. Used with permission.)

Axillary Metastases from Larynx Cancer

HEAD & NECK

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85

The patient's second jugular vein resection was

performed at this time because of tumor involvement. He developed marked facial swelling but
recovered nicely. He remained well until his
death from an apparent massive heart attack in
1989. He had normal upper extremity function to
90" of abduction. This jovial, outgoing patient remained active and healthy during all of those
years (Figure 2).
DISCUSSION

In Rouviere's12 classical text on lymphatic anatomy, nodes of the axillary apex and those of the
lower jugular and supraclavicular regions are
noted to be in close proximity. Gray's Anatomy
demonstrates this proximity very well (Figure 3).
(It is indeed remarkable that axillary metastases
seldom develop in patients with lower cervical
spread of squamous cell carcinomas of the head
and neck.) In the case presented here, one might
speculate that the skin involvement around the
tracheostomy resulted in tumor extension to the
axilla. In Sappey's14 famous lymphatic diagrams,
found to be extremely accurate today, skin lymphatic channels in the manubrial area extend directly to the axilla. Haagensen15has also demonstrated that skin involvement of the anterior
supraclavicular region drains not only into the
transverse cervical and spinal accessory chains
but also into the central group of axillary nodes.
On the other hand, with extensive lymphatic
spread in the lower jugular areas bilaterally,
spread to the axillary regions could have occurred
through direct pathways to the axilla from the
cervical nodes. Both Bartels" and Rouviere"
identified efferent lymphatics from the subclavicular group to the axillary nodes and the transverse cervical chain.
The flow of lymphatics can, however, be reversed in certain situations. Fisch17 has experimentally proven that after the normal lymphatic
anatomy of the neck has been altered, as in radical neck dissection or radiotherapy, the lymphatic flow will reverse. It has also been demonstrated by lymphography" that the axilla can
become the major lymphatic drainage site from
the anterior and lateral neck following radical
neck dissection o r radiotherapy."
The patient presented here had both total laryngectomy and right radical neck dissection, after failing radiotherapy t o the laryngeal area, before his axillary metastases occurred. Possibly
due to the well-differentiatedcharacter of the car86

Axillary Metastases from Larynx Cancer

cinoma in our case, tumor remained in nodes

without vascular spread.
From the Department of Radiation Otolaryngology in Abinsk in the Soviet Union, Ezhov and
Andreel' described a case identical to ours. Radiotherapy had failed in this patient as well. Tracheostomy was carried out for obstruction and
later axillary spread occurred. Local resection of
axillary masses was performed in stages. The patient died 6 months later with a massive myocardial infarction.
Klotch from the University of South Florida
(in a personal communication)has described a 1.5
year survival following removal of an axillary
mass containing squamous cell carcinoma from
the floor of the mouth. The axillary metastases
developed after local tumor resection and bilateral neck dissection.
From our case report, surgeons might well
consider radical axillary dissection for welldifferentiated squamous carcinoma in axillary
lymph nodes when no other signs of system
spread can be discovered. In the past, such cases
have undoubtedly been treated by palliative
means with the assumption that an incurable
state is present.

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January/February 1994

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