A Risk-Adapted Approach for Elective Neck Dissection in Salvage Total Laryngectomy: Revisiting the Role of Tumor Subsite and Occult Nodal Disease

Background: The role of elective neck dissection (END) during salvage total laryngectomy (STL) in clinically node-negative (cN0) patients remains controversial due to variable risks of occult nodal metastasis and surgical morbidity. Methods: We conducted a multicenter retrospective study of 178 cN0 patients undergoing STL after radiotherapy (RT) or chemoradiotherapy (CRT). Rates of occult nodal disease, survival outcomes, and predictive factors were analyzed. Results: Occult nodal metastases were found in 19.7% of cases, highest in hypopharyngeal (35.7%) and supraglottic (24.5%) tumors. Tumor subsite and lymphovascular invasion were independent predictors of nodal positivity, while prior chemotherapy reduced risk. Patients with occult nodal disease had significantly worse three-year overall and disease-specific survival. Conclusions: A risk-adapted approach to END in STL is recommended, particularly for supraglottic and hypopharyngeal tumors. Routine END may be unnecessary in low-risk subsites like glottic tumors. Prospective studies are needed to refine management strategies.