nullnullJoseph Califano, M.D.
Department of Otolaryngology-
Head and Neck Surgery
Johns Hopkins University
Baltimore, MD USA
Surgical Management of the Neck in Head and Neck CancerGeneral GoalsGeneral GoalsReview the indications for management of cervical nodal metastasis in head and neck cancer
Indications for selective, staging neck dissection
Newer techniques, including sentinel node biopsyLevels of the NeckLevels of the NeckIIVVIIIIIIVSublevels of the NeckSublevels of the NeckIAIVVIIIIIIAVAIBIIBVBNeck Dissection:TerminologyNeck Dissection:TerminologyAHNS recommendations favor descriptive terminology to obtain better precision
Neck levels
Structures preserved
Structures sacrificedSources of Bias in Literature Regarding Neck DissectionSources of Bias in Literature Regarding Neck DissectionAlmost all data from retrospective analyses
No standard method of identification of levels by pathologist
Both contralateral and ipsilateral necks are reported
Localization of primary sites can be challengingNeck DissectionNeck DissectionStaging: A variety of selective neck dissections for staging of HNSC with N0 disease
Therapy: Usually a comprehensive neck dissection for known presence of disease
Historical ApproachHistorical ApproachGeorge Crile’s initial description of neck dissection:
bleeding controlled by clamping of common carotid artery
“softening of the brain” noted postoperatively
Radical neck dissection: removal of
levels I-V
Internal Jugular Vein
Sternocleidomastoid
CN XI
Radical Neck DissectionRadical Neck DissectionModified Neck DissectionModified Neck DissectionModified neck dissection: preservation of one or more of the following if not directly invaded
Internal Jugular Vein
Sternocleidomastoid
CN XI
Submandibular gland, etc. (Bocca et al. 1967)
Comparison of MRND vs. RND regional recurrence
Radical Neck Dissection 13-16%
Modified Neck Dissection 6-9%
Improved shoulder function with CN XI preservation
Neck Dissection With Preservation of the SCM, IJ, and CN XINeck Dissection With Preservation of the SCM, IJ, and CN XISelective vs. Comprehensive/(I-V)
Neck DissectionSelective vs. Comprehensive/(I-V)
Neck DissectionRemoval of a portion of nodal groups based on preferential metastases from known primary site
Lindberg, Cancer, 1972
Buckley, Head and Neck, 2001
Primary Rationale: Staging, determination of nodal involvement to guide further therapy, usually radiotherapy or conversion to comprehensive neck dissection (I-V) if intraoperative diseaseSelective vs. Comprehensive/(I-V)
Neck DissectionSelective vs. Comprehensive/(I-V)
Neck DissectionSecondary Rationale: Therapy, clearance of known or suspected nodal disease
Controversy regarding use as therapy for N+ disease
Advantages: clear improvement in postoperative morbidity, particularly in CN XI function
Comprehensive Neck Dissection:
Levels I-VComprehensive Neck Dissection:
Levels I-VSafe, accepted, traditional means of addressing any N+ neck surgically
Major structures require sacrifice when involved with tumorDistribution of Nodal Metastases:
Oral CavityDistribution of Nodal Metastases:
Oral CavityI 30%
II 35%
III 23%
IV 9%
V 2%Level IV in Oral Cavity Selective Neck DissectionLevel IV in Oral Cavity Selective Neck Dissection16% of patients with oral tongue cancer have isolated positive node in level III or level IV
8% with isolated level IV node involvement during or after neck dissection
Byers et al. Head and Neck, 1997Risk of Occult Nodal Metastasis: Oral CavityRisk of Occult Nodal Metastasis: Oral CavityFor clinical T1, T2 N0 oral tongue SCC, risk of occult nodal metastasis is ~20%, 50%
Byers, et al, Head and Neck 1998
Oral Cavity tumor thickness >3-4 mm. predicts elevated risk of occult metastasis >40%
Spiro Am J Surg 1986,
Yuen Head and Neck 2002
Undissected T1, T2 N0 oral cavity cancer associated with a 50% regional recurrence rate
Yuen Head and Neck, 1997
Selective Neck Dissection I-III
for oral cavity N0 diseaseSelective Neck Dissection I-III
for oral cavity N0 diseaseIIIIIAIIIBIVT2-T4 NO oral cavity
Any T thickness > 0.4 cm
Isolated IIB metastasis rare
Distribution of Nodal Metastases:
OropharynxDistribution of Nodal Metastases:
OropharynxI 10%
II 52%
III 34%
IV 20%
V 7%
Oropharynx: Special ConsiderationsOropharynx: Special Considerations
Isolated level V nodal metastasis extremely rare
Retropharyngeal nodes are a primary nodal drainage site, but not addressed by neck dissection
Radiotherapy often administered for primary and regional control
High risk of bilateral nodal metastasisSelective Neck Dissection II-IV
for OropharynxSelective Neck Dissection II-IV
for OropharynxIVIIIIIAIIBT2-T4 NO oropharynx
T1N0 controversial
Retropharyngeal nodal basin may be treated with radiotherapy regardless of neck status, obviating need for selective neck dissection to determine therapyDistribution of Nodal Metastases:
Larynx and HypopharynxDistribution of Nodal Metastases:
Larynx and HypopharynxI 2%
II 31%
III 27%
IV 12%
V 2.6%Selective Neck Dissection Hypopharynx: ConsiderationsSelective Neck Dissection Hypopharynx: ConsiderationsPropensity to bilateral nodal metastasis
Usually presents at advanced stage
Selective Neck dissection used to determine need for radiotherapy in very early stage lesions treated with primary surgical therapy
Selective Neck Dissection Larynx: ConsiderationsSelective Neck Dissection Larynx: ConsiderationsT1 glottic tumors with low potential for cervical metastasis, <10%, selective neck dissection not performed
Supraglottic tumors have a high risk for occult nodal metastasis and bilateral nodal spread
T1, 20%
T2, 40%
Selective Neck Dissection II-IV
for Hypopharynx and LarynxSelective Neck Dissection II-IV
for Hypopharynx and LarynxIVIIIIIAIIBT1-T4 NO hypopharynx
If N0 treated with radiotherapy for primary, may be no need for selective neck dissectionT2-T4 NO Larynx
If N0 treated with radiotherapy for primary, may be no need for selective neck dissectionParatracheal Nodal Dissection for Larynx, HypopharynxParatracheal Nodal Dissection for Larynx, Hypopharynx10 –20 % risk of paratracheal nodal positivity for patients in whom level VI is dissected
Usually associated with contralateral positive nodes
Often associated with subglottic, pyriform apex, cervical esophageal tumors
Postoperative radiotherapy results in a reduced parastomal recurrence for patients with pathologic nodes in level VISelective Neck Dissection VI
for selected larynx/hypopharynx/thyroid tumorsSelective Neck Dissection VI
for selected larynx/hypopharynx/thyroid tumorsVIPostoperative Radiotherapy after Selective Neck DissectionPostoperative Radiotherapy after Selective Neck DissectionPatients with any single or multiple nodal metastasis have improved regional control with postoperative radiotherapy (6% vs.36% for single node)
Byers, et al. Head and Neck 1999 (n=517)
Ambrosch, et al., Otolaryngol HNS 2001 (n=503)
Approximately 50% of recurrences were within the dissected field
Approximate 5% improvement in regional control by radiotherapy for pN1 disease
Selective Neck Dissection for clinically N+ Disease: A ControversySelective Neck Dissection for clinically N+ Disease: A ControversyRationale: Postoperative radiotherapy may achieve control of microscopic/subclinical metastatic disease
Improved functional outcomeSelective Neck Dissection for clinically N+ Disease: A ControversySelective Neck Dissection for clinically N+ Disease: A ControversyMost studies limited, with highly selected group
Anderson et al. Arch Otol HNS, 2002
106 patients, 129 necks
55% N1, 26% N2b
72% irradiated
94% control with >2 Y follow upSelective Lymph Node SamplingSelective Lymph Node SamplingMentioned in order to be condemned
Positive necks discovered = positive necks missed
Manni et al. Am J Surg 1991
Sensitivity of less than 50%
Wein et al. Laryngoscope, 2002
Sensitivity 56%, specificity 70%
Finn S, et al. Laryngoscope. 2002 Apr;112(4):630-3. Sentinel node biopsySentinel node biopsy99Tc labeled colloid +/- blue colloid dye injected into tumor
Preoperative imaging, hand held gamma probe, visual identification used to dissect sentinel lymph node (initial draining node)Sentinel Node BiopsySentinel Node Biopsy10-15 reports in literature
Largest series is a collection of multicenter data (Ross et al., Ann Surg Oncol 2002)
316 necks evaluated
Sentinel node identified in 95%
76 positive necks
90% sensitivity
Sentinel Node Biopsy: PitfallsSentinel Node Biopsy: PitfallsOnly accessible tumors can be injected preoperatively, e.g. oropharynx, oral cavity
Additional cost, need for second procedure
Morbidity/cost analysis vs. selective neck dissection
10% of occult metastases that may be detected by selective neck dissection remain undiagnosed
Should be performed in prospective clinical trialsNeck Dissection After Chemotherapy and/or RadiationNeck Dissection After Chemotherapy and/or RadiationMost series advocate neck dissection in N2 or greater disease, regardless of clinical response
Residual tumor found in neck in over 30% of N2 necks and 50% of N3 necks after chemoradiation
Laryngoscope. 2007 Jan;117(1):121-8. Sewall GK, et al.
Residual disease may not correlate with response
Recurrences after chemoradiation are often unresectableLiauw SL, Amdur RJ, Morris CG, Werning JW, Villaret DB, Mendenhall WM. Isolated neck recurrence after definitive radiotherapy for node-positive head and neck cancer: Salvage in the dissected or undissected neck. Head Neck. 2007 Feb 1Liauw SL, Amdur RJ, Morris CG, Werning JW, Villaret DB, Mendenhall WM. Isolated neck recurrence after definitive radiotherapy for node-positive head and neck cancer: Salvage in the dissected or undissected neck. Head Neck. 2007 Feb 1
Well-differentiated Thyroid CancerWell-differentiated Thyroid CancerNo role for elective neck dissection
Central compartment, level VI nodal dissection for positive central nodes
Modified neck dissection, at least levels II-V for neck metastasis, to include level IIB
“Berry-picking” is not indicatedMedullary Thyroid CarcinomaMedullary Thyroid CarcinomaTotal thyroidectomy and central compartment dissection, level VI for most cases
Ipsilateral nodal dissection at least levels II-V if central compartment is N+Salivary Gland CarcinomaSalivary Gland CarcinomaNo added survival benefit to elective neck dissection
However, significant rate of occult nodal positivity for high grade tumors (adenoid cystic, squamous cell, high grade mucoepidermoid, etc.)
Comprehensive (I-V) ipsilateral nodal dissection for N+ disease or high grade tumor
Selective, I-III dissection for radiosensitive histologies with N0 necks and/or high grade tumorSummarySummaryComprehensive neck dissection Levels I-V recommended for clinically N+ necks
Sacrifice of structures only if clinically involved by tumor
Staging/Selective neck dissection indicated for N0 necks, dependent on primary tumor site
Comprehensive neck dissection Levels I-V indicated for N2+ neck disease treated by chemoradiation
SummarySummaryThe use of selective neck dissection for clinically N+ is controversial
The use of sentinel node biopsy is less sensitive that selective neck dissection, and remains investigational
Future Trials: Statistical ConsiderationFuture Trials: Statistical ConsiderationMost retrospective trials describe a 5-10% difference in clinical endpoints in comparison of sentinel node biopsy, selective neck dissection, and comprehensive neck dissection
Assuming 80% power, would require a randomized trial with 1400 patients (700/arm) to detect a statistically significant 5% difference.nullSurgeons must be very careful, When they take the knife! Underneath their fine incisions, Stirs the Culprit Life!
~Emily Dickinson