Selective neck dissection (IIA, III): a rational replacement for complete functional neck dissection in patients with N0 supraglottic and glottic squamous carcinoma

INTRODUCTION: The purpose of this paper is to determine the optimal elective treatment of the neck for patients with supraglottic and glottic squamous carcinoma. During the past century, various types of necks dissection have been employed including conventional and modified radical neck dissection (MRND), selective neck dissection (SND) and various modifications of SND. MATERIALS AND METHODS: A number of studies were reviewed to compare the results of MRND and SND in regional recurrence and survival of patients with supraglottic and glottic cancers, as well as the distribution of lymph node metastases in these tumors. RESULTS: Data from seven prospective, multi-institutional, pathologic, and molecular analyses of neck dissection specimens, obtained from 272 patients with laryngeal squamous carcinoma and clinically negative necks, revealed only four patients (1.4%) with positive lymph nodes at sublevel IIB. Data was also collected from three prospective, multi-institutional, pathologic and molecular studies of neck dissection specimens which include 175 patients with laryngeal squamous carcinoma (only 2 with subglottic cancer) and clinically negative necks. Only six patients (3.4%) had positive nodes at level IV. CONCLUSIONS: SND of sublevel IIA and level III appears to be adequate for elective surgical treatment of the neck in supraglottic and glottic squamous carcinoma. Dissection of level IV lymph nodes may not be justified for elective neck dissection of stage N0 supraglottic and glottic squamous carcinoma. Bilateral neck dissection in cases of supraglottic cancer may be necessary only in patients with centrally or bilaterally located tumors.     

Selective neck dissection for the treatment of neck metastasis from squamous cell carcinoma of the head and neck

OBJECTIVE: Our objective was to determine the proportion of patients disease free in the neck, with the primary site controlled, who have been treated with a selective neck dissection (SND) for squamous cell carcinoma (SCCa) of the upper aerodigestive tract, and who had cervical metastasis less than 3 cm. STUDY DESIGN: A cohort of patients who fit the inclusion/exclusion criteria was identified retrospectively. Then all surviving patients were followed for a minimum of 2 years. METHODS: A group of 52 patients who had 58 selective neck dissections for cervical metastases from SCCa of the upper aerodigestive tract were identified. The mean age was 56 years (range, 20-85 y), there were 40 males and 12 females, and mean follow-up was 24.5 months (range, 1-64 mo). Twenty-six patients had clinically negative (cNo) neck examinations and 26 had clinically positive neck examinations. Postoperative radiation was given for extracapsular spread, greater than 2 positive nodes, T3, T4, or recurrent disease if the patient had not received radiation before surgery. These radiation criteria excluded 18 patients from postoperative radiation treatment. RESULTS: Kaplan-Meier survival analysis showed that the regional control rate with the primary site controlled was 0.94. Six patients developed recurrent neck disease. Three of these 6 patientswere surgically salvaged. Four recurrences were in the dissected field and 2 were out of the dissected field (level V). CONCLUSIONS: With similar indications for radiation therapy, the regional control rate in this cohort is comparable to control rates obtained with modified radical neck dissection.     

Planned neck dissection after concomitant radiochemotherapy for advanced head and neck cancer

OBJECTIVES/HYPOTHESIS: Since 1998, at our academic, multidisciplinary head and neck cancer treatment center, it has been our policy to treat appropriate patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) with concomitant radiochemotherapy followed within 6 weeks by planned neck dissection(s). Our objective was to investigate the oncologic efficacy of planned neck dissection, to date, in this patient population with a focus on outcomes in the neck. STUDY DESIGN: Retrospective analysis of a cumulative patient database. METHODS: The medical records of all patients who underwent planned neck dissection(s) after concomitant radiochemotherapy for locoregionally advanced SCCHN at Beth Israel Medical Center and The Institute for Head and Neck Cancer in New York City were reviewed. For each patient, preradiochemotherapy primary and neck stage, postradiochemotherapy/preneck dissection clinical and radiographic neck status, type of neck dissection(s) performed, pathologic status of the neck dissection specimen(s), length of follow-up (after planned neck dissection), disease status at last follow-up, and site(s) of recurrence were recorded. Local, regional, and distant disease control rates were calculated by the Kaplan-Meier method. RESULTS: Fifty-one planned neck dissections were performed on 39 radiochemotherapy patients (12 patients had bilateral operations) between early 1998 and October, 2003. Thirty-two (82%) patients had N2 or greater neck disease, with 29 (74%) having T3/T4 disease at various upper aerodigestive tract primary sites. Patients received an average of 6,700 cGy and 6,000 cGy external beam radiation therapy to primary disease sites and involved cervical lymphatics respectively, concomitant with one of three platinum-based chemotherapy schedules. At a mean follow-up time of 24 (range 8-57) months for the entire study population, there has been only one neck recurrence (N2A neck). No patient with N2B (n = 11), N2C (n = 13, with majority of heminecks staged N2B), or N3 (n = 5) disease has recurred in the neck. No recurrences have occurred in the 41 heminecks (in 33 patients) where modified neck dissection (including 24 selective procedures) was performed despite the presence of residual carcinoma in 13 (32%) of these heminecks on pathologic review. Among all heminecks with residual carcinoma present (n = 18) in the neck dissection specimen, there has been only one neck recurrence. There have been no recurrences in the 26 heminecks (in 19 patients) with incomplete clinical response after radiochemotherapy despite the presence of residual carcinoma in 14 (54%) of these necks on pathologic review. The clinical and radiographic absence of residual disease after radiochemotherapy did not always predict a complete pathologic response. Surgical complications have been limited (1 chyle leak, 1 wound breakdown). CONCLUSIONS: The integration of planned neck dissection into the multidisciplinary management of patients with locoregionally advanced SCCHN is highly effective in controlling cervical metastatic disease. Modified and selective neck dissection procedures can be performed in the majority of patients, regardless of the response in the neck subsequent to concomitant radiochemotherapy. We recommend a planned neck dissection(s) in all patients staged (pretreatment) with N2 or greater neck disease and in select N1 cases.     

Upper neck (level II) dissection for N0 neck supraglottic carcinoma

OBJECTIVES: Elective neck dissection for the N0 neck in head and neck surgery is still controversial. This prospective nonrandomized study of N0 supraglottic carcinoma was designed to find an appropriate method of neck management. STUDY DESIGN: Anatomical studies show that the first echelon of lymphatic drainage from the supraglottic larynx is toward the upper jugular nodes (level II). An upper neck dissection (UND) was applied and all the lymph nodes were sent for frozen section. If the subclinical metastasis was found, a modified neck dissection was performed. If the nodes harbored no foci of cancer, the patients were observed after surgery on the supraglottic lesions. METHODS: Patient records of 142 patients with supraglottic laryngeal cancer (T1-4N0M0) were reviewed, with special attention paid to neck recurrences and survival rates. The cases were treated between 1976 and 1990 and all were observed for at least 5 years after the operation or until the time of death. RESULTS: The UND specimens of 142 patients were negative for metastasis. The 5-year survival rate for this group after surgery was 80.8%, according to the life table analysis. Fifteen of the 142 patients (10.6%) had neck recurrences during the period of observation within 5 years. The recurrence rate of this series with limited dissection on the neck was comparable with those reported in the literature after neck dissection, either radical or modified. CONCLUSIONS: There is no need for a comprehensive neck dissection for N0 supraglottic laryngeal cancer. A selective neck dissection such as UND (level II) or a supraomohyoid neck dissection (sparing the submandibular region) of level II and III will serve the purpose of radical neck treatment for the supraglottic cancer.     

Pleomorphic adenoma of the submandibular gland: an evolving change in practice following review of a personal case series

We reviewed patients with submandibular gland pleomorphic adenoma treated at a tertiary referral centre in the United Kingdom (1988–2004). Thirty-seven patients were identified, 32 newly diagnosed cases and 5 cases of recurrent disease previously treated elsewhere. The exact pre-operative diagnosis was “unknown” in 76% of the new cases. All cases were surgically excised (41% with extracapsular gland excision and 59% by selective level Ib, IIa and III neck dissection). Temporary marginal mandibular nerve neuropraxia was documented in 25% of cases. All 32 new cases remain clinically tumour free at the time of writing. In patients with recurrent disease, complete microscopic tumour clearance was achieved in three of the five cases, however all remain clinically tumour free. Pleomorphic adenomas of the submandibular gland are uncommon, with good prognosis following complete tumour excision. Recurrent tumours, however, are frequently multi-focal and difficult to excise completely. The adequacy of primary surgery is crucial and supports an approach for a more radical excision primarily by a selective level lb, IIa and III neck dissection; ensuring complete disease clearance for pleomorphic adenoma, avoiding the risks of tumour spillage associated with a limited excision and tumour handling; and removing the primary echelon of lymph nodes at risk of metastasis if the pathology turns out to be malignant.     

Clinical outcome following radiotherapy and planned neck dissection in N+ head and neck cancer patients

Conclusions. This study confirms earlier findings that patients with viable tumour cells in the neck after external beam radiotherapy (EBRT) have a poor prognosis. The study also indicates that neck dissection (ND) does not change the prognosis for patients with a complete clinical response in the neck. At the moment our guidelines concerning this matter are being reviewed. Objectives. The protocol at our institution stipulates a planned ND in patients with metastasis in the neck after EBRT regardless of the response in the neck. As the necessity for a planned ND has not been clarified we wanted to evaluate our results. Patients and methods. Patients diagnosed from 1998 to 2002 with metastasis in the neck who received EBRT were evaluated for histopathological findings and clinical outcome. Results. A total of 156 patients were included. Overall survival was 62% and disease-specific survival was 76%. There was a complete response (CR) in the neck in 63 patients (40%); among these 15 had viable tumour cells in the neck. In patients not achieving CR, 40% (37/93) had viable tumour cells left in the neck. Patients with viable tumour cells in the neck after EBRT had disease-specific survival of 48% compared with 90% among patients without viable tumour cells.     

Planned postradiotherapy neck dissection: Rationale and clinical outcomes

OBJECTIVES: In this study, we examine pathology results and clinical outcome for patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) who present with advanced neck disease and undergo planned postradiotherapy neck dissection. STUDY DESIGN: Review of all patients with SCCHN treated with primary radiation (or chemoradiation) and postradiotherapy neck dissection at the University of Wisconsin between 1992 to 2005 was performed. One hundred seven neck dissections were identified in 93 patients, 79 unilateral and 14 bilateral. All major treatment and outcome parameters were examined with particular emphasis on the postradiotherapy neck dissection. RESULTS: Thirty of 107 neck dissection specimens (28%) showed evidence of residual carcinoma on pathologic review. The mean number of lymph nodes identified at neck dissection for the entire cohort was 21 per specimen (range, 1-60) with 1.3 nodes per positive neck dissection demonstrating residual carcinoma. No correlation was found between the type of neck dissection performed and the presence of residual nodal disease. Eighty-two evaluated patients (93%) remain free of regional disease recurrence, whereas six patients have subsequently manifested neck recurrence. Four of the six patients who developed regional recurrence showed residual carcinoma in their neck dissection specimen. Five of these patients underwent comprehensive neck dissection (levels I-V); one underwent selective neck dissection (相似文献   

Accessory nerve function after modified radical and lateral neck dissections

OBJECTIVES: Evaluate preoperative and postoperative electrophysiological changes related to the accessory nerve with reference to dissection technique, modified radical neck dissection, and lateral neck dissection. STUDY DESIGN: Prospective electrophysiological analysis of accessory nerve function in a total of 20 laryngeal carcinoma patients after neck dissection, 12 being lateral neck dissection (4 bilateral) and 8 being modified radical neck dissection. METHODS: Distal latencies, compound muscle action potentials, and electromyography findings were investigated before surgery and, in early and late postoperative periods in 20 laryngeal carcinoma patients. Results were evaluated by Student t test and chi2 test for intragroup and intergroup differences. RESULTS: In the lateral neck dissection group, postoperative distal latencies were longer, without statistical significance, whereas in the modified radical neck dissection group postoperative latencies were statistically longer. Postoperative compound muscle action potentials were significantly lower in both groups. Electromyographic work-up showed deterioration in early postoperative periods and improvement in late postoperative periods. When intergroup differences were compared, both postoperative compound muscle action potential and electromyographic findings were worse in the lateral neck dissection group. CONCLUSIONS: The accessory nerve function after modified radical neck dissection is better than function after lateral neck dissection because of increased stress applied to the nerve during retraction of the sternocleidomastoid muscle for achievement of a better exposed surgical field in lateral neck dissection.     

Crile's neck dissection

George Crile, after a long experience with treatment of head and neck cancer and study of a large number of cases, appreciated that these tumors almost always drained through the lymphatic pathways of the neck, rarely metastasized distantly, and were thus theoretically curable by resection of the primary tumor and its lymphatic draining shed. After evaluation of his early failures, he found that a block resection of all of the lymph node-bearing tissue of the neck in addition to resection of the primary tumor was the most effective means of obtaining a cure, particularly in patients with clinical evidence of spread of disease to the neck. Such radical surgery, at the time, was fraught with difficulty because of the lack of blood transfusion, antibiotics, and endotracheal anesthesia, but Crile devised several strategies for combating these obstacles. Crile performed 36 such block resections with a determinate 3-year survival of 75% compared with 19% 3-year survival in patients who had not undergone block resection. The surgical precepts developed by Crile laid the foundation for the effective modern surgical treatment of head and neck cancer.     

功能性颈清扫术式治疗复发性第二及第三四鳃裂瘘管或囊肿16例

我科2001—05—2011-08对16例复发性第二及第三、四鳃裂瘘管（或囊肿）患者行功能性颈清扫术治疗，效果较好，报告如下。     

Safety of modified radical neck dissection for differentiated thyroid carcinoma

OBJECTIVES/HYPOTHESIS: The management of cervical metastases from differentiated thyroid carcinoma (DTC) remains controversial. Most surgeons perform a neck dissection (ND) for clinically apparent disease. The extent of nodal dissection varies from regional to comprehensive. Morbidity from ND in the setting of DTC remains high, particularly when performed in the setting of a thyroidectomy (TT). To determine complications from ND for DTC, we retrospectively reviewed our surgical experience of modified radical neck dissection for nodal metastases. STUDY DESIGN: Retrospective chart review. METHODS: Between 1997 and 2002, 39 consecutive patients (31 females and 8 males) underwent 44 comprehensive NDs of levels II-V for DTC. Central compartment dissection (CCD) (levels VI and VII) was also performed during 23 of these procedures. Twenty (45.5%) patients had prior treatment elsewhere. Preoperative pathology revealed papillary carcinoma in 22 patients (56.4%), tall cell variant in 11 (28.2%), and follicular variant in 6 (15.4%). RESULTS: Ten patients (20%) underwent ND alone, whereas 6 (14%) underwent simultaneous ND and TT. Fifteen patients underwent simultaneous ND, TT, and CCD (30%). Temporary hypocalcemia occurred after 21% of NDs that were performed in the setting of either TT or CCD or both. There were no cases of permanent hypoparathyroidism. Transient regional lymph node (RLN) paresis occurred in two patients and was associated with a concomitant central compartment nodal dissection; there were no permanent RLN palsies. Transient spinal accessory nerve paresis developed after 27% of NDs performed. Two patients developed chyle leaks. CONCLUSIONS: When ND is necessary for the treatment of thyroid malignancies, the procedure can be performed safely with acceptable morbidity.     

Para-tracheal neck dissection - is dissection of the upper part of level Ⅵ necessary?

Papillary thyroid carcinoma (PTC) has a high propensity for regional metastases, however, the impact of such metastases on the outcome of the patients is minimal. The central compartment of the neck is considered the first and the most common echelon of metastases from thyroid carcinoma. Physical examination along with ultrasonography are the gold standard pre-operative evaluation of patients with PTC. Ultrasonography is highly sensitive in evaluating lateral neck nodes, however, its value in evaluating the central compartment is limited, resulting in a relatively high rate of occult metastases in this compartment. The main potential complications of para-tracheal neck dissection (PTND) are recurrent laryngeal nerve paralysis and hypocalcemia and these may be higher in patients undergoing PTND compared to thyroidectomy alone. New histological data is available showing no evidence of lymph nodes in the central compartment above a level parallel to the inferior border of the cricoid cartilage. These findings support withholding dissection of the upper para-tracheal region routinely as a part of PTND in patients with well-differentiated thyroid cancer. By doing that, the complications may be lower and identical to thyroidectomy alone, thus may abolish arguments against more common use of elective PTND in patients with thyroid carcinoma.     

Conversion from Selective to Comprehensive Neck Dissection: Is It Necessary for Occult Nodal Metastasis? 5-Year Observational Study

Objectives

To compare the therapeutic results between selective neck dissection (SND) and conversion modified radical neck dissection (MRND) for the occult nodal metastasis cases in head and neck squamous cell carcinoma.

Methods

Forty-four cases with occult nodal metastasis were enrolled in this observational cohort study. For twenty-nine cases, SNDs were done and for fifteen cases, as metastatic nodes were found in the operative field, conversion from selective to MRNDs type II were done. Baseline data on primary site, T and N stage, extent of SND, extracapsular spread of occult metastatic node and type of postoperative adjuvant therapy were obtained. We compared locoregional control rate, overall survival rate and disease specific survival rate between two groups.

Results

Among the 29 patients who underwent SND, only one patient had a nodal recurrence which occurred in the contralateral undissected neck. On the other hand, among the 15 patients who underwent conversion MRND, two patients had nodal recurrences which occurred in previously undissected neck. According to the Kaplan Meier survival curve, there was no statistically significant difference for locoregional control rate, overall survival rate and disease specific survival rate between two groups (P=0.2719, P=0.7596, and P=0.2405, respectively).

Conclusion

SND is enough to treat occult nodal metastasis in head and neck squamous cell carcinoma and it is not necessary to convert from SND to comprehensive neck dissection.     

Combined radiotherapy with planned neck dissection for small head and neck cancers with advanced cervical metastases

BACKGROUND: We have previously described our treatment algorithm for patients with small head and neck cancers with advanced cervical metastases (stage N2 or greater). Primary radiotherapy is given to the primary site and neck, followed 6 weeks later with endoscopy and biopsy of the primary site. If biopsy of the primary site is negative by frozen section, an immediate neck dissection is performed even when no clinical residual neck disease is present. Our initial review found that 36% of patients with a complete clinical response to radiotherapy had positive nodes on histological examination. STUDY DESIGN: Retrospective. METHODS: The medical records of 71 patients treated at UCLA Medical Center from 1986 to 1999 by this algorithm were reviewed. RESULTS: After radiotherapy, 69 of 71 patients had a complete response at their primary site. Forty-two patients had a complete clinical response in the neck. Seventy-one neck dissections were performed. Overall, 31 of 71 neck dissections (44%) had positive nodes. Among the 42 patients with a complete response to radiotherapy, 13 (31%) had positive histological nodes. Among the 29 patients with a partial response to radiotherapy, 17 (59%) had positive nodes. Follow-up and incidence of neck recurrence are discussed. CONCLUSION: Planned neck dissection for advanced cervical metastases remains controversial for patients with a complete clinical response to radiotherapy. However, our results suggest that clinical assessment after radiotherapy cannot assure the absence of neck disease. Until there are reliable methods to distinguish which patients are truly free of neck disease, we believe the benefits of a planned neck dissection outweigh the low morbidity of this procedure.     

European surgeons were the first to perform neck dissection

The history of the surgical treatment of cervical lymph node metastases began in the 19th century, and, unfortunately, the initial attempts at surgical treatment of neck metastases were disastrous. Although some European surgeons reported few cases of radical en bloc dissection, the first successful surgical procedure was performed and described in detail by Franciszek Jawdyński, a Polish surgeon, in 1888. George Washington Crile popularized and illustrated radical en bloc neck dissection in the early 20th century.