The case for elective prophylactic neck dissection

The possibility of improving the cure rate of cancer of the head and neck by radical neck dissection of the clinically negative neck (elective neck dissection) continues to pose a therapeutic dilemma. This paper seeks to review the available information, analyze relevant aspects of the issue and attempt to draw conclusions which will be helpful both to physicians and their patients. The discussion is confined to squamous carcinoma of the larynx, pharynx, and oral cavity     

Ipsilateral neck cancer recurrences after elective supraomohyoid neck dissection

DESIGN: Retrospective analysis of a case series. SETTING: Referral center, private or institutional practice, hospitalized care. OBJECTIVE: To analyze the level (site) of ipsilateral neck recurrences after supraomohyoid (SOH) dissection in patients with lip, oral, and oropharyngeal cancer treated in a single institution. INTERVENTION: Supraomohyoid neck dissection. PATIENTS AND METHODS: From 1979 to 1997, 154 patients with oral and oropharyngeal carcinoma and no palpable lymph nodes at the neck underwent ipsilateral elective SOH dissection. RESULTS: Tumor sites were the lip, 5 cases (3.3%); oral cavity, 128 cases (83.1%); and oropharynx, 21 cases (13.6%). Tumor stages were T1, 13 cases (8.4%); T2, 77 cases (50.0%); T3, 40 cases (27.0%); and T4, 22 cases (14.3%). There were 7 cases (4.5%) of ipsilateral neck recurrences. Three were beyond the limits of the SOH dissection, and 4 were inside these limits. There was no association of neck recurrences with the pathological status of the lymph nodes. Six of the 7 recurrences were in patients who underwent postoperative radiotherapy. CONCLUSIONS: The incidence of neck recurrence after selective neck dissection was 4.5%, and it occurred either inside (57.1%) or beyond (42.9%) the limits of the selective neck dissection.     

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   

Effectiveness and pitfalls of elective neck dissection in N0 laryngeal cancer

The aim of the study was to evaluate the efficacy and potential pitfalls of selective neck dissection of levels II-IV in controlling occult neck disease in clinically negative neck (cN0) of patients with laryngeal squamous cell carcinoma. Charts of 96 consecutive cN0 laryngeal cancer patients undergoing 122 neck dissections at the University of Florence from January 2000 to December 2004 were reviewed. N0 neck was defined with contrast enhanced computed tomography scan. Occult neck disease rate was 12.5%, involvement per level was: 47.6% at level II, 38.1% at level III, 9.5% at level IV. Six patients developed neck recurrence (6.25%) after selective neck dissection of levels II-IV within the first two years after treatment. In conclusion, selective neck dissection of levels II-IV is effective in N0 laryngeal squamous cell carcinoma; posterior limits of surgical resection are missing therefore if post-operative radiation is required, the field should be extended beyond the dissected levels. The low incidence of occult neck disease indicates the need to refine treatment strategy, restricting elective neck dissection only to supraglottic T2 with epilaryngeal involvement, supraglottic T3-4 and glottic T4 tumours, and considering a "wait and see" protocol implemented with imaging techniques and cytological assessments for other lesions.     

Neck dissection in squamous cell carcinoma of the larynx. Indication of elective contralateral neck dissection

Unilateral or bilateral neck dissection must be considered in the treatment of laryngeal cancerAimTo evaluate the prevalence of contralateral metastases in larynx cancer and distribution of these metastases according to lymph node levels in the neck.MethodRetrospective longitudinal study of 272 charts from patients with squamous cell cancer of the larynx treated between 1996 and 2004; and we selected 104 surgical cases submitted to neck dissection. We evaluated the incidence of bilateral or contralateral metastases, according to the location and extension of the primary tumor, considering the anatomical sub-sites and the midline.ResultsContralateral metastases in lateral tumors were observed in 3.5% of glottic lesions and in 26% of supraglottic lesions. Contralateral metastases were uncommon in N0 patients. Lymph nodes levels IIa and III were the most commonly involved in the neck.ConclusionIn lateral glottic tumors there is no need for elective contralateral neck dissection. In supraglottic lesions without ipsilateral metastases, the incidence of hidden metastasis does not justify elective contralateral dissection. The midline is not a reliable indicator of the risk of contralateral laryngeal tumors.     

The value of elective neck dissection in treatment of cancer of the tongue

PURPOSE: The "adequate" therapy of tongue cancer has not yet been determined. The authors report their experience with 58 N(0) patients to elucidate the role of elective neck dissection in surgical treatment of cancer of the tongue. MATERIALS AND METHODS: The files of 58 N(0) patients with tongue cancer were evaluated retrospectively. In every patient, partial glossectomy continuous with neck dissection was the mainstay of the treatment. TNM staging, intraoperative N staging, pathologically confirmed cervical lymph node metastases and their levels, and clinical outcomes (local and regional recurrences) were recorded. The sensitivity and specificity of intraoperative staging was determined. RESULTS: Fifty-four percent (31/58) of the patients presented as T(1), and 26% (15/58) as T(2). The overall occult metastasis rate was 29.3% (17/58). The occult metastasis rate for T(1) and T(2) lesions was 19.4% (6/31) and 26.7% (4/15), respectively. The sensitivity of intraoperative staging was 76.5%, and the specificity was 51.2%. CONCLUSIONS: The rate of occult metastasis to the neck is too high in all tongue cancer cases to take the risk of regional recurrence, and the surgeon can not solely depend on neck palpation for determination of neck metastasis. Radiologic investigations and fine-needle aspiration decrease, but never reduce to zero the rate of false-negative examination. There is an obvious indication for neck dissection, even in early cases.     

Preserving level IIb lymph nodes in elective supraomohyoid neck dissection for oral cavity squamous cell carcinoma

OBJECTIVE: To determine whether level IIb lymph nodes can be saved in elective supraomohyoid neck dissection (SOHND) as a treatment for patients with squamous cell carcinoma of the oral cavity. DESIGN: Prospective analysis of a case series. SETTING: University hospital. PATIENTS AND INTERVENTIONS: From 1997 to 2001, 74 patients with squamous cell carcinoma of the oral cavity and with no palpable lymph nodes at the neck who underwent an elective SOHND were prospectively studied. MAIN OUTCOME MEASURES: The incidence of pathological metastasis to level IIb lymph nodes and the regional recurrence within this area after elective SOHND was performed were evaluated. RESULTS: Of the 74 patients, 24 (32%) had lymph nodes positive for microscopic metastatic squamous cell carcinoma. Four (5%) of the 74 patients had involvement of level IIb lymph nodes. There was no instance of isolated metastasis to level IIb lymph nodes without involvement of other nodes in the SOHND specimens. There were 6 cases of the ipsilateral neck recurrences, and of these, 2 patients (3% of all patients) developed recurrences in the level II lymph nodes. CONCLUSIONS: Level IIb lymph node metastasis was rare in this study, and nodal recurrence in this area after SOHND in squamous cell carcinoma of the oral cavity was infrequent. Therefore, this region may be preserved in elective SOHND in patients with squamous cell carcinoma of the oral cavity.     

Indications for and extent of elective neck dissection for lymph node metastasis from external auditory canal carcinoma

ObjectivesWe aim to clarify the frequency of lymph node metastasis of external auditory canal (EAC) carcinoma, including susceptible locations, adequate extent of elective neck dissection, and the relationship between the tumor infiltration site and lymph node metastasis.Patients and MethodsFrom 2003 to 2018, 63 patients with EAC carcinoma at Tokyo Medical and Dental University Hospital were enrolled in this study. The T and N stages, locations of clinically positive lymph nodes, prognoses, and anatomic site of tumor infiltration were analyzed after treatment.ResultsClinically positive lymph node metastasis (cN+) was detected in 18 patients (28.6%), consisting of T1, T2, T3, and T4 disease in 1 (6%), 2 (22%), 8 (38%), and 7 (41%) patients, respectively. The metastatic locations were at level II in 10 patients, parotid gland nodes in 7, preauricular nodes in 5, level Ib in 3, level Va in 3, level III in 1, and superficial cervical nodes in 1. Neck recurrence was determined in two of 45 patients with clinically negative lymph nodes (cN0), with the metastatic locations being levels II, Ib, and III. Among 18 cN+ cases, neck recurrence was noted in 2 of 9 patients who underwent neck dissection. Neck lesions were found to be manageable in all five patients who underwent docetaxel, cisplatin, 5-fluorouracil, and radiation therapy (TPF-RT). No relationship was noted between the tumor infiltration site and lymph node metastasis among T3/4 canrcinoma patients.ConclusionsElective neck dissection could be indicated only in T3/4 patients with free flap reconstruction. Levels Ib to III are considered appropriate for elective neck dissection in cN0 cases. Levels Ib to III and Va indicated favorable sites, even in cases with metastasis in the parotid gland or preauricular area. Furthermore, TPF-RT could be a useful option even in cN+ cases.