Quantification of lymph nodes in selective neck dissection

OBJECTIVES: Provide reference for surgeon and pathologist regarding expected yield from selective neck dissections. Quantify lymph nodes obtained from cadaver dissection based on current nodal classification and compare with clinical series. STUDY DESIGN: 1. Quantification of lymph nodes at levels I-V harvested from human cadavers and correlation with nodal grouping for supraomohyoid (I-III) and lateral (II-IV) neck dissections. 2. Retrospective review of operative specimens from clinical neck dissections for lymph node quantity. METHODS: 1. Twenty radical neck dissection specimens, harvested from 10 fresh human cadavers without evidence of head and neck cancer, were separated by nodal level for gross and microscopic examination by a pathologist. The quantity of nodes obtained per level for each specimen was tabulated. 2. Charts of patients treated with neck dissection for squamous cell carcinoma were reviewed and tabulated for type of dissection and number of lymph nodes reported. RESULTS: In the 20 cadaver neck dissections, the average number of lymph nodes removed for levels I-V was 24, with 13 for levels I-III and 19 for levels II-IV. In the clinical review, 98 total neck dissections were included. In the six supraomohyoid dissections, an average of 20 lymph nodes (range, 14-26) were found, with an average of 30 (range, 15-43) in the 11 lateral compartment specimens. In 81 radical or modified radical dissections, an average of 31 nodes (range, 19-63) was reported. CONCLUSIONS: The number of lymph nodes removed in selective neck dissection should be comparable to that of the corresponding levels in radical neck dissection, provided that strict adherence to surgical boundaries is maintained. Dissection of normal cadavers provides a reference for the surgeon and the pathologist but may under-represent lymph node quantity in the diseased state.     

Evaluation of selective lymph node sampling in the node-negative neck

OBJECTIVE: To determine whether intraoperative selective lymph node sampling before neck dissection in the node-negative (N0) neck accurately reflects the disease content of the neck and can be used to assist in treatment selection. STUDY DESIGN: A prospective clinical study at a university medical center. METHODS: Over a 2-year period, 36 patients with head and neck squamous cell carcinoma scheduled to undergo 41 elective neck dissections were enrolled. At the initiation of the neck dissection, biopsy of the "most suspicious" lymph node within the tumor's primary nodal drainage basin was performed, and the specimen was measured and sent for frozen-section evaluation. The results of lymph node sampling were compared with the final histopathologic interpretation of the resected primary and neck dissection. RESULTS: Of the 41 N0 necks, 29% (12 of 41) were positive for occult metastases. Results of selective lymph node biopsy correlated with the results of neck dissection in 34 of 41 specimens (83%). The specificity and positive predictive value of node sampling were both 100%. The proportion of cases with a positive neck dissection with a positive sampled node (sensitivity) was 42% (5 of 12). CONCLUSION: The results of selective lymph node biopsy with frozen-section analysis in the N0 neck, as defined in the current study, did not reflect a technique with adequate sensitivity to alter intraoperative treatment strategy.     

A prospective study of intraoperative lymphatic mapping for head and neck cutaneous melanoma

BACKGROUND: Intraoperative lymphatic mapping and sentinel lymph node biopsy have been used successfully to stage regional lymphatics for trunk and extremity melanomas. However, the accuracy and applicability of these techniques in the head and neck have not been determined conclusively. OBJECTIVE: To report the results of a prospective trial of intraoperative lymphatic mapping and sentinel lymph node identification in patients with head and neck cutaneous melanoma. METHODS: Using technetium Tc 99m--labeled sulfur colloid and isosulfan blue, intraoperative lymphatic mapping and sentinel lymph node identification were performed in 43 patients with melanomas of intermediate thickness. After the sentinel lymph nodes were identified in situ, an elective dissection of levels I through V or II through V was performed, based on the location of the primary tumor. The parotid, postauricular, and suboccipital lymphatics were dissected as clinically indicated. The sentinel lymph nodes were isolated ex vivo and evaluated pathologically by serial sectioning, and the accuracy of the lymphatic mapping was determined. RESULTS: Intraoperative lymphatic mapping identified 155 sentinel lymph nodes in 94 nodal basins, with a mean of 3.6 sentinel nodes and 2.2 basins per patient. Sentinel nodes were located in the parotid gland in 19 patients (44%), necessitating superficial parotidectomies, and they were distributed throughout nonadjacent nodal basins in 18 patients (42%). Nine patients (21%) had metastatic disease in 1 or more sentinel nodes, 3 of whom had metastatic disease in a nonsentinel node. No patient who had negative sentinel nodes had a positive nonsentinel node (false-negative incidence, 0). CONCLUSIONS: Although intraoperative lymphatic mapping accurately identifies sentinel lymph nodes for head and neck cutaneous melanomas, the multiplicity of these nodes, their widespread distribution, and their frequent location within the parotid gland may preclude sentinel lymph node biopsy in many patients. Therefore, we advocate selective lymphadenectomy of sentinel nodal basins, allowing histological staging of the regional lymphatics with limited morbidity. However, further study is necessary to define the true role of sentinel lymph node identification for head and neck cutaneous melanoma.     

Level IIb lymph node metastasis in neck dissection for papillary thyroid carcinoma

OBJECTIVE: To determine the patterns of lateral cervical metastasis and the incidence of level IIb lymph node metastasis in papillary thyroid carcinoma. DESIGN: Retrospective medical record review. SETTING: Academic medicine. PATIENTS: From March 1, 2000, to April 30, 2006, 46 consecutive patients (38 women and 8 men) with papillary thyroid carcinoma. INTERVENTIONS: Patients underwent 55 modified radical neck dissections for the management of lateral cervical metastasis. MAIN OUTCOME MEASURES: All patients had preoperative evidence of a metastatic cervical lymph node. All specimens were labeled and mapped by the operating surgeon to identify their levels. RESULTS: Among 55 specimens, 82% (45 specimens) exhibited nodal disease at multiple levels. The incidences of metastases at level II, III, IV, and V nodes were 60% (33 specimens), 82% (45 specimens), 75% (41 specimens), and 20% (11 specimens), respectively. Skip metastases were present at a low rate (6% [3 specimens]). Among 12 specimens (22%) with metastatic lymph nodes at level IIb, 92% (11 specimens) had disease at level IIa. The rate of level IIb lymph node involvement in patients with metastatic lymph nodes at level IIa was 34% (11 of 32). CONCLUSIONS: Tumor involvement at multiple nodal levels usually occurs when patients have lateral cervical lymph node metastasis. Neck dissection should include the level IIb lymph node whenever level IIa lymph node metastasis is found. Level IIb dissection is probably unnecessary when level IIa lymph nodes are uninvolved because the incidence of metastasis to level IIb is low if level IIa is not involved.     

Upper aerodigestive tract squamous cell carcinoma: distribution of extracapsular spread and soft tissue deposits in the neck

OBJECTIVE: Extracapsular spread (ECS) and soft tissue deposits (STD) of squamous cell carcinoma (SCC) in the neck of patients with metastatic SCC of the upper aerodigestive tract have been shown to adversely affect actuarial and disease-free survival. No studies to date have detailed the distribution of ECS and STD within the neck. MATERIAL AND METHODS: A total of 215 neck dissections from 155 patients were prospectively collected and analysed for the presence of both STD and ECS. As no classification for STD exists, their distribution was classified according to the nodal levels used for classification of cervical lymph nodes as described by the Memorial Sloan-Kettering Cancer Center. RESULTS: A total of 81 neck dissections from 59 patients were found to have either metastatic lymph nodes with ECS, STD or both. The distribution of lymph node metastasis, ECS and STD was very similar. Level II was most frequently affected, with Levels III and IV being affected less frequently. There were very few lymph node metastases to Level V, and this level contained no evidence of either ECS or STD. CONCLUSION: The method of pathological assessment of neck dissection specimens and reporting on the presence of ECS and STD has not been formalized. By analysing neck dissection specimens in the manner described we can report on the presence or absence of ECS and STD with increased accuracy. This has considerable implications for patient management.     

下咽癌颈淋巴结转移的颈侧清扫探讨

目的 为了探讨颈侧清扫可否应用于临床Ｎ＋的下咽癌的颈部治疗。方法 对９３例下咽部颈清扫标本的转移性淋巴结在颈部的分布进行了回顾性分析。结果 颌下淋巴结转移占３．２％。Ｎ０,Ｎ１,Ｎ２ａ和Ｎ２ｂ～Ｎ３的颈后三角淋巴结转移率分别为：５．９％,７．０％,３７．５％和３６．０％。病理证实仅有颌下淋巴结转移或上、中颈深淋巴结转移,而无下颈深淋巴结转移时,颈后三角淋巴结转移率为４．０％,有下颈深淋巴结转移时,     

Selective neck dissection in the management of the clinically node-negative neck

OBJECTIVE: To evaluate the efficacy of the selective neck dissection (SND) in the management of the clinically node-negative neck. STUDY DESIGN: Case histories were evaluated retrospectively. METHODS: The results of 300 neck dissections performed on 210 patients were studied. RESULTS: The primary sites were oral cavity (91), oropharynx (30), hypopharynx (16), and larynx (73). Seventy-one necks (23%) were node positive on pathological examination. The number of positive nodes varied from 1 to 9 per side. Of necks with positive nodes, 17 (24%) had extracapsular spread. The median follow-up was 41 months. Recurrent disease developed in the dissected neck of 11 patients (4%). Two recurrences developed outside the dissected field. The incidence of regional recurrences was similar in patients in whom nodes were negative on histological examination (3%) when compared with patients with positive nodes without extracapsular spread (4%). In contrast, regional recurrence developed in 18% of necks with extracapsular spread. This observation was statistically significant. Patients having more than two metastatic lymph nodes had a higher incidence of recurrent disease than the patients with carcinoma limited to one or two nodes. Recurrence rate in the pathologically node positive (pN+) necks was comparable to recurrence in those pathologically node negative (pNO) necks in the patients who did not have irradiation. CONCLUSION: SND is effective for controlling neck disease and serves to detect patients who require adjuvant therapy.     

Management of contralateral N0 neck in pyriform sinus carcinoma

OBJECTIVE: The hypopharynx has a rich lymphatic network that places patients with tumors of the hypopharynx at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, ipsilateral elective neck dissection of clinically N0 neck in lateralized lesions of hypopharyngeal squamous cell carcinomas (SCCs) is widely accepted as a standard treatment. However, the management of the contralateral N0 neck is still controversial. The aim of this study was to evaluate the incidence and predictive factors of contralateral occult lymph node metastasis in pyriform sinus SCC. MATERIALS AND METHODS: We performed a retrospective analysis of 43 patients with N0 to 3 pyriform sinus SCC with contralateral clinically node-negative necks who had also received contralateral elective neck dissections from 1994 to 2003. Surgical treatment was followed by postoperative radiotherapy in 41 patients. The follow-up period ranged from 4 to 135 months (mean, 40 months). The Kaplan-Meier method and log-rank test were used to calculate the disease-specific survival rates and prognostic significance of contralateral occult lymph node metastasis. RESULTS: Contralateral occult lymph node metastases occurred in 16% (seven of 43) of the subjects. Twenty-six percent of the 27 subjects with clinically node-positive ipsilateral neck developed contralateral occult lymph node metastases, whereas 0% of the 16 subjects with N0 ipsilateral necks (P=.035) developed the disease. Moreover, in cases with primary site extension across the midline, the rate of contralateral occult neck metastasis was significantly higher (P=.010). However, there were no statistically significant differences in age, sex, early versus advanced T stage, number of ipsilateral positive nodes, lymph nodes with extracapsular spread, primary subsite of medial versus lateral pyriform sinus, pyriform sinus apex involvement, and growth type. Patients with no evidence of contralateral nodal cancer had significantly improved disease-specific survival over patients with any pathologically positive nodes (5-year disease-specific survival rate, 66% vs. 33%, P<.05). CONCLUSION: The patients with pyriform sinus SCC with clinically ipsilateral N+ neck and/or extension across the midline are at greater risk for contralateral occult neck metastases. Furthermore, patients who present with a contralateral metastatic neck have a worse prognosis than those staged as N0. Therefore, we advocate bilateral neck treatment in patients with pyriform sinus SCC with clinically ipsilateral node metastases and/or extension across the midline.     

Level V Lymph Node Dissection in Oral and Oropharyngeal Carcinoma Patients with Clinically Node‐Positive Neck: Is it Absolutely Necessary?

OBJECTIVES: Postoperative shoulder dysfunction has been significantly associated with any dissection of level V secondary to traction or with ischemic injury to the spinal accessory nerve. The aim of this study was to determine whether the dissection of level V lymph node pads is absolutely necessary in therapeutic neck dissection as a treatment for oral and oropharyngeal squamous cell carcinoma (OOSCC) patients with clinically N+ neck. STUDY DESIGN: Retrospective chart review. METHODS: We performed a retrospective analysis of 93 OOSCC patients who underwent surgical treatment of the primary lesion along with a simultaneous comprehensive neck dissection from January 1992 to December 2003. Of these, only one patient had a clinically positive neck node at level V. During the neck dissection, the contents of the level V lymph nodes were dissected, labeled, and processed separately from the remainder of the major neck dissection specimen. We studied the incidence of pathologic metastasis to level V lymph nodes. In addition, we also evaluated several potential risk factors for metastatic disease in the level V lymph nodes such as sex, age, T stage, N stage, histologic grade, and presence of other positive lymph nodes. RESULTS: A total of 96 comprehensive neck dissections were performed in this series. The prevalence of metastases in the level V lymph nodes was 5% (5 of 93) in ipsilateral and 0% (0 of 3) in contralateral necks. One case with clinically positive node at level V had a pathologic positive node in level II, III, IV, and V. Occult metastasis rate of ipsilateral level V was 4% (4 of 92). There was a statistically significant association between level V metastases and a positive N stage above N2b (P=.01). The presence of metastasis in other multiple neck levels, particularly the combined neck levels II, III, and IV, also have a statistically significant association with level V metastasis (P=.023). CONCLUSION: Level V lymph node pads may be preserved in modified neck dissections on OOSCC patients with clinically N+ neck below the nodal stage N2a.     

Surgical treatment of the neck in cancer of the larynx

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher. The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal 'skip' metastases. The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.     

Sentinel lymph node biopsy in head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS: Sentinel lymph node biopsy is a minimally invasive method to stage the regional lymphatics that has revolutionized the management of patients with intermediate-thickness cutaneous melanoma. Head and neck surgeons have been encouraged by the accuracy of sentinel lymph node biopsy in cutaneous melanoma and have applied the technique to patients with head and neck squamous cell carcinoma (HNSCC). The objectives of the study were 1) to study the feasibility and accuracy of sentinel lymph node biopsy as a method to stage the regional lymphatics in HNSCC and 2) to determine whether there are qualitative differences between the cutaneous and mucosal lymphatics that would affect the technique used in HNSCC. STUDY DESIGN: Two methods of investigation were employed: a prospective laboratory study using a feline model for sentinel lymph node biopsy and a retrospective review of patients who received lymphoscintigraphy before neck dissection and intraoperative identification of the sentinel lymph node. METHODS: Lymphoscintigraphy and a gamma probe were used in four felines to study the kinetics of technetium-labeled sulfa colloid (Tc-SC) in the mucosal lymphatics. In the second part of the feline study, eight subjects were studied intraoperatively. Tc-SC and isosulfan blue dye were used to study the injection technique for the mucosal lymphatics and to determine the time course of the dye and Tc-SC to the sentinel lymph node. In Part II of the present study, a retrospective review of 33 patients with HNSCC was conducted. Twenty patients (stage N0) whose treatment included elective neck dissection were studied with preoperative lymphoscintigraphy and underwent intraoperative identification of the sentinel lymph node to determine the accuracy and feasibility of sentinel lymph node biopsy. Eight patients with palpable neck disease and five patients with recurrent or second primary disease whose previous treatment included neck dissection were also studied with lymphoscintigraphy before neck dissection. RESULTS: In the feline study, both Tc-SC and isosulfan blue dye traversed the lymphatics rapidly, appearing in the sentinel lymph node in less than 5 minutes. Modification of the injection technique used for cutaneous melanoma was required to depict the sentinel lymph node of the base of tongue. In the human study, the sentinel lymph node was accurately identified in 19 of 20 (95%) N0 patients. On average, 2.9 sentinel lymph nodes (range, 1-5) were identified in 2.2 (range, 1-4) levels of the neck. Sentinel lymph nodes were bilateral in 4 of 19 patients. When the sentinel lymph node was identified, it accurately predicted the pathological nodal status of the regional lymphatics. Three of 20 patients had cervical metastases, and the sentinel lymph node was identified in 2 of 3 patients with pathologic nodes (pN+). Focal areas of radiotracer uptake were identified in seven of eight patients with palpable disease. These areas corresponded to the level with palpable disease in four patients. The lymphatics delineated by lymphoscintigraphy in the five patients with previous neck dissection were outside the levels that had been dissected. Lymphoscintigraphy depicted collateral patterns of lymphatic drainage. CONCLUSIONS: Sentinel lymph node biopsy is technically feasible and is a promising, minimally invasive method for staging the regional lymphatics in patients with stage N0 HNSCC. Lymphoscintigraphy alone may determine the levels that require treatment in patients with disrupted or previously operated cervical lymphatics.     

The irradiated radical neck dissection in squamous carcinoma: a clinico-pathological study

The irradiated radical neck dissection in squamous carcinoma: a clinico-pathological study A preliminary clinico-pathological survey is presented of radical neck dissections from 50 patients with advanced (T3, T4) squamous carcinomas of the head and neck, previously treated by irradiation and combination chemotherapy. The total yield of lymph nodes (1411) from these dissections was high–mean of 28 nodes/dissection, range 8–60; the proportion of nodes containing metastatic carcinoma was low–100 (7%)–with only 1 or 2 nodal masses/dissection in most instances. The involved nodes tended to be concentrated in 1 or 2 anatomical groups, principally in the upper anterior neck, with apparent sparing of nodes in the posterior triangle. There was a high incidence (88%) of transcapsular spread. Keratin granulomas, with or without intact metastatic carcinoma, were commonly found; on occasions they formed large masses simulating nodal metastases. The morphological patterns in uninvolved lymph nodes were shown to be of no prognostic significance. Initial data on postoperative follow-up indicated a crude survival of 52% (24 patients) at 30 months. Most deaths (80%) occurred within 12 months of major surgery; the majority (72%) died with residual malignant disease; and uncontrolled primary rumour, particularly in the oral cavity and oropharynx, was found more frequently than metastatic disease in the neck or elsewhere. Clinical implications are discussed with reference to the use of modified radical neck dissections in the surgical salvage of this poor-risk group of previously irradiated patients.     

Upper aerodigestive tract squamous cell carcinoma: Distribution of extracapsular spread and soft tissue deposits in the neck

Objective Extracapsular spread (ECS) and soft tissue deposits (STD) of squamous cell carcinoma (SCC) in the neck of patients with metastatic SCC of the upper aerodigestive tract have been shown to adversely affect actuarial and disease-free survival. No studies to date have detailed the distribution of ECS and STD within the neck.

Material and Methods A total of 215 neck dissections from 155 patients were prospectively collected and analysed for the presence of both STD and ECS. As no classification for STD exists, their distribution was classified according to the nodal levels used for classification of cervical lymph nodes as described by the Memorial Sloan–Kettering Cancer Center.

Results A total of 81 neck dissections from 59 patients were found to have either metastatic lymph nodes with ECS, STD or both. The distribution of lymph node metastasis, ECS and STD was very similar. Level II was most frequently affected, with Levels III and IV being affected less frequently. There were very few lymph node metastases to Level V, and this level contained no evidence of either ECS or STD.

Conclusion The method of pathological assessment of neck dissection specimens and reporting on the presence of ECS and STD has not been formalized. By analysing neck dissection specimens in the manner described we can report on the presence or absence of ECS and STD with increased accuracy. This has considerable implications for patient management.     

Perifacial lymph node metastasis in the submandibular triangle of patients with oral and oropharyngeal squamous cell carcinoma with clinically node-positive neck

OBJECTIVES: The objectives of this retrospective chart review were to investigate the rate of metastasis to the perifacial lymph node, which was defined as the nodal pads that lie anterior or posterior to the anterior facial vein on top of the facial artery in the submandibular triangle, and to identify its risk factors in patients with oral and oropharyngeal squamous cell carcinoma (OOSCC) with clinically node-positive neck. METHODS: Beginning in July 1999, we routinely removed the perifacial lymph node pads of the submandibular triangle (level Ib) from the main therapeutic comprehensive neck dissection (level I-V) specimen for evaluation of metastatic rate to this nodal group in patients with OOSCC with clinically node-positive neck. This study is a retrospective analysis of patients undergoing perifacial node sampling from July 1999 to March 2006. A total of 66 patients (17 patients with oral cavity cancer and 49 with oropharyngeal cancer) underwent perifacial lymph node dissections. Of these, three (two with oral cavity tumors and one with an oropharynx tumor) had clinically positive node in level I. RESULTS: The incidence rate of metastasis to the perifacial lymph node was 35% in oral cavity carcinoma (six of 17) and 8% in oropharynx carcinoma (four of 49). In addition, in patients without clinically positive level I node, the occult metastasis rate of the perifacial node was 27% in oral cavity carcinoma (four of 15) and 6% in oropharynx carcinoma (three of 48). Clinical or pathologic nodal staging above the N2b advanced lesion had a statistically significant association with perifacial lymph node metastasis (P < .05). CONCLUSION: Our data suggest that these nodal pads should be removed thoroughly for the treatment of node-positive neck in patients with oral cavity carcinoma. In contrast, however, complete removal may be unnecessary in comprehensive neck dissection of patients with oropharyngeal carcinoma with clinically node-positive neck, especially below nodal stage N2a.     

Level IIb lymph node metastasis in laryngeal squamous cell carcinoma

OBJECTIVES: Selective neck dissection, despite preservation of the spinal accessory nerve, can lead to some degree of postoperative shoulder dysfunction as a result of removal of level IIb lymph nodes. The aim of this study was to determine whether level IIb lymph nodes can be preserved in elective or therapeutic neck dissection as a treatment for patients with laryngeal squamous cell carcinoma (SCC). STUDY DESIGN: This was a prospective analysis of a case series. METHODS: A prospective analysis of 65 patients with laryngeal SCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection from January 1999 to December 2002 was performed. During the neck dissection, the contents of the level IIb lymph nodes were dissected, labeled, and processed separately from the remainder of level II nodes and the main neck dissection specimen. The incidence of pathologic metastasis to level IIb lymph nodes and the regional recurrence within this area were evaluated. In addition, several potential risk factors for metastatic disease in the level IIb lymph nodes such as sex, age, cT stage, cN stage, and the presence of other positive lymph nodes were also evaluated. RESULTS: A total of 125 neck dissections were performed in this series. Of these dissections, 102 (82%) were elective and 23 (18%) were therapeutic. The prevalence of metastases in the level IIb lymph nodes was 1% (one of 46) and 0% (zero of 56) in clinically node-negative (N0) ipsilateral and contralateral necks, respectively, and 37% (seven of 19) and 0% (zero of four) in clinically node-positive ipsilateral and contralateral necks, respectively. There was a statistically significant association between level IIb metastases and clinically positive N stage (P<.001). The presence of other positive lymph nodes was also shown to have a statistically significant association with metastasis in the level IIb lymph nodes (P=.001). Only two of 46 patients (4%) with clinically N0 necks developed a regional recurrence. However, three of eight cases (38%) with positive pathologic level IIb lymph nodes developed regional recurrence. CONCLUSION: Level IIb lymph node pads may be preserved in elective neck dissection in patients with laryngeal SCC. However, this area should be removed thoroughly during therapeutic neck dissection in the treatment of clinically node-positive necks.     

Value of the supraomohyoid neck dissection with frozen section analysis as a staging procedure in the clinically negative neck in squamous cell carcinoma of the oral cavity

Summary A retrospective analysis was performed to evaluate with the efficacy of elective supraomohyoid neck dissection (SOND) with frozen section (FS) analysis in 57 newly diagnosed patients (62 SONDs) with squamous cell carinoma of the oral cavity. The protocol included sampling of both the most suspect and largest node in the jugulodigastric region (if present) and the most distal jugulo-omohyoid lymph node (if present). These nodes were then studied with FS histological examination. In the absence of evident nodes for FS analysis during surgery, histological examination uncovered occult metastatic disease in 3 of 11 SOND specimens. Among the remaining patients FS analysis revealed occult metastatic disease in 10 of the 51 samples (19.6%). In these latter cases surgery was continued using standard or modified radical neck dissection en bloc with the primary tumor. In 1 specimen only a single metastasis was found outside the original extent of the SOND. Among 41 FS analysis reports stating the absence of metastatic disease, histological examination of the SOND specimens demonstrated occult nodal disease in 7 (17%). All of the cervical metastases appeared in the ipsilateral side of the neck. False FS reports did not occur. In the histologically proven absence of metastatic disease in the SOND specimens, disease recurrence in the neck occurred only in 3 cases (7%), all in the presence of local failure: once in the previous SOND area, once in the ipsilateral supraclavicular region and once on the contralateral side. The results of our analyses support the conclusion that elective SOND with FS can be a valid staging procedure and a valuable approach to the management of the clinically negative neck in patients with squamous cell carcinoma of the oral cavity. Offprint requests to: J. J. Manni     

Strategy of neck dissection in parotid cancer

We conducted definitive surgery on 45 patients with untreated primary parotid cancer from 1975 to 1995, and evaluated methods of neck dissection and results of treatment. All 14 with clinical neck lymph node metastasis underwent ipsilateral radical neck dissection and only 1 developed neck lymph node recurrence at the peripheral dissected site. Of 31 patients without clinical neck lymph node metastasis, 27 of 19 of 36 with high-grade malignancy and 12 of 24 with T3 or T4 did not undergo prophylactic neck dissection and developed latent neck lymph node metastasis in 2 cases (7.4%). Whereas in most cases we achieved good control of the primary site but neck lymph node recurrences occurred, recurrent sites were observed all around the ipsilateral neck and prognosis were very poor if neck dissection was conducted as secondary treatment. Although histopathological diagnosis was considered feasible for predicting occult neck lymph node metastasis, correct diagnostic with fine needle aspiration cytology revealed only 21.8%. Pathological positive lymph nodes in 15 patients who underwent neck dissection were detected all over (level I to V) the ipsilateral neck and the recurrent positive rate at level II was 100%. Based on the above results, we conclude that (1) in cases with neck lymph node metastasis in preoperative evaluation, ipsilateral radical neck dissection is mandated, and (2) in cases without neck lymph node metastasis, prophylactic neck dissection is not usually needed. When pathological results of frozen section from intraoperative jugulodigastric nodal sampling are positive, ipsilateral radical neck dissection is mandated.     

Nodal size of metastatic squamous cell carcinoma of the neck

The preoperative use of computed tomographic (CT) scanning continues to be the best diagnostic method for preoperative detection of metastatic neck disease. Current accepted criteria for CT diagnosis of nodal disease are not uniform, although nodal size, nodal grouping, and central necrosis correlate strongly with malignancy. To assess the relationship of nodal size and malignancy, a multicenter study was designed to evaluate the nodes from 100 neck dissections. Sixty-nine positive neck dissections were analyzed, and every node was measured. The relationship of central necrosis was also compared with node size. Our results showed that CT scanning continues to provide a reliable picture of the histologic status of lymph nodes. Using the criterion of central necrosis or node size larger than 1 cm, only 7% of necks had nodal disease that would have been missed by CT interpretation. This study supports the continued use of preoperative CT evaluation for metastatic neck disease.     

Predictive ability of the CT to evaluate cervical lymph nodes in head and neck tumours

ObjectiveThe aim of this study was to determine the predictive value of computed tomography (CT) i.e., its sensitivity and specificity in detecting metastatic lymph nodes of head and neck tumours. We also studied the capacity of CT in correct nodal staging.Patients and methodsA CT was performed on 95 patients diagnosed with neoplastic disease of the pharynx and/or larynx. All patients subsequently underwent cervical lymph node dissections. In the imaging study, the following parameters were considered for suspected radiological nodal involvement: lymph node diameter greater than 10 mm, lesion margins poorly defined, capsule enhancement after contrast administration and lymph nodes that, despite their size, had signs of central necrosis.ResultsIn the dissections, 70.53% resulted N+ in the histological study. The sensitivity of CT was 82.09% and the specificity, 85.71%. The CT detected positivity in 55 of the 67 histologically pathological dissections, while the CT detected negativity in 24 of the 28 dissections histologically negative. The weighted kappa index value was 0.6408, indicating limited capacity for appropriate staging of the lymph nodes.ConclusionsWhile the ability of CT to detect metastatic lymph nodes in head and neck tumours is quite acceptable, it is less so for correctly staging them. It is therefore necessary to look for other imaging tests that provide greater accuracy to avoid unnecessary elective neck dissections and to reduce morbidity and mortality from them. We must now pay attention to new imaging techniques such as PET and PET/CT.     

Regional metastatic pattern of papillary thyroid carcinoma

The objective of the present study was to determine the pattern of lymphatic spread in papillary thyroid carcinoma with clinically positive nodes. Between 1999 and 2008, a total of 48 consecutive patients with clinical evidence of cervical lymph node metastasis of papillary thyroid carcinoma underwent 61 modified radical neck dissections (13 being bilateral) including levels II–VI. All neck dissection specimens were separated during surgery into levels and analysis was done with respect to the levels of neck. T value of tumor and demographic parameters were compared with the number of metastatic nodes with univariate analysis. The median number of pathologic nodes in neck dissection specimen was 7.0. The predominant site of metastasis was level VI (77%), followed by level III (69%), level IV (66%), and level II (46%). Level V showed 34% of nodal metastasis. Seven patients had level VII, and five patients had parapharyngeal lymph node dissections because of lymphatic involvement at these sites. There was no statistically significant correlation between T value, age, sex and the number of histologically positive lymph nodes (P = 0.39, P = 0.91 and P = 0.84, respectively). It was concluded that the high incidence of metastatic disease in levels II through VI supports the recommendation for level II through level VI neck dissection in patient with clinically positive neck disease.