Feasibility of supraomohyoid neck dissection in N1 and N2a oral cancer patients

BACKGROUND: The use of selective neck dissection in a positive neck is still controversial. The object of this study was to ascertain the possibility of doing this procedure in oral cavity carcinoma with a single clinically metastatic lymph node smaller than 6 cm (N1 and N2a). PATIENTS AND METHODS: From 1970 to 1994, we analyzed 164 oral cavity cancer patients with clinically N1 or N2a stage cancer submitted to radical neck dissection. RESULTS: The histologic findings did not confirm a metastatic lymph node in 69 (42.1%) cases (pN0) and showed multiple lymph nodes in 19 (11.6%) cases. Moreover, just one patient (0.6%) had a metastatic lymph node at level IV (one case with multiple lymph nodes) and none at level V. CONCLUSIONS: Because we did not find a single metastatic lymph node at levels IV and V and there was a high incidence of pN0 (57.4%) in patients with clinical N1 stage at level I, these patients could be candidates for a supraomohyoid neck dissection (extended or not to level IV) instead of radical neck dissection.     

Current philosophy in the surgical management of neck metastases for head and neck squamous cell carcinoma

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence‐based approach. © 2014 Wiley Periodicals, Inc. Head Neck 37: 915–926, 2015     

Selective dissection of levels II-III with intraoperative control of the upper and middle jugular nodes: a therapeutic option for the N0 neck

BACKGROUND: Selective neck dissections are accepted elective treatment in N0 patients. We present the results of a dissection of levels II to III and intraoperative pathologic control of a sample of subdigastric and supraomohyoid nodes in a group of patients with laryngeal carcinoma. When intraoperative analysis was positive, dissection of levels IV and V was completed. METHODS: Between 1991 and 1997, 145 neck dissections with intraoperative control were carried out in 79 patients with laryngeal carcinomas. Postoperative radiotherapy was used in 49 patients. RESULTS: There were occult metastases in 29 neck dissections (20%). In 22 cases (15%), tumor was found in the nodes sent to intraoperative pathologic study, and dissection of levels IV and V was completed. In 7 additional cases tumor was found in the postoperative study. The sensitivity of the use of frozen sections in the detection of occult metastases was 76%. In no case were positive nodes found at level V. There was no regional relapse in any of the 145 selective neck dissections. CONCLUSIONS: The lateral selective neck dissection is an effective method in the elective treatment of the neck of N0 laryngeal carcinoma patients. Dissection of level IV can be spared when intraoperative biopsy specimens of a sample of the subdigastric and supraomohyoid nodes are negative. According to our results, at present we do not consider it necessary to dissect level V in selective neck dissections in patients with laryngeal carcinoma.     

IS EXPLORATION MANDATORY IN PENETRATING ZONE II NECK INJURIES?

BACKGROUND: A policy of mandatory neck exploration for zone II injuries deep to platysma was promoted in the 1950s and was associated with a reduction in mortality when compared with expectant or delayed exploration. Recently many trauma centres have been practising selective neck exploration using physical examination and imaging to stratify patients to different management strategies. In the Auckland region, patients with penetrating zone II injury deep to platysma have been managed with mandatory neck exploration. As penetrating injuries in the Auckland region are caused by a range of sharp objects, with gunshot wounds rare, outcomes of management of zone II neck injuries in this population warrant investigation. The aim of this study was to determine the rate of therapeutic neck exploration in patients with penetrating zone II neck injury in the Auckland region and to suggest optimum management strategies for such injuries. METHODS: Retrospective audit of all patients presenting to Auckland and Middlemore Hospitals, Auckland, New Zealand, between 1995 and 2005 was carried out. Review of electronic clinical records and operation notes was also carried out. RESULTS: An overall positive neck exploration rate of 25% was obtained (87% for patients with hard signs on physical examination). Physical examination had a sensitivity of 93% and a positive predictive value of 87% in this case series. Neck exploration was not associated with known complications or missed injuries. CONCLUSION: In the Auckland setting, physical examination would appear to be a safe and reliable method for the stratification of patients for either operative or conservative management.     

Forty hours with a traumatic carotid transection: A diagnostic caveat and review of the contemporary management of penetrating neck trauma

Although penetrating neck trauma (PNT) is uncommon, it is associated with the significant morbidity and mortality. The management of PNT has changed significantly over the past 50 years. A radiological assessment now is a vital part of the management with a traditional surgical exploration. A 22 years old male was assaulted by a screwdriver and sustained multiple penetrating neck injuries. A contrast CT scan revealed a focal pseudoaneurysm in the left common carotid artery bulb. There was no active bleeding or any other vascular injuries and the patient remained haemodynamically stable. In view of these findings, he was initially managed conservatively without an open surgical exploration. However, the patient was noted to have an acute drop in his hemoglobin count overnight post injury and the catheter directed angiography showed active bleeding from the pseudoaneurysm. Surgical exploration 40 hours following the initial injury revealed a penetrating injury through both arterial walls of the left carotid bulb which was repaired with a great saphenous vein patch. A percutaneous drain was inserted in the carotid triangle and a course of intravenous antibiotics for five days was commenced. The patient recovered well with no complications and remained asymptomatic at five months followup.     

N2-N3 neck nodal control without planned neck dissection for clinical/radiologic complete responders-results of Trans Tasman Radiation Oncology Group Study 98.02

BACKGROUND: The aim of this study was to determine the incidence of isolated nodal failure in patients with N2/3 disease who achieved a complete clinical and radiological response (CR) at 12 weeks postchemoradiation, when no planned neck dissection was performed. METHODS: We analyzed the nodal response and subsequent neck control of 102 patients with initial N2/3 disease treated on the Trans Tasman Radiation Oncology Group 98.02 study. RESULTS: With a median 4.3 years follow-up, the patterns of first failure in the CR patients were local 4%, local and nodal 2%, distant 28%, and locoregional plus distant (within 1 month) 6%.There were no patients who had only neck failure. CONCLUSION: Patients in this trial with N2/3 disease who obtained a clinical and radiological complete response to chemoradiation had a zero incidence of isolated neck failure without a planned neck dissection. The continued use of planned neck dissections in this patient subset cannot be justified.     

Metastatic carcinoma to the cervical nodes from an unknown head and neck primary site: Is there a need for neck dissection?

BACKGROUND: The aim of the study was to evaluate the outcomes and patterns of failure in patients with metastatic carcinoma to cervical lymph nodes from an unknown head and neck primary origin, who were treated curatively with radiotherapy, with or without neck dissection. METHODS: The study included 61 patients referred to the McGill University Hospital Centers from 1987 to 2002. The median age was 57 years, with male to female ratio of 4:1. Distribution of patients by N status was as follows: N1, 16 patients (26%); N2a, 18 (30%); N2b, 13 (22%); N2c, 7 (11%); and N3, 7 (11%). Twenty patients underwent neck dissection (11 radical, 9 functional) and 41 patients had biopsy (9 fine-needle aspiration and 32 excisional biopsy). All patients received radiotherapy. The median dose to the involved node(s) was 64 Gy, and 60 Gy to the rest of the neck. Treatment of the neck was bilateral in 50 patients (82%) and ipsilateral in 11 (18%). The minimum duration of the follow-up was 12 months, with the median of 32 months. RESULTS: The 5- and 8-year overall survival for the whole population was 79% and 67%, respectively. There was no statistically significant difference in the 8-year actuarial overall survival (64.8% and 67.6%, respectively, p = .64) and local relapse-free survival (75% vs 74.5%, respectively, p = .57), among patients who had biopsy versus those who had neck dissection. CONCLUSION: In our experience, definitive radiotherapy to the neck and the potential mucosal sites, whether preceded by neck dissection or not, is effective to achieve a good local control rate in the unknown primary cancer of the head and neck. The indication for neck dissection, in particular for early nodal stage, is controversial.     

Functional assessment using Constant's Shoulder Scale after modified radical and selective neck dissection

BACKGROUND: Constant's Shoulder Scale is a validated and widely applied instrument for assessment of shoulder function. We used this instrument to assess which treatment and demographic variables contribute to shoulder dysfunction after neck dissection in head and neck cancer patients. METHODS: A convenience sample of 54 patients with 64 neck dissections and minimum follow-up of 11 months were evaluated. Thirty-two accessory nerve-sparing modified radical (MRND) and 32 selective neck (SND) dissections were performed. Multivariable regression analysis was used to determine the variables that were predictive for shoulder dysfunction. Clinical variables included age, time from surgery, handedness, weight, radiation therapy, neck dissection type, tumor stage, and site. RESULTS: Patients receiving MRND had significantly worse shoulder function than patients with SND (p =.0007). Radiation therapy contributed negatively, whereas weight contributed positively (p =.0001). CONCLUSIONS: The critical factors contributing to shoulder dysfunction after neck dissection were weight, radiation therapy, and neck dissection type.     

经尿道膀胱颈电切术治疗慢性前列腺炎并发膀胱颈梗阻疗效观察

目的 :探讨经尿道膀胱颈电切术治疗慢性前列腺炎并发膀胱颈梗阻的治疗效果。方法 :采用经尿道膀胱颈电切术治疗慢性前列腺炎并发膀胱颈梗阻 11例。 11例慢性前列腺炎病史平均1.67± 0 .34年 ,尿流动力学检查最大尿流率为 11.2 0± 1.33ml/ s,膀胱镜检查见膀胱颈后唇抬高。结果 :术后 1个月复查 ,最大尿流率上升至 19.30± 0 .61ml/ s,前列腺按摩液和精液常规检查未见异常。结论 :对膀胱颈梗阻的男性青壮年患者 ,经药物治疗无效后可慎重选用经尿道膀胱颈电切术来解除膀胱颈梗阻。     

Planned neck dissection for patients with complete response to chemoradiotherapy: A concept approaching obsolescence

The question of efficacy of “planned” neck dissection following complete response to chemoradiation of head and neck cancer is discussed. There is general agreement that preemptive neck dissection in patients who present initially with low volume (N1) neck disease is not necessary. However, routine performance of planned neck dissection for patients who present initially with high volume (≥N2) disease remains controversial. The authors reviewed a large number of studies reported in the recent literature and discuss how they affect this debate. Twenty‐four of the reviewed studies indicate a benefit in regional control obtained by “planned” neck dissection among patients who had bulky neck disease pretreatment. All these studies are retrospective, they do not assess treatment response prior to surgery, although they do show very good regional control rates. Twenty‐six studies demonstrate no benefit from “planned” neck dissection after complete clinical response. The reasons for these different conclusions include the development of more effective chemoradiation regimens which have improved the initial locoregional control rates of patients undergoing primary chemoradiation treatment, and improvements in diagnostic technology which have increased ability to detect low volume persistent tumor in the post treatment period. When neck dissection is necessary for persistent or recurrent disease, recent studies have shown that selective or superselective neck dissection may produce results therapeutically equivalent to those obtained with more extensive procedures, with less morbidity. There is now a large body of evidence, based on long‐term clinical outcomes, that patients who have achieved a complete clinical (including radiologic) response to chemoradiation have a low rate of isolated neck failure, and the continued use of planned neck dissection for these patients cannot be justified. © 2009 Wiley Periodicals, Inc. Head Neck, 2010     

Preservation of the Internal Jugular Vein in the Radical Treatment of Node-Positive Neck—Is It Safe?

Background The aim of this study was to evaluate risk factors of neck recurrence in patients with pN+ necks submitted to a modified or a classic radical neck dissection and the safety of preserving the internal jugular vein in the treatment of a subgroup of these patients. Methods The medical records of 311 untreated patients with squamous cell carcinoma of the oral cavity (106 cases), oropharynx (95 cases), larynx (49 cases), and hypopharynx (61 cases) were reviewed. Their clinical stages (CS) were CS II in 1%, CS III in 19.9%, CS IVA in 76.2%, and CS IVB in 19.6% of the cases. All patients were pN+. Results Ipsilateral neck recurrence occurred in 18 cases (5.8%), 14 cases (4.5%) where the internal jugular vein was resected, and 4 cases (1.3%) where the internal jugular vein was preserved. Neck recurrence did not have significant correlation with tumor site (P = .852), T stage (P = .369), N stage (P = .963), adjuvant radiotherapy (P = .701), number of positive lymph nodes (P = .886), jugular vein preservation (P = .240), and extracapsular spread (P = .670). There was significant correlation between neck recurrence and the lymph node size (.040). Conclusions Modified radical neck dissection with internal jugular vein preservation can be performed in selected patients with lymph node metastases, with no significant increase in the risk of neck recurrence.     

A SELECTIVE APPROACH TO NECK DISSECTION FOR MUCOSAL SQUAMOUS CELL CARCINOMA

A personal series of 189 neck dissections performed over 6 years among 154 patients with mucosal squamous cell carcinoma is presented. The most common primary sites were the oral cavity (66). oropharynx (38) and hypopharynx (17). There were 104 therapeutic and 85 elective neck dissections. Over 40% of therapeutic dissections were modified or selective procedures. Radical neck dissection was never used electively. Seventy-eight patients (50%) had postoperative radiotherapy to the neck. Nodes were histologically positive in 110 dissections overall (58%); 92% of therapeutic dissections and 17% of elective dissections. Extracapsular spread was present in 65% of positive dissections. Ipsilateral neck recurrence developed in 10 of 60 patients who had therapeutic radical dissections (17%) and in 2 of 44 patients who had therapeutic, modified or selective dissections (5%). Recurrence after elective dissection occurred in only one patient (1.2%). It is concluded that modified and selective neck dissection are safe and oncologically effective when used among selected patients and combined with adjuvant radiotherapy. Neck recurrence may still occur among patients with advanced and biologically aggressive disease despite radical therapy.