Joseph 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 Cancer

General Goals

• Review the indications for management of cervical nodal metastasis in head and neck cancer

• Indications for selective, staging neck dissection

• Newer techniques, including sentinel node biopsy

Levels of the Neck

I

IV

VI III

II

V

Sublevels of the Neck

IA

IV

VIIII

IIA

VA

IB IIB

VB

Neck Dissection:Terminology

• AHNS recommendations favor descriptive terminology to obtain better precision– Neck levels– Structures preserved– Structures sacrificed

Sources of Bias in Literature Regarding Neck Dissection

• Almost 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 challenging

Neck Dissection

• Staging: 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 Approach

• George 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 Dissection

Modified Neck Dissection

• Modified 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 XI

Selective vs. Comprehensive/(I-V)

Neck Dissection• Removal 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 disease

Selective vs. Comprehensive/(I-V)

Neck Dissection• Secondary 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-V

• Safe, accepted, traditional means of addressing any N+ neck surgically

• Major structures require sacrifice when involved with tumor

Distribution of Nodal Metastases:Oral Cavity

• I 30%

• II 35%

• III 23%

• IV 9%

• V 2%

Level IV in Oral Cavity Selective Neck Dissection

• 16% 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, 1997

Risk of Occult Nodal Metastasis: Oral Cavity

• For 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-IIIfor oral cavity N0 disease

III

IIAI

IIB

IV

• T2-T4 NO oral cavity

• Any T thickness > 0.4 cm

• Isolated IIB metastasis rare

Distribution of Nodal Metastases:Oropharynx

• I 10%

• II 52%

• III 34%

• IV 20%

• V 7%

Oropharynx: 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 metastasis

Selective Neck Dissection II-IVfor Oropharynx

IV

III

IIA

IIB

• T2-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 therapy

Distribution of Nodal Metastases:

Larynx and Hypopharynx

• I 2%• II 31%• III 27%• IV 12%• V 2.6%

Selective Neck Dissection Hypopharynx: Considerations

• Propensity 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: Considerations

• T1 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-IVfor Hypopharynx and Larynx

IV

III

IIA

IIB• T1-T4 NO hypopharynx

• If N0 treated with radiotherapy for primary, may be no need for selective neck dissection

• T2-T4 NO Larynx

• If N0 treated with radiotherapy for primary, may be no need for selective neck dissection

Paratracheal Nodal Dissection for Larynx, Hypopharynx

• 10 –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 VI

Selective Neck Dissection VIfor selected

larynx/hypopharynx/thyroid tumors

VI

Postoperative Radiotherapy after Selective Neck

Dissection• Patients 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

Controversy

• Rationale: Postoperative radiotherapy may achieve control of microscopic/subclinical metastatic disease

• Improved functional outcome

Selective Neck Dissection for clinically N+ Disease: A

Controversy• Most 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 up

Selective Lymph Node Sampling

• Mentioned 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 biopsy

• 99Tc 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 Biopsy

• 10-15 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: Pitfalls

• Only 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 trials

Neck Dissection After Chemotherapy and/or

Radiation• Most 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 unresectable

Liauw 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 Cancer

• No 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 indicated

Medullary Thyroid Carcinoma

• Total 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 Carcinoma

• No 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 tumor

Summary

• Comprehensive 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

Summary

• The 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 Consideration

• Most 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.

Surgeons must be very careful,When they take the knife!

Underneath their fine incisions,Stirs the Culprit Life!

~Emily Dickinson