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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. Joseph Califano, M.D. Department of Otolaryngology- Head and Neck Surgery Johns Hopkins University Baltimore, MD USA. General Goals. Review the indications for management of cervical nodal metastasis in head and neck cancer

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Joseph Califano, M.D. Department of Otolaryngology- Head and Neck Surgery Johns Hopkins University Baltimore, MD USA

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  1. Surgical Management of the Neck in Head and Neck Cancer Joseph Califano, M.D. Department of Otolaryngology- Head and Neck Surgery Johns Hopkins University Baltimore, MD USA

  2. 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

  3. Levels of the Neck II I III VI V IV

  4. Sublevels of the Neck IIB IB IIA IA III VA VI IV VB

  5. Neck Dissection:Terminology • AHNS recommendations favor descriptive terminology to obtain better precision • Neck levels • Structures preserved • Structures sacrificed

  6. 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

  7. 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

  8. 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

  9. Radical Neck Dissection

  10. 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

  11. Neck Dissection With Preservation of the SCM, IJ, and CN XI

  12. 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

  13. 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

  14. Comprehensive Neck Dissection:Levels I-V • Safe, accepted, traditional means of addressing any N+ neck surgically • Major structures require sacrifice when involved with tumor

  15. Distribution of Nodal Metastases:Oral Cavity • I 30% • II 35% • III 23% • IV 9% • V 2%

  16. 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

  17. 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

  18. Selective Neck Dissection I-IIIfor oral cavity N0 disease • T2-T4 NO oral cavity • Any T thickness > 0.4 cm • Isolated IIB metastasis rare IIB I IIA III IV

  19. Distribution of Nodal Metastases:Oropharynx • I 10% • II 52% • III 34% • IV 20% • V 7%

  20. 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

  21. Selective Neck Dissection II-IVfor Oropharynx • 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 IIB IIA III IV

  22. Distribution of Nodal Metastases:Larynx and Hypopharynx • I 2% • II 31% • III 27% • IV 12% • V 2.6%

  23. 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

  24. 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%

  25. Selective Neck Dissection II-IVfor Hypopharynx and Larynx • T2-T4 NO Larynx • If N0 treated with radiotherapy for primary, may be no need for selective neck dissection • T1-T4 NO hypopharynx • If N0 treated with radiotherapy for primary, may be no need for selective neck dissection IIB IIA III IV

  26. 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

  27. Selective Neck Dissection VIfor selected larynx/hypopharynx/thyroid tumors VI

  28. 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

  29. Selective Neck Dissection for clinically N+ Disease: A Controversy • Rationale: Postoperative radiotherapy may achieve control of microscopic/subclinical metastatic disease • Improved functional outcome

  30. 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

  31. 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.

  32. 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)

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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+

  39. 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

  40. 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

  41. 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

  42. 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.

  43. Surgeons must be very careful,When they take the knife!Underneath their fine incisions,Stirs the Culprit Life! ~Emily Dickinson

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