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Radical Neck Dissection: (RND) Classification, Indication and Techniques.

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Presentation on theme: "Radical Neck Dissection: (RND) Classification, Indication and Techniques."— Presentation transcript:

1 Radical Neck Dissection: (RND) Classification, Indication and Techniques

2 Introduction Crile in 1906 introduced RND and is followed by Martin as a the classical procedure for the management of cervical lymph node metastasisCrile in 1906 introduced RND and is followed by Martin as a the classical procedure for the management of cervical lymph node metastasis Recently changes in classification and indication led to inconsistencyRecently changes in classification and indication led to inconsistency –N 0 in recent studies may require selective RND to reduce morbidity

3 Staging of Neck Nodes N X :N X : –Regional lymph nodes can not be assessed N 0 :N 0 : –No regional lymph node metastasis N 1 :N 1 : –Metastasis in a single ipsilateral lymph nodes, 3 cm or less in greatest dimension N 2 :N 2 : –N 2a : Metastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cmMetastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cm

4 Staging of Neck Nodes –N 2b : Metastasis in multiple ipsilateral lymph nodes, not more than 6 cmMetastasis in multiple ipsilateral lymph nodes, not more than 6 cm –N 2c : Metastasis in bilateral or contralateral nodes not more than 6 cm in diameterMetastasis in bilateral or contralateral nodes not more than 6 cm in diameter N 3 :N 3 : –Metastasis in lymph nodes more than 6 cm in in greatest diameter Meyers & Eugene: Operative Otolaryngology. 1997

5 Lymph Node Regions Region I:Region I: –Submental and submandibular triangle I a : Submental triangle:I a : Submental triangle: –Bounded by the anterior belly of digastric and the mylohyoid muscle deep I b : Submandibular triangle:I b : Submandibular triangle: –Formed by the anterior and posterior belly of the digastric muscle and the body of the mandible Memorial Sloan-kettering Cancer center

6 Lymph Node Regions Region II – IV:Region II – IV: –Lymph nodes are associated with the Internal Jugular Vein (IJV) within the fibroadipose tissues that extend from the posterior border of sternocledo- mastoid muscle (SCM) medial to lateral border of the sternohyoid muscle Memorial Sloan-kettering Cancer center

7 Lymph Node Regions Region II:Region II: –Upper third including upper jugular, jugulodigastric and upper posterior cervical nodes –Bounded by the digastric muscle superiorly and the hyoid bone or carotid bifurcation inferiorly IIa:IIa: –nodes anterior to Spinal Accessory Nerve (SAN) IIb:IIb: –nodes posterior to Spinal Accessory Nerve (SAN) Memorial Sloan-kettering Cancer center

8 Lymph Node Regions Region III:Region III: –Middle third jugular nodes from the carotid bifurcation to cricothyroid notch or omohyoid muscle Region IV:Region IV: –Lower third jugular nodes from omohyoid muscle superiorly to the clavicle inferiorly Memorial Sloan-kettering Cancer center

9 Lymph Node Regions Region V:Region V: –Lymph nodes of the posterior triangle along the lower half of the SAN and the transverse cervical artery –Bounded by the anterior border of the trapezius posteriorly, the posterior border of SCM anteriorly and the clavicle inferiorly Memorial Sloan-kettering Cancer center

10 Lymph Node Regions Region VI:Region VI: –Anterior compartment, lymph nodes surrounding the midline visceral structures that extend from the hyoid bone superiorly to the suprasternal notch inferiorly –The lateral boundary is the medial border of the carotid sheath –Perithyroid, paratracheal, and lymph nodes around the recurrent laryngeal nerve Memorial Sloan-kettering Cancer center

11 Classification The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type :The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type : 1.Radical Neck Dissection (RND) 2.Modified Radical Neck Dissection (MRND) 3.Selective Neck Dissection (SND) 1.Supraomohyoid 2.Posterolateral 3.Lateral 4.Anterior 4.Extended Radical Neck Dissection (ERND)

12 Classification Radical neck Dissection:Radical neck Dissection: –Removing all lymphatic tissues in regions I - V and include removal of SAN, SCM and IJV Modified radical neck dissection:Modified radical neck dissection: –Excision of all lymph nodes removed with RND with preservation of one or more non- lymphatic structures, SAN, SCM and/or IJV Subtype I: Preserve SANSubtype I: Preserve SAN Subtype II: Preserve SAN & SJVSubtype II: Preserve SAN & SJV Subtype III: preserve SAN, SJV and SCMSubtype III: preserve SAN, SJV and SCM –Known as Functional neck dissection (Bocca)

13 Classification Selective Neck dissection:Selective Neck dissection: –Any type of cervical lymphadenectomy with preservation of one or more lymph node groups –Four subtype: Supraomohyoid neck dissectionSupraomohyoid neck dissection Posterolateral neck dissectionPosterolateral neck dissection Lateral neck dissectionLateral neck dissection Anterior neck dissectionAnterior neck dissection

14 Classification –Supraomohyoid neck dissection: Removal of lymph nodes in regions I –IIIRemoval of lymph nodes in regions I –III The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCMThe posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCM The inferior limit is the superior belly of the omohyoid where it cross IJNThe inferior limit is the superior belly of the omohyoid where it cross IJN –Posterolateral neck dissection Removal of suboccipital, retroauricular, levels II – V and level VRemoval of suboccipital, retroauricular, levels II – V and level V Subtyped I – III depending on the preservation of SAN, IJV and /or SCMSubtyped I – III depending on the preservation of SAN, IJV and /or SCM Medina

15 Classification –Lateral neck dissection: Remove lymph nodes in levels II – IVRemove lymph nodes in levels II – IV –Anterior neck dissection: Require the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VIRequire the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VI Superior limit, hyoid boneSuperior limit, hyoid bone Inferior limit, suprasternal notchInferior limit, suprasternal notch Laterally, the carotid sheathLaterally, the carotid sheath

16 Classification Extended neck dissection:Extended neck dissection: –Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues

17 Facts General nodal metastasis produce the following fact:General nodal metastasis produce the following fact: –The most important factor in prognosis of SCC of the upper aero-digestive tract is the status of cervical lymph nodes –Cure rate drops 50% with involvement of the regional lymph nodes

18 Indications For ND Radical neck dissection was believed by Martin to be the only method to control cervical lymphadenectomyRadical neck dissection was believed by Martin to be the only method to control cervical lymphadenectomy Anderson found that preservation of SAN did not change the survival or tumor control in the neckAnderson found that preservation of SAN did not change the survival or tumor control in the neck –Actual 5-year survival and neck failure rate is: RND: 63% and 12 %RND: 63% and 12 % MRND: 71% and 12%MRND: 71% and 12%

19 Indications Radical Neck DissectionRadical Neck Dissection 1.Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN 2.Large metastatic tumor mass or multiple matted in upper part of the neck Tumor should not be dissected to preserve StructuresTumor should not be dissected to preserve Structures

20 Indications Modified radical neck dissectionModified radical neck dissection –MRND Type I: 1.Clinically obvious neck lymph nodes metastasis and SAN not involved by tumor 2.Intraoperative decision just like preservation of the facial nerve in parotid surgery

21 Indications MRND Type II:MRND Type II: 1.Rarely planned 2.Intra-operative decision for tumor found adherent to SCM but away from SAN & IJV MRND Type III:MRND Type III: –Depend on the autopsy reports 1.Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels 2.They are not found within the aponeurosis or glandular capsule of the submandibular “Functional neck dissection”

22 Indications MRND Type III:MRND Type III: –For treatment of N 0 neck nodes –Indicated for N 1 mobile nodes and not greater than 2.5 – 3.0 cm Contra-indicated in the presence of node fixationContra-indicated in the presence of node fixation Result is difficult to interpret because of the use of radiation therapyResult is difficult to interpret because of the use of radiation therapy

23 Indications Selective/elective neck dissection:Selective/elective neck dissection: –For treatment of N 0 neck nodes –For N+ nodes when combined with radiotherapy Adjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spreadAdjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spread –Supraomohyoid is indicated for SCC of oral cavity with N 0 and N 1 with palpable mobile nodes less than 3 cm and located in level I and II –Upgrade intra-operatively following positive frozen section

24 Treatment option for N 0 nodes ObserveObserve Radiation therapyRadiation therapy Elective neck dissectionElective neck dissection –Low morbidity –Staging neck for possible extended surgery –Need for post-operative radiotherapy

25 Rationale for S/END Rate of occult metastasis in clinically negative nodes is 20 – 30% using clinical and radiographic findingsRate of occult metastasis in clinically negative nodes is 20 – 30% using clinical and radiographic findings –Ct scan combined with physical exam decreased the rate of occult metastasis to 12% –This suggested lowering of the criteria for elective neck dissection Friedman et al Laryngoscope 100; 54 – 59: 1990

26 Rationale for S/END Anatomic studies showed that lymphatic drainage from the mucosal surfaces follow a constant and predictable routeAnatomic studies showed that lymphatic drainage from the mucosal surfaces follow a constant and predictable route Lymph flow from SA chain to the jugular chain is unilateralLymph flow from SA chain to the jugular chain is unilateral Shah. Ann Surg Oncol 1(6); : 1994

27 Rationale for S/END in his study produced a compelling evidence of predictable nodal metastasis from SCC from upper aerodigastive tractShah, in his study produced a compelling evidence of predictable nodal metastasis from SCC from upper aerodigastive tract –He found a specific pattern for nodal spread by location of primary N O in patients with oral cavity SCC:N O in patients with oral cavity SCC: – 7/1119 (3.5%) had nodal involvement outside supraomohyoid dissection –3 (1.5%) had isolated involvement outside level I - III Friedman Laryngoscope 100; 54-59: 1990

28 Rationale for S/END –N + nodes in patients with oral SCC: 50/246 had nodal metastasis outside level IV50/246 had nodal metastasis outside level IV 10/246 had metastasis in level V10/246 had metastasis in level V –He examined nodal involvement in patients with nasopharynx and other upper parts of the aerodigastive tract Conclusion:Conclusion: –SCC of the oral cavity: Level I, II and III are at riskLevel I, II and III are at risk –SCC nasopharynx and larynx Level II, III and IV are at riskLevel II, III and IV are at risk Shah Amer J Surg 160; : 1990 Shah Cancer July 1 ; : 1990

29 Rationale for S/END Byers stated that SND combined with postoperative radiotherapy in selected patients with oral cavity SCC was adequate treatment with similar recurrence rate as those treated with MRND IIIByers stated that SND combined with postoperative radiotherapy in selected patients with oral cavity SCC was adequate treatment with similar recurrence rate as those treated with MRND III Spiro reported 12% with supraomohyoid dissection in N1 nodes but not all of them received radiotherapySpiro reported 12% with supraomohyoid dissection in N1 nodes but not all of them received radiotherapy Byers Head Neck Surg; Jan-Feb; : 1988

30 Selective/Elective Neck Dissection A good option for N0 neckA good option for N0 neck Not a suitable option for N+ neckNot a suitable option for N+ neck Is used N+ neck when combined with radiotherapyIs used N+ neck when combined with radiotherapy Intra-operative frozen section evaluation is needed to confirm in cases of intraoperative palpable nodesIntra-operative frozen section evaluation is needed to confirm in cases of intraoperative palpable nodes

31 The anatomy Skin:Skin: –Blood supply: Descending branches:Descending branches: –The facial –The submental –Occipital Ascending branchesAscending branches –Transverse cervical –Suprascapular –The branches perforate the platysma muscle, anastomose to form superficial vertically-directed network of vessels Skin incision is superiorly based apron-like incision from mastoid to mentum or to contralateral mastoid

32 The anatomy Platysma muscle:Platysma muscle: –Wide, quadrangular sheet-like muscle –Run obliquely from the upper part of the chest to lower face –Skin flap is raised immediately deep to the muscle –The posterior border is over or just anterior to IJV and great auricular nerve –Does not cover the inferior part of the anterior triangle and the posterolateral neck

33 The anatomy Sternocleidomastoid muscle: SCMSternocleidomastoid muscle: SCM –Differentiated from the platysma by the direction of its fibres –Crossed by the IJV and the great auricular nerve from inferior to posterior deep to platysma –The posterior border represent the posterior boundary of nodes level II - IV

34 The anatomy Marginal Mandibular nerve: MMNMarginal Mandibular nerve: MMN –Located 1 cm in front of and below the angle of the mandible –Deep to the superficial layer of the deep cervical fascia –Superficial to adventitia of the anterior facial vein

35 The anatomy Spinal Accessory nerve: SANSpinal Accessory nerve: SAN –Emerge from the jugular foramen medial to the digastric and stylohyoid muscles and lateral and posterior to IJV (30% medial to the vein and in 3 -5% split the nerve) –It passes obliquely downward and backward to reach the medial surface of the SCM near the junction of its superior and middle thirds, Erb’s point

36 The anatomy Trapezius muscle: –Its anterior border is the posterior boundary of level V –Difficult to identify because of its superficial position –Dissect superficial to the fascia in order to preserve the cervical nerves

37 The anatomy ; Posterior belly:Digastric Muscle; Posterior belly: –Originate from a groove in the mastoid process, digastric ridge –The marginal mandibular nerve lie superficial –The external and internal carotid artery, hypoglossal and 11 th cranial nerves and the IJV lie medial

38 The anatomy Omohyoid muscle: –Made of two bellies, and is the anatomic separation of nodal levels III and IV –The posterior belly is superficial to the brachial plexus, phrenic nerve and transverse cervical artery and vein –The anterior belly is superficial to the IJV

39 The anatomy Brachial Plexus & Phrenic nerve: –The plexus exit between the anterior and middle scalene muscles, pass inferiorly deep to the clavicle under the posterior belly of the omohyoid –The phrenic nerve lie on top of the anterior scalene muscle and receive it is cervical supply from C3 – C5

40 The anatomy Thoracic duct: –Located in the lower let neck posterior to the jugular vein and anterior to phrenic nerve and transverse cervical artery –Have a very thin wall and should be handled gently to avoid avulsion or tear leading to chyle leak

41 The anatomy Exit via the hypoglossal canal near the jugular foramenExit via the hypoglossal canal near the jugular foramen Passes deep to the IJV and over the ICA and ECA and then deep and inferior to the digastric muscle and enveloped by a venous plexus, the ranine veinsPasses deep to the IJV and over the ICA and ECA and then deep and inferior to the digastric muscle and enveloped by a venous plexus, the ranine veins Pass deep to the fascia of the floor of the submandibular triangle before entering the tonguePass deep to the fascia of the floor of the submandibular triangle before entering the tongue

42 Summary Unified classification is relatively newUnified classification is relatively new Indication and the type of ND, specially for N0, is controversialIndication and the type of ND, specially for N0, is controversial The following surgical outline was suggested:The following surgical outline was suggested: –SCC oral cavity anterior to circumvalate papilla SupraomohyoidSupraomohyoid –SCC Oropharynx, larynx and hypopharynx level I- IV or level II-Vlevel I- IV or level II-V –SCC with N+ nodes RNDRND –SCC with 2-4 positive nodes or extracapsular spread RND and adjuvant therapyRND and adjuvant therapy Shah Cancer July 1; : 1990


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