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 Indications for selective, staging neck dissection Newer techniques, including sentinel node biopsy

Levels of the Neck II I III VI V IV

Sublevels of the Neck IIB IB IIA IA III VA VI IV 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 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-III for oral cavity N0 disease T2-T4 NO oral cavity Any T thickness > 0.4 cm Isolated IIB metastasis rare IIB I IIA III IV

Distribution of Nodal Metastases: Oropharynx 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-IV for 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

Distribution of Nodal Metastases: Larynx and Hypopharynx 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-IV for 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

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 VI for selected larynx/hypopharynx/thyroid tumors

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