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
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-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

19. Distribution of Nodal Metastases: Oropharynx
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-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

22. Distribution of Nodal Metastases: Larynx and Hypopharynx
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-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

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 VI for selected larynx/hypopharynx/thyroid tumors

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 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 Jan;117(1): 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
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 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
Surgeons must be very careful, When they take the knife! Underneath their fine incisions, Stirs the Culprit Life!
~Emily Dickinson