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PubMed1990

Impact of diagnosis-related groups on the quality of postoperative care of patients with neck dissections.

Two hundred eighty patients underwent neck dissection over a 10-year period: 138 during the 5-year period before the institution of Diagnosis-Related Group (DRG) reimbursement and 142 during the 5 years after DRG regulations. A comparison of these two groups by site of tumor, stage of disease, histopathology, previous treatment, type of neck dissection, whether neck dissection was carried out alone or in combination with another procedure, presence of preexisting disease, postoperative complications, and mortality revealed no significant differences. A 35% reduction in the length of hospital stay from 16 to 10 days was identified in the post-DRG group with no detrimental effects on patient care. The variables found to have the greatest impact on length of hospital stay were the extent of operation and postoperative complications.

Diagnosis-Related Groups↗
PubMed1999

Complications from planned, posttreatment neck dissections.

OBJECTIVE: To report the complication rate from planned, posttreatment neck dissections in patients who show control of primary squamous cell carcinoma by chemotherapy and radiotherapy or radiotherapy alone. DESIGN: Retrospective review of case series. SETTING: Georgetown University Medical Center, Washington, DC. PATIENTS: Thirty-four patients with clinically positive neck disease treated with organ preservation therapy for squamous cell carcinoma of the head and neck. INTERVENTIONS: Planned neck dissection after treatment with chemotherapy and radiotherapy or radiotherapy alone. MAIN OUTCOME MEASURE: Perioperative complications. RESULTS: Forty-one neck dissections were performed on 34 patients. Complications were seen in 13 (38%) of 34 patients and 15 (37%) of 41 neck dissections. Wound complications occurred in 9 (22%) of 41 dissections. Neck dissection complication rate did not correlate with previous use of chemotherapy or with the use of brachytherapy at the primary site at the time of the neck dissection. Preoperative radiotherapy dose greater than 70 Gy was associated with complications in 58% vs 29% when preoperative dose was less than 70 Gy (P = .09). This trend was reflected primarily in wound complications (42% vs 14%; P = . 10) and reached significance for skin flap necrosis (33% vs 0%; P = .005). Other factors that were associated with increased complications were preoperative albumin level less than 38 g/L and early neck drain removal. CONCLUSIONS: The complication rate associated with planned posttreatment neck dissection is similar to that previously reported for neck dissection. Wound complications are more common when higher preoperative radiotherapy doses are used.

Carcinoma, Squamous Cell↗
PubMed1985

An evaluation of neck dissection in carcinoma of the tongue.

Forty-six neck dissection cases were performed out of 117 cases of tongue cancer occurring from 1973-1981 at the Gunma Cancer Center. Among the 47 cases, 27 were initially treated surgically. In 14 cases radium therapy was used for the primary lesion and was followed by neck dissection. In another 13 cases hemiglossectomy and neck dissection were performed together. In addition, in 19 cases neck dissection was performed as secondary treatment for metastatic nodes or for recurrence of the primary lesion following radium therapy. In the cases of neck dissection performed as initial treatment along with hemiglossectomy, 84.6% had a two-year survival rate. Neck dissection performed as a secondary treatment resulted in a 46.7% survival rate over 3 years. It is evident from these figures that neck dissection performed as initial treatment results in better prognosis for the patients. In cases where metastatic nodes are present or suspected, neck dissection and hemiglossectomy should be undertaken.

Combined Modality Therapy↗
PubMed1996

Supraomohyoid neck dissection.

BACKGROUND: Supraomohyoid neck dissection (SOHND) has assumed increasing importance as a staging lymphadenectomy in patients with N(o) oral and oropharyngeal squamous cell carcinoma (SCC), as well as a potentially curative procedure in selected patients with limited metastatic disease in the neck. METHODS: Retrospective chart review of 287 patients who had a total of 320 SOHND for SCC between 1986 and 1993 as a follow-up to an earlier report that covered our experience between 1980 and 1985. After excluding 24 patients who also had local recurrence, or a new primary, the remaining 296 SOHND were assessed for the effectiveness of tumor control in the neck. RESULTS: Of 248 elective SOHND, clinically negative nodes proved histologically positive in 60 patients (25%), only 4 of whom failed in the neck (7%). A total of 48 patients (16%) had a therapeutic SOHND for limited N+ disease, confirmed pathologically in 31, with neck recurrence documented in 2 (6%). Nodes proved negative histologically in 205 patients, 10 of whom failed in the neck (5%). Nine of the 16 patients with neck recurrence had received postoperative radiation therapy and 9 recurred within the field of the SOHND. CONCLUSIONS: SOHND is a reliable staging procedure in patients with N(o) oral or oropharyngeal SCC. Therapeutic SOHND, in conjunction with postoperative radiation therapy, was highly effective in controlling neck metastases in carefully selected patients with limited disease in the upper neck.

Adult↗
PubMed1994

The role of comprehensive neck dissection with preservation of the spinal accessory nerve in the clinically positive neck.

BACKGROUND: The most significant prognostic factor in patients with squamous cell carcinoma of the head and neck is the presence of cervical nodal metastases. Radical neck dissection is the standard by which all cervical lymphadenectomy procedures are judged. In the presence of clinically positive nodal metastasis, the benefit of preserving the spinal accessory nerve (SAN) has to be weighed against the possible risk of increased failure in the neck. We performed this retrospective study to determine if preservation of the SAN in patients with clinically evident nodal metastases was associated with increased risk of failure in the dissected neck. PATIENTS AND METHODS: Between January 1, 1984 and December 31, 1991, 378 comprehensive neck dissections were performed in 366 patients with clinically and pathologically positive nodal metastases from squamous carcinoma of the upper aerodigestive tract. We compared survival, neck control rates, and other factors in patients who had a classic radical neck dissection (RND) to those who had modified radical neck dissection sparing only the SAN (MRND I). RESULTS: Actuarial 5-year survival and neck failure rates for the RND group were 63% and 12%, compared to 71% and 8% for the MRND I group (P = NS). Survival and neck failure were not statistically different between the MRND I and RND groups when the analysis controlled for pathologic N stage, presence of extra capsular spread, and the presence of pathologically demonstrated metastatic nodes along the course of the SAN. Nor were there significantly different patterns of neck failure with RND versus MRND. CONCLUSION: Modification RND to preserve an uninvolved SAN in the clinically positive neck does not adversely affect survival or neck control.

Accessory Nerve↗
PubMed1999

Improved survival for patients with clinically T1/T2, N0 tongue tumors undergoing a prophylactic neck dissection.

BACKGROUND: Prophylactic surgical treatment of the neck in "early tongue tumors" is a controversial issue. METHODS: From a database of 226 patients with squamous cell carcinoma of the tongue treated at Canniesburn Hospital, Glasgow, U.K., between 1980 and 1996, a total of 137 patients with a minimum follow up of 24 months or until death were clinically identified as being T1/T2, N0 (UICC) when first seen. These patients were divided into three groups according to the management of the neck; 53 patients did not have a neck dissection at any time (NKD0), 47 patients underwent a synchronous neck dissection at the time of treatment of the primary (NKDS), and 37 patients subsequently required a metachronous neck dissection when lymph node metastasis became clinically apparent (NKDM). These three groups were compared with respect to age, sex, site, duration of symptoms, previous treatment (if any), initial treatment protocol, resection margin, type of neck dissection (if any), loco-regional recurrence, systemic escape, number of positive lymph nodes, and presence of extracapsular spread. Disease-related survival was calculated using Kaplan-Meier survival curves with logrank test and chi-square statistical analysis. RESULTS: The pT stage was upgraded to T3/4 in 3/53 patients (6%) of the NKD0 group, 11/47 patients (23%) of the NKDS group, and 2/37 patients (5%) of the NKDM group (p < 0.001). The 5-year determinate survival rates for the three groups were: NKD0 59.7%, NKDS 80.5%, NKDM 44.8%, and (NKD0 + NKDM) 53.6% with a statistically significant improvement in survival for NKDS vs NKDM (logrank 10.58, p = 0.001) and for NKDS vs (NKD0 + NKDM) (logrank 6.06, p = 0.014). The incidences of positive nodes in the NKDS and NKDM groups were 18/47 patients (38%) and 32/37 patients (86%) respectively. Neck positive patients in the NKDM group had a significantly greater number of positive nodes in comparison with N positive patients in the NKDS group (chi trend, p = 0.001), a higher incidence of extracapsular spread, 30/32 vs 9/18 (chi test, p < 0. 0001), and decreased survival. The incidence of occult cervical metastasis for the whole group was 41%. CONCLUSION: Patients with clinical T1/2, N0 tongue tumors who underwent a synchronous neck dissection had an improved survival outcome even though as a group they had a higher incidence of occult metastasis, relatively more T2 lesions, a worse pT stage, and had more posterior third lesions requiring more difficult initial surgery. Tongue tumors have a high incidence of subclinical nodal disease, which is less curable when it presents clinically. The information gleaned from the nodal status allows a more informed plan of adjuvant therapy.

Adult↗
PubMed1997

Surgical morbidity of neck dissection after chemoradiotherapy in advanced head and neck cancer.

The use of chemotherapy and irradiation for organ preservation attempts to eliminate the need for extensive surgery in patients with advanced squamous cell carcinoma of the head and neck (SCCHN). We sought to characterize the morbidity of surgery in patients who needed surgery after treatment with induction chemotherapy followed by simultaneous chemotherapy and radiotherapy (chemoradiotherapy). The surgical morbidity within the first 30 postoperative days of 17 patients treated in an organ preservation approach between July 1991 and December 1994 was compared with a control group of patients undergoing similar surgical procedures during the same period. The organ preservation study patients underwent surgical procedures consisting of 18 neck dissections and 5 resections of the primary site. Six patients in the organ preservation study group experienced 8 surgical complications within the first 30 postoperative days, and most complications were minor. There was no significant difference in the duration of surgery or length of hospitalization between study patients and matched controls. Our surgical complication rate (35.3%) was higher but not statistically different from that of the control group, and compared favorably to reports of surgical morbidity (44% to 61%) in the literature on patients treated with chemoradiotherapy. The lower complication rate seen in this study may be a reflection of early surgical intervention as part of our organ preservation study scheme, the preponderance of neck dissections performed, and the limited number of pharyngeal procedures performed.

Adult↗
PubMed1991

Elective radical neck dissection in epidermoid cancer of the head and neck. A retrospective analysis of 853 cases of mouth, pharynx, and larynx cancer.

A retrospective analysis of 853 patients with cancer of the mouth, pharynx, and larynx operated on over a 30-year period was performed. Four hundred fifty-seven of them had a radical neck dissection (RND) at some point. Five hundred ninety patients had no clinically positive nodes (N-o) necks at the time of primary treatment; 99 of these had elective neck dissection, whereas 95 others had a delayed RND when nodes became clinically involved. Twenty-three percent of all N-o patients had microscopically involved nodes and less than half of these were among those patients selected for elective RND. Furthermore, 58% of those patients who had elective RND did not have positive nodes. Comparative analysis of elective RND, delayed therapeutic RND after clinical appearance of nodes, and composite operations for patients with N1-N3 disease indicates little difference in disease-free survival when the nodes in the elective RND were positive microscopically for tumors (56%, 49% and 47% respectively). It thus seems that elective RND offers no real advantage over a careful watchful waiting approach in most patients.

Carcinoma, Squamous Cell↗
PubMed1980

Functional radical neck dissection.

A technique is described for performing a radical neck dissection by elevating the muscle out of the neck to facilitate the complete removal of all the neck structures without injury to the muscle and without significantly increasing the operative time. The neck dissection can be performed as a "classical" radical neck dissection by removing all the neck structures en bloc, including the jugular vein and spinal accessory nerve. Alternatively, a "functional" radical neck dissection can be done in selected cases by dissecting out and preserving the jugular vein and/or the spinal accessory nerve. The sternal end of the sternocleidomastoid muscle is then reattached before closing the neck wounds. This technique was used unilaterally in 11 patients and bilaterally in 2 patients, without complications. The cosmetic results demonstrate a significant advantage of this method over the routine classical radical neck dissection. The results in this small series, with follow-up periods of 18 to 40 months in patients with squamous cell carcinoma, suggest that this procedure gives good results in selected cases.

Accessory Nerve↗
PubMed1985

Objective comparison of physical dysfunction after neck dissection.

Thirty-five patients who underwent a total of 44 neck dissections of various types were prospectively studied to compare differences in postoperative shoulder function. Those who underwent a radical neck dissection suffered the greatest reduction in shoulder movement and had severely abnormal electromyograms. Those who underwent modified neck dissection with preservation of the spinal accessory nerve suffered less loss of shoulder function than the radical neck dissection group, but not to a significant degree at 16 weeks; however, the electromyograms of patients who underwent modified neck dissection were significantly better than those of the radical neck dissection group, which suggests that these patients may improve with time. Indeed, a reevaluation of several patients at 1 year showed improvement in both shoulder function and electromyograms in those who underwent modified neck dissection. Patients who underwent supraomohyoid neck dissection that involved minimal dissection of the spinal accessory nerve had minimal loss of shoulder function and usually, normal electromyograms at 16 weeks that documented less injury to the spinal accessory nerve. Again, these patients had improvement with time. A correlational analysis revealed that the physical parameters correlated well with the electromyographic findings, whereas each patient's perception of disability did not. These findings suggest that, in patients in whom it is oncologically sound, a neck dissection that spares the spinal accessory nerve offers significant benefit in terms of shoulder function.

Accessory Nerve↗
PubMedDate not supplied

Neck dissection: concepts, controversies, and technique.

The various types of neck dissections are described. The indications for each type of neck dissection are discussed for patients with necks staged N0, N+, for the patient with an unknown primary and for the patient whose neck dissection is in conjunction with radiation. The technical aspects of modified neck dissections are addressed but not in great detail. The indications for the use of postoperative radiation are emphasized. The nodal groups at risk for metastases from various primary sites are identified and a terminology for neck dissection is suggested.

Humans↗
PubMed1997

Postoperative hypertension after radical neck dissection.

Postoperative hypertension after radical neck dissection was detected in 20.2% of 109 neck dissections in our department between 1989 and 1993. It was probably caused by carotid sinus denervation and appeared after the vasodilation generated by anesthesia had subsided. If postoperative hypertension was encountered after the first operation, the risk of such hypertension after surgery on the contralateral side significantly increased.

Adult↗
PubMed1977

Indications for neck dissection in carcinoma of the lip.

In the past, neck dissections have been recommended only when nodes were clinically palpable or when they became so. A retrospective ten year study of thirty-seven patients with carcinoma of the lip and with an unusually high mortality has allowed reevaluation of indications for neck dissection. (1) Ten of thirty-seven patients died of this disease and nearly all of the ten died with and because of regional metastases. (2) Seven patients with nonpalpable nodes initally had nodal metastases later which, despite neck dissection at that later time, proved lethal. (3) Two patients who, despite nonpalpable nodes, had undergone neck dissections and were found to have occult bilateral nodal metastases were effectively cured with early neck dissection. This suggests that early bilateral supramohyoid neck dissections for small carcinomas of the lip and ipsilateral radical neck dissections for large primaries may yield higher cure rates than currently achieved.

Adult↗
PubMed1995

[Three cases of postoperative laryngopharyngeal edema following nonsimultaneous bilateral radical neck dissection].

Three cases of postoperative laryngopharyngeal edema following nonsimultaneous radical neck dissection are presented. Case 1 was a 65-year-old male with tongue cancer and left cervical lymph node metastases. Hemiglossectomy, reconstruction of the floor of the mouth with a free rectus abdominis flap, and left radical neck dissection had been performed. Postoperatively, the tongue and left upper neck were irradiated. Seven months later, right cervical lymph node metastases were observed. Right radical neck dissection was performed, and immediately after extubation, upper airway stenosis due to severe laryngopharyngeal edema occurred. Emergent tracheostomy saved his life. Case 2 was a 55-year-old female with tongue cancer and right cervical lymph node metastases. Radium needles had been implanted in the tongue, and right radical neck dissection was performed. Three months later, left cervical lymph node metastases were found. Left radical neck dissection was performed and, as in Case 1, upper airway stenosis revealed immediately after extubation. Since the situation was anticipated, an immediate tracheostomy was done. Case 3 was a 43-year-old male with laryngeal cancer and left cervical lymph node metastasis. Irradiation of the larynx and the bilateral upper neck followed by left radical neck dissection and partial laryngohypopharyngectomy had been performed. Five years later, right cervical lymph node metastasis was observed. Right radical neck dissection was performed, and laryngoscopic examination before extubation revealed severe laryngopharyngeal edema. In this case, tracheostomy was performed before extubation. To our knowledge, there have been only five cases of postoperative laryngopharyngeal edema, following nonsimultaneous radical neck dissection, reported in the literature.

Adult↗
PubMed1997

Long-term regional control after radiation therapy and neck dissection for base of tongue carcinoma.

PURPOSE: Minimal literature exists with 10-year data on neck control in advanced head and neck cancer. The purpose of this study is to determine long-term regional control for base of tongue carcinoma patients treated with primary radiation therapy plus neck dissection. METHODS AND MATERIALS: Between 1981-1996, primary radiation therapy was used to treat 68 patients with squamous cell carcinoma of the base of tongue. Neck dissection was added for those who presented with palpable lymph node metastases. The T-stage distribution was T1, 17; T2, 32; T3, 17; and T4, 2. The N-stage distribution was N0, 10; N1, 24; N2a, 6; N2b, 11, N2c, 8; N3, 7; and Nx, 2. Ages ranged from 35 to 77 (median 55 years) among the 59 males and nine females. Therapy generally consisted of initial external beam irradiation to the primary site (54 Gy) and neck (50 Gy). Clinically positive necks were boosted to 60 Gy with external beam irradiation. Three weeks later, the base of tongue was boosted with an Ir-192 interstitial implant (20-30 Gy). A neck dissection was done at the same anesthesia for those who presented with clinically positive necks, even if a complete clinical neck response was achieved with external beam irradiation. Neoadjuvant cisplatin-based chemotherapy was administered to nine patients who would have required a total laryngectomy if their primary tumors had been surgically managed. The median follow-up was 36 months with a range from 1 to 151 months. Eleven patients were followed for over 8 years. No patients were lost to follow-up. RESULTS: Actuarial 5- and 10-year neck control was 96% overall, 86% after radiation alone, and 100% after radiation plus neck dissection. Pathologically negative neck specimens were observed in 70% of necks dissected after external beam irradiation. The remaining 30% of dissected necks were pathologically positive. These specimens contained multiple positive nodes in 83% despite a 56% overall complete clinical neck response rate to irradiation. Regional failure occurred in only two patients, neither of whom underwent adjuvant neck dissection. Symptomatic neck fibrosis (RTOG grade 3) was not observed. Actuarial 5- and 10-year local control was 88% and 88%, disease-free survival was 80% and 67%, and overall survival was 86% and 52%. CONCLUSION: For base of tongue cancer, most patients can obtain long-term regional control with no severe complications after definitive radiation therapy, plus neck dissection for those who present with lymphadenopathy. Complete clinical regression of palpable neck metastases after irradiation poorly correlates with pathologic outcome. Our current policy is to include neck dissection at the time of implantation for patients who present with palpable neck metastases. We realize that this therapeutic approach may overtreat some patients, but we are reluctant to change our policy in light of these excellent outcomes.

Adult↗
PubMed1996

Selective neck dissection and the management of the node-positive neck.

OBJECTIVE: To assess the oncologic effectiveness of the selective neck dissection (SND) in patients with both clinically and pathologically proven regional metastases. METHODS: A 4-year retrospective medical chart review was conducted in an academic tertiary care referral center. Twenty-nine patients with a newly diagnosed upper aerodigestive tract squamous cell carcinoma, and both clinically and histologically proven cervical metastases who underwent 36 SND, had their records reviewed. Minimum follow-up was 2 years. RESULTS: Regional metastasis were staged N1 in 13 patients, N2A in 1, N2B in 8, and N2C in 7. Seventeen supraomohyoid and 19 lateral neck dissections were performed. Extracapsular spread of tumor was present in 11 patients. Postoperative radiation therapy was administered to 20 patients. Actuarial disease-specific survival at 4 years was 47% overall, 67% in N1 patients, and 41% in N2 patients. Only 1 failure in the treated neck occurred for a 4-year actuarial regional failure rate of 4%. The actuarial local failure and distant metastasis rate were 36% each. CONCLUSIONS: In carefully selected patients with clinically and histologically apparent regional metastases, the selective neck dissection can be an oncologically effective procedure.

Adult↗
PubMed1984

Functional neck dissection: an evaluation and review of 843 cases.

After briefly reviewing the principles, indications, and merits of functional neck dissection, the results of 1200 neck dissections performed on 843 patients in the period 1961-1979 are presented. They compare very favorably with those reported for classic (radical) neck dissection by other leading authors; however, a retrospective analysis of data derived from material of different origin is hardly possible and has a disputable value. Therefore, we decided to compare our data on functional neck dissections (FND) with those of classic neck dissections (CND) performed by the same surgical team at the same clinic in the period 1948-1960. The clinical material was largely the same in both cases, and the data were collected and analyzed using the same criteria. In both series, neck dissections were divided into elective and curative. It could be demonstrated that the number of neck recurrences observed in the dissected necks is the same for FND and CND in curative dissections, while it is considerably lower for FND in elective neck dissections. This of course does not prove improved radicality in FND, but only proves that a systematic bilateral elective neck dissection in N0 cases affords improved cancerological safety. This radical bilateral approach to regional lymph nodes is made possible routinely by FND which avoids the problems of unnecessary mutilation. The figures produced speak in favor of a wider adoption of FND especially for expanding the indications to elective treatment of regional lymph nodes in cancer of the head and neck. Elective neck dissection is made practically harmless by this newer technique and averts the dreadful appearance of late metastases in N0 cases.

Head and Neck Neoplasms↗
PubMed1998

Combined neck dissection and postoperative radiation therapy in the management of the high-risk neck: a matched-pair analysis.

PURPOSE: The purpose of this study was to determine the efficacy of postoperative adjuvant radiation therapy with regard to reducing the rate of recurrence in the neck, cancer-related death, and death from any cause in patients with squamous cell carcinoma of the head and neck region metastatic to neck nodes. METHODS: This was a retrospective review of patients with pathologically confirmed nodal metastases who underwent neck dissection and postoperative adjuvant radiation therapy for squamous cell carcinoma of the head and neck region. Time to recurrence in the dissected area of the neck, any recurrence in the neck, cancer-related death, and death from any cause were estimated with the Kaplan-Meier method. A matched-pair analysis was performed utilizing a cohort of patients who underwent neck dissection without postoperative radiation therapy. The patients from the two cohorts were matched according to previously reported high-risk features for cancer recurrence and death. Cox hazards models for the matched pairs were used to evaluate the relative risk of subsequent recurrence in the dissected side of the neck, any neck recurrence, cancer-related death, and overall survival. MATERIALS: The medical records and pathologic slides of 95 consecutive patients with pathologically confirmed nodal metastases from squamous cell carcinoma of the head and neck region who underwent neck dissection and postoperative adjuvant radiation therapy between January 1974 and December 1990 were reviewed. Previously published data from 284 patients with squamous cell carcinoma of the head and neck region treated with neck dissection alone between January 1970 and December 1980 were used for a matched-pair analysis. RESULTS: The relative risks for recurrence in the dissected side of the neck, any neck recurrence (dissected neck or delayed undissected neck metastasis), cancer-related death, and death from any cause for patients treated with operation alone relative to those treated with operation and postoperative radiation were 5.82, 4.72, 2.21, and 1.67, respectively. CONCLUSION: This study provides evidence that postoperative adjuvant radiation therapy for the high-risk neck can reduce the rate of recurrence within a dissected neck, delayed metastasis within an undissected neck, cancer-related death, and death from any cause.

Adult↗