[Experimental and clinical studies of tissue damage in combination neck dissection and radiotherapy].
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Animals↗
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[The spinal accessory nerve in the posterior sub-parotid space. Anatomic considerations based on 106 cadaveric neck dissections].
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Accessory Nerve↗
[Anatomic considerations concerning the spinal accessory nerve. Apropos of 106 cadaveric neck dissections].
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Accessory Nerve↗
Radiotherapy with or without neck dissection treatment of choice for base of tongue cancer.
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Brachytherapy↗
Failure in the neck following multimodality treatment for advanced head and neck cancer.
Failure in the neck is an important cause of morbidity and mortality in head and neck cancer. Patients who underwent therapeutic or elective radical neck dissection at Memorial Sloan-Kettering Cancer Center between 1960 and 1966 developed recurrence of cancer in the dissected neck in 36.5% of the cases when metastatic carcinoma was present in the cervical lymph nodes at one level, and in 71.3% when metastases were present at multiple levels. Between 1975 and 1980, we treated 114 previously untreated patients with stages III and IV epidermoid carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx with the combination of surgery and elective postoperative radiation therapy. Of these, 106 patients underwent radical neck dissection and 94 were proven to have metastatic carcinoma in the neck. Eleven patients developed recurrences in the neck. Recurrence developed in 16% of 19 patients with metastases at one level, and in 13% of 75 patients with metastases at multiple levels. For 53 patients, radiation therapy was started within 6 weeks after neck dissection and only 2% of them developed recurrence in the neck; for 41 patients, radiation therapy started later than 6 weeks and 29% of them developed recurrence (P less than 0.01). Comparison of these data with our historical control group suggests a decrease in the number of failures in the neck when a multimodality treatment is used. It appears, however, that irradiation must be started within 6 weeks after surgery for the best results.
Carcinoma, Squamous Cell↗
Experience with the modified hockey stick incision for block dissection of neck.
BACKGROUND: The modified hockey stick incision was originally described by Lahey in 1940. This allows elevation of a superiorly based cervical skin flap, with additional exposure of the parotid as necessary. METHODS: The longitudinal portion of the incision runs from the mastoid process downward, behind the anterior border of the trapezius muscle, and curves gently at the junction of the lateral one-third and medial two-thirds of the clavicle. The transverse component extends medially, approximately 2 cm below the clavicle. When parotidectomy is required, incision is extended in front of the ear and a forward cut is made for additional exposure. RESULTS: We present our experience with a series of 16 patients, undergoing a total of 17 neck dissections for various pathologies. The majority (11 patients) received postoperative radiotherapy. There were two episodes of minor skin necrosis which were not related to radiotherapy, but to patient co-morbidity, and settled with conservative management. All patients had a satisfactory cosmetic result. CONCLUSION: We find the modified hockey stick incision to be cosmetically superior and provide excellent exposure of the neck, with protection of the carotid vessels.
Aged↗
Preservation of the accessory nerve in block dissection of the neck.
The signs and symptoms resulting from division of the accessory nerve are discussed. The anatomical arguments for conservative neck dissection are also described. A method of preserving the nerve during radical neck dissection is described. A comparison of the symptomatology and functional results of two groups of patients follows, one group having had preservation and the other having had conventional neck dissection. It was shown that the group with conservative neck dissection had no symptomatic or functional abnormalities.
Accessory Nerve↗
Cervical nodal metastasis of squamous cell carcinoma of unknown origin: indications for withholding radiation therapy.
The records of patients with pathologically confirmed metastatic squamous cell carcinoma involving cervical lymph nodes who were treated at the Mayo Clinic between January 1965 and December 1987 were reviewed. In 117 patients a primary tumor could not be discovered. Of these, 24 patients underwent curative resection of all gross disease by neck dissection or excisional biopsy. All 24 patients presented with unilateral adenopathy. Their median age was 63 years. Eighteen patients were men. Fourteen patients were in clinical stage N1; six, N2a; three, N2b; and one, N3. Six patients had grade 1 or 2 nodal metastases; 14, grade 3; and 4, grade 4. Gross or microscopic evidence of extracapsular tumor extension was noted in eight patients. All patients were followed until death or for a median of 8.5 years (range, 3.3-20.4 years). A squamous cell carcinoma of the upper aerodigestive tract subsequently developed in only one patient (4%) within 5 years of operation. In six patients (25%), a recurrence developed in the dissected neck a median of 3 months (2.4 months-6.6 years) after operation. Five of these patients had extracapsular extension, and four had pathologic Stage N2a or higher neck disease. Both patients with pathologic Stage N1 disease who had recurrences in the dissected neck had extracapsular extension. Delayed, contralateral neck metastases in an undissected neck developed in two patients. The 5-year overall and cause-specific survivals for all 24 patients were 66% and 74%, respectively. Extracapsular extension was a predictor of neck recurrence, control of disease above the clavicles, cause-specific survival, and overall survival. Patients with pathologic Stage N1 neck disease with no extracapsular extension can be managed by surgery alone. Patients with pathologic Stage N2 or higher neck disease or extracapsular extension should be considered for postoperative, adjuvant radiation therapy.
Adult↗
Upper neck (level II) dissection for N0 neck supraglottic carcinoma.
OBJECTIVES: Elective neck dissection for the N0 neck in head and neck surgery is still controversial. This prospective nonrandomized study of N0 supraglottic carcinoma was designed to find an appropriate method of neck management. STUDY DESIGN: Anatomical studies show that the first echelon of lymphatic drainage from the supraglottic larynx is toward the upper jugular nodes (level II). An upper neck dissection (UND) was applied and all the lymph nodes were sent for frozen section. If the subclinical metastasis was found, a modified neck dissection was performed. If the nodes harbored no foci of cancer, the patients were observed after surgery on the supraglottic lesions. METHODS: Patient records of 142 patients with supraglottic laryngeal cancer (T1-4N0M0) were reviewed, with special attention paid to neck recurrences and survival rates. The cases were treated between 1976 and 1990 and all were observed for at least 5 years after the operation or until the time of death. RESULTS: The UND specimens of 142 patients were negative for metastasis. The 5-year survival rate for this group after surgery was 80.8%, according to the life table analysis. Fifteen of the 142 patients (10.6%) had neck recurrences during the period of observation within 5 years. The recurrence rate of this series with limited dissection on the neck was comparable with those reported in the literature after neck dissection, either radical or modified. CONCLUSIONS: There is no need for a comprehensive neck dissection for N0 supraglottic laryngeal cancer. A selective neck dissection such as UND (level II) or a supraomohyoid neck dissection (sparing the submandibular region) of level II and III will serve the purpose of radical neck treatment for the supraglottic cancer.
Adult↗
Clinical prognostic factors in malignant parotid gland tumors.
OBJECTIVE: To analyze the factors in parotid malignant epithelial tumors influencing recurrences and disease-specific survival. METHODS: We retrospectively reviewed the files of 150 patients treated at our institution, from 1974 to 1998. Twenty-four patients were not treated by surgery and were excluded from this study. The remaining 126 patients were treated with surgery and 74 patients had postoperative radiotherapy. Thirty-three patients were treated with parotidectomy plus neck dissection. Neck lymph node metastasis was found in 22 patients, 5 patients had occult neck metastasis, and 4 periparotid lymph nodes metastasis. The mean age was 49 years old. According to the UICC/1997 TNM Classification, 49 patients were stage I, 27 stage II, 22 stage III, and 28 stage IV. The influence of selected factors on the 10 year disease-specific survival was analyzed using the Kaplan-Meier actuarial method and the log-rank test. RESULTS: Forty patients had mucoepidermoid carcinoma, 18 patients adenocarcinoma NOS, 18 patients acinic cell carcinoma, 15 patients adenoid cystic carcinoma, 11 patients malignant mixed tumor, 11 patients salivary duct carcinoma, and 13 patients other pathology. Twenty-five patients had recurrences: 17 had local recurrences, 4 patients had neck recurrences, and 4 were loco-regional recurrences. Five factors influenced negatively the prognosis: 1) T stage (p.00001), 2) grade (p.00001), 3) + lymph nodes (p.0007), 4) facial nerve dysfunction (p.0001), and 5) age (p.004). Patients with high-grade tumors and high-stage tumors had the worst prognosis according to the multivariate analysis. The 10-year disease-specific survival was 97% for stage I, 81% for stage II, 56% for stage III, and 20% for stage IV. CONCLUSION: The grade of the tumor and stage were the most important prognostic factor. EBM RATING: C.
Adenocarcinoma↗
End results of 114 extended "commando" operations for retromolar trigone carcinoma.
Retromolar trigone carcinomas invade the mandible and the pterygoid and/or masseter muscles in a large number of cases. There is also a significant risk of ipsilateral lymph node neck metastasis. The purpose of this retrospective study was to report the survival results of 114 consecutive patients who underwent an extended "commando" operation (retromolar operation) from 1960 to 1991. The technique is a variation of a composite resection. The operation consists of hemimandibulectomy with resection of the pterygoid and masseter muscles, with an ipsilateral neck dissection (radical classical, modified, or supraomohyoid). The oral cavity and oropharyngeal defects were closed primarily in 83 patients. In the remaining 31 patients (27.2%), it was reconstructed by a tongue flap (12 patients), pectoralis major myocutaneous flap (10 patients), and other flaps (9 patients). There were 104 men and 10 women, with a median age of 55 years. All patients had squamous cell carcinoma. Tumor stages were T1 (5 patients), T2 (44 patients), T3 (24 patients), T4 (28 patients), and Tx (13 patients). The metastases were predominantly in levels I and II. Only patients with positive nodes at levels I and/or II had histologically positive nodes at levels IV or V. Complications occurred in 51.8% of the patients (wound infection in 21 patients, 18.4%). Sixty-six patients underwent postoperative irradiation (4 to 70 Gy, median: 50 Gy). To date, 41 patients have presented with 50 tumor recurrences: 31 local, 9 in the dissected neck, 3 in the contralateral neck, and 7 distant. The 5-year actuarial overall survival rate was 80.0% in patients with T1 tumors, 57.8% in those with T2 tumors, 46.5% in those with T3 tumors, and 65.2% in those with T4 tumors. In conclusion, the retromolar operation can be performed with acceptable morbidity, and it is effective (5-year overall survival rate of 55.3%). The rate of local recurrences (27.2%) suggests that radiotherapy as an adjunctive modality should be indicated in patients in whom recurrences are likely.
Adult↗
Palpation compared with ultrasound in the assessment of malignant cervical lymph nodes.
This prospective study compares the results of pre-operative clinical examination and simple ultrasound examination of the neck in 18 patients with proven head and neck primary tumours and palpable cervical lymphadenopathy, who then underwent 21 radical neck dissections. Neck palpation and ultrasound examination were compared with histological examination. Ultrasound did not add significantly to the information obtainable by simple neck palpation in this group of patients.
Carcinoma, Squamous Cell↗
Lymph node dissection for head and neck cancer.
A retrospective analysis of 141 neck dissections performed at the Royal Melbourne Hospital from 1975 to 1981 has been carried out with a view to identifying the prognostic factors. When a neck dissection is performed, the site of the primary disease did not affect the 5 year survival rate. A conservation neck dissection, especially when performed electively, had the best prognosis. Radiotherapy did not affect the overall survival rate in patients having a neck dissection, while chemotherapy appeared to exert a beneficial effect on patients with advanced disease. While clinical nodal staging was an important prognostic indicator, the number of nodes pathologically involved was not. Histologic differentiation of the tumour was not prognostically significant, whereas extracapsular nodal disease was. Most (70%) treatment failures occurred in the neck, while systemic metastases occurred in 12% of patients.
Adult↗
Diagnosis and management of esthesioneuroblastoma.
Esthesioneuroblastoma is an uncommon malignant neoplasm of the nasal vault that in the past was considered benign or low-grade malignant. Surgical approaches in the main were transnasal, with a high recurrence rate and ultimate patient death. With the modern imaging of CT and MRI, should the patient be willing and fit enough, esthesioneuroblastoma currently should be approached using a craniofacial resection. Large tumors should be considered for preoperative chemotherapy and postoperative radiotherapy. Local tumor recurrence is not uncommon and is generally related to the attention to local anatomic dissection. Neck metastases, when they present, should be excised using a modified neck dissection. Distant metastases may present at any time during the course of the disease, generally within 36 months, and may respond to local radiotherapy or systemic chemotherapy. Five-year survival currently appears to be optimized by surgery followed by postoperative radiotherapy and is approximately 65%.
Antineoplastic Combined Chemotherapy Protocols↗
[Management option for cervical metastases in tongue squamous cell carcinoma with clinically N0 neck].
OBJECTIVE: This study was designed to explore the optimal management option for cervical metastases in tongue squamous cell carcinoma (SCC) with clinically N0 neck in order to avoid excessive or inadequate treatment in clinical practice. METHODS: Clinical data of 327 cases of tongue SCC with cN0 neck were retrospectively analyzed. Neck control rates affected by different pathoclinical parameters were compared. Prognosis analysis and death analysis were also performed. RESULTS: Overall 3-year survival was 69.7% (228/327), 3-year survival of neck recurrent group and non-recurrent group was 39.1% (25/64) and 77.2% (203/263), and 51.5% (51/99) of the death related to neck failure. Overall neck control rate was 80.4% (263/327); neck control rate of wait and watch group, level I neck dissection, level I + II neck dissection, supraomohyoid neck dissection, radical neck dissection, functional neck dissection, was 67.5% (27/40), 72.7% (24/33), 60.0% (15/25), 84.9% (45/55), 86.8% (131/151), 84.0% (21/25), respectively. Treatment modality and cervical lymph node involvement were independent factors for neck control. CONCLUSIONS: Neck control is a key for prognosis of tongue SCC with cN0 neck. Supraomohyoid neck dissection is the first choice in management of cervical metastases in tongue SCC with cN0 neck, during which the suspected involved lymph nodes should be sent for frozen section to determine whether comprehensive neck dissection required. Multimodal metastasis and/or capsular spread are the indications for postoperative irradiation.
Adult↗
Management of patients with squamous cell carcinoma of the lower lip and N0-neck.
AIM: For lower lip carcinoma, an incidence of 15% of cervical lymph node metastasis at presentation is generally accepted. This is an argument in favour of an expectant approach. The purpose of this study was to compare the results of the different approaches to the clinically negative neck: prophylactic neck dissection, prophylactic neck irradiation and follow-up. MATERIAL AND METHOD: The retrospective study included 200 patients with lower lip carcinoma. The following data were evaluated: (1) the incidence of cervical lymph node metastasis in patients with a clinically negative neck; and (2) pathological confirmation of cervical lymph node metastasis. RESULTS: In the group undergoing prophylactic neck dissection, lymph node metastasis was found microscopically in 20% of the cases. More than half of the patients receiving prophylactic radiotherapy developed bulky neck lymph node metastases. Out of the patients attending the 2-year follow-up 64% developed a clinically positive neck. Cervical lymph node metastases in these patients was proven microscopically in 88% of cases. CONCLUSION: The high incidence of a clinically positive neck, along with the high incidence of neck node metastasis found in neck dissection specimens suggest that elective neck dissection is the treatment of choice for the neck in patients with lower lip carcinoma.
Carcinoma, Squamous Cell↗
Relevance of skip metastases for squamous cell carcinoma of the oral tongue and the floor of the mouth.
OBJECTIVE: To analyze the therapeutic implications of the distribution of neck metastases (NM) in patients with squamous cell carcinoma (SCC) of the tongue and the floor of the mouth (FOM). PATIENTS AND METHODS: From January 1987 through December 1997, 339 previously untreated patients with T1-2 N0 M0 SCC of the tongue and the FOM underwent primary surgical treatment in our institution. A retrospective review of the pathology reports and outcome of these patients was made to ascertain the prevalence and distribution of NM. Patients were grouped by clinical neck status at the time of neck dissection: elective neck dissection (END) in the NO neck and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+ or regional recurrences after END. All patients were classified according to the American Joint Committee on Cancer (AJCC)/UICC 2002 TNM classification. RESULTS: All patients underwent surgical treatment of the primary cancer and had negative margins at frozen section. Overall incidence of NM was 41.3%. Twenty-seven point eight percent of T1 N0 M0 and 48.2% of T2 N0 M0 patients developed NM (P = .0004). Occult neck metastases occurred in 24.1% of patients. Clinically, N+ metastases occurred in 23.6% of patients. The overall incidence of NM in levels IV and V was 8.5%. Neck level IV nodes were involved in only 1.5% of patients in the END group versus 23.7% in the STD group (P < 0.001). Level V was always associated to nodal metastases in other neck levels. Only 2% of patients in our study presented "skip metastases" in the neck. CONCLUSIONS: Neck levels I and II were at great risk for the development of NM (46.9% and 75.3% respectively). Levels IV (6.5%) and V (2%) were rarely involved in our group of patients. The results found in this study support the indication of supraomohyoid neck dissection for N0 and a more comprehensive neck dissection (levels I-V) for N+ patients in Stage I-II SCC of the tongue and FOM. EBM RATING: C-4.
Carcinoma, Squamous Cell↗
A technique for radical dissection of the neck.
Modifications in the technique for the performance of standard radical neck dissection have been used for the past 12 years at this institute. The use of transverse skin incisions, removal of the platysma muscle and proceedings from a posterior to anterior direction are stressed in this procedure. Primary healing, reconstruction and cosmesis have been quite good, and local recurrences have been minimal. The five year survival rates for each type of cancer of the head and neck are comparable with those obtained at other cancer referral centers.
Head and Neck Neoplasms↗