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PubMed2001

The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck.

BACKGROUND: Sentinel lymph node (SLN) biopsy originally was described as a means of identifying lymph node metastases in malignant melanoma and breast carcinoma. The use of SLN biopsy in patients with oral and oropharyngeal squamous cell carcinoma and clinically N0 necks was investigated to determine whether the pathology of the SLN reflected that of the neck. METHODS: Patients undergoing elective neck dissections for head and neck squamous cell carcinoma accessible to injection were enrolled into our study. Sentinel lymph node biopsy was performed after blue dye and radiocolloid injection. Preoperative lymphoscintigraphy and the perioperative use of a gamma probe identified radioactive SLNs; visualization of blue stained lymphatics identified blue SLNs. A neck dissection completed the surgical procedure, and the pathology of the SLN was compared with that of the remaining neck dissection. RESULTS: Sentinel lymph node biopsy was performed on 40 cases with clinically N0 necks. Twenty were pathologically clear of tumor and 20 contained subclinical metastases. SLNs were found in 17 necks with pathologic disease and contained metastases in 16. The sentinel lymph node was the only lymph node containing tumor in 12 of 16. CONCLUSIONS: The SLN, in head and neck carcinomas accessible to injection without anesthesia, is an accurate reflector of the status of the regional lymph nodes, when found in patients with early tumors. Sentinel lymph nodes may be found in clinically unpredictable sites, and SLN biopsy may aid in identifying the clinically N0 patient with early lymph node disease. If SLNs cannot be located in the neck, an elective lymph node dissection should be considered.

Adult↗
PubMed1999

Recurrent cutaneous melanoma of the head and neck.

INTRODUCTION: Recurrent cutaneous melanoma is generally regarded as having an extremely poor prognosis, particularly when regional lymph nodes are involved. A few reports have documented long-term survival among those patients treated for regionally recurrent melanoma. METHODS: This article reviews patients at our institution undergoing complete neck dissection for recurrent head and neck melanoma. RESULTS: Twenty-six patients with locoregionally recurrent cutaneous melanoma of the head and neck underwent complete neck dissection with or without parotidectomy. Seventeen of these procedures were for clinically evident cervical lymphadenopathy, whereas 9 of the neck dissections were done electively. Fourteen of the 17 patients with clinical adenopathy were confirmed to have cervical lymph node metastases. Two of the 9 patients who underwent elective neck dissections had pathologic lymph nodes. At 5 years, 38% of the patients with isolated neck recurrences not also having concurrent primary site recurrence were alive without disease. CONCLUSIONS: These results provide further evidence suggesting a benefit in the form of long-term survival or cure for patients receiving aggressive surgical treatment for resectable recurrent head and neck melanoma involving cervical lymphatics in the absence of distant metastases.

Disease-Free Survival↗
PubMed1997

The relationship of cervical lymph node metastases to primary sites of carcinoma of the upper aerodigestive tract: a pathological study.

BACKGROUND: Therapeutic and elective dissection of the neck is accepted management in the treatment of squamous cell carcinoma (SCC) of the upper aerodigestive tract (UADT). Accurate histological assessment of the levels of involvement of cervical metastatic spread from different sites within the UADT has allowed the increasing use of less than radical procedures, with associated reduced morbidity. METHODS: A total of 168 necks in 126 patients were examined pathologically. All levels were identified at surgery, marked and oriented by pinning the specimen to a cork board, and examined histologically. A total of 114 necks had a comprehensive neck dissection (CND) in which all levels were dissected. The number and level of involvement and the occult rate (114 necks) for each primary site was assessed. Of the total of 168 necks, 80 had pathologically involved nodes, and the number with greater than one node involved (N2b) was compared for each primary site. The number with extracapsular spread for each nodal staging was also examined. RESULTS: The sites of primary SCC were the oral cavity, oropharynx, hypopharynx, supraglottic and glottic larynx. In those patients with a primary in the oral cavity, no patient had level 5 involvement, but in two patients (7%) level 4 was involved. In the oropharynx, level 1 and 5 were involved in two patients (11%) each. In the hypopharynx, level 1 was not involved in any patient, however, level 5 contained metastasis in 7 (23%). In the supraglottic larynx, level 1 was involved in one (4%) patient and level 5 was involved in three (11%). In the glottis only one patient had bilateral multiple nodes which included level 5. In no case was level 5 involved without positive nodes in other levels. The occult rate for each primary site was 45%, 22%, 77%, 54% and 29%, respectively. The multiple node rate in the 80 necks with positive nodes was, respectively, 31%, 54%, 66%, 45% and 40%. All patients with a node larger than 3 cm had extracapsular spread of tumour. CONCLUSIONS: The level of nodal involvement and therefore the type of neck dissection should be determined by the site of the primary within the UADT and the presence or absence of nodes at surgery. There is a high number (39-66%) of pathologically involved necks which have multiple nodes and also nodes with extracapsular spread of tumour, which may influence the decision for postoperative radiotherapy.

Adult↗
PubMed1996

[Evaluation of results from radiotherapy and combined treatment of laryngeal cancer (surgery and radiotherapy) considering differentiation of procedures with respect to lymph nodes in the neck].

The aim of the work was to estimate the therapeutic results in patients with laryngeal cancer treated by combined method (surgery and radiotherapy) and radiotherapy alone. In the group of patients treated by combined method the randomised clinical study, concerning regional lymph nodes arrangement, has been performed (Tab. 5). The control group of patients was treated, as before, by radical neck dissection (RND), or modified neck dissection (MND), or regional modified neck dissection (RMND), depending on the advancement of the tumor and lymph nodes involvement, combined with moderate postoperative dose of irradiation (5000-5500 cGy). Adversely, the study group was subjected to more conservative surgery, namely MND, or RMND, or LAC (lymphadenectomy) combined with postoperative, slightly higher, dose of irradiation (5500-6000 cGy) (Tab. 6). Clinical material of 213 patients, treated between 1986-1990 at the Laryngology Department and Radiotherapy Department of Pomeranian Medical Academy, has been analysed. There were 84 patients in the study group, 68 in the control group, and 61 in exclusively irradiated group. The patients treated only surgically as well as those irradiated palliatively were excluded. The best results of treatment have been obtained in the study group (3-year survival 78%, and 5-year survival 69%), worse in the control group (3-year survival 62%, and 5-year survival 51%) and the worst in the exclusively irradiated group (3-year 51%, and 5-year 44%) (Fig. 4). The most frequent cause of failure was local and loco regional relapse. The acute and late radiation morbidity, according to RTOG/EORTC classification, has been also analysed. In the majority of patients only slight and moderate (1 and 2 grade), in some patients 3 grade, and in 2 patients 4 grade morbidity has been observed.

Adult↗
PubMed2004

Management of the neck in patients with T1 and T2 cancer in the mouth.

UNLABELLED: Our aim in this retrospective study was to evaluate the extent of control of metastatic disease in the neck and the survival of patients with T1 and T2 oral cancer. METHODS: All 171 patients with T1 and T2 squamous cell carcinoma (SCC) in the mouth were identified from our computerised database. All had had primary tumours resected and 21 patients with palpable neck nodes had therapeutic neck dissections. Among 150 patients with no palpable nodes, 75 had elective neck dissections, and 75 were observed. The decision to do an elective neck dissection was based on clinical criteria and was not randomised. RESULTS: Cervical nodes contained metastases in 17 of 21 patients who had therapeutic, and 27 of 75 who had elective, neck dissections. Neck metastases developed subsequently in 15 of 75 patients in the observed group, and 9 of these were salvaged by therapeutic neck dissection. The 5-year disease free survival was 19/21 after therapeutic dissection, 72/75 after elective dissection, and 69/75 in the observed group. Patients with cervical nodal metastases had significantly reduced 5-year survival compared with those without (63% and 91%, P = 0.003).

Adult↗
PubMed2000

[Management of the neck for patients with thyroid papillary carcinoma].

OBJECTIVE: To search an optimal management of the neck for patients with thyroid papillary carcinoma. METHODS: Clinical data of 424 cases with thyroid papillary carcinoma treated in our hospital from Jan, 1965 to Jan, 1987 were analyzed retrospectively. Patients with positive cervical lymph nodes (N+) were treated with radical excision of the primary tumor and neck dissection. For patients without cervical lymph node involvement (N0), neck dissection was spared. On follow-up, whenever cervical lymphatic node metastasis occurred, neck dissection was performed. All patients were followed up for more than 10 years. RESULTS: The 5- and 10-year survival rate of the 258 N+ patients was 84.3% and 80.4% respectively, and that of the 166 N0 patients was 94.1% and 91.3% respectively. Twenty-three N0 cases later developed cervical lymph node metastasis. Their 5- and 10-year survival rate was 91.4% and 82.2% respectively after neck dissection. CONCLUSION: Since only 13.9% of N0 thyroid papillary carcinoma patients who did not receive neck dissection develop cervical lymph node metastases later, and their survival rate was just as good where neck dissection is postponed until metastases occur, prophylactic neck dissection seems unnecessary.

Adolescent↗
PubMed2000

Is there a role for sentinel node biopsy in early N0 tongue tumors?

BACKGROUND: Detecting metastases to the cervical lymph nodes is the main problem in the management of squamous cell carcinoma of the tongue. We investigated the ability of sentinel node (SN) biopsy to predict neck status in 11 patients with lateral T1-T2, N0, and M0 squamous cell carcinoma of the tongue who underwent ipsilateral neck dissection 30 to 40 days after primary surgery. METHODS: In 5 patients, technetium 99m-labeled particles were injected close to the operation scar on the day before neck dissection, and the labeled neck nodes were revealed by lymphoscintigraphy. The next 6 patients underwent lymphoscintigraphy both before surgery and before neck dissection. During neck dissection, the ipsilateral SNs were identified by using a hand-held probe and removed separately. RESULTS: Three patients (27%) had metastatic neck nodes. In all cases, labeled nodes were revealed by scintigraphy. Ipsilateral SNs were removed from 8 patients and correctly predicted the state of the neck (6 negatives and 2 positives). Lymphoscintigraphy before and after surgery revealed that drainage was modified after surgery in 5 of 6 patients; the pre-surgery drainage pattern varied markedly among the 5 pN0 patients. CONCLUSIONS: The technique allows easy and safe identification of SNs and shows promise in guiding selective neck dissection. Surgery on the primary tumor often modifies lymphatic drainage, so that SN biopsy may only be useful if the primary operation and neck dissection are performed at the same time.

Adult↗
PubMedDate not supplied

[Elective dissection in cancer of the larynx].

OBJECTIVE: 1) To determine if elective neck dissection (END) is more effective than surgery without END in patients with cancer and a clinically negative neck (N0). 2) To determine if selective posterolateral neck dissection is effective in these patients. PATIENTS AND METHODS: The study included 74 patients with laryngeal cancer and no palpable nodes who were treated surgically at the ENT Department of the Universidad Complutense de Madrid between 1994 and 1997. Thirty-seven patients underwent surgery alone (Group A) and 37 patients underwent laryngeal surgery and elective neck dissection (Group B). No patient underwent irradiation. Minimum follow-up was 24 months. RESULTS: Cervical recurrence was observed in 4 (11%) patients who underwent laryngeal surgery alone and in 2 (5%) patients who underwent laryngeal surgery and elective neck dissection. CONCLUSIONS: Laryngeal surgery with elective neck dissection was more effective than laryngeal surgery without END in patients with laryngeal cancer and a clinically negative neck. Selective lateral neck dissection was effective for the elective treatment of these patients.

Adult↗
PubMed1991

The submandibular triangle in squamous cell carcinoma of the larynx and hypopharynx.

A 15-year retrospective analysis was carried out at the University of Illinois College of Medicine, Chicago, reviewing the tumor staging and pathology data of 239 patients treated for carcinoma of the larynx and hypopharynx requiring laryngectomy alone, laryngectomy with neck dissection, or laryngopharyngectomy and neck dissection. Surgery was the primary treatment modality in 205 of the 239 cases, with the remaining 34 having surgery to treat radiation therapy failure. Primary tumors were located within the supraglottic region, the glottic region and, less commonly, the pyriform sinus. Ninety-five of the 239 patients either presented with or developed nodal metastases following initial treatment. Of these, only two had tumors within the lymph nodes of the submandibular triangle. This data corroborates impressions that tumors of the larynx and hypopharynx rarely metastasize to the submandibular triangle and that sparing this area during neck dissection for lesions of the larynx would seem justified.

Carcinoma, Squamous Cell↗
PubMed1999

Salvage treatment for neck recurrence after irradiation alone for head and neck squamous cell carcinoma with clinically positive neck nodes.

BACKGROUND: To analyze the likelihood of salvage for patients with recurrence in the neck after radiotherapy. METHOD: Recurrent disease developed in the neck of 51 patients after primary irradiation for head and neck carcinoma. Salvage was defined as no recurrence of cancer anywhere for at least 1 year after initial salvage treatment and continuously thereafter. RESULTS: Thirty-three patients (65%) did not undergo a salvage attempt: 18 had unresectable disease; 9 were medically unfit, 4 had distant metastasis; and 2 refused treatment. Eighteen patients (35%) underwent salvage treatment with chemotherapy alone (4 patients), chemotherapy and neck dissection (1 patient), neck dissection alone (11 patients), or surgery with radiotherapy (2 patients). After the initial salvage treatment, recurrent local-regional and/or distant disease developed in all patients. Recurrence was in the neck alone in 10 patients (55%); neck and distant sites in 3 patients (17%); neck, primary site, and distant sites in 2 patients (11%); and with distant metastasis alone in 3 patients (17%). Control of neck disease at 5 years was 9% for the 18 patients who underwent a salvage attempt, as well as for all 51 patients. For the overall group, absolute and cause-specific survival rates were both 10% at 5 years. CONCLUSIONS: The likelihood of successful salvage treatment after a neck recurrence following radiotherapy is remote.

Adult↗
PubMed1985

Considering the spinal accessory nerve in head and neck surgery.

Loss of trapezius muscle function represents the single most important source of long-term morbidity from a radical neck dissection. Its preservation has been one of the central features of the conservative or modified neck dissection. We recently undertook an evaluation of 100 consecutive patients who had undergone composite resection for head and neck cancer and examined them with particular emphasis on the function of the trapezius muscle. The mean interval from the time of radical neck dissection to the time of this evaluation was 6.2 years. The operations included radical neck dissection with sacrifice of the spinal accessory nerve, radical neck dissection with preservation of the spinal accessory nerve, and radical neck dissection with interpositioned cable graft reconstruction. The survey showed that 67 percent of the patients who underwent radical neck dissection with sacrifice of the spinal accessory nerve, although they showed profound atrophy of the trapezius muscle, had few symptoms related to this deficit. Similarly, 47 percent of patients who underwent radical neck dissection with preservation of the spinal accessory nerve showed some signs of muscle atrophy, and 20 percent showed little or no function of the muscle. Interpositioned nerve grafts appeared to function well in 66 percent of the patients. The survey showed that a surprising number of patients treated with a standard radical neck dissection and sacrifice of the spinal accessory nerve had few postoperative symptoms related to the loss of trapezius muscle function. Also unexpected was the number of patients with signs of muscle dysfunction despite nerve preservation.

Accessory Nerve↗
PubMed1994

[Incidence and distribution of lymph node metastases in supraglottic squamous cell carcinoma: therapeutic implications].

This retrospective study was designed to establish some guidelines for the treatment of the neck in the case of supraglottic cancer. The patient population included a series of 264 patients, from 39 to 76 years old (mean age 58.3), who had undergone monolateral (76) or bilateral (188) neck dissection for a total of 452 neck dissections. The distribution of the patients, according to pT category, was the following: 17 T1 (6.4%), 88 T2 (33.3%), 107 T3 (40.5%) and 52 T4 (19.7%). In 121 patients the tumor was central (45.8%), whereas in 143 (54.2%) the neoplasm did not extend beyond the midline and was therefore defined as lateralized. The overall incidence of lymph node metastases was 43.4% (39 N1, 32 N2b, 28 N2c), and the rate of occult metastases was 24.7%. The distribution of metastases according to pT category was as follows: 6.2% T1, 30.7% T2, 38.3% T3 and 57.7% T4 (p < 0.001). Occult metastases distribution was: 0% T1, 19.6% T2, 26.7% T3 and 44.4% T4 (0.001 < p < 0.01). The incidence of bilateral metastases was significantly different (p < 0.001) in central (45.8%) and lateralized tumors (7.8%). The distribution of metastases according to level was 0.8% I, 82.4% II, 35.2% III, 13.6% IV and 0% V (p < 0.001). When level I or IV was involved, lymph node metastases were also present in level II and/or III. These results suggest that contralateral elective neck dissection is not required in lateralized tumors and elective neck dissection is not indicated in T1 lesions. Since no occult metastases were detected in level I or V, the management of choice for the clinically negative neck might well be a selective dissection limited to levels II, III and IV ("lateral neck dissection"). Levels I and V should be dissected only when metastatic nodes are found.

Adult↗
PubMedDate not supplied

Patterns of cervical node metastases from squamous carcinoma of the oropharynx and hypopharynx.

A retrospective review of 333 previously untreated patients from 1965 to 1986, with primary squamous cell carcinoma of the oropharynx or hypopharynx, was undertaken to ascertain the prevalence of neck node metastases by neck level. The 333 patients underwent 344 classical radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection in the N0 neck (N = 71), and immediate therapeutic dissection in the N+ neck (N = 259). Detailed analysis was performed for each group based on the specific primary site. This revealed a predominance of neck node metastases in levels II, III, and IV for both oropharyngeal and hypopharyngeal primaries. Isolated "skip" metastases outside of levels II, III, or IV occurred in only 1 patient (0.3%). Otherwise, level I or V involvement was always associated with nodal metastases at other levels (ie, N2 disease). These data support the trend toward selective limited neck dissection (anterior modified) in N0 patients. Furthermore, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection for carcinomas of the oropharynx or hypopharynx.

Adolescent↗
PubMed1988

Differentiated thyroid cancer: a stage adapted approach to the treatment of regional lymph node metastases.

The controversy in the management of regional lymph nodes in patients with differentiated thyroid cancer is discussed on the basis of a review of the literature. Since no prospective studies have yet compared limited dissections ('node picking') with more extensive dissections [(modified) radical neck dissection], a retrospective analysis was performed using two patient groups in which patients were managed differently with regard to the preoperative diagnosis and treatment of regional lymph node metastases. Only patients with proven lymph node metastases were included in the study. Because of selection methods necessary to create comparable patient groups, only 83 patients could be included in the analysis. There was no difference in survival or recurrence rate in either group, although recurrences occurred less frequently in the explored side of the neck after MRND (3.9% vs. 6.3%). More postoperative morbidity was found in the patients who had been subjected to a more extensive search for and treatment of lymph node metastases. Because of the relatively small number of patients only the difference in occurrence of accessory nerve palsies reached statistical significance (P = 0.05). It is advocated that only in the case of papillary carcinoma with limited lymph node involvement node picking is the procedure of choice. In all other cases a modified radical neck dissection should be standard treatment.

Female↗
PubMed1977

Surgical technique--the strap muscle flap.

The authors describe the use of the infrahyoid ("strap") muscles as a muscle transposition flap to obliterate the "dead space" created during resection of the anterior floor of the mouth for carcinoma concomitant with suprahyoid neck dissection or radical neck dissection. The flap is particularly useful if the mandible is partially resected and immediately stabilized with a steel pin or bolt.

Humans↗
PubMed2001

[Preservative surgery of medial wall pyriform sinus cancer].

OBJECTIVE: To study the surgical methods and functional outcome of preservative surgery for medial wall pyriform sinus cancer. METHODS: Seventy-one patients with medial wall pyriform sinus cancer, who were treated surgically between 1985 and 1997, were reviewed. Of the 71 cases, 49 underwent preservative surgery, and 22 total laryngectomy. Preservative surgical procedure was defined as follows: 1. Extent of resection: Supraglottic horizontal partial laryngectomy and resection of medial wall of pyriform sinus were performed in patients without fixation of the true vocal cord, and the section extended to paraglottic space, partial lateral wall of pyriform sinus, preepigottic space, superior-posterior of thyroid cartilage in those with restrained vocal cord motility. Supracricoid hemilaryngopharyngectomy and resection of medical wall and partial lateral wall of pyriform sinus were practiced in those with fixed hemilarynx. Cricoid ring and cervical esophagus were removed partially if the pyriform sinus apex was involved. 2. Reconstruction: Larynx: the remains of epiglottis, perichondrium of thyroid cartilage, the infrahyoid muscular fascia, and the platysmal flap were utilized to restore the defects of larynx. Pyriform sinus: Suturing the remaining pharyngeal mucosa directly to cover the wound if the defect was relatively small. For the large defect produced by extended resections, the pectoralis major myocutaneous flap and deltopectoral flap were used. 3. Surgical treatment of cervical lymphaden: Sixty five out of the 71 cases (91.5%) underwent neck dissection. Of which ipsilateral neck dissection were done in 39 cases, and bilateral neck dissection in 26 cases. 4. All patients received postoperative radiotherapy with doses of 60-75 Gy. RESULTS: In the group of preservative surgery the 3- and 5-year survival rates were 63.4% and 49.6% respectively, whereas those in the total laryngectomy group were 52.4% and 42.4% respectively. Of the 49 cases with preservative surgery, 71.4% (35/49) had all laryngeal functions restored and 28.6% (14/49) partially restored. CONCLUSION: Despite the fact that the medial wall pyriform sinus cancer tends to have laryngeal invasion, preservative surgery can be practiced for the majority of the cases with the lesions entirely removed.

Adult↗
PubMed1983

Carcinoma of the mobile tongue: incidence of cervical metastases in early lesions related to method of primary treatment.

One hundred thirty-eight patients receiving initial treatment for squamous cell carcinoma of the mobile tongue from 1960 to 1978 were reviewed to determine the frequency of cervical metastasis in early carcinoma (T1N0 and T2N0). Occult cervical node metastasis in an elective neck dissection or subsequent neck recurrence in an initially negative neck was found in 14.5% (9/62) of patients staged T1N0 and 30.6% (11/36) of patients staged T2N0. Refinement of the staging system demonstrated that 9.7% (3/31) of patients with a primary lesion less than or equal to 1.0 cm and a clinically negative neck (T1aN0) subsequently developed a cervical metastasis. Patients with primary lesions greater than 1.0 cm but less than or equal to 2.0 cm (T1bN0) had twice the risk of occult cervical metastasis (19.4% or 6/31). The crude 5-year survivals in Stage I for radium alone, partial glossectomy, and partial glossectomy with neck dissection were 64%, 58% and 75% respectively and in Stage II were 31%, 66% and 71% respectively. Local-regional failure is the principal mechanism of failure in patients treated locally particularly in Stage II.

Adult↗
PubMed1989

Radiotherapy or surgery for subclinical cervical node metastases.

This retrospective study compared elective neck dissection with elective neck radiotherapy for the control of subclinical nodal metastases. Four hundred ninety-eight patients with head and neck primary cancers and no clinically apparent neck metastases on initial presentation comprised the study population. Each patient was followed up for at least 5 years to detect failure to control neck metastases and control of the primary tumor at the time of neck recurrence. Analysis of neck recurrences occurring in patients with control of the primary tumor showed that there was no statistically significant difference between elective radiation therapy to the neck and elective neck dissection for oral cavity, oropharyngeal, and laryngeal cancers. The only statistically significant difference was noted for hypopharyngeal cancers, with radiation therapy being more effective than surgery.

Carcinoma, Squamous Cell↗