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PubMed2004

The carotid sheath: an anatomicophathologic study.

BACKGROUND: Recurrences in the neck after neck dissections occur even in previously operated fields. Although the pathogenesis is unclear, it is well established that recurrences commonly occur at the jugular chain of nodes close to the carotid artery. We investigated the carotid sheath as possibly responsible for such regional recurrences. METHODS: Patients undergoing therapeutic or elective neck dissections were prospectively enrolled. Following surgery, the carotid sheath was resected throughout its entire length, fixated in formalin, and histologically examined. RESULTS: Pathologic assessment of carotid sheaths harvested from 34 patients who underwent 40 uncomplicated neck dissections revealed fibro-fatty tissue and scarce neutrophilic infiltration in all 40 specimens. Four lymphoid aggregates composed almost exclusively of B cells were found at the carotid bifurcation level in three patients. No cancer cells were detected. CONCLUSION: The absence of cancer cells in patients with metastatic nodes argues against the need to resect the carotid sheath as part of a routine neck dissection. The occurrence of lymphoid aggregates within it, however, may indicate its participation in the pathogenesis of nodal recurrence following neck dissection.

B-Lymphocytes↗
PubMedDate not supplied

[Painful shoulder syndrome with drooping after cervical lymphatic dissection].

A study was made of 12 patients with head and neck cancer who underwent surgical neck dissection in 1993 to evaluate quantitatively the degree of postoperative shoulder dysfunction after surgical neck dissection. Nerve conduction studies were made of the accessory nerve and the range of motion, strength and position of the shoulder were evaluated. Patients were invited to complete a questionnaire about daily living activities, shoulder pain, shoulder movement and shoulder droop. Our results showed that abnormalities can be found in shoulder and arm function after any type of neck dissection and that these are evident when the accessory nerve is damaged. Subjective questionnaire findings generally coincided with objective postoperative dysfunction.

Aged↗
PubMed2003

Extent of surgical intervention in case of N0 neck in head and neck cancer patients: an analysis of data collection of 39 hospitals.

In the discussion on the treatment of the clinical N0 neck in head and neck cancer, the sentinel lymphonodectomy is gaining more and more in significance. Prior to a multicentre study on the value of sentinel lymphonodectomy, it seemed to be desirable to collect data on the current practice of neck dissection in German ENT departments. First a standardised questionnaire was sent to 50 hospitals in Germany. It contained questions on the respective therapeutic concepts (uni- or bilateral modified radical neck dissection versus selective neck dissection, wait-and-see policy) in histologically proven squamous cell carcinoma (G2) and defined localisation of the primary tumour (T1-T2 carcinoma of the oral cavity, the oropharynx and hypopharynx as well as larynx). Summing up the evaluation of 39 anonymously answered questionnaires, it can be stated that no uniform therapeutic concept for the treatment of the cervical lymph nodes in carcinomas of the upper aerodigestive tract based on the stage of lymphatic metastatic disease exists. It seems to be essential to elaborate such a concept in order to be able to compete in the international context. Likewise, a widespread uniform therapeutic strategy would be the basic prerequisite for the initiation and realisation of multicentric therapy studies.

Aged↗
PubMed1995

Base-of-tongue carcinoma: treatment results using concomitant boost radiotherapy.

PURPOSE: To evaluate the efficacy of accelerated fractionated radiotherapy using the concomitant boost schedule for patients with squamous cell carcinoma of the base of tongue. METHODS AND MATERIALS: Between September 1984 and July 1992, 54 patients with squamous carcinoma of the base of tongue were treated at The University of Texas M. D. Anderson Cancer Center using the concomitant boost schedule. The distribution of T and N stages was T1-4, T2-27, T3-22, and T4-1; N0-9, N1-11, N2-24, N3-7, and NX-3. American Joint Committee on Cancer (AJCC) stage groupings were II-6, III-14, and IV-34. Before radiation, nodal excision and neck dissection were done in 5 and 10 patients, respectively; 5 patients had neck dissections after radiotherapy. Standard on and off spinal cord fields were irradiated with 1.8 Gy fractions to 54 Gy given over 6 weeks. The boost was given concomitantly during the large field treatment as a second daily (1.5 Gy) fraction, with an interfraction interval of 4-6 h. The median dose to the primary tumor was 72 Gy (range, 66-74 Gy). The median treatment duration was 42 days (range, 39-48 days). Only three patients had treatment interrupted for more than one scheduled treatment day. RESULTS: The 5-year actuarial overall survival and disease-specific survival rates were 59 and 65%, respectively, with a median follow-up of 41 months. The 5-year actuarial locoregional control rate was 76%. The actuarial local control rates achieved with radiotherapy at 5 years for T1, T2, and T3 primary tumors were 100%, 96%, and 67%, respectively; including surgical salvage, the local control rate of T3 primary tumors was 70%. Six patients had regional failures, which in three patients occurred in conjunction with primary tumor recurrence. Twenty-six patients with regional adenopathy were treated with radiation alone to full dose and had a complete clinical response in the neck; no planned neck dissections were performed in these patients. Only 2 of these 26 patients had subsequent regional failures. The 5-year actuarial risk of distant metastases in patients whose disease was controlled locoregionally was 21%. Grade 3 or 4 confluent acute mucositis occurred in 94% of patients. However, late complications were limited to two cases of transient mandibular exposure and three cases of self-limited mucosal ulcerations. CONCLUSION: The concomitant boost fractionation schedule is a very effective regimen for this disease when appropriately selected patients are treated with meticulous technique. The therapeutic ratio is favorable, with a high rate of disease control and no persistent severe late complications. Patients whose neck disease responds completely to treatment with this schedule do not appear to need a planned neck dissection.

Adult↗
PubMed2007

Retropharyngeal node metastasis from papillary thyroid carcinoma.

BACKGROUND: Papillary thyroid carcinomas commonly metastasize to paratracheal and jugular lymph nodes. Metastasis to the retropharyngeal node is rare for this tumor. METHODS: Five patients underwent surgical treatment for metastasis of thyroid papillary carcinoma to the retropharyngeal lymph nodes that presented as a parapharyngeal or retropharyngeal mass. All patients had a history of total or subtotal thyroidectomy as their initial treatment. Among them, 3 patients had undergone ipsilateral modified radical neck dissection at their initial treatment. The other 2 patients had a history of bilateral or ipsilateral modified neck dissection for their subsequent cervical lymph node metastases. RESULTS: Metastatic retropharyngeal nodes were successfully resected via transcervical approach in all patients. Although aspiration and difficulty in swallowing were observed in 2 patients after surgical treatment for metastatic retropharyngeal nodes, these complications spontaneously resolved within a few months. CONCLUSIONS: This study suggests that neck dissection and/or metastatic cervical lymph nodes might alter the direction of lymphatic drainage to the retrograde fashion, resulting in the unusual metastasis to the retropharyngeal lymph nodes. Although the cases described here are rare, metastasis to the retropharyngeal node should be considered at the follow-up for thyroid papillary carcinoma. Because these metastases will be missed by routine ultrasonography of the neck, periodic CT scan or MRI is recommended for follow-up, especially for patients with a history of neck dissection.

Adult↗
PubMed2004

Morbidity of the neck after head and neck cancer therapy.

BACKGROUND: Studies on morbidity of the neck after head and neck cancer therapy are scarcely described. METHODS: Patients who underwent surgery, including neck dissection, with and without radiation therapy at least 1 year before the study were asked to participate. We assessed neck pain, loss of sensation, range of motion of the cervical spine, and shoulder pain. RESULTS: Of the 220 patients who were invited, 153 (70%) participated in the study. Neck pain was present in 33% of the patients (n = 51), and shoulder pain was present in 37% of the patients (n = 57). Neuropathic pain of the neck was present in 32% (n = 49); myofascial pain, in 46% (n = 70); and joint pain, in 24% (n = 37). Loss of sensation of the neck was present in 65% (n = 99) and was related to type of neck dissection and radiation therapy. Range of motion of the neck was significantly decreased because of the neck dissection and/or radiation therapy in lateral flexion away from the operated side. CONCLUSIONS: The occurrences of morbidity of the neck after cancer therapy were considerable and consisted of neck pain, loss of sensation, and decreased range of motion.

Adult↗
PubMed1998

[Invasive carcinomas of the hypopharynx with esophageal involvement--multidisciplinary treatment concept].

In UICC stage IV hypopharnygeal cancer, a radical approach with circular laryngo-pharyngo-esophagectomy with ipsilateral radical neck dissection and contralateral modified radical neck dissection, reconstruction of the pharynx defect with a fundus-rotation-gastroplasty, and postoperative high-dose cervical radiotherapy improves long term survival and maintains a good quality of life.

Aged↗
PubMedDate not supplied

Supraglottic laryngectomy with postoperative radiation versus primary radiation in the management of supraglottic laryngeal cancer.

PURPOSE: The purpose of this review was to study the results of horizontal partial laryngectomy (HPL) for supraglottic laryngeal cancer (stages N0 and N+) and the effects and morbidity of postoperative radiation therapy (RT), especially after bilateral neck dissection, as opposed to primary RT. PATIENTS AND METHODS: Of a total of 89 patients, 26 were treated by HPL, 44 by primary RT, and 19 by total laryngectomy (TL). Of the HPL patients, 19 of 26 had neck dissection, 10 were bilateral. Twelve of the patients received postoperative RT, and 10 of 12 procedures were combined with neck dissection. RESULTS: When comparing the results of HPL and primary RT, the locoregional control was equivalent for the N0 patients, but HPL showed better results in locoregional control for the N+ patients (P < .0024). Postoperative RT with or without bilateral neck dissection did not show an increase in postoperative morbidity. CONCLUSION: Therefore, our data suggest that there should be no hesitation in giving postoperative RT where indicated, after performing HPL plus unilateral or bilateral neck dissection. Patients that are stage N0 should receive primary RT.

Humans↗
PubMed2003

Management of cervical metastases in advanced squamous cell carcinoma of the base of tongue.

OBJECTIVE: To clarify the role of neck dissection following primary radiotherapy for treatment of squamous cell carcinoma of the base of tongue. DESIGN: Case series. SETTING: Academic, tertiary care medical center. PATIENTS OR OTHER PARTICIPANTS: A consecutive series of 45 patients with biopsy-proven squamous cell carcinoma of the base of tongue and cervical metastases treated with primary radiotherapy at The University of California, San Francisco, was examined. Patients with a prior history of neck irradiation, neck dissection, or head and neck cancer within 5 years were excluded. MAIN OUTCOME MEASURES: Overall survival and regional control. RESULTS: Of the 45 patients treated with definitive radiotherapy, 25 (56%) achieved a complete response, 13 (29%) achieved a partial response, 4 (9%) were nonresponders, and 3 (7%) did not complete radiotherapy. Two thirds of the complete responders had N2 or N3 disease; 3 had recurrences in the neck, 1 of which was an isolated neck recurrence. Of the 13 partial responders, 5 had isolated persistence of disease, with 4 undergoing neck dissections. The only long-term survivors among the partial responders were those 4 who underwent a neck dissection. Overall survival was 50% at 3 years and 32% at 5 years. Regional control for complete responders was 84% at 5 years. CONCLUSIONS: The low rate of isolated regional recurrence in patients with a complete response to radiotherapy supports the practice of surveillance alone in such patients. Patients with less than a complete response appear to benefit from prompt surgical salvage.

Adult↗
PubMed1985

The influence of excisional or incisional biopsy of metastatic neck nodes on the management of head and neck cancer.

Between November 1964 and December 1981, 80 patients who had undergone an open biopsy of a cervical lymph node containing squamous cell carcinoma were treated with curative intent in the University of Florida Division of Radiation Therapy. Irradiation was the initial step in the definitive treatment of all patients, followed by neck dissection and/or primary resection, as indicated. The patients were divided into two groups. (a) NX (no gross residual neck disease) (25 patients): According to the referring surgeons' and pathologists' reports, a single, clinically positive lymph node was totally excised in 25 patients. No other clinically positive lymph nodes were appreciated upon referral. No neck dissections were added following irradiation in this group of patients. The absolute 5 year disease-free survival in the NX group was 79%, and the rate of neck disease control was 96%. (b) Gross residual neck disease (55 patients): Gross residual disease remained in the neck in 55 patients following biopsy. In some patients, only an incisional biopsy of a large mass had been performed; in others, only one of several involved nodes was removed. The absolute 5 year disease-free survival in this group of patients was 31%, and the rate of neck disease control was 64%. The more consistent addition of a neck dissection in recent years has resulted in improved neck control rates in this group: 13/20 (65%) for N1-N2 disease and 2/7 (29%) for N3A disease following irradiation alone versus 6/7 (86%) for N2 disease and 5/8 (63%) for N3A disease when a neck dissection was added following irradiation. There are some differences in the rates of neck control, control above the clavicles, survival, distant metastasis, and complications between this series and other reported series in which open neck-node biopsy preceded definitive treatment. Possible reasons for these differences are discussed.

Adolescent↗
PubMed2004

Basaloid squamous cell carcinoma of the larynx: a report of four new cases.

OBJECTIVES: This study is designed to report the clinical and pathologic features and outcome of cases of basaloid squamous cell carcinoma (BSCC) of the larynx treated in our clinic. STUDY DESIGN: A retrospective review of the medical records of these patients. METHODS: Four cases of BSCC of the larynx were treated in our department. Histopathologic slides were reevaluated to confirm the diagnosis. Immunohistochemical studies were performed, and file records were reviewed. Follow-up was available for all patients and ranged between 11 and 72 (mean 37) months. RESULTS: All patients were male (mean 57), with supraglottic or transglottic larynx tumors. Two patients presented with stage-II disease and the other 2 with stage-IV disease. Initial diagnosis was invasive squamous cell carcinoma in 3 patients and BSCC in one patient. Two patients who had stage-II disease underwent partial laryngectomy and bilateral neck dissections; total laryngectomy and bilateral neck dissections were performed in stage-IV patients. Three patients received adjuvant postoperative radiotherapy, and 2 of them also received additional chemotherapy. Patients with stage-IV disease were found to have 4 and 27 metastatic lymph nodes on histopathologic examination and died because of distant metastases at 11 and 14 months, respectively. Patients with stage-II disease did not have cervical metastasis on histopathologic examination and were alive and free of disease at 52 and 72 months respectively. CONCLUSION: In contrast with the literature reporting the tendency of more aggressive clinical behavior of the BSCC, we can say that BSCC has a behavior similar to conventional squamous cell carcinoma based on our 4 cases.

Carcinoma, Basosquamous↗
PubMed1988

[Phrenic nerve paralysis complicating cervicofacial surgery].

Radical neck dissection remains the keystone to lymph nodes control in modern Head and Neck Surgery. Like any major operation, it has inherent complications ranging from minor surgical complications such as wound infection to potentially life-threatening complications such as fistula or carotid rupture. We have observed two cases of surgical damage of the phrenic nerve following radical neck dissection. Transient or definitive phrenic nerve palsy after radical neck dissection has been previously reported. The physiopathology according to the age and the clinical implications of that rare complication are discussed.

Adult↗
PubMed1991

Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck.

A consecutive series of 111 patients treated between 1964 and 1989 with primary cutaneous malignant melanoma of the head and neck and histologically proven regional metastases was reviewed to determine the patterns of nodal metastases. The primary sites were grouped in the following categories: face (34), anterior scalp (25), anterior neck (16), posterior scalp (15), ear (11), and posterior neck (10). All patients underwent radical neck dissection: 80 of the procedures were therapeutic and 31 elective. A total of 106 specimens were positive for metastases. Thirty-three of the 57 patients undergoing parotidectomy had positive results for metastases (14 of 20 in therapeutic parotidectomies and 19 of 37 in elective parotidectomies). Based on the incidence of involvement of the parotid gland and the patterns of lymph node metastases from levels I through V, three observations are made. Patients undergoing regional lymphadenectomy for primary melanomas on the ear, face, and anterior scalp should be considered for parotidectomy. The use of selective limited neck dissection for elective regional lymphadenectomy appears justified based on the location of the primary site. In patients undergoing therapeutic neck dissection, a complete neck dissection should be performed due to the unpredictable distribution of lymph node metastases to the cervical lymph nodes.

Female↗
PubMed2004

Functional surgical approach to the level I for staging early carcinoma of the lower lip.

OBJECTIVE: The management of the neck in patients with T1-T2 carcinoma of the lower lip (LLC) remains controversial. Suprahyoid neck dissection seems a reliable diagnostic approach, although it sacrifices the submandibular gland and its vascularity. STUDY DESIGN AND SETTING: This study was a prospective, randomized study. Patients with previously untreated T1 or T2 primary LLC underwent either classical suprahyoid neck dissection (CSHD) or functional suprahyoid neck dissection (FSHD) in continuity with the resection of the cancer of the lip. RESULTS: A total of 48 suprahyoid neck dissections were performed in 36 patients. Among these dissections, 27 were CSHD and 21 were FSHD. The average number of dissected lymph nodes was similar for both classical and functional type operations. The overall follow-up period was 40.5 months. CONCLUSIONS: The end result of this series supports the idea that FSHD is a reliable diagnostic method for the management of level I lymph nodes in LLC. FSHD can avoid undertreatment or overtreatment of the patients with early LLC while preserving the submandibular gland.

Adult↗
PubMedDate not supplied

Prognostic value of sentinel node in oral cancer.

AIMS AND BACKGROUND: In stage I oral squamous cell carcinoma, clinical examination and imaging techniques are unable to identify 60-90% of patients at risk of micrometastasis, while the sentinel node biopsy technique allows to avoid the morbidity of elective neck dissection in patients not actually affected by micrometastases. MATERIALS AND METHODS: Forty-one T1-T2N0 patients underwent lymphoscintigraphy after peritumoral injection of human albumin labeled with 99Tc. Focal areas of radiotracer uptake were marked on the skin preoperatively. The sentinel lymph node (SLN) was identified by the combined use of blue dye and gamma probe and subsequently removed. Complete neck dissection was then performed in all patients and the histological findings were compared with those of SLN biopsy. RESULTS: The SLN was identified in 95% of the patients; in four cases (10%) two SLNs were isolated. In 18% of our patients the SLNs were located outside the expected drainage area. When the histology of the negative SLNs was compared with the pathological status of the neck dissection specimens no false negatives were found. Five SLNs in four patients contained micrometastases and were the only positive lymph nodes. CONCLUSIONS: SLN biopsy can be a valuable staging technique in T2 and T2 oral cancer with uninvolved neck in patients whose lymphatic drainage of the neck has not been altered by previous surgery or radiotherapy. It provides reliable detection of micrometastasis, indicating which level(s) should be removed ipsilaterally or contralaterally, and allows the surgeon to accurately plan neck dissection, taking into consideration the pattern of lymphatic drainage of each individual patient. In this way unnecessary neck dissection and its morphofunctional sequelae can be avoided in a considerable number of patients.

Adult↗
PubMed2004

Controversies in management of the neck in head and neck cancer.

As definitive external radiation and multimodality organ preservation strategies (eg, combined chemotherapy and radiation therapy ) improve, the role of surgery is being re-examined in the management of locally advanced head and neck cancer. Consensus regarding the use of neck dissections for complete responders and incomplete responders has yet to be achieved and the data are surprisingly controversial. A possible benefit from neck dissection after a complete response of the primary tumor after CCRT or definitive external radiation for advanced squamous cell carcinoma of the head and neck may only be anticipated in patients with persisting subclinical neck disease who have no other sites of disease. Some clinicians have even argued that the salvage rate for clinically detectable residual neck disease does not justify neck dissection. Randomized data addressing these questions and a trial addressing the accuracy of new imaging modalities, such as postchemotherapy and postradiation positron emission tomography scanning, across multiple institutions would be appropriate. As a department, we are aggressive in our treatment of isolated residual neck disease after CCRT or definitive external radiation and for patients initially diagnosed with N3 nodal disease. We are investigating the use of adjuvant neck brachytherapy at the time of neck dissection and we are pleased with our early results.

Antineoplastic Agents↗
PubMed2001

Clinicopathological study of carcinomas of the lip and the mucosa of the upper and lower lips.

BACKGROUND: Lip carcinomas are rare oral tumors, and there have been few reports of lip carcinoma in Japan. METHODS: Of 914 patients with oral carcinomas treated between January 1980 and December 1998, 12 (1.3%) had lip carcinoma and 5 (0.5%) had lip mucosal carcinoma. We investigated the clinicopathological features of these 17 patients. RESULTS: Of the 12 patients with carcinoma of the lip, 10 had squamous cell carcinomas (9, external lower lip; 1 commissures) and 2 had mucoepidermoid carcinomas (external upper lip). Of the 5 patients with lip mucosal carcinoma, 3 had squamous cell carcinomas (2, mucosa of the lower lip; 1, mucosa of the upper lip), 1 had mucoepidermoid carcinoma (mucosa of the lower lip), and 1 had acinic cell carcinoma (mucosa of the lower lip). Of the 12 patients with lip carcinoma, 9 were classified as stage I, 2 as stage II, and 1 as stage III; all 5 of the patients with lip mucosal carcinoma were stage I. Five patients with lip carcinoma were treated by resection, 5 by a combination of resection and reconstruction, and 2 by radiotherapy alone. All patients with lip mucosal carcinoma were treated by resection. After the initial therapy, 3 patients without neck dissection had regional recurrences and received delayed neck dissection, and 2 died with neck regional recurrence after dissection. The 5-year cumulative survival rates of the patients with lip carcinoma and those with lip mucosal carcinoma were 82.5% and 80.0%, respectively. CONCLUSION: We suggest that early-stage carcinomas of the lip and of the mucosa of the upper and lower lips are frequent, and we found that the outcome of these patients was excellent. However, an aggressive therapeutic approach to the lip carcinoma patient with cervical metastasis appears warranted, in an attempt to improve locoregional control and ultimate survival.

Aged↗
PubMed1994

Carcinoma of the larynx: selective approach to the management of cervical lymphatics.

Our experience with the surgical management of 472 patients with squamous cell carcinoma of the larynx suggests that more aggressive management of the N0 neck is effective in managing patients with laryngeal carcinoma. Only 3% of patients developed recurrence at the primary site. Patients with T3 and T4 carcinoma of the glottic larynx and all patients treated surgically for carcinoma of the supraglottic larynx should undergo routine elective neck dissection of the N0 neck. This is undertaken on the ipsilateral side for T3 and T4 glottic lesions. Selective neck dissection is undertaken bilaterally for patients with carcinoma of the supraglottic larynx irrespective of the side of the primary tumor. Distant metastasis develops as a sole site of recurrent disease in 9% of patients overall. Additionally, 14% of patients developed a second primary carcinoma sometime during the postoperative period. Strategies to prevent and manage these problems are the challenge for the future.

Carcinoma, Squamous Cell↗