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1、Joseph Califano, M.D.Department of Otolaryngology-Head and Neck Surgery Johns Hopkins UniversityBaltimore, MD USASurgical Management of the Neck in Head and Neck CancerGeneral GoalsReview the indications for management of cervical nodal metastasis in head and neck cancerIndications for selective, st
2、aging neck dissectionNewer techniques, including sentinel node biopsyLevels of the NeckIIVVIIIIIIVSublevels of the NeckIAIVVIIIIIIAVAIBIIBVBNeck Dissection:TerminologyAHNS recommendations favor descriptive terminology to obtain better precisionNeck levelsStructures preservedStructures sacrificedSour
3、ces of Bias in Literature Regarding Neck DissectionAlmost all data from retrospective analysesNo standard method of identification of levels by pathologistBoth contralateral and ipsilateral necks are reportedLocalization of primary sites can be challengingNeck DissectionStaging: A variety of selecti
4、ve neck dissections for staging of HNSC with N0 diseaseTherapy: Usually a comprehensive neck dissection for known presence of diseaseHistorical ApproachGeorge Criles initial description of neck dissection: bleeding controlled by clamping of common carotid artery“softening of the brain” noted postope
5、rativelyRadical neck dissection: removal of levels I-VInternal Jugular VeinSternocleidomastoid CN XIRadical Neck DissectionModified Neck DissectionModified neck dissection: preservation of one or more of the following if not directly invadedInternal Jugular VeinSternocleidomastoid CN XISubmandibular
6、 gland, etc. (Bocca et al. 1967)Comparison of MRND vs. RND regional recurrenceRadical Neck Dissection 13-16%Modified Neck Dissection 6-9%Improved shoulder function with CN XI preservationNeck Dissection With Preservation of the SCM, IJ, and CN XISelective vs. Comprehensive/(I-V) Neck DissectionRemov
7、al of a portion of nodal groups based on preferential metastases from known primary site Lindberg, Cancer, 1972Buckley, Head and Neck, 2001Primary Rationale: Staging, determination of nodal involvement to guide further therapy, usually radiotherapy or conversion to comprehensive neck dissection (I-V
8、) if intraoperative diseaseSelective vs. Comprehensive/(I-V) Neck DissectionSecondary Rationale: Therapy, clearance of known or suspected nodal diseaseControversy regarding use as therapy for N+ diseaseAdvantages: clear improvement in postoperative morbidity, particularly in CN XI functionComprehens
9、ive Neck Dissection:Levels I-VSafe, accepted, traditional means of addressing any N+ neck surgicallyMajor structures require sacrifice when involved with tumorDistribution of Nodal Metastases:Oral CavityI 30%II35%III23%IV9%V2%Level IV in Oral Cavity Selective Neck Dissection16% of patients with oral
10、 tongue cancer have isolated positive node in level III or level IV8% with isolated level IV node involvement during or after neck dissectionByers et al. Head and Neck, 1997Risk of Occult Nodal Metastasis: Oral CavityFor clinical T1, T2 N0 oral tongue SCC, risk of occult nodal metastasis is 20%, 50%
11、Byers, et al, Head and Neck 1998Oral Cavity tumor thickness 3-4 mm. predicts elevated risk of occult metastasis 40%Spiro Am J Surg 1986, Yuen Head and Neck 2002Undissected T1, T2 N0 oral cavity cancer associated with a 50% regional recurrence rate Yuen Head and Neck, 1997Selective Neck Dissection I-
12、IIIfor oral cavity N0 diseaseIIIIIAIIIBIVT2-T4 NO oral cavityAny T thickness 0.4 cmIsolated IIB metastasis rareDistribution of Nodal Metastases:OropharynxI 10%II52%III34%IV20%V7%Oropharynx: Special ConsiderationsIsolated level V nodal metastasis extremely rareRetropharyngeal nodes are a primary noda
13、l drainage site, but not addressed by neck dissectionRadiotherapy often administered for primary and regional controlHigh risk of bilateral nodal metastasisSelective Neck Dissection II-IVfor OropharynxIVIIIIIAIIBT2-T4 NO oropharynxT1N0 controversialRetropharyngeal nodal basin may be treated with rad
14、iotherapy regardless of neck status, obviating need for selective neck dissection to determine therapyDistribution of Nodal Metastases:Larynx and HypopharynxI 2%II31%III27%IV12%V2.6%Selective Neck Dissection Hypopharynx: ConsiderationsPropensity to bilateral nodal metastasisUsually presents at advan
15、ced stageSelective Neck dissection used to determine need for radiotherapy in very early stage lesions treated with primary surgical therapySelective Neck Dissection Larynx: ConsiderationsT1 glottic tumors with low potential for cervical metastasis, 2 Y follow upSelective Lymph Node SamplingMentione
16、d in order to be condemnedPositive necks discovered = positive necks missedManni et al. Am J Surg 1991Sensitivity of less than 50%Wein et al. Laryngoscope, 2002Sensitivity 56%, specificity 70% Finn S, et al. Laryngoscope. 2002 Apr;112(4):630-3. Sentinel node biopsy99Tc labeled colloid +/- blue collo
17、id dye injected into tumorPreoperative imaging, hand held gamma probe, visual identification used to dissect sentinel lymph node (initial draining node)Sentinel Node Biopsy10-15 reports in literatureLargest series is a collection of multicenter data (Ross et al., Ann Surg Oncol 2002)316 necks evalua
18、tedSentinel node identified in 95%76 positive necks90% sensitivitySentinel Node Biopsy: PitfallsOnly accessible tumors can be injected preoperatively, e.g. oropharynx, oral cavityAdditional cost, need for second procedureMorbidity/cost analysis vs. selective neck dissection10% of occult metastases t
19、hat may be detected by selective neck dissection remain undiagnosedShould be performed in prospective clinical trialsNeck Dissection After Chemotherapy and/or RadiationMost series advocate neck dissection in N2 or greater disease, regardless of clinical responseResidual tumor found in neck in over 3
20、0% of N2 necks and 50% of N3 necks after chemoradiationLaryngoscope. 2007 Jan;117(1):121-8. Sewall GK, et al.Residual disease may not correlate with responseRecurrences after chemoradiation are often unresectableLiauw SL, Amdur RJ, Morris CG, Werning JW, Villaret DB, Mendenhall WM. Isolated neck rec
21、urrence after definitive radiotherapy for node-positive head and neck cancer: Salvage in the dissected or undissected neck. Head Neck. 2007 Feb 1Well-differentiated Thyroid CancerNo role for elective neck dissectionCentral compartment, level VI nodal dissection for positive central nodesModified nec
22、k dissection, at least levels II-V for neck metastasis, to include level IIB “Berry-picking” is not indicatedMedullary Thyroid CarcinomaTotal thyroidectomy and central compartment dissection, level VI for most casesIpsilateral nodal dissection at least levels II-V if central compartment is N+Salivar
23、y Gland CarcinomaNo added survival benefit to elective neck dissectionHowever, significant rate of occult nodal positivity for high grade tumors (adenoid cystic, squamous cell, high grade mucoepidermoid, etc.)Comprehensive (I-V) ipsilateral nodal dissection for N+ disease or high grade tumorSelectiv
24、e, I-III dissection for radiosensitive histologies with N0 necks and/or high grade tumorSummaryComprehensive neck dissection Levels I-V recommended for clinically N+ necksSacrifice of structures only if clinically involved by tumorStaging/Selective neck dissection indicated for N0 necks, dependent o
25、n primary tumor siteComprehensive neck dissection Levels I-V indicated for N2+ neck disease treated by chemoradiationSummaryThe use of selective neck dissection for clinically N+ is controversialThe use of sentinel node biopsy is less sensitive that selective neck dissection, and remains investigati
26、onalFuture Trials: Statistical ConsiderationMost retrospective trials describe a 5-10% difference in clinical endpoints in comparison of sentinel node biopsy, selective neck dissection, and comprehensive neck dissectionAssuming 80% power, would require a randomized trial with 1400 patients (700/arm) to detect a statistically significant 5% difference.Surgeons must be very careful,When they take the knife!Underneath their fine incisions,Stirs the Culprit Life!Emily Dickinson
