This document discusses the management of neck nodes in head and neck cancer. It covers lymph node levels, risk factors for metastasis, diagnostic workup, staging, surgical and radiation treatment options. For clinically negative nodes, elective neck irradiation or dissection are equally effective at controlling subclinical disease. For clinically positive nodes, factors like number of positive nodes and size influence treatment planning. Combined modality treatment with surgery and radiation provides better control than either alone for more advanced neck disease.

1. Dr Sailendra Narayan Parida
PG Student
Dept of Radiation Oncology
AHRCC
MANAGEMENT OF NECK NODE
IN HEAD AND NECK CANCER

2. • The incidence of lymphnode metastasis
depends upon relative density of the capillary
lymphatic network.
• nasopharynx and hypopharynx – most profuse
• Paranasal sinus,middle ear and true vocal cord
- sparse or no capillary lymphatics.

3. Lymph node levels of the neck
• Lymph nodes - seven levels( generally for the
purpose of squamous cell carcinoma
staging.)
• Parotid and retropharyngeal group of LN are
not included in this system.

4. • Level I, submental (IA) and submandibular (IB)
nodes;
• Level II, upper internal jugular nodes, from the skull
base to the level of the hyoid bone;
• Level III, middle internal jugular nodes, from the
level of the hyoid bone to the omohyoid muscle;
• Level IV, inferior internal jugular nodes, from the
level of the omohyoid muscle to the clavicle;
• Level V, spinal accessory lymph nodes; and
• Level VI, anterior neck nodes, bounded by the hyoid
bone, the sternum, and the common carotid
arteries.

5. • Included in level VI are the paratracheal,
pretracheal, precricoid (Delphian), and
tracheoesophageal groove nodes.
• Level VII-superior mediastinal group of
lymphnodes

7. • The risk of lymph node metastases is
influenced by -
1. the location of the primary tumor
2. histologic differentiation
3. size of the lesion
4. availability of capillary lymphatics

9. • The most commonly involved lymph nodes in
the head and neck are the subdigastric lymph
nodes, followed by the midjugular lymph
nodes.
• When contralateral lymph node metastases
occur, the subdigastric lymph nodes are most
frequently involved, followed by the
midjugular and lower jugular lymph node
groups.

10. Diagnostic work up
• Physical examination
• Radiological evaluation

11. STAGING

13. SURGERY
• Radical neck dissection- Removal of the superficial
and deep cervical fascia with its lymph nodes in
levels I to V in continuity with the
sternocleidomastoid muscle, omohyoid muscle,
internal and external jugular veins, spinal accessory
nerve, and submandibular gland.
• MODIFIED RADICAL NECK DISSECTION-
spares 1.spinal accessory nerve
2.sternocledomastoid muscle
3.internal jugular vein

14. SELECTIVE NECK DISSECTION-
one or more of lymph node groups I to V are
not removed.
SOND – level I – III.
Used for small oral cavity cancers and clinically
negative neck.
LATERAL NECK DISSECTION – level II – IV
Used in the treatment of laryngeal,
oropharyngeal, and hypopharyngeal cancers.

18. • COMPLICATIONS OF NECK DISSECTION –
 Hematoma, seroma, lymphedema, wound infection, wound
dehiscence, chyle fistula, damage to cranial nerves VII, X, XI,
and XII, carotid exposure, and carotid rupture.
 The incidence of complications is higher when neck
dissection is combined with resection of the primary lesion or
when it follows a course of radiation therapy.
 Study done by Talor et al showed that the incidence of wound
complications increased with total dose and dose per fraction.

19. RADIATION THERAPY
• Elective node irradiation in clinically node
negative cases.
• As a single modality.
• Preoperative.
• Post operative.

20. • With clinically negative neck nodes, treatment
planning depends on the estimated risk of
subclinical disease in the nodes.
• With clinically positive lymph nodes, the plan
is influenced by the number of lymph nodes,
size and location.

22. ELECTIVE RT OF CERVICAL
LYMPHNODES WHEN PRIMARY
TUMOUR IS TREATED BY RT
• Patients in whom the primary lesion is to be
treated by radiation therapy, who have
clinically negative nodes, and in whom the risk
of subclinical disease is 20% or greater
usually receive elective neck irradiation to a
minimum dose equivalent to 45 to 50 Gy
during 4.5 to 5 weeks

23. • Elective neck irradiation for early oral cavity lesions
includes the submandibular and subdigastric lymph
nodes. The midjugular and low jugular lymph nodes
are treated as well by using a narrow anterior field.
• For primary lesions located in the oropharynx,
nasopharynx, supraglottic larynx, and hypopharynx,
the lower neck nodes are also routinely included.
• The low neck is treated with a single anterior field.
• A tapered midline larynx/trachea shield is added to
protect the spinal cord, the larynx, and the pharynx.

24. Treatment of Clinically Positive Cervical Lymph
Nodes When the Primary Tumor Is Treated by
Radiation Therapy
• Relatively recent data suggest that advanced
disease has a better chance of cure after altered
fractionation and/or concomitant chemotherapy.
• The decision to add a neck dissection after
radiation therapy for multiple unilateral positive
nodes or bilateral lymph node disease is
individualized and is based on
1) the diameter of the largest node
2)node fixation
3)number of clinically positive nodes in the
neck

26. • If clinically positive lymph nodes disappear
completely during radiation therapy, the likelihood of
control by radiation therapy alone is improved, and a
neck dissection may be withheld.

27. Peterson et al.(MD Anderson)
• 1984-1993
• N=100 patients with node +ve Sq.cell ca. of
oropharynx.
• RESULT - The 2-year neck disease control rates
did not vary significantly with pretreatment nodal
size: <3 cm, 87%, and >3 cm, 85%.
• The incidence of subcutaneous fibrosis was
similar following irradiation alone compared with
another group of patients who underwent a neck
dissection in addition to radiation therapy.

28. Johnson et al. Medical College of
Virginia (Richmond).
• N=81, N+ve stage III and IV SCC of H&N.
• RESULT- The 3-year neck disease control rates
were 94% for nodes <3 cm compared with
86% for those >3 cm.

29. • If a neck dissection is planned to follow radiation
therapy in patients with clinically positive lymph
nodes, the preoperative dose varies with the size
and location of the lymph node, fixation, and
response to radiation therapy.
• 50 Gy are sufficient for mobile lymph nodes 3 to
4 cm in size,
• 60 Gy or more is recommended for 5- to 6-cm
nodes and for fixed nodes.

30. • Lymph nodes measuring 7 to 8 cm are almost
always fixed to adjacent structures and often
require doses of 70 to 75 Gy for the surgeon
to achieve a complete resection.
• If the lymph node lies behind the plane of the
spinal cord, electrons may be used to boost
the dose after the primary fields have been
reduced off the spinal cord after 45Gy.

31. • Patients with bilateral neck disease require
individualized treatment planning jointly by the
radiation oncologist and the surgeon.
• If disease is minimal on one side, radiation
therapy alone may be used to control the disease
on that side of the neck, and a neck dissection
may be used on the side with more disease.
• If major bilateral disease is present, bilateral
neck dissection should follow radiation therapy.

32. Complications of neck irradiation
• Subcutaneous fibrosis
• Lymphedema of larynx and submentum.

35. Treatment of the neck after incisional
or excisional biopsy
• McGuirt and McCabe reported that incisional or
excisional biopsy of positive neck nodes before definitive
surgery increased the risk of neck failure and worsened
the prognosis for patients with squamous cell carcinoma
of the head and neck.
• Parson et al.-After excisional biopsy of a single lymph
node, radiation therapy alone to the primary lesion and
to the neck resulted in a 95% rate of neck control.
• If residual disease - radiation therapy followed by neck
dissection was more successful than radiation therapy
alone for controlling neck disease.

36. • If there is no palpable disease remaining in
the neck after excisional biopsy of a positive
node, the neck may be treated with radiation
therapy alone.
• If an incisional biopsy of the node has been
performed (leaving gross disease) or if other
positive nodes remain after an excisional neck
node biopsy, radiation therapy is followed by a
neck dissection.

37. RESULTS OF TREATMENT
• CLINICALLY NEGATIVE NODES-
Elective neck dissection and elective neck
irradiation are equally effective in controlling
subclinical disease.
Patients with a relatively early primary lesion and
clinically negative nodes should be treated with
one modality.
Patients whose primary lesion is treated
surgically may undergo an elective neck
dissection, and those whose primary lesion is to
be treated with radiation therapy should be
considered for elective neck irradiation.

38. • STUDY DONE IN UNIVERSITY OF FLORIDA-
There were six (21%) neck failures in 28
patients who did not receive elective neck
irradiation and eight (5%) neck failures in 162
patients who received elective neck
irradiation.
Elective neck irradiation is equally efficacious
for squamous cell carcinoma arising from
various head and neck primary sites.

40. • In patients in whom primary failure occurs in
addition to failure in the clinically negative nodes,
the chances of surgical salvage are poor. In patients
in whom the primary lesion is controlled and in
whom failure develops in the initially negative neck,
the chances of salvage with neck dissection are
approximately 60%.
• Although elective neck irradiation significantly
reduces the risk of neck recurrence, there is no
definite evidence that it improves survival.

41. • Vandenbrouck et al. and Fakih et al. have conducted
randomized trials comparing elective neck dissection
with no elective neck treatment for patients with oral
cavity carcinoma and oral tongue cancer, respectively.
• No survival advantage was noted for patients
undergoing elective neck dissection in either study.
• However, because of the small number of patients in
both trials, it is likely that even if a survival difference
existed, it would have been missed.

42. • Dearnaley et al. reported a series of 148
patients treated with an interstitial implant,
alone or combined with external-beam
irradiation, for cancer of the tongue or floor of
mouth.
• A multivariate analysis showed that elective
neck irradiation significantly improved survival
and reduced the risk of dying of cancer.

43. • Piedbois et al.reported a series of 233 patients with
T1-2N0 carcinoma of the oral cavity treated with
interstitial iridium brachytherapy,123 patients
received no elective neck treatment and 110 patients
underwent an elective neck dissection.
• A multivariate analysis showed that elective neck
dissection was significantly associated with improved
survival.

44. CLINICALLY POSITIVE NODES
• Olsen et al. (89) reported a series of 284 patients who
underwent neck dissection at the Mayo Clinic for pathologic
stage N1 and N2 squamous cell carcinoma.
• No patient received adjuvant therapy.
• Neck recurrence-free survival rates at 5 years were as follows:
• N1,76%; N2, 60%; and overall, 69%carcinoma of the head and
neck
• A multivariate analysis showed that factors significantly
associated with an increased risk of recurrence in the neck
are-
 four or more positive nodes (p = .005)
 invasion of lymphatic and/or vascular spaces (p = .003)
 invasion of soft tissue (p = .0008),
 desmoplastic stromal pattern (p = .0001)

47. • The postoperative dose prescribed is usually
60 Gy in 30 fractions to 65 Gy in 35 fractions
during 6 to 7 weeks for patients with negative
margins.
• higher doses may be prescribed when residual
disease is present in the neck.
• If radiation therapy is to be added after
surgery, it is usually initiated within 4 to 6
weeks after the operation
• Although it has been reported that a delay to
10 weeks is not associated with an increased
risk of neck failure.

48. • Radiation therapy alone is sufficient for
patients with N1 (up to 2 cm) disease as long
as the fraction size (2 Gy) and the total dose
are sufficient.
• Radiation therapy followed by neck dissection
has provided better rates of disease control
than radiation therapy alone for patients with
more advanced neck disease.
• As shown in a multivariate analysis by Ellis et
al.the addition of neck dissection after
radiation therapy is independently related to a
significantly decreased risk of dying from
cancer.

49. • No difference is seen in the rate of control as a
function of the interval between radiation
therapy and neck dissection when comparing
patients who have surgery within 6 weeks
with those who have neck dissection more
than 6 weeks after radiation therapy.

50. Results after Incisional or Excisional
Biopsy
• Patients who have undergone an incisional or
excisional biopsy of a metastatic lymph node before
referral do not have an increased risk of neck failure or
a decreased cure rate if radiation therapy is the next
step in treatment.
• The likelihood of control and the cure rate are probably
diminished if an operation without prior radiation
therapy follows incisional or excisional biopsy of a
metastatic neck node because of the risk that the
biopsy procedure disseminated tumor cells into tissues
not removed by neck dissection.