neck dissection

1. Management of
Secondaries Neck with
Occult Primary
Sujay Susikar
PG in Surgical Oncology
Prof RR Unit
Government Royapettah Hospital

2. Management of neck secondaries
with occult primary
 The unknown primary carcinoma in the head
and neck has been estimated to represent up to
7% of all head and neck carcinomas
 Good prognosis with possibility of cure in SCC
of head and neck
 Warrants aggressive treatment

3. Management of neck secondaries with
occult primary
Based on the histology:
 SCC
 Lymphoma
 Thyroid Ca
 Melanoma

4. Management of neck secondaries with
occult primary - SCC
Definitive management options include:
 Surgery
 RT or Chemo RT
 A combination of both

5. Management Algorithm
Neck secondaries with occult primary - SCC
Yes
Was open biopsy performed ? Residual neck disease?
No Yes
Consider radiotherapy Neck dissection followed
No
without further surgery by Radiotherapy
Resectable No Chemotherapy and/ or radiotherapy with
surgical salvage as indicated by response
Yes
Neck dissection
Single pathologic node < 3 cm Yes
Consider observation alone
without extracapsular extension
with /without management
No of suspected primary site
Post operative radiotherapy

6. Management of neck secondaries with
occult primary –SCC - Radiotherapy
Radiotherapy options
Limited
Comprehensive radiotherapy
irradiation
Inclusion of Ipsilateral Vs
potential bilateral
aerodigestive Radiotherapy
tract primary
sites

7. Management of neck secondaries with
occult primary - SCC

8. Management of neck secondaries with
occult primary – Radiotherapy
Radiation dose and technique
 Opposed lateral fields
 Single anterior yoke field
 With/ without blocks
Dose:
 Neck :66 – 74 Gy to gross disease,
44- 64 Gy for subclinical disease
 Mucosa: 50 – 66 Gy, 2.0 Gy/ fraction

9. Management of neck secondaries with
occult primary – Radiotherapy
principles
1. High posterior triangle node - treat as primary
nasopharyngeal carcinoma.
2. Jugulodigastric or midjugular node - treat as
primary nasopharyngeal carcinoma, omit larynx
shield.
3.Upper or midjugular node – fields include the
ipsilateral tonsillar fossa, posterior tongue,
pyriform fossa, and ipsilateral neck nodes

10. Management of neck secondaries with
occult primary – Radiotherapy
principles
4. Multiple or bilateral nodes: treat as primary
nasopharyngeal carcinoma, but omit larynx
shield.
5. Supraclavicular node only: palliative irradiation.
6. Radical radiation doses – as for stageT1 primary
cancer, with additional boost to the the
metastatic node

11. Radiotherapy – complications
 Mucositis
 Laryngeal edema
 Mandibular radionecrosis
 Massetter fibrosis
 Temporo mandibular joint dysfunction

12. Surgery - Neck dissection

13. What is a neck dissection ?
It is a procedure by which nodes, with fat ,
fascia ,muscle, vein and nerves are removed
enbloc from mandible to clavicle and trapezius
to midline

14. Why neck dissection?
 H&N cancers remain loco regional even when
fairly advanced
 Other than Lung rarely metastasis
 Lesion confined to one anatomic boundary,
when extirpated radically-cure expected

15. Why not limited excision of
nodes?
 Metastasis evident in one node-cancer cells
might have already spread to non palpable nodes
in contiguous area
 Less than RND
 Risk of leaving behind involved node
 Worse than not treating the pt
 Radiation not an ALTERNATIVE THERAPY for
less than optimal surgery

16. Evolution of the neck dissection
 1880 – Kocher proposed removing nodal
metastases
 1906 – George Crile described the classic
radical neck dissection (RND)
 1933 and 1941 – Blair and Martin
popularized the RND
 1953 – Pietrantoni recommended sparing
the spinal accessory nerves

17. Evolution of the neck dissection
 1967 - Bocca and Pignataro described the
“functional neck dissection” (FND)
 1975 – Bocca established oncologic safety
of the FND compared to the RND
 1989, 1991, and 1994 – Medina, Robbins,
and Byers respectively proposed classifications
of neck dissections

18. Classification of Neck
Dissections
Academy’s classification
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
3) Selective neck dissection (SND)
• Supra-omohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type
4) Extended radical neck dissection

19. Classification of Neck
Dissections
Medina classification (1989)
– Comprehensive neck dissection
• Radical neck dissection
• Modified radical neck dissection
# Type I (XI preserved)
# Type II (XI, IJV preserved)
# Type III (XI, IJV, and SCM preserved)
– Selective neck dissection

20. Radical Neck Dissection - Right
Mandible
Midline
Clavicle
Trapezius

21. Radical Neck Dissection
Indications as part of combination treatment with
RT:
– Extensive cervical involvement or matted
lymph nodes with gross extracapsular spread
and invasion into the SAN, IJV, or SCM

22. Modified Radical Neck
Dissection (MRND)
Definition
– Excision of same lymph node bearing regions as
RND with preservation of one or more
nonlymphatic structures (SAN, SCM, IJV)
– Spared structure specifically named
– MRND III is analogous to the “functional neck
dissection” described by Bocca

23. Modified Radical Neck
Dissection
Rationale
– Reduce postsurgical shoulder pain and shoulder
dysfunction
– Improve cosmetic outcome
– Reduce likelihood of bilateral IJV resection
• Contralateral neck involvement

24. MRND
Rationale
 Actuarial 5-year survival and neck failure rates for RND (63% and 12%)
not statistically different compared to MRND I (71% and 12%)
(Andersen)
 No difference in pattern of neck failure
 Suarez (1963) – necropsy and surgery specimens of larynx and
hypopharynx – lymph nodes do not share the same adventitia as
adjacent blood Vessels
 Nodes not within muscular aponeurosis or glandular capsule
(submandibular gland)
 Survival approximates RND assuming IJV, and SCM not involved

26. Modified Radical Neck Dissection II right
Internal Jugular Vein
Accessory Nerve

27. Modified Radical Neck Dissection III (Functional) left
Jugular vein
Carotid Submandibular gland
Phrenic Nerve
Sternomastoid muscle
Brachial Plexus
Accessory Nerve

28. SELECTIVE NECK
DISSECTION
Definition
– Cervical lymphadenectomy with preservation
of one or more lymph node groups
– Four common subtypes:
 Supraomohyoid neck dissection
 Posterolateral neck dissection
 Lateral neck dissection
 Anterior neck dissection

29. SELECTIVE NECK
DISSECTION
• Rate of occult metastasis in clinically negative neck
20-30%
• Indication: primary lesion with 20% or greater risk
of occult metastasis
• Studies by Fisch and Sigel (1964) demonstrated
predictable routes of lymphatic spread from
mucosal surfaces of the H&N
• May elect to upgrade neck dissection intraoperatively
• Need for post-op XRT

30. Risk stratification for Elective Neck
Dissection
Group Estimated risk of T Stage Site
subclinical neck
disease
I Low risk < 20 % T1 FOM, Oral tongue,
RMT, Gingiva, hard
palate, buccal mucosa
II Intermediate risk 20% -30% T1 Soft palate, pharyngeal
wall, supraglottic larynx,
tonsil
FOM, Oral tongue,
T2 RMT, Gingiva, hard
palate, buccal mucosa
III High risk > 30 % T1-4 Nasopharynx, pyriform
sinus, base of tongue
Soft palate, pharyngeal
wall, supraglottic larynx,
T2- 4 tonsil
FOM, Oral tongue,
RMT, Gingiva, hard
T3- 4 palate, buccal mucosa

31. SND: Supraomohyoid type
Rationale
– Expectant management of the N0 neck is not
advocated
– Based on Linberg’s study (1972)
• Distribution of lymph node mets in H&N SCCA
• Subdigastric and midjugular nodes mostly
affected in oral cavity carcinomas
• Rarely involved Level IV and V

32. SND: Supraomohyoid type
Most commonly performed SND
Definition
– En bloc removal of cervical lymph node groups I-
III
– Posterior limit is the cervical plexus and posterior
border of the SCM
– Inferior limit is the omohyoid muscle overlying the
IJV
Indications
– Oral cavity carcinoma with N0 neck

33. SND: Supraomohyoid type

34. Raising a subplatysmal flap Removing level Ia
Removing level Ib Removing level II
SND: Supraomohyoid type

35. After completion of level II
Level III dissection
Level III dissection
After completion of level III
SND: Supraomohyoid type

36. SND: Supraomohyoid type

37. SND: Lateral Type
Definition
– En bloc removal of the jugular lymph nodes
including Levels II-IV
Indications
– N0 neck in carcinomas of the oropharynx,
hypopharynx, supraglottis, and larynx

38. SND: Posterolateral Type
Definition
– En bloc excision of lymph bearing tissues in
Levels II-IV and additional node groups –
suboccipital and postauricular
Indications
– Cutaneous malignancies
• Melanoma
• Squamous cell carcinoma
• Merkel cell carcinoma
– Soft tissue sarcomas of the scalp and neck

39. SND: Anterior Compartment
Definition
– En bloc removal of lymph structures in Level VI
– Limits of the dissection are the hyoid bone,
suprasternal notch and carotid sheaths
Indications
– Selected cases of thyroid carcinoma
– Parathyroid carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma with subglottic extension
– CA of the cervical esophagus

40. Extended Neck Dissection
Definition
– Any previous dissection which includes removal
of one or more additional lymph node groups
and/or non-lymphatic structures.
– Usually performed with N+ necks in MRND or
RND when metastases invade structures usually
preserved

41. Extended Neck Dissection
Indications
– Carotid artery invasion
– Other examples:
• Resection of the hypoglossal nerve or digastric
muscle,
• dissection of mediastinal nodes and central
compartment for subglottic involvement, and
• removal of retropharyngeal lymph nodes for tumors
originating in the pharyngeal walls

42. Incisions
 Ideal incision
 Adequate exposure
 Safety
 Accommodation of flaps
 Cosmesis & function

43. Risk of ischemic necrosis

44. Types of Incisions
Crile’s incision Martin’s incision
Hockey stick incision MacFee incision

45. Conley Incision

46. MacFee Incision

47. Y Incision

48. Modified Schobinger Incision

49. Utilitarian incision

50. Exposure of upper end of IJV

51. Raising the specimen from below

52. Bed after completion of neck dissection

53. Bed after completion of neck dissection- MRND III

54. Bed after completion of neck dissection- RND

55. Complications of neck dissection
 Wound disruption Nerve damage
 Frozen shoulder  Vagus
 Seroma  XI nerve
 Chylous fistula  Hypoglossal
 Carotid blow out  Sympathetic chain
 Hemorrhage  Phrinic nerve
Injury to subclavian  Recurrent laryngeal
vein Marginalmandibular
Laryngeal edema  Brachial plexus injury
SIAHs

56. SUMMARY
 Secondaries neck with occult primary – has
good prognosis with possibility of cure
 Treatment is based on the histology
 Usually treated with combination of Surgery and
RT
 Treatment of possible primary sites may be
added

57. SUMMARY
 Academy classification of neck dissection is in
use now
 Indications for neck dissection and type of neck
dissection, especially in the N0 neck should be
individualised