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JosephCalifano,M.D.DepartmentofOtolaryngology-HeadandNeckSurgeryJohnsHopkinsUniversityBaltimore,MDUSASurgicalManagementoft

heNeckinHeadandNeckCancerGeneralGoals•Reviewtheindicationsformanagementofcervicalnodalmetastasisinheadandneckcancer•Indicationsforselecti

ve,stagingneckdissection•Newertechniques,includingsentinelnodebiopsyLevelsoftheNeckIIVVIIIIIIVSublevelsoftheNeckIAIVVIIII

IIAVAIBIIBVBNeckDissection:Terminology•AHNSrecommendationsfavordescriptiveterminologytoobtainbetterprecision–Nec

klevels–Structurespreserved–StructuressacrificedSourcesofBiasinLiteratureRegardingNeckDissection•Almostalldatafromretrospectiveanalyses•Nostan

dardmethodofidentificationoflevelsbypathologist•Bothcontralateralandipsilateralnecksarereported•Localizationofprimarysitesca

nbechallengingNeckDissection•Staging:AvarietyofselectiveneckdissectionsforstagingofHNSCwithN0disease•Therapy:Usuallyacomprehensiveneckdissectionforkn

ownpresenceofdiseaseHistoricalApproach•GeorgeCrile’sinitialdescriptionofneckdissection:–bleedingcontrolledbyclampingofcommoncarotid

artery–“softeningofthebrain”notedpostoperatively•Radicalneckdissection:removalof–levelsI-V–InternalJugularVein–Sternocleidomastoid–CNX

IRadicalNeckDissectionModifiedNeckDissection•Modifiedneckdissection:preservationofoneormoreofthefollowingifnotdirectlyinvaded–InternalJugular

Vein–Sternocleidomastoid–CNXI–Submandibulargland,etc.(Boccaetal.1967)•ComparisonofMRNDvs.RNDregionalrecu

rrence–RadicalNeckDissection13-16%–ModifiedNeckDissection6-9%–ImprovedshoulderfunctionwithCNXIpreservationNeckDissecti

onWithPreservationoftheSCM,IJ,andCNXISelectivevs.Comprehensive/(I-V)NeckDissection•Removalofaportionofnodalgroupsbas

edonpreferentialmetastasesfromknownprimarysite–Lindberg,Cancer,1972–Buckley,HeadandNeck,2001•PrimaryRationale:Staging,dete

rminationofnodalinvolvementtoguidefurthertherapy,usuallyradiotherapyorconversiontocomprehensiveneckdissect

ion(I-V)ifintraoperativediseaseSelectivevs.Comprehensive/(I-V)NeckDissection•SecondaryRationale:Therapy,clearanceofknownorsuspectednodald

isease–ControversyregardinguseastherapyforN+disease•Advantages:clearimprovementinpostoperativemorbidity,particularlyinCNXIfunctionComprehensive

NeckDissection:LevelsI-V•Safe,accepted,traditionalmeansofaddressinganyN+necksurgically•Majorstructuresrequiresacrif

icewheninvolvedwithtumorDistributionofNodalMetastases:OralCavity•I30%•II35%•III23%•IV9%•V2%LevelIVinOralCavitySelectiveNeckDisse

ction•16%ofpatientswithoraltonguecancerhaveisolatedpositivenodeinlevelIIIorlevelIV•8%withisolatedlevelIVnodeinvolvementduringor

afterneckdissection–Byersetal.HeadandNeck,1997RiskofOccultNodalMetastasis:OralCavity•ForclinicalT1,T2N0oraltongueSCC,riskofoccultnodal

metastasisis~20%,50%–Byers,etal,HeadandNeck1998•OralCavitytumorthickness>3-4mm.predictselevatedriskofoccultmetastasis>40%–SpiroAmJSurg198

6,–YuenHeadandNeck2002•UndissectedT1,T2N0oralcavitycancerassociatedwitha50%regionalrecurrencerateYuenHeadandNeck,1997SelectiveNec

kDissectionI-IIIfororalcavityN0diseaseIIIIIAIIIBIV•T2-T4NOoralcavity•AnyTthickness>0.4cm•IsolatedIIBmetastasisrareDistributionofNodalMetas

tases:Oropharynx•I10%•II52%•III34%•IV20%•V7%Oropharynx:SpecialConsiderations•IsolatedlevelVnodalmetastasisextreme

lyrare•Retropharyngealnodesareaprimarynodaldrainagesite,butnotaddressedbyneckdissection•Radiotherapyoftenadministeredforprimar

yandregionalcontrol•HighriskofbilateralnodalmetastasisSelectiveNeckDissectionII-IVforOropharynxIVIIIII

AIIB•T2-T4NOoropharynx•T1N0controversial•Retropharyngealnodalbasinmaybetreatedwithradiotherapyregardlessofneckstatus,obviat

ingneedforselectiveneckdissectiontodeterminetherapyDistributionofNodalMetastases:LarynxandHypopharynx•I2%•

II31%•III27%•IV12%•V2.6%SelectiveNeckDissectionHypopharynx:Considerations•Propensitytobilateralnodalmetastasis•Usuallypresentsatadvancedstage•Selec

tiveNeckdissectionusedtodetermineneedforradiotherapyinveryearlystagelesionstreatedwithprimarysurgicaltherapySelectiveNeckDissectionLarynx:Co

nsiderations•T1glottictumorswithlowpotentialforcervicalmetastasis,<10%,selectiveneckdissectionnotperform

ed•Supraglottictumorshaveahighriskforoccultnodalmetastasisandbilateralnodalspread–T1,20%–T2,40%SelectiveNeckDissectionII-IVforHypopharynxan

dLarynxIVIIIIIAIIB•T1-T4NOhypopharynx•IfN0treatedwithradiotherapyforprimary,maybenoneedforselectivene

ckdissection•T2-T4NOLarynx•IfN0treatedwithradiotherapyforprimary,maybenoneedforselectiveneckdissectionParatrach

ealNodalDissectionforLarynx,Hypopharynx•10–20%riskofparatrachealnodalpositivityforpatientsinwhomlevel

VIisdissected•Usuallyassociatedwithcontralateralpositivenodes•Oftenassociatedwithsubglottic,pyriformapex,cervicalesophagealtumors•Postoperativera

diotherapyresultsinareducedparastomalrecurrenceforpatientswithpathologicnodesinlevelVISelectiveNeckDissectionVIforselectedlary

nx/hypopharynx/thyroidtumorsVIPostoperativeRadiotherapyafterSelectiveNeckDissection•Patientswithanysingleormultiplenod

almetastasishaveimprovedregionalcontrolwithpostoperativeradiotherapy(6%vs.36%forsinglenode)–Byers,etal.HeadandNeck1999(n=517)–Ambrosch,etal.,Otolar

yngolHNS2001(n=503)•Approximately50%ofrecurrenceswerewithinthedissectedfield•Approximate5%improvementinregionalcontrolbyradioth

erapyforpN1diseaseSelectiveNeckDissectionforclinicallyN+Disease:AControversy•Rationale:Postoperativeradioth

erapymayachievecontrolofmicroscopic/subclinicalmetastaticdisease•ImprovedfunctionaloutcomeSelectiveNeckDissectionforclinicallyN+Disease:ACon

troversy•Moststudieslimited,withhighlyselectedgroup•Andersonetal.ArchOtolHNS,2002–106patients,129necks–55%N1,26%N2b–72%irradiated–94%controlwi

th>2YfollowupSelectiveLymphNodeSampling•Mentionedinordertobecondemned•Positivenecksdiscovered=positivenecksmissed–M

annietal.AmJSurg1991•Sensitivityoflessthan50%–Weinetal.Laryngoscope,2002•Sensitivity56%,specificity70%–FinnS,etal.Laryngoscope.2002Apr;112(4):630-3.S

entinelnodebiopsy•99Tclabeledcolloid+/-bluecolloiddyeinjectedintotumor•Preoperativeimaging,handheldgamma

probe,visualidentificationusedtodissectsentinellymphnode(initialdrainingnode)SentinelNodeBiopsy•10-15reportsi

nliterature•Largestseriesisacollectionofmulticenterdata(Rossetal.,AnnSurgOncol2002)•316necksevaluated–Sentinelnodeidentifiedin95%–76posit

ivenecks–90%sensitivitySentinelNodeBiopsy:Pitfalls•Onlyaccessibletumorscanbeinjectedpreoperatively,e.

g.oropharynx,oralcavity•Additionalcost,needforsecondprocedure•Morbidity/costanalysisvs.selectiveneckdissection•10%ofoccultmetastasesthatmaybed

etectedbyselectiveneckdissectionremainundiagnosed•ShouldbeperformedinprospectiveclinicaltrialsNeckDissectionAfterChe

motherapyand/orRadiation•MostseriesadvocateneckdissectioninN2orgreaterdisease,regardlessofclinicalresponse•Residual

tumorfoundinneckinover30%ofN2necksand50%ofN3necksafterchemoradiation–Laryngoscope.2007Jan;117(1):121-8.SewallG

K,etal.•Residualdiseasemaynotcorrelatewithresponse•RecurrencesafterchemoradiationareoftenunresectableLiauwSL,AmdurRJ,MorrisCG,WerningJW,Villaret

DB,MendenhallWM.Isolatedneckrecurrenceafterdefinitiveradiotherapyfornode-positiveheadandneckcancer:Salvage

inthedissectedorundissectedneck.HeadNeck.2007Feb1Well-differentiatedThyroidCancer•Noroleforelectiveneckdissection•Centralcompartment,lev

elVInodaldissectionforpositivecentralnodes•Modifiedneckdissection,atleastlevelsII-Vforneckmetastasis,toincludelevelIIB•“Berry-pic

king”isnotindicatedMedullaryThyroidCarcinoma•Totalthyroidectomyandcentralcompartmentdissection,levelVI

formostcases•IpsilateralnodaldissectionatleastlevelsII-VifcentralcompartmentisN+SalivaryGlandCarcinoma•Noaddedsurvivalbenefittoelectiveneckdissectio

n•However,significantrateofoccultnodalpositivityforhighgradetumors(adenoidcystic,squamouscell,highgrademucoepidermoid,

etc.)•Comprehensive(I-V)ipsilateralnodaldissectionforN+diseaseorhighgradetumor•Selective,I-IIIdissectionforradiosensitivehistologiesw

ithN0necksand/orhighgradetumorSummary•ComprehensiveneckdissectionLevelsI-VrecommendedforclinicallyN+necks–Sacrifice

ofstructuresonlyifclinicallyinvolvedbytumor•Staging/SelectiveneckdissectionindicatedforN0necks,dependentonprimarytumorsite•Comprehensiveneckdissect

ionLevelsI-VindicatedforN2+neckdiseasetreatedbychemoradiationSummary•TheuseofselectiveneckdissectionforclinicallyN+is

controversial•Theuseofsentinelnodebiopsyislesssensitivethatselectiveneckdissection,andremainsinvestigationalFutureTrials:Statis

ticalConsideration•Mostretrospectivetrialsdescribea5-10%differenceinclinicalendpointsincomparisonofse

ntinelnodebiopsy,selectiveneckdissection,andcomprehensiveneckdissection•Assuming80%power,wouldrequirearandomizedtrialwith1400

patients(700/arm)todetectastatisticallysignificant5%difference.Surgeonsmustbeverycareful,Whentheytakethekni

fe!Underneaththeirfineincisions,StirstheCulpritLife!~EmilyDickinson