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JosephCalifano,M.D.DepartmentofOtolaryngology-HeadandNeckSurgeryJohnsHopkinsUniversityBaltimore,MDUSASurgicalManagementoftheNeckinHea

dandNeckCancerGeneralGoals•Reviewtheindicationsformanagementofcervicalnodalmetastasisinheadandneckcancer•Indicationsfors

elective,stagingneckdissection•Newertechniques,includingsentinelnodebiopsyLevelsoftheNeckIIVVIIIIIIVSublevelsoftheNeckIAIVVIIIIIIAVAIBI

IBVBNeckDissection:Terminology•AHNSrecommendationsfavordescriptiveterminologytoobtainbetterprecision–Ne

cklevels–Structurespreserved–StructuressacrificedSourcesofBiasinLiteratureRegardingNeckDissection•Almostalldatafro

mretrospectiveanalyses•Nostandardmethodofidentificationoflevelsbypathologist•Bothcontralateralandipsilateralnecksare

reported•LocalizationofprimarysitescanbechallengingNeckDissection•Staging:AvarietyofselectiveneckdissectionsforstagingofHNSCwithN0disease•Thera

py:UsuallyacomprehensiveneckdissectionforknownpresenceofdiseaseHistoricalApproach•GeorgeCrile’sinitialdescriptionofneckdissect

ion:–bleedingcontrolledbyclampingofcommoncarotidartery–“softeningofthebrain”notedpostoperatively•Radicalne

ckdissection:removalof–levelsI-V–InternalJugularVein–Sternocleidomastoid–CNXIRadicalNeckDissectionModifiedNeckDissection•Modifiedneckdiss

ection:preservationofoneormoreofthefollowingifnotdirectlyinvaded–InternalJugularVein–Sternocleidomastoid–CNXI–Submandibulargland,etc.(Bo

ccaetal.1967)•ComparisonofMRNDvs.RNDregionalrecurrence–RadicalNeckDissection13-16%–ModifiedNeckDissection6-9%

–ImprovedshoulderfunctionwithCNXIpreservationNeckDissectionWithPreservationoftheSCM,IJ,andCNXISelectivevs.Comprehensive/(I-V)NeckDissection•R

emovalofaportionofnodalgroupsbasedonpreferentialmetastasesfromknownprimarysite–Lindberg,Cancer,1972–Buckley,HeadandNeck,2001•PrimaryRationale:Stagin

g,determinationofnodalinvolvementtoguidefurthertherapy,usuallyradiotherapyorconversiontocomprehensiveneckdis

section(I-V)ifintraoperativediseaseSelectivevs.Comprehensive/(I-V)NeckDissection•SecondaryRationale:Therapy,clearanceofknownorsuspectednodaldis

ease–ControversyregardinguseastherapyforN+disease•Advantages:clearimprovementinpostoperativemorbidity,particularlyinCNXIfunctionComprehensiveNe

ckDissection:LevelsI-V•Safe,accepted,traditionalmeansofaddressinganyN+necksurgically•Majorstructuresrequiresac

rificewheninvolvedwithtumorDistributionofNodalMetastases:OralCavity•I30%•II35%•III23%•IV9%•V2%LevelIVinOralCavitySelectiveNeckDissection•16%o

fpatientswithoraltonguecancerhaveisolatedpositivenodeinlevelIIIorlevelIV•8%withisolatedlevelIVnodeinvol

vementduringorafterneckdissection–Byersetal.HeadandNeck,1997RiskofOccultNodalMetastasis:OralCavity•ForclinicalT1,T2N0oraltongueSCC,riskofoccu

ltnodalmetastasisis~20%,50%–Byers,etal,HeadandNeck1998•OralCavitytumorthickness>3-4mm.predictselevatedriskof

occultmetastasis>40%–SpiroAmJSurg1986,–YuenHeadandNeck2002•UndissectedT1,T2N0oralcavitycancerassociatedwitha50%r

egionalrecurrencerateYuenHeadandNeck,1997SelectiveNeckDissectionI-IIIfororalcavityN0diseaseIIIIIAIIIBIV•T2-T4NOoral

cavity•AnyTthickness>0.4cm•IsolatedIIBmetastasisrareDistributionofNodalMetastases:Oropharynx•I10%•II52%•III34%•IV20%•V7%Oropharynx:SpecialConsi

derations•IsolatedlevelVnodalmetastasisextremelyrare•Retropharyngealnodesareaprimarynodaldrainagesite,butnotaddressedbyneckdissection•Radi

otherapyoftenadministeredforprimaryandregionalcontrol•HighriskofbilateralnodalmetastasisSelectiveNeckDissectionII-IVforOrop

harynxIVIIIIIAIIB•T2-T4NOoropharynx•T1N0controversial•Retropharyngealnodalbasinmaybetreatedwithradiotherapyregardlessofneckstatus,obv

iatingneedforselectiveneckdissectiontodeterminetherapyDistributionofNodalMetastases:LarynxandHypopharynx•I2%•II31%•III2

7%•IV12%•V2.6%SelectiveNeckDissectionHypopharynx:Considerations•Propensitytobilateralnodalmetastasis•Usuallypresentsatadvancedstage•Sel

ectiveNeckdissectionusedtodetermineneedforradiotherapyinveryearlystagelesionstreatedwithprimarysurgicaltherapySelectiveNeck

DissectionLarynx:Considerations•T1glottictumorswithlowpotentialforcervicalmetastasis,<10%,selectiveneckdissectionnotperformed•Supraglottictumor

shaveahighriskforoccultnodalmetastasisandbilateralnodalspread–T1,20%–T2,40%SelectiveNeckDissectionII-IVforHypopharynxandLarynxIVI

IIIIAIIB•T1-T4NOhypopharynx•IfN0treatedwithradiotherapyforprimary,maybenoneedforselectiveneckdissection•T2-T4NOLarynx•IfN0treatedwithr

adiotherapyforprimary,maybenoneedforselectiveneckdissectionParatrachealNodalDissectionforLarynx,Hypopharynx•10–20%riskofparatrachealnodalpositivit

yforpatientsinwhomlevelVIisdissected•Usuallyassociatedwithcontralateralpositivenodes•Oftenassociatedwithsu

bglottic,pyriformapex,cervicalesophagealtumors•Postoperativeradiotherapyresultsinareducedparastomalrecurrenceforpatientswithpathologic

nodesinlevelVISelectiveNeckDissectionVIforselectedlarynx/hypopharynx/thyroidtumorsVIPostoperativeRadiotherapyafterSelectiveNeckDissecti

on•Patientswithanysingleormultiplenodalmetastasishaveimprovedregionalcontrolwithpostoperativeradiotherapy(6

%vs.36%forsinglenode)–Byers,etal.HeadandNeck1999(n=517)–Ambrosch,etal.,OtolaryngolHNS2001(n=503)•Approximat

ely50%ofrecurrenceswerewithinthedissectedfield•Approximate5%improvementinregionalcontrolbyradiotherapyforpN1di

seaseSelectiveNeckDissectionforclinicallyN+Disease:AControversy•Rationale:Postoperativeradiotherapymayachievecontrolofmicroscopic/subclinic

almetastaticdisease•ImprovedfunctionaloutcomeSelectiveNeckDissectionforclinicallyN+Disease:AControversy•Moststudieslimited,withhigh

lyselectedgroup•Andersonetal.ArchOtolHNS,2002–106patients,129necks–55%N1,26%N2b–72%irradiated–94%controlwith>2YfollowupSelectiveLymphNodeSa

mpling•Mentionedinordertobecondemned•Positivenecksdiscovered=positivenecksmissed–Mannietal.AmJSurg1991•Sensitivityof

lessthan50%–Weinetal.Laryngoscope,2002•Sensitivity56%,specificity70%–FinnS,etal.Laryngoscope.2002Apr;11

2(4):630-3.Sentinelnodebiopsy•99Tclabeledcolloid+/-bluecolloiddyeinjectedintotumor•Preoperativeimaging,handheldgammaprobe,visualidentificationus

edtodissectsentinellymphnode(initialdrainingnode)SentinelNodeBiopsy•10-15reportsinliterature•Largestseriesisacollectionofmulticenterdata(Ros

setal.,AnnSurgOncol2002)•316necksevaluated–Sentinelnodeidentifiedin95%–76positivenecks–90%sensitivitySentinelNodeBiopsy

:Pitfalls•Onlyaccessibletumorscanbeinjectedpreoperatively,e.g.oropharynx,oralcavity•Additionalcost,ne

edforsecondprocedure•Morbidity/costanalysisvs.selectiveneckdissection•10%ofoccultmetastasesthatmaybedetectedbysel

ectiveneckdissectionremainundiagnosed•ShouldbeperformedinprospectiveclinicaltrialsNeckDissectionAfterChemotherapyand/orRadiation•Mos

tseriesadvocateneckdissectioninN2orgreaterdisease,regardlessofclinicalresponse•Residualtumorfoundinneckinover30%ofN2necksand50%o

fN3necksafterchemoradiation–Laryngoscope.2007Jan;117(1):121-8.SewallGK,etal.•Residualdiseasemaynotcorrelatewithresponse•Recurrencesafterchemor

adiationareoftenunresectableLiauwSL,AmdurRJ,MorrisCG,WerningJW,VillaretDB,MendenhallWM.Isolatedneckrecurrenceafterdefinitiver

adiotherapyfornode-positiveheadandneckcancer:Salvageinthedissectedorundissectedneck.HeadNeck.2007Feb1Well-differentiatedThyroidCancer•Norol

eforelectiveneckdissection•Centralcompartment,levelVInodaldissectionforpositivecentralnodes•Modifiedneckdissecti

on,atleastlevelsII-Vforneckmetastasis,toincludelevelIIB•“Berry-picking”isnotindicatedMedullaryThyroidCarcinoma•Totalthyro

idectomyandcentralcompartmentdissection,levelVIformostcases•IpsilateralnodaldissectionatleastlevelsII-VifcentralcompartmentisN+Salivar

yGlandCarcinoma•Noaddedsurvivalbenefittoelectiveneckdissection•However,significantrateofoccultnodalpositivityforhighgradetumors

(adenoidcystic,squamouscell,highgrademucoepidermoid,etc.)•Comprehensive(I-V)ipsilateralnodaldissectionforN+diseaseorhighgradetumor•Selective,

I-IIIdissectionforradiosensitivehistologieswithN0necksand/orhighgradetumorSummary•ComprehensiveneckdissectionLevelsI-Vrecommen

dedforclinicallyN+necks–Sacrificeofstructuresonlyifclinicallyinvolvedbytumor•Staging/SelectiveneckdissectionindicatedforN0necks

,dependentonprimarytumorsite•ComprehensiveneckdissectionLevelsI-VindicatedforN2+neckdiseasetreatedbychemoradiationSummary•Theuseofselectiveneck

dissectionforclinicallyN+iscontroversial•Theuseofsentinelnodebiopsyislesssensitivethatselectiveneckdissection,andremainsin

vestigationalFutureTrials:StatisticalConsideration•Mostretrospectivetrialsdescribea5-10%differenceinclinicalendpointsincomparisonofsentine

lnodebiopsy,selectiveneckdissection,andcomprehensiveneckdissection•Assuming80%power,wouldrequirearandomizedtrialwith1400patients(700/ar

m)todetectastatisticallysignificant5%difference.Surgeonsmustbeverycareful,Whentheytaketheknife!Underneaththeirfine

incisions,StirstheCulpritLife!~EmilyDickinson