**Meet the editor**

Professor Raja Kummoona, Fellow of the Royal College of Surgeons of England (FDSRCS), Emiratus professor of Maxillofacial Surgery of Iraqi Board for Medical Specializations, is one of 40 top scientist in Iraq. He has been a member of the Research Fellow Royal college of Surgeons of England (1975-1977), the President of Iraqi Dental Society (1977-1985). Prof. Kummoona has con-

tributed to the field with a number of publications and also by advocating many surgical procedures. He has conducted research in cancer surgery, flap reconstruction, TMJ surgery and facial injuries caused by missiles.

Contents

**Preface IX** 

**A Personal View 1**  Raja Kummoona

**Part 1 History of Neck Dissection 5** 

Jeremiah C. Tracy

**Head and Neck Cancer and Neck Dissection -** 

**Part 2 Different Techniques of Neck Dissection & Complications 23** 

Chapter 1 **A Brief History of Cervical Lymphadenectomy 7** 

Chapter 2 **Neck Dissection – Techniques and Complications 25** 

Abdul Wadood Mohammed and Anil K. Dash

**Dissection in Multidisciplinary Treatment 49**  Muneyuki Masuda, Ken-ichi Kamizono, Hideoki Uryu,

**Part 3 Advances and Modification of Neck Dissection 69** 

Chapter 6 **Advanced Developments in Neck Dissection Technique: Perspectives in Minimally Invasive Surgery 87** 

Jaimanti Bakshi, Naresh K. Panda,

Akiko Fujimura and Ryutaro Uchi

Chapter 4 **Complications of Neck Dissection 61**  Nader Saki and Soheila Nikakhlagh

Chapter 5 **Lateral Cervical Flap a Good Access** 

Raja Kummoona

**for Radical Neck Dissection 71** 

Jandee Lee and Woong Youn Chung

Chapter 3 **Roles of Therapeutic Selective Neck** 

### Contents

#### **Preface XI**

**Head and Neck Cancer and Neck Dissection - A Personal View 1**  Raja Kummoona

#### **Part 1 History of Neck Dissection 5**

	- **Part 2 Different Techniques of Neck Dissection & Complications 23**
	- **Part 3 Advances and Modification of Neck Dissection 69**

### Preface

Advances in the management of cervical lymph node deposit required many modalities in surgery, deep X-ray therapy and chemotherapy. In order to achieve maximal effectiveness when treating a patient, it is essential to take considerable criteria factors such as: the pathology of a particular tumor (beside the status of patient's general condition) and the anatomy of the region. It is important that the pathology is assessed by the surgeon and not by the pathologist.

The chosen title of the book is based on different techniques used for lymphadenactomy: radical neck dissection, selective neck dissection and conservative neck dissection, including the preservation of the spinal accessory nerve, internal jugular vein and sterno mastoid muscle, using techniques such as the endoscopic technique with reboot surgery and other types of incisions. Recently the design of the lateral cervical flap proved to be an excellent access for different modalities of lymph adenactomy.

The treatment of the majority of patients with lymph node metastasis required a multidisciplinary approach. The joined efforts of the surgeon, radiotherapist, oncologist and pathologist are necessary for a successful outcome. They should all be involved in the treatment plan and should understand the principle and current applications of chemotherapy and radiotherapy in neck cancer metastasis.

The book comprises 11 chapters (including the Introductory chapter), which fall naturally into three main sections: I) History of neck dissection, II) Different techniques of neck dissection and Complications, III) Advances and modification of neck dissection.

This type of publication required a great support and effort both from the book editor and from the publishing team. I would like to extend my thanks and gratitude to Ms Natalia Reinic, editor relations consultant, and to the publishing process managers Ms Alenka Urbancic, Mr Marko Rebrovic and Ms Silvia Vlase. All these people spent a lot of time into making this book a worthwhile publication and interesting to the readers and top specialist concerned with neck dissection.

**Prof. Raja Kummoona**

Professor Emeritus of Maxillofacial Surgery Acting Chairman of Maxillofacial Surgery Iraqi Board for Medical Specializations Baghdad, Iraq

**Head and Neck Cancer and Neck Dissection -** 

Head and neck cancer represent nearly 12% of total malignancies, including the face, the oropharynx, the parotid gland and other salivary glands, the orbit, the jaw , the sinuses and other parts of the face including the skin. These anatomical sites might be affected by other varieties of cancer, such as basal cell carcinoma, squamous-cell carcinoma, fibro sarcoma, osteogenic sarcoma and jaw lymphoma, and non-Hodgkin's lymphoma and Hodgkin's lymphoma. Jaw lymphoma is nominated from other parts of the world and Africa, such as Burkitt lymphoma. Jaw lymphoma is quite different from Burkitt lymphoma in its clinical features, aetiology and even with regard to its treatment. Jaw lymphoma is presented as having a very rapid onset with a fast spread to internal organs and the brain, while Burkitt lymphoma is a slowly growing tumour; it is well known that Burkitt lymphoma can be treated successfully by a few courses of cyclophosphamide (40 mg/square meter) but jaw lymphoma requires a more complicated regimen with combination of many chemotherapeutic agents, such as CHOP( therapeutic regimen of jaw lymphoma consist of eight doses over 24 weeks including 1.5mg/m2 Vincristine,50mg/m2 Adriamycin, 1000mg/m2 Cyclophosphomide, 10mg/m2 Methotroxate and 50mg/m2 prednisolone ) and it rarely deposits its tumour to the lymph nodes. Cancer of the head and neck constitute an important section of the total cancers affecting the body, and oral cancer represents about 4% of this; it is not necessary that all such cancers have nodal deposits in the neck, such jaw lymphoma or Burkitt Lymphoma. Malignant tumours such as squamous cell carcinoma – which form about 95% of oral cancers – and Melanoma – a highly malignant tumour with early metastasis – are rare and aggressive types of tumours and the survival rate is very low. Other malignant tumours, such as adenocarcinoma – which is a slowly growing malignant

Cancer of the paranasal sinuses is considered to be an aggressive type of malignancy with a tendency to invade the orbit and the base of the skull. The most common tumour of the sinuses is squamous cell carcinoma rather than adenocarcinoma, as a result of cellular changes from respiratory columnar type to squamous type due to the recurrence of infection and other irritating agents. These types of tumour metastasise in the cervical lymph nodes. Cancer of the oral cavity represents somewhat less than 4% of total cancer incidence but this might increase to more than 40% – as in India due to dietary causes such as spicy foods and

tumour – have less of a tendency for cervical node metastasis.

**A Personal View** 

*Professor Emeritus of Maxillofacial Surgery, Acting Chairman of Maxillofacial Surgery, Iraqi Board for Medical Specializations,* 

Raja Kummoona

*Baghdad, Iraq* 

## **Head and Neck Cancer and Neck Dissection - A Personal View**

#### Raja Kummoona

*Professor Emeritus of Maxillofacial Surgery, Acting Chairman of Maxillofacial Surgery, Iraqi Board for Medical Specializations, Baghdad, Iraq* 

Head and neck cancer represent nearly 12% of total malignancies, including the face, the oropharynx, the parotid gland and other salivary glands, the orbit, the jaw , the sinuses and other parts of the face including the skin. These anatomical sites might be affected by other varieties of cancer, such as basal cell carcinoma, squamous-cell carcinoma, fibro sarcoma, osteogenic sarcoma and jaw lymphoma, and non-Hodgkin's lymphoma and Hodgkin's lymphoma. Jaw lymphoma is nominated from other parts of the world and Africa, such as Burkitt lymphoma. Jaw lymphoma is quite different from Burkitt lymphoma in its clinical features, aetiology and even with regard to its treatment. Jaw lymphoma is presented as having a very rapid onset with a fast spread to internal organs and the brain, while Burkitt lymphoma is a slowly growing tumour; it is well known that Burkitt lymphoma can be treated successfully by a few courses of cyclophosphamide (40 mg/square meter) but jaw lymphoma requires a more complicated regimen with combination of many chemotherapeutic agents, such as CHOP( therapeutic regimen of jaw lymphoma consist of eight doses over 24 weeks including 1.5mg/m2 Vincristine,50mg/m2 Adriamycin, 1000mg/m2 Cyclophosphomide, 10mg/m2 Methotroxate and 50mg/m2 prednisolone ) and it rarely deposits its tumour to the lymph nodes. Cancer of the head and neck constitute an important section of the total cancers affecting the body, and oral cancer represents about 4% of this; it is not necessary that all such cancers have nodal deposits in the neck, such jaw lymphoma or Burkitt Lymphoma. Malignant tumours such as squamous cell carcinoma – which form about 95% of oral cancers – and Melanoma – a highly malignant tumour with early metastasis – are rare and aggressive types of tumours and the survival rate is very low. Other malignant tumours, such as adenocarcinoma – which is a slowly growing malignant tumour – have less of a tendency for cervical node metastasis.

Cancer of the paranasal sinuses is considered to be an aggressive type of malignancy with a tendency to invade the orbit and the base of the skull. The most common tumour of the sinuses is squamous cell carcinoma rather than adenocarcinoma, as a result of cellular changes from respiratory columnar type to squamous type due to the recurrence of infection and other irritating agents. These types of tumour metastasise in the cervical lymph nodes. Cancer of the oral cavity represents somewhat less than 4% of total cancer incidence but this might increase to more than 40% – as in India due to dietary causes such as spicy foods and

Head and Neck Cancer and Neck Dissection - A Personal View 3

advances in chemotherapy have seen the application of Gemzar (gencitabin) (this drug interferes with the growth and spread of cancer cells by inducing apoptosis and ant metabolite and also been used with Carboplatin) – which is a specific chemotherapy for this type of malignancy and was a promising type of chemotherapy even in cases of fourth-stage of pancreatic adenocarcinoma. In the parotid glands, adenocarcinoma is common and also is mucoepidermoid carcinoma and other malignancies; only rarely is the parotid affected by malignant oncocytoma, this type of tumour metastasises in cervical lymph nodes and

The majority of head and neck tumours require neck dissection at once, affecting the oral cavity and parotid region. However, tumours affecting the middle third of the face – such as the maxilla or the orbit – require radical surgery with flap reconstruction followed by DXT and chemotherapy, rather than radical neck dissection and as there is rarely any metastasis

Melanoma of the orofacial tumour is a highly malignant type of tumour with a high tendency for early cervical metastasis, and the prognosis is not very promising. It requires multiple therapies for controlling its tumours, including chemotherapy and radical surgery, while melanoma of the lower limbs is less aggressive and responds to radical surgery and is

Current cancer research focused now a days on understanding on the response and resistance to treatment and apoptosis. Cancer treatment depend not only on cellular damages as achieved by chemotherapy and DXT but also on the ability of the cell to respond to damages by inducing apoptotic changes and mutation in apoptotic pathway to end with resistance to chemotherapy drugs and radiation. Mitochondria and cell surface receptors

Fig. 1. Jaw lymphoma of the right side of the face of a 2 year old boy with a history of one

requires radical resection of the tumour with chemotherapy and DXT.

in the cervical lymph nodes.

month.

diagnosed with lymphoscintigraphy.

smoking – and these tumours appear as a fissure or exophytic growth or ulcer with white leukoplakia, and the most common site which is affected is the tongue and floor of the mouth. Both of these lesions in early metastasis affect the deep chain of the cervical lymph nodes, and the managements of these cases was based on a combination of three modalities in the form of radical surgery, chemotherapy and deep x-ray therapy. There is no possibility of a single technique for treatment in these cases. A frozen section in theatre is required for any assessment of the complete eradication of tumours

Nowadays, chemotherapy has played an important role in the management of head and neck cancers due to advances in the manufacturing of these drugs and DXT (deep x-ray therapy) which have become more specific and more precise in targeting cancer tumours. One technique of note is the use of the gamma Knife (Cobalt 60) in the management of brain tumours and intraocular malignancies without evisceration of the eye ball (which can be very depressing and inconvenient for patients).

The advancement of surgical management of head and neck tumours was based on advances in flap surgeries, such as a pedicle flaps like the forehead flap, the lateral cervical flap, the deltopectoral flap and the trapezius flap, or else by using free flaps like the forearm flap and the tapes dorsalis flap; these flaps are required for microanastomosis for the reconstruction the surgical defects after radical cancer surgery. We have not forgotten that the traditional use of radical neck dissection as a method of treatment for cervical lymph node metastasis has not often been used as a surgical procedure for the total radical excision of cervical lymph nodes with the radical excision of the sternomastoid muscle, the accessory nerve, deep cervical fascia and internal jugular vein ligation. This procedure has become less popular due to the creation of an obvious vertical band of scars extending all over the neck and dropping off the shoulder with a superficial exposure of the carotid tree just below the skin. This problem was overcome by the advancement of the trapezius flap so as to cover the carotid tree and so avoid any traumatic injuries to carotid content. These complications have been avoided by advances in other techniques, such as selective neck dissection, functional neck dissection and supraomohyoid neck dissection.

The advancements of different diagnostic tools for detection of any cervical lymph node metastasis and assessment of these deposit been used by application of ultra sonography , MRI and CT scan with protocol for management of cervical lymph nodes metastasis is the basis for management of cervical lymph node metastasis.

The most common malignant tumours of the orofacial region is basal cell carcinoma affecting the skin of the face and this is more common among white people who have less melanin pigment in their skin and who have continuous exposure to sun light. This tumour is a slowly growing type with a tendency to invade the underlying structures and it does not metastasis to the cervical lymph nodes. Squamous cell carcinoma represents about 95% of the total oral malignancies mainly affecting the tongue and the floor of the mouth with tendency for cervical lymph node deposits. The management of these tumours requires the application of all modalities of treatment, surgery, DXT and chemotherapy.

Adenocarcinoma is less common in the oral cavity and affects the minor salivary glands – it is more common in the maxilla and it is a slowly growing tumour that rarely metastasises in the cervical lymph nodes and is less aggressive than adenocarcinoma of the gastro-intestinal tract, which is a highly malignant tumour with early metastasis in mesenteric lymph nodes. The eradication of these tumours is rather difficult due to their early metastasis and the complicated anatomy of the area, which makes radical surgery rather difficult. Recent

smoking – and these tumours appear as a fissure or exophytic growth or ulcer with white leukoplakia, and the most common site which is affected is the tongue and floor of the mouth. Both of these lesions in early metastasis affect the deep chain of the cervical lymph nodes, and the managements of these cases was based on a combination of three modalities in the form of radical surgery, chemotherapy and deep x-ray therapy. There is no possibility of a single technique for treatment in these cases. A frozen section in theatre is required for

Nowadays, chemotherapy has played an important role in the management of head and neck cancers due to advances in the manufacturing of these drugs and DXT (deep x-ray therapy) which have become more specific and more precise in targeting cancer tumours. One technique of note is the use of the gamma Knife (Cobalt 60) in the management of brain tumours and intraocular malignancies without evisceration of the eye ball (which can be

The advancement of surgical management of head and neck tumours was based on advances in flap surgeries, such as a pedicle flaps like the forehead flap, the lateral cervical flap, the deltopectoral flap and the trapezius flap, or else by using free flaps like the forearm flap and the tapes dorsalis flap; these flaps are required for microanastomosis for the reconstruction the surgical defects after radical cancer surgery. We have not forgotten that the traditional use of radical neck dissection as a method of treatment for cervical lymph node metastasis has not often been used as a surgical procedure for the total radical excision of cervical lymph nodes with the radical excision of the sternomastoid muscle, the accessory nerve, deep cervical fascia and internal jugular vein ligation. This procedure has become less popular due to the creation of an obvious vertical band of scars extending all over the neck and dropping off the shoulder with a superficial exposure of the carotid tree just below the skin. This problem was overcome by the advancement of the trapezius flap so as to cover the carotid tree and so avoid any traumatic injuries to carotid content. These complications have been avoided by advances in other techniques, such as selective neck dissection,

The advancements of different diagnostic tools for detection of any cervical lymph node metastasis and assessment of these deposit been used by application of ultra sonography , MRI and CT scan with protocol for management of cervical lymph nodes metastasis is the

The most common malignant tumours of the orofacial region is basal cell carcinoma affecting the skin of the face and this is more common among white people who have less melanin pigment in their skin and who have continuous exposure to sun light. This tumour is a slowly growing type with a tendency to invade the underlying structures and it does not metastasis to the cervical lymph nodes. Squamous cell carcinoma represents about 95% of the total oral malignancies mainly affecting the tongue and the floor of the mouth with tendency for cervical lymph node deposits. The management of these tumours requires the

Adenocarcinoma is less common in the oral cavity and affects the minor salivary glands – it is more common in the maxilla and it is a slowly growing tumour that rarely metastasises in the cervical lymph nodes and is less aggressive than adenocarcinoma of the gastro-intestinal tract, which is a highly malignant tumour with early metastasis in mesenteric lymph nodes. The eradication of these tumours is rather difficult due to their early metastasis and the complicated anatomy of the area, which makes radical surgery rather difficult. Recent

application of all modalities of treatment, surgery, DXT and chemotherapy.

any assessment of the complete eradication of tumours

functional neck dissection and supraomohyoid neck dissection.

basis for management of cervical lymph node metastasis.

very depressing and inconvenient for patients).

advances in chemotherapy have seen the application of Gemzar (gencitabin) (this drug interferes with the growth and spread of cancer cells by inducing apoptosis and ant metabolite and also been used with Carboplatin) – which is a specific chemotherapy for this type of malignancy and was a promising type of chemotherapy even in cases of fourth-stage of pancreatic adenocarcinoma. In the parotid glands, adenocarcinoma is common and also is mucoepidermoid carcinoma and other malignancies; only rarely is the parotid affected by malignant oncocytoma, this type of tumour metastasises in cervical lymph nodes and requires radical resection of the tumour with chemotherapy and DXT.

The majority of head and neck tumours require neck dissection at once, affecting the oral cavity and parotid region. However, tumours affecting the middle third of the face – such as the maxilla or the orbit – require radical surgery with flap reconstruction followed by DXT and chemotherapy, rather than radical neck dissection and as there is rarely any metastasis in the cervical lymph nodes.

Melanoma of the orofacial tumour is a highly malignant type of tumour with a high tendency for early cervical metastasis, and the prognosis is not very promising. It requires multiple therapies for controlling its tumours, including chemotherapy and radical surgery, while melanoma of the lower limbs is less aggressive and responds to radical surgery and is diagnosed with lymphoscintigraphy.

Current cancer research focused now a days on understanding on the response and resistance to treatment and apoptosis. Cancer treatment depend not only on cellular damages as achieved by chemotherapy and DXT but also on the ability of the cell to respond to damages by inducing apoptotic changes and mutation in apoptotic pathway to end with resistance to chemotherapy drugs and radiation. Mitochondria and cell surface receptors

Fig. 1. Jaw lymphoma of the right side of the face of a 2 year old boy with a history of one month.

**Part 1** 

**History of Neck Dissection** 

mediate the pathway of apoptosis and this pathways mediated by Bcl-2 family protein and the final excursion of cell death is performed by caspace cascade which is triggered by release cytochrome C from mitochondria. Most of the activity in the development of apoptosis drugs was concentrated on apoptosis inducers for treatment of malignancies.

The future might be very promising for the control of lymph node deposits by using different methods of accessing neck dissection as well as the recent application of robot surgery (the da Vinci surgical robot system) which is more widely used in prostatic eradication than in any other specialty and which might be used in general surgery. However, this technique is limited in its application in all fields and even in head and neck malignancies. Expanding the role of DXT and chemotherapy as the first line of treatment and as a curative therapy without the need for radical neck dissection, either as an adjuvant with surgery or without as in jaw lymphoma (which is the only line of treatment for such a highly malignant tumour, being a fast spreading and fatal tumour).

Fig. 2. Post-therapy after 2 years of treatment of jaw lymphoma by 6 courses of chemotherapy, with the collaboration with Prof. Selma Al Hadad, Paediatric Oncologist, Medical City Baghdad.
