**Neck Dissection – Techniques and Complications**

Jaimanti Bakshi1, Naresh K. Panda2, Abdul Wadood Mohammed3 and Anil K. Dash4 *1Dept. Of Otolaryngology&HNS, PGIMER, CHANDIGRH 2Dept. Of Otolaryngology&HNS, PGIMER, CHANDIGARH 3Dept. Of Otolaryngology&HNS, PGIMER 4Dept. Of Otolaryngology&HNS, PGIMER, CHANDIGARH India* 

#### **1. Introduction**

"Neck dissection" refers to the surgical procedure where the lymphatics and the fibro fatty tissue of neck are removed as a treatment for cervical lymphatic metastasis. As malignancies of the upper aero-digestive tract mainly metastasize to the cervical lymph nodes, neck dissections are performed along with surgical excision of these malignancies.

#### **2. Relevant anatomy**

The cervical lymph nodes are surgically divided into six levels. Each level of lymph node is interconnected by lymphatic channels and drain specific anatomic sites of the aerodigestive tract.

#### **Level 1a** – sub-mental group

It is the midline group bounded on both sides by the anterior belly of digastrics and the hyoid bone inferiorly. Tumors of floor of mouth, anterior oral tongue, anterior mandibular alveolar ridge, and lower lip metastasize to these nodes.

**Level 1b** – submandibular group

These are the lymph node groups bounded by the anterior and posterior belly of digastric and mandible superiorly. The submandibular gland is usually included in the specimen when this group of lymph nodes is removed. Cancers of oral cavity, anterior nasal cavity, soft tissue structures of mid face and submandibular gland commonly metastasize to this group of lymph nodes.

#### **Level 2a and 2b** – upper jugular group

This group of lymph nodes is related to the upper 1/3rd of the internal jugular vein. They are bounded by the skull base above , inferior border of hyoid bone below , lateral border of sternohyoid and stylohyoid anteriorly and posterior border of sternocleidomastoid posteriorly. This group is further divided by the vertical plane in relation to the spinal accessory nerve. Level 2a is anterior to this plane and level 2b is posterior. Cancers of oral

Neck Dissection – Techniques and Complications 27

comprehensive classification widely accepted. It is based on the rationale that radical neck dissection is the standard basic procedure for cervical lymphadenectomy, and all other procedures represent one or more modifications of this procedure. When the modification of the radical neck dissection involves *preservation* of one or more *non-lymphatic structures,* the procedure is termed a modified radical neck dissection, when the modification involves *preservation* of one or more *lymph node groups* that are routinely removed in the radical neck dissection; the procedure is termed a selective neck dissection and when the modification involves removal of *additional lymph node groups or non-lymphatic structures* relative to the

radical neck dissection, the procedure is termed an extended radical neck dissection.

Medina et al has suggested that the term"comprehensive neck dissection" be used whenever all of the lymph nodes contained in levels I through V have been removed. Hence, the radical neck dissection and modified radical neck dissection would each be considered a

Three subtypes of modified radical neck dissection were recommended to denote which of the three non lymphatic structures were removed. The neck dissection is labeled as type 1, when only spinal accessory nerve is preserved, type 2 when spinal accessory nerve and the internal jugular vein was preserved and type 3 when all three non lymphatic structures were preserved. Spiro et al also have suggested changes to the existing Academy's classification system. He used the term radical neck dissection when 4 or 5 levels are resected, which included conventional radical neck dissection, modified radical neck dissection and extended radical neck dissection. The term selective neck dissection was used when 3 levels of lymph nodes are dissected and limited neck dissection when no more than

Fig. 1. Lymph node levels of neck

comprehensive neck dissection.

2 levels of lymph nodes are dissected.

cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx and parotid gland mainly metastasize to this group.

#### **Level 3** – middle jugular group

These lymph nodes are related to the middle 1/3rd of the internal jugular vein. This level is bounded by inferior border of hyoid bone above, inferior border of cricoid cartilage below, lateral border of sternohyoid anteriorly and posterior border of sternocleidomastoid posteriorly. Cancers of oral cavity, nasopharynx, oropharynx , hypopharynx, and larynx metastasize to this group of lymph nodes.

#### **Level 4** – lower jugular group

This group of lymph nodes is related to the lower 1/3rd of internal jugular vein. They are bounded by the lateral border of sternohyoid anteriorly, posterior border of sternocleidomastoid posteriorly, inferior border of cricoid cartilage superiorly and the clavicle inferiorly. Cancers from hypopharynx, cervical esophagus and larynx metastasize to this level.

#### **Level 5a and 5b** – posterior triangle group

This group of lymph nodes is related to the lower 1/3rd of the internal jugular vein along the lower half of the spinal accessory nerve and the transverse cervical artery. They also included the supraclavicular group of nodes. They are bounded by the posterior border of sternocleidomastoid anteriorly, anterior border of trapezius posteriorly and inferiorly the clavicle. Sublevel 5a and 5b are separated by a horizontal plane marking the inferior border of arch of the cricoid cartilage. Cancers of the nasopharynx, oropharynx and the thyroid gland mainly metastasize to this group.

#### **Level 6** – anterior compartment group

This group includes the pre and para tracheal nodes, the precricoid (Delphian) and the perithyroidal nodes. They are bounded by hyoid bone superiorly, supra sternal notch inferiorly and common carotid arteries laterally. Cancers arising from the thyroid gland, glottic and subglottic larynx, apex of pyriform sinus and cervical esophagus mainly metastasize to this group of lymph nodes.

#### **3. History**


#### **4. Classification of neck dissections**

The classification proposed by the Committee for head and neck surgery and oncology of the American Academy of Otolaryngology and Head and Neck surgery is the first

cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx and parotid gland

These lymph nodes are related to the middle 1/3rd of the internal jugular vein. This level is bounded by inferior border of hyoid bone above, inferior border of cricoid cartilage below, lateral border of sternohyoid anteriorly and posterior border of sternocleidomastoid posteriorly. Cancers of oral cavity, nasopharynx, oropharynx , hypopharynx, and larynx

This group of lymph nodes is related to the lower 1/3rd of internal jugular vein. They are bounded by the lateral border of sternohyoid anteriorly, posterior border of sternocleidomastoid posteriorly, inferior border of cricoid cartilage superiorly and the clavicle inferiorly. Cancers from hypopharynx, cervical esophagus and larynx metastasize to this level.

This group of lymph nodes is related to the lower 1/3rd of the internal jugular vein along the lower half of the spinal accessory nerve and the transverse cervical artery. They also included the supraclavicular group of nodes. They are bounded by the posterior border of sternocleidomastoid anteriorly, anterior border of trapezius posteriorly and inferiorly the clavicle. Sublevel 5a and 5b are separated by a horizontal plane marking the inferior border of arch of the cricoid cartilage. Cancers of the nasopharynx, oropharynx and the thyroid

This group includes the pre and para tracheal nodes, the precricoid (Delphian) and the perithyroidal nodes. They are bounded by hyoid bone superiorly, supra sternal notch inferiorly and common carotid arteries laterally. Cancers arising from the thyroid gland, glottic and subglottic larynx, apex of pyriform sinus and cervical esophagus mainly

 In 1888, *Jawdynski* described en bloc resection of cervical lymph nodes with resection of carotid, internal jugular vein and sternocleidomastoid muscle which was associated

 In 1906, *George W. Crile* of the Cleveland Clinic described the radical neck dissection. The operation encompasses removal of all the lymph nodes on one side along with the

The classification proposed by the Committee for head and neck surgery and oncology of the American Academy of Otolaryngology and Head and Neck surgery is the first

spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle. In 1967 - *Oscar Suarez* and *E. Bocca* described a more conservative operation which preserves spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle

which further improved the quality of life of patients post operatively.

mainly metastasize to this group. **Level 3** – middle jugular group

**Level 4** – lower jugular group

metastasize to this group of lymph nodes.

**Level 5a and 5b** – posterior triangle group

gland mainly metastasize to this group. **Level 6** – anterior compartment group

metastasize to this group of lymph nodes.

with very high rate of mortality.

**4. Classification of neck dissections** 

**3. History** 

comprehensive classification widely accepted. It is based on the rationale that radical neck dissection is the standard basic procedure for cervical lymphadenectomy, and all other procedures represent one or more modifications of this procedure. When the modification of the radical neck dissection involves *preservation* of one or more *non-lymphatic structures,* the procedure is termed a modified radical neck dissection, when the modification involves *preservation* of one or more *lymph node groups* that are routinely removed in the radical neck dissection; the procedure is termed a selective neck dissection and when the modification involves removal of *additional lymph node groups or non-lymphatic structures* relative to the radical neck dissection, the procedure is termed an extended radical neck dissection.

Medina et al has suggested that the term"comprehensive neck dissection" be used whenever all of the lymph nodes contained in levels I through V have been removed. Hence, the radical neck dissection and modified radical neck dissection would each be considered a comprehensive neck dissection.

Three subtypes of modified radical neck dissection were recommended to denote which of the three non lymphatic structures were removed. The neck dissection is labeled as type 1, when only spinal accessory nerve is preserved, type 2 when spinal accessory nerve and the internal jugular vein was preserved and type 3 when all three non lymphatic structures were preserved. Spiro et al also have suggested changes to the existing Academy's classification system. He used the term radical neck dissection when 4 or 5 levels are resected, which included conventional radical neck dissection, modified radical neck dissection and extended radical neck dissection. The term selective neck dissection was used when 3 levels of lymph nodes are dissected and limited neck dissection when no more than 2 levels of lymph nodes are dissected.

Neck Dissection – Techniques and Complications 29

Fig. 2. Neck dissection showing left level II lymph node adherent to IJV

#### **Surgical procedure:**

**Radical Neck Dissection:** Procedure is done under general anesthesia. Position the patient in reverse Trendelenberg's position with neck extended at atlanto-axial joint and head elevated 10 degree above the table. Face should be turned to the opposite side of the dissection. Neck skin should be cleaned with Betadine scrub and after that with 3 layers of Betadine solution. Drap the operating site with sterile towels over a polydrape sheet to minimize the infection rate. Our preferred incision for R.N.D. is Lahey's lateral utility incision in post-irradiated patients. Modified Schobinger's incision has been found to be useful in patients undergoing commando operation. We are using Mc fees double horizontal incision in some selected post-irradiated cases.

Incision is marked with surgical marker pen, infiltrate with 10-15 ml of 1% xylocaine with 1:4 lacs adrenaline solution. Wait for 5 minutes , make skin incision with 10 number surgical blade, raise the sub-platysmal flap superiorly till lower border of mandible, mastoid tip posteriorly, midline of neck anteriorly, anterior border of trapezius posteriorly, and till clavicle inferiorly. Then the lower part of sterno-cliedomastiod muscle is cut with electrocautery, 2cms above clavicle after dissecting it carefully from internal jugular vein. Dissect the IJV from its fascial attachments with common carotid artery and vagus nerve. The lower end of IJV is ligated at level of common tendinous attachment of 2 bellies of omo-hyoid muscle crossing over IJV. Transfix the IJV after ligating with double ligatures. Pull the IJV up gradually with SCM muscle after holding with Babcock forceps. Dissect all lymph nodes, lymphatics,fat and fascia from the supra clavicular fossa including level 5 nodes. Take care not to damage the brachial plexus, phrenic nerve, transverse cervical vessels. At the junction of upper 1/3 and lower 2/3 of SCM muscle, greater auricular nerve,can be seen exiting from cervical plexus crossing over external jugular vein along posterior border. GAN winds around the posterior border of SCM muscle and crosses obliquely upwards to enter into the tail of parotid gland. Spinal accessory nerve also exits at this point, known as Erb's point and runs in the posterior triangle to enter into trapezius muscle. These nerves have to be dissected from cutaneous branches supplying the fascia and skin. Ligate middle thyroid vein at level of thyroid cartilage and remove all lymph nodes along the middle 1/3 of IJV thus clearing level 3&4. Now, we have reached at the upper end of IJV. Dissect at the level of posterior belly of digastric muscle which is the landmark for ligating the upper end. Bony landmark is the transverse process of atlas. Ligate with double ligatures, transfix with 3-0 silk suture and cut the IJV after ligating the venae commitante for hypoglossal nerve. This will clear level 2a & 2b lymph nodes. Last step is removal of level 1a & 1b nodes along with submandibular gland. Remove the complete specimen enbloc. Irrigate the dissected field with normal saline and dilute betadine solution. After securing hemostasis, put Romovac 14-16 FG size drain, fix it with braided silk sutures, and connect to the bellow. After repositing the skin flap, first layer is sutured with 3-0 vicryl/ catgut suture and skin with staples /3-0 Ethicon monocryl sutures. Apply pressure dressing and check the drain function before extubating the patient. Post opetatively, patient is kept in fowler's position and give I.V. antibiotics for 5 days. Remove drain when collection is < 10 ml. Remove sutures on 7th post operative day. Discharge the patient on 7th day. Follow up will be after 1 week, check the histopathology report to see how many lymph nodes were dissected and the number of positive nodes. Refer for radiotherapy if needed. Thereafter at 1 month. Contrast CT scan /PET-CT scan should be ordered at 6 month follow up for recurrent disease. One monthly follow up will continue for 1 year ,thereafter 3 monthly for 2 years and then yearly for 10 years.

**Radical Neck Dissection:** Procedure is done under general anesthesia. Position the patient in reverse Trendelenberg's position with neck extended at atlanto-axial joint and head elevated 10 degree above the table. Face should be turned to the opposite side of the dissection. Neck skin should be cleaned with Betadine scrub and after that with 3 layers of Betadine solution. Drap the operating site with sterile towels over a polydrape sheet to minimize the infection rate. Our preferred incision for R.N.D. is Lahey's lateral utility incision in post-irradiated patients. Modified Schobinger's incision has been found to be useful in patients undergoing commando operation. We are using Mc fees double horizontal

Incision is marked with surgical marker pen, infiltrate with 10-15 ml of 1% xylocaine with 1:4 lacs adrenaline solution. Wait for 5 minutes , make skin incision with 10 number surgical blade, raise the sub-platysmal flap superiorly till lower border of mandible, mastoid tip posteriorly, midline of neck anteriorly, anterior border of trapezius posteriorly, and till clavicle inferiorly. Then the lower part of sterno-cliedomastiod muscle is cut with electrocautery, 2cms above clavicle after dissecting it carefully from internal jugular vein. Dissect the IJV from its fascial attachments with common carotid artery and vagus nerve. The lower end of IJV is ligated at level of common tendinous attachment of 2 bellies of omo-hyoid muscle crossing over IJV. Transfix the IJV after ligating with double ligatures. Pull the IJV up gradually with SCM muscle after holding with Babcock forceps. Dissect all lymph nodes, lymphatics,fat and fascia from the supra clavicular fossa including level 5 nodes. Take care not to damage the brachial plexus, phrenic nerve, transverse cervical vessels. At the junction of upper 1/3 and lower 2/3 of SCM muscle, greater auricular nerve,can be seen exiting from cervical plexus crossing over external jugular vein along posterior border. GAN winds around the posterior border of SCM muscle and crosses obliquely upwards to enter into the tail of parotid gland. Spinal accessory nerve also exits at this point, known as Erb's point and runs in the posterior triangle to enter into trapezius muscle. These nerves have to be dissected from cutaneous branches supplying the fascia and skin. Ligate middle thyroid vein at level of thyroid cartilage and remove all lymph nodes along the middle 1/3 of IJV thus clearing level 3&4. Now, we have reached at the upper end of IJV. Dissect at the level of posterior belly of digastric muscle which is the landmark for ligating the upper end. Bony landmark is the transverse process of atlas. Ligate with double ligatures, transfix with 3-0 silk suture and cut the IJV after ligating the venae commitante for hypoglossal nerve. This will clear level 2a & 2b lymph nodes. Last step is removal of level 1a & 1b nodes along with submandibular gland. Remove the complete specimen enbloc. Irrigate the dissected field with normal saline and dilute betadine solution. After securing hemostasis, put Romovac 14-16 FG size drain, fix it with braided silk sutures, and connect to the bellow. After repositing the skin flap, first layer is sutured with 3-0 vicryl/ catgut suture and skin with staples /3-0 Ethicon monocryl sutures. Apply pressure dressing and check the drain function before extubating the patient. Post opetatively, patient is kept in fowler's position and give I.V. antibiotics for 5 days. Remove drain when collection is < 10 ml. Remove sutures on 7th post operative day. Discharge the patient on 7th day. Follow up will be after 1 week, check the histopathology report to see how many lymph nodes were dissected and the number of positive nodes. Refer for radiotherapy if needed. Thereafter at 1 month. Contrast CT scan /PET-CT scan should be ordered at 6 month follow up for recurrent disease. One monthly follow up will continue for 1 year ,thereafter 3 monthly for 2 years

**Surgical procedure:**

incision in some selected post-irradiated cases.

and then yearly for 10 years.

Fig. 2. Neck dissection showing left level II lymph node adherent to IJV

Neck Dissection – Techniques and Complications 31

Fig. 4. Post Modified Radical Neck Dissection on Left side

Fig. 3. Commando operation showing left radical neck dissection

#### **Modified Neck Dissection:**

The basic procedure will remain same as for RND but we have to preserve one/more than one of the 3 structures i.e. SCM muscle, Spinal accessory nerve and IJV. Preserve the greater auricular nerve and transverse cervical vessels for decreased morbidity.

Fig. 3. Commando operation showing left radical neck dissection

auricular nerve and transverse cervical vessels for decreased morbidity.

The basic procedure will remain same as for RND but we have to preserve one/more than one of the 3 structures i.e. SCM muscle, Spinal accessory nerve and IJV. Preserve the greater

**Modified Neck Dissection:** 

Fig. 4. Post Modified Radical Neck Dissection on Left side

Neck Dissection – Techniques and Complications 33

Fig. 6. Post left supra-omohyoid neck dissection

operatively or in post irradiated neck.

Type 3 Modified neck dissections and selective neck dissections are the most common neck dissections performed in our institute. The decision is made intra operatively. In general,for N0 neck , supraomohyoid neck dissection and for N1 neck, type 3 modified radical neck dissection is done. Radical neck dissection is done only when there is gross infilteration of the sternocleidomastoid muscle or spinal accessory nerve or internal jugular vein intra

**5. Our experience** 

Fig. 5. Left Modified Radical Neck dissection exposing preserved structures

#### **Selective Neck Dissection:**

Modified Schobinger incision/ Apron flap incision are the best incisions for this procedure. Dissection will start from level I and will go to level III/IV in Supra omohyoid neck dissection and will include level VI in Anterior compartment dissection.

Fig. 5. Left Modified Radical Neck dissection exposing preserved structures

dissection and will include level VI in Anterior compartment dissection.

Modified Schobinger incision/ Apron flap incision are the best incisions for this procedure. Dissection will start from level I and will go to level III/IV in Supra omohyoid neck

**Selective Neck Dissection:** 

Fig. 6. Post left supra-omohyoid neck dissection

#### **5. Our experience**

Type 3 Modified neck dissections and selective neck dissections are the most common neck dissections performed in our institute. The decision is made intra operatively. In general,for N0 neck , supraomohyoid neck dissection and for N1 neck, type 3 modified radical neck dissection is done. Radical neck dissection is done only when there is gross infilteration of the sternocleidomastoid muscle or spinal accessory nerve or internal jugular vein intra operatively or in post irradiated neck.

Neck Dissection – Techniques and Complications 35

Fig. 8. Lateral Utility incision Lahey's

Fig. 9. Apron flap incision

Modified schobinger's incision is the most common incision used for Modified radical neck dissection. It has the advantage of adequate exposure and the incision can be easily extended anteriorly as lip splitting incision in order to expose the primary oral cavity tumor. The Lahey's lateral utility incision is commonly used in post irradiated neck as it has the advantage of not forming a three point junction and prevents wound dehiscence and carotid blow out. Transverse cervical neck incision would suffice for supra omohyoid neck dissection. Other incisions occasionally used are the Wisor flap, Boomerang incision and Mc fee's incision. Post operatively negative suction drains are put for an average period of 3-5 days and patient needs hospital admission for an average period of 10 days. Plan for post operative radiotherapy is done according to the stage of disease and post operative histopathology report. External Beam radiotherapy is given in the dose of 50 to 55 Grays in 20 to 30 fractions with in a period of 6 weeks started as early as possible when the wound is healed. Radiotherapy is given for all advanced stage disease (Stage 3 and 4) and when the histopathology report shows resection margins involved or close to tumour, more than 2 lymph nodes involved, perineural spread or extracapsular spread.

Figures 7, 8, 9 show the types of incisions which we use for neck dissections.

Fig. 7. Modified Schobinger's incision

Modified schobinger's incision is the most common incision used for Modified radical neck dissection. It has the advantage of adequate exposure and the incision can be easily extended anteriorly as lip splitting incision in order to expose the primary oral cavity tumor. The Lahey's lateral utility incision is commonly used in post irradiated neck as it has the advantage of not forming a three point junction and prevents wound dehiscence and carotid blow out. Transverse cervical neck incision would suffice for supra omohyoid neck dissection. Other incisions occasionally used are the Wisor flap, Boomerang incision and Mc fee's incision. Post operatively negative suction drains are put for an average period of 3-5 days and patient needs hospital admission for an average period of 10 days. Plan for post operative radiotherapy is done according to the stage of disease and post operative histopathology report. External Beam radiotherapy is given in the dose of 50 to 55 Grays in 20 to 30 fractions with in a period of 6 weeks started as early as possible when the wound is healed. Radiotherapy is given for all advanced stage disease (Stage 3 and 4) and when the histopathology report shows resection margins involved or close to tumour, more than 2

lymph nodes involved, perineural spread or extracapsular spread.

Fig. 7. Modified Schobinger's incision

Figures 7, 8, 9 show the types of incisions which we use for neck dissections.

Fig. 8. Lateral Utility incision Lahey's

Fig. 9. Apron flap incision

Neck Dissection – Techniques and Complications 37

Fig. 11. PET/CT showing increased uptake in right lateral border of tongue and Right level

1b and 2 lymph nodes

Fig. 12. Right level 1b lymph node

#### **6. Complications**


#### **Case 1**

32 year old male presented to our out patient department with complaints of non healing ulcer over the tongue for which he was taking medication from local practisioners. He had been taking Gutka (a local tobacco preparation) and was smoking cigarettes around cigarattes 2 – 3 packs/day for 15 years. On examination he had a 2 x 2 cm ulcero indurated lesion over the right lateral border of tongue. His neck examination showed a 1 x 1.5 cm right level 1b lymph node. A PET/CT was done for metastatic work up which showed intense uptake over the lesion on the right lateral border of tongue, moderate uptake in right level 1b and 2 lymph nodes and no distant metastasis. Patient underwent right partial glossectomy with right type 3 functional neck dissection. The post operative histopathology report came as all resection margins free of tumor, however the posterior resection margin was close to tumor and 0/33 lymph nodes free of tumor. Patient underwent post operative external radiotherapy of 55 Gys 25 fractions in 6 weeks and is now on follow up for the last 6 months without any locoregional recurrence.

Fig. 10. Ulcero indurated growth involving right lateral border of tongue

2. Black/ bluish discoloration of the skin flap at 3 point junction or at posterior lip can

5. Chyle leak can occur in 2-3% patients and heals with conservative treatment most of the

7. Carotid blow out has been seen in < 1% patients after RND. It is common in irradiated

32 year old male presented to our out patient department with complaints of non healing ulcer over the tongue for which he was taking medication from local practisioners. He had been taking Gutka (a local tobacco preparation) and was smoking cigarettes around cigarattes 2 – 3 packs/day for 15 years. On examination he had a 2 x 2 cm ulcero indurated lesion over the right lateral border of tongue. His neck examination showed a 1 x 1.5 cm right level 1b lymph node. A PET/CT was done for metastatic work up which showed intense uptake over the lesion on the right lateral border of tongue, moderate uptake in right level 1b and 2 lymph nodes and no distant metastasis. Patient underwent right partial glossectomy with right type 3 functional neck dissection. The post operative histopathology report came as all resection margins free of tumor, however the posterior resection margin was close to tumor and 0/33 lymph nodes free of tumor. Patient underwent post operative external radiotherapy of 55 Gys 25 fractions in 6 weeks and is now on follow up for the last 6 months without any locoregional recurrence.

times. No patient required neck exploration for repair of the thoracic duct.

1. Anesthesia of the skin of the neck is most common complication.

3. Minor wound dehiscences and wound infections can occur in some.

6. Air embolism can occur in <1% cases due to inadvertent injury to IJV.

Fig. 10. Ulcero indurated growth involving right lateral border of tongue

**6. Complications** 

necks

**Case 1** 

occur in some patients.

4. Seroma formation has been seen occasionally.

Fig. 11. PET/CT showing increased uptake in right lateral border of tongue and Right level 1b and 2 lymph nodes

Fig. 12. Right level 1b lymph node

Neck Dissection – Techniques and Complications 39

Fig. 15. Neck dissection. Showing Marginal Mandibular nerve and Level Ib lymph node

Fig. 14. Segmental mandibulectomy with tumor

#### **Case 2**

50 year old chronic Zarda chewer (local tobacco preparation) and cigarette smoker presented with growth over the left lower alveolus for 3 months. On examination he had a 4 x 3 cm ulcero proliferative growth extending from the (L) lateral incisor to the 3 rd molar involving the lower gingivo buccal sulcus and the buccal mucosa till the level of crown of teeth. There was a 3x 3 cm swelling over the left mandible 1 cm away from the angle of mouth with free overlying skin. On neck examination the left level 1b had 1x 1 cm lymph node and level 2 3 x 2 cm. A PET/CT was done for metastatic work up which showed intense uptake SUV 22.3 over the lesion over (L) lower alveolus and (L) level 1b and 2 without any distant metastasis. Patient underwent (L) segmental mandibulectomy with (L) Radical neck dissection as the level 2 lymph node was adherent to the IJV and sternocleidomastoid intra operatively and reconstruction with pectoralis major myocutaneous flap. Patient received 50 Gys External Radiotherapy and is disease free for 12 months.

Fig. 13. case 2

50 year old chronic Zarda chewer (local tobacco preparation) and cigarette smoker presented with growth over the left lower alveolus for 3 months. On examination he had a 4 x 3 cm ulcero proliferative growth extending from the (L) lateral incisor to the 3 rd molar involving the lower gingivo buccal sulcus and the buccal mucosa till the level of crown of teeth. There was a 3x 3 cm swelling over the left mandible 1 cm away from the angle of mouth with free overlying skin. On neck examination the left level 1b had 1x 1 cm lymph node and level 2 3 x 2 cm. A PET/CT was done for metastatic work up which showed intense uptake SUV 22.3 over the lesion over (L) lower alveolus and (L) level 1b and 2 without any distant metastasis. Patient underwent (L) segmental mandibulectomy with (L) Radical neck dissection as the level 2 lymph node was adherent to the IJV and sternocleidomastoid intra operatively and reconstruction with pectoralis major myocutaneous flap. Patient received 50 Gys External Radiotherapy and is disease free for 12

**Case 2** 

months.

Fig. 13. case 2

Fig. 14. Segmental mandibulectomy with tumor

Fig. 15. Neck dissection. Showing Marginal Mandibular nerve and Level Ib lymph node

Neck Dissection – Techniques and Complications 41

Fig. 17. Primary lesion. Incision is modified for resection of primary tumor

#### **Case 3**

37 year old female with no history of any addiction presented with history of swelling over the left cheek which was rapidly increasing in size and difficulty in opening mouth for 3 month. On examination there was a 6 x 8 cm swelling over the left cheek which was fluctuant. The swelling late ruptured to form an ulcer as shown in figure 17. There was a 3 x 3 cm ulcer in the left buccal mucosa with extension into the lower gingivo buccal sulcus. On neck examination left level 1b was 1 x 2 cm enlarged. CECT of neck was done which showed the primary tumor involving left buccal mucosa and skin with ipsilateral involvement of level 1b and 2 lymph node levels. The patient underwent a Wide local excision with left type 3 modified neck dissection and the defect was reconstructed using antero-lateral thigh free flap. The patient received 60 Gys postoperative radiotherapy over 6 weeks and is disease free for 12 months now.

37 year old female with no history of any addiction presented with history of swelling over the left cheek which was rapidly increasing in size and difficulty in opening mouth for 3 month. On examination there was a 6 x 8 cm swelling over the left cheek which was fluctuant. The swelling late ruptured to form an ulcer as shown in figure 17. There was a 3 x 3 cm ulcer in the left buccal mucosa with extension into the lower gingivo buccal sulcus. On neck examination left level 1b was 1 x 2 cm enlarged. CECT of neck was done which showed the primary tumor involving left buccal mucosa and skin with ipsilateral involvement of level 1b and 2 lymph node levels. The patient underwent a Wide local excision with left type 3 modified neck dissection and the defect was reconstructed using antero-lateral thigh free flap. The patient received 60 Gys postoperative radiotherapy over 6

Fig. 16. PET/CT image case 2

weeks and is disease free for 12 months now.

**Case 3** 

Fig. 17. Primary lesion. Incision is modified for resection of primary tumor

Neck Dissection – Techniques and Complications 43

Fig. 19. Post resection with Segmental Mandibulectomy and Modified neck dissection

Fig. 20. After reconstruction with Antero lateral thigh free flap

Fig. 18. CECT of case 3 showing primary tumour and neck node

Fig. 18. CECT of case 3 showing primary tumour and neck node

Fig. 19. Post resection with Segmental Mandibulectomy and Modified neck dissection

Fig. 20. After reconstruction with Antero lateral thigh free flap

Neck Dissection – Techniques and Complications 45

Basal collapse and bronchopneumonia may occur in patients who are smokers and have

This is seen in patients in old age, surgeries lasting for more duration, long bedridden patients and patients with previous history of deep vein thrombosis, pulmonary embolism,

This happens due injury to the thoracic duct while performing a radical surgery low in the neck or mediastinum. If chylous fistula is suspected every attempt should be made to seal it at the time of surgery by identifying it by head down positions and performing modified valsalva manoeuvre. It should be suspected when the drain collection increases dramatically by volume. Fat restricted diet, and daily pressure dressings are the form of conservative treatment for chyle leak. When the drain collection reaches 600 ml per day or more, it is an

This usually occurs when the skin wound breaks down because of previous irradiation, secondary infection, poor metabolic condition of the patient. It is a fatal complication resulting in immediate mortality if not intervened immediately. Control of bleeding by immediate finger pressure, airway management, blood transfusion and exploration in

When both the internal jugular veins are ligated , lymphedema often follows owing to

From year 1998 to 2011, the author has done over 250 neck dissections which included around 50 selective neck dissections and 200 comprehensive neck dissections. Out of the 200 comprehensive neck dissections, 75 were radical neck dissections and 125 were modified neck dissections. However if we look at the year wise distribution, we could clearly see a change in trend from radical neck dissection to less radical, modified radical neck dissection. 60 out of 75 i.e. 91% were done before year 2006 and 15 ie only 9 % were done after 2006. A separate study has been done in year 2009-2010 by Bakshi et al which compared selective neck dissection with modified/radical neck dissection in terms of outcome and disease control in patients with carcinoma of buccal mucosa and also analyzed whether selective neck dissection can be used as a safe and effective treatment modality in N0 and N+ necks in cases of carcinoma buccal mucosa. The study included 22 patients who underwent

indication for exploration and repair of the injured thoracic duct under microscope.

Recurrences can be at the primary site, in the neck nodes or as a distant metastasis.

interruption of the lymphatic drainage channels from the head.

**Intermediate complications**  Pulmonary complications

Deep vein thrombosis

Carotid artery rupture

**Late complications** 

Recurrence

Lymph edema

Hypertrophic scars **Author's experience** 

operation theatre has to be done.

Chylous fistula

pre-existing chronic obstructive lung disease.

myocardial infarction and thrombophilia.

#### **Complications**

Complications of neck dissection can be broadly divided into early, intermediate and late.

#### **Immediate**

#### Hemorrhage

Postoperative hemorrhage usually occurs immediately after surgery. External bleeding through the incision often originates in a subcutaneous blood vessel. In most patients, this may be readily controlled by ligation, direct cauterization or infiltration of the surrounding tissues with an anesthetic solution containing epinephrine. Pronounced swelling or ballooning of the skin flaps immediately after surgery, with or without external bleeding, should be attributed to a hematoma in the wound. If a hematoma is detected early, "milking" the drains occasionally may result in evacuation of the accumulated blood and the problem will resolve. If this is not accomplished immediately or if blood re-accumulates quickly, it is best to return the patient to the operating room, explore the wound under sterile conditions, evacuate the hematoma, and control the bleeding.

#### Airway obstruction

In cases of bilateral neck dissections there may be associated soft tissue edema. Moreover resection of the primary upper aero-digestive malignancy may also add to the edema of the airway. It is always prudent to carry out a temporary elective tracheotomy to protect the airway.

#### Increased intracranial pressure

This usually occurs when the internal jugular vein is ligated. When one internal jugular vein is ligated the pressure rises by 3 fold and when both are ligated it increases by 5 fold. This usually is temporary and will normalize in 24 hours. If it persists, head end elevation, steroids and mannitol can be used.

#### Nerve injury

The main nerves which are at risk during neck dissection are spinal accessory nerve, vagus nerve, hypoglossal nerve, phrenic nerve and lingual nerve. Spinal accessory nerve injury causes difficulty in shrugging shoulders and shoulder hand syndrome. Hypoglossal nerve injury will cause tongue paralysis. Vagus nerve injury may manifest as aspiration and voice problems. Phrenic nerve injury causes paradoxical breathing and lingual nerve injury causes taste problems. Neuropraxia may recover within months; where as neurotemesis and axonotemesis have varying outcome.

#### Carotid sinus syndrome

This is due to undue pressure and manipulation on the carotid sinus baroreceptor which may result in hypotension and bradycardia. Post operative scarring may also make the receptor sensitive to even palpation and turning head.

#### Pneumothorax

Too much lower neck dissection may cause injury to the apical pleura causing pneumothorax. Patient may become restless, cyanosed and dyspnoeic after operation. A plain radiograph of chest most often provides the diagnosis. Minimal emphysema may resolve itself but whereas severe cases may require intercostal chest drains.

#### **Intermediate complications**

#### Pulmonary complications

Basal collapse and bronchopneumonia may occur in patients who are smokers and have pre-existing chronic obstructive lung disease.

#### Deep vein thrombosis

This is seen in patients in old age, surgeries lasting for more duration, long bedridden patients and patients with previous history of deep vein thrombosis, pulmonary embolism, myocardial infarction and thrombophilia.

#### Chylous fistula

44 Neck Dissection – Clinical Application and Recent Advances

Complications of neck dissection can be broadly divided into early, intermediate and late.

Postoperative hemorrhage usually occurs immediately after surgery. External bleeding through the incision often originates in a subcutaneous blood vessel. In most patients, this may be readily controlled by ligation, direct cauterization or infiltration of the surrounding tissues with an anesthetic solution containing epinephrine. Pronounced swelling or ballooning of the skin flaps immediately after surgery, with or without external bleeding, should be attributed to a hematoma in the wound. If a hematoma is detected early, "milking" the drains occasionally may result in evacuation of the accumulated blood and the problem will resolve. If this is not accomplished immediately or if blood re-accumulates quickly, it is best to return the patient to the operating room, explore the wound under

In cases of bilateral neck dissections there may be associated soft tissue edema. Moreover resection of the primary upper aero-digestive malignancy may also add to the edema of the airway. It is always prudent to carry out a temporary elective tracheotomy to protect the

This usually occurs when the internal jugular vein is ligated. When one internal jugular vein is ligated the pressure rises by 3 fold and when both are ligated it increases by 5 fold. This usually is temporary and will normalize in 24 hours. If it persists, head end elevation,

The main nerves which are at risk during neck dissection are spinal accessory nerve, vagus nerve, hypoglossal nerve, phrenic nerve and lingual nerve. Spinal accessory nerve injury causes difficulty in shrugging shoulders and shoulder hand syndrome. Hypoglossal nerve injury will cause tongue paralysis. Vagus nerve injury may manifest as aspiration and voice problems. Phrenic nerve injury causes paradoxical breathing and lingual nerve injury causes taste problems. Neuropraxia may recover within months; where as neurotemesis and

This is due to undue pressure and manipulation on the carotid sinus baroreceptor which may result in hypotension and bradycardia. Post operative scarring may also make the

Too much lower neck dissection may cause injury to the apical pleura causing pneumothorax. Patient may become restless, cyanosed and dyspnoeic after operation. A plain radiograph of chest most often provides the diagnosis. Minimal emphysema may

resolve itself but whereas severe cases may require intercostal chest drains.

sterile conditions, evacuate the hematoma, and control the bleeding.

**Complications** 

Airway obstruction

Increased intracranial pressure

steroids and mannitol can be used.

axonotemesis have varying outcome.

receptor sensitive to even palpation and turning head.

Carotid sinus syndrome

Pneumothorax

airway.

Nerve injury

**Immediate**  Hemorrhage

> This happens due injury to the thoracic duct while performing a radical surgery low in the neck or mediastinum. If chylous fistula is suspected every attempt should be made to seal it at the time of surgery by identifying it by head down positions and performing modified valsalva manoeuvre. It should be suspected when the drain collection increases dramatically by volume. Fat restricted diet, and daily pressure dressings are the form of conservative treatment for chyle leak. When the drain collection reaches 600 ml per day or more, it is an indication for exploration and repair of the injured thoracic duct under microscope.

#### Carotid artery rupture

This usually occurs when the skin wound breaks down because of previous irradiation, secondary infection, poor metabolic condition of the patient. It is a fatal complication resulting in immediate mortality if not intervened immediately. Control of bleeding by immediate finger pressure, airway management, blood transfusion and exploration in operation theatre has to be done.

#### **Late complications**

Recurrence

Recurrences can be at the primary site, in the neck nodes or as a distant metastasis.

#### Lymph edema

When both the internal jugular veins are ligated , lymphedema often follows owing to interruption of the lymphatic drainage channels from the head.

#### Hypertrophic scars

#### **Author's experience**

From year 1998 to 2011, the author has done over 250 neck dissections which included around 50 selective neck dissections and 200 comprehensive neck dissections. Out of the 200 comprehensive neck dissections, 75 were radical neck dissections and 125 were modified neck dissections. However if we look at the year wise distribution, we could clearly see a change in trend from radical neck dissection to less radical, modified radical neck dissection. 60 out of 75 i.e. 91% were done before year 2006 and 15 ie only 9 % were done after 2006.

A separate study has been done in year 2009-2010 by Bakshi et al which compared selective neck dissection with modified/radical neck dissection in terms of outcome and disease control in patients with carcinoma of buccal mucosa and also analyzed whether selective neck dissection can be used as a safe and effective treatment modality in N0 and N+ necks in cases of carcinoma buccal mucosa. The study included 22 patients who underwent

Neck Dissection – Techniques and Complications 47

Another study done by the author which analysed the outcome of surgical treatment for squamous cell carcinoma of the oral cavity taking into consideration mode of presentation, histopathological aspects, treatment , recurrence, prognostic factors and survival in patients undergoing various surgical modalities for primary oral cancer and metastatic cervical nodes. The study included 80 patients and was done between 2001 and 2006. The study concluded that combined modality of treatment would be a better approach to deal with advanced oral cancer as it offers good loco regional control and survival rate. However, tumor size and extent, type and grade, the neck node status and the status of excision

Group

A B

Count 9 7 16 % within Group 40.9% 35.0% 38.09%

Count 13 13 26 % within Group 59.1% 65.0% 61.91%

Total

margins do affect surgical prognosis and survival rate.

Fig. 23. Patient Distribution

Recurrence

Survived

OUTCOME

Table 1. Study results

Fig. 21. Number of neck dissections by author

Fig. 22. Year wise distribution of Neck dissections

modified/radical neck dissection and 20 patients who underwent selective neck dissection. It was seen that 16(38.09%) patients out of the total group of 42 patients , had recurrence/residual disease at the time of completion of study whereas the remaining 26 patients(61.91%) were disease free for a minimum period of 6 months (ranging from 12- 24months) with a mean follow up of 18 months . When studied group wise it was noticed that 9 (40.90%) patients in Group A (RADICAL NECK DISSECTION/MODIFIED RADICAL NECK DISSECTION) had recurrence whereas only 7 (35%) patients in Group B(SELECTIVE NECK DISSECTION) had recurrence. The difference between the number of patients with recurrent disease between the groups was not found to be statistically significant (p=0.790). The study puts into perspective, selective neck dissection in the cases of carcinoma buccal mucosa, as a safe and effective modality for addressing the neck disease in both N0 and N1, N2a and N2b necks with failure rate being comparable to that of radical/modified radical neck dissections. Hence patients can be spared from the morbidity of more radical procedures without compromising on the oncological safety. Most common lymphnode group involved in this study was level Ib followed by IIa.

modified/radical neck dissection and 20 patients who underwent selective neck dissection. It was seen that 16(38.09%) patients out of the total group of 42 patients , had recurrence/residual disease at the time of completion of study whereas the remaining 26 patients(61.91%) were disease free for a minimum period of 6 months (ranging from 12- 24months) with a mean follow up of 18 months . When studied group wise it was noticed that 9 (40.90%) patients in Group A (RADICAL NECK DISSECTION/MODIFIED RADICAL NECK DISSECTION) had recurrence whereas only 7 (35%) patients in Group B(SELECTIVE NECK DISSECTION) had recurrence. The difference between the number of patients with recurrent disease between the groups was not found to be statistically significant (p=0.790). The study puts into perspective, selective neck dissection in the cases of carcinoma buccal mucosa, as a safe and effective modality for addressing the neck disease in both N0 and N1, N2a and N2b necks with failure rate being comparable to that of radical/modified radical neck dissections. Hence patients can be spared from the morbidity of more radical procedures without compromising on the oncological safety. Most common lymphnode

Fig. 21. Number of neck dissections by author

Fig. 22. Year wise distribution of Neck dissections

group involved in this study was level Ib followed by IIa.

Another study done by the author which analysed the outcome of surgical treatment for squamous cell carcinoma of the oral cavity taking into consideration mode of presentation, histopathological aspects, treatment , recurrence, prognostic factors and survival in patients undergoing various surgical modalities for primary oral cancer and metastatic cervical nodes. The study included 80 patients and was done between 2001 and 2006. The study concluded that combined modality of treatment would be a better approach to deal with advanced oral cancer as it offers good loco regional control and survival rate. However, tumor size and extent, type and grade, the neck node status and the status of excision margins do affect surgical prognosis and survival rate.

Fig. 23. Patient Distribution


Table 1. Study results

**3** 

 *Japan* 

**Roles of Therapeutic Selective Neck Dissection** 

*Department of Otolaryngology and Head and Neck Surgery, Kyushu Koseinenkin* 

In the treatment of head and neck squamous cell carcinoma (HNSCC), management of cervical lymph nodal metastases has a crucial impact on the prognosis of patients. The "radical neck dissection (RND)", which was proposed by Crile (Crile, 1906) in 1906, had long been played a role of standard treatment for neck metastases due to its high curability. However, during the last two to three decades, modified neck dissection (MND), also called as "functional neck dissection", which preserves non-lymphatic structures, has replaced the position of RND, because patients as well as surgeons have become more aware of the significance of the quality of life. In addition, it has become apparent that under current multimodality treatment protocols, MND can achieve improved functional results without compromising oncological outcomes, compared to the conventional RND (Ferlito et al., 2003). Of note, in this study, MND implies the comprehensive (I-V) ND that is generally termed as "modified radical neck dissection (MRND)", unless described otherwise. Moreover, the detailed studies on the patterns of potential neck metastases clearly demonstrated that the laryngeal and pharyngeal cancers seldom metastasize to the level I and V, while the oral cavity cancers to the level IV and V (Lindberg, 1972; Shah, 1990). These data have strongly encouraged the application of selective neck dissection (SND) that spares the dissection of at least one level in the treatment of clinically N0 neck as "elective" SND (ESND). It is now widely accepted that ESND can achieve similar regional control rates compared to comprehensive neck dissection (CND) (i.e., RND or MRND) in this N0 clinical setting with improved functional outcomes as summarized in a comprehensive review (Ferlito et al., 2006). Recent remarkable advancements in chemoradiation have further extended the application of SND to clinically N+ cases as "therapeutic" SND (TSND) instead of therapeutic CND (TCND). Efficacy of TSND performed either as an initial treatment or as a planed ND (PND) in the course of multidisciplinary treatments has been reported by an increasing number of studies (Ambrosch et al., 2001; Byers et al., 1999; Ferlito et al., 2009; Lohuis et al., 2004; Muzaffar, 2003; Patel et al., 2008; Shepard et al., 2010). Moreover, a recent study by Robins et. al., (Robbins et al., 2005) demonstrated that super selective (i.e., only two levels) neck dissection can achieve quite favorable outcomes, when performed as a PND after RADPLAT. In view of these observations, neck dissection (ND)

**1. Introduction** 

**in Multidisciplinary Treatment** 

*Hospital, 1-8-1 Kishinoura, Nishiku, Kitakyushu , Fukuoka* 

Akiko Fujimura and Ryutaro Uchi

Muneyuki Masuda, Ken-ichi Kamizono, Hideoki Uryu,

#### **7. References**


## **Roles of Therapeutic Selective Neck Dissection in Multidisciplinary Treatment**

Muneyuki Masuda, Ken-ichi Kamizono, Hideoki Uryu, Akiko Fujimura and Ryutaro Uchi *Department of Otolaryngology and Head and Neck Surgery, Kyushu Koseinenkin Hospital, 1-8-1 Kishinoura, Nishiku, Kitakyushu , Fukuoka Japan* 

#### **1. Introduction**

48 Neck Dissection – Clinical Application and Recent Advances

Robbins KT. Classification of neck dissection: current concepts and future considerations.

Medina JE, Byers RM: Supraomohyoid neck dissection: Rationale, indication and surgical

Shah JP: Patterns of lymph node metastasis from squamous carcinomas of the upper

Michael J. Gleeson Scott-Brown's Otorhinolaryngology: Head and Neck Surgery 7Ed ,

Medina JE. Neck Dissection. In: Bailey BJ and Johnson JT. *Head & Neck Surgery-*

Ashok R. Shaha Radical Neck Dissection. Operative Techniques in General Surgery, Vol 6,

Javier Gavilan et al, Modified Neck dissection. Operative Techniques in General Surgery,

*Otolaryngology*. 2. 4th ed. Chapter 113: Lippincott Williams & Wilkins; 2006:1585-

Fig. 24. Patient survival as calculated by Kaplan Meier method

*Otolaryngol Clin North Am*. Aug 1998;31(4):639-55

aerodigestive tract. *Am J Surg* 1990, 160:405-409.

**7. References** 

technique. *Head Neck* 1989, 11:111-122

Chapter 199

No 2 (June), 2004: pp 72-82

Vol 6, No 2 (June),2001: pp 83-94

1609

In the treatment of head and neck squamous cell carcinoma (HNSCC), management of cervical lymph nodal metastases has a crucial impact on the prognosis of patients. The "radical neck dissection (RND)", which was proposed by Crile (Crile, 1906) in 1906, had long been played a role of standard treatment for neck metastases due to its high curability. However, during the last two to three decades, modified neck dissection (MND), also called as "functional neck dissection", which preserves non-lymphatic structures, has replaced the position of RND, because patients as well as surgeons have become more aware of the significance of the quality of life. In addition, it has become apparent that under current multimodality treatment protocols, MND can achieve improved functional results without compromising oncological outcomes, compared to the conventional RND (Ferlito et al., 2003). Of note, in this study, MND implies the comprehensive (I-V) ND that is generally termed as "modified radical neck dissection (MRND)", unless described otherwise. Moreover, the detailed studies on the patterns of potential neck metastases clearly demonstrated that the laryngeal and pharyngeal cancers seldom metastasize to the level I and V, while the oral cavity cancers to the level IV and V (Lindberg, 1972; Shah, 1990). These data have strongly encouraged the application of selective neck dissection (SND) that spares the dissection of at least one level in the treatment of clinically N0 neck as "elective" SND (ESND). It is now widely accepted that ESND can achieve similar regional control rates compared to comprehensive neck dissection (CND) (i.e., RND or MRND) in this N0 clinical setting with improved functional outcomes as summarized in a comprehensive review (Ferlito et al., 2006). Recent remarkable advancements in chemoradiation have further extended the application of SND to clinically N+ cases as "therapeutic" SND (TSND) instead of therapeutic CND (TCND). Efficacy of TSND performed either as an initial treatment or as a planed ND (PND) in the course of multidisciplinary treatments has been reported by an increasing number of studies (Ambrosch et al., 2001; Byers et al., 1999; Ferlito et al., 2009; Lohuis et al., 2004; Muzaffar, 2003; Patel et al., 2008; Shepard et al., 2010). Moreover, a recent study by Robins et. al., (Robbins et al., 2005) demonstrated that super selective (i.e., only two levels) neck dissection can achieve quite favorable outcomes, when performed as a PND after RADPLAT. In view of these observations, neck dissection (ND)

Roles of Therapeutic Selective Neck Dissection in Multidisciplinary Treatment 51

All patients, expect for one primary unknown case, were treated with our treatment

Briefly, tumors from the pharynx and larynx (Fig.1), and oral tumors with advanced T and N+ (Fig.2) were initially treated with 30-40 Gy of concurrent chemoradiotherapy (CCR) composed of S-1 (80-120mg/day, p.o.), Vitamin A (50.000 IU/day, i.m.) and external beam of irradiation (1.8-2.0 Gy/day), which we have termed "TAR therapy" (Kumamoto et al., 2002; Nakashima et al., 2005). Then further treatments course were determined according to

For oral cavity tumors with early T and N+ or any T and N0, surgery was adopted as an initial treatment modality and then additional CCR was administered when necessary. One primary unknown case underwent an initial ND and additional 50 Gy of CCR. In these protocols, ND has been considered as a part of multidisciplinary treatment, and therefore organ preserving ND and both elective and therapeutic SND have been employed as our standard option for neck metastases. Our basic policies for ND are as follows: (1) preserve the spinary accessory verve (XI), internal jugula vein (IJV) and sternocleidmastoid muscle (SCM) (of note, the SCM is sacrificed when primary tumor site is reconstructed with a pectoralis major myocutaneous flap), unless direct invasion of tumors is highly suspected, (2) in N+ cases, the dissection of positive N levels is mandatory, but omit the dissection of respective I and V for laryngeal and pharyngeal cancer and IV and V for oral cavity cancer (Figs. 1 and 2), considering the size, position, number and invasiveness of the positive N located in the adjacent levels, and (3) in N0 cases, we employ ESND: II, III, and IV dissection for laryngeal and pharyngeal cancer, and I, II, and III dissection for oral cavity cancer (i.e.,

SOND) (Figs. 1 and 2). These protocols are approved by the Hospital Review Board.

drop are prominent. He has severe difficulty in stretching up of the left arm.

Fig.3 demonstrates the surgical view of RND for primary unknown bulky nodes and consequent cosmetic and functional results. Deformity of the dissected neck and shoulder-

Fig. 2. Algorisms for the treatments of oral cavity carcinomas

**2.2 Treatment protocol** 

**2.3 Neck dissection** 

**2.3.1 RND** 

protocols shown in Figs. 1 and 2.

the algorism demonstrated in Figs.1 and 2.

has been recognized as a part of the multidisciplinary treatments composed of surgeries and concurrent chemoradiotherapy (CCR) in our institute. Consequently, we have applied MND as well as less extensive SN in both elective and therapeutic settings to patients with HNSCC, based on relatively simple principals. In this study, we have evaluated the efficacy of our application of ND.

Fig. 1. Algorisms for the treatment of laryngeal and pharyngeal cancers

#### **2. Patients and method**

#### **2.1 Eligibility and background of patients**

Enrolled patients to this study were primary HNSCC patients who: (1) could have accomplished our protocol-based treatments with curative intent (Figs. 1 and 2), (2) underwent ND during primary treatment course and (3) had been followed more than 12 months. Based on a chart review of HNSCC patients who had been treated at the Department of Otolaryngology, and Head and Neck Surgery, Kyushu Koseinenkin Hospital, from June 2004 to June 2010, 66 subjects were selected. There were 55 male and 11 female. Their ages ranged from 34 to 80 with an average of 62.1. The primary tumors sites were: nasopharynx (n = 3), mesopharynx (n = 16), hypopharynx (n = 14), larynx (n = 11), oral cavity (n = 21), and primary unknown (n = 1). Clinical stage was determined using the 6th UICC TNM classification (2002). T stage was categorized as T1a (n = 1); T1 (n = 5); T2b (n = 1); T2 (n = 21); T3 (n = 20); T4a (n = 14); and T4b (n = 3), N stage as N0 (n = 14); N1 (n = 10); N2 (n = 2); N2a (n = 5); N2b (n = 26); N2c (n = 6); and N3 (n = 2), and clinical stage as I (n = 0); II (4); III (n = 15); Iva (n = 32); and IVb (n = 4). Of note, one primary unknown case was excluded from T and clinical stage classification. Thus, 63.6% (42/66) of patients displayed ≧N2 necks and 78.5% (51/66) of patients were categorized as having stage III-IV advanced HNSCCs. The median follow-up period was 34.1 months ranging from 7 - 85 months.

Fig. 2. Algorisms for the treatments of oral cavity carcinomas

#### **2.2 Treatment protocol**

50 Neck Dissection – Clinical Application and Recent Advances

has been recognized as a part of the multidisciplinary treatments composed of surgeries and concurrent chemoradiotherapy (CCR) in our institute. Consequently, we have applied MND as well as less extensive SN in both elective and therapeutic settings to patients with HNSCC, based on relatively simple principals. In this study, we have evaluated the efficacy

Fig. 1. Algorisms for the treatment of laryngeal and pharyngeal cancers

Enrolled patients to this study were primary HNSCC patients who: (1) could have accomplished our protocol-based treatments with curative intent (Figs. 1 and 2), (2) underwent ND during primary treatment course and (3) had been followed more than 12 months. Based on a chart review of HNSCC patients who had been treated at the Department of Otolaryngology, and Head and Neck Surgery, Kyushu Koseinenkin Hospital, from June 2004 to June 2010, 66 subjects were selected. There were 55 male and 11 female. Their ages ranged from 34 to 80 with an average of 62.1. The primary tumors sites were: nasopharynx (n = 3), mesopharynx (n = 16), hypopharynx (n = 14), larynx (n = 11), oral cavity (n = 21), and primary unknown (n = 1). Clinical stage was determined using the 6th UICC TNM classification (2002). T stage was categorized as T1a (n = 1); T1 (n = 5); T2b (n = 1); T2 (n = 21); T3 (n = 20); T4a (n = 14); and T4b (n = 3), N stage as N0 (n = 14); N1 (n = 10); N2 (n = 2); N2a (n = 5); N2b (n = 26); N2c (n = 6); and N3 (n = 2), and clinical stage as I (n = 0); II (4); III (n = 15); Iva (n = 32); and IVb (n = 4). Of note, one primary unknown case was excluded from T and clinical stage classification. Thus, 63.6% (42/66) of patients displayed ≧N2 necks and 78.5% (51/66) of patients were categorized as having stage III-IV advanced HNSCCs. The median follow-up

of our application of ND.

**2. Patients and method** 

**2.1 Eligibility and background of patients** 

period was 34.1 months ranging from 7 - 85 months.

All patients, expect for one primary unknown case, were treated with our treatment protocols shown in Figs. 1 and 2.

Briefly, tumors from the pharynx and larynx (Fig.1), and oral tumors with advanced T and N+ (Fig.2) were initially treated with 30-40 Gy of concurrent chemoradiotherapy (CCR) composed of S-1 (80-120mg/day, p.o.), Vitamin A (50.000 IU/day, i.m.) and external beam of irradiation (1.8-2.0 Gy/day), which we have termed "TAR therapy" (Kumamoto et al., 2002; Nakashima et al., 2005). Then further treatments course were determined according to the algorism demonstrated in Figs.1 and 2.

For oral cavity tumors with early T and N+ or any T and N0, surgery was adopted as an initial treatment modality and then additional CCR was administered when necessary. One primary unknown case underwent an initial ND and additional 50 Gy of CCR. In these protocols, ND has been considered as a part of multidisciplinary treatment, and therefore organ preserving ND and both elective and therapeutic SND have been employed as our standard option for neck metastases. Our basic policies for ND are as follows: (1) preserve the spinary accessory verve (XI), internal jugula vein (IJV) and sternocleidmastoid muscle (SCM) (of note, the SCM is sacrificed when primary tumor site is reconstructed with a pectoralis major myocutaneous flap), unless direct invasion of tumors is highly suspected, (2) in N+ cases, the dissection of positive N levels is mandatory, but omit the dissection of respective I and V for laryngeal and pharyngeal cancer and IV and V for oral cavity cancer (Figs. 1 and 2), considering the size, position, number and invasiveness of the positive N located in the adjacent levels, and (3) in N0 cases, we employ ESND: II, III, and IV dissection for laryngeal and pharyngeal cancer, and I, II, and III dissection for oral cavity cancer (i.e., SOND) (Figs. 1 and 2). These protocols are approved by the Hospital Review Board.

#### **2.3 Neck dissection**

#### **2.3.1 RND**

Fig.3 demonstrates the surgical view of RND for primary unknown bulky nodes and consequent cosmetic and functional results. Deformity of the dissected neck and shoulderdrop are prominent. He has severe difficulty in stretching up of the left arm.

Roles of Therapeutic Selective Neck Dissection in Multidisciplinary Treatment 53

Fig.5 displays the surgical view of TSND (II-IV) for mandibular preserving pull-through oropharyngectomy (Masuda et al., 2010). In addition to the XI nerve, SCM and IJV, the facial vein, the external jugular vein, the great auricular and the cervical nerves were preserved.

Postoperative view of SOND (I-III) performed as an ESND (Fig.6). In this case, the submandibular gland, facial vein, external jugular vein and great auricular nerve were

**2.3.3** 

Fig.5. TSND

Fig. 6. SOND

preserved, as well as the XI nerve, SCM and IJV

**2.3.4** 

#### Fig. 3. RND

#### **2.3.2**

Fig.4 displays the surgical view of MRND performed during a pull-through glossectomy. The SCM muscle was sacrificed for the reconstruction with a PMMC flap.

Fig. 4. MRND

#### **2.3.3**

52 Neck Dissection – Clinical Application and Recent Advances

Fig.4 displays the surgical view of MRND performed during a pull-through glossectomy.

The SCM muscle was sacrificed for the reconstruction with a PMMC flap.

Fig. 3. RND

Fig. 4. MRND

**2.3.2** 

Fig.5 displays the surgical view of TSND (II-IV) for mandibular preserving pull-through oropharyngectomy (Masuda et al., 2010). In addition to the XI nerve, SCM and IJV, the facial vein, the external jugular vein, the great auricular and the cervical nerves were preserved.

Fig.5. TSND

Fig. 6. SOND

#### **2.3.4**

Postoperative view of SOND (I-III) performed as an ESND (Fig.6). In this case, the submandibular gland, facial vein, external jugular vein and great auricular nerve were preserved, as well as the XI nerve, SCM and IJV

Roles of Therapeutic Selective Neck Dissection in Multidisciplinary Treatment 55

In Table 3, the clinical stages of dissected necks were categorized based on the type of neck dissection: SND or CND. A majority of cases in both groups belonged to the advanced stage: 93.5% in SND and 100% in CND. This difference was not statistically significant. A primary

The 78 dissected necks developed 6 (6.8%) recurrences, which were observed in the cases that underwent therapeutic ND (i.e., Group 3 and Group 4) (Fig.7). The recurrence rate was

Table 1. Organ preservation rates

Table 2. Level preserved

**3.3 Local control and survival** 

**3.2 Distribution of Clinical Stage in SND and CND** 

Table 3. Comparison of the clinical stages between SND and CND

unknown case was excluded from this analysis.

#### **2.4 Treatment course**

Under these protocol-based treatments, 66 patients received 78 NDs. According to the status of nodal metastases and the type of ND they received, 78 necks were divided into 4 groups (Fig.7). Among 15 N0 necks, Group1 (n = 12) underwent ESND, while Group 2 (n = 3) received CND (MRND). For 63 N+ necks, 36 TSNDs were administered to Group 3, while 27 TCNDs (20 MRNDs and 7 RNDs) to Group 4. Except for 3 cases in Group1 and 1 case (pN0) in the Group 3, CCR was administered to 94.9 % (74/78) of cases.

Fig. 7. Grouping of the 78 necks based on the status of nodal metastases and treatment courses

#### **3. Results**

#### **3.1 Non-lymphatic structures and level preserved**

Conventional RNDs were applied for 7 N+ cases, accounting for only 9% of all NDs. In more than 90% of cases, at least one of the XI nerve, SCM, or IJV was preserved. The detail with respect to organ preservation is shown in Table.1. The XI nerve and SCM were left intact in more than 80% of cases and the SCM in 55.1% of cases. The lowest preservation rate of the SCM among these three organs was due to its sacrifice for reconstruction by a PMMC flap. All the three XI nerve, SCM, and IJV were spared in approximately half (47.4%) cases.

In 21 necks with oral cavity cancer, the dissection of level III, IV and V was omitted at 9.5%, 33.3% and 66.7%, respectively. For 56 necks with laryngeal and pharyngeal cancer the preserving rates of respective I, IV and V were 50.1%, 14.0% and 49.1% (Table.2).

One patient with primary unknown neck metastases (N2b) was treated with RND (Fig. 3).


Table 1. Organ preservation rates

54 Neck Dissection – Clinical Application and Recent Advances

Under these protocol-based treatments, 66 patients received 78 NDs. According to the status of nodal metastases and the type of ND they received, 78 necks were divided into 4 groups (Fig.7). Among 15 N0 necks, Group1 (n = 12) underwent ESND, while Group 2 (n = 3) received CND (MRND). For 63 N+ necks, 36 TSNDs were administered to Group 3, while 27 TCNDs (20 MRNDs and 7 RNDs) to Group 4. Except for 3 cases in Group1 and 1 case (pN0)

Fig. 7. Grouping of the 78 necks based on the status of nodal metastases and treatment

Conventional RNDs were applied for 7 N+ cases, accounting for only 9% of all NDs. In more than 90% of cases, at least one of the XI nerve, SCM, or IJV was preserved. The detail with respect to organ preservation is shown in Table.1. The XI nerve and SCM were left intact in more than 80% of cases and the SCM in 55.1% of cases. The lowest preservation rate of the SCM among these three organs was due to its sacrifice for reconstruction by a PMMC flap. All the three XI nerve, SCM, and IJV were spared in approximately half (47.4%) cases. In 21 necks with oral cavity cancer, the dissection of level III, IV and V was omitted at 9.5%, 33.3% and 66.7%, respectively. For 56 necks with laryngeal and pharyngeal cancer the

preserving rates of respective I, IV and V were 50.1%, 14.0% and 49.1% (Table.2).

One patient with primary unknown neck metastases (N2b) was treated with RND (Fig. 3).

**3.1 Non-lymphatic structures and level preserved** 

in the Group 3, CCR was administered to 94.9 % (74/78) of cases.

**2.4 Treatment course** 

courses

**3. Results** 


Table 2. Level preserved

#### **3.2 Distribution of Clinical Stage in SND and CND**

In Table 3, the clinical stages of dissected necks were categorized based on the type of neck dissection: SND or CND. A majority of cases in both groups belonged to the advanced stage: 93.5% in SND and 100% in CND. This difference was not statistically significant. A primary unknown case was excluded from this analysis.


Table 3. Comparison of the clinical stages between SND and CND

#### **3.3 Local control and survival**

The 78 dissected necks developed 6 (6.8%) recurrences, which were observed in the cases that underwent therapeutic ND (i.e., Group 3 and Group 4) (Fig.7). The recurrence rate was

Roles of Therapeutic Selective Neck Dissection in Multidisciplinary Treatment 57

In the present study, 22 deaths were observed. Twenty patients were died with causes related to the primary cancer: distant metastases, (n = 10), metastases to the Rouviere node (n = 2), primary tumor recurrence (n = 4), nodal metastases in the un-dissected neck (n = 2), and nodal metastases in the dissected neck (n = 3). The remaining two deaths were unrelated to the primary tumor: accident and pancreatic cancer. Consequently, regional failures in both dissected and un-dissected necks accounted for only 22.7 % (5/22) of deaths. Moreover, only 3 regional failures in the dissected necks were responsible for the deaths.

The efficacy of SND for N0 necks as an elective ND has been confirmed by a solid body of evidence (Ferlito et al., 2003; Ferlito et al., 2006). Thus, it is not surprising that in the present study there were no recurrences in Group 1 undergoing ESND as well as in Group2 undergoing ECND (Fig.3). This high control rate might also be attributable to the fact that as many as 75 % (9/12) of necks in Group 1 received CCR. Thus, application of ESND for N0 necks, especially when they are treated with multidisciplinary treatment, seems to be

In accordance with the trend of multidisciplinary treatment, TSND has gained a wider acceptance in the treatment of HNSCCs. In general, TSND has been applied under two different lines of treatment regimens: (1) as an initial surgery followed by radiotherapy (Ambrosch et al., 2001; Byers et al., 1999; Lohuis et al., 2004; Muzaffar, 2003; Patel et al., 2008; Shepard et al., 2010), or (2) as a planned ND following CCR (Ferlito et al., 2009). In the former regimen, the indication of adjuvant radiotherapy was not uniform and in some studies it was mandatory but in others it was given to selected patients with risks including extracapusular spread, multiple pathological nodes and advanced T stage. However, irrespective of the application pattern of adjuvant radiotherapy, the regional recurrence rates of SND were 3-13% and more importantly theses figures were equivocal to or lower than those of CND in the studies that compared these two cohorts. The latter regimen apparently reflects the recent paradigm shift of the treatment for advanced HNSCCs. Thus, the current mainstay is induction CCR - in particular, dose-intensified - followed by a planned ND (PND). It was clearly demonstrated in a recent comprehensive review (Ferlito et al., 2009) that by means of SND or super SND, equivalent and safer results can be obtained compared to more extensive ND, although the indication of PND to cases that

In view of these two lines of regimens, our treatments protocols seem to be unique and lie at the intermediate between them. Thus, except for the early stage oral cancers, for which surgery has been reported to be more efficient than external irradiation, CCR is administered first. Then, at 30-40 Gy of CCR, we screen responders who can proceed to organ preservation arm; a screening method we have termed "chemoradioselection". Since 1972, we have used this method for approximately 40 years for the treatments of HNSCC,

displayed complete response after CCR is now raising a hot debate.

More detail about regional failures of the dissected necks is described above.

**3.4 Causes of deaths** 

**4. Discussion** 

**4.1 SND for N0 necks** 

adequate for selected patients.

**4.2 TSND in multidiciplinary treatment** 

8.3%(3/35) in Group 3 with TSND and 11.1 % (3/27) in Group 4 with CND. All 6 recurrences occurred in the dissected levels. Extracapsular spread of dissected nodes was observed in 50% (3/6) of recurrent cases: 1 case in Group 3 and 2 cases in Group 4, and caused the death of the patient. The remaining three recurrences without extracapsular spread, 2 in Group 3 and 1 in Group 4, have been surgically salvaged so far. The cumulative regional control rates, disease specific survival rates and overall survival rates were plotted with the Kaplan-Meier method, comparing the results of SND to those of CND (Fig.8).

Fig. 8. The Kaplan-Meier plots for regional control and survival rates

In the overall (SND + CND) analysis, quite favorable regional control was obtained in the cohort of all necks (92.2%) (Fig. 8a) as well as in the cohort of N+ necks (90.3%) (Fig.4b). There was a tendency that the regional control rate of SND was higher than those of CND, thus SND yielded 94.7% in all necks and 89.9% in N+ necks, while CND 89.9% in all necks and 87.8% in N+ necks (Figs.8a and 8b). However, these differences were not statistically significant in the comparison studies by the Logrank test. The cumulative and over all disease specific survival rates were 60.7% and 57.3%, respectively (Figs. 8c and 8d). In the disease specific analyses, the SND group displayed significantly (*P* = 0.025) better prognosis (69.7%) than the CND group (46.8%)(Fig.8c). This tendency was also observed in the overall survival curves, but the difference between SND (64%) and CND (46.8%), was not statistically significant (*P* = 0.065) (Fig.8d).

#### **3.4 Causes of deaths**

56 Neck Dissection – Clinical Application and Recent Advances

8.3%(3/35) in Group 3 with TSND and 11.1 % (3/27) in Group 4 with CND. All 6 recurrences occurred in the dissected levels. Extracapsular spread of dissected nodes was observed in 50% (3/6) of recurrent cases: 1 case in Group 3 and 2 cases in Group 4, and caused the death of the patient. The remaining three recurrences without extracapsular spread, 2 in Group 3 and 1 in Group 4, have been surgically salvaged so far. The cumulative regional control rates, disease specific survival rates and overall survival rates were plotted with the Kaplan-Meier method,

comparing the results of SND to those of CND (Fig.8).

Fig. 8. The Kaplan-Meier plots for regional control and survival rates

statistically significant (*P* = 0.065) (Fig.8d).

In the overall (SND + CND) analysis, quite favorable regional control was obtained in the cohort of all necks (92.2%) (Fig. 8a) as well as in the cohort of N+ necks (90.3%) (Fig.4b). There was a tendency that the regional control rate of SND was higher than those of CND, thus SND yielded 94.7% in all necks and 89.9% in N+ necks, while CND 89.9% in all necks and 87.8% in N+ necks (Figs.8a and 8b). However, these differences were not statistically significant in the comparison studies by the Logrank test. The cumulative and over all disease specific survival rates were 60.7% and 57.3%, respectively (Figs. 8c and 8d). In the disease specific analyses, the SND group displayed significantly (*P* = 0.025) better prognosis (69.7%) than the CND group (46.8%)(Fig.8c). This tendency was also observed in the overall survival curves, but the difference between SND (64%) and CND (46.8%), was not In the present study, 22 deaths were observed. Twenty patients were died with causes related to the primary cancer: distant metastases, (n = 10), metastases to the Rouviere node (n = 2), primary tumor recurrence (n = 4), nodal metastases in the un-dissected neck (n = 2), and nodal metastases in the dissected neck (n = 3). The remaining two deaths were unrelated to the primary tumor: accident and pancreatic cancer. Consequently, regional failures in both dissected and un-dissected necks accounted for only 22.7 % (5/22) of deaths. Moreover, only 3 regional failures in the dissected necks were responsible for the deaths. More detail about regional failures of the dissected necks is described above.

#### **4. Discussion**

#### **4.1 SND for N0 necks**

The efficacy of SND for N0 necks as an elective ND has been confirmed by a solid body of evidence (Ferlito et al., 2003; Ferlito et al., 2006). Thus, it is not surprising that in the present study there were no recurrences in Group 1 undergoing ESND as well as in Group2 undergoing ECND (Fig.3). This high control rate might also be attributable to the fact that as many as 75 % (9/12) of necks in Group 1 received CCR. Thus, application of ESND for N0 necks, especially when they are treated with multidisciplinary treatment, seems to be adequate for selected patients.

#### **4.2 TSND in multidiciplinary treatment**

In accordance with the trend of multidisciplinary treatment, TSND has gained a wider acceptance in the treatment of HNSCCs. In general, TSND has been applied under two different lines of treatment regimens: (1) as an initial surgery followed by radiotherapy (Ambrosch et al., 2001; Byers et al., 1999; Lohuis et al., 2004; Muzaffar, 2003; Patel et al., 2008; Shepard et al., 2010), or (2) as a planned ND following CCR (Ferlito et al., 2009). In the former regimen, the indication of adjuvant radiotherapy was not uniform and in some studies it was mandatory but in others it was given to selected patients with risks including extracapusular spread, multiple pathological nodes and advanced T stage. However, irrespective of the application pattern of adjuvant radiotherapy, the regional recurrence rates of SND were 3-13% and more importantly theses figures were equivocal to or lower than those of CND in the studies that compared these two cohorts. The latter regimen apparently reflects the recent paradigm shift of the treatment for advanced HNSCCs. Thus, the current mainstay is induction CCR - in particular, dose-intensified - followed by a planned ND (PND). It was clearly demonstrated in a recent comprehensive review (Ferlito et al., 2009) that by means of SND or super SND, equivalent and safer results can be obtained compared to more extensive ND, although the indication of PND to cases that displayed complete response after CCR is now raising a hot debate.

In view of these two lines of regimens, our treatments protocols seem to be unique and lie at the intermediate between them. Thus, except for the early stage oral cancers, for which surgery has been reported to be more efficient than external irradiation, CCR is administered first. Then, at 30-40 Gy of CCR, we screen responders who can proceed to organ preservation arm; a screening method we have termed "chemoradioselection". Since 1972, we have used this method for approximately 40 years for the treatments of HNSCC,

Roles of Therapeutic Selective Neck Dissection in Multidisciplinary Treatment 59

Byers R.M. et al (1999). Selective neck dissections for squamous carcinoma of the

Crile G. (1906). Excision of cancer of the head and neck. With special reference to the

Ferlito A. et al (2009). Planned neck dissection for patients with complete response to

Ferlito A. et al (2003). Changing concepts in the surgical management of the cervical node

Ferlito A. et al (2006). Elective and therapeutic selective neck dissection. *Oral Oncol* 42: 14-25,

Kumamoto Y. et al (2002). "FAR" chemoradiotherapy improves laryngeal preservation rates in patients with T2N0 glottic carcinoma. *Head Neck* 24: 637-42, 1043-3074 Lindberg R. (1972). Distribution of cervical lymph node metastases from squamous cell

Lohuis P.J. et al (2004). Effectiveness of therapeutic (N1, N2) selective neck dissection (levels

Masuda M. et al (2010). Mandible preserving pull-through oropharyngectomy for advanced oropharyngeal cancer: A pilot study. *Auris Nasus Larynx* 38: 392-7, 1879-1476 Muzaffar K. (2003). Therapeutic selective neck dissection: a 25-year review. *Laryngoscope* 113:

Nakashima T. et al (2005). [Phase I study of concurrent radiotherapy with TS-1 and vitamin

Patel R.S. et al (2008). Effectiveness of selective neck dissection in the treatment of the

Robbins K.T. et al (2005). Effectiveness of superselective and selective neck dissection for

Shah J.P. (1990). Patterns of cervical lymph node metastasis from squamous carcinomas of

Shepard P.M. et al (2010). Therapeutic selective neck dissection outcomes. *Otolaryngol Head* 

Urba S. et al (2006). Single-cycle induction chemotherapy selects patients with advanced

Worden F.P. et al (2008). Chemoselection as a strategy for organ preservation in advanced

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plan of dissection based on one hundred and thirty-two operation. *JAMA* 47: 1780-

chemoradiotherapy: a concept approaching obsolescence. *Head Neck* 32: 253-61,

carcinoma of the upper respiratory and digestive tracts. *Cancer* 29: 1446-9, 0008-

II to V) in patients with laryngeal and hypopharyngeal squamous cell carcinoma.

A (TAR Therapy) for head and neck cancer]. *Gan To Kagaku Ryoho* 32: 803-7, 0385-

advanced nodal metastases after chemoradiation. *Arch Otolaryngol Head Neck Surg*

laryngeal cancer for combined chemoradiation: a new treatment paradigm. *J Clin* 

oropharynx cancer: response and survival positively associated with HPV16 copy

achieving high organ preservation and survival rates especially in laryngeal cancer (Kumamoto et al., 2002). Similar concept of "chemoselection" has been recently proposed by the group of University of Michigan (Urba et al., 2006; Worden et al., 2008; Worden et al., 2009). They demonstrated that those who display favorable responses to induction chemotherapy tend to be cured by additional chemoradiotherapy without surgical intervention, facilitating organ preservation.

Considering the above mentioned trend for less extensive ND in the context of our treatment concept, we have applied organ preserving MND and SND in both elective and therapeutic clinical settings for the treatment of HNSCC. The aim of this study was to evaluate the efficacy of our application of ND, in particular, that of TSND. In both clinical settings, quite favorable regional control rates (84.7-94.7%) were obtained (Figs. 4a and 4b). These figures are similar to or better than those reported in the studies mentioned above. Thus, it is apparent that high organ preservation rates in the present study (Table 1) do not compromise regional control. Furthermore, it is also demonstrated that our indication of ND determined in the algorism-based protocols (Fig. 1 and 2) is quite acceptable. In conclusion, when employed under a definite principal, TSND is a reliable alternative to MRND and RND in multidisciplinary treatment.

In addition to the high regional control rates, patients in the present study displayed relatively favorable disease-specific (60.7%) and overall (57.3%) survival (Figs. 4c and 4d), although 77 % of patients had advanced stage. This is, at least in part, due to the high regional control rates observed in both SND and CND cohort, thus only 5 patients died with regional failure. However, in both disease-specific and overall survival analyses, the CND cohort displayed apparently poor prognosis, reflecting the aggressiveness of the initial tumor status of this population that led to deaths unrelated to the regional failure (e.g., distant metastases, the Rouviere nodal metastases and primary tumor recurrences). This finding might imply the limit of our treatment protocol. However, considering that the survival rates of this study is favorable even compared to those obtained by the recent doseintensified types of treatment protocols summarized in a recent review (Ferlito et al., 2009), it seems to be quite challenging to develop a practical countermeasure to improve the prognosis of this population with highly aggressive tumors.

#### **5. Conclusions**

Organ preserving SND in both elective and therapeutic clinical settings is a quite reliable alternative to more aggressive ND (i.e., RND and MRND), when properly applied in multidisciplinary treatment.

#### **6. Acknowledgement**

This study was supported in part by fund from Grants-in-Aid for Scientific Research (C): 21592195 to Muneyuki Masuda

#### **7. References**

Ambrosch P. et al (2001). Efficacy of selective neck dissection: a review of 503 cases of elective and therapeutic treatment of the neck in squamous cell carcinoma of the upper aerodigestive tract. *Otolaryngol Head Neck Surg* 124: 180-7, 0194-5998

achieving high organ preservation and survival rates especially in laryngeal cancer (Kumamoto et al., 2002). Similar concept of "chemoselection" has been recently proposed by the group of University of Michigan (Urba et al., 2006; Worden et al., 2008; Worden et al., 2009). They demonstrated that those who display favorable responses to induction chemotherapy tend to be cured by additional chemoradiotherapy without surgical

Considering the above mentioned trend for less extensive ND in the context of our treatment concept, we have applied organ preserving MND and SND in both elective and therapeutic clinical settings for the treatment of HNSCC. The aim of this study was to evaluate the efficacy of our application of ND, in particular, that of TSND. In both clinical settings, quite favorable regional control rates (84.7-94.7%) were obtained (Figs. 4a and 4b). These figures are similar to or better than those reported in the studies mentioned above. Thus, it is apparent that high organ preservation rates in the present study (Table 1) do not compromise regional control. Furthermore, it is also demonstrated that our indication of ND determined in the algorism-based protocols (Fig. 1 and 2) is quite acceptable. In conclusion, when employed under a definite principal, TSND is a reliable alternative to MRND and

In addition to the high regional control rates, patients in the present study displayed relatively favorable disease-specific (60.7%) and overall (57.3%) survival (Figs. 4c and 4d), although 77 % of patients had advanced stage. This is, at least in part, due to the high regional control rates observed in both SND and CND cohort, thus only 5 patients died with regional failure. However, in both disease-specific and overall survival analyses, the CND cohort displayed apparently poor prognosis, reflecting the aggressiveness of the initial tumor status of this population that led to deaths unrelated to the regional failure (e.g., distant metastases, the Rouviere nodal metastases and primary tumor recurrences). This finding might imply the limit of our treatment protocol. However, considering that the survival rates of this study is favorable even compared to those obtained by the recent doseintensified types of treatment protocols summarized in a recent review (Ferlito et al., 2009), it seems to be quite challenging to develop a practical countermeasure to improve the

Organ preserving SND in both elective and therapeutic clinical settings is a quite reliable alternative to more aggressive ND (i.e., RND and MRND), when properly applied in

This study was supported in part by fund from Grants-in-Aid for Scientific Research (C):

Ambrosch P. et al (2001). Efficacy of selective neck dissection: a review of 503 cases of

upper aerodigestive tract. *Otolaryngol Head Neck Surg* 124: 180-7, 0194-5998

elective and therapeutic treatment of the neck in squamous cell carcinoma of the

intervention, facilitating organ preservation.

RND in multidisciplinary treatment.

**5. Conclusions** 

**7. References** 

multidisciplinary treatment.

21592195 to Muneyuki Masuda

**6. Acknowledgement** 

prognosis of this population with highly aggressive tumors.


**4** 

*Iran* 

**Complications of Neck Dissection** 

*Cancer Research Center of Ahvaz Jundishapur University of Medical Science,* 

Head & neck cancer is the major problem due to its associated morbidity and mortality. It is the sixth most common cancers and the eighth cause of cancer mortality in the world(1). The most important prognostic factor in the management of head and neck cancer is the presence of cervical lymph node metastasis. Neck dissection has been a well‐established procedure for diagnosing (staging) and treating head and neck cancer for almost a century(2). This procedure is used to eradicate metastases to the regional lymph nodes of the neck. Since Crile introduced radical neck dissection at the beginning of the 20th century, a few changes have been proposed by Hays Martin in 1951 and Suárez which aimed for a more conservative approach to preserve vital anatomical structures in the neck without compromising the completeness of lymph node removal. The transition from radical to selective neck dissection has resulted in fewer complications and lower morbidity, at the

same time preserving surgical efficacy and compliance with oncologic principles.(4)

predispose to complications including as wound infection. (5)

**2. Prevention of complications** 

 Depending on the location and extent of the tumor, the type of neck dissection performed may be radical, modified, selective and extended and either unilateral or bilateral. Complications of neck dissection affect every surgeon regardless of experience and technical skill. In addition to the various medical complications that may occur after any surgical procedure in head & neck region, a number of surgical complications may be related to the neck dissection. Complications of neck dissection are divided into three major categories: wound complications, Nerve complications, Vascular complications. Co-morbidities such as cardiac, respiratory and hepatic disease are common place in patients undergoing neck dissections in either an elective or therapeutic sense. Additional immunosuppression caused by conditions such as diabetes or relative malnutrition should be optimised since they

A careful history begins any thorough surgical evaluation. The surgeon should inquire about prior surgery and tumor therapy. Previous neck surgery may have an impact on incision design. Careful study of the lesion to be excised is of great importance. Its precise location, size, firmness, and mobility with respect to surrounding structures should be noted(6). Prior radiation therapy also slows healing, thus heightening the risk of postoperative complication. Patients should be encouraged to cease smoking as long before surgery as possible. Smoking exacerbates pulmonary dysfunction and may impair vascular perfusion, resulting in flap loss. The importance of communication between the anaesthetic

**1. Introduction** 

Nader Saki and Soheila Nikakhlagh

Worden F.P. et al (2009). Chemoselection as a strategy for organ preservation in patients with T4 laryngeal squamous cell carcinoma with cartilage invasion. *Laryngoscope* 119: 1510-7, 1531-4995
