Lymph Node Metastasis in the Head and Neck Generalities

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The regional state of lymph nodes:
    • Is one of the most important parameters determining prognosis in patients with HNSCC
  • The presence of only one positive lymph node:
    • Can decrease survival by up to 50% in most HNSCC
  • The risk of lymph node metastasis can be predicted in relation to:
    • Differentiation of tumor:
      • The more poorly differentiated the tumor:
        • The greater the risk
    • To the size and depth of the invasion
    • The availability of capillary lymphatics
  • The risk of lymphatic spread:
    • Increases with tumor recurrence
  • Embryologically:
    • The lymphatic system is formed from its germination from the venous system:
      • Explaining the close anatomical relationship between these two systems
    • Blood capillaries have tight endothelial junctions:
      • That normally do not reabsorb larger molecules and cells
    • However, lymphatic capillaries have relatively open endothelial junctions:
      • That allow molecules and larger cells to be more easily reabsorbed:
        • Explaining the reason for easier lymphatic than vascular propensity
  • The lymphatic system of the head and neck:
    • Is the region of the body composed by more lymphatic capillaries, lymphatic trunks and lymph nodes:
      • Epithelium, bone and cartilage are devoid of lymphatic capillaries:
        • While a small minority is found in the periosteum and perichondrium
  • Lymph node arrangement is archetypal and each group receives drainage (directly or indirectly) from specific areas:
    • In a deep cervical group (a terminal group for the head and region of the neck) before finally flowing into the lymphatic duct (right) / thoracic duct (left) or in the jugular-subclavian junction
  • Due to the absence of lymphatic vessels in the epithelium:
    • The tumor must penetrate the lamina propria before lymphatic invasion
  • In the superficial layer:
    • The diameter of lymphatic capillaries is usually narrower than it is in the deeper layer
  • The richness of the capillary network in each subsite can increase the relative incidence of lymph node metastases:
    • The nasopharynx, pyriform sinus (hypopharynx), supraglottic larynx and oropharynx:
      • Have the most profitable network of capillary lymphatic vessels:
        • Which is the clinical reflection of the potential presence of neoplastic lymph nodes
    • Paranasal sinuses, middle ear and vocal folds:
      • Have few or no capillary lymphatics:
        • Which is consistent with the low rate of lymph node metastases when the tumor is confined to these sites
  • The involvement of lymph nodes usually follows an ordered progression and, rarely, skip nodal metastasis is revealed (exception lateral ventral tongue)
  • Well lateralized lesions:
    • Determine ipsilateral lymph node metastases
  • Lesions near the midline or lateral margin of tongue or nasopharyngeal lesions:
    • Can also spread contra-laterally or bilaterally:
      • But generally, tend to spread from the side of the lesion
  • Patients with ipsilateral tumor nodal disease are at risk of contralateral disease:
    • Especially if the lymph node exceeds a certain size or if multiple lymph nodes are involved
  • Obstruction of lymphatic pathways:
    • Caused by surgery or radiation therapy:
      • Can divert lymphatic flow on the opposite side of the neck through anastomotic channels
  • Finally, it should be remembered that metastases in cervical-cephalic regions:
    • Occur in approximately 10% of patients as neoplastic metastases from unknown primary sites
    • The histopathology of these metastases is generally referable to squamous cell carcinomas in various degrees of differentiation:
      • But metastases of adenocarcinomas, melanomas, or anaplastic tumors can also be found
    • The lymph node level is indicative of possible neoplastic origin
  • Distant metastasis (DM):
    • In the absence of nodal metastasis is very rare in HNSCC
    • Untreated occult disease in the lymphatic venous system:
      • Can produce DM while the lymph node is growing
    • Patients with advanced disease have a high incidence of DM:
      • Particularly in the presence of jugular vein invasion or extensive soft tissue disease in the neck:
        • The rate of DM increases by up to 25% to 30% for N3 disease compared to 18% to 20% for N2 disease
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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