Elective Management of Clinically N0 Neck

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The basis and need for elective nodal treatment in head and neck cancer:
    • Have been based largely on surgical series evaluating pathologic nodal involvement found on elective neck dissection in patients with clinically negative necks
  • In a consecutive series of 1,081 head and neck cancer patients undergoing radical neck dissection:
    • The incidence of pathologic node involvement:
      • Was 33% among those undergoing elective neck surgery
    • The pathologic findings identified the nodal stations at risk by tumor site:
      • To establish the rationale for selective neck dissection (SND) as the elective surgical procedure
  • Several reports have summarized the risk for metastases and nodal stations at risk
  • Some general observations from such data can be made:
    • Regarding larynx cancers:
      • Candela reported the Memorial Sloan Kettering Cancer Center (MSKCC) experience in determining the patterns of cervical nodal metastases in 247 larynx cancer patients undergoing radical neck dissections:
        • Seventy-eight underwent elective radical neck dissection whereas 118 underwent immediate radical dissection for clinically node-positive disease
        • The majority of patients (n = 189) were supraglottic larynx and 58 were glottic
        • Pathologic nodal involvement:
          • Was found in 37% undergoing elective neck dissection
        • It is noted that cervical nodes spread in a similar fashion whether the patients are clinically node negative or positive:
          • With predominant involvement of:
            • Level II and III jugular nodes
        • In clinically node-negative patients:
          • The incidence of involvement of level I and V:
            • Is less than 5% with less than 10% involvement of level IV
        • In node-positive patients:
          • The incidence of level IV node increases from 15% to 31% with greater involvement of levels II and III
        • In clinically node-positive patients:
          • Very rarely did patients present with isolated level I nodal metastases without involvement of the jugular nodes
  • Shah and Candela reported that among oropharynx or hypopharynx cancers:
    • Treated with elective radical neck dissection:
      • Occult metastases are found in 26%
    • Level I and V were involved in only 1.4%:
      • Always in association with nodal disease at level II to IV
    • No skip metastases were reported
    • Among oropharynx patients:
      • Levels II to IV were predominantly involved
    • Among hypopharynx lesions:
      • The primary levels involved were levels II and III
    • In patients clinically node positive undergoing therapeutic neck dissection:
      • The incidence of level I and V involvement increased to about 10% to 15%:
        • However, levels II to IV were predominantly involved
      • Level V involvement:
        • Only occurred in association with nodal involvement at levels II to IV
      • Whereas the incidence isolated level I involvement without levels II to IV involvement (“skip metastasis”):
        • Occurred in 0.4%:
          • Thus, based on these studies, elective treatment of the neck in oropharynx or hypopharynx can be directed at levels II to IV
  • Among oral cavity patients:
    • The incidence of nodal disease was 34% on elective evaluation
    • The majority of metastatic nodes involved:
      • Levels I to III:
        • With only 1.5% incidence of skip metastasis to level IV
    • Level V involvement:
      • Is found in only 0.5% with occult disease simultaneously involving other levels
    • Among those undergoing therapeutic neck dissections:
      • The incidence of level IV involvement increased to 20%
      • Level V was 4% always restricted to lower gum or floor of mouth primary sites
  • The need for elective treatment not only relates to the estimated probability of nodal involvement and usually is implemented when the risk is 20% or greater but also relates to the morbidity of such treatment as well as the adequacy of coverage
Unknown's avatar

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.

Leave a comment