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Radical Neck Dissection

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  • 1. Radical Neck Dissection: (RND) Classification, Indication and Techniques
  • 2. Introduction
    • Crile in 1906 introduced RND and is followed by Martin as a the classical procedure for the management of cervical lymph node metastasis
    • Recently changes in classification and indication led to inconsistency
      • N 0 in recent studies may require selective RND to reduce morbidity
  • 3. Staging of Neck Nodes
    • N X :
      • Regional lymph nodes can not be assessed
    • N 0 :
      • No regional lymph node metastasis
    • N 1 :
      • Metastasis in a single ipsilateral lymph nodes, 3 cm or less in greatest dimension
    • N 2 :
      • N 2a :
        • Metastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cm
  • 4. Staging of Neck Nodes
      • N 2b :
        • Metastasis in multiple ipsilateral lymph nodes, not more than 6 cm
      • N 2c :
        • Metastasis in bilateral or contralateral nodes not more than 6 cm in diameter
    • N 3 :
      • Metastasis in lymph nodes more than 6 cm in in greatest diameter
    Meyers & Eugene: Operative Otolaryngology. 1997
  • 5. Lymph Node Regions
    • Region I:
      • Submental and submandibular triangle
        • I a : Submental triangle:
          • Bounded by the anterior belly of digastric and the mylohyoid muscle deep
        • I b : Submandibular triangle:
          • Formed by the anterior and posterior belly of the digastric muscle and the body of the mandible
    Memorial Sloan-kettering Cancer center
  • 6. Lymph Node Regions
    • Region II – IV:
      • Lymph nodes are associated with the Internal Jugular Vein (IJV) within the fibroadipose tissues that extend from the posterior border of sternocledo-mastoid muscle (SCM) medial to lateral border of the sternohyoid muscle
    Memorial Sloan-kettering Cancer center
  • 7. Lymph Node Regions
    • Region II:
      • Upper third including upper jugular, jugulodigastric and upper posterior cervical nodes
      • Bounded by the digastric muscle superiorly and the hyoid bone or carotid bifurcation inferiorly
        • IIa:
          • nodes anterior to Spinal Accessory Nerve (SAN)
        • IIb:
          • nodes posterior to Spinal Accessory Nerve (SAN)
    Memorial Sloan-kettering Cancer center
  • 8. Lymph Node Regions
    • Region III:
      • Middle third jugular nodes from the carotid bifurcation to cricothyroid notch or omohyoid muscle
    • Region IV:
      • Lower third jugular nodes from omohyoid muscle superiorly to the clavicle inferiorly
    Memorial Sloan-kettering Cancer center
  • 9. Lymph Node Regions
    • Region V:
      • Lymph nodes of the posterior triangle along the lower half of the SAN and the transverse cervical artery
      • Bounded by the anterior border of the trapezius posteriorly, the posterior border of SCM anteriorly and the clavicle inferiorly
    Memorial Sloan-kettering Cancer center
  • 10. Lymph Node Regions
    • Region VI:
      • Anterior compartment, lymph nodes surrounding the midline visceral structures that extend from the hyoid bone superiorly to the suprasternal notch inferiorly
      • The lateral boundary is the medial border of the carotid sheath
      • Perithyroid, paratracheal, and lymph nodes around the recurrent laryngeal nerve
    Memorial Sloan-kettering Cancer center
  • 11. Classification
    • The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type :
      • Radical Neck Dissection (RND)
      • Modified Radical Neck Dissection (MRND)
      • Selective Neck Dissection (SND)
        • Supraomohyoid
        • Posterolateral
        • Lateral
        • Anterior
      • Extended Radical Neck Dissection (ERND)
  • 12. Classification
    • Radical neck Dissection:
      • Removing all lymphatic tissues in regions I - V and include removal of SAN, SCM and IJV
    • Modified radical neck dissection:
      • Excision of all lymph nodes removed with RND with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJV
        • Subtype I: Preserve SAN
        • Subtype II: Preserve SAN & SJV
        • Subtype III: preserve SAN, SJV and SCM
          • Known as Functional neck dissection (Bocca)
  • 13. Classification
    • Selective Neck dissection:
      • Any type of cervical lymphadenectomy with preservation of one or more lymph node groups
      • Four subtype:
        • Supraomohyoid neck dissection
        • Posterolateral neck dissection
        • Lateral neck dissection
        • Anterior neck dissection
  • 14. Classification
      • Supraomohyoid neck dissection:
        • Removal of lymph nodes in regions I –III
        • The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCM
        • The inferior limit is the superior belly of the omohyoid where it cross IJN
      • Posterolateral neck dissection
        • Removal of suboccipital, retroauricular, levels II – V and level V
        • Subtyped I – III depending on the preservation of SAN, IJV and /or SCM
    Medina
  • 15. Classification
      • Lateral neck dissection:
        • Remove lymph nodes in levels II – IV
      • Anterior neck dissection:
        • Require the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VI
        • Superior limit, hyoid bone
        • Inferior limit, suprasternal notch
        • Laterally, the carotid sheath
  • 16. Classification
    • Extended neck dissection:
      • Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues
  • 17. Facts
    • General nodal metastasis produce the following fact:
      • The most important factor in prognosis of SCC of the upper aero-digestive tract is the status of cervical lymph nodes
      • Cure rate drops 50% with involvement of the regional lymph nodes
  • 18. Indications For ND
    • Radical neck dissection was believed by Martin to be the only method to control cervical lymphadenectomy
    • Anderson found that preservation of SAN did not change the survival or tumor control in the neck
      • Actual 5-year survival and neck failure rate is:
        • RND: 63% and 12 %
        • MRND: 71% and 12%
  • 19. Indications
    • Radical Neck Dissection
      • Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN
      • Large metastatic tumor mass or multiple matted in upper part of the neck
        • Tumor should not be dissected to preserve Structures
  • 20. Indications
    • Modified radical neck dissection
      • MRND Type I:
        • Clinically obvious neck lymph nodes metastasis and SAN not involved by tumor
        • Intraoperative decision just like preservation of the facial nerve in parotid surgery
  • 21. Indications
    • MRND Type II:
      • Rarely planned
      • Intra-operative decision for tumor found adherent to SCM but away from SAN & IJV
    • MRND Type III:
      • Depend on the autopsy reports
        • Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels
        • They are not found within the aponeurosis or glandular capsule of the submandibular “Functional neck dissection”
  • 22. Indications
    • MRND Type III:
      • For treatment of N 0 neck nodes
      • Indicated for N 1 mobile nodes and not greater than 2.5 – 3.0 cm
        • Contra-indicated in the presence of node fixation
        • Result is difficult to interpret because of the use of radiation therapy
  • 23. Indications
    • Selective/elective neck dissection:
      • For treatment of N 0 neck nodes
      • For N+ nodes when combined with radiotherapy
        • Adjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spread
      • Supraomohyoid is indicated for SCC of oral cavity with N 0 and N 1 with palpable mobile nodes less than 3 cm and located in level I and II
      • Upgrade intra-operatively following positive frozen section
  • 24. Treatment option for N 0 nodes
    • Observe
    • Radiation therapy
    • Elective neck dissection
      • Low morbidity
      • Staging neck for possible extended surgery
      • Need for post-operative radiotherapy
  • 25. Rationale for S/END
    • Rate of occult metastasis in clinically negative nodes is 20 – 30% using clinical and radiographic findings
      • Ct scan combined with physical exam decreased the rate of occult metastasis to 12%
      • This suggested lowering of the criteria for elective neck dissection
      • Friedman et al Laryngoscope 100; 54 – 59: 1990
  • 26. Rationale for S/END
    • Anatomic studies showed that lymphatic drainage from the mucosal surfaces follow a constant and predictable route
    • Lymph flow from SA chain to the jugular chain is unilateral
    Shah. Ann Surg Oncol 1(6); 521-532: 1994
  • 27. Rationale for S/END
    • Shah, in his study produced a compelling evidence of predictable nodal metastasis from SCC from upper aerodigastive tract
      • He found a specific pattern for nodal spread by location of primary
        • N O in patients with oral cavity SCC:
          • 7/1119 (3.5%) had nodal involvement outside supraomohyoid dissection
          • 3 (1.5%) had isolated involvement outside level I - III
    Friedman Laryngoscope 100; 54-59: 1990
  • 28. Rationale for S/END
      • N + nodes in patients with oral SCC:
        • 50/246 had nodal metastasis outside level IV
        • 10/246 had metastasis in level V
      • He examined nodal involvement in patients with nasopharynx and other upper parts of the aerodigastive tract
    • Conclusion:
      • SCC of the oral cavity:
        • Level I, II and III are at risk
      • SCC nasopharynx and larynx
        • Level II, III and IV are at risk
    Shah Amer J Surg 160; 405-409: 1990 Shah Cancer July 1 ; 109-113: 1990
  • 29. Rationale for S/END
    • Byers stated that SND combined with postoperative radiotherapy in selected patients with oral cavity SCC was adequate treatment with similar recurrence rate as those treated with MRND III
    • Spiro reported 12% with supraomohyoid dissection in N1 nodes but not all of them received radiotherapy
    Byers Head Neck Surg; Jan-Feb; 160-167: 1988
  • 30. Selective/Elective Neck Dissection
    • A good option for N0 neck
    • Not a suitable option for N+ neck
    • Is used N+ neck when combined with radiotherapy
    • Intra-operative frozen section evaluation is needed to confirm in cases of intraoperative palpable nodes
  • 31. The anatomy
    • Skin:
      • Blood supply:
        • Descending branches:
          • The facial
          • The submental
          • Occipital
        • Ascending branches
          • Transverse cervical
          • Suprascapular
      • The branches perforate the platysma muscle, anastomose to form superficial vertically-directed network of vessels
    • Skin incision is superiorly based apron-like incision from mastoid to mentum or to contralateral mastoid
  • 32. The anatomy
    • Platysma muscle:
      • Wide, quadrangular sheet-like muscle
      • Run obliquely from the upper part of the chest to lower face
      • Skin flap is raised immediately deep to the muscle
      • The posterior border is over or just anterior to IJV and great auricular nerve
      • Does not cover the inferior part of the anterior triangle and the posterolateral neck
  • 33. The anatomy
    • Sternocleidomastoid muscle: SCM
      • Differentiated from the platysma by the direction of its fibres
      • Crossed by the IJV and the great auricular nerve from inferior to posterior deep to platysma
      • The posterior border represent the posterior boundary of nodes level II - IV
  • 34. The anatomy
    • Marginal Mandibular nerve: MMN
      • Located 1 cm in front of and below the angle of the mandible
      • Deep to the superficial layer of the deep cervical fascia
      • Superficial to adventitia of the anterior facial vein
  • 35. The anatomy
    • Spinal Accessory nerve: SAN
      • Emerge from the jugular foramen medial to the digastric and stylohyoid muscles and lateral and posterior to IJV (30% medial to the vein and in 3 -5% split the nerve)
      • It passes obliquely downward and backward to reach the medial surface of the SCM near the junction of its superior and middle thirds, Erb’s point
  • 36. The anatomy
    • Trapezius muscle:
      • Its anterior border is the posterior boundary of level V
      • Difficult to identify because of its superficial position
      • Dissect superficial to the fascia in order to preserve the cervical nerves
  • 37. The anatomy
    • Digastric Muscle ; Posterior belly:
      • Originate from a groove in the mastoid process, digastric ridge
      • The marginal mandibular nerve lie superficial
      • The external and internal carotid artery, hypoglossal and 11 th cranial nerves and the IJV lie medial
  • 38. The anatomy
    • Omohyoid muscle:
      • Made of two bellies, and is the anatomic separation of nodal levels III and IV
      • The posterior belly is superficial to the brachial plexus, phrenic nerve and transverse cervical artery and vein
      • The anterior belly is superficial to the IJV
  • 39. The anatomy
    • Brachial Plexus & Phrenic nerve:
      • The plexus exit between the anterior and middle scalene muscles, pass inferiorly deep to the clavicle under the posterior belly of the omohyoid
      • The phrenic nerve lie on top of the anterior scalene muscle and receive it is cervical supply from C3 – C5
  • 40. The anatomy
    • Thoracic duct:
      • Located in the lower let neck posterior to the jugular vein and anterior to phrenic nerve and transverse cervical artery
      • Have a very thin wall and should be handled gently to avoid avulsion or tear leading to chyle leak
  • 41. The anatomy
    • Exit via the hypoglossal canal near the jugular foramen
    • Passes deep to the IJV and over the ICA and ECA and then deep and inferior to the digastric muscle and enveloped by a venous plexus, the ranine veins
    • Pass deep to the fascia of the floor of the submandibular triangle before entering the tongue
  • 42. Summary
    • Unified classification is relatively new
    • Indication and the type of ND, specially for N0, is controversial
    • The following surgical outline was suggested:
      • SCC oral cavity anterior to circumvalate papilla
        • Supraomohyoid
      • SCC Oropharynx, larynx and hypopharynx
        • level I- IV or level II-V
      • SCC with N+ nodes
        • RND
      • SCC with 2-4 positive nodes or extracapsular spread
        • RND and adjuvant therapy
    Shah Cancer July 1;109-113: 1990