Radical neck dissection


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Radical neck dissection

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