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Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
1
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma
of the scalp: results in 14 patients.
F. Fouad Saleep(1)
, I. Fayek(1)
, I. Farahat(2)
(1)National Cancer Institute - Cairo University, Surgical Oncology Department, Cairo, Egypt.
(2)National Cancer Institute - Cairo University, Pathology Department, Cairo, Egypt.
Abstract
Aim: to highlight the role and benefit of suboccipital lymph node dissection as an integral step in the surgical
management of occipital scalp squamous cell carcinoma.
Methods: Between 2007 to 2011 fourteen patients (10 males and 4 females) aging 51-75 years old (mean 62.9)
with pathologically proven squamous cell carcinoma at the occipital region of the scalp underwent suboccipital and
retroauricular lymph node dissection in continuity with the contents of the upper part of the posterior triangle of the
neck.
Results: Scalp lesions ranged from 3-8 cm in diameters (mean 5.7cm) were all excised with an adequate safety
margin of 2 cm. all around and the defect is closed with rotational scalp flaps. The periosteum was always taken as
deep safety margin and was microscopically infiltrated in 3 cases. In 2 patients suboccipital lymph nodes were
clinically positive. All patients underwent elective suboccipital lymphadenectomy; the number of dissected lymph
nodes ranged from 3-9 LNs (mean 5.8 LNs). No serious complications were observed apart from mild wound
infections in 2 patients. In 6 out of 14 patients lymph nodes were metastatic (42.8%). 4 patients lost follow-up. All
the remaining 10 patients were followed up between 12-26 months (mean 18.4 months). One patient developed
local recurrence after 8 months and another one developed nodal recurrence at the spinal accessory group of lymph
nodes after 14 months; both patients had +ve LN metastases at the suboccipital nodes at the initial dissection.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
2
Conclusion: Suboccipital lymphadenectomy is a safe procedure with low morbidity and should be done in all
patients with scalp squamous cell carcinoma at the occipital region of the scalp which could add to the locoregional
control of the disease and serves as a prognostic indicator for future locoregional recurrences.
Keywords: Suboccipital lymphadenectomy ; Scalp ; Squamous cell carcinoma.
Contact: Fouad A. Fouad Saleep, MD. Surgical Oncology Department – National Cancer Institute – Cairo, Egypt
(fouadfs@yahoo.com)
INTRODUCTION
Squamous cell carcinoma (SCC) of the scalp is a
common cutaneous lesion. Generally it can give
metastases to specific groups of regional neck nodes
according to its location in the scalp. retroauricular
and suboccipital lymph node metastases from
malignant epithelial tumors of the posterior scalp
cannot be removed adequately by standard radical
neck dissection [1-4]. Only by a posterolateral neck
dissection can occult and clinically manifest lymph
node metastases in this region be adequately removed.
This type of neck dissection consists of
comprehensive removal of all lymph node-bearing
tissue of the retroauricular and suboccipital region in
continuity with the contents of the posterior triangle
of the neck and internal jugular chain. The operation
is usually performed as an en bloc procedure with
excision of the primary tumor [1, 5-8]. In this study,
we highlight the role and benefit of suboccipital
lymph node dissection as an integral step in the
surgical management of occipital scalp squamous cell
carcinoma.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
3
PATIENTS AND METHODS
Between 2007 to 2011 fourteen patients (10 males and
4 females) aging 51-75 years old (mean 62.9) with
pathologically proven squamous cell carcinoma at the
occipital region of the scalp (Figure 1) underwent
wide local excision of the lesion with suboccipital and
retroauricular lymph node dissection in continuity
with the contents of the upper part of the posterior
triangle of the neck (Figure 2 and 3). Closure of the
scalp defects was done using rotational scalp flaps in
all our patients (Figure 4).
RESULTS [Table1]
Scalp lesions ranged from 3-8 cm in diameters (mean
5.7cm) were all excised with an adequate safety
margin of 2 cm. all around and the defect is closed
with rotational scalp flaps. The periosteum was
always taken as deep safety margin and was
microscopically infiltrated in 3 cases. In 2 patients
suboccipital lymph nodes were clinically positive. All
patients underwent elective suboccipital
lymphadenectomy; the number of dissected lymph
nodes ranged from 3-9 LNs (mean 5.8 LNs). No
serious complications were observed apart from mild
wound infections in 2 patients. In 6 out of 14 patients
lymph nodes were metastatic (42.8%). 4 patients lost
follow-up. All the remaining 10 patients were
followed up between 12-26 months (mean 18.4
months). One patient developed local recurrence after
8 months and another one developed nodal recurrence
at the spinal accessory group of lymph nodes after 14
months; both patients had +ve LN metastases at the
suboccipital nodes at the initial dissection.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
4
Table 1: Clinicopathologic features and follow-up of patients.
No. of
Patients
Age Sex
Diameter
of the
lesion
(cm.)
Safety
margin
Nodes
dissected
metastatic
nodes
Follow-up
period
(months)
Events on
follow-up
1 58 F 5.6 -ve 4 0 24
2 63 M 3 -ve 5 0 17
3 54 M 5 -ve 7 0 21
4 71 M 7.5
Microscopic
infiltration of
periosteum
3 1 lost
5 67 F 6.3 -ve 9 2 26
6 59 M 4.9 -ve 6 0 20
7 65 M 6.9
Microscopic
infiltration of
periosteum
6 1 15 Local
recurrence
8 51 M 7 -ve 5 0 lost
9 75 F 7.9 -ve 4 1 24
10 55 M 3.2 -ve 8 0 lost
11 66 M 3.7 -ve 9 0 lost
12 60 M 4.5 -ve 4 0 12
13 67 M 6.1
Microscopic
infiltration of
periosteum
3 1 13 Nodal
recurrence
14 69 F 8 -ve 8 2 12
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
5
DISCUSSION
Cutaneous lesions of the scalp are a common
presentation in head and neck surgery. Skin cancers of
the scalp have a propensity to spread, due to the
subgaleal plane that provides limited resistance. At
the periosteal level, tumor spread can go for
unperceived distances (9). In all our patients the
periosteum was excised as a deep safety margin and
inspite it was grossly not infiltrated by the tumor,
microscopic infiltration was evident in 3 patients.
Furthermore, the vigorous blood supply and dense
lymphatics create further potential for spread of
disease, making the scalp a high risk site. Elective
prophylactic lymph node dissection has been
proposed for cutaneous SCC greater than 8 mm in
depth, but evidence for this is weak (10) and putting
in mind that Patients with metastatic cutaneous
squamous cell carcinoma of the scalp have a poor
prognosis with most dying from regional relapse (11)
and that accurate preoperative identification of lymph
node metastases in this region by palpation alone is
insufficient (12); so in all our patients we did a
suboccipital and retroauricular lymph node dissection
in continuity with the contents of the upper part of the
posterior triangle of the neck as an integral step of the
operation seeking to achieve regional control (Figure
2 and 3).
It is well known that seventy five percent of local
recurrences and metastases are detected within 2 years
and 95% within 5 years (13). In our study, during the
follow up period which was up to 26 months, 2 from
10 patients (20%) developed locoregional recurrences
which is less than the percentage previously
mentioned in the literature. Histopathologically
microscopic infiltration of the periosteum was
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
6
associated with both nodal metastases and
locoregional recurrences.
CONCLUSION
Suboccipital lymphadenectomy is a safe procedure
with low morbidity and should be done in all patients
with scalp squamous cell carcinoma at the occipital
region of the scalp which could add to the
locoregional control of the disease and serves as a
prognostic indicator for future locoregional
recurrences.
REFERENCES
1] De Langen ZJ, Vermey A. Posterolateral
neck dissection. Head Neck Surg 1988; 10:
252-6.
2] Robbins KT, Medina JE, Wolfe GT,
Levine PA, Session RB, Pruet CW.
Standardizing neck dissection terminology.
Official report of the Academy's Committee for
head and neck surgery and oncology. Arch
Otolurynyol Heud Neck Surg 1991; 117: 601-
5.
3] Byers RM. The role of modified neck
dissection in the treatment of cutaneous
melanoma of the head and neck. Arch Sury
1986; 121: 1338-41.
4] Roses DF, Harris MN, Grunsberger I,
Gumport S. Selective surgical management of
cutaneous melanoma of the head and neck. Ann
Sury 1980; 192: 629-32.
5] Rochlin DB. Posterolateral neck dissection
for malignant neoplasms. Surg Gynecol Ohsret
1962; 115: 369-73.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
7
6] Wander JV, Chaudhuri PK. Dissection of
the posterior part of the neck. Surg Gynecol
Ohsrer 1976; 143: 97-100.
7] Goepfert H, Jesse RH, Ballantyne AJ.
Posterolateral neck dissection. Arch
Otolaryngol 1980; 106: 618 -20.
8] Fischer SR, Cole TB, Seigler HF, Durham
NC. Application of posterior neck dissection in
treating malignant melanoma of the posterior
scalp. Laryngoscope 1983; 93: 760-5.
9] Lang et al. Aggressive squamous
carcinomas of the scalp. Dermatol Surg (2006)
vol. 32 (9) pp. 1163-70.
10] Friedman NR. Prognostic factors for local
recurrence, metastases and survival rates in
squamous cell carcinoma of the skin, ear and
lip. J Am Acad Dermatol 1993; 28: 281-2.
11] Howle JR, Morgan GJ, Kalnins I, Palme
CE, Veness MJ. Metastatic cutaneous
squamous cell carcinoma of the scalp. ANZ J
Surg. 2008 Jun; 78(6):449-53.
12] Plukker J, Vermey A, Roodenburg JLN
and Oldhoff J. Posterolateral neck dissection:
technique and results. Br. J. Surg. 1993, Vol.
80, September, 1127-1129.
13] Rowe DE, Carroll RJ, Day CL.
Prognostic Factors for local recurrence,
metastasis and survival rates in squamous cell
carcinoma of the skin, ear and lip. J Am Acad
Dermatol 1992:26: 976-90.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
8
Figure 1: Preoperative view of the scalp lesion and marking of the suboccipital lymphadenectomy incision.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
9
Figure 2: Intraoperative view showing extent of dissection.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
10
Figure 3: Complete evacuation of the suboccipital triangle in continuity with the posterior triangle of the neck.
Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013
F. Fouad Saleep, I. Fayek, I. Farahat
11
Figure 4: Immediate postoperative view with closure of the scalp defect using rotational scalp flap.

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Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients.

  • 1. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 1 Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. F. Fouad Saleep(1) , I. Fayek(1) , I. Farahat(2) (1)National Cancer Institute - Cairo University, Surgical Oncology Department, Cairo, Egypt. (2)National Cancer Institute - Cairo University, Pathology Department, Cairo, Egypt. Abstract Aim: to highlight the role and benefit of suboccipital lymph node dissection as an integral step in the surgical management of occipital scalp squamous cell carcinoma. Methods: Between 2007 to 2011 fourteen patients (10 males and 4 females) aging 51-75 years old (mean 62.9) with pathologically proven squamous cell carcinoma at the occipital region of the scalp underwent suboccipital and retroauricular lymph node dissection in continuity with the contents of the upper part of the posterior triangle of the neck. Results: Scalp lesions ranged from 3-8 cm in diameters (mean 5.7cm) were all excised with an adequate safety margin of 2 cm. all around and the defect is closed with rotational scalp flaps. The periosteum was always taken as deep safety margin and was microscopically infiltrated in 3 cases. In 2 patients suboccipital lymph nodes were clinically positive. All patients underwent elective suboccipital lymphadenectomy; the number of dissected lymph nodes ranged from 3-9 LNs (mean 5.8 LNs). No serious complications were observed apart from mild wound infections in 2 patients. In 6 out of 14 patients lymph nodes were metastatic (42.8%). 4 patients lost follow-up. All the remaining 10 patients were followed up between 12-26 months (mean 18.4 months). One patient developed local recurrence after 8 months and another one developed nodal recurrence at the spinal accessory group of lymph nodes after 14 months; both patients had +ve LN metastases at the suboccipital nodes at the initial dissection.
  • 2. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 2 Conclusion: Suboccipital lymphadenectomy is a safe procedure with low morbidity and should be done in all patients with scalp squamous cell carcinoma at the occipital region of the scalp which could add to the locoregional control of the disease and serves as a prognostic indicator for future locoregional recurrences. Keywords: Suboccipital lymphadenectomy ; Scalp ; Squamous cell carcinoma. Contact: Fouad A. Fouad Saleep, MD. Surgical Oncology Department – National Cancer Institute – Cairo, Egypt (fouadfs@yahoo.com) INTRODUCTION Squamous cell carcinoma (SCC) of the scalp is a common cutaneous lesion. Generally it can give metastases to specific groups of regional neck nodes according to its location in the scalp. retroauricular and suboccipital lymph node metastases from malignant epithelial tumors of the posterior scalp cannot be removed adequately by standard radical neck dissection [1-4]. Only by a posterolateral neck dissection can occult and clinically manifest lymph node metastases in this region be adequately removed. This type of neck dissection consists of comprehensive removal of all lymph node-bearing tissue of the retroauricular and suboccipital region in continuity with the contents of the posterior triangle of the neck and internal jugular chain. The operation is usually performed as an en bloc procedure with excision of the primary tumor [1, 5-8]. In this study, we highlight the role and benefit of suboccipital lymph node dissection as an integral step in the surgical management of occipital scalp squamous cell carcinoma.
  • 3. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 3 PATIENTS AND METHODS Between 2007 to 2011 fourteen patients (10 males and 4 females) aging 51-75 years old (mean 62.9) with pathologically proven squamous cell carcinoma at the occipital region of the scalp (Figure 1) underwent wide local excision of the lesion with suboccipital and retroauricular lymph node dissection in continuity with the contents of the upper part of the posterior triangle of the neck (Figure 2 and 3). Closure of the scalp defects was done using rotational scalp flaps in all our patients (Figure 4). RESULTS [Table1] Scalp lesions ranged from 3-8 cm in diameters (mean 5.7cm) were all excised with an adequate safety margin of 2 cm. all around and the defect is closed with rotational scalp flaps. The periosteum was always taken as deep safety margin and was microscopically infiltrated in 3 cases. In 2 patients suboccipital lymph nodes were clinically positive. All patients underwent elective suboccipital lymphadenectomy; the number of dissected lymph nodes ranged from 3-9 LNs (mean 5.8 LNs). No serious complications were observed apart from mild wound infections in 2 patients. In 6 out of 14 patients lymph nodes were metastatic (42.8%). 4 patients lost follow-up. All the remaining 10 patients were followed up between 12-26 months (mean 18.4 months). One patient developed local recurrence after 8 months and another one developed nodal recurrence at the spinal accessory group of lymph nodes after 14 months; both patients had +ve LN metastases at the suboccipital nodes at the initial dissection.
  • 4. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 4 Table 1: Clinicopathologic features and follow-up of patients. No. of Patients Age Sex Diameter of the lesion (cm.) Safety margin Nodes dissected metastatic nodes Follow-up period (months) Events on follow-up 1 58 F 5.6 -ve 4 0 24 2 63 M 3 -ve 5 0 17 3 54 M 5 -ve 7 0 21 4 71 M 7.5 Microscopic infiltration of periosteum 3 1 lost 5 67 F 6.3 -ve 9 2 26 6 59 M 4.9 -ve 6 0 20 7 65 M 6.9 Microscopic infiltration of periosteum 6 1 15 Local recurrence 8 51 M 7 -ve 5 0 lost 9 75 F 7.9 -ve 4 1 24 10 55 M 3.2 -ve 8 0 lost 11 66 M 3.7 -ve 9 0 lost 12 60 M 4.5 -ve 4 0 12 13 67 M 6.1 Microscopic infiltration of periosteum 3 1 13 Nodal recurrence 14 69 F 8 -ve 8 2 12
  • 5. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 5 DISCUSSION Cutaneous lesions of the scalp are a common presentation in head and neck surgery. Skin cancers of the scalp have a propensity to spread, due to the subgaleal plane that provides limited resistance. At the periosteal level, tumor spread can go for unperceived distances (9). In all our patients the periosteum was excised as a deep safety margin and inspite it was grossly not infiltrated by the tumor, microscopic infiltration was evident in 3 patients. Furthermore, the vigorous blood supply and dense lymphatics create further potential for spread of disease, making the scalp a high risk site. Elective prophylactic lymph node dissection has been proposed for cutaneous SCC greater than 8 mm in depth, but evidence for this is weak (10) and putting in mind that Patients with metastatic cutaneous squamous cell carcinoma of the scalp have a poor prognosis with most dying from regional relapse (11) and that accurate preoperative identification of lymph node metastases in this region by palpation alone is insufficient (12); so in all our patients we did a suboccipital and retroauricular lymph node dissection in continuity with the contents of the upper part of the posterior triangle of the neck as an integral step of the operation seeking to achieve regional control (Figure 2 and 3). It is well known that seventy five percent of local recurrences and metastases are detected within 2 years and 95% within 5 years (13). In our study, during the follow up period which was up to 26 months, 2 from 10 patients (20%) developed locoregional recurrences which is less than the percentage previously mentioned in the literature. Histopathologically microscopic infiltration of the periosteum was
  • 6. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 6 associated with both nodal metastases and locoregional recurrences. CONCLUSION Suboccipital lymphadenectomy is a safe procedure with low morbidity and should be done in all patients with scalp squamous cell carcinoma at the occipital region of the scalp which could add to the locoregional control of the disease and serves as a prognostic indicator for future locoregional recurrences. REFERENCES 1] De Langen ZJ, Vermey A. Posterolateral neck dissection. Head Neck Surg 1988; 10: 252-6. 2] Robbins KT, Medina JE, Wolfe GT, Levine PA, Session RB, Pruet CW. Standardizing neck dissection terminology. Official report of the Academy's Committee for head and neck surgery and oncology. Arch Otolurynyol Heud Neck Surg 1991; 117: 601- 5. 3] Byers RM. The role of modified neck dissection in the treatment of cutaneous melanoma of the head and neck. Arch Sury 1986; 121: 1338-41. 4] Roses DF, Harris MN, Grunsberger I, Gumport S. Selective surgical management of cutaneous melanoma of the head and neck. Ann Sury 1980; 192: 629-32. 5] Rochlin DB. Posterolateral neck dissection for malignant neoplasms. Surg Gynecol Ohsret 1962; 115: 369-73.
  • 7. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 7 6] Wander JV, Chaudhuri PK. Dissection of the posterior part of the neck. Surg Gynecol Ohsrer 1976; 143: 97-100. 7] Goepfert H, Jesse RH, Ballantyne AJ. Posterolateral neck dissection. Arch Otolaryngol 1980; 106: 618 -20. 8] Fischer SR, Cole TB, Seigler HF, Durham NC. Application of posterior neck dissection in treating malignant melanoma of the posterior scalp. Laryngoscope 1983; 93: 760-5. 9] Lang et al. Aggressive squamous carcinomas of the scalp. Dermatol Surg (2006) vol. 32 (9) pp. 1163-70. 10] Friedman NR. Prognostic factors for local recurrence, metastases and survival rates in squamous cell carcinoma of the skin, ear and lip. J Am Acad Dermatol 1993; 28: 281-2. 11] Howle JR, Morgan GJ, Kalnins I, Palme CE, Veness MJ. Metastatic cutaneous squamous cell carcinoma of the scalp. ANZ J Surg. 2008 Jun; 78(6):449-53. 12] Plukker J, Vermey A, Roodenburg JLN and Oldhoff J. Posterolateral neck dissection: technique and results. Br. J. Surg. 1993, Vol. 80, September, 1127-1129. 13] Rowe DE, Carroll RJ, Day CL. Prognostic Factors for local recurrence, metastasis and survival rates in squamous cell carcinoma of the skin, ear and lip. J Am Acad Dermatol 1992:26: 976-90.
  • 8. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 8 Figure 1: Preoperative view of the scalp lesion and marking of the suboccipital lymphadenectomy incision.
  • 9. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 9 Figure 2: Intraoperative view showing extent of dissection.
  • 10. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 10 Figure 3: Complete evacuation of the suboccipital triangle in continuity with the posterior triangle of the neck.
  • 11. Suboccipital lymphadenectomy for patients with occipital squamous cell carcinoma of the scalp: results in 14 patients. 2013 F. Fouad Saleep, I. Fayek, I. Farahat 11 Figure 4: Immediate postoperative view with closure of the scalp defect using rotational scalp flap.