Management of secondaries neck with occult primary


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neck dissection

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Management of secondaries neck with occult primary

  1. 1. Management ofSecondaries Neck with Occult Primary Sujay Susikar PG in Surgical Oncology Prof RR Unit Government Royapettah Hospital
  2. 2. Management of neck secondaries with occult primary The unknown primary carcinoma in the head and neck has been estimated to represent up to 7% of all head and neck carcinomas Good prognosis with possibility of cure in SCC of head and neck Warrants aggressive treatment
  3. 3. Management of neck secondaries with occult primaryBased on the histology: SCC Lymphoma Thyroid Ca Melanoma
  4. 4. Management of neck secondaries with occult primary - SCCDefinitive management options include: Surgery RT or Chemo RT A combination of both
  5. 5. Management AlgorithmNeck secondaries with occult primary - SCC Yes Was open biopsy performed ? Residual neck disease? No Yes Consider radiotherapy Neck dissection followed No without further surgery by Radiotherapy Resectable No Chemotherapy and/ or radiotherapy with surgical salvage as indicated by response Yes Neck dissection Single pathologic node < 3 cm Yes Consider observation alone without extracapsular extension with /without management No of suspected primary site Post operative radiotherapy
  6. 6. Management of neck secondaries with occult primary –SCC - Radiotherapy Radiotherapy options LimitedComprehensive radiotherapyirradiation Inclusion of Ipsilateral Vs potential bilateral aerodigestive Radiotherapy tract primary sites
  7. 7. Management of neck secondaries with occult primary - SCC
  8. 8. Management of neck secondaries with occult primary – Radiotherapy Radiation dose and technique Opposed lateral fields Single anterior yoke field With/ without blocksDose: Neck :66 – 74 Gy to gross disease, 44- 64 Gy for subclinical disease Mucosa: 50 – 66 Gy, 2.0 Gy/ fraction
  9. 9. Management of neck secondaries with occult primary – Radiotherapy principles1. High posterior triangle node - treat as primary nasopharyngeal carcinoma.2. Jugulodigastric or midjugular node - treat as primary nasopharyngeal carcinoma, omit larynx shield.3.Upper or midjugular node – fields include the ipsilateral tonsillar fossa, posterior tongue, pyriform fossa, and ipsilateral neck nodes
  10. 10. Management of neck secondaries with occult primary – Radiotherapy principles4. Multiple or bilateral nodes: treat as primary nasopharyngeal carcinoma, but omit larynx shield.5. Supraclavicular node only: palliative irradiation.6. Radical radiation doses – as for stageT1 primary cancer, with additional boost to the the metastatic node
  11. 11. Radiotherapy – complications Mucositis Laryngeal edema Mandibular radionecrosis Massetter fibrosis Temporo mandibular joint dysfunction
  12. 12. Surgery - Neck dissection
  13. 13. What is a neck dissection ? It is a procedure by which nodes, with fat , fascia ,muscle, vein and nerves are removedenbloc from mandible to clavicle and trapezius to midline
  14. 14. Why neck dissection? H&N cancers remain loco regional even when fairly advanced Other than Lung rarely metastasis Lesion confined to one anatomic boundary, when extirpated radically-cure expected
  15. 15. Why not limited excision of nodes? Metastasis evident in one node-cancer cells might have already spread to non palpable nodes in contiguous area Less than RND  Risk of leaving behind involved node  Worse than not treating the pt  Radiation not an ALTERNATIVE THERAPY for less than optimal surgery
  16. 16. Evolution of the neck dissection 1880 – Kocher proposed removing nodal metastases 1906 – George Crile described the classic radical neck dissection (RND) 1933 and 1941 – Blair and Martin popularized the RND 1953 – Pietrantoni recommended sparing the spinal accessory nerves
  17. 17. Evolution of the neck dissection 1967 - Bocca and Pignataro described the “functional neck dissection” (FND) 1975 – Bocca established oncologic safety of the FND compared to the RND 1989, 1991, and 1994 – Medina, Robbins, and Byers respectively proposed classifications of neck dissections
  18. 18. Classification of Neck DissectionsAcademy’s classification 1) Radical neck dissection (RND) 2) Modified radical neck dissection (MRND)3) Selective neck dissection (SND) • Supra-omohyoid type • Lateral type • Posterolateral type • Anterior compartment type4) Extended radical neck dissection
  19. 19. Classification of Neck DissectionsMedina classification (1989)– Comprehensive neck dissection • Radical neck dissection • Modified radical neck dissection # Type I (XI preserved) # Type II (XI, IJV preserved) # Type III (XI, IJV, and SCM preserved)– Selective neck dissection
  20. 20. Radical Neck Dissection - RightMandible Midline Clavicle Trapezius
  21. 21. Radical Neck DissectionIndications as part of combination treatment with RT:– Extensive cervical involvement or mattedlymph nodes with gross extracapsular spreadand invasion into the SAN, IJV, or SCM
  22. 22. Modified Radical Neck Dissection (MRND)Definition– Excision of same lymph node bearing regions as RND with preservation of one or more nonlymphatic structures (SAN, SCM, IJV)– Spared structure specifically named– MRND III is analogous to the “functional neck dissection” described by Bocca
  23. 23. Modified Radical Neck DissectionRationale– Reduce postsurgical shoulder pain and shoulder dysfunction– Improve cosmetic outcome– Reduce likelihood of bilateral IJV resection• Contralateral neck involvement
  24. 24. MRNDRationale Actuarial 5-year survival and neck failure rates for RND (63% and 12%) not statistically different compared to MRND I (71% and 12%) (Andersen) No difference in pattern of neck failure Suarez (1963) – necropsy and surgery specimens of larynx and hypopharynx – lymph nodes do not share the same adventitia as adjacent blood Vessels Nodes not within muscular aponeurosis or glandular capsule (submandibular gland) Survival approximates RND assuming IJV, and SCM not involved
  25. 25. Modified Radical Neck Dissection II right Internal Jugular VeinAccessory Nerve
  26. 26. Modified Radical Neck Dissection III (Functional) left Jugular vein Carotid Submandibular gland Phrenic Nerve Sternomastoid muscleBrachial Plexus Accessory Nerve
  27. 27. SELECTIVE NECK DISSECTIONDefinition – Cervical lymphadenectomy with preservation of one or more lymph node groups – Four common subtypes: Supraomohyoid neck dissection Posterolateral neck dissection Lateral neck dissection Anterior neck dissection
  28. 28. SELECTIVE NECK DISSECTION• Rate of occult metastasis in clinically negative neck 20-30%• Indication: primary lesion with 20% or greater risk of occult metastasis• Studies by Fisch and Sigel (1964) demonstrated predictable routes of lymphatic spread from mucosal surfaces of the H&N• May elect to upgrade neck dissection intraoperatively• Need for post-op XRT
  29. 29. Risk stratification for Elective Neck DissectionGroup Estimated risk of T Stage Site subclinical neck diseaseI Low risk < 20 % T1 FOM, Oral tongue, RMT, Gingiva, hard palate, buccal mucosaII Intermediate risk 20% -30% T1 Soft palate, pharyngeal wall, supraglottic larynx, tonsil FOM, Oral tongue, T2 RMT, Gingiva, hard palate, buccal mucosaIII High risk > 30 % T1-4 Nasopharynx, pyriform sinus, base of tongue Soft palate, pharyngeal wall, supraglottic larynx, T2- 4 tonsil FOM, Oral tongue, RMT, Gingiva, hard T3- 4 palate, buccal mucosa
  30. 30. SND: Supraomohyoid typeRationale– Expectant management of the N0 neck is not advocated– Based on Linberg’s study (1972)• Distribution of lymph node mets in H&N SCCA• Subdigastric and midjugular nodes mostly affected in oral cavity carcinomas• Rarely involved Level IV and V
  31. 31. SND: Supraomohyoid typeMost commonly performed SNDDefinition – En bloc removal of cervical lymph node groups I- III – Posterior limit is the cervical plexus and posterior border of the SCM – Inferior limit is the omohyoid muscle overlying the IJVIndications – Oral cavity carcinoma with N0 neck
  32. 32. SND: Supraomohyoid type
  33. 33. Raising a subplatysmal flap Removing level Ia Removing level Ib Removing level II SND: Supraomohyoid type
  34. 34. After completion of level II Level III dissection Level III dissection After completion of level III SND: Supraomohyoid type
  35. 35. SND: Supraomohyoid type
  36. 36. SND: Lateral TypeDefinition – En bloc removal of the jugular lymph nodesincluding Levels II-IVIndications – N0 neck in carcinomas of the oropharynx,hypopharynx, supraglottis, and larynx
  37. 37. SND: Posterolateral TypeDefinition– En bloc excision of lymph bearing tissues inLevels II-IV and additional node groups –suboccipital and postauricularIndications– Cutaneous malignancies• Melanoma• Squamous cell carcinoma• Merkel cell carcinoma– Soft tissue sarcomas of the scalp and neck
  38. 38. SND: Anterior CompartmentDefinition– En bloc removal of lymph structures in Level VI– Limits of the dissection are the hyoid bone, suprasternal notch and carotid sheathsIndications– Selected cases of thyroid carcinoma– Parathyroid carcinoma– Subglottic carcinoma– Laryngeal carcinoma with subglottic extension– CA of the cervical esophagus
  39. 39. Extended Neck DissectionDefinition– Any previous dissection which includes removal of one or more additional lymph node groups and/or non-lymphatic structures.– Usually performed with N+ necks in MRND or RND when metastases invade structures usually preserved
  40. 40. Extended Neck DissectionIndications– Carotid artery invasion– Other examples:• Resection of the hypoglossal nerve or digastric muscle,• dissection of mediastinal nodes and central compartment for subglottic involvement, and• removal of retropharyngeal lymph nodes for tumors originating in the pharyngeal walls
  41. 41. Incisions Ideal incision  Adequate exposure  Safety  Accommodation of flaps  Cosmesis & function
  42. 42. Risk of ischemic necrosis
  43. 43. Types of IncisionsCrile’s incision Martin’s incision Hockey stick incision MacFee incision
  44. 44. Conley Incision
  45. 45. MacFee Incision
  46. 46. Y Incision
  47. 47. Modified Schobinger Incision
  48. 48. Utilitarian incision
  49. 49. Exposure of upper end of IJV
  50. 50. Raising the specimen from below
  51. 51. Bed after completion of neck dissection
  52. 52. Bed after completion of neck dissection- MRND III
  53. 53. Bed after completion of neck dissection- RND
  54. 54. Complications of neck dissection Wound disruption Nerve damage Frozen shoulder  Vagus Seroma  XI nerve Chylous fistula  Hypoglossal Carotid blow out  Sympathetic chain Hemorrhage  Phrinic nerve Injury to subclavian  Recurrent laryngeal vein Marginalmandibular Laryngeal edema  Brachial plexus injury SIAHs
  55. 55. SUMMARY Secondaries neck with occult primary – has good prognosis with possibility of cure Treatment is based on the histology Usually treated with combination of Surgery and RT Treatment of possible primary sites may be added
  56. 56. SUMMARY Academy classification of neck dissection is in use now Indications for neck dissection and type of neck dissection, especially in the N0 neck should be individualised