History Of CANCER Anatomy of HEAD & NECK LYMPH NODE levels Staging of CANCER NECK DISSECTIONS COMPLICATIONS
1880 Kocher advocates wide margin lymphadenectomy 1881 Kocher and Packard recommend dissection of submandibular triangle for lingual cancer 1885 Butlin questions RND for oral N 0 disease 1888 Jawdynski describes en bloc resection with resection of carotid, IJV, SCM. Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
1901 Solis-Cohen advocate lymphadenectomy for N0 laryngeal CA 1905 -1906 Crile describes en bloc resection in JAMA 1926 Bartlett and Callander advocate preservation of XI, IJV, SCM, platysma, stylohyoid, digastric 1933 Blair and Brown advocate removal of XI. Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
1951 Martin advocates Radical Neck Dissection after analysis of 1450 cases › Advocated RND for N+ cases. 1952 – Suarez describes a functional neck dissection › Preservation of SCM, omohyoid, submandibular gland, IJV, XI. › Enables protection of carotid. 1960’s – MD Anderson advocate selective ND of highest risk nodal basins 1967 - Bocca and Pignataro describe the “functional neck dissection” 1975 – Bocca establishes oncologic safety of the FND compared to the RND Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
The region of the body that lies between: The LOWER BORDER OF THE MANDIBLE& The SUPRASTERNAL NOTCH and the UPPER BORDER OF CLAVICLE.
• Origin – fascia overlying the pectoralis major and deltoid muscle• Insertion – 1) depression muscles of the corner of the mouth, 2) the mandible, and 3) the SMAS layer of the face• Function –1) wrinkles the the neck2) depresses the corner of the mouth3) increases the diameter of the neck4) assists in venous return
Surgical considerations – Increases blood supply to skin flaps – Absent in the midline of the neck – Fibers run in an opposite direction to the SCM
pretracheal fascia Infrahyoid m. trachea esophagu thyroid s Internal jugular Pretracheal layer vein s.c. Common carotid m Carotid sheath a. Vagus n.Buccopharynge scalenus al fascia Investing layer Prevertebral Trapezius layer
• Origin – 1) medial third of the clavicle(clavicular head)2) manubrium (sternal head) • Insertion – mastoid process • Nerve supply – spinal accessory nerve (CN XI) • Blood supply –1) occipital a. or direct from ECA2) superior thyroid a.3) transverse cervical a.
Function – turns head toward opposite side and tilts head toward the ipsilateral shoulder • Surgical considerations– Leave overlying fascia (superficial layer of deep cervical fascia down)– Lateral retraction exposes the submuscular recess
• Origin – upper border of the scapula• Insertion – 1) via the intermediate tendon onto the clavicle and first rib 2) hyoid bone lateral to the sternohyoid muscle • Blood supply – Inferior thyroid a. • Function – 1) depress the hyoid2) tense the deep cervical fascia
Surgical considerations – Absent in 10% of individuals – Landmark demarcating level III from IV – Inferior belly lies superficial to• The brachial plexus• Phrenic nerve• Transverse cervical vessels – Superior belly lies superficial to• IJV
• Origin –1) medial 1/3 of the sup. Nuchal line2) external occipital protuberance3) ligamentum nuchae4) spinous process of C7 and T1-T12 • Insertion –1) lateral 1/3 of the clavicle2) acromion process3) spine of the scapula • Function – elevate and rotate the scapula andstabilize the shoulder
Surgical considerations – Posterior limit of Level V neck dissection – Denervation results in shoulder drop and winged scapula
• Origin – digastric fossa of the mandible (at the symphyseal border• Insertion –1) hyoid bone via the intermediate tendon2) mastoid process• Function –1) elevate the hyoid bone2) depress the mandible (assists lateral pterygoid)
– Posterior belly is superficial to:• ECA• Hypoglossal nerve• ICA• IJV – Anterior belly• Landmark for identification of mylohyoid for dissection of the submandibular triangle
Division of the neckAnterior triangleSuprahyoid region: submental triangle submandibular triangleInfrahyoid region: muscular triangle carotid trianglePosterior triangle
Submental triangle Lies below the chin and is bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone Covered by skin, superficial fascia and investing fascia Floor － mylohyoid muscles Contents － submental lymph nodes
Suprahyoid muscles stylohyoid digastric (anterior and posterior belly)mylohyoid
Submandibular triangle Bounded by anterior and posterior bellies of digastric and lower border of the body of the mandible Covered by skin, superficial fascia, platysma and investing fascia Floor － mylohyoid, hyoglossus and middle constrictor of pharynx Contents － submandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes
Carotid triangle sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles Covered by skin, superficial fascia, platysma and investing fascia Floor － prevertebral fascia and lateral wall of pharynx Contents － common carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes
Muscular triangle Bounded by midline of the neck, superior belly of the omohyoid and anterior border of the sternocleidomastoid. Covered by skin, superficial fascia, platysma, anterior jugular v., coutaneous n. and investing fascia Floor － prevertebral fascia Contents － sternohyoid, sternothyroid, thyrohyoid, thyroid gland, parathyroid gland, cervical part of trachea and esophagus
Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and middle third of clavicle Divided by inferior belly of omohyoid into occipital and supraclavicular triangles
Arteries: Subclavian (3rd part) Superficial cervical & suprascapular (branches of thyrocervical trunk, a branch of 1st part of subclavian artery Occipital, a branch of external carotid artery
Nerves: Branches of cervical plexus Spinal part of accessory nerve Brachial plexus
Occipital triangle Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid Covered by skin, superficial fascia, and investing fascia Floor － prevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae
Contents › Accessory n. － emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius › Cervical and brachial PLEXUS
Supraclavicular triangle Bounded by posterior border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle Covered by skin, superficial fascia, and investing fascia Floor － prevertebral fascia and inferior parts of scalenus Contents › Subclavian v. and venous angle › Subclavian a. › Brachial plexus
Most commonly injury dissection level Ib Landmarks: › 1cm anterior and inferior to angle of mandible › Mandibular notch Subplatysmal Deep to fascia of the submandibular gland Superficial to facial vein
Motor nerve to the tongue • Cell bodies are in the Hypoglossal nucleus of the Medulla oblongata • Exits the skull via the hypoglossal canal • Lies deep to the IJV, ICA, CN IX, X, and XI
• Curves 90 degrees and passes between the IJV and ICA– Surrounded by venous plexus • Extends upward along hyoglossus muscle and into the genioglossus to the tip of the tongue. Iatrogenic injury – Most common site - floor of the submandibular triangle, just deep to the duct
Penetrates deep surface of the SCM Exits posterior surface of SCM deep to Erb’s point Traverses the posterior Accessory n. (XI) triangle on the levator Hypoglossal n. (XII) scapulae Ansa cervicalis Enters the trapezius about 5 cm above the clavicle Vagus n. (X) Phrenic n.
Crosses the IJV • Crosses lateral to the transverse process of the atlas • Occipital artery crosses the nerve • Descends obliquely in level II (forms Level IIa and IIb
Developed by Memorial Sloan-Kettering Cancer Center Ease and uniformity in describing regional nodal involvement in cancer of the head and neck
LYMPH NODES acts as a barrier to the spread of the disease . Virchow in 1860
CAN BE DIVIDED INTO;a) SUPERFICIAL CHAIN OF LYMPH NODES…..b) VERTICAL DEEP CHAIN OF LYMPH NODES This consists of nodes lying in relation to carotid sheath.These lie along the vessels,trachea,oesophagusand extend from base of skull to root of neck.
Face and Scalp Anterior Facial, Ib Lateral Parotid Posterior Occipital, VEyelids Medial Ib Lateral Parotid, IIChin Ia, Ib, IIExternal Ear Anterior Parotid, II Posterior Post auricular, II, VMiddle Ear Parotid, IIFloor of mouth Anterior Ia, Ib, IIa > IIb Lower incisors Ia, Ib, IIa > IIb Lateral Ib, IIa > IIb, III Teeth except incisors Ib, IIa > IIb, IIINasal Cavity Anterior Ib Posterior Retropharyngeal, II, V
Nasal Cavity Posterior Retropharyngeal, II, VNasopharynx Retropharyngeal, II, III, VOropharynx IIb > IIa, III, IV, VLarynx Supraglottic IIa > IIb, III, IV Subglottic VI, IVCervical esophagus IV, VIThyroid VI, IV, V, MediastinalTongue Tip Ia, Ib, IIa > IIb, III, IV Lateral Ib, IIa > IIb, III, IV
• “N” classification – AJCC (1997) • Consistent for all mucosal sites except the nasopharynx • Thyroid and nasopharynx have different staging based on tumor behavior and prognosis • Based on extent of disease prior to first treatment
Nx: Regional lymph nodes cannot be assessed. N0: No regional lymph node metastases. N1: Single ipsilateral lymph node, < 3 cm
N2a: Single ipsilateral lymph node 3 to 6 cm N2b: Multiple ipsilateral lymph nodes > 6 cm N2c: Bilateral or contralateral nodes > 6cm N3: Metastases > 6 cm
• Standardized until 1991 • Academy’s Committee for Head and Neck Surgery and Oncology publicized standard classification system
Academy’s classification – Based on 4 concepts• 1) RND is the standard basic procedure for cervical lymphadenectomy against which all other modifications are compared• 2) Modifications of the RND which include preservation of any non-lymphatic structures are referred to as modified radical neck dissection (MRND)
Academy’s classification• 3) Any neck dissection that preserves one or more groups or levels of lymph nodes is referred to as a selective neck dissection (SND)• 4) An extended neck dissection refers to the removal of additional lymph node groups or non- lymphatic structures relative to the RND
Removes › Nodal groups I-V Preserves › SCM, IJV, XI (any combination) › TYPE A MRND
Three types (Medina 1989) commonly referred to not specifically named by committee.• Type I: Preservation of SAN• Type II: Preservation of SAN and IJV• Type III: Preservation of SAN, IJV, and SCM ( “Functional neck dissection”)
• Indications – Clinically obvious lymph node metastases– SAN not involved by tumor–Intraoperative decision
• Indications– Rarely planned– Intraoperative tumor found adherent to the SCM, but not IJV and SAN
• Rationale– Suarez (1963) – necropsy and surgery specimens of larynx and hypopharynx – lymph nodes do not share the same adventitia as adjacent BV’s– Nodes not within muscular aponeurosis or glandular capsule (submandibular gland)– Sharpe (1981) showed ) 0% involvement of the SCM in 98 RND specimens despite 73 have nodal metastases – Survival approximates MRND Type I assuming IJV, and SCM not involved Widely accepted in Europe• Neck dissection of choice for N0 neck
Definition– 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
Also known as an elective 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• Need for post-op RT
• Most commonly performed SND• Definition – 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 IJV
Indications– Oral cavity carcinoma with N0 neck • Boundaries – Vermillion border of lips to junction of hard and soft palate, circumvallate papillae • Subsites - Lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone, hard palate, and anterior 2/3s of the tongue and FOM– Medina recommends SOHND with T2-T4 NO or TX N1 (palpable node is <3cm, mobile, and in levels I or II)
Bilateral SOHND • Anterior tongue • Oral tongue and FOM that approach the midline – SOHND + parotidectomy • Cutaneous SCCA of the cheek • Melanoma (Stage I – 1.5 to 4mm) of the cheek• Byers does not advocate elective neck dissection for buccal carcinoma – Adjuvant RT given to patients with > 2- 4 positive nodes +/- ECS.
• Definition – En bloc removal of the jugular lymph nodes including Levels II-IV. Indications – N0 neck in carcinomas of the oropharynx, hypopharynx, supraglottis, and larynx
• Definition– En bloc excision of lymph bearing tissues in Levels II-IV and additional node groups – suboccipital and postauricular. Indications– Cutaneous malignancies• Melanoma• Squamous cell carcinoma• Merkel cell carcinoma– Soft tissue sarcomas of the scalp and neck
• Definition – En bloc removal of lymph structures in Level VI • Perithyroidal nodes • Pretracheal nodes • Precricoid nodes (Delphian) • Paratracheal nodes along recurrent nerves – Limits of the dissection are the hyoid bone, suprasternal notch and carotid sheaths
Indications – Selected cases of thyroid carcinoma – Parathyroid carcinoma – Subglottic carcinoma – Laryngeal carcinoma with subglottic extension – CA of the cervical esophagus
• Definition – 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
Indications – Carotid artery invasion – Other examples: • Resection of the hypoglossal nerve resection 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.
SUPERSELECTIVE NECK DISSECTION OF HEAD AND NECK cancer – Yet to come
4 TYPES- INTRA OP- IMMEDIATE POST OP- LATE POST OP- DELAYED COMPLICATIONS
Inadequate planning Inadvertent injury to local blood vessels and nerves .-marginal mandibular N.- Spinal accessory N.- Cervical plexus- Brachial plexus- Thoracic duct injury .
Haemorrhage: Needs evaluation of the extent of bleeding and occasionally may need re-exploration. Lymph leak: When the drainage is of milky fluid and is persistently high >100ml /day after 2days.A possibility of lymph leak has to be considered.
Carotid blow out: A dreaded complication that occurs secondary to wound break down. If exposed the carotids have to be covered using vascularised flaps. Facial oedema: A common occurrence usually settles down in 4-6 weeks.
Wound infection Fistulae Devitalisation of the reconstructed flap
• Cervical metastasis in SCCA of the upper aerodigestive tract continues to portend a poor prognosis • Staging will help determine what type neck dissection should be performed • Unified classification of neck nodal levels and classification of neck dissection has to understood well. • Indications for neck dissection and type of neck dissection, especially in the N0 neck, is a still controversial