The document discusses different treatment options for metastatic neck disease depending on the extent and location of lymph node involvement. For clinically negative necks (N0), options include elective neck surgery, radiotherapy, or observation. For single small palpable nodes (N1), surgery is generally recommended. Larger or multiple unilateral nodes (N2) may receive surgery with postoperative radiotherapy. Bilateral nodes (N2c) are often treated with surgery and radiotherapy. Recurrent or extensive disease involving vital structures poses treatment challenges but may be addressed with aggressive surgery or radiotherapy in some cases.

1. Treatment of metastatic neck disease
The presence of metastatic cervical lymphadenopathy has an adverse effect on survival & that only
50% of patients with neck disease survive five years.
In the untreated neck ,patterns of spread may be predictable,& In the N0 neck ,occult disease is
usually found within the first echelon lymph node drainage basin. This permits the selective neck
dissection.
Once the patents has had previous treatment involving either surgery or radiation, drainage pattern
may be altered so usually all five levels should be either dissected or irradiated.
In those patients with palpable neck disease ,nonpalpable spread may be present in the anywhere,so
dissect all levels together in the form of modified radical dissection or extended radical neck
dissection. Radiotherapy may have a place for low volume N1 (nodes less than 2cm).
Patients with nopalpable nodes (N0)
Treatment of N0 neck is one of the great dilemma & treatment still controversial. Treatment options
for N0 neck.
Elective surgery
Elective radiotherapy
Elective neck investigation
Adopting a police of wait &see.
Elective surgery
Arguments for & against elective neck surgery.
FOR ELECTIVE NECK SURGERY
1)The high incidence of occult metastatic disease
2) limited neck dissection has a low morbidity & mortality
3) If the neck has to be entered to remove the primary lesion, it is better to perform an incontinuity
resection.
4) It is impossible to provide the clinical follow up to detect the earliest conversion of the neck from
N0 to N1.
5) The cure rate for neck dissection is decrease if gland enlargement occurs or multiple nodes
appear.
AGINGNIST ELECTIVE NECK SURGERY
1) Cure rate are lower if the surgeon waits for the neck to convert from N0 to N1.

2. 2) Careful clinical follow up will allow detection at the earliest conversion from N0 to N1.
3) Radiotherpy is as effective as neck dissection for nonpalpable disease.
4) Associated with inevitable morbidity.
5) Remove barrier to spread of disease &may have a detrimental immunological effects.
Elective neck irradiation
External beam radiation of approximately 40-50Gy to the clinically N0 neck will control occult
metastases in up to 90-95%,conversion of N0 to N1 necks after elective neck irradiation 3-15%.
Where the primary tumour is being treated with surgery ,then neck should be treated with elective
surgery as well. Radiation does have potentially unfavourable local &systemic effects & CAN MASK
deep recurrence.
When the primary tumour T1 is being treated with radiotherapy then elective treatment should be
with radiotherapy to at least the first echelon lymph nodes or whole neck where midline extension
occurs, treatment should be bilateral.
When primary tumour is treated with surgery (i.e T2 /T3) ,then elective neck surgery should be
carried out since it provides further information for clinical staging, give assess to vessels for
reconsruction purposes,reduced local recurrence& survival enhanced.
ANOTHER OPTION IN THE N0 NECK IS TO CONSIDER ELECTIVE NECK INVESTIGATION. CT ,MRI ,USG
ANOTHER OPTION WAIT & SEE IN LOW RISK NECKS. CARCINOMA IN GLOTTIS & SOFT PALATE MAY
DETRIMENTAL EFFECT TO THE PATIENT.
Single palpable metastasis in one side of the neck less than 3cm in
diameter(N1)
Generally ,these nodes are treated surgically & since the survival figures are good.The gold standard
operation is Radical neck dissection.but majority of cases the accessory nerve can be preserved, so
that minimum operation that is usually performed is a modified radical dissection type -1.
There is no doubt that the morbidity of a neck dissection arises largely from level V dissection &
there is low incidence of nodal involvement at this level unless two or more levels especially IV are
involved. IJV & sternocleoidmastoid are sacrified.these two structure are basis for metastases down
to the neck.
Recurrence rate following neck dissection 10% for N1, 20-30% for N2, 85% for N3.
A recent review of the literature suggested that the sternomastoid muscle should only be removed if
involved by disease.
The role of radiotherapy in the treatment of N1 disease ,the current consensus is that is less
efficient than surgery. Less preferred option unless the primary site is being treated with
radiotherapy as well the patient is unfit.

3. The classic example of this carcinoma of the nasopharynx with unilateral or bilateral cervical
lymphadenopathy ,conventional approach is radical radiotherapy & subsequent surgery for salvage.
Large (greater than 3cm less than 6cm ) nodes (N2a) or multiple unilateral
nodes (N2b).
Modified radical neck dissection (type -1) where accessory nerve can be preserved. or radical neck
dissection, postoperative radiotherapy is usually administered.
Bilateral & contralateral nodes (N2c)
Supraglottic tumours with bilateral nodes are often treated with laryngectomy with neck dissections.
Bilateral nodes are either N1 Or N2a treatment conventional surgery, conservative neck surgery on
the less involved side & radical on more involved side with post-operative radiotherapy.
Interval contralateral lymphadenopathy
A proportion of patients in whom a node appears on the contralateral side of the neck, provided
there is no recurrence at the primary site. In this situation RND/modified RND will produce a five
years survival about 30%.This incidence can be reduced by administration of post-operative
radiotherapy.
Massive nodes(greater than 6cm;N3)
Any node greater than 6cm in size are often fixed to skin or underlying structures. Fixation to the
mandibule ,sternomastoid & prevertebral fascia, muscles in the midline may not as problem as
fixation to the brachial plexus or carotid artery.
The difficult neck
The difficult neck includes those neck that are difficult to assess such as short stocky neck , those
with recurrent disease, assessment of the retropharyngeal nodes & those necks with extensive
disease which involves vital structures carotid artery, prevertebral muscles, brachial plexus.
Careful clinical assessment with mandatory radiological imaging will help to assess operability. Some
of the patients are helped by extended radical neck dissection.
Fixation to skull base & brachial plexus is contraindication of surgical treatment but fixation to the
skin may be treated with wide resection & flap repair.
Contraindications to neck dissection
There are a number of absolute & relative contraindications to neck dissection.
1) Primary tumour are untreatable.
2) Patient who is unfit for major surgery.
3) Patient with inoperable neck disease.
4) Patient with distant metastases.

4. Recurrence & salvage surgery
Recurrence in the neck following dissection carries a gloomy prognosis. Chance of salvaging
recurrent cancer 50% in the untreated neck,25% in an electively irradiated neck, & 5% in a
previously dissected neck.
If surgery is possible wide resections should be undertaken& postoperative radiotherapy given.
Many of these masses is fixed to vital structures which negate extensive surgery.
Radiotherapy in the management of metastatic neck disease
1)The clinically negative neck (N0 neck). There is now consensus view that the neck should be
treated in eases with a high probability >25% of cervical micrometastases.
2) The clinically positive neck (N+ neck).general speaking ,involved nodes are best managed with
surgery & postoperative radiotherapy. This is especially true for large lymph node masses.
Undifferentiated nasopharyngeal carcinoma & lymphoma can be controlled by radiotherapy.
Another exception appears to be tonsillar carcinoma with N1 neck node as good as surgery.
3) Electively after surgery (pathologically N+neck).
4)Neck disease developing or recurring after initial treatment.
-nodal metastasis developing in the untreated neck after initial treatment of the primary
tumour alone.
-Recurrence after previous surgery to the neck.
- nodal recurrence after combination treatment.