The document discusses metastatic neck disease in head and neck cancer. It covers the natural history and evaluation of neck disease, including the levels and regions of cervical lymph nodes. It also discusses factors that affect the probability of cervical metastases based on primary tumor site and stage. Additionally, it summarizes the drainage patterns of different head and neck primary sites and describes investigations used to evaluate neck disease.
- Metastatic neck disease is an important prognostic factor in head and neck cancer.
- Management of neck disease involves choices of treatment modality, timing, and combination of treatments which are controversial.
- Assessment of cervical lymphadenopathy involves clinical examination, fine needle aspiration cytology, imaging like ultrasound, CT, MRI, and PET.
- Treatment depends on neck stage - elective neck treatment for N0, neck dissection for N1, neck dissection with postoperative radiation for N2, and debate over treatment for massive N3 nodes.
Management of secondaries neck with occult primarySujay Susikar
This document discusses the management of neck metastases when the primary tumor is unknown or occult. It summarizes that treatment options include surgery such as different types of neck dissection, radiation therapy, or a combination of the two. The type of treatment is based on the histology and may involve treating possible primary sites in addition to the neck.
This document discusses the lymph node levels of the neck and management of unknown primary cancers of the neck. It begins with an overview of neck anatomy and the different lymph node groups. It then covers the classification of lymph node levels, evaluation and diagnosis of unknown primary neck cancers, and treatment approaches based on nodal staging. Physical exam, biopsy, imaging, and endoscopy are used to diagnose while treatment involves neck dissection and/or radiation depending on nodal stage and characteristics.
This document discusses management of the clinically node-negative neck in early-stage oral squamous cell carcinoma. The risk of occult nodal involvement is estimated to be 20-30% for T1/T2 tumors. Main management approaches are upfront elective neck dissection, watch and wait, or sentinel node biopsy. Tumor depth of invasion is a better predictor of nodal metastasis than thickness. Elective neck dissection provides accurate staging and optimal locoregional control, while sentinel node biopsy carries risk of missing occult disease and delaying adjuvant treatment. Floor of mouth tumors have early nodal spread necessitating bilateral neck dissection.
This document provides an anatomical and clinical classification of cervical lymph nodes (LN). Anatomically, it lists 10 cervical LNs, including occipital, mastoid, parotid, submandibular, facial, submental, sublingual, retropharyngeal, anterior cervical, and lateral cervical LNs. Clinically, it describes the submental, submandibular, upper internal jugular, mid jugular, lower jugular, posterior triangle, and retropharyngeal LNs based on their location and boundaries. It also notes structures contained in the submandibular triangle.
This document discusses the management of neck nodes in head and neck cancer. It covers lymph node levels, risk factors for metastasis, diagnostic workup, staging, surgical and radiation treatment options. For clinically negative nodes, elective neck irradiation or dissection are equally effective at controlling subclinical disease. For clinically positive nodes, factors like number of positive nodes and size influence treatment planning. Combined modality treatment with surgery and radiation provides better control than either alone for more advanced neck disease.
- Metastatic neck disease is an important prognostic factor in head and neck cancer.
- Management of neck disease involves choices of treatment modality, timing, and combination of treatments which are controversial.
- Assessment of cervical lymphadenopathy involves clinical examination, fine needle aspiration cytology, imaging like ultrasound, CT, MRI, and PET.
- Treatment depends on neck stage - elective neck treatment for N0, neck dissection for N1, neck dissection with postoperative radiation for N2, and debate over treatment for massive N3 nodes.
Management of secondaries neck with occult primarySujay Susikar
This document discusses the management of neck metastases when the primary tumor is unknown or occult. It summarizes that treatment options include surgery such as different types of neck dissection, radiation therapy, or a combination of the two. The type of treatment is based on the histology and may involve treating possible primary sites in addition to the neck.
This document discusses the lymph node levels of the neck and management of unknown primary cancers of the neck. It begins with an overview of neck anatomy and the different lymph node groups. It then covers the classification of lymph node levels, evaluation and diagnosis of unknown primary neck cancers, and treatment approaches based on nodal staging. Physical exam, biopsy, imaging, and endoscopy are used to diagnose while treatment involves neck dissection and/or radiation depending on nodal stage and characteristics.
This document discusses management of the clinically node-negative neck in early-stage oral squamous cell carcinoma. The risk of occult nodal involvement is estimated to be 20-30% for T1/T2 tumors. Main management approaches are upfront elective neck dissection, watch and wait, or sentinel node biopsy. Tumor depth of invasion is a better predictor of nodal metastasis than thickness. Elective neck dissection provides accurate staging and optimal locoregional control, while sentinel node biopsy carries risk of missing occult disease and delaying adjuvant treatment. Floor of mouth tumors have early nodal spread necessitating bilateral neck dissection.
This document provides an anatomical and clinical classification of cervical lymph nodes (LN). Anatomically, it lists 10 cervical LNs, including occipital, mastoid, parotid, submandibular, facial, submental, sublingual, retropharyngeal, anterior cervical, and lateral cervical LNs. Clinically, it describes the submental, submandibular, upper internal jugular, mid jugular, lower jugular, posterior triangle, and retropharyngeal LNs based on their location and boundaries. It also notes structures contained in the submandibular triangle.
This document discusses the management of neck nodes in head and neck cancer. It covers lymph node levels, risk factors for metastasis, diagnostic workup, staging, surgical and radiation treatment options. For clinically negative nodes, elective neck irradiation or dissection are equally effective at controlling subclinical disease. For clinically positive nodes, factors like number of positive nodes and size influence treatment planning. Combined modality treatment with surgery and radiation provides better control than either alone for more advanced neck disease.
This document discusses types of neck dissection procedures performed to treat neck metastases from head and neck cancers. It describes radical neck dissection, modified radical neck dissection, and selective neck dissection. Radical neck dissection removes all lymph nodes from levels I-V, while modified versions preserve one or more non-lymphatic structures like the spinal accessory nerve or internal jugular vein. Selective neck dissection removes only the lymph nodes at levels that drain the primary tumor site. The indications, techniques, and complications of these neck dissection procedures are examined in detail.
This document provides an overview of neck anatomy and neck dissection procedures. It describes the boundaries and contents of the neck regions. It then discusses the different types of neck dissections including radical neck dissection, modified radical neck dissection, and selective neck dissections. Key structures such as lymph nodes, muscles, nerves and vessels are identified. Surgical considerations and indications for different procedures are also outlined.
This document discusses neck dissection, which refers to the systematic resection of lymph nodes and surrounding tissue from the neck. It describes the 7 levels of neck nodes and provides details on different types of neck dissections like radical, modified radical, and selective dissections. Complications of neck dissection like hemorrhage, nerve injury, chyle leak, and wound issues are outlined. The document also briefly discusses sentinel lymph node biopsy, minimally invasive approaches, and robotic neck surgery.
This document provides information about neck dissection procedures. It discusses the history and evolution of neck dissection, defines the different types of neck dissections including radical, modified radical and selective neck dissections, and describes the key steps in performing a modified radical neck dissection. Complications of neck dissection such as hemorrhage, wound infection, and carotid artery rupture are also summarized.
Neck dissections involve removing lymph nodes in the neck to stage and treat head and neck cancers. The key points are:
1. There are different types and levels of neck dissections based on the lymph nodes and structures removed. A radical neck dissection removes the most nodes and structures while more functional dissections preserve the spinal accessory nerve and veins.
2. The neck has important structures like the marginal mandibular nerve and spinal accessory nerve that must be preserved. Key triangles in the neck include the anterior and posterior triangles.
3. Lymph nodes are divided into superficial and deep chains. The deep cervical nodes are the most important for staging and treating head and neck cancers. Ultrasound and biopsy
1) Neck dissection refers to surgical removal of lymph nodes and tissue in the neck to treat cervical lymph node metastasis from cancers like head and neck cancers.
2) The procedure has evolved from radical neck dissections removing most neck structures to more selective and modified radical neck dissections that preserve key structures like the spinal accessory nerve and internal jugular vein.
3) Proper classification of neck dissection types and the specific lymph node levels involved is important for standardized reporting and determining prognosis.
This document discusses principles of conservative surgery for head and neck cancers. It covers selective and comprehensive neck dissection techniques for managing cervical lymph nodes. It describes various open and endoscopic surgical procedures to preserve structure and function for cancers of the larynx and hypopharynx, including vertical partial laryngectomy, supracricoid laryngectomy, and transoral laser resection. Complications and oncologic outcomes of these organ preservation techniques are also discussed.
This document discusses neck dissections for squamous cell carcinoma of the head and neck. It describes the surgical anatomy of the neck, classifications of neck dissections including radical, modified radical and selective types, lymph node levels, indications for different procedures, and surgical techniques. Complications of neck dissections are also summarized.
This document provides treatment recommendations for carcinoma of the hypopharynx based on tumor stage. For early stage disease, definitive radiotherapy or voice-preserving surgery are options. Most patients present with stage III or IV disease requiring multimodality treatment including chemotherapy and radiation. Advanced tumors may be treated with surgery or organ-preserving approaches like transoral laser microsurgery. Post-operative radiation is recommended for high-risk features. Definitive chemoradiation is a standard non-surgical option. Induction chemotherapy followed by chemoradiation is also used for locally advanced cases. Palliative radiation aims to relieve symptoms for poor performance patients.
1. A neck dissection is a surgical procedure to remove lymph nodes and surrounding tissue in the neck to treat cancer that has spread from areas like the oral cavity or larynx.
2. There are different types of neck dissections classified based on the extent of lymph nodes and structures removed, including radical, modified radical, and selective neck dissections.
3. The specific type of neck dissection performed depends on factors like the location and stage of the cancer, and whether preservation of structures like the spinal accessory nerve or internal jugular vein is needed.
Neck node management of unknown primaryDr Rekha Arya
The document discusses the management of neck nodes with an occult primary tumor. It begins by defining an occult primary tumor as one that presents with lymph node or distant metastases when investigations fail to identify the primary site. It then discusses the diagnostic workup, which includes history, physical exam, imaging studies like PET CT, and biopsy of lymph nodes. Treatment depends on the lymph node level and stage. For early stage disease, neck dissection may be sufficient, while advanced disease requires chemoradiation. Post-treatment neck dissection may be needed depending on response. Radiation techniques like IMRT can help reduce toxicity compared to conventional radiation. Complications of treatment include risks of surgery and side effects of high-dose radiation.
This document discusses the anatomy, staging, treatment and techniques for carcinoma of the nasopharynx. It describes the parapharyngeal space and lymphatic drainage of the nasopharynx. It discusses the AJCC staging system and Ho's staging system. It covers treatment techniques including two-field and three-field approaches, doses used, treatment volumes, nodal volumes, planning and field matching considerations.
This document provides an overview of hypopharyngeal carcinoma, including its anatomy, epidemiology, etiology, presentation, investigations, treatment options, and complications. Hypopharyngeal carcinoma most commonly arises in the piriform fossa and affects males over age 60, with risk factors including alcohol, smoking, and irradiation. Presenting symptoms include dysphagia, sore throat, and neck mass. Treatment depends on staging and may include surgical excision, chemoradiotherapy, or radiotherapy alone. Complications can include bleeding, tracheal damage, leakage, and swallowing difficulties.
This document provides an overview of neck dissection procedures, including:
- A classification system for neck dissections and descriptions of radical, modified radical, extended, and selective neck dissections.
- Generic steps for all neck dissections including incision, exposure, and lymph node removal.
- Detailed descriptions of performing a radical neck dissection, focusing on three areas of special attention: the lower end of the internal jugular vein, the junction of the clavicle and trapezius muscle, and the upper end of the internal jugular vein.
Oropharynx cancer practical target delineation 2013 aprYong Chan Ahn
This document provides an overview of the anatomy, patterns of spread, and treatment considerations for oropharyngeal cancer. It describes the boundaries and common spread patterns for primary tumors originating in different sites within the oropharynx, including the tonsillar fossa, soft palate, and base of tongue. It also discusses the incidence of subclinical lymph node metastases and the order of lymphatic spread. Important considerations for target delineation and elective neck irradiation are presented. Practical points for contouring and treatment planning with newer imaging technologies are provided.
This document summarizes the history and current practices of neck dissection. It discusses the evolution of neck dissection from the 19th century, when it was considered incurable, to the 21st century, where it remains an important prognostic indicator. It outlines the modern classification of neck dissection levels and types, including radical, modified radical, selective, and extended dissections. Finally, it reviews sentinel lymph node biopsy for early stage head and neck cancers, noting various techniques used and sensitivity ranges reported.
Nasopharyngeal carcinoma is a prevalent malignancy in Southeast Asia. External beam radiation therapy is the primary treatment, but recurrent disease remains challenging. Salvage nasopharyngectomy is used in some institutions for recurrent NPC after failed radiation. The nasopharynx has a complex anatomy near critical structures like the carotid artery. Staging involves imaging like CT and MRI to determine tumor extent and involvement of surrounding areas. Prognosis depends on staging, with 5-year survival rates from 24-95% depending on stage.
This document provides an overview of laryngeal anatomy and laryngeal cancer. It discusses the anatomy of the larynx including its cartilages, membranes, ligaments, muscles, blood supply, nerve supply and lymphatic drainage. It then covers the epidemiology, risk factors, clinical presentation and routes of spread of laryngeal cancer. Key points include that smoking and alcohol are major risk factors, supraglottic cancers often spread bilaterally to lymph nodes while glottic cancers have less lymphatic spread.
1. The document discusses the classification, indications, and techniques for radical neck dissection in the treatment of cervical lymph node metastasis.
2. It describes the different types of neck dissection including radical, modified radical, and selective neck dissection as well as the lymph node regions.
3. The indications for the different neck dissection types depend on factors like the primary tumor site, clinical nodal involvement, and whether postoperative radiotherapy will be given. Selective neck dissection is often preferred for clinically node-negative necks.
1. Management of metastatic squamous neck cancer with unknown primary depends on nodal stage, presence of extracapsular spread, and risk of primary sites. Excision biopsy and neck dissection followed by postoperative radiotherapy is often recommended.
2. Intensity modulated radiotherapy has improved outcomes over conventional radiotherapy by better targeting tumor tissue and reducing dose to surrounding organs.
3. The addition of chemotherapy to surgery or radiotherapy can provide even better survival results.
This document describes the anatomy of the neck relevant to neck dissection surgery. It outlines the boundaries of the neck, key muscles and structures like the platysma, sternocleidomastoid, trapezius and vessels. It discusses the lymph node levels and types of neck dissection surgeries like radical and selective dissections. The document provides details of the surgical approach including skin incisions and dissection of structures to completely remove lymph nodes while preserving nearby nerves and vessels.
This document discusses types of neck dissection procedures performed to treat neck metastases from head and neck cancers. It describes radical neck dissection, modified radical neck dissection, and selective neck dissection. Radical neck dissection removes all lymph nodes from levels I-V, while modified versions preserve one or more non-lymphatic structures like the spinal accessory nerve or internal jugular vein. Selective neck dissection removes only the lymph nodes at levels that drain the primary tumor site. The indications, techniques, and complications of these neck dissection procedures are examined in detail.
This document provides an overview of neck anatomy and neck dissection procedures. It describes the boundaries and contents of the neck regions. It then discusses the different types of neck dissections including radical neck dissection, modified radical neck dissection, and selective neck dissections. Key structures such as lymph nodes, muscles, nerves and vessels are identified. Surgical considerations and indications for different procedures are also outlined.
This document discusses neck dissection, which refers to the systematic resection of lymph nodes and surrounding tissue from the neck. It describes the 7 levels of neck nodes and provides details on different types of neck dissections like radical, modified radical, and selective dissections. Complications of neck dissection like hemorrhage, nerve injury, chyle leak, and wound issues are outlined. The document also briefly discusses sentinel lymph node biopsy, minimally invasive approaches, and robotic neck surgery.
This document provides information about neck dissection procedures. It discusses the history and evolution of neck dissection, defines the different types of neck dissections including radical, modified radical and selective neck dissections, and describes the key steps in performing a modified radical neck dissection. Complications of neck dissection such as hemorrhage, wound infection, and carotid artery rupture are also summarized.
Neck dissections involve removing lymph nodes in the neck to stage and treat head and neck cancers. The key points are:
1. There are different types and levels of neck dissections based on the lymph nodes and structures removed. A radical neck dissection removes the most nodes and structures while more functional dissections preserve the spinal accessory nerve and veins.
2. The neck has important structures like the marginal mandibular nerve and spinal accessory nerve that must be preserved. Key triangles in the neck include the anterior and posterior triangles.
3. Lymph nodes are divided into superficial and deep chains. The deep cervical nodes are the most important for staging and treating head and neck cancers. Ultrasound and biopsy
1) Neck dissection refers to surgical removal of lymph nodes and tissue in the neck to treat cervical lymph node metastasis from cancers like head and neck cancers.
2) The procedure has evolved from radical neck dissections removing most neck structures to more selective and modified radical neck dissections that preserve key structures like the spinal accessory nerve and internal jugular vein.
3) Proper classification of neck dissection types and the specific lymph node levels involved is important for standardized reporting and determining prognosis.
This document discusses principles of conservative surgery for head and neck cancers. It covers selective and comprehensive neck dissection techniques for managing cervical lymph nodes. It describes various open and endoscopic surgical procedures to preserve structure and function for cancers of the larynx and hypopharynx, including vertical partial laryngectomy, supracricoid laryngectomy, and transoral laser resection. Complications and oncologic outcomes of these organ preservation techniques are also discussed.
This document discusses neck dissections for squamous cell carcinoma of the head and neck. It describes the surgical anatomy of the neck, classifications of neck dissections including radical, modified radical and selective types, lymph node levels, indications for different procedures, and surgical techniques. Complications of neck dissections are also summarized.
This document provides treatment recommendations for carcinoma of the hypopharynx based on tumor stage. For early stage disease, definitive radiotherapy or voice-preserving surgery are options. Most patients present with stage III or IV disease requiring multimodality treatment including chemotherapy and radiation. Advanced tumors may be treated with surgery or organ-preserving approaches like transoral laser microsurgery. Post-operative radiation is recommended for high-risk features. Definitive chemoradiation is a standard non-surgical option. Induction chemotherapy followed by chemoradiation is also used for locally advanced cases. Palliative radiation aims to relieve symptoms for poor performance patients.
1. A neck dissection is a surgical procedure to remove lymph nodes and surrounding tissue in the neck to treat cancer that has spread from areas like the oral cavity or larynx.
2. There are different types of neck dissections classified based on the extent of lymph nodes and structures removed, including radical, modified radical, and selective neck dissections.
3. The specific type of neck dissection performed depends on factors like the location and stage of the cancer, and whether preservation of structures like the spinal accessory nerve or internal jugular vein is needed.
Neck node management of unknown primaryDr Rekha Arya
The document discusses the management of neck nodes with an occult primary tumor. It begins by defining an occult primary tumor as one that presents with lymph node or distant metastases when investigations fail to identify the primary site. It then discusses the diagnostic workup, which includes history, physical exam, imaging studies like PET CT, and biopsy of lymph nodes. Treatment depends on the lymph node level and stage. For early stage disease, neck dissection may be sufficient, while advanced disease requires chemoradiation. Post-treatment neck dissection may be needed depending on response. Radiation techniques like IMRT can help reduce toxicity compared to conventional radiation. Complications of treatment include risks of surgery and side effects of high-dose radiation.
This document discusses the anatomy, staging, treatment and techniques for carcinoma of the nasopharynx. It describes the parapharyngeal space and lymphatic drainage of the nasopharynx. It discusses the AJCC staging system and Ho's staging system. It covers treatment techniques including two-field and three-field approaches, doses used, treatment volumes, nodal volumes, planning and field matching considerations.
This document provides an overview of hypopharyngeal carcinoma, including its anatomy, epidemiology, etiology, presentation, investigations, treatment options, and complications. Hypopharyngeal carcinoma most commonly arises in the piriform fossa and affects males over age 60, with risk factors including alcohol, smoking, and irradiation. Presenting symptoms include dysphagia, sore throat, and neck mass. Treatment depends on staging and may include surgical excision, chemoradiotherapy, or radiotherapy alone. Complications can include bleeding, tracheal damage, leakage, and swallowing difficulties.
This document provides an overview of neck dissection procedures, including:
- A classification system for neck dissections and descriptions of radical, modified radical, extended, and selective neck dissections.
- Generic steps for all neck dissections including incision, exposure, and lymph node removal.
- Detailed descriptions of performing a radical neck dissection, focusing on three areas of special attention: the lower end of the internal jugular vein, the junction of the clavicle and trapezius muscle, and the upper end of the internal jugular vein.
Oropharynx cancer practical target delineation 2013 aprYong Chan Ahn
This document provides an overview of the anatomy, patterns of spread, and treatment considerations for oropharyngeal cancer. It describes the boundaries and common spread patterns for primary tumors originating in different sites within the oropharynx, including the tonsillar fossa, soft palate, and base of tongue. It also discusses the incidence of subclinical lymph node metastases and the order of lymphatic spread. Important considerations for target delineation and elective neck irradiation are presented. Practical points for contouring and treatment planning with newer imaging technologies are provided.
This document summarizes the history and current practices of neck dissection. It discusses the evolution of neck dissection from the 19th century, when it was considered incurable, to the 21st century, where it remains an important prognostic indicator. It outlines the modern classification of neck dissection levels and types, including radical, modified radical, selective, and extended dissections. Finally, it reviews sentinel lymph node biopsy for early stage head and neck cancers, noting various techniques used and sensitivity ranges reported.
Nasopharyngeal carcinoma is a prevalent malignancy in Southeast Asia. External beam radiation therapy is the primary treatment, but recurrent disease remains challenging. Salvage nasopharyngectomy is used in some institutions for recurrent NPC after failed radiation. The nasopharynx has a complex anatomy near critical structures like the carotid artery. Staging involves imaging like CT and MRI to determine tumor extent and involvement of surrounding areas. Prognosis depends on staging, with 5-year survival rates from 24-95% depending on stage.
This document provides an overview of laryngeal anatomy and laryngeal cancer. It discusses the anatomy of the larynx including its cartilages, membranes, ligaments, muscles, blood supply, nerve supply and lymphatic drainage. It then covers the epidemiology, risk factors, clinical presentation and routes of spread of laryngeal cancer. Key points include that smoking and alcohol are major risk factors, supraglottic cancers often spread bilaterally to lymph nodes while glottic cancers have less lymphatic spread.
1. The document discusses the classification, indications, and techniques for radical neck dissection in the treatment of cervical lymph node metastasis.
2. It describes the different types of neck dissection including radical, modified radical, and selective neck dissection as well as the lymph node regions.
3. The indications for the different neck dissection types depend on factors like the primary tumor site, clinical nodal involvement, and whether postoperative radiotherapy will be given. Selective neck dissection is often preferred for clinically node-negative necks.
1. Management of metastatic squamous neck cancer with unknown primary depends on nodal stage, presence of extracapsular spread, and risk of primary sites. Excision biopsy and neck dissection followed by postoperative radiotherapy is often recommended.
2. Intensity modulated radiotherapy has improved outcomes over conventional radiotherapy by better targeting tumor tissue and reducing dose to surrounding organs.
3. The addition of chemotherapy to surgery or radiotherapy can provide even better survival results.
This document describes the anatomy of the neck relevant to neck dissection surgery. It outlines the boundaries of the neck, key muscles and structures like the platysma, sternocleidomastoid, trapezius and vessels. It discusses the lymph node levels and types of neck dissection surgeries like radical and selective dissections. The document provides details of the surgical approach including skin incisions and dissection of structures to completely remove lymph nodes while preserving nearby nerves and vessels.
This document discusses head and neck cancers, which account for over 550,000 cases worldwide annually. Males are affected significantly more than females. The most common sites are the oral cavity, pharynx, and larynx. Squamous cell carcinoma makes up 90-95% of head and neck cancers. Major risk factors include smoking, alcohol consumption, HPV infection, and betel nut chewing. Evaluation involves physical examination, endoscopy, and imaging to determine the extent of the primary tumor and metastasis. Biopsy is required for diagnosis.
1. Congenital neck masses are abnormal growths present from birth between the clavicles and mandible. The most common congenital neck mass is a thyroglossal cyst, which forms from a persistent thyroglossal duct during development.
2. Other congenital neck masses include branchial cysts, dermoid cysts, cystic hygromas, hamartomas, and teratomas.
3. Evaluation of congenital neck masses involves inspection, imaging like ultrasound or CT to determine if the mass is solid or cystic in nature, and biopsy if needed to arrive at a definitive diagnosis. Surgical excision is usually the treatment for congenital neck masses.
managment of neck nodes with occult primaryBharti Devnani
This document discusses the management of neck nodes with an occult primary tumor. It defines this condition as biopsy-proven cancer of the neck that cannot be linked to a primary lesion after a full clinical and radiological workup. It notes the estimated incidence is 3-7% of head and neck cancers initially presenting with cervical lymph node metastases. Risk of lymph node metastases depends on factors like density of lymphatics in the potential primary site and histologic characteristics of the lesion. Diagnostic workup involves imaging, biopsies of suspicious areas, and examination under anesthesia. Treatment involves neck dissection, with options like radical, modified radical or selective dissection depending on the extent of disease. Post-surgery management considers disease
The document discusses the anatomy and triangles of the neck, describing boundaries, contents, and clinical significance. It also covers common neck masses including cysts, sinuses, fistulas, ulcers, tumors, and infections. Lymphatic drainage is described for deep cervical nodes along vertical and circular chains.
1. Neck dissection involves removing lymph nodes from different levels in the neck to stage and treat head and neck cancers.
2. The extent of neck dissection, such as radical or modified radical, depends on how many non-lymphatic structures like the spinal accessory nerve are preserved.
3. Selective neck dissections remove nodes from only certain levels, while comprehensive dissections are used to treat cancer that has spread to lymph nodes.
The document discusses the anatomy of the neck region. It begins by outlining the gross anatomy including the extent and boundaries of the neck. It then describes the divisions of the neck created by the sternocleidomastoid muscle and details the contents of the anterior and posterior triangles. Next, it discusses the layers of cervical fascia and the spaces they enclose, including the visceral, retropharyngeal, parapharyngeal, danger, and prevertebral spaces. It notes the clinical importance of understanding the neck spaces for localizing lesions, differential diagnosis, and guided procedures. Finally, it briefly summarizes some of the key structures contained within the neck, such as the thyroid gland, larynx, and parathy
This document provides information on head and neck cancer including:
1. It describes the anatomy of the head and neck region including lymph nodes and locations of salivary glands.
2. It discusses imaging techniques like CT and PET scans which are used to detect and stage head and neck cancers.
3. It outlines the AJCC TNM staging system for various head and neck cancers and describes how the cancer can spread from different primary sites.
The document describes the anatomy of the anterior and posterior triangles of the neck. It details the bones, muscles, blood vessels, nerves and other structures found in each triangle. Key structures mentioned include the cervical vertebrae, carotid artery, thyroid gland, larynx, and various nerves such as the hypoglossal and recurrent laryngeal nerves. The triangles described are the submandibular, submental and carotid triangles located in the anterior neck region.
The document describes the triangles of the neck, including the anterior triangle, posterior triangle, and their subdivisions. Key points include:
- The anterior triangle is bounded by the median line anteriorly, sternocleidomastoid posteriorly, and the clavicle inferiorly. It is subdivided by the digastric, submental, muscular, and carotid triangles.
- The posterior triangle is bounded by sternocleidomastoid anteriorly, trapezius posteriorly, and the clavicle inferiorly. It is subdivided into the occipital and supraclavicular triangles by the omohyoid muscle.
- Structures like arteries, veins
This document summarizes benign and malignant tumors of the oropharynx. Benign tumors include papillomas, haemangiomas, pleomorphic adenomas, and mucous cysts. Malignant tumors most commonly occur in the base of the tongue, tonsils, soft palate, and posterior pharyngeal wall. Squamous cell carcinoma is the most frequent malignant tumor. Treatment depends on the site and size of the tumor, and may include surgery, radiation therapy, chemotherapy, or a combination. Cancers of the base of tongue and tonsils often spread early to cervical lymph nodes. Wide local excision with neck dissection and postoperative radiation is the standard treatment for larger tumors.
The document provides an overview of neck dissections, including their history, surgical anatomy of the neck, lymph node levels and staging, classifications of neck dissections, and indications for different types of neck dissections. It discusses the evolution of neck dissections from the radical neck dissection to more selective procedures. Key classifications covered are the radical, modified radical, and selective neck dissections, with the latter including supraomohyoid, lateral, and posterolateral variants. Indications and structures preserved for each type of dissection are outlined.
This document discusses the lymphatic system and lymph nodes. It provides information on lymph composition and flow through the lymphatic vessels and nodes. It describes how lymph nodes can become enlarged (lymphadenopathy) due to infections, inflammatory conditions, or malignancies. The document outlines techniques used to evaluate lymph nodes, including physical examination, imaging, biopsy procedures, and sentinel lymph node biopsy. It discusses the staging of head and neck cancers using lymph node involvement.
This document provides information about pharyngeal cancers, including nasopharyngeal carcinoma, oropharyngeal cancer, and hypopharyngeal carcinoma. It discusses the relevant anatomy, risk factors, signs and symptoms, diagnostic tests, staging, treatment options including radiation, chemotherapy, and surgery, as well as reconstruction techniques and prognosis. The surgical approaches covered include transoral, transcervical, mandibular swing, and others. Reconstruction options like skin grafts, flaps, and free tissue transfer are also summarized.
Tobacco and alcohol use are major risk factors for head and neck cancers. Cigarette smokers have a 5-25 times higher lifetime risk of developing these cancers compared to the general population. Other risk factors include leukoplakia, betel nut chewing, and certain occupational exposures. Symptoms depend on the location of the primary tumor but may include neck masses, hoarseness, ear pain, and difficulty swallowing. Treatment involves surgery, radiation therapy, and chemotherapy depending on the cancer's stage and grade. The level of lymph node involvement is a key prognostic indicator.
The document discusses lymph node metastasis in head and neck squamous cell carcinoma (HNSCC). It covers topics such as:
1) The most common sites of lymph node metastasis in HNSCC are levels II and III, with less frequent involvement of levels I and IV-VI.
2) Factors that influence lymph node metastasis include primary tumor characteristics, lymphangiogenesis induced by VEGF-C/D signaling, and the genetic makeup of the tumor which regulates genes involved in invasion and migration.
3) Once tumor cells reach lymph nodes, they can proliferate, remain dormant, or enter circulation to spread hematogenously to distant sites. The presence of lymph node metastases is associated with worse
The document discusses carcinoma of the esophagus, including its anatomy, epidemiology, risk factors, staging, types, and management. It covers the various surgical techniques for esophagectomy, such as Ivor Lewis, McKeown, and transhiatal procedures. Post-operative care including drainage tube removal and diet progression is also summarized.
The document discusses management of oropharyngeal cancers. The oropharynx includes areas like the base of the tongue, soft palate, tonsils and posterior pharyngeal walls. Oropharyngeal cancers commonly spread to cervical lymph nodes in levels II, III and IV. Risk factors include age, gender, smoking, alcohol and HPV infection. Treatment may involve surgery, radiation therapy or chemotherapy depending on the stage of cancer. Imaging tests like CT, MRI and PET scans are used to stage the cancer and detect metastases.
The document discusses tumors of the pharynx, including anatomy, histology, risk factors, types, diagnosis, staging, and treatment. The pharynx is divided into nasopharynx, oropharynx, and hypopharynx. Common pharyngeal cancers include squamous cell carcinoma and nasopharyngeal carcinoma. Risk factors include smoking, alcohol, radiation exposure, and viruses. Diagnosis involves medical history, examination, and imaging tests. Treatment depends on cancer type and stage but may include surgery, radiation therapy, or chemoradiation.
The document discusses tumors of the pharynx, including anatomy, histology, risk factors, types, diagnosis, staging, and treatment. The pharynx is divided into nasopharynx, oropharynx, and hypopharynx. Common pharyngeal cancers include squamous cell carcinoma and nasopharyngeal carcinoma. Risk factors include smoking, alcohol, radiation exposure, and viruses. Diagnosis involves medical history, examination, and imaging tests. Treatment depends on cancer type and stage but may include surgery, radiation therapy, or chemoradiation.
This document discusses the anatomy and patterns of lymph node metastasis in head and neck cancers. It covers the history of neck dissection techniques, anatomy of cervical lymph nodes, levels of lymph node involvement, factors affecting prognosis, and terminology such as occult metastasis and skip metastasis. Select sections discuss findings from studies on patterns of nodal spread in oral cancers and the risk of occult metastases. The conclusion is that lymph node level IV must be included in neck dissections for tongue cancers due to the risk of skip metastases bypassing upper levels.
Malignancies of the larynx are most commonly squamous cell carcinomas. They are staged based on tumor size, location within the larynx, and spread to lymph nodes. Treatment depends on the stage and location of the tumor. Early vocal cord lesions are often treated with radiation therapy alone. Moderately advanced tumors may be treated with either radiation or total laryngectomy. Advanced tumors usually require total laryngectomy along with neck dissection and adjuvant treatment. The goal is cure while preserving laryngeal function when possible.
This document provides information on tumors and cancers of the larynx. It discusses benign tumors like papillomas and nodules/polyps. It then focuses on laryngeal cancer, which is usually squamous cell carcinoma. Risk factors include smoking, alcohol, asbestos, and chemicals. Symptoms depend on tumor size and location but can include hoarseness, neck masses, throat pain, and difficulty swallowing. Treatment options evaluated include surgery (partial laryngectomy, total laryngectomy), radiation, and chemotherapy depending on cancer stage. Prognosis depends on stage, age, gender, and tumor characteristics.
CA larynx Presentation - diag. & treatmentShubham Yadav
This document discusses laryngeal cancer, including:
- Types are mostly squamous cell carcinoma, with some other rare types. Glottic cancer is most common.
- Symptoms depend on location - glottic causes hoarseness, supraglottic causes throat pain and dysphagia, subglottic causes stridor.
- Staging involves examination, imaging, and considers tumor size and spread. Treatment options include radiation, surgery like laryngectomy, and rehabilitation techniques after total laryngectomy like oesophageal speech.
This document discusses carcinoma of the hypopharynx. It begins with the anatomy of the hypopharynx and then discusses the epidemiology, etiology, prognostic factors, pathology, patterns of spread, clinical presentation, evaluation and staging, and management. For management, it describes both surgical and radiation therapy approaches. Radiation therapy techniques including simulation, conventional planning, and fractionation are covered in detail.
Oral cancer most commonly occurs in individuals over age 40 and accounts for less than 3% of all cancers. Squamous cell carcinoma makes up over 90% of oral cancers. Risk factors include tobacco, alcohol, HPV infection, and nutritional deficiencies. Oral cancers most commonly occur on the tongue, floor of mouth, and lower gingiva. Treatment involves surgery, radiation, chemotherapy or a combination depending on cancer stage. Post-treatment follow up is important for monitoring recurrence.
Vulvar cancer accounts for about 5% of cancers of the female genital system in the US. Possible signs include bleeding, itching, lumps or growths on the vulva, skin color changes, or ulcers. Risk factors include HPV infection, smoking, and precancerous skin conditions. Treatment depends on stage but may involve surgery to remove the tumor and nearby lymph nodes, radiation therapy, or chemoradiation. Side effects can include skin irritation in the vulvar area, as well as urinary and bowel issues. Overall survival rates vary from over 80% for local stage to under 20% for distant stage disease.
1) Cancers of the penis are rare but devastating, accounting for 0.4-0.6% of cancers in men in the US and Europe but up to 10% in some other regions.
2) Risk factors include poor hygiene, phimosis, HPV infection, and lack of circumcision. Over 95% are squamous cell carcinoma.
3) Staging involves physical exam, biopsy, and imaging of lymph nodes and distant organs. Treatment may include organ-sparing surgery or penile amputation depending on size, grade, and extent of invasion.
This document provides an overview of laryngeal carcinoma. It notes that there are approximately 11,000 new cases per year in the US, accounting for 25% of head and neck cancers. Risk factors include tobacco and alcohol use. Presentation is often hoarseness. Diagnosis involves biopsy. Treatment options depend on staging and include surgery such as total laryngectomy or organ preservation approaches combining chemotherapy and radiation. Prognosis remains challenging with many recurrences within the first two years.
This document provides information about cancer of the anal canal, including its anatomy, risk factors, staging, classification, and treatment. It notes that anal canal cancer is uncommon but increasing in incidence. The anal canal is approximately 4 cm long and lines by squamous epithelium. Risk factors include HPV infection and immunosuppression. Treatment typically involves chemoradiotherapy to preserve the sphincter, which provides high survival and local control rates of 60-90%. Combined modality therapy with 5-FU and mitomycin C or cisplatin is the standard of care.
The Pure Tone Audiometry (PTA) test is used to determine a person's hearing threshold levels using pure tone pulses presented at standardized frequencies from 125-8000Hz. The threshold is the lowest sound level at which a person detects 50% of tones. Specific test conditions include the type and presentation of tones. Tones are presented one ear at a time through earphones to determine if hearing loss is present and what type based on the audiogram configuration. Sources of error in PTA tests include physiological, psychological, methodological, physical/acoustic factors, and ambient noise levels.
This document summarizes different types of vertigo and nystagmus. It describes 7 causes of vertigo: 1) Benign Paroxysmal Positional Vertigo, 2) Meniere's disease, 3) Vestibular Neuronitis, 4) Perilymph Fistula, 5) Vestibulotoxic drugs, 6) Labyrinthitis, and 7) Acoustic Neuroma. It also defines nystagmus as involuntary eye movements and classifies the degree of nystagmus into three levels based on the components of eye movement involved.
Stridor is an abnormal noise caused by partial airway obstruction. The document discusses different types of stridor and common causes of stridor in children, including croup (laryngotracheobronchitis), epiglottitis, and spasmodic croup. Croup most often affects children ages 3 months to 3 years and is caused by influenza viruses. Epiglottitis typically affects children ages 3 to 6 years and can cause drooling, muffled voice, and stridor. Management of airway obstruction may include oxygen, humidification, steroids, nebulizers, and intubation or tracheostomy in severe cases.
Obstructive sleep apnea in children is defined as cessation of breathing for 6 seconds or more during sleep, which can lead to hypoxia and hypercapnia, disrupting normal sleep patterns. The severity of obstructive sleep apnea is classified based on the number of apneas per hour as mild, moderate, or severe. Obstructive sleep apnea can be caused by blockages at four levels - the adenoid pad, tonsils, tongue base, or supraglottic area. Treatment depends on the site of obstruction and may include adenoidectomy, tonsillectomy, use of nasal airways or mandibular advancement devices, or laser procedures. Adenotonsillectomy c
The nose has important anatomical structures that allow it to carry out its key physiological functions. Externally, the nose is made up of bone and cartilage, including the nasal bones and lateral cartilages. Internally, the nasal cavity contains three turbinates that divide it into air passages. The osteomeatal complex includes structures like the agger nasi and ethmoid bulla that are involved in drainage and ventilation of the paranasal sinuses. Physiologically, the nose conditions inhaled air by warming, humidifying and filtering it. It also plays a role in respiration and protects the lower airways through mucociliary clearance.
This document discusses diseases of the tonsils, including recurrent acute tonsillitis and chronic tonsillitis. It outlines indications for tonsillectomy in cases of recurrent tonsillitis. The normal flora found on the tonsils is described, as are complications of tonsillitis like scarlet fever and rheumatic fever. Treatment approaches for acute and chronic tonsillitis are discussed. The role of the tonsils in immunity is covered. Finally, potential transmission of prion diseases like Creutzfeldt-Jakob disease via contaminated tonsillectomy instruments is mentioned.
The tonsils are lymphoid tissues located in the throat that help protect the respiratory and digestive tracts from infection. Common pathogens found in the tonsils include streptococcus and other bacteria. Acute tonsillitis is usually caused by streptococcus and presents with fever, sore throat, and painful swallowing. It is generally self-limiting but complications can include abscesses or spread of the infection. Chronic or recurrent tonsillitis may require treatment like antibiotics or tonsillectomy.
Corticosteroids readily diffuse into cells and bind with glucocorticoid receptors to form complexes that interact with proteins and act as transcription factors, reducing inflammation. Intranasal corticosteroids become effective within 3 hours and are most effective for symptoms like itching and sneezing, while systemic corticosteroids are more effective for blockage and anosmia. Methylprednisolone and dexamethasone are preferred for intravenous use due to their minimal mineralocorticoid effects. Prednisone is converted to prednisolone in the liver, while dexamethasone has minimal mineralocorticoid effects.
The document discusses several viruses that cause respiratory infections including influenza, respiratory syncytial virus, parainfluenza, adenovirus, rhinovirus, and coronaviruses. It notes that respiratory tract infections are very common worldwide and responsible for many lost work days. Diagnosis methods include enzyme immunoassays, immunofluorescent antibody tests, and PCR tests. Treatment depends on the virus but may include antivirals like acyclovir, oseltamivir, ribavirin, and interferon. Herpes simplex virus, Epstein-Barr virus, human papillomavirus, and others are described in relation to various diseases. Conditions with possible viral etiologies include Bell's p
The document discusses several types of tumors that can occur in the head and neck region of children. Lymphoma, rhabdomyosarcoma, medullary carcinoma of the thyroid, and neuroblastoma are some of the tumors mentioned. For lymphoma, the most common presentation is cervical lymphadenopathy, while rhabdomyosarcoma often presents with pain and swelling in locations like the orbit or paranasal sinuses. Diagnosis involves biopsy along with imaging and lab tests. Treatment depends on the specific tumor but may involve chemotherapy, radiation, and surgery. All childhood cancer cases should be referred to a specialist center.
The document discusses the adenoid and adenoidectomy procedure. It covers the anatomy and function of the adenoid, including its role in immunity. It describes pathological effects like otitis media, upper airway obstruction, and rhinosinusitis. The assessment, management, and complications of adenoidectomy are outlined. While adenoidectomy is effective for upper airway obstruction and otitis media with effusion, its efficacy for other issues like recurrent ear infections, sleep apnea, and sinusitis requires more research. Mild adenoid hypertrophy does not always require surgery.
This document provides information on otitis media with effusion (OME), including its definition, causes, characteristics, diagnosis, and epidemiology. Specifically:
- OME is the chronic accumulation of fluid in the middle ear for at least 12 weeks, usually presenting as hearing impairment. It is often preceded by acute otitis media or upper respiratory infection.
- The fluid results from inflammation of the Eustachian tube epithelium that prevents drainage of the middle ear. Histological examination shows replacement of normal epithelium with mucus-secreting cells.
- Diagnosis involves otoscopy, pneumatic otoscopy, and tympanometry which can classify effusions. Type B
This document defines and discusses gastro-oesophageal reflux, aspiration, their causes, symptoms, diagnostic tests and treatments. It notes that reflux is common in infants and usually physiological, but can become pathological if harming the child. Aspiration risks include impaired swallowing coordination or laryngeal protection. Diagnostic tests are videofluoroscopy and fibreoptic evaluation of swallowing. Treatments include positioning, thickened feeds, acid suppression, and sometimes surgery to control severe reflux or reduce saliva production for aspiration.
1) Mycotic diseases of the paranasal sinuses range from indolent infections in healthy individuals to lethal infections in immunocompromised people.
2) Fungal sinusitis is classified into invasive, noninvasive, and allergic types based on histopathology and clinical presentation. Invasive types can spread to nearby structures like the orbit and brain.
3) Diagnosis involves imaging like CT scans to assess bone destruction, biopsy and culture of tissue to confirm infection and identify the fungal species. Treatment depends on the type but may include antifungal drugs, surgery, and improving immune function.
The tonsils are lymphoid tissue located in the throat that help the immune system. Acute tonsillitis is usually caused by viruses or bacteria like Streptococcus and is typically self-limiting. Treatment focuses on pain relief and hydration. Antibiotics may help if symptoms persist after 2-3 days. Complications are rare but include peritonsillar abscesses, which are treated with antibiotics and needle aspiration. The tonsils can also present lymphomas or cancers.
This document discusses chronic otitis media, including the histology and pathogenesis. It notes that chronic inflammation is characterized by both tissue destruction and attempts at healing. Repeated infections from the nasopharynx or external ear canal can prevent resolution of otitis media. Persistent bacterial biofilms and chronic perforations of the tympanic membrane also contribute. Chronic retraction of the pars tensa portion of the eardrum can lead to atrophy and complications like cholesteatoma formation over time if not addressed. Early intervention may be warranted for more advanced retractions to prevent future problems.
This document discusses the embryology and presentation of several congenital anomalies of the head and neck region, including branchial arch fistulae, thyroglossal duct anomalies, preauricular sinuses, and lymphangioma. It describes how these structures develop from the branchial arches and pouches during embryogenesis. Common locations and presentations of each anomaly are provided, along with diagnostic evaluation and treatment approaches. Surgical excision is often needed but can be challenging due to the relationship of these structures to nearby nerves and vessels.
The document discusses the use of antimicrobial therapy and various classes of antibiotics. It provides details on the mechanisms of action, spectra of activity, indications for use, and side effects of different classes of antibiotics including beta-lactams (penicillins, cephalosporins, carbapenems), glycopeptides, quinolones, sulfonamides/trimethoprim, metronidazole, tetracyclines, chloramphenicol, macrolides, aminoglycosides, streptogramins, and oxazolidinones. It also discusses Clostridium difficile infection as a common gastrointestinal side effect caused by antibiotic use.
Acute otitis media (AOM) is an inflammation of the middle ear caused by bacterial or viral infection. It is common in young children and causes symptoms like ear pain, fever, and hearing loss. While most cases clear up without treatment, antibiotics are usually prescribed to reduce symptoms and risk of complications. For recurrent cases, management involves identifying and addressing risk factors, medical or surgical prophylaxis including ventilation tubes, and vaccination when available. AOM poses a significant burden as it is one of the most frequent reasons children receive antibiotics.
Swallowing involves three phases - oral, pharyngeal, and esophageal. In the oral phase, food is mixed with saliva and moved to the back of the throat by the tongue. The soft palate then elevates to protect the nasal airway. In the pharyngeal phase, the larynx and pharynx elevate to allow food to pass while protecting the airway, and a series of muscle contractions propel the food over the epiglottis and into the esophagus. In the esophageal phase, the upper esophageal sphincter relaxes to allow the food to pass into the esophagus for peristalsis down to the stomach.
1. Metastatic neck disease
One of the most important prognostic factors in head &neck cancer is the presence or absence ,
level& size of metastatic neck disease.
Natural history &evalution of neck disease
The factors are which affect natural history of neck disease are
Tumour site;
Tumour size;
Tumour thickness;
Previous recurrence;
Tumour history;
Tumour immunology.
Perineural & perivascular invasion,the degree of tumour differtiation.
It is possible to predict the site of a primary tumour based upon the distribution of cervical
metastases.A number of levels or regions within neck which contain groups of lymph nodes
representing the first echelon sites for metastatic head –neck primary sites.
Level I ;Ia ,submental &Ib, submandibular lymph node,
Level II; Upper jugular chain above the level of the hyoid bone.IIa is anterior to accessory nerve& IIb
posterior to the accessory nerve.
Level III; middle jugular chain nodes from the level of the hyoid bone to the level of the cricoids.
LevelIV;lower jugular chain nodes from the level of the cricoids to the suprasternal notch.
Level V; posterior triangle lymph nodes, can be divided into Va above the level the of the
omohyoid,& Vb below the level of the omohyoid.
Level VI; Central compartment lymph nodes;
Level VII; superior mediastinal nodes.
Retropharyngeal & paraphyngeal nodes are not classified in these levels.
It is important to realize that the above drainage patterns apply to the nontreated neck.
An incision in the neck for a lymph node biopsy can altered patterns of lymphatic drainage for up to
one year following surgery. Further shunting of lymph with opening opening up of abnormal
channels occurs when more extensive surgery & radiotherapy is undertaken,& once a lymph node is
palpable & contains tumour there may be shunting of cells to the contralateral neck.
2. The probability of cervical metastases (N) related to primary (T) staging in patients with head &neck
cancer.
Primary site T-stage N0% N1% N2-3%
Floor of mouth T1 89% 9 2
Oral tongue T1 86 10 4
Retromolar
T1 88 2 9
trigone,anterior
faucial pillar
Nasopharynx T1 8 11 82
Soft palate T1 92 0 8
Base of tongue T1 30 15 55
Tonsilar fossa T1 30 41 30
Supraglottic
larynx
Hypopharynx
T1
T1
61
37
10
21
29
42
Organ specific drainage
The nasopharynx ,nasal cavities & sinuses drain via the junctional nodes into the upper deep cervical
nodes (levels II & III), having passed through retropharyngeal or submandibular lymph nodes.
Oropharynx similarly drains into the upper & middle deep cervical nodes, again either directly or via
the retropharyngeal or submandibular nodes.
Total lymph node in the body 500, & 200 of these are in the head & neck. The normal range in size is
from 3mm to 3cm but most nodes are less than a centimetre.
The jugulodigastric node(low-level II or high-levelII) is situated within the triangle formed by the
internal jugular vein, facial vein ,&posterior belly of digastrics muscle.Receives lymph from
submandibular region, the oropharynx & oral cavity.
The jugulo-omohyoid nodes(low-levelII or high level IV) where omohyoid crosses the internal vein,
Receives lymph from anterior floor of mouth, oropharynx, larynx.
Laryngeal drainage is separated into upper & lower systems at the level of the true vocal cords.
3. Supraglottis drains (Upper syetem) via thyroid membrane to reach the deep cervical nodes (levels
II/III).
The lower system drains directly via cricothyroid membrane to reach the deep cervical nodes (levels
III/IV).Behind the cricothyroid membrane drain into the prelaryngeal , pretracheal or paratracheal
nodes.
The first echelon of lymph node for oral cavity I,II,III.
The first echelon of lymph node for larynx & pharynx II,III,IV.
The first echelon of lymph node submandibular & sublingual I,II,III.
The first echelon of lymph node parotid preparotid,paraparotid.intraparotid.
The first echelon of lymph node for thyroid VI(trachea-oeshopheal groove) & IV.
Tumour biology:
Once squamous cells carcinoma is established within the lymphatic system,tumour growth is difficult
to arrest.Other reports that the regional lymph node are involved in effective tumourlysis.One
important question need to be resolved is if there is any benefit treating the regional lymphatic
basin early (N0) ,or later on in the disease process(N+).
Cancer cells gain access to the lymphatic system from the tumour periphery through gaps between
the lymphatic endothelial cells.Then passive transport to the regional lymph node within lymph.The
afferent lymphatic join the marginal sinus in the cortex of lymph nodes,so that cellular division
occurs first periphery in the cortex & TUMOUR MIGRATION can then occur to involve the medulla.
Once tumour cells arrive at a draining lymph node, they can proliferate, die, remain dormant, or
enter the circulation through nodal blood vessels.A number of important properities have recently
been assigned to tumour cells or metastatic seeds & these include cell growth
,chemotaxis,immunological, metabolic & hormonal factors.Similar host environment (soil factors)
include tissue & stromal environmental, hormonal ,inflammatory & immunological response& the
presence or absence of vital nutrients.
From lymph node, 1)efferent channels leave the hilum to join the terminal collecting trunks (Right &
left lymphatic ducts) then drainage is into venous system.
2)cancer cells can gain access the bloodstream entering directly from a node
3) alternatively lymph node may be completely bypassed through collateral channels
& this mechanism is enhanced by local obstruction due to metastasis ,reactive hyperplasia,&sinus
histiocytosis.This is called skip metastases.
Regional lymph node have a reasonable constant holding capacity & above that threshold ,all other
tumour cells pass to efferent channels & then into the general circulation.Lymph node are not
simple mechanical barrier but involved in conferring anti-tmour immunity,some lymphocyte are
cytotoxic to cancer cells.
4. Molecular method for the detection of metastases
Molecular assays are estimated to be over 500 more times more sensitive than histological methods
for detection of cancer cells.
1) Tumour specific p53 mutations
2) Oligonucleotide-mediated mismatch ligation assay for detection of cancer cells in
histologically negative regional lymph node in colorectal & lung cancer.
3) Recently, mitochondrial DNA mutations ,identification of these mutations in regional lymph
nodes may have potential for molecular staging in the future.
Patients with positive lymph nodes in head & neck cancer have approximately a 50% decreased
chance of survival when compared with those who are node negative.
This philosophy is now being questioned with regard to locoregional discase being cured with local
treatments (surgery & radiation),since distant metastasis are now a significant problem.Locoregional
controlled patient may die more frequently of second primaries or distant metastases.overall
survival has not changed.
The main arguments for prophylactic elective node treatment assumes that regional lymph node
are not only effective barriers to tumour ,but also represent further sources of disease dissemination
with regard to distant metastases.It Is now well recognized that metastatic lesions do have the
ability to metastasize.
Tumour metastasis
Tumour metastasis is a complex process which involves many different interaction between the
tumour & its host & influenced by a number of humoral factors endocrine, cellular,metabolic
&nutritional factors.
Treatment modalities can effect tumour-host equilibrium in unpredictable ways & these include the
following:
1)Surgery 2)chemotherapy3)radiotherapy4) trauma5) wound infection.
Surgery can alter the locoregional tumour environment, collateral channels form,alter patterns of
lymphatic metasatic spread & divert lymph flow to the contralateral neck.
Surgical scarring can trap tumour cells, leads to established local recurrence.
Extracapsular nodal spread
There is a general consensus that the presence of extracapsular spread outside a lymph node is
associated with a poor prognosis.Extracapsular spread due to increase in tumour burden or an
increase in tumour aggressiveness or may indicate the presence of a depressed host-immune
response.
5. Extracapsular spread are at increased risk of local recurrence ,distant metastases, & the time to
recurrence is shorter.In presence of extracapsular spread decrease survival rate by approximately
half compared with patients whose tumour was confined to the node.
In addition , postoperative radiotherapy doesnot appear to improve the outcome of patients with
extracapsular spread & have suggested that some form of systemic adjuvant therapy(chemotherapy)
is required as well, although this has not been of proven use in increasing locoregional control,
decreasing the incidence of distant metastases or improving overall survival.
Retropharyngeal nodes
The presence of retropharyngeal nodes with a very poor prognosis.Tumours that are associated with
these nodes include primary disease of the oropharynx,paranasal sinuses & pyriform sinus as well as
advanced primary tumour at any site together with massive unilateral or bilateral neck disease due
to shunting from obstructed lymphatic ducts or channels.
A new designation in the tumour node metastases TNM staging system N4/stageV
N4A represent Retropharyngeal lymph node positive without cervical lymphadenopathy.
N4B represent retropharyngeal lymph node positive with cervical lymphadenopathy.
MRI more accurate than CT scan to assess the retropharyngeal nodes.
Predictors for distant metastases
The overall five year survival rates are reduced by at least 50% when cervical nodes are positive &
reason for that is an aggressive primary tumour & its ability to metastases.The incidence of distant
metastases is related the size of the primary tumour,the presence of neck disease, & overall stage.
Another important finding is that the incidence of distant metastases increases by 50% when there
is recurrent disease present either at primary site or in the neck.
Prognostic nodal features
There are number of features of cervical lymph nodes which indicate a poor prognosis:
1) Site ,size& number
2) Level(low level& multiple level)
3) Extracapsular extension
4) Morphology(these include lymphocyte predominate &sinus histocytosis)
5) Laterality (,bilateral & contralateral disease)
Involvement of low level nodes & noncontiguous or multiple sites was associated a worse prognosis.
6. Criticism of the current staging system
The most important prognostic factors are the number of nodes involved& the presence of
extracapsular spread.
Bilateral lymph node particularly if they are N1 donot carry any worse prognosis than unilateral N1
nodes at certain sites (supraglottis).For other sites contralateral or bilateral nodes carry a dismal
prognosis as such deserve an N3 grouping.
Finally massive nodes on both side of the neck which is often fixed & almost universally fatal don’t
have independent classification.
Investigations
CT :There is no doubt that CT scanning can detect malignant cervical lymphadenopathy within neck.
The detection of malignant disease is based on the fact that a cancer invades the lymph node,Its
size, shape & characteristic change so that as it enlarges ,its centre dies, & appears necrotic & there
is a thin rim of inflammation around edge which shows up on scanning as rim enhancement.
The range of non-malignant cervical lymph node 3mm to 3cm, but greater than 1cm in size on CT
may contain metastatic disease. All nodes greater than 1 cm in size as containing malignant disease,
except those in the low level II high level III region when a 1.5 cm size criterion is often applied.
The two most difficult area in imaging head &neck region are the detection of low-volume neck
disease, residual & recurrent disease following surgery & irradiation.
CT or MRI should definiately be considered ,
1) If neck is being scanned as part of primary tumour assessment.
2) High chance of occult disease >20%
3) In the presence of significant ipsilateral disease when the presence of deep fixation or
contralateral spread may management from surgery to no treatment at all.
4) To assess the difficult neck;
5) Staging prior to non surgical treatment
6) For restaging.
MRI
Can detect cervical lymphadenopathy with similar accuracy rates to CT.However MRI may be better
in evaluating the N0 neck.
USG
USG useful in assessing of the carotid artery & jugular vein by lymph node metastases.
7. PET
We can assess the metabolic activity of cervical lymph nodes using 18 fluorodeoxyglucose. But poor
sensitivity & specificity for low volumne disease.CT/PET is confined to detect occult primary &
assessment of residual & recurrent disease following surgery &irradiation.
FNAC
The possibility of anaplastic carcinoma Or lymphoma usually makes a tru-cut or open biopsy
mandatory.
Open biopsy
Where FNAC not available, equivocal, or nondiagnostic or results suggest either a lymphoma Or
anaplastic carcinoma.An incision should be made to facilitate the removal of the scar via a
subsequent standard neck dissection.
Sentinel node biopsy;
Much attention has given non-head &neck melanoma ,breast cancer,Technique is injection of
radionuclide at the primary site & the patient is then imaged to identify the first lymph node that is
involved in the drainage of a tumour within the primary lymphatic basin of a N0 neck.Due to skip
metastases , & collateral channels are often present.So no role of sentinel node biopsy in head
&neck cancer.