Management of neck in oral squamous cell carcinoma

MANAGEMENT OF NECK IN
ORAL SQUAMOUS CELL
CARCINOMA
By- Dr. Chirag Patil

CONTENTS
• Introduction
• Demographic & clinical profile in OSCC
- Age
- Gender
- Habit
- Tumor dimension
- Tumor thickness
- Total tumor volume
- Depth of invasion
- Bone invasion
- Margin status
- Pattern of invasion
- Perineural invasion
- Extracapsular spread
• Assessment of lymphnode
- Lymph node level
-Lymphatic drainage
-Diagnosis and evaluation
-Sentinel node biopsy
-NCCN guideline for SNB
-Choice of imaging methods
• Neck dissection
- Classification
- Radical neck dissection

• Modified radical neck dissection
• Extended neck dissection
• Therapeutic neck dissection
• Elective neck dissection
• NCCN Clinical practice guideline 2018
• Decision making in OSCC
• Curative intent treatment
• Palliative intent treatment
• Management of N0 neck
• Management of N+ neck
• Management of N+ neck when chemo-radiation is
primary modality
• Management of contralateral neck
• Management of recurrence
• Adjuvant treatment
• Follow up recommendation
• Recommendation
CONTENTS

INTRODUCTION
• Worldwide, oral cancer accounts for 2% - 4% of all cancer
cases
• In India, oral cancer is one of the most common cancer and
constitutes a major public health problem.
• Prevalence oral cancer is higher, reaching around 45% in
India.
Sharma P, Saxena S, Aggarwal P. Trends in the epidemiology of oral
squamous cell carcinoma in Western UP: an institutional study. Ind J Dent
Res 2010; 21: 316-9.

• Percentages of morbidity and mortality in males are 6.6/100,000 and
3.1/100,000 respectively, while in females the same percentages are
2.9/100,000 and 1.4/100,000
• The percentage of 5-year survival for patients with OSCC varies from 40-
50%.
• One-third of all cases of OSCC present as stage I/II disease & two-thirds of
patients present with stage III or IV disease.
• Presence of Lymphatic metastases is associated with decrease of 50% in
survival rate.
Mehrotra R, Yadav S. Oral squamous cell carcinoma: etiology, pathogenesis and
prognostic value of genomic alterations. Indian J Cancer 2006; 43: 60-6.
INTRODUCTION

• Contralateral and/or Bilateral nodal metastases further reduces prognosis by
50%.
• Patients with cervical nodal metastases show increased likelihood for
distant metastases and local recurrence.
• Prognosis in patients with extra nodal spread of tumor in cervical lymph
nodes is poor.
INTRODUCTION
Mehrotra R, Yadav S. Oral squamous cell carcinoma: etiology,
pathogenesis and prognostic value of genomic alterations. Indian J
Cancer 2006; 43: 60-6

• It allows the removal and identification of occult
metastasis in patients in whom cervical metastasis are at
risk, which is referred to as an elective neck dissectionFirst
• It allows the removal of disease in patients in whom
metastasis are highly suspected based on imaging, clinical
examination or fine needle aspiration, which is referred to as
a therapeutic neck dissection
Second
Jon D. Holmes et al “Neck Dissection: Nomenclature,
Classification, and Technique” Oral Maxillofacial Surg
Clin N Am 20 (2008) 459–475
REMOVAL OF THE ATRISK LYMPHATIC BASINS SERVES
TWO IMPORTANT PURPOSES

DEMOGRAPHIC AND CLINICAL PROFILE OF ORAL
SQUAMOUS CELL CARCINOMA PATIENTS
AGE-
• In a study from Eastern India, mean age was 52 years.
• 91 percent of the cases occur after the age of 40 years and highest
incidence is found between ages 60 and 70 years.
• Schantz et al. 2006 , had stated that genetic susceptibility to environmental
carcinogens may influence the risk for OSCC in young adults
Kiran B. Jadhav et al “Clinicopathological Prognostic Implicators of Oral
Squamous Cell Carcinoma: Need to Understand and Revise” North American
Journal of Medical Sciences,December 2013,Volume 5,Issue 12.

• Epidemiological study of oral cancer in India by Chattopadhyay et
al. 1985 and Mathew et al.2001 reported that in developing
countries, oral cancer may affect younger men and women more
frequently than seen in the western world.
• Increase in incidence of tongue cancer in young adults as
compared to older adults (< 40 years).
• It is generally held view that OSCC in young people are less
aggressive and have a good prognosis
AGE-

GENDER
• Male-to-female distribution (2.54:1)
• Survival analysis confirmed that gender did not affect survival.
• Although some authors have reported lower survival rates in females, it
was attributed to delayed seeking of medical care and lower acceptance
of treatment.
Squamous Cell Carcinoma: Need to Understand and Revise” North
American Journal of Medical Sciences,December 2013,Volume 5,Issue 12.

HABITS
• Massona J, et al 2006 - Higher mortality in smokers and alcohol
drinkers.
• Betel quid chewing had poorer prognosis.
• The effect of alcohol was tested by using Michigan Alcoholism
Screening Test (MAST) given by Deleyiannis et al. 1966 for
assessing prognosis of head and neck cancer.
• patients with present drinking habit and having history of alcohol related
systemic health problems were more likely to die as compared to non
alcoholics
Kiran B. Jadhav et al “Clinicopathological Prognostic Implicators of
Oral Squamous Cell Carcinoma: Need to Understand and Revise” North
American Journal of Medical Sciences,December 2013,Volume 5,Issue 12

• Any smoking during 6 weeks course of radiotherapy decreased the
complete response from 74 to 45%.
• Cessation of smoking habit had a significant relation with survival.
• In such patients 2 year survival decreased from 66 to 39%, and the
survival time from 30 to 16 months.
• Risk reduction is 40% for those who quit habit less than 12 weeks
prior to diagnosis and 70% for those who quit habit 1 year prior to
diagnosis.
HABITS

TUMOR DIMENSION
• Clinically, tumor dimension is the maximum surface diameter of mucosal
neoplasm.
• Pathologically, it is the maximal cross-sectional diameter of a resected
specimen.
• Moore et al., stated that 84% of patients with tumor diameter less than 2
cm survived a disease free period of 3 years as compared to 52% of
patients with a tumor larger than 2 cm in diameter

TUMOR THICKNESS
• Tumor thickness is defined simply as the largest vertical dimension
between the surface of the tumor (excluding ulcerated areas, keratin
and parakeratin) and the deepest point of invasion
• Pentenero et al. 2005 have summarized TT measurements in
different ways as follows:
• From the surface of the wound to the deepest point of invasion.
• From the adjacent healthy and intact mucosa to the deepest point of
invasion.
• From the base membrane to the deepest point of invasion
Pentenero et al. “Importance of tumor thickness and depth of invasion in
nodal involvement and prognosis of oral squamous cell carcinoma: A review of
the literature” Journal of science and specialties of head and neck 2005
Dec;27(12):1080-91.

Tumor thickness-
0 to 0.76 mm - Considered as superficial.
0.76 to 1.50 mm- Intermediate depth.
Greater than 1.50 mm- Deep lesion
Five year disease free survival was 98% for superficial lesions,
44-63% for deep lesions group
TUMOR THICKNESS

• Tumor thickness is measured with ocular micrometer.
• Wolggar et al., 1999 showed mean tumor thickness with a positive
nodal metastasis was 19 mm.
• Tumor depth exceeded 5 mm, the metastatic rate was 64.7%.
• Higher incidence of lymph node involvement in tumors with TT of
more than 5 mm.
• There is a critical point at 5 mm of tumor depth at which cervical
metastasis was probable. Because deeper connective tissue the
presence of lymphatic channels acts as road entry for cervical
metastasis.
TUMOR THICKNESS
Contemporary oral oncology- diagnosis and management vol-2

TOTAL TUMOR VOLUME
• Total tumor volume (TTV) is measured by (CT) scan, which can
act as a prognostic indicator.
• TTV of less than 6 cm had better local control over tumor
progression.
• Tumors less than 2 mm demonstrated a 5–13 % rate of occult
metastasis and a 95 % 5-year survival.
• Tumors >5 mm thick, the rate of occult metastasis increased to
64 % and 85 % 5-year survival
Journal of Medical Sciences,December 2013,Volume 5,Issue 12

DEPTH OF INVASION (DOI)
• Measured from the deepest tumor point to the level of basement membrane
• Depth of invasion is currently the best predictor of occult metastatic disease
and should be used to guide for decision making.
• For tumours with a depth grater 4mm elective dissection should be strongly
considered if RT is not already planed
• For depth less than 2mm elective dissection is only indicated in highly
selective situation.

• For depth of 2 to 4mm clinical judgement as to reliability of follow up,
clinical suspicion, and other factors must be utilized to determine
appropriateness of elective dissection.
• Increase in DOI along with tumor volume is often associated with the
increased risk of local recurrence.
• Depth of invasion was less than 5 mm, the incidence of cervical metastasis
was only 5.9%.
• A depth of invasion greater than 9 mm was associated with a 65 % rate of
regional metastasis and a 5-year survival of 65 %
DEPTH OF INVASION (DOI)

BONE INVASION
• Mandibular bone is by far the most commonly involved in OSCC
(>90 %) by tumors of gingiva/alveolar mucosa, retromolar trigone,
floor of mouth, and tongue.
• But the most common point of bone involvement to be the junction
of reflected and attached gingival mucosa in both dentate and
edentulous patients.
Ardalan Ebrahimi et al The Prognostic and Staging Implications of Bone Invasion in
Oral Squamous Cell Carcinoma Cancer October 1, 2011

• Deep (i.e., medullary) bone invasion has been associated with
increased local recurrence and decreased survival
• large tumors (>4 cm) have approximately triple the risk of cancer-
related death and that cortical bone invasion had no association
with recurrence or survival.
• Tumors with bone invasion limited to the cortex have a similar
prognosis to those without bone invasion
BONE INVASION
Ardalan Ebrahimi et al The Prognostic and Staging Implications of Bone Invasion in
Oral Squamous Cell Carcinoma Cancer October 1, 2011

Margin status
• The margin refers to how close the cancer cells are to the edge of the normal
tissue surrounding the tumor.
• Risk factor for local recurrence in OSCC
• Margins were described in the following three ways
• Clinical margins: The margins of tumor on clinical examination that is on
observation and palpation. It was always included during the surgical removal of
tumor tissue.
• Surgical margins- The status of the surgical margin was an important predictor
of outcome. The surgical margin, in contrast to the other prognostic indicators is
under the direct control of the surgeon.
• Close surgical margins- Were considered as positive margins.
• These results implied that close surgical margins in OSCC could be regarded as
an indicator of aggressive disease.

METHODS TO INTERPRET
THE MARGINS

PATTERN OF INVASION
• Deep positive margin carried a worse prognosis compared to mucosal
positive margin.
• Pattern of invasion of tumor is considered as the primary determinant of
probability of deep margin positivity.

PATTERN OF INVASION
• Correlation of pattern of invasion and cancer stem cells.
(a) Pushing boarder, (b) Fingerlike boarder, (c) Infiltrative boarder.
(d) Concept of cancer stem cells defining the pattern of invasion
Ch’ng S, Corbett-Burns S, Stanton N. Close margin alone does not warrant postoperative
adjuvant radiotherapy in oral squamous cell carcinoma. Cancer. 2013;119:2427–37.

PATTERN OF INVASION
• They have hypothesized that the pattern of invasion of oral cancer is
determined by the density of cancer stem cells (CSC); the higher the
density of cancer stem cells the worse the pattern of invasion
• CSCs have higher migration capacity as well as are resistant to both
radiation and chemotherapy.
• They have observed a close correlation of pattern of invasion and putative
cancer stem cell marker CD44 and poor treatment outcome.
• The CD44 expression also correlated with perineural invasion as well as
lower lymphocyte infiltration.
Ch’ng S, Corbett-Burns S, Stanton N. Close margin alone does not warrant
postoperative adjuvant radiotherapy in oral squamous cell carcinoma. Cancer.
2013;119:2427–37.

PERINEURAL INVASION
• Occurs in upto 52% of OSCC.
• Mediated through nerve cell adhesion molecule (NCAM), on the surface
of cancer cells which engage in homophilic binding with NCAM receptors
(expressed by neural and perineural tissue).
• Perineural invasion (PI) in primary tumor is a predictor for cervical
metastasis, locoregional recurrence.
•

PERINEURAL INVASION
• Most tumors allow 2 cm of dissemination of tumor cells along
perineural space, so malignant cells that evade surgical excision
and radiotherapy, results in local recurrence.
• Relationship between PI and prognosis is independent of nerve
diameter, so in all cases of OSCC,The pathological specimen
should be examined for PI even in nerves less than 1 mm in
diameter
Kiran B. Jadhav et al “Clinicopathological Prognostic Implicators of Oral Squamous Cell
Carcinoma: Need to Understand and Revise” North American Journal of Medical
Sciences,December 2013,Volume 5,Issue 12.

(a) Complete encirclement,
intratumoral location
(b) complete encirclement
(c) incomplete “crescent-
like” encirclement,
peripheral location
(d) sandwiching “onion skin”
(e) partial invasion,
extratumoral location
(f) neural permeation.
Abbreviations: PN:
Peripheral nerve, TI: Tumor
island, MS: Mesenchymal
stroma, TM: Tumor mass, IE:
Invasive edge, TN: Tumor
necrosis, DSM:
Degenerating skeletal
muscle, AT: Adipose tissue

VASCULAR INVASION
• The presence of neoplastic cells within an endothelial cell lined channel.
• It occurs in more than 50% of head and neck squamous cell carcinomas
(HNSCCs).
• It correlates with the presence of cervical metastases and showed an
increased risk of distant metastatic disease.
• The skin of face and scalp is most commonly affected by metastases
Kiran B. Jadhav et al “Clinicopathological Prognostic Implicators of Oral Squamous
Cell Carcinoma: Need to Understand and Revise” North American Journal of Medical
Sciences,December 2013,Volume 5,Issue 12.

EXTRACAPSULAR
EXTENSION
• Occurs in approximately 60% of patients with positive cervical
nodes and is importance in predicting patient outcomes.
• A recent study reported a strong association between the
presence of ECE and clinical N stage, in TNM staging.

LEVEL OF ECE
• THE EXTENT OF ECE IS BASED ON THREE LEVELS
(a) Macroscopic extracapsular spread with the involvement of
adjacent anatomic structures such as the internal jugular vein or
skeletal muscle;
(b) Macroscopic extracapsular spread confined to the perinodal
fibroadipose tissue;
(c) Microscopic extracapsular spread.

• ECE is a significant in determining of prognosis
• Associated with an increased risk of recurrence in the neck and distant
metastasis.
• The presence of gross or macroscopic ECE tripled the risk of neck
recurrence.
• ECE is strong predictor for estimation of survival
- 3 years was 32%
- 5 year survival rate was 24%.
LEVEL OF ECE

LYMPH NODES acts as a barrier to the spread
of the disease .
-Virchow in 1860

LYMPH NODE LEVEL
(Transverse
cervical)
VI Central compartment

DIAGNOSIS AND
EVALUATION
• Evaluation of presence of regional lymph nodes and any second primary.
• Pathological diagnosis should be confirmed with tissue biopsy.
• A fine-needle aspiration (FNA) should be done (ultrasound-guided FNA
improves the accuracy and specificity) of suspected regional cervical
metastases.
• The clinical evaluation needs to be supplemented with imaging studies.

DIAGNOSIS AND
EVALUATION
• Investigations for bony involvement - OPG or CT scan
• Minimum of 30 % bone erosion is required for detection in OPG.
• May not be the best for assessing the midline lesions of the mandible due
to the overlap by the spine.
• CT scan is better in demonstrating mandibular cortical involvement and
the status of cervical lymph nodes.

DIAGNOSIS AND
EVALUATION
• MRI is preferred - soft tissue, skull base, and infratemporal fossa.
• Useful in radiotherapy planning and medullary bone involvement.
• CT scan is preferred in buccal mucosa cancer, while MRI is favored for
tongue cancer.
• In early-stage lesions with a clinically node negative neck, ultrasound with
or without FNA is the initial investigation of choice for the neck
• Ultrasound is also preferred for close observation and follow-up of the neck
in patients who are lymph node negative.
• The role of PET-CT scan is useful in assessing post treatment residual/
recurrent disease

SENTINEL NODE
BIOPSY (SNB):
It is the first echelon lymph
node that is most likely to
drain a part.
Or
Lymph node to which a
tumor first metastasis

SENTINEL NODE
BIOPSY (SNB):
• If this lymph node is biopsied there are optimum chances of detecting
the nodal metastasis.
• The first successful SNB in a head and neck SCC was performed, in
1996, by Alex and Krag on a patient with a laryngeal supraglottic
carcinoma.

SENTINEL NODE BIOPSY
(SNB):
• RATIONALE:
• Cervical metastasis is most important prognostic factor
• presence of nodal spread decreasing the 5-year disease-free survival rate
by approx. 50 %.
• SNB is a staging tool.
• Improved the accuracy of staging, while reducing the morbidity
caused by unnecessary lymphadenectomy.

SENTINEL NODE
BIOPSY (SNB):
• SLNB if negative for metastases, lymph node dissection is not
necessary.
• One of the main problem of SLNB of oral cancer is skip metastasis
in which the disease by passes level 1 and 2 nodes and goes directly
to level 3-4
• The presence of lower neck lymph node indicated chances of
distant metastasis increasing by 33%

NCCN GUIDELINE 2018
FOR SNB
• Alternative to elective neck dissection for identifying occult
cervical metastasis in patient with early (T1 or T2) lesion.
• Reduce morbidity and improve cosmetic outcome.
• Rate of detection of Sentinel node is 95%
• Positive SND- Complete neck dissection
• Negative SND – Observation
• Sufficient caution must be exercised when offering it as an
alternative to elective neck dissection

NCCN GUIDELINE 2018
FOR SNB
• The accuracy of SNB in cases of floor of mouth cancer
• Lower in tongue lesion
• Upper gingiva and hard palate may not lead themselves well
technically to this procedure.
• Occult cervical metastases are uncommon in early lip cancer but
SLN has been shown to be feasible and effective in patient with
lip cancer with high risk metastases based on tumor size or depth

CHOICE OF IMAGING METHODS FOR T STAGING
AT VARIOUS SUBSITES OF ORAL CAVITY
SQUAMOUS CELL CARCINOMA
Arya S, Rane P, Deshmukh A. Oral cavity squamous cell carcinoma: role of pretreatment
imaging and its influence on management. Clin Radiol. 2014;69(9):916–30.

Site of SCC Imaging method
of choice
Advantages Disadvantages
Oral tongue and
floor of mouth
CE-MRI A. Superior soft-tissue
characterization for
✓ Extrinsic muscle
invasion
✓ Posterior and inferior
soft tissue extent
B. Highly sensitive for
bone erosion (that occurs
in <10 % cases in tongue
cancers)
overestimate
inferior alveolar canal
involvement and mandibular
cortical erosion (due to
chemical shift artifacts)
Gingival and
buccal cancers
CE-MDCT with
puffed-cheek
technique
A. Bone erosion (high
positive predictive value)
B. Speed of scanning
C. Adequate for posterior
soft tissue extent to decide
resectability
May miss early
perineural spread
RMT CE-MRI Accurate T staging and
relations
Overestimation of
mandibular invasion
CE-MDCT with
puffed cheek
technique
High accuracy for bone
erosion adequate for
soft-tissue extent
May miss early perineural
spread
Hard palate CE-MRI A. High accuracy for
marrow and perineural
invasion
B. Complete soft-tissue
extent depicted
Cortical erosion less well
depicted (CE-MDCT is
therefore complementary)
Lip CE-MDCT with
puffed-cheek
technique
High accuracy for bone
erosion adequate for
soft-tissue extent
CT may miss early perineural
spread, but MRI could
overestimate perineural spread

DEFINiTION
It is a procedure to remove lymph nodes and
surrounding fibro fatty tissues from neck to eradicate
metastasis to cervical lymph nodes in cancer of
aerodigestive tract.
NECK DISSECTION

COMPARISON OF 1991 AND 2002 NECK
DISSECTION CLASSIFICATION
1991 classification 2002 classification
1. Radical neck dissection
2. Modified radical neck dissection
3. Selective neck dissection
a. Supraomohyoid
b. Lateral
c. Posterolateral
d. Anterior
4. Extended neck dissection
1. Radical neck dissection
2. Modified radical neck Dissection
3. Selective neck dissection:
Avoid named neck dissection. Instead each
variation should be denoted SND followed
by parenthesis containing designations for
the nodal levels or
sublevels removed
4. Extended neck dissection
Robbins KT, Clayman G, et al. Neck dissection classification update. Arch Otolaryngol Head
Neck Surg 2002;128:751–8; with permission.

RADICAL NECK
DISSECTION
Removal of levels I–
V, accessory nerve,
internal jugular
vein and
sternocleidomastoid
muscle

SELECTIVE NECK
DISSECTION
• Preservation of one
or more levels of
lymph nodes
• SND I-III OR
Supraomohyoid
neck dissection

SELECTIVE NECK
DISSECTION
• Lateral neck
dissection
• SND (II-IV)
• Oropharyngeal,
Hypopharyngeal
Laryngeal Cancer

SELECTIVE NECK
DISSECTION
• Posteriolateral
neck dissection
• SND (II-V)
• Posterior scalp
• Upper
posteriolateral
neck cutaneous
malignancy

SELECTIVE NECK
DISSECTION
• Anterior neck
dissection
• SND VI
• Thyroid
cancer

MODIFIED RADICAL
NECK DISSECTION
Removal of levels I–V dissected; preservation
of one or more of the accessory nerve, internal
jugular vein or sternocleidomastoid muscle
(Types I, II, III, respectively)

MODIFICATION I:
Selectively
preserves only
spinal accessory
nerve

MODIFICATION II
Selectively preserves
IJV and spinal
accessory nerve

MODIFICATION III
Selectively preserves
SCM, IJV and spinal
accessory nerve

EXTENDED NECK DISSECTION:
• Removal of one or
more additional
lymphatic and/or
non-lymphatic
structures(s) relative
to a RND, e.g. level
VII, retropharyngeal
lymph nodes,
hypoglossal nerve,
vagus nerve
,superior
mediastinal,paratrac
heal lymph node.

• THERAPEUTIC NECK DISSECTION : When the positive
nodes exist and are excised.
• ELECTIVE OR PROPHYLACTIC: In the N0 neck the
surgeon elects to perform the prophylactic neck dissection (for
carcinoma of tongue, floor of mouth, retromolar trigone or
where the patient compliance is poor and he/she is unlikely to
come for follow-up as seen in Indian conditions, which is due to
illiteracy, poverty and ignorance).

NCCN clinical practice guidelines in oncology
Head and Neck cancers
 The patients can be grouped into following categories:
 Curative intent treatment group
 Palliative intent treatment group

STAGING OF CANCER
• Curative intent treatment group
1. T1, N0, M0
2. T2-T4a, N0, M0
3. T2-T4a, N1, M0
4. T2-T4a, N2,3, M0
• Palliative intent treatment group
1. T4b, any N-stage, M0
2. Any T-stage, N3 with carotid or paraspinal muscle involvement
3. Any T-stage, any N-stage with M1
4. Any T-stage, any N-stage, any M-stage with poor performance
status

DECISION MAKING ALGORITHM FOR ORAL
CAVITY SQUAMOUS CELL CARCINOMA

CURATIVE-INTENT TREATMENT GUIDELINES

PALLIATIVE-INTENT TREATMENT GUIDELINE

• Chemotherapy prior to definitive surgery for HNSCC (a.k.a. induction) has been
• studied for many years. Induction has also been studied extensively prior to definitive
• CRT in other cancers of the head and neck. This approach has many supporters
• and is backed by a wealth of hypothetical advantages. These facts aside, there is a
• lack of high-level evidence supporting the use of this modality. Large phase III trials
• have concluded the optimal regimen to be TPF (docetaxel, cisplatinum,
• 5-fluorouracil)
• [43, 44]. Recently, a phase III trial comparing induction chemotherapy
• followed by surgery to up-front surgery was reported in the OCSCC population.
• This trial randomized patients to two cycles of TPF followed by curative resection
• and postoperative RT vs. surgery and postoperative RT alone. Two hundred fifty-six
• patients were enrolled, and 222 completed the full course of treatment. Clinical
• response was 81 %. After a median of 30 months, there was no difference in OS or
• DFS. Again, clinical response was found to be predictive [45]. Induction chemotherapy
• prior to definitive surgery for OCSCC is not a recommendation from the
• National Comprehensive Cancer Network (NCCN) [46].

V Paleri, T G Urbano et al Management of
neck metastases in head and neck cancer:
United Kingdom National Multidisciplinary
Guidelines The Journal of Laryngology &
Otology (2016), 130 (Suppl. S2), S161–
S169.
ALGORITHM FOR
MANAGEMENT OF
THE N0 NECK.

Algorithm for management of the N+ neck when
surgery is the primary modality.
V Paleri, T G Urbano et al Management of neck metastases
in head and neck cancer: United Kingdom National
Multidisciplinary Guidelines The Journal of Laryngology &
Otology (2016), 130 (Suppl. S2), S161–S169.

Algorithm for management of the N+ neck when
chemo-radiation is the primary modality
V Paleri, T G Urbano et al Management of neck metastases in head and neck cancer:
United Kingdom National Multidisciplinary Guidelines The Journal of Laryngology

MANAGEMENT OF THE
CONTRALATERAL NECK
• Contralateral node-positive neck will require a comprehensive neck
dissection.
• Contralateral node-negative neck needs to be addressed prophylactically
with a selective neck dissection in large midline lesions or lesions crossing
over the midline to involve the opposite side.
• The conventional recommendation for any patients with clinically and
radiologically node-positive disease is to undertake modified radical neck
dissection clearing levels 1–5.

INDICATION OF
CONTRALATERAL NECK
DISSECTION
(1) Tumours crossing the midline
(2) Advanced staging (T 3, 4)
(3) Primary tumour more than 3.75 mm thick
(4) Multiple ipsilateral node involvement
(5) Tumours arising in the base of the tongue and
floor of the mouth.
Fan S, Tang QL, Lin YJ, Chen WL, Li JS, Huang ZQ, Yang ZH, Wang YY, Zhang DM,
Wang HJ, Dias-Ribeiro E, Cai Q, Wang L. A review of clinical and histological parameters
associated with contralateral neck metastases in oral squamous cell carcinoma. Int J
Oral Sci 2011;3:180-91

MANAGEMENT OF THE RECURRENCES
• Surgically resectable primary recurrences should be re-resected with a
curative intent.
• Neck recurrences in an untreated neck should be treated with neck
dissection.
• Recurrence in an already treated area of the primary and neck has to be
resected if possible.
• If no prior radiotherapy has been given, adjuvant radiotherapy has to be
considered.
• Re-irradiation should be considered only in very selected cases after
concurrence from a multidisciplinary tumor board.

ADJUVANT TREATMENT
• Postsurgical adjuvant treatment options depend on whether
adverse features are present on pathology.
• Indications of adjuvant radiotherapy :
1. Advanced T-stage (T3/T4)
2. Presence of lymphovascular invasion
3. Presence of perineural invasion
4. Positive surgical margins
5. Multiple lymph node involvement
6. Extracapsular nodal extension
• Indications of adjuvant chemoradiotherapy :
1. Positive tumor margins
2. Extracapsular nodal extension

ADJUVANT TREATMENT
• For patients with positive surgical margins, management options
include re-resection or chemoradiotherapy.
• In adjuvant setting, postoperative adjuvant EBRT is given in
conventional fractionation, with a dose of 60Gy in 30 fractions to the
surgical bed and first echelon nodal stations, while the low-risk nodal
stations are treated with 50–54 Gy in conventional fractionation.
• In case of high-risk features like perinodal spread or positive or close
margins, patients are treated with concurrent chemoradiation, and the
high-risk regions are treated to a total dose of 66Gy.

FOLLOW UP RECOMMENDATION
(NCCN GUIDELINES 2018)
• Year 1, every 1-3months
• Year 2, every 2-6 months
• Year 3-5, every 4-8 months
• > 5 years, every 12 months

FOLLOW UP RECOMMENDATION
(NCCN GUIDELINES 2018)
Imaging-
 Post treatment, considering repeating pretreatment baseline
imaging within 6 months of treatment
 Chest CT with or without contrast as clinically indicated for
patients with smoking history
 Further reimaging as indicated based on worrisome or equivocal
signs/symptoms, smoking history & areas inaccessible to
clinical examination
 Thyroid stimulating hormone(TSH) every 6-12 months if neck
irradiated
 Dental evaluation for oral cavity and site exposed to significant
intraoral radiation treatment

RECOMENDATION
 CT or MRI imaging is mandatory for staging neck disease, with
choice of modality dependent on imaging modality used for the
primary site, local availability and expertise.
 Patients with a clinically N0 neck, with more than 15–20 per cent
risk of occult nodal metastases, should be offered prophylactic
treatment of the neck. (R)
 The treatment choice of for the N0 and N+ neck should be guided
by the treatment to the primary site.
 If observation is planned for the N0 neck, this should be
supplemented by regular USG to ensure early detection.
 All patients with T1 and T2 oral cavity cancer and N0 neck should
receive prophylactic neck treatment.
V PALERI et al, “Management of neck metastases in head and neck cancer: United Kingdom National
Multidisciplinary Guidelines” The Journal of Laryngology & Otology (2016), 130 (Suppl. S2), S161–S169

RECOMENDATION
 Selective neck dissection (SND) is as effective as modified radical
neck dissection for controlling regional disease in N0 necks for all
primary sites.
 SND alone is adequate treatment for pN1 neck disease without
adverse histological features.
 Post-operative radiation for adverse histologic features following
SND confers control rates comparable with more extensive
procedures.
 Adjuvant radiation following surgery for patients with adverse
histological features improves regional control rates. (R)
 Post-operative chemoradiation improves regional control in
patients with extracapsular spread and/or microscopically
involved surgical margins. (R)

RECOMENDATION
• Following chemoradiation therapy, complete responders who do
not show evidence of active disease on co-registered (PET–CT)
scans performed at 10–12 weeks, do not need salvage neck
dissection.
• Salvage surgery should be considered for those with incomplete or
equivocal response of nodal disease on PET–CT. (R)
V PALERI et al, “Management of neck metastases in head and neck
cancer: United Kingdom National Multidisciplinary Guidelines” The Journal of
Laryngology & Otology (2016), 130 (Suppl. S2), S161–S169

REFERENCES
• Sharma P, Saxena S, Aggarwal P. Trends in the epidemiology of oral squamous cell
carcinoma in Western UP: an institutional study. Ind J Dent Res 2010; 21: 316-9.
• Mehrotra R, Yadav S. Oral squamous cell carcinoma: etiology, pathogenesis and
prognostic value of genomic alterations. Indian J Cancer 2006; 43: 60-6.
• Jon D. Holmes et al “Neck Dissection: Nomenclature, Classification, and
Technique” Oral Maxillofacial Surg Clin N Am 20 (2008) 459–475
• Kiran B. Jadhav et al “Clinicopathological Prognostic Implicators of Oral
• Pentenero et al. “Importance of tumor thickness and depth of invasion in nodal
involvement and prognosis of oral squamous cell carcinoma: A review of the
literature” Journal of science and specialties of head and neck 2005
Dec;27(12):1080-91.

REFERENCES
• Ardalan Ebrahimi et al The Prognostic and Staging Implications of
Bone Invasion in Oral Squamous Cell Carcinoma Cancer October 1,
2011
• Ch’ng S, Corbett-Burns S, Stanton N. Close margin alone does not
warrant postoperative adjuvant radiotherapy in oral squamous cell
carcinoma. Cancer. 2013;119:2427–37
• V PALERI et al, “Management of neck metastases in head and neck
cancer: United Kingdom National Multidisciplinary Guidelines” The
Journal of Laryngology & Otology (2016), 130 (Suppl. S2), S161–
S169
• Jon D ET AL “Neck Dissection: Nomenclature, Classification, and
Technique” Oral Maxillofacial Surg Clin N Am 20 (2008) 459–475
• Contemporary oral oncology- diagnosis and management vol-2
• NCCN guideline 2018 head and neck cancers

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